Professional Documents
Culture Documents
Management
• Fetal distress
– Cord prolapse
– Hand prolapse
– Obstructed labor(large head)
– Uteroplacental insufficiency
– Shoulder dystocia
– Vaginal breech delivery (head entrapment)
HEMORRHAGE
• PREPARTUM/INTRAPARTUM:
– Placenta previa
– Placental abruption
– Placenta accreta/increta/percreta
– Uterine rupture
• POSTPARTUM:
– Retained placenta
– Uterine atony
– Uterine inversion
– Birth trauma/laceration
PLACENTA PREVIA
• 1 in 200-250deliveries.
• Cardinal symptom of placenta previa is painless vaginal bleeding.
• first episode usually stops spontaneously.
• Bleeding typically manifests at approximately 32week of gestation, when the lower
uterine segment begins to form.
• When this diagnosis is suspected, the position of the placenta needs to be
confirmed via ultrasonography or radioisotope scan.
• Placenta previa occurs when implantation of the placenta is low in the uterus;
• it is either overlying or encroaching on the cervical os.
• Placenta previa is present in approximately 0.6% of all pregnancies.
• It categorized as :
– complete if the placenta completely covers the os,
– partial if there is some encroachment on the os by the placenta,
– marginal if the placenta is not covering but is close to the internal os
Conti……
• ETIOLOGY:
• Unknown
• Previous placenta previa
• Advanced maternal age
• The condition is more common in multiparous women, and it is especially common
in women who have had a previous cesarean section.
• Typically, in contrast with placental abruption,
• placenta previa is characterized by painless vaginal bleeding in the third trimester.
• Management :
• Bleeding may stop spontaneously, in which case conservative management is
recommended.
• Urgent/emergent cesarean delivery for active or persistent bleeding or fetal
distress.
• Except for a patient with a marginal previa who might elect. vaginal delivery, other
patient will be delivered by cesarean section.
Conti..
• Anesthetic Management
• Anesthetic management is dependent on the obstetric plan and the
condition of the parturient.
• Preoperative
• Mild to moderate blood loss is well tolerated by the patient .
• Adequate volume resuscitation is thus paramount to the patient's care.
• All patients should be typed and cross-matched to ensure continuous availability of
packed red blood cells and, if needed, blood products.
• Intraoperative
• Parturients with a total or partial previa will deliver by cesarean section.
• Anesthetic management will depend on maternal and fetal status and the urgency
of the surgery.
Conti...
• If patient has not had recent bleeding and is scheduled electively, regional
anesthesia is preferred.
• Large-bore intravenous access should be established as the patient is at greater
risk of intraoperative bleeding.
• Cross-matched blood should be immediately available.
• If hemorrhage necessitates emergency delivery, general anesthesia is the
anesthetic technique of choice.
• Ketamine and etomidate are the preferred induction agents in the hypovolemic
patient. Maintenance of anesthesia will be determined by the hemodynamic
status of the mother.
Placental abruption
Treatment
• Definitive treatment of abruptio placentae is delivery of the fetus and placenta.
Delivery may be vaginal if the abruption is not jeopardizing maternal or fetal well-
being. Otherwise, delivery is by cesarean section.
Conti....
Anesthetic Management
• If maternal hypotension is absent, clotting studies are acceptable, and there is no
evidence of fetal distress due to uteroplacental insufficiency,
• epidural analgesia is useful for providing analgesia for labor and vaginal delivery.
• When magnitude of placental separation and resulting hemorrhage are severe,
emergency cesarean section is necessary.
• most often, general anesthesia is used, as regional anesthesia in a
hemodynamically unstable.
• Anesthetic management is similar to that employed with placenta previa. Blood
and blood products should be readily available due to the risk of bleeding and DIC.
• It is not uncommon for blood to dissect between layers of the myometrium after
premature separation of the placenta.
• As a result, the uterus is unable to contract adequately after delivery, and
postpartum hemorrhage occurs.
• Uncontrolled hemorrhage may require an emergency hysterectomy.
• Bleeding may be exaggerated by coagulopathy, in which case infusion of fresh
frozen plasma and platelets may be indicated to replace deficient clotting factors.
• Clotting parameters usually revert to normal within a few hours after delivery of
the neonate.
Placenta Accreta
• Definition: abnormal development and implantation of the placenta. Or
abnormally adherent to the myometrium.
• Placenta accreta is an adherent placenta that has not invaded the myometrium.
• placenta increta, the placenta has invaded the myometrium
• placenta percreta is invasion through the
serosa.
• Incidence: 1 in 2000 deliveries but higher in
– placenta previa
– prior C-section
Conti..
• ETIOLOGY:
– Prior cesarean delivery especially classical cesarean scar
– Rupture of myomectomy scar
– Precipitous labor
– Prolonged labor with cephalopelvic disproportion
– Excessive oxytocin stimulation
– Abdominal trauma
– Grand multiparity
– Iatrogenic
– Direct uterine trauma-forceps or curettage
Conti..
• Management
• Manual removal of the placenta(MRP) is the standard treatment and is usually
carried out under anaesthesia (or more rarely, under sedation and analgesia).
Comparison of general anaesthesia, regional anaesthesia and sedation
• Causes-
– Trauma
– Blood Loss
– Occult fluid loss (GI)
– Burns
– Pancreatitis
– Sepsis (distributive, relative hypovolemia)
CLASSIFICATION OF HEMORRHAGIC SHOCK
Class I Class II Class III Class IV
Blood loss (ml) ≤750 750-1500 1500-2000 >2000
% blood loss ≤15 15-30 30-40 >40
Heart rate (bpm) <100 >100 >120 >140
SBP N N ↓ ↓
Pulse pressure N or ↑ ↓ ↓ ↓
Cap Refill < 3 sec > 3 sec >3 sec or absent absent
Colloid Solutions
• Pentastarch
• Albumin 5%
• Red Blood Cells
• Fresh Frozen Plasma
• Replacement of lost volume in 1:1 ratio
Oxygen Carrying Capacity
• Only RBC contribute to oxygen carrying capacity (hemoglobin)
• Replacement with all other solutions will
o support volume
o Improve end organ perfusion
o Will NOT provide additional oxygen carrying capacity.
RBC Transfusion
BC Red Cell Transfusion Guidelines recommend transfusion only to keep Hgb >7
g/dL unless
– Comorbid disease necessitating higher transfusion trigger (CAD, pulmonary
disease, sepsis)
– Hemodynamic instability despite adequate fluid resuscitation.
– PRBC’s at 5-10 cc/kg.
Estimating the resuscitating volume
Normal blood volume(BV)= 66ml/kg in male and 60ml/kg in female
Volume deficit(VD)= BV ˣ % of loss blood volume
Determine resuscitating volume(RV)= VD ˣ1.5(colloids)
=VD ˣ 4(crystalloid)
Definition of massive transfusion
• The replacement of patient’s entire blood volume in a 24-hour period.
or
• The transfusion of more than 20u of whole blood or 40u of PRBC.
or
• The replacement of over 50% of circulating blood volume in 3 hour or less
or
• Loss of blood or more than 150ml/min
Blood component
– Whole blood: 250ml. containing PRBC 1u, FFP 1u and 30ml preservatives.
– PRBC: ~100ml. Hct 70~80%. PRBC 1u can increase Hb 0.5 (Hct 1.5)
– FFP: ~125ml. Containing coagulation factor, protein and plasma.
– PLT: ~25ml. PLT 12u can increase PLT 60000.
INDICATIONS FOR BLOOD COMPONENT
Component Indication Usual starting dose
Whole blood Blood loss > 1500ml better than PRBC + FFP.
SBP N N ↓ ↓
Pulse pressure N or ↑ ↓ ↓ ↓
Cap Refill < 3 sec > 3 sec >3 sec or absent absent