Looks like we got ourselves a Bleeder

 

The Post-Partum Hemorrhage: Notes from Anesthesiology Core Review Part Two Advanced Exam

most common cause of blood loss in OB practice

leading cause of fetal and maternal M&M globally

definition: bleeding w/in 6wks of delivery

->500ml for vaginal, >1000ml for c/s

-decrease of 10% in hct from admission

-often underestimated!

Uterine blood flow = 700ml/min

-get good access fast

Uterine Atony

2-5% of all deliversies

cause of >90% of pp hemorrhage

results from failure of uterus to contract

risk factors:

-multiparity

-macrosomia

-polyhydramnios

-long labor (+oxytocin)

-chorioamnionitis

-placenta: retained, accreta, increta, percreta

-poor perfused myometrium

-drugs: inhalationals, oxytocin, tocolytics

Management of Atony

Oxytocin to contract uterus

-rapid: hypotension, decrease svr, tachy (rare card collapse), chest pain, ischemia, anaphylaxis

-ECG changes resolve spontaneously

-similar to ADH, so watch for water intox. so never give with hypotonic solution!

Ergot Alkaloids

-0.4mg – methylergonovine IM only

-10 minutes to action, lasts 3-6hrs

-vasoconstrictive -> HTN, avoid with pre-eclempsia.eclampsia

-if given IV -> intense vasoconstric -> siezures, CVA, retinal detach – MI

-Common ade: nausea vomiting

-2 dose then move on

Prostaglandins

-increase calcium -> myosin kinase

-carboprost = 15-methyl prostaglandin f2alpha given 260ucg IM

-increase force/interval of contraction

-also don’t give IV

-side effects: diarrhea, HTN, fever, flush, tachy

-bronchospasm, pulmonary vasoconstriction – so careful with asthmatics

-Misoprostol (prostaglandin E1) oral, rectal intrauterine also effective, side effect hypothermia

Retained Placenta

1-3 in 100 deliveries

result: uterus unable to fully contract –> bleeding

Need for uterine relaxation to explore and fix

GA -> 1MAC+ Inhalational

IV or sublingual Nitorglycerin
-100 ug works in 30-45seconds
-60-90 seconds return to baseline, may need redosing
-tx hypotension with phenylephrine

The Abnormal Placenta

Normal interface between placenta and uterus : Decidua basalis
When that’s missing -> uteri gets implanted
Placenta Accreta = ON myometrium
Placenta Increta = IN myometrium
Placenta Perceta = through and to other organs!
Bleeding serious complication and common
1:2000 births have accreta
-prior c/s
-placenta previa
-more c/s higher risk

If known beforehand, discuss plan about possible hysterectomy
-this can incur massive blood loss
-cell saver, think general anesthesia, secure airway, arterial line
-also consider prophylactic internal iliac balloon catheters in IR preop

Genital Trauma

lacerations of cervix, vagina, perinuem most common injuries of childbirth
if continued hypotension: think retriperitoneal hematoma!
-CT or MRI, tx with ex lap

help along repair with IV meds, neuraxial continuation, or nitrous oxide, think low dose ketamine too