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Massive obstetric haemorrhage (Complications (Shock, Pulmonary oedema,…
Massive
obstetric
haemorrhage
Definition
Loss of 30-40% of patients
blood volume during labour
Epidemiology
High cause of
morbidity and mortality
Pathophysiology
Haemodynamics
Increased blood volume in pregnancy
High blood flow to uterus and placenta
Effective compensation until 30% vol loss
Shock
Reduced circulating blood volume resulting
in reduced perfusion and O2 supply to vital organs
DIC
Caused by massive blood loss, amniotic fluid emoolus,
loss of clotting factors (platelets, fibrinogen etc.)
Iatrogenic resus with fluid and packed RBCs further dilutes clotting factors and exacerbates DIC
Aetiology
Intrapartum
Vascular: amniotic fluid embolism
Trauma: intrapartum abruption, uterine rupture
Iatrogenic: CS complications
Developmental: adherent placenta (accrete/percreta)
Postpartum
Vascular: uterine AVM
Infection: infection of retained products
Trauma: uterine trauma
Idiopathic: uterine atony, retained products
Genetic: coagulation disorder
Drugs: anticoagulants
Antepartum
Infection: sepsis, chorioamnionitis
Trauma: placental abruption
Idiopathic: pre-eclampsia, retained dead foetus
Developmental: PP
Clinical
presentation
PV bleed
(massive or small)
Shock
Diagnosis
Examination
General: shock
Uterine: may be tender, PV bleeding
Investigations
Bloods
FBC (anaemia, infection), CRP, U+E (AKI),
LFTs (liver disease), group&save
clotting (APTT, PTT deranged in DIC)
Imaging
USS: placenta
Bedside
Obs (shock, infection), ECG
History
HPC: PV bleed, risk factors
PMH: clotting disorder
DH: anticoagulants
SH: alcohol, smoking, drugs
Management
Initial ABCDE
Massive haemorrhage protocol
Definitive
Medical
Transfusions
Indication: major haemorrhage
E.g. red cells, FFP, Plts, cryoprecipitate
Tranexamic acid
Indication: major trauma/bleed
Uterine contraction agonists
Indication: uterine atony
E.g. oxytocin, ergometrine, misoprostol, carboprost
Surgical
Repair
Indication: genital tract injuries
Laparotomy
Indication: bleeding continued
MOA: oversewing and sutures,
arterial ligation, hysterectomy (subtotal or total)
Empty uterus
Indication: deliver foetus, remove
placenta/retained tissue
Uterine tamponade
Indication: heavy bleed
MOA: insertion of Rusch balloon/
Sengstaken-Blakemore tube, leave 12-24h
Conservative
Referrals
O+G anaesthetist, HDU/ITU
Alert blood bank, theatres
Manual measures
Rubbing up contractions (uterine massage)
Bimanual compression (to reduce bleeding)
Complications
Shock
Pulmonary oedema
Hypovolemia
Transfusion reactions
DIC
ARDS
Sheehan's syndrome
MOF
Loss of clotting factors
(iatrogenic washout phenomenon)