Management Of Massive Obstetric Haemorrhage Research Articles

How Learning from Trauma Benefits the Obstetric Population? Damage Control Surgery

Abstract The recent implementation of trauma-validated damage control strategies in severe postpartum hemorrhage proves the importance of interdisciplinary management in the obstetric patient. Massive hemorrhage control techniques and damage control surgery are clear examples of how learning from trauma can benefit the obstetric population. Currently, most obstetric programs do not include training in this type of interventions. Nevertheless, it has been shown that these interventions are useful in the management of severe postpartum hemorrhage. The aim of this article is to introduce the application of damage control surgery principles in the management of massive obstetric hemorrhage. We propose to include appropriate training and the implementation of damage control surgery in obstetric management protocols. The prompt application of damage control principles can be considered in patients with persistent hemodynamic instability despite control of the source of bleeding.

Efficacy of resuscitative infusion with hemoglobin vesicles in rabbits with massive obstetric hemorrhage

Hemoglobin vesicles have been developed as artificial oxygen carriers, and they have the potential to serve as a substitute for red blood cell transfusion. This study aimed to evaluate the efficacy of hemoglobin vesicle infusion for the initial treatment instead of red blood cell transfusion in rabbits with massive obstetric hemorrhage. Pregnant New Zealand white rabbits (28th day of pregnancy; normal gestation period, 29-35 days) underwent uncontrolled hemorrhage to induce shock by transecting the right midartery and concomitant vein in the myometrium. Subsequently, rabbits received isovolemic fluid resuscitation through the femoral vein with an equivalent volume of hemorrhage every 5 minutes. Resuscitative infusion regimens included 5% human serum albumin (n=6), stored washed red blood cells with plasma (vol/vol=1:1; n=5), and hemoglobin vesicle with 5% human serum albumin (vol/vol=4:1; n=5). A total of 60 minutes after the start of bleeding, rabbits underwent surgical hemostasis by ligation of the bleeding vessels and then were monitored for survival within 24 hours. During fluid resuscitation, hemoglobin vesicle infusion and red blood cell transfusion maintained a mean arterial pressure of >50 mm Hg and a hemoglobin concentration of >9 g/dL and prevented the elevation of plasma lactate. In contrast, resuscitation with 5% human serum albumin alone could not prevent hemorrhagic shock as evidenced by a low mean arterial pressure (40 mm Hg), a low hemoglobin concentration (2 g/dL), and a marked elevation of plasma lactate. All animals in the red blood cell group and the hemoglobin vesicle group survived more than 8 hours, whereas all animals in the 5% human serum albumin group died within 8 hours. Hemoglobin vesicle infusion may be effective in the initial management of massive obstetric hemorrhage.

Clinical pearls part 3: anaesthetic management of abnormally invasive placentation.

Abnormal placentation is a clinical condition seen increasingly in the pregnant population. It is associated with significant morbidity and mortality, which may be mitigated through robust multidisciplinary care for these patients. The role of maternal critical care for these patients has largely been ignored in the literature. Advances in pharmacological management of bleeding with recent publications of large multicentre trials in addition to new technologies in the management of massive obstetric haemorrhage (MOH) have revolutionized the management of abnormal placentation. These include the use of tranexamic acid, interventional radiology, cell saver technology, and point-of-care coagulation tests. The role of maternal critical care for the optimization of postoperative complications and physiological derangements has not been considered widely in the literature. This article summarizes the current evidence for interventions and suggests a protocol for the management of these high-risk patients. A robust protocol outlining the key elements of the management of placenta accreta, including optimizing postoperative care, should be in place to promote desired outcomes.

Use of Condom Tamponade to Manage Massive Obstetric Hemorrhage at a Tertiary Center in Rajasthan.

Conventionally postpartum hemorrhage (PPH) has been defined as blood loss of more than 500ml following vaginal delivery and 1000ml following a cesarean section [Pritchard et al. in Am J Obstet Gynecol 84(10):1271-1282, (1962)]. Another definition labels PPH as any blood loss which causes a 10% drop in hematocrit [Combs et al. in Obstet Gynecol 77:69-76, (1991)] or which threatens the hemodynamic stability of the patient and necessitates blood transfusion [Prendiville et al. in Cochrane Database Syst Rev 2:CD000007, (2000)]. The purpose of this study was to evaluate the effectiveness of condom tamponade in the management of massive obstetric hemorrhage. To evaluate the efficacy of a condom as a tamponade for intrauterine pressure to stop massive PPH. This prospective study was done in the Obstetrics and Gynecology Department of NIMS Medical College and Hospital, Jaipur, between December 2013 and February 2015. With aseptic precautions, a sterile rubber catheter fitted with a condom was introduced into the uterus. The condom was inflated with 250-500ml normal saline according to need. Vaginal bleeding was observed, and further inflation was stopped when bleeding ceased. In all but 2 (94.44%) the cases, postpartum bleeding was stopped within 10min of creation of tamponade. On an average, 350ml of normal saline was required to create adequate tamponade to stop the bleeding. Use of condom tamponade can effectively help in reducing both maternal morbidity and mortality associated with PPH. Our study encourages use of condom tamponade which is efficient, cost-effective, easily available and requires lesser skills as compared to the traditional surgical procedures.

Evaluation of Role of Functional Endoscopic Sinus Surgery in Patients of Sinonasal Diseases & Nasal Polyposis

Bilateral internal iliac artery ligation is an invaluable tool in the management of massive obstetric hemorrhage. However complications could occur and if not properly managed it could result in morbidity or even mortality. We report a case of accidental injury to the internal iliac vein during internal iliac artery ligation for severe post partum hemorrhage with broad ligament and retroperitoneal hematoma due to rupture of uterus, which was successfully managed and the patient did well postoperatively.

Condom Tamponade in the Management of Massive Obstetric Hemorrhage: An Experience at a Teaching Hospital

Aims:This study evaluates the effectiveness of condom tamponade in the management of massive obstetric hemorrhage. Methods: This hospital based prospective descriptive study was done in the department of obstetrics and gynecology of KIST Medical College Teaching Hospital, Lalitpur, Nepal from January 2013 to December 2013. During the study period, patients with obstetric hemorrhage(>500ml blood loss) were identified and the details of the patient and their treatment were acquired. Data analysis was done by descriptive statistics using mean, median and frequency cross tabulations. The decision for condom tamponade was made when active continuous hemorrhage persisted despite of initial conservative measures. Results: Among 39 patients of obstetric hemorrhage out of 1522 deliveries, eight were managed by condom tamponade which includes 6 postpartum hemorrhage cases, 1 incomplete abortion case and 1 antepartum case managed prophylactically in anticipation of postpartum hemorrhage. Conclusions: Despite of the small study sample, the study concludes the use of condom tamponade as an effective means of controlling massive obstetrical hemorrhage due to uterine atony (both in post partum and post abortion cases). It is safe, easily available, inexpensive, minimally invasive, does not require anesthesia, easy to use and can be performed by any level of health personnel with some training. DOI: http://dx.doi.org/10.3126/njog.v9i1.11187 NJOG 2014 Jan-Jun; 2(1):41-47

Uterine sepsis with uterine artery embolisation in the management of obstetric bleeding

This paper reports three complicated clinical cases of uterine artery embolisation (UAE) in the management of massive obstetric haemorrhage (MPPH), and the consequences of impaired uterine perfusion.

Management of Massive Obstetric Haemorrhage

Obstetric haemorrhage refers to any bleeding that occurs during pregnancy, delivery or in the postpartum period. It is associated with maternal morbidity and remains the leading cause of direct maternal deaths in developing countries. Antepartum haemorrhage (APH) refers to any genital tract bleeding prior to the delivery of the baby. Identifiable causes of APH include placenta praevia, placental abruption, vasa praevia and local organic pathology such as genital tract tumours. The exact cause of APH remains uncertain in approximately 50% of patients. Postpartum haemorrhage (PPH) refers to excessive bleeding from the genital tract after the delivery of the baby and is termed primary when it occurs within the first 24 hours of birth. Common causes include atonic uterus, genital tract trauma, retained placental tissue and coagulopathy. Secondary PPH occurs after the first 24 hours and is due to retained products of conception and/or infection (endometritis). The management algorithm ‘HAEMOSTASIS’ has been proposed to aid the systematic management of postpartum haemorrhage. A multidisciplinary approach is essential to improve outcomes. Early diagnosis, timely institution of appropriate measures to arrest haemorrhage, replacement of blood volume (intravenous fluids), ensuring oxygen carrying capacity of blood (by blood transfusion) and correction of coagulopathy may help save lives. Keywords: Massive obstetric haemorrhage, abruption, placenta praevia, coagulopathy, compression sutures, hysterectomy, postpartum period, Postpartum haemorrhage, PPH, haemostasis

O735 Shortcomings in the management of massive obstetric haemorrhage

O735 Shortcomings in the management of massive obstetric haemorrhage

Use of recombinant factor VIIa in massive post-partum haemorrhage

Massive post-partum haemorrhage continues to be one of the world's leading causes of maternal morbidity and mortality. Any new treatment that potentially helps at risk parturients should be thoroughly investigated. Recombinant factor VIIa (rVIIa) is increasingly being used in the treatment of massive haemorrhage. We performed a case-matched analysis of its use since 2003 in the treatment of massive post-partum haemorrhage at our hospital. Twenty-eight cases of massive post-partum haemorrhage were identified over a 3-yr period since 2003. In six of these cases, rVIIa was used as part of their management. Six case-matched controls were sought. The six women with the greatest requirement for packed red cell transfusion who also had a deranged prothrombin time were included. The groups were then compared for differences. The worst prothrombin time in each group was noted as was the best prothrombin time within 6 h, this was used as our measure of response to treatment. There was no statistical difference in age, gestation, parity, transfusion requirements, mode of delivery or the severity of the coagulopathy between the two groups. In both groups the prothrombin time improved with management. There was no significant difference in either the magnitude of the improvement in the value of the prothrombin time or the absolute value of the best prothrombin time (P = 0.09). Five out of the six women in the rFVIIa group had normal or low prothrombin times within 6 h yet only one woman who did not receive rFVIIa had a normal prothrombin time within 6 h though this was not significant (P = 0.08). This case-matched analysis supports the management of massive post-partum haemorrhage with appropriate resuscitation, surgical intervention and use of blood and blood products. This study does not support the routine use of rFVIIa in the management of massive obstetric haemorrhage. rFVIIa may have a role to play in this management but further studies and analyses will be required.

Anaesthetic Implications of Uterine Artery Embolisation in Management of Massive Obstetric Haemorrhage

Anaesthetic Implications of Uterine Artery Embolisation in Management of Massive Obstetric Haemorrhage

Obstetric critical care: A blueprint for improved outcomes

Obstetric patients are generally young and healthy. However, the potential for catastrophic complications is real, and despite the therapeutic advances of the last few decades, maternal morbidity and mortality continue to occur. This may be related to the pregnancy itself, aggravation of a preexisting illness, or complications of the (operative) delivery. The purpose of this review is two-fold: first, to provide an update on currently available reports pertaining to important critical care issues of the obstetric patient population and, second, to present current comprehensive treatment options for preeclampsia and massive obstetric hemorrhage because both are responsible for the majority of maternal mortality and morbidity worldwide. The most common reasons for intensive care unit admission are hypertensive disorders and massive obstetric hemorrhage. Timely delivery and prompt initiation of antihypertensive therapy for severe hypertension form the mainstay of care in preeclampsia. Restoration of circulating blood volume and rapid control of bleeding and impaired coagulation are the main factors in the management of massive obstetric hemorrhage. Puerperal morbidity has become the main topic of quality of care issues in maternity care. Although the Acute Physiology and Chronic Health Evaluation II score is commonly used in the intensive care unit, it does not seem to be appropriate for pregnant women because it overestimates their mortality rates. A high-dependency care unit suits the needs for at least half of the obstetric patient population in need of higher acuity care and will save considerable cost. Emphasis on early detection of maternal problems and prompt referral to tertiary centers with intensive care unit facilities to provide optimum care of the circulation, blood pressure, and respiration at an early stage could minimize the prevalence of multiple organ failure and mortality in critically ill obstetric patients.

Anaesthetic implications of uterine artery embolisation in management of massive obstetric haemorrhage

The latest triennial report on maternal deaths has recommended the consideration of uterine artery embolisation in management of cases of massive obstetric haemorrhage. We have been using interventional radiology to manage both expected and unanticipated postpartum bleeding in our centre. Three case reports are presented to highlight the value of this technique and issues relating to the anaesthetic and postoperative management of these patients are discussed.

Massive or recurrent antepartum haemorrhage

Haemorrhage complicates approximately 3% of pregnancies. Of these, about one-third are caused by placenta praevia, one-third by placental abruption and the remainder by other causes. Both placenta praevia and abruption can cause sudden unexpected and significant haemorrhage. They are potentially dangerous to both mother and fetus. Both require resuscitation of the mother and possibly delivery of the fetus. Complications such as disseminated intravascular coagulation and postpartum haemorrhage may occur. Numerous reports have emphasised the need for all obstetric units to have in place plans for the management of massive obstetric haemorrhage and for all units to practise these protocols regularly.

Massive obstetric haemorrhage

Summary Controversial areas surrounding the management of massive obstetric haemorrhage are discussed including the use of general versus regional anaesthesia, cell salvage techniques, antifibrinolytic agents, recombinant factor VIIa and radiological interventions.

Disseminated intravascular coagulation

Healthy pregnancy is accompanied by changes in the haemostatic system which convert it into a hypercoagulable state vulnerable to a spectrum of disorders ranging from venous thromboembolism to disseminated intravascular coagulation (DIC). This latter is always a secondary phenomenon triggered by specific disorders such as abruptio placentae and amniotic fluid embolism due to release of thromboplastin intravascularly or endothelial damage resulting from pre-eclampsia and sepsis. In modern obstetric practice the most common cause is haemorrhagic shock with delay in resuscitation leading to endothelial damage. The initial management of massive obstetric haemorrhage is the same whether associated with coagulopathy initially or not. Low-grade DIC, associated with pre-eclampsia, is monitored haematologically by serial platelet counts and serum fibrin degradation products (FDPs). Supportive measures and removal of the triggering mechanism are the key to successful management. Outcome depends primarily on our ability to deal with the trigger and not on direct attempts to correct the coagulation deficit.

Successful Management of Massive Obstetric Haemorrhage due to Placenta Previa/Accreta - A Case Report

DOI: 10.3329/jbsp.v29i1.7172J Bangladesh Coll Phys Surg 2011; 29:46-48