This document discusses the anaesthetic management of obstetric haemorrhage. It begins by stating that haemorrhage is a major cause of maternal death worldwide and in India. It then defines massive obstetric haemorrhage and classifies the causes. It emphasizes the importance of quickly evaluating, resuscitating and preparing patients for surgery. It provides guidelines on fluid resuscitation and blood transfusion. It notes the challenges in estimating blood loss and discusses end-points for resuscitation. It provides recommendations on anaesthetic techniques for caesarean sections depending on the urgency and degree of hypovolemia. Finally, it discusses postoperative management and recent advances like cell salvage, thromboelastography

1. ANAESTHETIC MANAGEMENT OF
OBSTETRIC HAEMORRHAGE
DR. DILIP KUMAR BHOWMICK
Associate Professor
Dept. of anaesthesia, Analgesia & Intensive Care Medicine
Bangabandhu Sheikh Mujib Medical University

2. EPIDEMIOLOGY
• Worldwide, haemorrhage remains a major cause of
maternal death.
• Major obstetric haemorrhage complicates up to 10.5% of
all births
• In India obstetric haemorrhage contributes to 22.34% of
all maternal deaths
• One-third of OH, are due to placenta previa
Ref: F Platit et. Al. Continuing education in Anaesthesia,
Critical Care & Pain-2014

3. MASSIVE OBSTETRIC HAEMORRHAGE
1. MOH is a major cause of maternal death and morbidity
2. Variably defined as;
. blood loss >1500ml
. decrease in hb >4g/dl or
.acute transfusion requirements
>4 units
3. The gravid uterus receives up to 12% of cardiac output ,thus
OH can be un expected and rapidly become life threatening.

4. CLASSIFICATION
• Antepartum placenta previa/accreta
placental abruption
uterine rupture
• Post partum uterine inversion
uterine atony
birth trauma or laceration
Bleeding disorder

5. PATIENT WITH BLEEDING
• Patient evaluation, resuscitation, and preparation for
operative delivery all proceed simultaneously
• Careful assessment of the parturient's airway and
intravascular volume
• Equipment for invasive monitoring

6. RESUSCITATION
• ABC, 100% oxygen
• 2 large bore canula and bloods for cross-match
• Fluid resuscitation; crystalloid 2000mls via rapid infuser or
pressure bags
• Transfuse blood ideally through fluid warming device. Give
group specific blood if cross-matched blood not yet
available. O-negative blood if available and life threatening
bleed
• Transfer to theatre

7. • Four issues should be considered when treating
hemorrhagic shock:
• type of fluid to give, how much, how fast, and what the
therapeutic end-points are.
• The three-to-one rule has been applied to the
classification of hemorrhage to establish a baseline for
guiding therapy, and use of crystalloid (Ringers lactate or
normal saline) is recommended by the American College of
Surgeons.

8. BLOOD LOSS
• Blood loss can be notoriously difficult to assess in obstetric
bleeds. Bleeding may sometimes be concealed and the
presence of amniotic fluid makes accurate estimation
challenging.
• Massive obstetric haemorrhage is variably defined as
blood loss from the uterus or genital tract >1500ml, a
decrease in haemaglobin of > 4 g/dl or acute transfusion of
> 4 units blood.

9. METHODS OF ESTIMATING BLOOD LOSS

11. END-POINTS IN RESUSCITATION
• Defining the end-points of resuscitation is a difficult area .
• Up to 85% of patients are under-resuscitated when using
blood pressure and urine output as the sole guides to fluid
replacement .
• The problem may be 'compensated shock', in which
cellular perfusion lags behind gross physiologic
parameters.
• Other end-points, such as oxygen transport variables, DO2,
cardiac index, VO2, lactate, base deficit, and mucosal
gastric pH, are all more sensitive endpoints of cellular
resuscitation. Recent data on tissue oxygen parameters
also suggest that these measures are promising markers of
adequate restoration of perfusion.

12. FOR CAESAREAN SECTION
• Choice of anaesthetic technique depends on the indication
and urgency for caesarean section and the degree of
maternal hypovolemia
• High risk of intra operative blood loss due to
Lower uterine segment implantation site
does not contract well
Increased risk for placenta accreta
 Obstetrician may cut into the placenta
during uterine incision

13. • A retrospective study with 350 cases of placenta previa [
60 % regional , 40 % GA ] found
Decreased EBL with RA vs. GA
Decreased transfusions needs with RA
No difference in hypotension
N Parekh et al Br J Anaesth 2000;84;725

14. FOR GENERAL ANAESTHESIA
• Rapid-sequence induction of general anesthesia is the
preferred technique
• Avoid thiopental sodium
• Propofol should not be used in hypovolemic patients
• Ketamine (0.5 to 1.0 mg/kg) is the best induction agents
for bleeding patients
• Patients with severe hypovolemic shock, intubation may
require only a muscle relaxant

15. MAINTENANCE
• Nitrous oxide and oxygen with a low concentration of
a volatile halogenated agent
• Concentration of nitrous oxide can be reduced (or
omitted) in cases of foetal distress
• Oxytocin immediately after delivery
• Best to eliminate the volatile halogenated agent after
delivery of foetus

16. POSTOPERATIVE MANAGEMENT
• Transfer to a high dependency unit or intensive care facility
• Anticipate coagulopathy and treat clinically until
coagulation results available

17. ELECTIVE CASES OF PLACENTA PREVIA

18. ANAESTHETIC MANAGEMENT
• Preoperative diagnosis of placental abnormalities
• Identifying patients with high risk for placenta accreta
• Availability of blood and blood products
• Equipment for rapid infusion of fluids
• Establish invasive monitoring
• Preparation for hysterectomy
• Senior obstetrician, anaesthesiologist , neonatologist and others

19. REGIONAL ANAESTHESIA FOR C/S
• Depending on pre op sonographic diagnosis,most of the cases-SA
• Except placenta accreta , increta and percreta--GA

20. ANAESTHETIC MANAGEMENT OF CAESAREAN
HYSTERECTOMY
• Obstetrician requires good skeletal muscle relaxation and a quiet
operative field
• Most of the cases require GA for emergency obstetric hysterectomy
• In case of SAB already given may need to convert

21. POST OPERATIVE
• If blood loss has stopped:
• Fluid replacement with crystalloid and blood
products until clinical signs of normovolaemia.
• Monitor heamoglobin
• Consider transfer to a critical care area for monitoring.

22. RECENT ADVANCES
• Intra operative cell salvage
Chance of amniotic fluid embolism
Haemolytic disease in future pregnancies
Leukocyte depletion filter is useful
Separate suction for amniotic fluid advised
• Thromboelastography
Useful guide in massive haemorrhage
Provides information regarding coagulation factors
Platelet function, fibrinogen levels , fibrinolysis
Can be done near the patient but not available in
our setup

23. • Role of tranexaemic acid
Antifibrinolytic
1gm IV stat dose
Followed by a second dose after 30 min if bleeding doesn’t
stop

24. CONCLUSION
• Anticipation of diagnosis
• Experienced Obstetrician, Anaesthesiologist &
Haematologist
• Invasive monitoring
• Available blood & blood products
• Trained theatre personnel

25. THANK YOU