This document discusses anesthesia considerations for obstetric hemorrhage. It provides statistics on causes of maternal mortality, including that obstetric hemorrhage accounts for 67.4% of maternal deaths in Vietnam. Common causes of obstetric hemorrhage are uterine atony, retained placenta, abnormal placentation. Risk factors include previous cesarean sections, placenta previa, and placenta accreta. Treatment involves medical uterotonics, blood transfusion, and in severe cases, hysterectomy. Anesthesia management includes anticipating blood loss and having blood products available.

1. Anesthesia in obstetric
haemorrhage
Nguyen Duc Lam PhD, MD, Hanoi Medical University
Department of anesthesia, HN Obstetric and Gynecology
Hospital

2. Percentage of postpartum bleeding
Autors year location
Total
delivery
n percentage
TrÇn Ch©n Hμ 1996-2000
National
hospital of
OG
38801 247 0,63%
NguyÔn Đøc Vy 1996-2001
National
hospital of
OG
48528 264 0,54%
Ph¹m ThÞ Xu©n
Minh
1999-2004
National
hospital of
OG
51807 332 0,64%
B¹ch ThÞ Cóc 2008-2009
National
hospital of
OG
38084 262 0,69%
NguyÔn ThÞ Ngäc
Phượng
1991-1994
Tu Du
hospital
44675 164 0.38%
F. Reyal 1992-1998 France 19182 44 0,23%
J. Lankoande 1993-1997 Burkina Faso 12175 200 1,6%
Bạch Thị Cúc, thesis, HMU, 2012

3. Obstetric haemorrhage, the first cause
of death and maternal complications
In Vietnam: 67.4% of all maternal deaths
In French:
= 30% of deaths from direct obstetric causes = 10 deaths / year
Maternal complication rate = 6.7 / 1000 births (6.0 to 7.5): shock
bleeding, severe anemia, complications of large volume blood
transfusions, kidney, pituitary necrosis.
Around the world:
140,000 deaths / year every 4 minutes with a maternal mortality.
Half of these deaths occur 24 hours after birth

4. Obstetric haemorrhage
The leading cause of direct maternal death (%)
20
15
10
5
0
UK France
1988-1990 1991-1993 1997-1999
Statistics on maternal mortality in the UK
Statistics from the National Advisory Council on Maternal mortality France

5. Maternal deaths could be avoided
Causes of maternal deaths N
Tử vong mẹ có thể tránh khỏi
Yes May be % evitable No Conclusion inevitable
Due to direct obstetric
causes
92 30 12 51,6 26 19
hemorragie 30 15 4 73,3 3 5
Amniotic fluid embolism 10 0 0 0,0 9 1
Hypertention 16 4 3 43,7 4 5
MTE ? 14 2 3 35,7 7 2
Infection 7 3 2 71,4 2 0
Obstetric complications 5 3 1 80,0 0 1
Anesthesia complications 1 0 1 100,0 0 0
Another causes 9 2 1 37,5 1 5
Due to indirect obstetric
49 6 8 28,6 28 7
causes
Total causes 141 35 25 43,6 54 26
Statistics from the National Advisory Council on Maternal mortality France

6. Definition
• Physiological blood loss
- Vaginal delivery <500 ml
- C-section: 500 - 1000 ml
• Haemorrhage
- When normal delivery: 500 - 1000 ml
- In cesarean section:> 1000 mL
- Severe haemorrhage > 1500 mL

7. Causes
• Hematome retro-placenta
• Placenta previa
• Uterine rupture
• Postpartum coagulopathy
• Postpartum bleeding (45%)

8. Cause of obstetric haemorrhage
according Lariboisier
Uterine
atony
Genital
trauma
Retained
placenta
Anormal
placenta Trombus Placental
abruption
Another
causes

9. The cause bleeding after birth in National hospital of OG
Total Percentage %
Group Causes
Atonie
Uterine atony 59 22,5
Retained placenta 18 6,9
Vaginal trauma
Genital trauma 33 12,6
perineal hematoma 4 1,5
Placenta
Placenta previa 51 19,5
Placenta abruption 12 4,6
Placenta accreta 15 5,7
Placenta increta 4 1,5
Complication of
cesarean
section
Vaginal trauma 10 3,8
Hematome abdominal 5 1,9
infection 11 4,2
Postpartum bleeding at the National Hospital of OG at 2008-2009 (Thesis, Bach Thi Cuc, HMU)

10. Factors related to postpartum bleeding and vaginal
delivery
Case-control study (USA)
9598 vaginal delivery
374 postpartum bleeding
(= 3.9%)
Risk Factors
Factors OR
Prolonged labor 7,56
preeclampsia 5,02
Episiotomy 4,67
History of obstetric
3,55
haemorrhage
multiple pregnancy 3,31
Labor induction 2,91
Soft tissue injury 2,05
Forceps 1,66
race 1,58-1,73
first pregnancy 1,45
Epidural anesthesia 1,00
Hight risks
Normal risks
Combs CA et al. Obstet Gynecol 1991;77:69-76

11. Factors related to bleeding and cesarean section
Case-control study (USA)
3052 cesarean section
196 bleeding (= 6.4%)
Risk Factors
Factors OR
General anesthesia 2,94
Chorioamnionitis 2,69
Preeclampsia 2,18
Labor dirigee prolongee 2,40
Cervical not progress 1,90
Race 1,58-1,73
Epidural anesthesia 1,00
Hight risks
Normal risks
Combs CA et al. Obstet Gynecol 1991;77:69-76

12. May prevent obstetric haemorrhage?
The risk factors for antenatal period
Age of women
Race
Marital status
Living standards and education levels
No follow-up pregnancy
Multiple pregnancy
Preeclampsia
Uterus had a previous caesarean scar +++
Placenta previa +++
Caesarean section
History of bleeding
Prehistoric yourself or a history of high-risk obstetric
Did not find any risk factor in
50% of cases

13. Abnormal placental
Location
• Placenta implants in low grip
• Placenta previa
The level of adherent placenta
• Placenta accreta
• Placenta increta
• Placenta percreta
15
10
5
0
Deaths
1985-1887 1988-1990 1991-1993
Postpartum hemorrhage
Placenta previa
placenta abruption
Statistics from the National Advisory Council on
Maternal mortality France

14. Uterine incision and anormal placenta
10
8
6
4
2
0
Số lần mổ đẻ trước đó
0 1 2 3 > 3
accreta
100
80
60
40
20
0
Số lần mổ đẻ trước đó
0 1 2 3 > 3
praevia + accreta
Clark SL et al. Obstet Gynecol 1985;66:89-
Time of cesarean
section in hystory
Time of cesarean
section in hystory
Time of cesarean section in
hystory

15. Placenta previa
The proportion of Placenta accreta / placenta previa:
3.7% by Xa Thi Minh Hoa, Hanoi Hospital of OG in 2012
5.4% by Le Thi Huong Tra, National Hospital of OG in 2007-2011

16. Placenta accreta
Abnormally adherent placenta
• Scale: 1/2000 - 1/7000 births
• Classify
- Placenta accreta vera: adherence to the myometrium without
invasion of uterine muscle
- Placenta increta: invasion uterine muscle.
- Placenta percreta: invasion of the uterine serosa or other pelvic
structures
• Risk: a fulminant bleeding in surgery, can be life-threatening

17. Placenta acreta
Research on the periode of 2007-2011, Placenta accreta in the
National Hospital of Obstetric and Gynecology
•100 cases
•60% had a history of cesarean section
•83% had placenta previa
•76% hysterectomy, ligation uterus artery 25%, 3% Blynch suture
•57% had a blood transfusion, in which 35% transmission> 5 units of
packed red blood cells (1 case 9 units of packed red blood cells )
(Le Thi Huong Tra, thesis of master, HMU, 2012)

18. Placenta acreta
Report 8 cases of Placenta percreta bladder in Central hospital of Hue
•7 patients require blood transfusion (87.5%)
•2 patients transfusion 5800 ml and 7500 ml of red blood cells
•100% total hysterectomy
(Bach Cam An)
Reported 1 case of Placenta accreta in patient had 2 times cesarean
section at Tu Du Hospital
•Operation time of 200 minutes, mobilizing 20 people
•6500 ml blood loss
•26 units of packed red blood cells, 12 Plasma, 16 Cryo, 1 packed of
platelete
(Ma Thanh Tung)

19. Placenta acreta
Attention of anesthesia
• Common in women with placenta previa, multiple previous caesarean
• Color Doppler diagnosis: sensitivity 96.8%, specificity 87.5% (Tran
Danh Cuong)
• Scheduled surgery plans
• 2 large intravenous lines, invasive blood pressure
• General anesthesia
• Packed red blood cells (PRBC)availability expected, plasma, Cryo,
platelete
• 2 units of PRBC available in the operating room before incision
• Request obstetrician clamp and cut the uterus immediately after
delivery

20. Placenta abruption

21. Haemorrhage post delivery
Uterine atony 80%
- Multiparity
- Placenta previa
- Urinary retention
- Precipitous labor or prolonged labor
- Chorioamnionitis
- Halogen anesthetics, tocolytic therapy, MgSO4

22. Haemorrhage post delivery
Accumulation in the uterus 10%
• Retained placenta
• Hematoma in the uterus
• Placenta accreta
• Fibroids uterus, uterus anomaly
• Uterine leiomyomas

23. Haemorrhage post delivery
another causes 10%
• Obstetric trauma (cervical, vaginal, perineal tears…)
• Vaginal hematomas
• Uterine inversion
• Coagulopathy (placenta abruption, amniotic fluid
embolism, intrauterine fetal death)

24. Haemorrhage post delivery
• 30-50% of cases do not see a clear risk factors (to
think of amniotic fluid embolism)
• Well tolerated in terms of hemodynamic, can not
change the loss of 1,500 ml of blood
• There coagulopathy in 50% of cases
• Incorrect or lately management caused 70%
mortality

25. Haemorrhage post delivery
Treatment
- Alert obstetrician and midwife
- Examination of uterus
• Removal and inspection of the placenta
• Currettage and surgical repair
• Evaluation of circulating volume
• Antibiotics

26. Measurement of blood loss

27. Medical uterotonic therapy
• Uterine massage
• These drugs increase the contraction of uterus
• * Oxytocin: Do not exceed 30 UI
• * Sulproston (Nalador): 30 minutes
• - Initial doses of 500 mcg for 1 hour, then 500 mcg / 6
hours
• - CI: asthma, coronary, severe hypertension
• - How to use: dilution 50 ml, perfusion 10 ml / hour. Add
10 ml / hr every 10 minutes for up to 50 ml / hour
• Maintenance dose of 10 ml / h for 6 hours

28. 101 women with normal pregnancies
Measuring the pressure in the chamber TC TC contraction taking 3 different medications
0 15 30 45 60 120 min
sulprostone
oxytocin
placebo
Baumgarten K et al. Eur J Obstet Gynecol 1983;16:181-92
%
methylergometrine
Onset of
efficacity sulpr. >
methylerg. ou
oxytocine.
Time methylerg. >
sulpr. >
oxytocine.
The pressure intra - uterus

29. Early drug use Nalador®
100
90
80
70
60
50
40
30
20
10
0
Treatment failure Treatment efficace
> 30 mn
< 30 mn
%
OR=8,3 ; IC à 95% : 2,2-31,7
Goffinet F. J Gynecol Obstet Biol Reprod 1995 ; 24 : 209-16

30. Management of severe postpartum bleeding
by PGF2
Hayashi RH, Obs Gyn 1984
• 18 000 births in 3 years
• 900 cases of postpartum bleeding
• 54 cases uterine atony with oxytocin and treated with
PGF2a
- Success: 86%
- Fever: 6%
- Sides effects on the digestive system: 9%

31. Why mothers die 1997-1999
Spinal anesthesia for caesarean section - direct intravenous oxytocin 5 UI

32. Blood transfusion
• Rarely, <1% of all births
• The risk of immune complications
secondary to blood transfusion:
need to prepare for future pregnancies
Research across France in 2003: 4% of the
scientific production time for a transfusion
of> 30 minutes

33. Control of blood transfusion
• Set the 2 line large diameter peripheral vein
• Try FBC
Bilan fluid and blood
Surveillance hémoglobin
Test hemoglobin, use the HemoCue ou Radical 7 Masimo
Coagulation test
Labo, Vitro test dry, TEG
2 dry test tubes: Tubes 1/3 blood volume in each tube
Tube 1: Tilt the tube every minute / time
When blood clot tube = recorded clotting time of tube 1
How well do the 2nd tube.
Then add the clotting time of 2 tubes back
- Normal <7 minutes
- Sure, coagulopathy when> 20 min

34. Practice of blood transfusion in trauma of war

35. The mortality rate related to the transmission rate
Plasma / globulin

36. Reanimation
• Antithrombin III và Aprotinin
• Fibrinogen
• Role of Transamin
• Activated factor VII
(Novo seven - FVII exogene)

37. Disseminated intravascular coagulation (CIVD): Specific treatment
Antithrombine in CIVD heamorrage
During labor and birth
• Evaluation
• Number of units of plasma transfusion (PFC)
• Percentage of AT> 70%
Result
• clinical condition improved
• XN (TC number and percentage of prothrombin (TP)
increased significantly since firt day
• But the efficiency is very low
• Mortality rates did not differ between the 2 groups
Maki M. Gyn Obst Invest 1987

38. Reduce the number Fibrinogen is a marker for early
severity of postpartum bleeding
Fibrinogen concentration index is the only independent
related to the progression of postpartum bleeding
Prognostic value of these results focus between
The first hour to hour 4

39. Anti-fibrinolytic
•Randomized multicenter
• Measure the volume of blood loss during and after cesarean
• 180 nulliparous women with no risk factors
• Tranexamique acid injection before incision:
•1g then transmit 3 g / 3 hours
• 20% reduction in bleeding in the period from
• when taken during pregnancy through the first 2 hours after
surgery

40. Tissue factor and factor VII
activation
essential for blood clotting
Important step is
Moving from prothrombin
to Thrombin
independently of FVIII
and FIX.
This step is independent
of TF.
The thrombin burst leads
to the formation of
a stable clot

41. Temporary treatment regimen
•After obstetric interventions (constriction of RESERVED, circuit nodes)
•- If the blood continues to flow mauchay
•- Before you decide to cut styptic TC (if possible)
Dose
Second dose
Temperature normal
platelete

42. Techniques in surgical hemostasis
• Manual removal and inspection of the placenta
• Clamp pulling / twisting Cervix
• Examination of uterus, surgical repair
• Other measures

43. Hemostasis by ballon
•
•
•
sonde of Foley
sonde of Rüsch
Sonde of
Blakemore
• sonde of Linton-
Nachlas

44. Hemostatic techniques ....
cluster

45. Hemostatic surgical techniques
Adominal way
• Uterine artery ligation
• Hypogastric artery ligation
• Round ligamen artery ligation
• Measure the final:
Hysterectomy hemostatic

47. Ligation nonselective

48. Selective ligation

49. Ligation external iliac arteries in obstetric haemorrhage
Succès (%) 0
Evans 1985 Clark 1985 Chatto 1990 O'Leary
1995
Lédée 1996
100
75
50
25
Successful
%

50. Arterial embolization

51. Arterial embolization
• The center is equipped with
• Button-screen circuit in the operating room through brightening
due to radiologist do
Can proceed in the following cases:
• After cesarean section, after hemostatic suture lines under
• Can be conducted even when the patient has coagulopathy

52. Results of arterial embolization
(n) Succès
successful(%)
nombre (%)
Greenwood et al 6 83
Gilbert et al 10 100
Mitty et al 7 86
Yamashita et al 15 100
Merland et al 15 93
Pelage et al 37 89
Vandelet et al 15 73

53. Arterial embolization
Research effective treatment of arterial embolization at
National hospital of OG 2009-2011
17 patients were node artery at Bach Mai Hospital and Vietnam Germany
(14: bleeding after cesarean section, postpartum usually 1, 1 to abortion, after
cutting the TC 1)
100% stop bleeding, bleeding in 3 1/3 days off
No one hysterectomy
Not yet infected patients after occlusion of the vessel
1 Patients with lower extremity arthritis rules, medical treatment
100% return of menstruation
(Nguyen Phuong Tu, thesis of graduade Dr , HNU, 2012)

54. Dangerous if transfere
•State of shock not control:
•- BP drops (had a blood transfusion / catecholamine)
•- Need to control resuscitation of shock
•Not only good for the circuit node:
•- Shock bleeding during cesarean section
•- Bleeding after cesarean
•No blood and blood products
•- A rare blood type, antibodies against the human erythrocyte
•- Problem organizations
•- Prognosis: deadline to stop bleeding

55. Pregnant women treated in the ICU,
and maternal mortality
%
20
15
10
5
0
maternal death
total transfere grade III
Bouvier-Colle MH et al, Eur J Obstet Gynecol 1996,65:121-5

56. Classification of obstetric hospital
*Grade 1
•Get the patient has no risk factors
•Full-term newborn care
* Grade 2
•Get the care of patients requiring more complex
•Have neonatal department
* Grade 3
•Get the severely ill patients requiring intensive care
•Have neonatal ICU unit

59. Anesthesia
• Epidural anesthesia if available is sufficient for the
hemostatic surgical echniques
• Anesthetic when bleeding more
and surgery to stop bleeding
• Priority selection ketamine (1 mg / kg) or
Etomidat (0.3mg/kg)

60. Conclusion
• 87% of deaths due to bleeding that could have been avoided
• Pay attention to time detection, treatment usually late
• The discreet clinical sign
• Blood transfusion in proportion 1/1 - Fibrinogen - Transamin
• Keep progressing syndrome CIVD
• Position the insertion of the ballon, arterial embolization and
circuit activates factor VII?

61. TThhaannkk ffoorr yyoouurr aatttteennttiioonn!!