Obstetric hemorrhage

Causes of obstetric hemorrhage

Ante partum

• Ectopic pregnancy
• Abortion
• H mole
• Placenta praevia
• Placental abruption

Intra partum and post partum

• Placenta praevia
• Previous caesarian section with placenta praevia
• Placental abruption
• Placenta accrete
• Uterine rupture
• Uterine atony
• Over distended uterus
• Retained products of conception
• Genital tract injury
• Broad ligament tear

Associated with coagulation failure

• Placental abruption
• Coagulopathy associated with pre eclampsia and HELLP syndrome
• Septicemia / intrauterine sepsis
• Retained dead fetus
• Amniotic fluid embolism
• Incompatible blood transfusion
• Existing coagulation abnormalities

Cardiovascular parameters in hemorrhage

In a 70kg healthy adult patient with an estimated blood volume of 5L

Blood loss	Heart rate	Blood pressure	Capillary refilling time	Respiratory rate	Urine volume	Mental state
Up to 750 ml (class 1)	< 100	Normal	Normal	Normal	> 30 ml/hr	Normal
750 – 1500 ml (class 2)	> 100	Systolic normal	Increased	20 – 30	20 – 30	Mild concern
1500 – 2000 ml (class 3)	> 120	Decreased	Increased++	30 – 40	5 – 15	Anxious / confused
> 2000 ml (class 4)	> 140	Decreased	Increased+++	> 40	< 10	Confused / coma

 

Transfusion of blood and blood products 

• While blood is gushing out it is a waste to give coagulation factors and platelets.
• Once bleeding is controlled by surgical intervention more blood as required and blood products can be given.
• Once surgical haemostasis has been more or less achieved continued oozing may be due to clotting factor deficiencies.

Indications for transfusion of FFP

* If blood loss exceeds half the patients blood volume. Give two units of FFP or FFP 10-15 ml /kg

* If coagulation or oozing from puncture sites, infuse FFP 10-15 ml /kg

*If  PT>1.5 times normal, INR > 2 or APTT > 2

Indications for platelet transfusion

Give platelets according to hematologist report or after platelet count testing.

Platelet transfusion

* If platelet count is less than 50000 or decreasing trend, platelets 1 unit /10kg should be given. 

* If platelet count is between 50000 and 100000 but there is a potential for platelet dysfunction. (E.g. Pre eclampsia)

* Continuous bleeding and oozing in spite of blood, FFP and cryoprecipitate.

Indication for transfusion of cryoprecipitate

* When the fibrinogen concentration is < 80mg/dl

* In the presence of excessive micro vascular bleeding with a fibrinogen concentration of 100-150 mg/dl

* Continuous bleeding and oozing in spite of blood and FFP

* Patients with known Von Willebrand’s disease and hemophilia A if factor viii is not available.

 

If refractory hemorrhage not responding to FFP, platelets and cryoprecipitate, recombinant activated factor VII, IV bolus 90micrograms/kg

Two doses

Antifibrinolytics - aprotinin, thromboxane

Repeat investigations at least every 4 hours until patient is stabilized