Anesthesia in obstetric haemorrhage

Nguyen Duc Lam PhD, MD, Hanoi Medical UniversityDepartment of anesthesia, HN Obstetric and Gynecology

Hospital

Percentage of postpartum bleedingAutors year location

Total

deliveryn percentage

TrÇn Ch©n Hµ 1996-2000National

hospital of OG

38801 247 0,63%

NguyÔn Đøc Vy 1996-2001National

hospital of OG

48528 264 0,54%

Ph¹m ThÞ Xu©n

Minh1999-2004

National hospital of

OG51807 332 0,64%

B¹ch ThÞ Cóc 2008-2009National

hospital of OG

38084 262 0,69%

NguyÔn ThÞ Ngäc

Phượng1991-1994

Tu Du

hospital44675 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

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

Obstetric haemorrhage

0

5

10

15

20

1988-1990 1991-1993 1997-1999

UK France

The leading cause of direct maternal death (%)

Statistics on maternal mortality in the UK Statistics from the National Advisory Council on Maternal mortality France

Maternal deaths could be avoided

Statistics from the National Advisory Council on Maternal mortality France

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 causes

49 6 8 28,6 28 7

Total causes 141 35 25 43,6 54 26

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

Causes

• Hematome retro-placenta

• Placenta previa

• Uterine rupture

• Postpartum coagulopathy

• Postpartum bleeding (45%)

Cause of obstetric haemorrhage according Lariboisier

Uterine atony

Genital trauma

Retained placenta

Anormalplacenta

TrombusPlacental abruption

Anothercauses

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 traumaGenital 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 cesareansection

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)

Factors related to postpartum bleeding and vaginal delivery

Case-control study (USA) 9598 vaginal delivery374 postpartum bleeding

(= 3.9%)

Risk Factors

Factors OR

Prolonged labor 7,56

preeclampsia 5,02

Episiotomy 4,67

History of obstetric haemorrhage

3,55

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 1,00Combs CA et al. Obstet Gynecol 1991;77:69-76

Hight risks

Normal risks

Factors related to bleeding and cesarean section

Case-control study (USA) 3052 cesarean section196 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

Combs CA et al. Obstet Gynecol 1991;77:69-76

Hight risks Normal risks

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 sectionHistory of bleeding Prehistoric yourself or a history of high-risk obstetric

Did not find any risk factor in 50% of cases

Abnormal placental

Location

• Placenta implants in low grip

• Placenta previa

The level of adherent placenta • Placenta accreta

• Placenta increta

• Placenta percreta

0

5

10

15

1985-1887 1988-1990 1991-1993

Postpartum hemorrhage

Placenta previa

placenta abruption

Deaths

Statistics from the National Advisory Council on Maternal mortality France

Uterine incision and anormal placenta

Clark SL et al. Obstet Gynecol 1985;66:89-

0

2

4

6

8

10

0 1 2 3 > 3

Số lần mổ đẻ trước đó

accreta

0

20

40

60

80

100

0 1 2 3 > 3

Số lần mổ đẻ trước đó

praevia + accreta

Time of cesarean section in hystory

Time of cesarean section in hystory

Time of cesarean section in hystory

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

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

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)

Placenta acretaReport 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)

Placenta acretaAttention 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

Placenta abruption

Haemorrhage post deliveryUterine atony 80%

- Multiparity

- Placenta previa

- Urinary retention

- Precipitous labor or prolonged labor

- Chorioamnionitis

- Halogen anesthetics, tocolytic therapy, MgSO4

Haemorrhage post deliveryAccumulation in the uterus 10%

• Retained placenta

• Hematoma in the uterus

• Placenta accreta

• Fibroids uterus, uterus anomaly

• Uterine leiomyomas

Haemorrhage post deliveryanother causes 10%

• Obstetric trauma (cervical, vaginal, perineal tears…)

• Vaginal hematomas

• Uterine inversion

• Coagulopathy (placenta abruption, amniotic fluid embolism, intrauterine fetal death)

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

Haemorrhage post deliveryTreatment

- Alert obstetrician and midwife

- Examination of uterus

• Removal and inspection of the placenta

• Currettage and surgical repair

• Evaluation of circulating volume

• Antibiotics

Measurement of blood loss

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

Baumgarten K et al. Eur J Obstet Gynecol 1983;16:181-92

0 15 30 45 60 120 min

%methylergometrinesulprostone

oxytocinplacebo

101 women with normal pregnancies Measuring the pressure in the chamber TC TC contraction taking 3 different medications

Onset of efficacity sulpr. >

methylerg. ou oxytocine.

Time methylerg. > sulpr. >

oxytocine.

The pressure intra - uterus

Early drug use Nalador®

50

40

30

20

10

0

100

90

80

70

60

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

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%

Why mothers die 1997-1999

Spinal anesthesia for caesarean section - direct intravenous oxytocin 5 UI

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

Control of blood transfusion

• Set the 2 line large diameter peripheral vein • Try FBCBilan fluid and blood

Surveillance hémoglobinTest hemoglobin, use the HemoCue ou Radical 7 Masimo

Coagulation testLabo, 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

Practice of blood transfusion in trauma of war

The mortality rate related to the transmission rate Plasma / globulin

Reanimation

• Antithrombin III và Aprotinin

• Fibrinogen

• Role of Transamin• Activated factor VII (Novo seven - FVII exogene)

• 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

Disseminated intravascular coagulation (CIVD): Specific treatment

Antithrombine in CIVD heamorrage During labor and birth

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

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

Tissue factor and factor VII activation essential for blood clotting

Important step is Moving from prothrombin to Thrombin

independently of FVIIIand FIX.

This step is independentof TF.

The thrombin burst leadsto the formation ofa stable clot

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

Techniques in surgical hemostasis

• Manual removal and inspection of the placenta

• Clamp pulling / twisting Cervix

• Examination of uterus, surgical repair

• Other measures

Hemostasis by ballon

•

•

•

sonde of Foley

sonde of Rüsch

Sonde ofBlakemore

• sonde of Linton-Nachlas

cluster

Hemostatic techniques ....

Hemostatic surgical techniques

Adominal way

• Uterine artery ligation• Hypogastric artery ligation

• Round ligamen artery ligation

• Measure the final:Hysterectomy hemostatic

Ligation nonselective

Selective ligation

Suc

cès

(%)

0Evans 1985 Clark 1985 Chatto 1990 O'Leary

1995Lédée 1996

Ligation external iliac arteries in obstetric haemorrhage

100

75

50

25

Successful%

Arterial embolization

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

(n) Succèsnombre (%)

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

Results of arterial embolization

successful(%)

Arterial embolizationResearch 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)

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

Pregnant women treated in the ICU, and maternal mortality

0

5

10

15

20

total transfere grade III

maternal death

Bouvier-Colle MH et al, Eur J Obstet Gynecol 1996,65:121-5

%

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

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)

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?

Thank for your attention!Thank for your attention!