CBP: Obstetrics. April 30 2009. CASE # 1.
April 30 2009
Normal pregnancy is characterized by an increase in cardiac output, a reduction in systemic vascular resistance, and a modest decline in mean blood pressure. These changes are associated with a 10 to 15 beat/min increase in heart rate.
…Walking confidently into the ER with your rediscovered knowledge of obstetric physiology, you do your best to look bored and ask the ER doc where your pregnant patient is.
The doc thanks you for coming so quickly, and promptly tells you that the patient was just brought in by ambulance with acute onset shortness of breath.
She is on 100% oxygen via non-rebreather, with an O2 sat of 89%, and a soft blood pressure that’s responded to boluses so far. You manage to whimper “Is that all?” and promptly turn to your R2 to pimp him some more:
Crit Care Med 2005; 33[Suppl.]:S248 –S255
(<18 or > 35)
What are the major causes of post-partum hemorrhage, and how should it be worked up? (Yoan)
(blood volume [mL] = weight [kg] x 80) or loss of 1000 mL or a change in vital signs.)
If exploration shows no trauma and no retained tissue + well contracted uterus
Oxytocin (10 to 40 U in 1 liter of normal saline via intravenous infusion; 80 U in 1 liter of normal saline may be given for a short time)
Methergine (0.2 mg intramuscularly every two to four hours) if not hypertensive
Carboprost tromethamine (Hemabate) (250 mcg intramuscularly every 15 to 90 minutes, as needed, to a total dose of 2 mg) if no asthma
Misoprostol (800 to 1000 mcg rectally) can be given to women with hypertension or asthma
Inspect the vagina and cervix for lacerations; repair as necessary
Transarterial embolization - If the woman is stable and there is time for personnel and facilities to mobilize
Uterine tamponade (Bakri or Sengstaken-Blakemore tube, Foley, packing) is performed if medical therapy fails and prior to or in conjunction with preparations for surgery
Laparotomy - If the above measures fail, surgical approaches that are quick, relatively easy, and effective should be tried first. In utilizing these measures, the surgeon should be cognizant of the amount of blood loss and the stability of the patient, and should perform hysterectomy rather than resort to temporizing measures if her cardiovascular status is unstable or if it appears that the anesthesiologist will not be able to keep up with her fluid needs.
Ligation of bleeding sites
Uterine artery ligation, including utero-ovarian arcade
Hysterectomy - Hysterectomy is the last resort, but should not be delayed in women who have disseminated intravascular coagulation and require prompt control of uterine hemorrhage to prevent death
Suturing and tacking of deep pelvic bleeders
Recombinant activated factor VIIa
Sequential steps in managing postpartum hemorrhage
→ 87% chance no need for further Tx