Obstetric anaesthesia09 / 17
Placental abruption for crash caesarean34-year-old woman, 82 kg, at 35 weeks with chronic hypertension
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Know this first
- Abruption can hide large blood loss behind the placenta.
- Abruption raises the odds of coagulopathy 54 times.
- Neuraxial only if she is stable and clotting is normal.
- Ketamine 1–1.5 mg/kg suits a mother compromised by bleeding.
- Obstetric fibrinogen target: 150–200 mg/dL.
The patient
34-year-old woman, 82 kg, at 35 weeks with chronic hypertension; sudden abdominal pain and dark vaginal bleeding; uterus tense and tender.
Fetal heart 70/min for 6 minutes; visible loss 400 mL.
Drugs: oral labetalol.
Immediate caesarean under general anaesthesia.
Vitals: BP 104/66 (usually 150/95), HR 118, SpO2 98% on air, RR 22.
The examiner asks
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Consider
What are your concerns?
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- A 34-year-old with chronic hypertension at 35 weeks, abruption and fetal bradycardia, for immediate caesarean. Patient
- At 35 weeks general anaesthesia means aspiration risk, a difficult airway and caval compression.
- Concealed bleeding: her visible 400 mL understates what's trapped behind the placenta. Disease
- Her usual BP is 150/95, so 104/66 with HR 118 is real hypovolaemia.
- Abruption makes coagulopathy 54 times more likely.
Prepare
How do you prepare in the next few minutes?
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- Intrauterine resuscitation: left tilt, oxytocin off, fluids and blood, her pressure back towards baseline. Disease
- Clotting, fibrinogen and a viscoelastic test now; crossmatched blood to theatre.
- Neuraxial needs stability and normal clotting; she has neither confirmed, so general.
- Two large-bore cannulas; warmed red cells ready before induction. Patient
Plan
Take me through the induction.
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- Sodium citrate, then rapid sequence with videolaryngoscope and a size 7.0 tube. Airway
- Ketamine 1 mg/kg rather than a full propofol dose; it supports a bleeding mother's pressure.
- Rocuronium 1.0 mg/kg, or suxamethonium 1–1.5 mg/kg.
- Phenylephrine drawn up and connected before induction. Disease
- Neonatal team in theatre; oxytocin 1–3 IU slowly after delivery, then an infusion. After surgery
Crisis
Thirty seconds after induction, BP is 64/38 and HR 136. What do you do?
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- Induction has unmasked hypovolaemia from concealed bleeding. (Crisis)
- Call for help; tilt kept, volatile kept minimal.
- Phenylephrine 50–100 mcg boluses while red cells go in through the rapid infuser.
- Major haemorrhage protocol activated; blood, not crystalloid.
- Tell the obstetrician to deliver now; delivery treats both of them.
Crisis
After delivery the uterus is atonic and the wound oozes; fibrinogen 0.9 g/L, platelets 58 ×10⁹/L, PT 19 s. BP 82/44, HR 128. What do you do?
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- DIC from abruption plus atony: major haemorrhage protocol running. Crisis
- Fibrinogen first to 150–200 mg/dL; plasma and platelets with the red cells.
- Tranexamic acid 1 g given over 10 minutes.
- Oxytocin infusion and carboprost 0.25 mg IM; methylergonovine avoided with her hypertension.
- Calcium and temperature maintained; repeat viscoelastic tests.
- ICU or HDU afterwards, watching urine output and creatinine. After surgery
Fatal mistakes
- Taking the visible blood loss as her total loss.
- A neuraxial block with abnormal clotting.
- A full propofol induction dose in a hypovolaemic mother.
Checked against: Miller 10e · Barash 9e
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