Obstetric anaesthesia · Core07 / 17
Atonic PPH with coagulopathy for laparotomy35-year-old woman, 80 kg, para 3, 1 hour after vaginal birth following a 20-hour oxytocin-augmented labour with chorioamnionitis
Postpartum haemorrhage: massive obstetric bleeding, coagulopathy and transfusion lung injury
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Know this first
- PPH: 1000 mL or more after any birth, or loss with signs of hypovolaemia.
- Low fibrinogen strongly predicts severe PPH; target 150–200 mg/dL.
- Tranexamic acid works if given in the first 3 hours: 1 g over 10 minutes, a second gram after 30 minutes if bleeding.
- TRALI: within 6 hours, no left atrial hypertension. TACO: overload, responds to diuretics.
- Cell salvage is absolutely contraindicated when the surgical field is contaminated by microbes.
The patient
35-year-old woman, 80 kg, para 3, 1 hour after vaginal birth following a 20-hour oxytocin-augmented labour with chorioamnionitis.
Atony despite oxytocin, carboprost and balloon tamponade; estimated loss 2500 mL; labour epidural in place. Now for laparotomy and compression suture.
Drugs: ampicillin, gentamicin; oxytocin infusion.
Vitals: BP 80/45, HR 132, SpO2 96% on air, RR 26, temperature 38.2 °C. Hb 7.1 g/dL.
The examiner asks
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Consider
What are your concerns?
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- A 35-year-old para 3 with 2500 mL atonic PPH after chorioamnionitis, now for laparotomy. Patient
- Just delivered: she keeps a pregnant airway and aspiration risk for the first day or two.
- Causes: tone, trauma, retained tissue and clotting; atony is clear, but I check the rest. Disease
- Long augmented labour, infection, oxytocin and parity all drive her atony.
- Visual estimates mislead; I want measured loss from swabs and suction.
Plan
How do you manage her now?
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- Major haemorrhage call: blood bank, senior obstetrician and a second anaesthetist. Patient
- Transfuse on the clinical picture now; lab results will lag behind her. Disease
- Tranexamic acid 1 g now; 1 g more if bleeding continues at 30 minutes or recurs inside 24 h.
- Unstable and bleeding, so general anaesthesia by rapid sequence, not an epidural top-up. Airway
- Ketamine 1 mg/kg for induction holds her pressure better than propofol.
- Misoprostol 800 mcg sublingual; methylergonovine 0.2 mg IM if she isn't hypertensive. Disease
- No cell salvage: her chorioamnionitis contaminates the field, which rules it out.
Crisis
Thirty minutes in, after 6 units of red cells and 2 of plasma, everything oozes; fibrinogen 1.1 g/L, platelets 62 ×10⁹/L, ionised calcium 0.9 mmol/L. BP 84/48, HR 128. What do you do?
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- Massive obstetric haemorrhage, now with dilutional and consumptive coagulopathy. (Crisis)
- Fibrinogen first: cryoprecipitate or concentrate to reach 150–200 mg/dL.
- Plasma and platelets brought towards 1:1 with her red cells.
- Calcium chloride 10 mL of 10% over 10 minutes; citrate in the blood is binding hers.
- Everything warmed, including her; cold impairs her clotting factors and platelets.
- Viscoelastic tests every few units to target products.
- Still bleeding: interventional radiology if she can travel, otherwise hysterectomy.
Crisis
In recovery, 2 hours later, she is breathless with crackles; SpO2 86% on 6 L, RR 34, BP 168/94, HR 118. What do you do?
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- Acute lung injury after massive transfusion: TACO or TRALI. Crisis
- Sit her up, high-flow oxygen; CPAP or intubation if she tires.
- Her hypertension suggests TACO, which settles with a diuretic.
- TRALI is within 6 hours too, but without left atrial hypertension.
- Echo, BNP and chest X-ray to tell them apart; no more products unless she bleeds.
- Report to the blood bank and admit her to ICU. After surgery
Fatal mistakes
- Waiting for lab results before transfusing her.
- Ignoring fibrinogen in obstetric bleeding.
- Methylergonovine in a hypertensive mother.
- Topping up the epidural in an unstable, bleeding woman.
Checked against: Barash 9e · Miller 10e
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