Abstract
Massive obstetric haemorrhage causes significant maternal morbidity and mortality as well as many ‘near misses’. Antepartum haemorrhage due to placental abruption and intrapartum haemorrhage due to uterine rupture are associated with increased perinatal mortality.
Moreover, massive obstetric haemorrhage due to placenta praevia may result in fetal complications secondary to prematurity as well as severe maternal hypovolemia and hypotension.
Key Facts
Definition Blood loss of >2000 mL (or >30% of blood volume) is defined as massive obstetric haemorrhage (MOH). There is a tendency to underestimate rather than overestimate the actual blood loss.
Types Massive obstetric haemorrhage can occur either in the antepartum period secondary to placental abruption, placenta praevia or accreta or in the postpartum period due to the ‘4 T’s’ (tone, trauma, tissue and thrombin). Other rare obstetric disorders such as amniotic fluid embolism (AFE) or acute inversion of uterus may also present with massive obstetric haemorrhage.
Incidence Postpartum haemorrhage (PPH) occurs in 2%–10% of deliveries but the incidence of major obstetric haemorrhage is estimated to be 3.7–5 per 1000 maternities.
It is estimated that every year about 356,000 women die during childbirth around the world. In the developing world, PPH occurs in about 4%–10% of deliveries. The last Report of the Confidential Enquiries into Maternal Deaths in the UK has listed PPH as the third most common direct cause of maternal mortality [1]. Massive blood loss leads to sudden and rapid cardiovascular decompensation and coagulopathy.
Three delays have been identified as the causes of maternal deaths due to massive obstetric haemorrhage: delay in seeking medical care, delay in reaching healthcare facilities and delay in receiving appropriate care in a healthcare institution. The latter is common to both developing and developed countries. The Confidential Enquiries report has emphasised that deaths caused by PPH are due to ‘too little done too late’.
Management of massive obstetric haemorrhage should follow a logical sequence of steps. Figure 5.1 provides an algorithm for the management of massive obstetric haemorrhage [2]. The mnemonic ‘HAEMOSTASIS’ [1] spells out the suggested actions that may facilitate the management of atonic PPH in a logical and stepwise manner (Table 5.1). Involvement of a multidisciplinary team of anaesthetists, haematologists and intensivists is essential to improve outcome [3]. Special Massive Haemorrhage Protocols such as ‘Code Blue’ should be in place for the effective, multidisciplinary management of massive obstetric haemorrhage.
| H | Ask for Help and hands on uterus (uterine massage) |
| A | Assess (ABC) and resuscitate (crystalloids 2 L, colloids 1 L, oxygen by mask [15 L/min]) |
| E | Establish aetiology (atonic, traumatic, coagulopathy or trauma), ensure availability of blood and administer ecbolics (drugs that contract the uterus: oxytocin, ergometrine or Syntometrine intramuscularly) |
| M | Massage uterus |
| O | Oxytocin infusion/prostaglandins: IV/IM/per rectal (second-line medications to contract the uterus) |
| S | Shift to theatre: aortic pressure or anti-shock garment/bimanual compression as Appropriate |
| T | Tamponade balloon/uterine packing: after exclusion of tissue and trauma |
| A | Apply compression sutures: B–Lynch/modified |
| S | Systematic pelvic devascularisation: uterine/ovarian/ quadruple/internal iliac |
| I | Interventional radiology and, if appropriate, uterine artery embolization |
| S | Subtotal/total abdominal hysterectomy |
Key Implications
Massive obstetric haemorrhage causes significant maternal morbidity and mortality as well as many ‘near misses’. Antepartum haemorrhage due to placental abruption and intrapartum haemorrhage due to uterine rupture are associated with increased perinatal mortality.
Moreover, massive obstetric haemorrhage due to placenta praevia may result in fetal complications secondary to prematurity as well as severe maternal hypovolemia and hypotension.
Immediate Implications
Hypovolemia, hypoxaemia and cardiac arrest
Blood transfusion and effects of multiple blood transfusions including transfusion reactions, risk of infections and transfusion associated acute lung injury (TRALI)
Acute renal failure
Pulmonary oedema
Coagulopathy
Risk of peripartum hysterectomy
Intensive care treatment
Key Aetiological Factors
Antepartum
Intrapartum
Amniotic fluid embolism (AFE) with coagulopathy
Uterine rupture secondary to previous uterine scar or grand multiparity, especially with injudicious use of oxytocin
Surgical complications (extension of uterine angular tear during caesarean section)
Placental: Placenta praevia, placental abruption, retained placenta, morbidly adherent placenta
Vaginal: Laceration and tears, haematoma.
Coagulopathy: Preexisting coagulopathy, treatment with anticoagulants, obstetric causes – HELLP, amniotic fluid embolism, chorioamnionitis
Key Pointers to Massive Obstetric Haemorrhage
Ongoing bleeding (>150 mL/minute).
Loss of >30% of blood volume as assessed by visible blood loss (estimated blood loss or EBL expressed as the percentage of estimated blood volume = EBL/100 mL/kg).
‘Rule of 30’ (Rise in pulse >30/minute, drop in systolic blood pressure by 30 mm Hg, increased respiratory rate >30/minute, a drop in haematocrit [packed cell volume] by 30%), which is suggestive of at least 30% loss of blood volume.
Shock index (pulse rate/systolic blood pressure) 0.9. Normal shock index in pregnancy is between 0.7 and 0.9, as the pulse rate is less than systolic blood pressure.
Tense, tender abdomen with evidence of intrauterine death (massive placental abruption).
Key Actions: Massive Obstetric Haemorrhage Prior to Delivery
Placental Abruption
Placental abruption refers to the premature separation of a normally situated placenta. Maternal consequences include haemorrhage secondary to accumulation of blood in the retro-placental space after separation of placenta as well as, in severe cases, bleeding into the uterine myometrium, leading to the ‘couvelaire uterus’.
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