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Pregnancy and Postpartum Considerations 723

Severe Obstetric Haemorrhage complicates fluid resuscitation. 100,101 Standard resuscita-
Management Priorities tion fluids, such as normal saline, should be infused
Whilst it is feasible for a pregnant woman in ICU according to routine practice of the non-obstetric haem-
to develop placental abruption, for example, the vast orrhage, remembering that large volumes of blood prod-
majority of women admitted to ICU with obstetric ucts may also be required.
haemorrhage will be transferred following birth, and
are thus postpartum on admission to ICU. These
priorities focus on postpartum management. As with
any major haemorrhage (see Chapter 20), the principles Practice tip
of treatment are:
Keep in mind that:
l restore an adequate circulating volume and maintain
oxygen and perfusion to vital organs l Serum albumin levels are decreased in normal pregnancy,
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l obtain haemostasis and correct coagulopathy with the lowest levels recorded in the postpartum period.
l prevent complications. l Cardiac output remains elevated postpartum for the first
few days at least.
See Box 26.9 for acute immediate treatment. l CVP and PAP can be interpreted the same as for non-
obstetric patients.
Maintaining circulating volume, oxygenation
and perfusion
Haemodynamic instability following substantial blood
99
loss is a frequent reason for admission to ICU. Accurate Achieving haemostasis and correct coagulopathy
estimation of blood loss is difficult as bleeding can Specific interventions to control haemostasis include
be concealed, and the presence of amniotic fluid makes radiological arterial embolisation or balloon occlusion of
accurate blood volume loss estimation a challenge, the internal iliac arteries and emergency hysterectomy. It
potentially leading to an underestimation of fluid resus- is not uncommon for women to need to return to theatre
citation needs. Furthermore, peripartum women are at an for abdominal packing for ongoing ‘ooze’ that may con-
increased risk of acute pulmonary oedema, which further
tinue after a hysterectomy. Most women with severe
obstetric haemorrhage in ICU have developed DIC that
requires treatment with the appropriate blood prod-
ucts. DIC is particularly common in these women in
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part because of the normal changes in the clotting factors
during pregnancy and in part due to the potential for
BOX 26.9 Summary of acute immediate an amniotic fluid embolism to have been the triggering
treatment for PPH event for the haemorrhage. 86,103,104
Large volumes of blood products, such as packed red
Resuscitation and immediate management:
l ABC; administer 100% oxygen cells, fresh frozen plasma, platelets and cryoprecipitate
l ‘Rub’ up the uterus are often required. Guidelines recommending the ratio of
l 2 large bore cannulae and send bloods for rapid crossmatch red blood cells:fresh frozen plasma:platelets in acute
l Administer oxytocics e.g. syntocinon 98 major haemorrhage are under development in many
l Fluid resuscitation countries. Increasingly it is thought that more aggressive
l Determine the cause (4 Ts) use of fresh frozen plasma and platelets in line with red
l Transfuse blood (O-negative in the first instance then type blood cell usage is needed to prevent and/or correct
specific) haemorrhage coagulopathy. A recent large trauma study
l Prepare for transfer to theatre found that a 1 : 1 ratio for both red blood cells/fresh
frozen plasma and red blood cells/platelets, if given early
Surgical treatment and other interventions: following a major blood loss, resulted in significantly
105
l Delivery of placenta and uterine pathology, if applicable improved mortality. There has been no similar study
l B-lynch suture conducted in obstetric patients, although it is likely that
l Uterine tamponade, e.g. inflation of uterine balloon for obstetric patients may also benefit from more liberal early
local compression use of fresh frozen plasma and platelet transfusions.
l Surgical ligation Importantly, the large trauma study found the increased
l Hysterectomy ratios of FFPs and platelets were not associated with
l Compression of the aorta an increase in transfusion-related acute lung injury and
l Uterine replacement (if uterine inversion noted) acute respiratory distress syndrome from inflammatory
105
l Radiological arterial embolisation or balloon occlusion mediators. Finally, recombinant Factor VIIa has been
l Consider systemic haemostatic agents used successfully in the management of severe obstetric
l Aprotinin (Trasylol) haemorrhage and should be considered for use early in
l Vitamin K the management of the bleeding woman, with treatment
l Tranexamic acid more likely to be effective if administered before the
woman becomes hypothermic and acidotic. 106