Big Belly Baby Bleed – managing late-term Obstetric bleeding
It is ladies month here still – and today we are going to get into one of the the big Emergency scenarios of Women’s health. Imagine this:
Its a quiet night shift – you are contemplating a third cuppa when the triage nurse rolls in with a young woman on a wheelchair.
Your powers of observation tell you three things: (1) she is heavily pregnant, (2) she is in a lot of pain and (3) there is a trail of blood flowing behind the wheelchair.
This is not good. If you work in an adult ED this is probably a pretty rare occurrence – but in a mixed Obs / Paed place this is one of those moments – action stations!
Now I imagine most of you will be thinking – “get that patient outta my ED ASAP!”, however this is a scenario where time is of the essence – and it is worth knowing where the decisions are made, how to start the resuscitation and how do obstetricians think about this scenario
I sat down with my old sparring partner – Dr Wendy Hughes, our resident O&G specialist to go over a case – how should we go about the early management and where are the crucial decision points.
Have a listen and let us know if you have any insights. There are a heap of pearls and great practical tips crammed into about 20 minutes.
Casey
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About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
Good stuff, had a listen whilst walking this morning and a nive follow on to the recent MROP case on ruraldoctors.net
Couple of things I thought about
1/ layout of hospital
You mention move from ED to the birthing sheds (sorry, labour ward). Sensible. Recently found that medicare rebate for management of PPH and MROP only applies if in an OT.
Which raises next issue – having OT and labour ward in close proximity…better still having ED, ICU, OT and LW all on same floor, relatively close. When time is of the essence there is nothing worse than mad dashes along corridors or waiting for lifts…
2/ big bleeds
broomeDocs has covered this before…inc use of various factors. Any chance of a link to previous discussion on this (trauma). And of course for those of us in smaller hospitals that still manage truma and emLSCS, but have nothing more than iStat and three units pack cells, what other options are there?
3/ Bakri, B-lynch, intramyometrial prostaglandins and uterine a clipps – any practical ‘how to do it’ links?
4/ value of checklists?
Good stuff.
remote hospital big obstetric bleeding patient.
some clinical pearls from Retrieval Xp
take any pregnancy bleeding seriously in a remote area. Need 2 know location of placenta and obstetric history. Until you know those things, you have no idea.
blood product availability is vital. if not somewhere that has that, must bring to patient or patient to it.
Dont forget TXA ( WOMAN trial ongoing)
If you dont know how to ultrasound pregnant women , you need to learn.
A surgeon is a portable resuscitation intervention in the bleeding pregnant woman.
An anaesthetist is the team leader in resus of the bleeding pregnant woman
Retrieval medicine can bring all elements together if carefully thought through.
Scoop and run does not always cut it.
Great podcast and very good summary of how to manage a case such as this.
I’d like to reiterate most important thing is stop the bleeding i.e. oxytocics/ surgery / physical measures as discussed in the podcast. Usually if this is done quickly & well you don’t get into a coagulopathic situation so please keep my comments below in perspective. Counter intuitive to start using fancy blood products etc if you haven’t even tried ergometrine and a bakri!
My comments to add;
– Don’t forget to warm your fluids and especially cold blood products, a bair hugger on the patient as well. Hypothermia markedly impairs coagulation.
– Avoid colloids if possible especially starches, they all interfere with fibrinogen polymerisation and also make clots more susceptible to fibrinolysis. None of this is detectable on traditional coag clotting tests. If they have had lots of voluven before you see them and they are now coagulopathic the treatment is fibrinogen (cryo or fib concentrate) and tranexamic acid.
– For those of you working in a hospital / remote location where you don’t have a lab or easy access to blood products and you could possibly have to look after a patient such as this (or a bleding trauma patient, massive GI bleed etc) I highly recommend you consider also obtaining the following:
– Tranexamic acid ; will treat or prevent systemic hyperfibrinolysis, I give it after about 1-1.5 litres blood loss (still awaiting results of WOMAN trial in 2015).
– Fibrinogen concentrate 3-4g ampoule=1g (4 ampoules is the equivalent of cryo 8 units); give if fibrinogen 2litres blood loss or if obviously coaguolpathic.
– Prothrombinex , dose 25iu/kg (4-5 amps for most adults), can be used to replace clotting factors (alternative to FFP) so consider if the above 2 treatments haven’t worked and abn coags or if blood loss >3litres and ongoing.
In my humble opinion with the above plus red cells you can correct most abnormalities except platelets (having said that a high fibrinogen will help compensate for thrombocytopaenia so not completely true).
We are considering (hoping) to get fibrinogen concentrate for use in obstetric haemorrhage at KEMH and some peripheral hospitals in Perth (e.g. Osborne Park, Kaleeya) in the near future. It has been used widely in europe for 20-30 years (they got rid of cryo in the 80s when HIV appeared) and is available in Australia since 2011. If you have cryo you could just use that but be aware that you still need a lab member to cross match compatible units, thaw it etc and sometimes it takes a lot longer to get than you expect. If you don’t have cryo in your hospital I would state getting some is a no brainer…… Hospitals need to purchase it directly from CSL as it is not supplied by the ARCBS, at $6-700 an ampoule ($2400 for an adult dose) its not super cheap but in this scenario in a remote hospital without any blood bank I would say that’s a bargain…..
We have only used novoseven at KEMH once in the last 4 years (and that was because old habits die hard) especially since we moved to using a ROTEM. Our ROTEM guided approach in the last 3 years has shown that 80-90% of the time the only treatment needed apart from red cells has been cryoprecipitate (fibrinogen). I personally don’t think I’ll ever use novoseven again but you never know i guess, might be useful in a JW who won’t accept cryo / fibrinogen or prothrombinex.
I know this is early days but I’m going to put my neck out and state that in 5years or less most places that manage major haemorrhage will have a stock of fibrinogen concentrate (this includes teaching hospitals and remote /rural settings). You can hunt me down in 2018 and hold me to my word!!
There is a lot in the literature on this now, feel free to peruse it yourself:
Google: Fib-PPH trial
and read latest Fib concentrate RCT :
15.Effects of fibrinogen concentrate as first-line therapy during major aortic replacement surgery: a randomized, placebo-controlled trial.
Anesthesiology. 2013 Jan;118(1):40-50.
CV: Consultant anaesthetist at KEMH, Fremantle and Osborne Park Hospital.
Thanks Roger, good stuff. We won;t get ROTEM / TEGS etc … but we should have the fibrinogen concentrate and TXA in smaller places
The hard bit is rolling this out in the face of lack of direction from top-down – clearly WA is further ahead than SA!
For massive and obviously life-threatening haemorrhage, whatever the cause, is there still a case of cross matching warm fresh red blood from volunteers? I know it sounds third world.
I have access to three units of O negative. Once that has gone; I hope Medstar are well and truly on the way.
What would you need.
Volunteers
Point of care testing for HIV, HepC
Venesection equipment (we have that for haemochromotosis patients)
from wikipedia
“In an emergency, blood grouping can be done easily and quickly in 2 or 3 minutes in the laboratory on glass slides with appropriate reagents, by trained technical staff. This method depends on the presence or absence of agglutination, which can usually be visualized directly, although occasionally a light microscope may be needed. If laboratory services are not available, another system of deciding which type of blood to use in an emergency is the bedside card method of blood grouping, where a drop of the intended recipients’ blood is added to dried reagents on a prepared card. This method may not be as reliable as laboratory methods, which are preferable.”
From a medical student’s perspective, that was definitely a worthwhile listen, and pitched at a good level. I feel like I would have a decent idea of how to approach a situation that I would have previously completely freaked out about. Looking forward to more Women’s Health this month.
Josh