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  • Severe hemorrhage happens in about 6.7/1,000 deliveries:
    • Seventeen percent of maternal deaths are due to hemorrhage in the United States
    • Maternal hemorrhage is the leading cause for maternal death in developing countries

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See following table.

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Changes in Vital Signs Associated with Maternal Hemorrhage
Changes in vital signsEstimated blood loss (% of total blood volume)
NoneUp to 15–20%
  • Tachycardia (<100 bpm)
  • Mild hypotension
  • Peripheral vasoconstriction
20–25%
  • Tachycardia (100–120 bpm)
  • Hypotension (SBP 80–100 mm Hg)
  • Restlessness
  • Oliguria
25–35%
  • Tachycardia (>120 bpm)
  • Hypotension (SBP <60 mm Hg)
  • Altered consciousness
  • Anuria
>35%
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  • Trivial bleeding:
    • Occurs in about 6% of pregnancies
    • Usually secondary to cervicitis. Important to exclude more serious scenarios
    • No bleeding is trivial in the pregnant patient until serious causes have been excluded
  • Placental abruption:
    • Occurs in 10% of pregnancies
    • May occur at any gestational age
    • Known risk factors:
      • Hypertension
      • Smoking
      • Advanced maternal age
      • Cocaine
      • Trauma
      • PROM
      • History of previous abruption
    • May be complicated by:
      • Amniotic fluid embolism
      • Uterine rupture
      • Coagulopathy
    • IUGR, fetal malformations are common
    • Presents with:
      • Vaginal bleeding (often concealed)
      • Uterine tenderness
      • Increased uterine activity
    • Ultrasound exam often diagnostic but may miss small abruptions
    • Tocolytic therapy in preterm patients is controversial
    • FHR monitoring is essential
    • Mode of delivery is determined by:
      • Condition of mother
      • Condition of fetus
    • Labor and vaginal delivery:
      • If coagulation studies normal, epidural analgesia is not contraindicated
      • Place two large IVs
      • Monitor hemodynamic status closely
    • Cesarean section:
      • Often emergent
      • General anesthesia in most cases
      • Aggressive volume resuscitation is a must; large-bore venous access may necessitate central venous cannulation
      • If necessary, place an arterial line to guide therapy
      • Uterine atony, rapidly developing coagulopathy may worsen hemorrhage
      • Consider postdelivery ICU admission of unstable patients
  • Placenta previa:
    • Prior uterine trauma is often associated
    • Painless vaginal bleed is often first sign
    • Up to 10% may have associated abruption
    • Diagnosed by ultrasonography
    • MRI may be helpful if uterine wall invasion is suspected
    • Avoid vaginal examination
    • Expectant management with admission to hospital
    • Optimal tocolytic is still debated:
      • MgSO4 worsens maternal hypotension
    • IUGR is common
    • Always abdominal delivery
    • All patients should be evaluated on arrival
    • Place at least one large-bore IV
    • Send labs, type, and crossmatch (2 U PRBC)
    • Start volume resuscitation if indicated
    • Double setup if vaginal examination is necessary
    • Cesarean section:
      • Increased risk of bleeding even during elective case
      • Place second IV before start
      • Order a minimum of 4 U PRBC in actively bleeding patients
      • Consider general anesthesia for patients presenting with significant hypovolemia

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  • In case of uncertainty as the source of hemorrhage in a patient with known placenta previa it may become necessary to perform a vaginal examination
  • The patient is prepped and draped as for a Cesarean section with a team ready to perform an emergency abdominal delivery should the hemorrhage become threatening
  • An obstetrician then performs the vaginal examination
  • An anesthesiologist is always present, ready to induce GA in case of an emergency:...

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