OB case, massive blood loss: thoughts?

[jetproppilot]

Speaking from the OB side. Was there a discussion of a likely accreta in this situation? A patient with 3 prior C/Ds and a current previa has a fairly high likelihood of having a placenta accreta and although they are picked up often by U/S, no imaging test is perfect.

This would lead into the additional IV placement and having blood products available and like others have echoed having the massive transfusion protocol ready to go. Another thought is potentially having a cell saver available which again would require advance notice.

The other issue would be where the case would be done. I would probably be more likely to do this case in the main OR rather than in a L and D OR and have additional back up in the form of gyn onc.

The other option if interventional radiology was available would be for prophylactic uterine artery balloon catheters which have been shown to be fairly effective.

I would have a low threshold for a hysterectomy in this situation.

The main thing with this case is the need for a lot of advanced planning. It's hard to gauge whether this was adequately done in this scenario because this surgery requires a lot of cross coordination with anesthesia, OB, and the transfusion service.

The

MOST IMPORTANT PART OF YOUR POST,

DR. OB/GYN DOCTOR,

is that despite your academic posts, in

THE REAL WORLD,

YOU. Yeah, YOU

HAFFTA MAKE A DECISION

CDAZY FAST

LIFE OR DEATH MAN

There are only a few

OB ROKKSTARRS

out there.

THAT WOULD'VE PREVENTED

THIS DEBACLE OF

PRBCS/FFP.....

Sorry man.

THE TRUTH HURTS.

---

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[45408]

1:1.5 FFP to PRBC and redosing abx in the setting of massive transfusion are both new concepts to me. Are these specific to your institution or are these becoming more established/based on papers I should know about? Thanks.

Massive transfusion protocols are usually 1:1 for PRBCs and FFP, and then platelets after 6 of each of the above have gone in. This is fairly established, and I believe it grew out of military experience. Re-dosing antibiotics is usually just for a case that's gone >3-4 hours, and I've not heard it suggested for a massive transfusion.

 

[Idiopathic]

Massive transfusion protocols are usually 1:1 for PRBCs and FFP, and then platelets after 6 of each of the above have gone in. This is fairly established, and I believe it grew out of military experience. Re-dosing antibiotics is usually just for a case that's gone >3-4 hours, and I've not heard it suggested for a massive transfusion.

its in various protocols. the idea stems from the fact that the ABX are carried by the blood right out of the body into the Neptune, so might as well replace them with every lost blood volume or so (ive seen suggestions ranging from every 5 units to every 8 units PRBC)

 

[lilycat]

Massive transfusion protocols are usually 1:1 for PRBCs and FFP, and then platelets after 6 of each of the above have gone in. This is fairly established, and I believe it grew out of military experience. Re-dosing antibiotics is usually just for a case that's gone >3-4 hours, and I've not heard it suggested for a massive transfusion.

SOAP guidelines are to redose antibiotics in accretas after 1500 cc EBL, or after 2-3 hrs in the case. They just talked about this again at the recent meeting in Puerto Rico.

To the OP - on the OB side, I'm absolutely floored that they didn't seem to seriously consider the possibility of an accreta in this patient from the get-go. As others mentioned, previous c/s x 3, with a previa, carries an accreta risk of around 60% according to the literature. And the absolute worst thing you can do with an accreta is to manipulate the placenta - that's when you see your massive blood loss in the span of minutes, as you saw in this case. If the OB doesn't manipulate the placenta, they instead concentrate on closing hysterotomy quickly and start the c-hyst, blood loss can actually be fairly minimal. I've done c-hysts with as little as 1200-1500 cc EBL when the OB's knew exactly what they were dealing with and operated quickly and conservatively. And I've had 7L EBL c-hysts when the OB's were yanking on the placenta, losing blood and wasting time. Honestly, the OB management of this patient is shocking - that's not even just a Monday morning quarterback perspective, that's just shock at the OB's not applying standard textbook teaching to this patient.

As for the anesthesia plan, yes, I would have started with 2 large-bore PIVs before starting the case and would have had 4 units PRBCs in the room, checked and ready to go. As others have commented, the starting Hct makes me highly suspicious for volume depletion in this patient. In situations where I'm managing a c/s that is high-risk for accreta, but not a known accreta prior to surgery, I'm watching the OB's like a hawk after baby is delivered. You, as the anesthesiologist, may actually be a better judge of the likelihood that there is massive blood loss occurring as they attempt to manipulate the placenta unsuccessfully - I've seen many cases where the OBs just refuse to believe that it's truly an accreta and keep repeating the same unsuccessful maneuvers over and over, meanwhile your suction cannister is now full of blood and you still see the uterus still hosing. When I start to see that the placenta is not coming easily AND the cannister is starting to fill up, I get ready to induce - I prefer to have my patient asleep before the MAP starts dropping. And, if I don't have help in the room at that point, I call for help. Another set of hands is vital for quickly inducing/intubating, hanging blood, starting arterial line and central line (if needed), etc.

 

[anonperson]

The

MOST IMPORTANT PART OF YOUR POST,

DR. OB/GYN DOCTOR,

is that despite your academic posts, in

THE REAL WORLD,

YOU. Yeah, YOU

HAFFTA MAKE A DECISION

CDAZY FAST

LIFE OR DEATH MAN

There are only a few

OB ROKKSTARRS

out there.

THAT WOULD'VE PREVENTED

THIS DEBACLE OF

PRBCS/FFP.....

Sorry man.

THE TRUTH HURTS.

I'm not hurt by the truth. This case was mishandled from the beginning. Why the primary OBs didn't have a discussion with the patient on the high likelihood of an accreta doesn't make sense.

What should have happened was a planned cesarean hysterectomy at 36-37 weeks with IR placing preop balloon catheters and NO placental manipulation whatsoever. Why the OBs dicked around with the placenta is beyond me.

 

[dhb]

NO placental manipulation whatsoever. Why the OBs dicked around with the placenta is beyond me.

It's going to have to come out somehow...

 

[pgg]

What should have happened was a planned cesarean hysterectomy at 36-37 weeks with IR placing preop balloon catheters and NO placental manipulation whatsoever. Why the OBs dicked around with the placenta is beyond me.

That's a little extreme.

When I read this scenario I assumed basic competency on the part of the OBs. Of course they know that a previa + repeat section carries a risk of accreta. Where I practice it is standard to follow previas fairly closely, including an u/s on the morning of admission to reassess it. Apparently this patient made it to the OR without raising the OB doc's level of concern too high. Sometimes **** just happens.

For known accreta/percreta, sure, balloons + extra IV access + an a-line + GETA from the start is a fine plan and one I would endorse.

But you can't go around putting balloons in everyone who comes in with a previa and a history of prior section. That's nuts.

 

[KLPM]

30 year old G4 with history of C-section x 3 comes in for scheduled C-section due to placenta previa. Otherwise healthy. Starting Hct 42. Normal weight and airway exam for a pregnant person. 16g PIV with 2L bolus pre-operatively. We decide to have 2 units of blood in the room, already checked in. We put on standard monitors, proceed with spinal anesthesia, baby comes out without any problems.

But as they try to pull the placenta out, some of it is stuck to the uterus. Pitocin is running, the surgeons fish around for a couple of minutes, there is notable bleeding at the surgical field, and they keep saying "Her hematocrit is 42" and "we think we have the bleeding under control." Meanwhile the patient's MAP dips down to the 40s and the patient starts vomiting.

Now there are like 3 anesthesiologists in the room. We immediately start giving blood through a high flow ranger, put in a 2nd IV, induce with etomidate and succinylcholine, intubate with a C-MAC, and then throw in an arterial line.

The patient ends up losing almost 4 liters of blood, getting 7U pRBC and 2U FFP, we keep her intubated and send her to PACU. She ends up doing fine.

What would you guys do differently in retrospect? Action was taken quickly and effectively in this case, but I'm sure others on this discussion board have different ways of approaching a potentially undiagnosed accreta.

Just wanted to share a case that happened yesterday which reminded me of this thread.

35yo with molar pregnancy underwent suction+curette. Nothing significant in the history. Once the mole has been sucked out the bleeding wouldn't stop and eventually lost 2.2L of blood. Resuscitated and eventually managed to halt the bleeding with Bakri balloon. Wheeled off to ICU. Not sure if she will need a hysterectomy yet.

The O+G team said this was an unexpected bleed but her ultrasound report said it was a highly vascular lesion. Was this really unexpected? Should they have anticipated a large bleed?

 

[Idiopathic]

Just wanted to share a case that happened yesterday which reminded me of this thread.

35yo with molar pregnancy underwent suction+curette. Nothing significant in the history. Once the mole has been sucked out the bleeding wouldn't stop and eventually lost 2.2L of blood. Resuscitated and eventually managed to halt the bleeding with Bakri balloon. Wheeled off to ICU. Not sure if she will need a hysterectomy yet.

The O+G team said this was an unexpected bleed but her ultrasound report said it was a highly vascular lesion. Was this really unexpected? Should they have anticipated a large bleed?

i always anticipate one; they rarely do. this is a broad generalization of my experience with obstetric anesthesia.

 

[lilycat]

Just wanted to share a case that happened yesterday which reminded me of this thread.

35yo with molar pregnancy underwent suction+curette. Nothing significant in the history. Once the mole has been sucked out the bleeding wouldn't stop and eventually lost 2.2L of blood. Resuscitated and eventually managed to halt the bleeding with Bakri balloon. Wheeled off to ICU. Not sure if she will need a hysterectomy yet.

The O+G team said this was an unexpected bleed but her ultrasound report said it was a highly vascular lesion. Was this really unexpected? Should they have anticipated a large bleed?

Look up the relevant chapter in Chestnut - there is an associated risk of hemorrhage with molar pregnancies, and according to the literature, up to 30-40% of patients may require transfusion. I've had two molar D&Cs that have exceeded 1 L EBL. I think it's reasonable for both the OB and the anesthesia services involved in such a case to be aware that there is an increased risk for hemorrhage in these patients. Personally I make sure that I have one good large-bore PIV, and all available uterotonics in the room. I usually don't start a second IV unless my starting IV is really small or positional and unreliable.

 

[joshmir]

In addition to the Bakri baloon, there is some type of stitch or suture that the OB can throw to kinda squeeze down on the uterus; unsure what its called, or if its appropriate in this situation

Bakri balloons are rarely used, make sure the nurse and OB are used to using it, waste a couple; kinda like the trach kit in the corner of the ER gathering dust

Could a foley be used in place of a Bakri balloon if this was a third world country? just wondering theoretically

If using cell saver, may be a theoretical benefit of hooking up a different suction for the amniotic fluid, and sucking it out before delivering the baby, cutting the uterus, so you don't have amniotic fluid mixing in with what you get in the cell saver

wonder what color the urine was in the foley with the insertion with the Hct 42

Agree with skipping epidural and going to sleep; can do TAP blocks afterwards; or put in the epidural and don't dose it; then go to sleep; then you can use it after placenta is out if all goes well

 

[KLPM]

In addition to the Bakri baloon, there is some type of stitch or suture that the OB can throw to kinda squeeze down on the uterus; unsure what its called, or if its appropriate in this situation

Is that the one that actually requires a laparotomy though?

 

[Idiopathic]

Is that the one that actually requires a laparotomy though?

if its the B-lynch stitch, then no, that can be done through the low transverse incision