Peripartum life-threatening bleeding

Peripartum life-threatening bleeding can be explained as a very rapidly increasing blood loss, estimated to be approximately over 1500 ml.

Etiology
In many cases, we can imagine under peripartum life-threatening bleeding: The biggest danger with bleeding is that it can happen silently, so it is necessary for the midwife to check the woman regularly after the birth.
 * 1) primarily obstetric non-surgical bleeding - the cause is then most often hypotonia to atony of the uterus,
 * 2) primarily surgical bleeding - the causes are then disorders of separation of the placenta or various obstetric injuries,
 * 3) coagulation disorders - the cause can also be disseminated intravascular coagulopathy.

Main assumptions of minimization
The main prerequisites for minimizing the occurrence of life-threatening peripartum bleeding are prevention, early diagnosis and effective treatment. Effective treatment of peripartum bleeding requires precise coordination and a multidisciplinary approach. The goal of treatment is not only life saving, but preferably also possible preserving reproductive health.

Organization
The basics of a possible quick solution to the situation are:
 * elaborated crisis plan,
 * definition of individual positions and work of expert members of the crisis plan
 * maintaining continuous documentation of peripartum life-threatening bleeding
 * management by one professional person all organization of work and instructions

Stabilization of the mother's condition
The most basic thing is to find out the cause of peripartum bleeding and eliminate this cause. Furthermore, we locate the source of the bleeding through examination in mirrors, ultrasound or palpation by bimanual examination. We will assess and ensure vital functions. We will give oxygen. We will administer fluid replacements using an intravenous line. Via i.v. we give uterotonics. We must ensure that the mother does not suffer from hypothermia, or we will start treatment for hypothermia. We will insert a urinary catheter and consider the type of other treatment for life-threatening peripartum bleeding.

Laboratory examination
We will send the collected blood sample to:
 * examination of blood count,
 * examination of fibrinogen levels
 * basic coagulation examination
 * orientation test blood coagulation with thrombin
 * pre-transfusion examination.

First aid procedure for hypotonia to uterine atony
Procedure no. 1: massage of the uterus, administration of uterotonic i.v. (oxytocin, carbetocin, methylergometrine), administration of prostaglandins i.v. infusion or i.m. into the uterine muscle, performing an instrumental or digital revision of the uterine cavity. Procedure no. 2 (if procedure no. 1 fails): we remove the coagulum, administer i.v. uterotonics, apply a Bakri balloon catheter or perform vaginal tamponade Procedure no. 3 (in the event of failure of procedure no. 2): performing surgical intervention (ligature of aa.uterinae and aa.ovaricae, B-Lynch uterine suture, etc.), performing selective catheterization embolization of arteriae uterinae, we can consider administration of recombinant activated factor VII. Procedure no. 4 (if all previous procedures fail): here we lean toward hysterectomy because of the devastating injury to the entire uterus and because of the possible source of sepsis represented by the uterus itself.

Coagulation Support
In order to restore the overall effectiveness of the hemostatic mechanism and promote coagulation, it is necessary to observe the following measures:
 * maximum hypothermia correction
 * maximum correction of acidosis
 * correction of parameters of the whole systemic homeostasis
 * correction of hypocalcemia

Erythrocytes
The minimum hemoglobin value should be 70g/l. The ratio of transfused units of plasma to transfused units of erythrocytes should be 1:1, at most 1:1.5.

Plasma
The minimum value of plasma administered at the beginning is assumed to be between 15 to 20 ml/kg.

Platelets
If the amount of platelets in the body drops below 70x 109l, administration of platelets is recommended.

Fibrinogen
If fibrinogen in the body drops below 1.5-2 g/l, administration of fibrinogen is recommended.

Recombinant activated factor VII(rFVIIa)
When we encounter the failure of all the procedures possible so far, we are inclined to administer recombinant activated factor VII (rFVIIa), especially because of the possible prevention of destruction of the uterus, when we would have to be forced to perform a hysterectomy. Initial dose i.v. represents 90-120 μg/kg. After securing the mother's life, thromboprophylaxis is carried out in the form of  low-molecular-weight heparin .

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