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The patient with perinatal bleeding (2), female, 41 years old, came to the hospital mainly because of "38 weeks of intrauterine pregnancy, painless vaginal bleedin.
Thepatient had a painless vaginal bleeding at 28 weeks of pregnancy, and then spontaneously Remissi.
There have been three cesarean sections in the pa.
Because of persistent vaginal bleeding, the obstetrician suggested that cesarean section should be performed immediate.
The patient's vital signs are as follows: BP 90/36mmHg, HR 112 times/min, RR 22 times/min , SpO2 97% (no oxyge.
Hematocrit: 2
Intraoperative managementWhat are the precautions for anesthesia management of placenta accreta?After the fetus and placenta are delivered, you find that there are Diffuse oozi.
What is disseminated intravascular coagulation DIC?If you suspect DIC in this patient, what blood products can be transfused in a patient with DIC?What are the consequences of acute blood loss? How would you proceed accordingly Follow-up treatment?How should anesthesia be managed in patients with postpartum hemorrhage?What laboratory tests should be performed during patient resuscitation?What is the definition of amniotic fluid embolism? How to treat? C Intraoperative management 01 Implantation What are the precautions for anesthesia management of placenta accreta? Placenta accreta can cause postpartum hemorrhage because the uterine spiral arteries at the site of placenta accreta cannot contract effective.
Removal of the placenta will expose larger sinusoids in the myometrium, allowing bleeding Exacerbati.
If placenta accreta is suspected or determined prior to delivery, the medical team should discuss the management of the mother and the fetus, primarily the placement of the internal iliac artery balloon preoperative.
Theballoon is delivered after the fetus is delivered Post-dilation opens, which in turn reduces blood flow to the uterus, allowing time for better management of the placenta accreta
Placenta accreta is the most common reason for obstetric hysterecto.
Due to the possibility of massive bleeding, it is necessary to open an unobstructed venous channel for the patient, preferably two venous channels with large diamete.
Because the patient may experience acute hemodynamic changes, the patient should also undergo an arterial puncture measureme.
Monitoring of central venous pressure is also an instructive indicator during resuscitati.
Know the patient's hematocrit and coagulati.
Prepare 4 units of packed red blood cel.
If the packed red blood cells are not ready, surgery should not be perform.
Usually, the bleeding after the internal iliac artery balloon is not much, and the anesthesiologist can decide whether to apply epidural anesthesia according to the patient's circulati.
If bleeding is poorly controlled or the patient is circulatory unstable, transfer to general anesthesia should be done immediate.
In addition, if a patient is suspected of having a placenta accreta and a hysterectomy is to be performed, general anesthesia should be the first choi.
Similarly, general anesthesia is also the first choice for emergency surgery for postpartum hemorrha.
02After delivery of the fetus and placenta, you notice diffuse oozing from the surgical si.
What is disseminated intravascular coagulation DIC? DIC occurs when excessive consumption of coagulation factors, platelets, and fibrinogen causes thrombus deposition in the microcirculati.
Thrombus deposition leads to reduced blood flow to various organs, eventually leading to multisystem organ failu.
At the same time, the fibrinolysis process is initiated, and fibrin cleavage products are form.
Bleeding is difficult to control due to excessive consumption of clotting factors and platele.
The coagulopathy can be so severe that extensive spontaneous bleeding occurs, including uterine bleeding and bleeding at the puncture site of an intravenous li.
DIC usually occurs with postpartum hemorrhage, which can make the patient's condition wor.
During the perinatal period, DIC progresses rapid.
DIC occurs in 10% of patients with placental abruption, and intrauterine stillbirth is more comm.
Patients with severe gestational hypertension or amniotic fluid embolism are also prone to D.
In addition, patients with sepsis, severe trauma, solid tumors, and hematological tumors are also prone to D.
Laboratory findings can be used to guide treatment and typically include the following: PT, PTT, International Standard Ratio (INR), platelet count, fibrin degradation products, and fibrinog.
Observation of fibrinogen levels can help differentiate DIC from dilutional coagulation disorde.
Treatment of DIC should focus on addressing the underlying disorder and supporting the patie.
Low-dose unfractionated heparin, infused at a rate of 300 to 500 U/h, may be helpful in the treatment of D.
Antifibrinolytic drugs are not recommended clinically for the treatment of DIC because the patient is already in a state of abnormal fibrinolys.
03If you suspect that the patient has DIC, what blood products can be transfused in patients with DIC? If the patient has not been intubated, we want to ensure that the patient's airway is op.
During resuscitation, the creation of a third space will exacerbate airway ede.
Pulmonary edema can cause respiratory insufficien.
To correct DIC, coagulation factors and platelets must be transfus.
We should dilate the volume with crystalloids and/or colloids to correct hypotensive, hypovolemic states before getting blood produc.
If bleeding persists, packed red blood cells are transfused according to the amount of bleeding and the hematocrit lev.
Whether to transfuse fresh frozen plasma should be decided according to the clinical bleeding and the results of PT and P.
If the level of PT or PTT is 5 times higher than normal, or when factor V or VIII is deficient, fresh frozen plasma should be transfus.
In the event of DIC, platelets should be transfused according to consumption, ie, platelet counts and clinical bleedi.
If the platelet count is less than 50 x 103/ul, or the platelet count is between (50 to 100) x 103/ul, but the bleeding persists, platelets should be transfus.
Because of the high consumption of fibrinogen, cryoprecipitate containing large amounts of fibrinogen should also be infus.
04What are the consequences of acute blood loss? How will you follow up with this? When an obstetric patient develops postpartum hemorrhage or DIC, the situation deteriorates rapid.
Before blood typing and cross-matching are completed, supportive therapy with crystalloids and colloids is administer.
If the hemodynamics deteriorate to a point where patient safety may be compromised, an emergency transfusion of Rh-negative type O red blood cells can be giv.
05How should anesthesia be managed in patients with postpartum hemorrhage? The patient needs to open a thick-diameter venous chann.
Arterial catheterization is performed to continuously monitor the patient's hemodynamics, and central venous catheterization is performed to assist in resuscitati.
Use a warmed infusion set if large volumes of fluids and blood products need to be infus.
In addition, maintaining a suitable room temperature and applying a heating blanket can also prevent hypotherm.
If bleeding persists, the patient is given a crystalloid or colloid to replace the volume loss before blood products are availab.
General anesthesia is required if the bleeding persists or if the patient is unable to keep their airway op.
06Which laboratory tests should be performed during patient resuscitation? Some routine tests are performed as soon as possible, including hematocrit, platelet count, coagulation (PTT, PT, INR, and fibrinogen levels), and arterial blood gas.
During the resuscitation process, the above checks should be reviewed regularly to guide treatment and blood transfusi.
If a large blood transfusion is performed, an electrolyte test is also performed, focusing on potassium and calcium leve.
The transfused blood contains a large amount of potassium, and the potassium from the cells is also effluxed during acidosis, so there is a risk of hyperkalem.
The anticoagulant in blood transfusions is citrate, and patients may develop hypocalcemia as a resu.
In addition, blood gases should be reviewed frequently to monitor and evaluate acidosis that may be caused by poor tissue perfusi.
07What is the definition of amniotic fluid embolism? How to treat? Amniotic fluid embolism is prone to occur when the amniotic fluid is in direct contact with the maternal blood circulatory syst.
Most occur in cases of multiple births and difficult lab.
The blood vessels and amniotic fluid at the internal cervical os, placenta or uterine injury may be in direct contact with the maternal circulatory syst.
Patients experience sudden hypotension, dyspnea, hypoxemia, cyanosis, loss of consciousness, and possibly convulsio.
The above symptoms occur partly due to mechanical obstruction of the pulmonary vasculature, resulting in the release of prostaglandins, histamine, serotonin, or interleukins, which in turn mediate pulmonary vasoconstricti.
Patients may develop acute cor pulmonale and right heart failu.
Cardiopulmonary arrest occurs in more than 80% of patien.
Also prone to D.
At this time, the patient's airway needs to be controlled and ventilatory support is given, and positive end-expiratory pressure can improve the patient's oxygenati.
Arterial catheterization can monitor hemodynamics and monitor central venous pressure to guide volume thera.
In addition, vasopressors should be used to maintain blood pressure, and DIC should be treated using the methods previously describ.
Amniotic fluid embolism is usually a diagnosis of exclusion, generally based on clinical symptoms and sig.
Squamous cells, fat, and mucin may be found in blood drawn from a pulmonary artery cathet.
Postoperative ManagementIf a patient develops D.
After the DIC is under control, when do you choose to have the epidural catheter removed?Suppose you have successfully treated this patient with DIC and her laboratory tests, CVP, and urine output are normal, but the patient is hypotensive despite volume replaceme.
What are you thinking about?.
Postoperative Management D If a patient develops D.
After the DIC is under control, when do you choose to have the epidural catheter removed? The patient's neurological status and coagulation therapy should be assessed multiple tim.
The catheter can be removed at any time if there is no intraspinal hemorrhage due to the catheter puncturing the blood vess.
If bleeding continues from the catheter indwelling site, the catheter cannot be removed because of the potential for epidural or subarachnoid hemorrhage packing due to the action of the cathet.
In addition, once the patient has neurological abnormalities, it should be checked immediately, and surgical decompression should be performed if necessa.
Often, neurological abnormalities are difficult to evaluate because patients are intubated and sedated postoperative.
At this time, the epidural catheter should be indwelled until the neurological condition of the patient can be evaluat.
Coagulation tests can also be used to guide removal of epidural cathete.
We should note that epidural hematoma may occur not only during catheter insertion, but also during catheter removal; therefore, it is important to ensure that the patient's coagulation function is good before removing the epidural cathet.
D Suppose you have successfully treated this patient with DIC and her laboratory tests, CVP, and urine output are normal, but the patient is hypotensive despite volume replaceme.
What are you thinking about? The patient has just been resuscitated for a massive hemorrhage, so Sheehan syndrome, a pituitary infarction, may have occurr.
Pituitary infarction is associated with hypotension and massive bleedi.
The clinical symptoms of Sheehan syndrome are hypotension that cannot be corrected with fluid therapy and vasoactive drugs, and may also include poor lactation, fatigue, and aversion to co.
We should suspect Sheehan syndrome in any patient with these symptoms and a history of major bleeding and perinatal hypotensi.
Notes/Chen Lingjun Typesetting/Dingdang Maruko Ma Happy Labor Day to pay tribute to laborers forging ahead in a new era
Thepatient had a painless vaginal bleeding at 28 weeks of pregnancy, and then spontaneously Remissi.
There have been three cesarean sections in the pa.
Because of persistent vaginal bleeding, the obstetrician suggested that cesarean section should be performed immediate.
The patient's vital signs are as follows: BP 90/36mmHg, HR 112 times/min, RR 22 times/min , SpO2 97% (no oxyge.
Hematocrit: 2
Intraoperative managementWhat are the precautions for anesthesia management of placenta accreta?After the fetus and placenta are delivered, you find that there are Diffuse oozi.
What is disseminated intravascular coagulation DIC?If you suspect DIC in this patient, what blood products can be transfused in a patient with DIC?What are the consequences of acute blood loss? How would you proceed accordingly Follow-up treatment?How should anesthesia be managed in patients with postpartum hemorrhage?What laboratory tests should be performed during patient resuscitation?What is the definition of amniotic fluid embolism? How to treat? C Intraoperative management 01 Implantation What are the precautions for anesthesia management of placenta accreta? Placenta accreta can cause postpartum hemorrhage because the uterine spiral arteries at the site of placenta accreta cannot contract effective.
Removal of the placenta will expose larger sinusoids in the myometrium, allowing bleeding Exacerbati.
If placenta accreta is suspected or determined prior to delivery, the medical team should discuss the management of the mother and the fetus, primarily the placement of the internal iliac artery balloon preoperative.
Theballoon is delivered after the fetus is delivered Post-dilation opens, which in turn reduces blood flow to the uterus, allowing time for better management of the placenta accreta
Placenta accreta is the most common reason for obstetric hysterecto.
Due to the possibility of massive bleeding, it is necessary to open an unobstructed venous channel for the patient, preferably two venous channels with large diamete.
Because the patient may experience acute hemodynamic changes, the patient should also undergo an arterial puncture measureme.
Monitoring of central venous pressure is also an instructive indicator during resuscitati.
Know the patient's hematocrit and coagulati.
Prepare 4 units of packed red blood cel.
If the packed red blood cells are not ready, surgery should not be perform.
Usually, the bleeding after the internal iliac artery balloon is not much, and the anesthesiologist can decide whether to apply epidural anesthesia according to the patient's circulati.
If bleeding is poorly controlled or the patient is circulatory unstable, transfer to general anesthesia should be done immediate.
In addition, if a patient is suspected of having a placenta accreta and a hysterectomy is to be performed, general anesthesia should be the first choi.
Similarly, general anesthesia is also the first choice for emergency surgery for postpartum hemorrha.
02After delivery of the fetus and placenta, you notice diffuse oozing from the surgical si.
What is disseminated intravascular coagulation DIC? DIC occurs when excessive consumption of coagulation factors, platelets, and fibrinogen causes thrombus deposition in the microcirculati.
Thrombus deposition leads to reduced blood flow to various organs, eventually leading to multisystem organ failu.
At the same time, the fibrinolysis process is initiated, and fibrin cleavage products are form.
Bleeding is difficult to control due to excessive consumption of clotting factors and platele.
The coagulopathy can be so severe that extensive spontaneous bleeding occurs, including uterine bleeding and bleeding at the puncture site of an intravenous li.
DIC usually occurs with postpartum hemorrhage, which can make the patient's condition wor.
During the perinatal period, DIC progresses rapid.
DIC occurs in 10% of patients with placental abruption, and intrauterine stillbirth is more comm.
Patients with severe gestational hypertension or amniotic fluid embolism are also prone to D.
In addition, patients with sepsis, severe trauma, solid tumors, and hematological tumors are also prone to D.
Laboratory findings can be used to guide treatment and typically include the following: PT, PTT, International Standard Ratio (INR), platelet count, fibrin degradation products, and fibrinog.
Observation of fibrinogen levels can help differentiate DIC from dilutional coagulation disorde.
Treatment of DIC should focus on addressing the underlying disorder and supporting the patie.
Low-dose unfractionated heparin, infused at a rate of 300 to 500 U/h, may be helpful in the treatment of D.
Antifibrinolytic drugs are not recommended clinically for the treatment of DIC because the patient is already in a state of abnormal fibrinolys.
03If you suspect that the patient has DIC, what blood products can be transfused in patients with DIC? If the patient has not been intubated, we want to ensure that the patient's airway is op.
During resuscitation, the creation of a third space will exacerbate airway ede.
Pulmonary edema can cause respiratory insufficien.
To correct DIC, coagulation factors and platelets must be transfus.
We should dilate the volume with crystalloids and/or colloids to correct hypotensive, hypovolemic states before getting blood produc.
If bleeding persists, packed red blood cells are transfused according to the amount of bleeding and the hematocrit lev.
Whether to transfuse fresh frozen plasma should be decided according to the clinical bleeding and the results of PT and P.
If the level of PT or PTT is 5 times higher than normal, or when factor V or VIII is deficient, fresh frozen plasma should be transfus.
In the event of DIC, platelets should be transfused according to consumption, ie, platelet counts and clinical bleedi.
If the platelet count is less than 50 x 103/ul, or the platelet count is between (50 to 100) x 103/ul, but the bleeding persists, platelets should be transfus.
Because of the high consumption of fibrinogen, cryoprecipitate containing large amounts of fibrinogen should also be infus.
04What are the consequences of acute blood loss? How will you follow up with this? When an obstetric patient develops postpartum hemorrhage or DIC, the situation deteriorates rapid.
Before blood typing and cross-matching are completed, supportive therapy with crystalloids and colloids is administer.
If the hemodynamics deteriorate to a point where patient safety may be compromised, an emergency transfusion of Rh-negative type O red blood cells can be giv.
05How should anesthesia be managed in patients with postpartum hemorrhage? The patient needs to open a thick-diameter venous chann.
Arterial catheterization is performed to continuously monitor the patient's hemodynamics, and central venous catheterization is performed to assist in resuscitati.
Use a warmed infusion set if large volumes of fluids and blood products need to be infus.
In addition, maintaining a suitable room temperature and applying a heating blanket can also prevent hypotherm.
If bleeding persists, the patient is given a crystalloid or colloid to replace the volume loss before blood products are availab.
General anesthesia is required if the bleeding persists or if the patient is unable to keep their airway op.
06Which laboratory tests should be performed during patient resuscitation? Some routine tests are performed as soon as possible, including hematocrit, platelet count, coagulation (PTT, PT, INR, and fibrinogen levels), and arterial blood gas.
During the resuscitation process, the above checks should be reviewed regularly to guide treatment and blood transfusi.
If a large blood transfusion is performed, an electrolyte test is also performed, focusing on potassium and calcium leve.
The transfused blood contains a large amount of potassium, and the potassium from the cells is also effluxed during acidosis, so there is a risk of hyperkalem.
The anticoagulant in blood transfusions is citrate, and patients may develop hypocalcemia as a resu.
In addition, blood gases should be reviewed frequently to monitor and evaluate acidosis that may be caused by poor tissue perfusi.
07What is the definition of amniotic fluid embolism? How to treat? Amniotic fluid embolism is prone to occur when the amniotic fluid is in direct contact with the maternal blood circulatory syst.
Most occur in cases of multiple births and difficult lab.
The blood vessels and amniotic fluid at the internal cervical os, placenta or uterine injury may be in direct contact with the maternal circulatory syst.
Patients experience sudden hypotension, dyspnea, hypoxemia, cyanosis, loss of consciousness, and possibly convulsio.
The above symptoms occur partly due to mechanical obstruction of the pulmonary vasculature, resulting in the release of prostaglandins, histamine, serotonin, or interleukins, which in turn mediate pulmonary vasoconstricti.
Patients may develop acute cor pulmonale and right heart failu.
Cardiopulmonary arrest occurs in more than 80% of patien.
Also prone to D.
At this time, the patient's airway needs to be controlled and ventilatory support is given, and positive end-expiratory pressure can improve the patient's oxygenati.
Arterial catheterization can monitor hemodynamics and monitor central venous pressure to guide volume thera.
In addition, vasopressors should be used to maintain blood pressure, and DIC should be treated using the methods previously describ.
Amniotic fluid embolism is usually a diagnosis of exclusion, generally based on clinical symptoms and sig.
Squamous cells, fat, and mucin may be found in blood drawn from a pulmonary artery cathet.
Postoperative ManagementIf a patient develops D.
After the DIC is under control, when do you choose to have the epidural catheter removed?Suppose you have successfully treated this patient with DIC and her laboratory tests, CVP, and urine output are normal, but the patient is hypotensive despite volume replaceme.
What are you thinking about?.
Postoperative Management D If a patient develops D.
After the DIC is under control, when do you choose to have the epidural catheter removed? The patient's neurological status and coagulation therapy should be assessed multiple tim.
The catheter can be removed at any time if there is no intraspinal hemorrhage due to the catheter puncturing the blood vess.
If bleeding continues from the catheter indwelling site, the catheter cannot be removed because of the potential for epidural or subarachnoid hemorrhage packing due to the action of the cathet.
In addition, once the patient has neurological abnormalities, it should be checked immediately, and surgical decompression should be performed if necessa.
Often, neurological abnormalities are difficult to evaluate because patients are intubated and sedated postoperative.
At this time, the epidural catheter should be indwelled until the neurological condition of the patient can be evaluat.
Coagulation tests can also be used to guide removal of epidural cathete.
We should note that epidural hematoma may occur not only during catheter insertion, but also during catheter removal; therefore, it is important to ensure that the patient's coagulation function is good before removing the epidural cathet.
D Suppose you have successfully treated this patient with DIC and her laboratory tests, CVP, and urine output are normal, but the patient is hypotensive despite volume replaceme.
What are you thinking about? The patient has just been resuscitated for a massive hemorrhage, so Sheehan syndrome, a pituitary infarction, may have occurr.
Pituitary infarction is associated with hypotension and massive bleedi.
The clinical symptoms of Sheehan syndrome are hypotension that cannot be corrected with fluid therapy and vasoactive drugs, and may also include poor lactation, fatigue, and aversion to co.
We should suspect Sheehan syndrome in any patient with these symptoms and a history of major bleeding and perinatal hypotensi.
Notes/Chen Lingjun Typesetting/Dingdang Maruko Ma Happy Labor Day to pay tribute to laborers forging ahead in a new era
