Major obstetric hemorrhage

Area of Science:

• Obstetrics and Gynecology
• Anesthesiology
• Critical Care Medicine

Background:

• Major obstetric hemorrhage contributes to over 10% of maternal deaths in high-income nations.
• Underestimation of blood loss is a common challenge, necessitating objective measurement tools like collection bags.
• Effective management requires a thorough understanding of both antenatal and postpartum etiologies.

Purpose of the Study:

• To outline a standardized, multidisciplinary approach for managing major obstetric hemorrhage.
• To emphasize the importance of early diagnosis, timely interventions, and aggressive resuscitation strategies.
• To provide guidance on managing specific etiologies, including uterine atony and abnormal placentation.

Main Methods:

• Implementing locally validated protocols based on international guidelines.
• Utilizing collection bags for accurate bleeding assessment.
• Employing a stepwise approach involving medical management (prostaglandins), minimally invasive procedures (ligations, plication), and surgical options (hysterectomy).
• Initiating early and aggressive resuscitation with massive transfusion (4:4:1 ratio), fibrinogen concentrates, and tranexamic acid.
• Guiding transfusion strategies with thromboelastography/thromboelastometry and bedside hemoglobin monitoring.
• Considering activated factor VII for refractory bleeding, primarily around hysterectomy.

Main Results:

• Standardized protocols improve outcomes in managing obstetric hemorrhage.
• Early recognition and intervention significantly reduce maternal mortality.
• Aggressive resuscitation and timely surgical or radiological procedures are vital.
• Management of abnormal placentation requires anticipation and mastery due to potential for severe hemorrhage.

Conclusions:

• A standardized, multidisciplinary management strategy is essential for preventing maternal deaths from obstetric hemorrhage.
• Early diagnosis, prompt treatment of etiologies, and aggressive resuscitation are critical components.
• Anticipation and mastery of managing placentation abnormalities are necessary for catastrophic hemorrhage control.