Planes, Pregnancy and Bleeding

aka Prehospital Predicament 001

This is post by LITFL’s newest contributing author, Dr Minh Le Cong, a specialist in rural generalism and the current Medical Education Officer for RFDS Queensland.

Hi folks. I want to present this scenario based on a real case to highlight the challenges of dealing with critically ill pregnant women in remote Australia.

This is not just an issue for obstetrically-trained doctors but for all health providers who may have to deal with obstetric emergencies and provide resuscitation and arrange urgent retrieval. As we are all aware, emergency and critical care training lacks detailed coverage of obstetric skills and knowledge. This might be acceptable in city-based practice where specialist maternity units are available for on call support but in rural areas it falls upon the remote doctor or nurse to provide all the initial and ongoing care whilst transport is arranged. Then during retrieval it is the flight doctor, nurse or paramedic who has to continue to provide ongoing obstetric resuscitation and stabilisation of not only the mother but the unborn baby as well.

Many consider these emergencies to be ‘worst case scenarios’…

Let’s set THE SCENE

You are an RFDS doctor in Mount Isa, a remote mining city in north Queensland.

  • A regional hospital with a resident obstetrician and an anaesthetist.
  • HDU on site, no ICU
  • RFDS base with 24 hr fixed wing retrieval service

Now you get THE CALL

  • 36 yo Indigenous woman at Doomadgee (Indigenous community)
  • G7 P5, currently 34 weeks gestation
  • Presents with small PV bleed that has settled
  • Obs stable
  • Doomadgee has small hospital with resident doctor but no acute birthing service or OT

OK, now its over to you…

Q1. Regarding RETRIEVAL TRIAGE AND PLANNING:

a. What is the priority of this call?
b. What crew mix is required?
c. What special preparations are needed?
d. What further medical information do you need? 

Retrieval triage and planning:

  • This is an urgent priority (1-3hrs response time). The patient is currently stable but is in a facility without surgical services or a blood bank with no obstetric trained staff.
  • Ideally a two person retrieval team should be sent. At least one of them should be competent in acute obstetric emergency care including managing obstetric haemorrhage
  • It is difficult to define best practice but, in general, taking blood products to a known obstetric haemorrhage case, even if the patient is currently no longer bleeding is prudent retrieval practice. This is particuarly important with remote locations where transport times may be prolonged. Prehospital ultrasound assessment is a growing field with no best practice established yet. Obstetric retrieval cases are ideal candidates for prehospital USS assessment as majorly relevant findings can be determined rapidly ( number of foetuses, presenting part, placental location)
  • Ideally prior to setting off on the retrieval, basic antenatal information including obstetric examination findings would be handy!

You obtain the further information requested.

Antenatal history:

  • G7P5, 1 termination
  • Poor antenatal care this pregnancy
  • Had one USS but results lost
  • EDC from USS was recorded and 34 weeks currently by that
  • All previous pregnancies delivered vaginally
  • Rh positive

Current obstetric exam by midwife:

  • BP 120/80, PR 80, RR12
  • Not in distress, no contractions
  • FHR 130
  • Cervical exam not done
  • Foetal fibronectin not done

Q2. What is your interpretation of the history and examination findings?

There are a number of worrying features of the history.

  • A multiparous mother is paradoxically at more risk of obstetric complications such as post partum haemorrhage.
  • She has had almost no routine antenatal care with the only obstetric USS result being lost. We do not know the placental location with certainty and in the setting of a small PV bleeding in third trimester this could spell disaster such as a praevia or worse.

Whilst the obstetric exam findings are reassuring for now the remoteness of the patient location and the worrying history would place this retrieval as a high priority.

Q3. What is foetal fibronectin? Is it useful in this situation?

Foetal fibronectin is a protein released when separation of chorion and decidua starts to occur. It can be detected by a simple point of care test.

  • It is a useful negative predictor of preterm delivery within next 7-10 days. In other words, if the test is negative, mother is unlikely to proceed to deliver within 7-10 days.
  • Unfortunately a few things mess up the test and one of them is blood. Therefore it is not helpful in this case and really the concern here is not with preterm delivery but bleeding to death!

… SECOND CALL:

COME QUICK SHE IS BLEEDING AGAIN!!!

Q4. Regarding the PV bleeding:
a. What 3 likely causes should you consider?
b. What is the uterine blood flow at term?
c. Do you want to take blood with you, if so, how much?

The three most important causes of PV bleeding to consider are:

  1. placenta (abruption, praevia, abnormal implantation)
  2. uterus (uterine rupture)
  3. fetus (vasa praevia)

Uterine blood flow at term is approximately 500ml/min. This is important when considering the need for blood products… Which brings us to part c.

Anyone doing this retrieval should want to take blood. How much? As much as possible — if you’re dealing potential blood losses of 500ml/min, you’ll want as much as your service can take on a retrieval!

Q5. Is there an indication for tocolysis, and what would you advise?

No!

You are not treating preterm labour.. Active obstetric haemorrhage is an absolute contraindication to tocolysis!

You arrive at Doomadgee with your retrieval team.

This is the handover:

  • Woman in blood soaked bed
  • Semi conscious
  • BP 60/, HR 140, RR40
  • SaO2 unrecordable
  • Rx = IV Saline 4 litres, O2

Now, you have some decisions to make.

Q6. What is definitive care for this woman? Can you provide it as a retrieval team?

Definitive care requires an obstetrically skilled surgeon, an obstetric anesthetist, a surgical suite, and a blood bank and pathology service capable of massive blood transfusion therapy.

Clearly, this cannot be provided by the retrieval team.

Q7. What are your immediate management priorities? Is there a role for a ‘permissive hypotension’ resuscitative strategy in this case?

The management priority is resuscitation with emphasis on:

  • uterine displacement with lateral tilt of the pelvis
  • aggressive fluid therapy with early blood product replacement

A role for permissive hypotension in the resuscitation of the bleeding obstetric patient is unproven and may contribute to a poor fetal outcome. I suggest avoiding it in this scenario.

Q8. Apart from the administration of replacement blood products, what other agents might be considered for use in the retrieval of a critically bleeding obstetric patient?

Australian guidelines for critical bleeding/ massive transfusion are considered in Hematology Hoodwinker 003 — Managing the Critical Bleeder!!

Haemostatic agents have actions that are either:

  • Systemic — inhibit fibrinolysis or promote coagulation, or
  • Local — cause vasoconstriction or promote platelet aggregation

Let’s consider FRecombinant factor VII first. We must remember that pregnancy is already a pro-coagulant state. Furthermore, in the retrieval setting, prior to knowing what the coagulation status is, giving Recombinant factor VII is not proven for traumatic bleeding let alone obstetric bleeding! The definitive care is surgical control of the anatomy. Factor VIIa is generally reserved for situations that involve a salvageable patient, bleeding that cannot be surgically corrected, and there has been adequate replacement of blood products (e.g. platelets >80, INR <1.5), and correction of acidosis (e.g. PH>7.2) and hypothermia (e.g. T>34C).

For a detailed discussion of Recombinant Factor VIIa check out: Hematology Hoodwinker 002 — Factor VIIa to the Rescue!?

What about tranexamic acid?

  • The CRASH 2 trial indicates early use under 3hrs from injury improves outcomes in haemorrhaging trauma patients
  • There are recommendations for prehospital use in absence of liberal blood product availability and long transport times

Tranexamic acid is an intriguing potential prehospital haemostatic agent with current studies looking at its role in obstetric bleeding and reducing need for transfusion. It is also cheap and easy to administer.

Prothrombinex is another option:

  • Freeze dried human clotting factors
  • Licensed for warfarin overdose or congenital clotting deficiency
  • Off label for trauma
  • Theoretical clot risk combined with tranexamic acid

Now, back to the case…

This is where we’re at:

  • Patient given more saline and two units of O neg… BP and GCS improved.
  • Fetal HR is 180/min.
  • You ‘load and go’
  • Portable USS inflight demonstrated abnormal vasculature of the placenta

Q9. What is your interpretation of the above clinical information?

Foetal tachycardia

  • This is not a good sign in the setting of obstetric bleeding. It implies foetal distress, probably from acute placental blood loss.
  • The baby is bleeding to death! 
  • It does matter but in retrieval setting little can be done apart from resuscitation of the mother as best as possible. Ideally baby should be delivered emergently.

Abnormal vasculature of the placenta

  • Abnormal vasculature on placental USS in setting of major obstetric haemorrhage must make one suspiscious of abnormal placenta such as an accreta or percreta.
  • The likelihood of the patient needing emergency peripartum hysterectomy is high.

Well done, you’ve made it to Mt. Isa ED

This is the situation now:

  • Obstetrician waiting
  • BP 90/50, HR 100, Hb 37
  • Coags – borderline abnormal
  • Decision made for emergency LSCS
  • Husband on commercial flight to Mt. Isa… he was refused transport with wife due to her criticality.

Q10. Was it appropriate for the patient’s husband to travel separately from the retrieved patient?

This is a difficult decision to make. It is akin to letting parents into the resuscitation room with their critically ill/injured child. My personal view is that if you are going to die, you should  have your family with you if possible.

Furthermore, leaving country for Indigenous folk is a big deal and dying out of country is an even bigger cultural issue. Thus, I believe we should try to ensure that the next of kin is transported with all critically ill/injured patients from remote areas.

Now, the patient has made it to the operating theatre in Mt Isa:

  • LSCS performed and abnormal placental anatomy is found
  • The placenta is adherent to uterus and penetrated to bladder
  • The baby delivered in distress
  • The surgeon is unable to control haemorrhage from uterine incision and placenta

Things are looking grim…

  • The anaesthetist having trouble maintaining MAP >60
  • 19 Units PRBC and 19 Units FFP given
  • 10 units of platelets
  • The surgeon is not willing to do hysterectomy in Mt Isa due to a lack of recent experience
  • The pelvis is packed…
  • Mt Isa is running out of blood products…

Q11. What are your options at this point?

This is what happened:

  • RFDS flies in another surgeon from Townsville
  • Brings Novoseven ($30000 worth) as well as 12 PRBC and 12 FFP and 10 PLT
  • Surgeon goes straight to OT and performs a hysterectomy

Now its your job is to perform an interhospital trnsfer to the nearest ICU in Townsville.

Q12. Is this a good idea?

  • It is not ideal to subject a post operative patient who has had a massive blood transfusion to the added stress of aeromedical transport. However, it also not ideal to leave them in a hospital that has exhausted it blood supplies and its staff!
  • I also was asked to return the surgeon back to Townsville so he could go home… a request that is hard to refuse. Indeed, this the first I had a surgeon escort on a retrieval flight!

It is nearly 900 km from Mt. Isa to Townsville, another 2.5h flight…

Q13. What are the key management issues for her aeromedical retrieval care  given that she is post-operative patient having sustained massive blood loss?

What is needed is basically good critical care with some minor adjustments for aeromedicine such as checking ETT cuff pressure with a manometer during climb, cruise and descent. Among supportive care measures, good analgesia and sedation are important minimise the stress from vibration and noise.

You’ve made it to Townsville!

The outcome

  • The patient survived after 3 days in ICU.
  • The patient’s husband was understandably very traumatised by whole ordeal
  • Sadly, their baby suffered hypoxic brain injury

The key learning points

  • Unexplained obstetric PV bleeding is an emergency till proven otherwise
  • Beware the multigravid patient in a remote community
  • Never forget the baby during resuscitiation
  • Haemorrhagic resuscitation in the retrieval setting = preserve blood volume + coagulation
  • Always consider the trauma of retrieval for the patient and family

THE END
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Comments

  1. says

    Wonderful work by all. Well done. The circumstances were very frightening and you handled them brilliantly. I’m not sure from the story why the partner couldn’t accompany his wife -- was it a matter of space in the aircraft given the critical and emergency nature of the woman’s condition? The last link didn’t work, but given the great care, I’m deciding that both mother and baby were fine at the end, despite the woman needing a hysterectomy.

  2. Lee Poole says

    Interesting post Minh. In regards to family accompanying critically ill patients I agree that it is akin to witnessing resuscitation, however the one big difference is that once onboard the aircraft there is not the option for the relative to leave as is the case of stepping outside of the resus room if they are feeling overwhelmed. Family is always a consideration when retrieving a patient and their wishes to accompany the patient or follow later should be accommodated if safe.

    • Minh le Cong says

      Thank you Paul for sharing that case.
      In my time with RFDS Cairns base I have had the honour to meet and work with two Canadian rural family physicians who came to be with us for a 6 month stint each. We shared many stories about rural medicine and the themes seemed remarkably similar. keep the faith, mate!

  3. doug lynch says

    Hello Minh,

    Nice case.

    I habitually bring family into resus situations and have had a very positive (if emotionally draining) experience with that practice.

    Just to follow up on the interesting question about hypotensive resus in this scenario.

    As you said;

    “A role for permissive hypotension in the resuscitation of the bleeding obstetric patient is unproven and may contribute to a poor fetal outcome. I suggest avoiding it in this scenario.”

    I was pondering this very recently.

    I would avoid it too.

    I anaesthetised a patient with uterine rupture a few days ago. (G2 P1 (-1))

    Large fibroid and rupture through previous c/s scar , 1000 mls blood poured out of the abdomen on incision, marked HD instability, BP 60-70 systolic, fetal distress.

    My practice includes a lot of Retrieval, ICU, Emergency and Anaesthetics. I am a trainee.

    Being trained largely in metropolitan facilities I consider myself to be deficient in Obstetrics. (And many other things)

    I was considering what I should be trying to bring the BP up to and what role there was for hypotensive resus especially as I was expecting bleeding and problems with uterine contractility.

    However I did not go Hypotensive. My thinking being;

    Fetal blood flow is proportional to uterine blood flow, which is not autoregulated.

    This uterus was compromised locally and the maternal BP was already poor.

    The mechanism for bleeding is different to the sort of penetrating trauma bleeding that Madox, Dutton, the US Military etc had published on.

    I elected to aim for three figure systolic blood pressures until the moment of delivery.

    Thereafter I immediately used 4 pharmacological adjuncts to aid uterine contraction, moved to a total intravenous anaesthetic and tolerated lower BP while my surgeon struggled with the uterus.

    No ballon was required and mother and baby are doing very well.

    I am interested in what the experienced campaigners out there think.

    Ultimately I was basing this on my knowledge of physiology and NOT a clinical evidence base.

    Is there evidence out there that I could look into?

    Thanks.

    • Minh le Cong says

      Hi Doug
      Sounds like you gave a fine emergency anaesthetic and in these zero evidence based areas of critical care obstetrics, I think you have to do what is physiologically sensible, in particular prior to emergent delivery of the baby.

      As long as you have a reasonable rationale for what you are doing, if there is no evidence to guide you, you have to make your own call based on the case before you.

  4. says

    Hi Minh
    Great case. A lot of points have come out in the comments -- good stuff. I have a few additional random thoughts for consideration

    Calcium. No evidence but this patient could do with some empirical Ca -- would help with clotting and hypotension. I do this in my practice now after a few bags of red / big bleeds

    Love the tranexamic acid idea. Ironic how a gynae drug makes it’s way into obstetrics via trauma!

    Surgical options. Did anyone consider:
    - clamp internal iliacs. Or even aorta if it was going pear shaped
    - intramuometrial PGF2a -- have seen this work well but transiently on a few nasty post CS uteri bleeds
    - fly a surgeon to the patient rather than vice versa

    Gotta say I like having the family there but it is a tough call in flight. Probably would have said no -- unless the father was a trauma surgeon!

    Good job
    Casey

    • Minh le Cong says

      Thanks Casey for your comments

      I moved her post op to Townsville so was not in OT during the crisis but I think she did get some calcium . Can’t answer for the surgeons involved but I guess they would have considered iliac arterial ligation ..basically needed a hysterectomy and a second surgeon was needed to effect that.

      PGF2 alpha myometrially probably would not have worked for placenta percreta..is it worth a shot..sure if you got nothing else at hand but it was not done in this case.

      I disagree with some of my retrieval colleagues in having family escort the patient inflight. I personally think there should be family on board but not everyone agrees with me. Lee’s point about not having anywhere to go once on board is true but I have not found that to be an issue. yes we get deaths inflight..its about 3% of flights from memory. there is no hard and fast rule about this but I preference is to have family escort the critical patient.

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