aka Prehospital Predicament 001
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.
- 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:
- placenta (abruption, praevia, abnormal implantation)
- uterus (uterine rupture)
- 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?
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?
- 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 key learning points
The key learning points