Clinical obstetrics and gynecology
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Clin Obstet Gynecol · Mar 2010
ReviewPostpartum hemorrhage: evidence-based medical interventions for prevention and treatment.
Postpartum hemorrhage (PPH) remains a significant contributor to maternal morbidity and mortality throughout the world. The majority of research on this topic has focused on efforts to prevent PPH. ⋯ Misoprostol may be a reasonable option where parenteral administration of an uterotonic is not feasible. There is little evidence to guide treatment decisions should PPH occur.
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Hemorrhage requiring blood transfusion is a common occurrence in obstetrics. This article reviews each step in the transfusion process, including laboratory preparation of blood, indications for various blood components, complications of blood transfusion, massive transfusion, and alternatives to homologous blood. Current thinking regarding transfusion-related acute lung injury, transfusion-related immunomodulation, early use of plasma for massive transfusion, and the use of adjuvant agents such as activated recombinant factor VII are also discussed.
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Clin Obstet Gynecol · Mar 2010
ReviewPostpartum hemorrhage: epidemiology, risk factors, and causes.
Postpartum hemorrhage (PPH) is a leading cause of death and morbidity relating to pregnancy. Uterine atony is the leading cause of PPH, and trauma, including iatrogenic trauma, increases the risk for postpartum hemorrhage. ⋯ Awareness of these facts, and anticipation and prevention of uterine atony, as well as avoiding unnecessary cesareans, episiotomies, and other genital tract trauma have the potential to significantly reduce the mortality and morbidity from postpartum hemorrhage. The epidemiology of postpartum hemorrhage, including the incidence and temporal trends as well as the causes and risk factors associated with it are presented.
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In the United States, trauma is the leading nonobstetric cause of maternal death. The principal causes of trauma in pregnancy include motor vehicle accidents, falls, assaults, homicides, domestic violence, and penetrating wounds. The managing team evaluating and coordinating the care of the pregnant trauma patient should be multidisciplinary so that it is able to understand the physiologic changes in pregnancy. ⋯ Evaluation of the pregnant trauma patient requires a primary and secondary survey with emphasis on airway, breathing, circulation, and disability. The use of imaging studies, invasive hemodynamics, critical care medications, and surgery, if necessary, should be individualized and guided by a coordinating team effort to improve maternal and fetal conditions. A clear understanding of gestational age and fetal viability should be documented in the record.
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The need for cardiac surgery during pregnancy is rare. Only 1% to 4% of pregnancies are complicated by maternal cardiac disease and most of these can be managed with medical therapy and lifestyle changes. On occasion, whether owing to natural progression of the underlying cardiac disease or precipitated by the cardiovascular changes of pregnancy, cardiac surgical therapy must be considered. ⋯ For others, cardiac surgery, including procedures that mandate the use of cardiopulmonary bypass, must be entertained to save the life of the mother. Given the extreme risks to the fetus, if the patient is in the third trimester, strong consideration should be given to delivery before surgery involving cardiopulmonary bypass. At earlier gestational ages when this is not feasible, modifications to the perfusion protocol including higher flow rates, normothermic perfusion, pulsatile flow, and the use of intraoperative external fetal heart rate monitoring should be considered.