180 Review Articles Medical Education Emergencies in J. Wallenborn1 · I. Kühnert2 · D. O. Chebac1 · H. Stepan3 obstetric anaesthesia Citation: Wallenborn J, Kühnert I, Chebac DO, Stepan H: Emergencies in obstetric anaesthesia. Anästh Intensivmed 2017;58:180-193. DOI: 10.19224/ai2017.180 Summary The main causes of maternal and neo­‑ 1 Klinik für Anästhesie und Intensivmedizin, natal morbidity and mortality are HELIOS Klinikum Aue The main factors of maternal and 2 Klinik und Poliklinik für Anästhesiologie peripartum haemorrhage, hypertensive neonatal morbidity and mortality are und Intensivmedizin, Universitätsklinikum pregnancy diseases and sepsis [1,2], in Leipzig peripartum haemorrhage, hypertensive addition, critical situations during deli- 3 Abteilung für Geburtsmedizin, Universitäts- pregnancy diseases and maternal sepsis very and endocrinological emergencies klinikum Leipzig as well as critical situations under during pregnancy. labour and endocrine emergencies. Peripartum haemorrhage is the main reason of pregnancy-induced mortality; Peripartum haemorrhage early detection of the life-threatening situation and interdisciplinary coopera- Epidemiology and general aspects t ion are imperative. During hypertensive pregnancy diseases, prolongation of Peripartum haemorrhage (PPH) is the pregnancy and prevention of maternal most frequent cause of pregnancy- complications have priority; the anaes- related mortalities [1,2,3]. thetist is mainly challenged during delivery. Risk factors for maternal sepsis In Western Europe, seven women per are divided in obstetrical and patient- 100,000 live births die of PPH, in Central related reasons; therapy is conducted Africa their number amounts to 1,570 in accordance with general guidelines. [4]. In Germany, the incidence rate of Stalled labour and umbilical cord pro- PPH has increased to approx. One out lapse are common indications for caesa- of 250 deliveries, to which the increas- rean delivery. Amniotic fluid embolism ing rate of caesarean deliveries (>30%) is treated symptomatically. Endocrine with consecutively increasing placenta emergencies like hyperthyroid and dia- implantation disorders and an increased betic disorders are of rare occurrence. risk of uterus rupture during subsequent pregnancies have made a contribution. Introduction In the Netherlands, 0.7% of all home births had to be admitted to hospital because of PPH [5]. In emergency situations in obstetric Keywords anaesthesia, the anaesthetist and The blood loss during a delivery pro- Obstetric Emergencies – obstetrician must focus their atten - ceeding without complications amounts Peripartum Haemorrhage – t ion on the welfare of both the mother to up to 500 ml; bleeding is terminated Hypertensive Pregnancy and the unborn child, whereby the and/or compensated for by the con- Diseases – Maternal Sepsis – well-being of the child requires that traction of the uterus and physiological Stalled Labour – Umbilical the vital functions of the mother are hypervolemia. A blood loss of >500 ml Cord Prolapse – Amniotic Fluid consistently stable. within a period of 24 hours is referred Embolism to as primary postpartum haemorrhage; Medical Education Review Articles 181 frequent causes are uterine atony and Tab. 2 shows the potential causes, Injuries of the genital tract placental retention. Every larger bleed- their frequencies and the risk of PPH ing after 24 hours and up to 12 weeks occurrences. In addition, PPH might Injuries of the genital tract might be postpartum is considered as secondary develop as a consequence of dissemi- either unintentional (laceration of postpartum haemorrhage [6,7]. In ad- nated intravascular coagulation (DIC) the perineum, cervical rupture) or dition, the following definitions apply due to amniotic fluid embolism, septic iatrogenic (episiotomy). [6,7]: abortion, intrauterine infection, eclamp- • In German-speaking countries PPH sia and HELLP syndrome (haemolysis, • The best prophylaxis of PPH consists exists if the loss of blood after either elevated liver enzymes, low platelet in rapid surgical treatment of the vaginal or caesarean delivery amounts count). injury, whereby a high vaginal tear is to >500 ml and >1,000 ml, respec- tively. A serious case of PPH exists if Tab. 1 the acute blood loss exceeds 1,500 Risk factors for peripartum haemorrhage (PPH) [1,7]. HELLP syndrome = haemolysis, elevated liver – 2,000 ml. enzymes, low platelet count. • The WHO (World Health Organi- zation) considers every blood loss Factor Prepartum Intrapartum /Postpartum greater than 500 ml as PPH irrespec- Placenta Placental abruption Placental retention tive of the birth modality. Placenta praevia Placenta accreta, percreta, increta Most young and healthy mothers are Uterus Precedent uterine atony Uterine atony initially able to compensate for a greater Precedent uterine surgery Uterine rupture blood loss for quite some time, before a Uterus myomatosus Inversion of the uterus haemorrhagic shock with agitation or Distension of the uterus (multiparity, clouding of consciousness, cold sweat, polyhydramnios, transverse foetal position) paleness, tachycardia, hypotension and Coagulation Congenital or acquired haemostasis Consumptive coagulopathy due to hyperventilation sets in. The amount of disorder pre-eclampsia /HELLP syndrome blood captured in towels, compresses Placental abruption and sponges etc. is often underestimated, Amnion infection syndrome, sepsis Amniotic fluid embolism for which reason the use of calibrated blood collection bags or surgical drapes Other Haemorrhages prior to delivery Protracted delivery Multipara with blood collection pouches is recom- Induction of labour and prolonged Nicotine abuse administration of oxytocin mended [7,8]. Advanced age Macrosomia (>4,500 g) Non-Caucasian ethnicity • From a blood loss of approx. 1,000 Surgical vaginal delivery PPH in the medical case history ml onward, the basic actions pre- Injury of the genital tract sented in more detail below must be Section, emergency section immediately taken, e.g. retention of warmth, application of large-lumen indwelling venous cannulas, basic Tab. 2 laboratory analyses, cross-matching Potential causes and their frequencies as well as the odds ratio (OR) with 95% confidence interval of erythrocyte concentrates (EC) etc. (CI) for the occurrence of peripartum haemorrhage (PPH) [6,7,8,9,10]. • From a blood loss of about 1,500 ml and more, regular antifibrinolysis Cause Frequency OR for PPH (95% CI) and, if indicated, a transfusion of Injury of the genital tract 1:8 1.4-4.7 (1.04-8.4) EC and coagulation factors will be Uterine atony 1:20 No data available necessary [3,7,8,9]. Pre-eclampsia 1:20 5 (3.0-8.5) Multiparity 1:85 5 (3.0-6.6) Next to recognising the life-threaten- ing situation in time, interdiscipli- Emergency section 1:150 4 (3.28-3.95) nary cooperation will be essential. Premature detachment of the placenta 1:80 - 1:150 13 (7.61-12.9) Placental retention 1:100 - 1:500 5 (3.36-7.87) Risk factors and potential causes Placenta praevia 1:200 12 (7.17-23.0) A summary of the risk factors for PPH Placenta accreta 1:2,000 - 1:2,500 3.3 (1.7-6.4) are shown Tab. 1. The medical case Uterine rupture 1:1,250 - 1:3,000 history, physical examination and sono- Inversion of the uterus 1:6,400 graphy contribute to the diagnosis. 182 Review Articles Medical Education surgically very demanding and likely Fig. 1 to be accompanied by great blood losses not to be underestimated. Placental retention Normal placenta with Placenta increta intact decidua basalis In case of a placental retention with- out haemorrhage one can wait at maximum for 30 minutes for the placenta to detach spontaneously – however, it is a corroborated fact Placenta accreta Placenta percreta that the incidence rate of PPH can be reduced by about 60 percent through an active initiation of the placental stage of labour [11]. • Active procedures are – apart from Placental implantation disorders. a controlled traction on the umbi- lical cord (CCT) – the administration of uterotonic drugs, clamping and residues can be loosened by means We distinguish: cutting of the umbilical cord and of a curettage, whereas hysterectomy • Low-lying placenta – one part of massage of the uterus. Recent studies will have to be carried out in case of the placenta lies in the lower uterine indicated that only the administration placenta increta or placenta percreta. segment; vaginal delivery is possible. of uterotonic drugs reduces the inci- • Placenta praevia marginalis – the Placental malposition dence rate of PPH [12]. placental tissue reaches the internal • The expelled placenta must always cervical os; in most cases vaginal A placenta praevia develops in be examined for completeness. Pos­‑ delivery will still be possible. 0.5% of all pregnancies – the pla- sible placental residues can be iden- centa is either situated near the • Placenta praevia partialis – the pla­‑ tified by ultrasound. Then, a manual uterine cervix or obstructs the birth cental tissue overlies the cervical or instrumental palpation done in canal (Fig. 2). os to some extent; vaginal delivery proper time will prevent the develop- should be avoided. ment of a larger PPH. Placental implantation disorders Fig. 2 A placental retention might conceal a placental implantation disorder (Fig. 1). If the placenta lacks the basal decidua, in part or fully, trophoblasts and thus placental villi may grow all the way into the uterine musculature (placenta accreta, 78%), (placenta increta, 17%), or even cross it into neighbouring organs (placenta