Antepartum Hemorrhage
Considerations
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Emergency situation
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Pregnancy considerations (difficult intubation, aspiration, ↓ time to desaturation, aortocaval compression, 2 patients)
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Potential for maternal massive hemorrhage, hemodynamic instability & lethal triad (coagulopathy, acidosis, hypothermia)
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Potential for fetal distress & need for FHR monitoring
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Discussion with obstetrics to determine the extent & cause of hemorrhage & whether emergency cesarean is required
Management
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Simultaneous diagnosis & management in collaboration with obstetrics
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Monitors (maternal & fetal), O2, & start 2 large bore IVs
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Obtain history, perform physical examination including airway exam & intravascular volume status
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Resuscitate to goal end points including FHR stability
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Gather resources, get help, have OR set up for emergency cesarean section & possible massive hemorrhage:
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Rapid transfuser
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Massive transfusion protocol
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Blood conservation techniques (cell saver, tranexamic acid, avoid lethal triad)
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If emergency cesarean, will likely need GA (provided airway is reassuring) & titrated induction with ketamine & succinylcholine
Differential Diagnosis for Antepartum Hemorrhage
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Placenta previa (painless)
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Placenta abruption (painful)
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Uterine rupture (true emergency)
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Vasa previa (lethal to fetus, ok for mom)
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Other less serious causes
Conflicts
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Full stomach (RSI) vs. hemodynamic instability & need for titrated induction
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Difficult airway vs. STAT cesarean section