Placental Abruption
Considerations
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Emergency with high maternal & fetal morbidity/mortality
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Pregnancy considerations (difficult intubation, aspiration, ↓ time to desaturation, aortocaval compression, 2 patients)
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Need to determine severity of abruption, amount of hemorrhage & degree of maternal/fetal compromise
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Comorbidities associated with abruption:
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Hypertension, pregnancy-induced hypertension, smoking, cocaine, EtOH, advanced maternal age, multiparity, multiple gestation, trauma, premature rupture of membranes, polyhydramnios
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Mobilization of resources & personnel:
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Multidisciplinary (2nd Anesthesiologist/anesthetic assistant, obstetrician, pediatrician, hematology/blood bank, ICU)
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Resources (rapid infusers, blood products/massive transfusion protocol, uterotonics/tocolytics, invasive monitoring, tranexamic acid, cell salvage, rFVIIa)
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Management
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Urgency of delivery depends on severity of abruption
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Establish large bore IV access, draw blood work, ensure close maternal & fetal monitoring, cross match & prepare for massive hemorrhage
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Labor & vaginal delivery with epidural is safe for partial abruption without significant hypovolemia or coagulopathy
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Urgent cesarean for more significant abruption with maternal or fetal compromise:
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GA with RSI (ketamine & succinylcholine) if hemodynamic compromise
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Aggressive volume resuscitation
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Invasive monitors
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Control & treat hemorrhage:
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Massive transfusion protocol, rapid infuser, avoid acidosis/hypothermia/coagulopathy
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Use of uterotonics
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Blood conservation techniques: tranexamic acid, cell saver, rFVIIa, surgical technique
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