Obstetrics work has put forward a very incisive “two precepts, three sexes”,. The so-called “two precautions” is: one precautions against blind observation, two precautions against rash action; “three” is: principle, flexibility, initiative. This “four-word policy” for the diagnosis and management of postpartum hemorrhagic shock can not be more appropriate,.
1, a quit blind observation
The future direction of modern medicine can be summarized as “3P”: i.e. P, predictive (predictive); Preventive (prevention); Personalized (individualized). In the case of postpartum hemorrhagic shock, it is important to understand each woman’s risk factors for postpartum hemorrhage and to predict whether she is likely to have postpartum hemorrhage. Measures can be taken to prevent postpartum hemorrhage during and after delivery. Therefore, the best way to deal with postpartum hemorrhagic shock is to emphasize early diagnosis and prevention of its occurrence, and to wait for the emergence of shock before dealing with it is rather passive. However, in clinical practice, for various reasons, many postpartum hemorrhages are often overlooked, leading to hemorrhagic shock. One of the most important causes of clinical judgment errors is the over-reliance on laboratory tests and examinations, neglecting the most basic medical history questioning, physical examination, resulting in the loss of the doctor’s ability to make normal judgments.
1.1 What if there is no way to do D, I, C screening and confirmatory tests? DIC often occurs before and at the time of shock in postpartum hemorrhage, and accurate and timely diagnosis is of great significance for the rescue of patients. However, accurate results are often not available in a timely manner at primary care facilities, on holidays, or in the middle of the night. In cases where there is a lot of bleeding and it is not possible to determine whether there is DIC, is it better to just replenish red blood cells and keep waiting passively and blindly, risking losing the chance of resuscitation? Or should we just use a lot of valuable clotting factors, fibrinogen, and plasma, and risk thromboembolism? In this case, a simple in-tube coagulation test can be used to help determine this: 5mL of venous blood is placed in a 15mL test tube and observed at 5min intervals. In the case of normal coagulation, the blood generally clots within 5-6 min, suggesting that the fibrinogen content in the blood is >115 g/L. If it does not clot in 30 min, suggesting that the fibrinogen content in the blood is <110 g/L. Generally, it is not necessary to wait for 30 min, but if it does not clot in 15 min, DIC should be highly suspected and appropriate treatment measures can be taken.
1.2, , how to rely on clinical symptoms to determine the amount of bleeding? When estimating the amount of postpartum bleeding, there is often underestimation. If one believes too much in the estimation of bleeding volume by others, the narrative of the patient’s family, and the records of the referring hospital, and ignores the patient’s examination, there is a risk of losing the chance of resuscitation. In cases where it is impossible to know exactly how much a patient is bleeding, we can use the following methods to initially determine the patient’s
Bleeding volume (for a pregnant woman weighing 60 kg, the whole body blood volume is about 5000 mL): 20% bleeding (1000 mL), BP does not drop and heart rate increases; 30% bleeding (1500 mL), BP starts to drop and shock symptoms begin to appear; 40% bleeding (2000 mL), BP drops and severe shock symptoms appear.
1.3, blood pressure is not low enough, there is no problem? Low blood pressure is an important indicator to determine the shock, but not the only indicator, if only look at the blood pressure and ignore other symptoms may lead to a big disaster. A post-operative patient who had a low blood pressure after a cesarean section was considered by the doctor to be a normal manifestation of post-anesthesia and was only supplemented with crystals. Later, the patient became irritable and the doctor checked again and found that the blood pressure was not very low, so he thought it was a postpartum psychiatric disorder and asked for a psychiatric consultation. In fact, the patient was a posterior peritoneal hematoma caused by arterial retraction at the uterine incision, which was not diagnosed in time, delaying resuscitation and eventually leading to the patient’s death. This case is a typical blind observation! When the patient had hypotension after surgery, the doctor did not carefully examine and deal with it (in addition to low blood pressure, careful examination would also reveal a fast heartbeat and a relatively low hemoglobin level); when shock symptoms appeared and manifested as irritability, it was simply considered as a psychiatric disease with a small possibility (see more, consider more, see less, do not see! (All forgotten!) I do not know that the blood pressure does not fall at this time is a temporary change caused by irritability,. The lesson of blood ah!
1.4. Is there no problem if no internal bleeding is found on ultrasound? When internal bleeding is suspected after a cesarean section, it is often necessary to ask an ultrasonographer to assist in the diagnosis, and if the bleeding is from the lower incisional site to form a hematoma, it is usually not difficult to detect. However, if it is a hematoma in other parts of the uterus or in the retroperitoneum, it is often difficult to detect. There was a case of severe preeclampsia in which a cesarean section had to be performed to terminate the pregnancy due to the occurrence of eclamptic convulsions. The procedure went well, but the postoperative blood pressure was relatively low, the urine output was not high, and the hemoglobin level was low. Internal bleeding was then suspected and an ultrasonographer was asked to examine the patient. The report was that no hematoma was found in the lower segment incision site and there was no fluid accumulation in the rectal uterine trap. Because of the fear of the patient’s family’s opinion and the psychological pressure on the surgeon, he did not dare to easily perform a second open surgical exploration, so he took conservative treatment. However, after the transfusion, the hemoglobin was still unable to rise, and after the consultation with outside experts, it was thought that the patient had internal bleeding, and it was not too clear where it was, so there was an indication for a caesarean section. The patient’s blood pressure was stabilized after the operation, and a large retroperitoneal hematoma was found on the left side of the pelvis.
This shows that ultrasonography is not a panacea, and seeing a hematoma can be diagnostic, but not seeing it does not rule out the possibility of a hematoma. It is important to combine the changes in the patient’s condition and laboratory tests to make a comprehensive judgment and consideration.
1.5 How much blood volume supplementation is enough? The principle of blood volume replenishment for postpartum hemorrhage is: how much is out, how much is replenished. However, the amount of bleeding is often underestimated, the narrative of the patient’s family, and the records of the referring hospital are incomplete or not true enough. In this case, the patient’s complaints and other people’s records should not be easily believed. The principle of blood volume replenishment is: the patient should achieve two “100” and two “30”, i.e. systolic blood pressure >100mmHg, heart rate <100>30mL/h, and red blood cell pressure >0.3. Red blood cell pressure > 0.3 (30%), which indicates that the patient’s blood volume has been fully restored.
2. Secondly, abstain from rash actions
Be a good obstetrician to be proactive, not blind, in order not to be reactive. Obstetricians have a common characteristic: they like to be hands-on! Childbirth is a natural process, and under normal circumstances obstetricians should intervene as little as possible. In fact, we should: see more (observation), talk more (communication), and do less (less intervention). But once there is a real clinical need, or should be decisive treatment.
3. The “principle” of shock management
To deal with postpartum hemorrhage to follow the following principles of treatment: REACT.
(1), Resucitation (resuscitation): resuscitation to follow the HOT principles: ①Head, down, tilt: take the head down position, increase the blood supply to the heart and brain. ②Oxygen, by, mask: mask oxygen, the speed should reach 8L/min. ③Transfuse: timely opening of the two veins, to use 14G needle, to facilitate the replenishment of blood products.
(2) Evaluation: Monitor laboratory and vital indicators, perform routine blood tests, coagulation tests, measure T, P, R, BP, check ECG, oxygen saturation, hourly urine volume, and measure central venous pressure if necessary.
(3), Arresthemorrhage (hemostasis): the MOPPABE method summarized by the authors themselves: massage of the uterus (Massage), contractions, (Oxytocin), prostaglandins (Prostaglandins),,, uterine cavity filling gauze (uterine, packing), uterine artery ligation ( Artery, ligation), uterine fundal compression suture (B-Lynch), uterine artery embolization (Embolization).
(4), Consult (request consultation): Ask the following six types of personnel to consult to help resuscitation: experienced midwives, experienced obstetricians and supervisors, experienced anesthesiologists and supervisors, hematologists, blood bank personnel, auxiliary personnel to take blood to send specimens,.
(5) Treatcomplications (treatment of complications): ask internal medicine doctors to assist in the treatment of complications such as renal failure, ARDS, DIC, infection, etc.
4. “Flexibility” of shock management
The causes of postpartum hemorrhage are different, and so is the patient’s condition, so the clinical management should not be too confined to the methods listed in the textbook. For example, in the case of postpartum hemorrhage due to amniotic fluid embolism, textbooks generally recommend heparin. My experience is that heparin is only suitable for the early stage of amniotic fluid embolism, when the blood is in a hypercoagulable state. If the amniotic fluid embolism causes postpartum hemorrhage, using heparin will often aggravate the hemorrhage. This is because there are two clinical situations that make us suspect amniotic fluid embolism: one is that the patient screams and passes out or dies, and the other is that the bleeding does not coagulate, and the reason for the bleeding does not coagulate is that the tangible fraction in the amniotic fluid consumes a large amount of coagulation factors in the blood, in which case using heparin again is undoubtedly adding insult to injury. The treatment of postpartum hemorrhage should be carried out according to the principles, but also according to the patient’s
The actual situation “flexible”, not too mechanical and rigid.
5, the shock treatment “initiative”
The golden rule for the successful management of postpartum hemorrhage is: the diagnosis must be predictive! Treatment should always be one step earlier! In the management of postpartum hemorrhage, hysterectomy is often the last resort, not to the end of the mountain, doctors are generally not easy to remove the obstetric uterus. Because hysterectomy means the loss of fertility of the patient, it also often means endless medical disputes. But there is a big difference between an active hysterectomy and a passive hysterectomy, as evidence from evidence-based medicine shows: Hysterectomy, earlier, rather, than, later, is better! Late resection still removes the uterus and often leads to massive bleeding, even DIC and death. The opening real-life case illustrates this point very well.