placenta previa

[Sonny Crocket]

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So I get a call last night from the OB resident that they want to section a bleeding placenta previa. She has just come in at 33wks. Healthy. 100kg but good airway. No lab work as she has just arrived to the hospital.

I meet them in the OR. Do a quick pre op. Her airway looks easy to intubate. She is in fact healthy without any medical problems. She says she has had a lot of bleeding. I check a quick BP. 127/62. Pulse 100.

I tell them, this is going to be general anesthesia. Start prepping the abdomen.

My thinking is that I don't know how much blood loss I am dealing with here and she is about to lose another litre with the section. Yes her vitals are stable but she could be compensating. If there is a lot of bleeding during the surgery, I would rather have a controlled airway and have one less thing to worry about. And I am dealing with obgyns so who knows what will happen.

They really pushed for a spinal because they wanted more time to get the baby out. The resident says "no, we want a spinal." I bypassed her immediately and talked to her attending which should have been done in the first place.

Everything goes fine, she is stable throughout. Baby did well.

Any thoughts on this case? Would you guys have done regional here?

 

[Mr Wizard]

I think you summed up your concerns nicely. You have very little information on how stable or unstable she is. The last thing you want to do is place a spinal in a decompensating patient to then worry about securing an airway when you may need to begin giving blood products.

A planned section in a previa patient could be a scenario where you can do a spinal, yet I feel a lot of providers may say these patients are going to sleep too.

 

[Mman]

So I get a call last night from the OB resident that they want to section a bleeding placenta previa. She has just come in at 33wks. Healthy. 100kg but good airway. No lab work as she has just arrived to the hospital.

I meet them in the OR. Do a quick pre op. Her airway looks easy to intubate. She is in fact healthy without any medical problems. She says she has had a lot of bleeding. I check a quick BP. 127/62. Pulse 100.

I tell them, this is going to be general anesthesia. Start prepping the abdomen.

My thinking is that I don't know how much blood loss I am dealing with here and she is about to lose another litre with the section. Yes her vitals are stable but she could be compensating. If there is a lot of bleeding during the surgery, I would rather have a controlled airway and have one less thing to worry about. And I am dealing with obgyns so who knows what will happen.

They really pushed for a spinal because they wanted more time to get the baby out. The resident says "no, we want a spinal." I bypassed her immediately and talked to her attending which should have been done in the first place.

Everything goes fine, she is stable throughout. Baby did well.

Any thoughts on this case? Would you guys have done regional here?

have done plenty of spinals on previas without problems, though I'd probably have 2 IVs. Rarely encounter massive hemorrhage in that situation, certainly not as bad as an accreta. Although I'll be honest the previas that are going to section I usually see in their room and not being wheeled immediately into OR for some sort of urgent/emergent procedure.

Nothing wrong with a GA in a potentially unstable situation, I just haven't seen many of those be that unstable. Think I've had to convert 1 out of quite a few to GA halfway through.

 

[Idiopathic]

one of the indications for general anesthesia in the parturient is significant hemorrhage. its up to you to determine the level of significance.

 

[Idiopathic]

have done plenty of spinals on previas without problems, though I'd probably have 2 IVs. Rarely encounter massive hemorrhage in that situation, certainly not as bad as an accreta. Although I'll be honest the previas that are going to section I usually see in their room and not being wheeled immediately into OR for some sort of urgent/emergent procedure.

this previa could also be a -creta of some sort.

 

[lilycat]

So I get a call last night from the OB resident that they want to section a bleeding placenta previa. She has just come in at 33wks. Healthy. 100kg but good airway. No lab work as she has just arrived to the hospital.

I meet them in the OR. Do a quick pre op. Her airway looks easy to intubate. She is in fact healthy without any medical problems. She says she has had a lot of bleeding. I check a quick BP. 127/62. Pulse 100.

I tell them, this is going to be general anesthesia. Start prepping the abdomen.

My thinking is that I don't know how much blood loss I am dealing with here and she is about to lose another litre with the section. Yes her vitals are stable but she could be compensating. If there is a lot of bleeding during the surgery, I would rather have a controlled airway and have one less thing to worry about. And I am dealing with obgyns so who knows what will happen.

It seems like a reasonable thought process and subsequent plan. I would press the patient and the OB for a more quantifiable amount of blood - are we talking multiple soaked pads in an hour or is it more like a low but steady trickle. From your description, it sounds like they felt that it was fairly significant bleeding in that they needed to go before you even had a CBC or H/H back (unless your hospital just takes forever on labs). If they felt it was urgent enough to start without any labs, and that decision was based on either EBL to that point or fetal condition, then I'd probably strongly consider GA from the start. (If they want to take their time getting baby out, then they can probably wait for labs too). The other thing that would sway me towards GA would be if the patient had a history of prior c/s or uterine surgeries, increasing her risk of accreta in this scenario. All that being said, my experience is similar to Mman's - I've very rarely encountered massive hemorrhage in a previa patient, at least not to the extent of an accreta patient (unless it turned out to indeed be an accreta), and I do spinals or CSEs on probably 100% of my previas, both scheduled and urgent (unless there is another mitigating factor). However, I've never been pushed to take a previa back without labs, and I'm always on L&D with 2 CRNAs in-house, which also colors my decision-making process (availability of extra helping hands). However, I usually have two large-bore PIVs in situ prior to incision.

Another point on hemorrhage with a previa - usually it's due to poor contraction of the lower uterine segment, which improves once hysterotomy is closed. So, it's not unusual to see some brisk blood loss up front once placenta is removed and closure is started, even though the top of the uterus is contracting nicely in response to the pitocin infusion.

 

[Yangkower]

I would have done regional (probably CSE), but the best thing to do is what you feel most comfortable with.

I recently had a patient with severe post partum hemorrhage. We gave 20 units of blood and never intubated. She was very calm and pleaded with us not to put her to sleep. OBs didn't have to open her up and were finally able to control bleeding with D&C. We just dosed epidural for the procedure. It was actually somewhat helpful/interesting in this "calm" patient to have the ability to evaluate her mental status throughout the whole ordeal.

We were ready to tube her should she ever become uncooperative.

 

[Planktonmd]

The airway looked good, so you did the right thing.
GA on a parturient is not as scary as many might have been taught provided you know what you are doing.
And it is definitely smarter than causing a sympathectomy on a patient who could have significant bleeding while a bunch of residents operate on her.

 

[Idiopathic]

I would have done regional (probably CSE), but the best thing to do is what you feel most comfortable with.

I recently had a patient with severe post partum hemorrhage. We gave 20 units of blood and never intubated. She was very calm and pleaded with us not to put her to sleep. OBs didn't have to open her up and were finally able to control bleeding with D&C. We just dosed epidural for the procedure. It was actually somewhat helpful/interesting in this "calm" patient to have the ability to evaluate her mental status throughout the whole ordeal.

We were ready to tube her should she ever become uncooperative.

how many units of ffp and how many platelets did you give

edit: and how fast did you give it all

 

[pgg]

And it is definitely smarter than causing a sympathectomy on a patient who could have significant bleeding while a bunch of residents operate on her.

Amen to that. Never regretted intubating someone, and planning for a sympathectomy when you think blood loss is coming never struck me as a great idea.

The only downside is a little volatile can go a long way with regard to uterine atony.

 

[Planktonmd]

The only downside is a little volatile can go a long way with regard to uterine atony.

And that's why you should use Ntrous oxide and very little vapor.

 

[G0S2]

this previa could also be a -creta of some sort.

Exactly. STAT CS (as opposed to elective CS) on a women who has been bleeding? First Q is how many CS in past, if any. I would have done GA. I know the Obs want a spinal and it did work out in the end but they consulted for an expert opinion and in my hands pt would go to sleep due to favorable airway. If horrible airway, neuraxial certianly comes into play.

Some of the previas ive done had imaging beforehand and at times the accreta/percreta was worse than imaging suggested. Sure you could do neuraxial in her and if the SHTF you can tube but I would rather tube under more controlled conditions.

 

[KLPM]

Why isn't there a "pent/prop sux tube" or "retrograde" suggestion in this thread yet?

 

[ssmallz]

Exactly. STAT CS (as opposed to elective CS) on a women who has been bleeding? First Q is how many CS in past, if any. I would have done GA. I know the Obs want a spinal and it did work out in the end but they consulted for an expert opinion and in my hands pt would go to sleep due to favorable airway. If horrible airway, neuraxial certianly comes into play.

Some of the previas ive done had imaging beforehand and at times the accreta/percreta was worse than imaging suggested. Sure you could do neuraxial in her and if the SHTF you can tube but I would rather tube under more controlled conditions.

Why does everyone think we need to intubate her if bleeding? She may not bleed a ton, and even if she does you can replace volume w/out intubating so we might not even have to intuabate her at all. She's got a good airway so I'm OK waiting until I need to intubate her rather than doing it from the start. I would be much more likely to intubate from the start if she had a bad airway then a good one given that it will be hard to tube her later if we need to. Another plus for regional is that it allows the OBs to take their time with the disection and uterine incision so that could mean less bleeding or bleeding that is easier to control. Also don't forget that VAs are a uterine relaxant will which will cause more bleeding. All in all I woulda just popped a spinal in and dealt with the airway if I needed to. IMO the bigger concern is IV access and do we place an A-line? GA vs RA = meh either way is fine

 

[pgg]

And that's why you should use Ntrous oxide and very little vapor.

Yes, GA for OB is one of two occasions nitrous is part of my default plan, for exactly that reason.

The other time I use nitrous is for mask inductions in cooperative kids.

 

[Sonny Crocket]

Why does everyone think we need to intubate her if bleeding? She may not bleed a ton, and even if she does you can replace volume w/out intubating so we might not even have to intuabate her at all. She's got a good airway so I'm OK waiting until I need to intubate her rather than doing it from the start. I would be much more likely to intubate from the start if she had a bad airway then a good one given that I will be hard to tube her later if we need to. Another plus for regional is that it allows the OBs to take their time with the disection and uterine incision so that could mean less bleeding or bleeding that is easier to control. Also don't forget that VAs are a uterine relaxant will which will cause more bleeding. All in all I woulda just popped a spinal in and dealt with the airway if I needed to. IMO the bigger concern is IV access and do we place an A-line? GA vs RA = meh either way is fine

I somewhat agree with smallz which is why I posted this thread. If you think about a C-section, we are doing commonly regional anesthesia for these with operators that can be unreliable and patients that typically can bleed a lot. At the same time, they are usually healthy young females that can generally tolerate a lot of Bloodloss.

I also tend to use intraoperative epidurals as soon as I can during big laparotomy cases. This is contrary to what I was taught during residency by my academic attendings. They would pretty much always Bolus the epidural only when the case was ending. Academic dogma as jet would say.

However, for this previa case, my intuition told me general.

 

[Yangkower]

how many units of ffp and how many platelets did you give

edit: and how fast did you give it all

Approx 2:1 RBC:FFP. 1 platelets.

Over 2 hours

 

[Jay K]

Geta

 

[drccw]

I think it also depends on how much help you have...
for instance, at my hospital in the middle of the night it's me.. and a bunch of L/D nurses/resitards... aka no help.. so if it's a case where I'm remotely worried about having to push blood/massive hemmorhage... I intubate from the start.. primarily because it's one last thing for me to have to worry about... when the fhit hits the san I don't want to have to worry about the airway....

drccw

 

[prongs]

I agree, GA planned from the start. Urgent enough to straight to OR, and I have no help. Good chance 33 weeker is going to need help from the start, and is not the greatest "birthing" experience anyway. Does she need to watch her baby be intubated? GA is safe and reliable even in parturients. I never regret having an ETT.

 

[Gern Blansten]

I would do a GETA. As mentioned, intentionally producing a sympathectomy in a patient who may soon hemorrhage may not be the best idea. As mentioned in another thread, you may get away with it a few times and think it seems safe, but then the one critical case comes along and you are left with your pants around your ankles.
I am not typically an academic dogma type. I think there are many ways to approach issues and I try to be respectful of other people's decisions. My confidence in the surgical ability of a run of the mill obstetrician to control the hemorrhage is obviously not as high as if it were a vascular or trauma surgeon. Then, as it has been mentioned before, many obstetrician's decisions get clouded by trying to save the uterus in a patient that is dying. It is how they are programmed and it can lead to delay in definitive control of the bleeding. I prefer to have as many advantages on my side as possible (lack of sympathectomy).

Overall, a good discussion of the issue.

 

[Idiopathic]

Approx 2:1 RBC:FFP. 1 platelets.

Over 2 hours

If you were confronted with a situation where someone asked if you would be comfortable losing (and replacing) 2 blood volumes in someone with a possibly questionable airway at baseline and they asked you to do it under regional, how would you respond?

 

[jetproppilot]

So I get a call last night from the OB resident that they want to section a bleeding placenta previa. She has just come in at 33wks. Healthy. 100kg but good airway. No lab work as she has just arrived to the hospital.

I meet them in the OR. Do a quick pre op. Her airway looks easy to intubate. She is in fact healthy without any medical problems. She says she has had a lot of bleeding. I check a quick BP. 127/62. Pulse 100.

I tell them, this is going to be general anesthesia. Start prepping the abdomen.

My thinking is that I don't know how much blood loss I am dealing with here and she is about to lose another litre with the section. Yes her vitals are stable but she could be compensating. If there is a lot of bleeding during the surgery, I would rather have a controlled airway and have one less thing to worry about. And I am dealing with obgyns so who knows what will happen.

They really pushed for a spinal because they wanted more time to get the baby out. The resident says "no, we want a spinal." I bypassed her immediately and talked to her attending which should have been done in the first place.

Everything goes fine, she is stable throughout. Baby did well.

Any thoughts on this case? Would you guys have done regional here?

Yes.

I would've put in a spinal.

That being said,

noone can argue with your thought process and your clinical plan.

In this Biz, there's many ways to skin a cat.