Anesthetic Management: Term Primigravida with IUD + Bleeding in Shock + Suspected Uterine Rupture

1. Hemorrhagic shock (class III/IV)
2. A full stomach / aspiration risk
3. A dead fetus (no fetal considerations limiting your drug choices)
4. Possible uterine rupture requiring immediate laparotomy
5. Potential coagulopathy (DIC from IUD)

STEP 1 - Rapid Simultaneous Assessment (< 5 minutes)

• Class III (30-40% loss, 1500-2000 mL): BP dropped, HR >120, confused - needs urgent surgery
• Class IV (>40% loss): BP very low/unrecordable, HR >140, unconscious - exsanguinating, no time to lose

STEP 2 - Simultaneous Resuscitation (Do Not Delay Surgery)

• 2 large-bore IV lines (14-16G) in antecubital fossae
• Consider intraosseous access if IV fails
• Warmed Balanced crystalloid (Hartmann's / Ringer's Lactate) - limit to 1-1.5L, do NOT over-resuscitate with crystalloids (worsens coagulopathy, hypothermia, acidosis - the "lethal triad")
• Target permissive hypotension: MAP 50-65 mmHg until surgical bleeding control (avoid aggressive BP normalization as it dislodges clots)
• Activate Massive Transfusion Protocol (MTP) immediately:
  • Packed RBC : FFP : Platelets in 1:1:1 ratio (evidence-based from PROPPR trial)
  • O-negative blood if crossmatch not ready
  • Tranexamic acid (TXA) 1g IV over 10 min - GIVE IMMEDIATELY (WOMAN trial showed 31% reduction in death from bleeding if given within 3 hours; no adverse events)
  • Target: Hb ≥7, platelets ≥50,000, fibrinogen ≥200mg/dL, PT/aPTT <1.5x normal
• 10% Calcium gluconate 10 mL IV - correct hypocalcemia from massive transfusion
• Keep patient warm - warm fluids, forced air warming blanket (hypothermia <35°C worsens coagulopathy)
• Foley catheter for urine output (target >0.5 mL/kg/hr)
• Nasogastric tube to decompress stomach if time permits

STEP 3 - Anesthetic Plan: GENERAL ANESTHESIA (GA) is Mandatory

Why NOT Regional Anesthesia (spinal/epidural)?

• Sympathetic blockade will catastrophically drop BP further (vasodilation + reduced cardiac output)
• Coagulopathy makes neuraxial block dangerous (epidural hematoma risk)
• Patient may be unconscious or uncooperative
• Epidural/spinal onset is too slow for an exsanguinating patient

Anesthetic Technique: MODIFIED RAPID SEQUENCE INDUCTION (RSI)

Pre-oxygenation

• 100% O2 for 3-5 minutes (or 8 deep breaths if no time)
• Elevate head of bed 20-30 degrees (reduces aspiration risk, improves FRC)
• Full-term patients have reduced FRC + increased O2 consumption - desaturate FAST
• Apply cricoid pressure (Sellick's maneuver) before induction

Induction Agent - KEY DECISION based on hemodynamic status:

• Maintains/elevates BP via sympathomimetic effect
• Provides analgesia
• Is a bronchodilator
• Has a rapid onset (60-90 seconds)

Neuromuscular Blockade

• Succinylcholine 1.5 mg/kg IV - still the gold standard for RSI (fastest onset, shortest duration)
  • Check: no history of malignant hyperthermia, pseudocholinesterase deficiency, hyperkalemia (burns, crush injury, denervation)
• Alternative: Rocuronium 1.2 mg/kg (high-dose for RSI) with sugammadex 16 mg/kg available for reversal

Intubation

• Video laryngoscopy preferred if available (airway edema is common in term pregnancy)
• Have difficult airway cart ready (obstetric patients have higher failed intubation rate - 1:300 vs 1:3000 in general surgical patients)
• Cuffed ETT size 7.0-7.5
• Confirm position: capnography + chest auscultation
• Release cricoid pressure only after ETT cuff inflated and position confirmed

STEP 4 - Maintenance of Anesthesia (Intraoperative)

• Fentanyl 1-2 mcg/kg IV after airway is secured and BP stabilized
• Since fetus is dead, no concern about neonatal respiratory depression

STEP 5 - Vasopressors & Cardiovascular Support

• Ephedrine (mixed alpha+beta): 6-12 mg IV bolus - good first-line for moderate hypotension in obstetric patients; maintains uterine blood flow
• Phenylephrine (alpha agonist): 50-100 mcg IV bolus - can use but may cause reflex bradycardia and reduce cardiac output; better in spinal-induced hypotension than hemorrhagic shock
• Norepinephrine infusion (0.1-0.3 mcg/kg/min): preferred vasopressor in hemorrhagic shock once resuscitation underway
• Vasopressin 0.03-0.04 units/min if refractory shock
• Have Atropine 0.6 mg and Adrenaline 1 mg drawn up and ready in case of cardiac arrest

STEP 6 - Surgical Priorities (Coordinated with Surgeon)

1. Emergency laparotomy (midline incision - fastest access)
2. Gain immediate control of bleeding (manual compression, then vascular control)
3. Repair vs. hysterectomy: In primigravida, surgeons attempt repair if feasible; however if rupture is extensive, peripartum hysterectomy is definitive
4. Uterotonic agents after delivery/control:
   • Oxytocin 10 units slow IV (never rapid IV bolus - causes hypotension)
   • Ergometrine 0.25 mg IM (avoid in hypertension)
   • Misoprostol 800-1000 mcg rectal/sublingual
   • Carboprost (PGF2alpha) 0.25 mg IM every 15 min if atony persists
5. Pelvic packing for diffuse coagulopathic ooze
6. Bakri balloon if uterus preserved
7. B-Lynch suture for uterine atony after repair

STEP 7 - Coagulopathy Management (DIC from IUD)

• Serial coag tests every 30-60 min intraoperatively
• Fresh Frozen Plasma (FFP) - 10-15 mL/kg
• Cryoprecipitate - if fibrinogen <150 mg/dL (contains fibrinogen + factor VIII + vWF)
• Platelet concentrate - if <50,000/mm3
• TXA 1g IV (antifibrinolytic) - give early if not already given
• Recombinant Factor VIIa (rFVIIa, 60 mcg/kg) - only if all above fail, surgical bleeding is controlled, and temperature/pH are corrected

STEP 8 - Monitoring

STEP 9 - Avoid the "Lethal Triad"

HYPOTHERMIA (<35°C) + ACIDOSIS (pH <7.2) + COAGULOPATHY = DEATH

• Warm ALL fluids and blood products
• Warm the OR to 26°C
• Treat acidosis with bicarbonate if pH <7.1 (after surgical control)
• Correct coagulopathy as above

STEP 10 - Postoperative ICU Care

• Transfer to ICU intubated if:
  • Still hemodynamically unstable
  • Ongoing coagulopathy
  • Large transfusion requirement (>10 units pRBC)
  • Hypothermic, acidotic
• Continue vasopressor support as needed
• Ventilate protectively (6 mL/kg IBW, PEEP 5-8 cmH2O)
• Rewarming protocol
• Serial coag tests + lactate monitoring
• Extubate only when: hemostasis achieved, coagulopathy corrected, hemodynamically stable, awake and following commands
• Grief counseling and psychological support for the mother after recovery (loss of baby)

Summary: Anesthetic Algorithm at a Glance

CALL FOR HELP → 2x large-bore IV → O-negative blood → MTP activation → TXA 1g IV
       ↓
Preoxygenate 100% O2 → Cricoid pressure
       ↓
RSI: Ketamine 1-1.5 mg/kg + Succinylcholine 1.5 mg/kg
       ↓
Intubate (video laryngoscopy preferred) → Confirm → Release cricoid
       ↓
Maintain: low-dose volatile / ketamine infusion + fentanyl
       ↓
Vasopressors (norepinephrine infusion) + 1:1:1 blood products
       ↓
Monitor: A-line, CVP, temp, urine output, TEG/ROTEM, serial ABG
       ↓
Avoid lethal triad → ICU postop → Extubate when stable

• Morgan & Mikhail's Clinical Anesthesiology 7e (9781260473797) - Chapter on Obstetric Anesthesia
• Creasy & Resnik's Maternal-Fetal Medicine, Principles and Practice - Chapters on Hemorrhage in Peripartum Period and Massive Transfusion Protocol
• WOMAN Trial (TXA in PPH) - Lancet 2017; The Lancet's WOMAN Trial Collaborators
• PROPPR Trial (1:1:1 ratio MTP) - JAMA 2015

When to Shift to OT: The Core Principle

There is NO vitals threshold to "wait for" before shifting to OT.

The Decision Framework: Shift to OT When...

The surgical indication is confirmed (or strongly suspected):

What "Minimum Preparation" Means Before Shifting (Minutes, NOT Hours)

The "Permissive Hypotension" Concept During Transfer

• Dislodge forming clots ("pop the clot")
• Worsen coagulopathy (dilutional)
• Cause hypothermia
• Worsen acidosis

When Do You NOT Shift Immediately?

Practical Decision Checklist: "Go/No-Go" for OT Shift

✅ Suspected uterine rupture + hemorrhagic shock diagnosed?  → GO
✅ At least 1 IV access with fluids/blood running?            → GO
✅ O2 on patient?                                             → GO
✅ Anesthetist + surgeon ready in OT?                         → GO
✅ TXA given (or running)?                                    → GO (give in OT if not done)

❌ Waiting for BP to reach 100/70?      → WRONG - do NOT wait
❌ Waiting for Hb result?               → WRONG - shift, treat empirically
❌ Waiting for crossmatch?              → WRONG - use O-negative blood
❌ Waiting for coag results?            → WRONG - treat empirically in OT
❌ Waiting for senior surgeon to arrive? → WRONG (unless truly 2 minutes away)

Summary Table

"Do not resuscitate to go to the OT. Go to the OT to resuscitate."