- Urgent Dilatation and Curettage for Retained Placenta
- Guidelines: Anesthesia for Retained Placenta
- Guidelines: Uterine Atony
- Obstetrical Hemorrhage Guidelines CheckList
- includes When to institute Massive Transfusion Protocol
compiled and adapted from University of Michigan, 2013
Two possible major complications with retained placenta are
▪ uterine atony, and
▪ maternal hemorrhage
Assess the volume status and Hct of the patient, and
determine from the obstetrician the degree of uterine exploration necessary to remove the placenta.
These two factors determine the type of anesthesia performed.
Anesthetic types comprise regional and general anesthesia. [Regional anesthesia does not cause uterine relaxation]
General anesthesia or IV NTG may need to be considered if uterine relaxation is necessary to remove the retained products.
When evaluating a patient with retained placenta take appropriate time to evaluate the volume status and if necessary start another intravenous line for appropriate hydration. Bear this in mind throughout the procedure and communicate with the obstetrician regarding uterine tone.
Drugs other than oxytocin (see Uterotonic Agents) may be necessary to establish uterine tone, and in extreme cases, a hysterectomy may be required to stop hemorrhage. O negative blood is always available from the Blood Bank (MMC: 662-2121, Mercy: 829-3283).
Prior to Induction
⁃ You must assess patient’s volume status carefully! How much bleeding has occurred? Is the patient orthostatic? What was the last hematocrit? Should you be spinning one now? What degree of uterine relaxation is required for the proposed procedure?
⁃ Assess IV access, if bleeding is severe you should have two large bore IVs in place
⁃ Confirm type and screen. Consider Crosmatch blood if bleeding is severe
⁃ Consider Bicitra 30 mL PO prior to induction
⁃ Apply basic monitors and 100% inspired oxygen by tight fitting circuit mask (i.e., begin to pre- oxygenate as if proceeding with a general anesthetic)
⁃ Get baseline vital signs, make sure IVs are patent and freely flowing
⁃ Make sure that blood, if appropriate, is in the OR refrigerator or in transit to the OR. Apply pressure bags to IVs as needed
A. Regional Anesthesia: Remember regional anesthesia does not cause uterine relaxation. Assess patient's volume status carefully prior to regional. (See additional anesthetic guidelines: Uterine Relaxation)
⁃ Spinal - Hyperbaric 0.75% Marcaine 1.2-1.6 cc
⁃ Epidural - An indwelling labor epidural may be used to provide anesthesia - 3% 2-Chloroprocaine - a T10 level is required; 10-15 mL; repeat q 40'.
B. General Anesthesia
⁃ Get Help
⁃ Rapid Sequence Induction with ETT: Consider Etomidate (0.2 mg/kg) or Ketamine (2 mg/kg) induction if patient is hypovolemic
⁃ Maintenance: 50% oxygen; 50% N2O; Isoflurane or sevoflurane as tolerated by the patient if uterine relaxation is required. Decrease to 0.25% MAC after uterus evacuated, consider switch to TIVA.
⁃ Emergence: Extubate awake
⁃ Start oxytocin infusion (30units/liter) after uterus evacuated. Have available Methergine (0.2mg) or Prostaglandin F2α (0.25mg).
C. Postoperative Period
Watch for continued vaginal bleeding.
Evaluate vital signs
A. Uterine massage by obstetrician
B. Oxytocin infusion 30 units/liter
C. Five (5) units oxytocin IVPush in addition to (B) (watch for hypotension)
D. 0.20 mg Methergine IM or intrauterine if (B) & (C) inadequate. Note: Rarely a request is made to give IV Methergine. Administer slowly in a dilute solution of 0.2 mg in 20 mL LR or .9NS. WATCH FOR HYPERTENSION
E. 0.25 mg prostaglandin F2 alpha IM or intrauterine (Carboprost, Hemabate) if B &C & D inadequate (NOT APPROVED FOR IV USE)
F. If General Anesthesia, go to TIVA and D/C halogenated agents.
G. Extreme uterine atony unresponsive to pharmacological treatment may involve an emergency hysterectomy