**4. Management of massive obstetric hemorrhage**

**Definition** Blood loss >2000 mL (or > 30% of blood volume) is defined as massive obstetric hemorrhage (MOH). There is a tendency to underestimate rather than overestimate the actual blood loss.

Types MOH can occur either in the antepartum period secondary to placental abruption, placenta previa or accrete or in the postpartum period due to the '4Ts (tone, trauma, tissue and thrombin). Other rare obstetric disorders such as AFE or acute inversion of the uterus may also present with MOH.

Incidence PPH occurs in 2–10% of delivers but the incidence of major obstetric hemorrhage is estimated to be 3.7–5 per 1000 maternities.

It is estimated that every year about 356,000 women die during childbirth around the world. In the developing world the PPH occurs in about 4–10% of deliveries. The last report of the Confidential Enquires into Maternal Deaths in the UK has listed PPH as the third most common cause of maternal mortality [5]. Massive blood loss leads to sudden and rapid cardiovascular decompensation and coagulopathy.

### **4.1 Key etiological factors**

#### Antepartum


• Morbidly adherent placenta (accrete, increate, percreta)

### Intrapartum


### **4.2 Key points to massive obstetric hemorrhage**

Visible Blood loss >2 L.

Ongoing bleeding (> 150 mL/min).

Loss of >30% of blood volume as assessed by visible blood loss (estimated blood loss or EBL expressed as percentage of estimated blood volume = EBL/100 mL/kg).

Rule of 30 (Rise of pulse >30/minutes, drop in systolic blood pressure by 30 mmHg, increased respiratory rate > 30 per minute, a drop in hematocrit [packed cell volume]by 30%), which is suggestive of at least 30% loss of blood volume.

Shock index (pulse rate/systolic blood pressure) 0.9. Normal Shock Index in

pregnancy is between 0.7 and 0.9, as the pulse rate is less than systolic blood pressure. Tense, tender abdomen with evidence of intrauterine death (massive placental

abruption).
