Know your enemy and know thyself

Yasuhiro Morimoto, MD

Department of Anesthesia, Ube Industries Central Hospital, 750 Nishikiwa Ube Yamaguchi (Japan); E-mail: yasumorimo@gmail.com


This editorial complements an invited review by Ghodki et alon ‘Obstetric hemorrhage: anesthetic implications and management’ in this special issue on ‘Perioperative Management of Obstetric Emergencies’. The author emphasizes on the importance of understanding the pathogenesis, early recognition and adequate preparation in each type of hemorrhage. Newer therapies have been mentioned.
Key words: Hemorrhage, obstetric; Blood loss; Cesarean section
Citation: Morimoto Y. Know your enemy and know thyself. Anesth Pain & Intensive Care 2014;18(4):235-36
The ancient Chinese military strategist Sun Tzu said ‘Know your enemy, know yourself, and you shall not fear a hundred battles’. In this issue, Ghodki et al1 review the nature of obstetric hemorrhage and strategies for its treatment.

First, it is necessary to understand how obstetric hemorrhage differs from other categories of hemorrhage. The authors summarize the differences in 4 points: inability to recognize risk factors; difficulties in accurately estimating blood loss; difficulties in achieving an early diagnosis; and the rich blood flow to the uteroplacental unit.

There are several types of obstetric hemorrhage; an awareness of each type is also important. Antepartum hemorrhage is defined as hemorrhage occurring after 24 weeks of gestation, but before delivery. Causes of antepartum hemorrhage include placental abruption and hemorrhage associated with placenta previa. Careful anesthetic planning prior to Cesarean section is crucial in these patients, as the choice of anesthetic agent and the intraoperative treatment of blood loss have an important influence on outcome.

Intrapartum hemorrhage occurs in 1 in 2000 deliveries; the most common causes are abnormal placentation and uterine rupture.

Postpartum hemorrhage is defined as hemorrhage occurring after delivery. Postpartum hemorrhage may be caused by pathology of one or more of the ‘4Ts’ (2): tone, tissue, trauma, and thrombin. It is important to ascertain the cause of the hemorrhage and the appropriate treatment. Tone is necessary for contraction of the uterus. Approximately 70% of cases of postpartum hemorrhage are considered to be secondary to uterine atony. The appropriate use of uterotonic drugs is important in the management of reduced uterine tone. Retention of tissue within the uterus will disrupt uterine constriction; in some cases, surgical treatment will be required. Trauma during the delivery may also cause postpartum hemorrhage. In this case, surgical treatment is generally required. Finally, thrombin is essential for the coagulation of blood. There are 2 types of coagulopathy; the first is due to consumption of coagulation factors, as occurs in placental abruption and amniotic embolism. Replacement of coagulation factors, including administration of fresh frozen plasma, is essential. The second cause of postpartum coagulopathy is dilution secondary to massive fluid infusion. In such cases, transfusion of red blood cells is essential.

Anesthetists have an important role in the treatment of obstetric hemorrhage, which includes taking on the role of medical team leader. In order to lead effectively, thorough knowledge, quick judgment, and communication skills are also necessary. Simulation training involving all medical staff, including those working in the operating theatres, those involved in blood transfusion services, and blood examination staff might be useful.

In summary, knowing the nature of the disease, knowing the strategy which we anesthesiologist have, and then treat the patients successfully. I am sure that this review will help us to improve maternal mortality.


  1. Ghodki PS, Sardesai SP. Obstetric hemorrhage: Anesthetic implications and treatment. Anaesth Pain & Intensive Care 2014;18(4):___
  2. Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician 2007;75:875-82 [PubMed] [Free full text]