Hematologic management of massive PPH Mehran Karimi Professor of Pediatric Hematology- Oncology...
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- Slide 1
- Hematologic management of massive PPH Mehran Karimi Professor
of Pediatric Hematology- Oncology Shiraz University of Medical
Science 29 Khordad,Shiraz
- Slide 2
- postpartum hemorrhage (PPH) PPH is the loss of 500 ml or more
of blood from the genital tract within 24 hours of the birth of a
baby PPH can be minor (5001000 ml) or major (more than 1000 ml) PPH
is the most common cause of maternal death worldwide PPH is
responsible for 25% of the deaths of an estimated 358000 women
world-wide each year WHO guidelines for the management of
postpartum haemorrhage and retained placenta, 2009
- Slide 3
- Severe PPH Pale, sweating PR > systolic blood pressure Blood
loss: watery, non clot Decreased Hb more than 2-4 gr/dl from
baseline (anemia is a risk factor for PPH) Decreased HR + decreased
BP when blood loss > 1500 mls
- Slide 4
- Hematological Changes in Pregnancy Non pregnant: < 1% of her
cardiac output flows through her uterus but at the end of pregnancy
uterine blood flow accounts for 15% of CO 40% expansion of blood
volume by 30 weeks 600 ml/min of blood flows through intervillous
space Appreciable increase in concentration of Factors I
(fibrinogen), VII, VIII, IX, X Plasminogen appreciably increased
Plasmin activity decreased Decreased colloid oncotic pressure
secondary to 25% reduction in serum albumin
- Slide 5
- Blood Products Utilization Local protocols are helpful Dont
wait for lab abnormalities if actively bleeding! Massive hemorrhage
without replacement of coagulation factors (FFP) will result in
coagulation abnormalities
- Slide 6
- Causes and treatment of massive PPH Causes Uterine atony: The
most common cause of PPH that bleeding leading to coagulopathy
Incisions and lacerations Hemostatsis defect Treatment Massage,
remove clot, uterotonic agent, uterine tamponade Surgical repaire
Factor replacement Early hysterectomy indications : 1- Placenta
accreta 2- Uterine rupture
- Slide 7
- Goals in management of a postpartum hemorrhage Journal of
Thrombosis and Haemostasis, 2011; 9: 14411451
- Slide 8
- Blood components for prevention of massive bleeding Whole blood
and RBC Fresh frozen plasma (FFP) Cryopercipitate Platelets
Fibrinogen rFVIIa
- Slide 9
- Main therapeutic goals of management of massive blood loss
crystalloid,colloid, blood transfusionRestore circulating volume
Early surgical or obstetric interventionArrest bleeding >
8g/dlHaemoglobin > 75000//Platelets count < 1.5 x mean
controlProthrombin Time (PT) < 1.5 x mean controlActivated
Partial Thromboplastin time (PTT) > 1.5 g/lFibrinogen Treat
underlying cause (shock, hypothermia, acidosis, hypotension) Avoid
DIC
- Slide 10
- Blood Product Utilization ProductContentsVolumeEffect Whole
Blood500ml Hct 3% PRBCsRBCs, WBCs, few plasma proteins 300ml Hct 3%
PlateletsPooled concentrate 1 unit = 6 pack 50ml PLT 5000 30000
FFPFibrinogen, ATIII, clotting factors, plasma 250ml fibrinogen 5-
10mg/dl CryoprecipitateFibrinogen, Factor VIII, XIII, vWF 40ml
fibrinogen 5- 10mg/dl
- Slide 11
- blood components When the blood loss reaches about 4.5 liters
(80% of blood volume) and large volumes of replacement fluids have
been given, there will be clotting factor defects and blood
components should be given transfusion of coagulation factors, up
to 1 liter of FFP and 10 units of cryoprecipitate may be prevent
bleeding Critical levels of fibrinogen rich after a loss only 140%
of the calculated blood volume Critical levels of prothrombin, FV,
FVII and PLT rich after a loss only 200% of the calculated blood
volume
- Slide 12
- Fluid therapy and blood products transfusion CrystalloidUp to 2
liters Hartmann's solution ColloidUp to 12 liters colloid until
blood arrives BloodCrossmatched. If crossmatched blood is still
unavailable, give uncrossmatched group-specific blood OR give 'O
RhD negative' blood Fresh frozen plasma4 units for every 6 units*
of red cells or prothrombin time/activated partial thromboplastin
time >1.5 x normal (1215 ml/kg or total 1 litre) Platelets
concentratesIf platelet count
- rFVIIa rVIIa should be considered in management of massive PPH
Timing ? Prior to hysterectomy unless bleeding surgical Optimal
dose ? 90mcg/Kg two doses 15-30 minutes apart Ensure Platelet >
50 and Fibrinogen > 2gm/l Grade C-IV evidence
- Slide 22
- Algorithm approach of rFVIIa in PPH P/E: R/O GYN problem If :
-PLT > 50000 - FIB> 1 gr/dl - Normal PT - PH 7.2 - Temp 35
Hematology consult : rFVIIa: 40-60 g/kg *By: MOH
- Slide 23
- Conclusion Severe bleeding because of placenta accreta or
uterine rupture cause early hysterectomy (HST) Before early
hysterectomy: compression suture or balloon tomponade is indicated
Uterine Atony: bleeding persist in spite of correction:
I.Coagulopathy II.Hypothermia rFVIIa (max: 2 doses) III.Acidosis
and hypocalcemia 90 g/kg before HST
- Slide 24
- Case presentation The patient was a 37 years old women She had
normal first vaginal delivery without history of coagulation
disorders Three months after second normal vaginal delivery she
developed severe skin ecchymosis and bleeding of right upper and
lower extremities (compartment syndrome)
- Slide 25
- What is your next evaluation for definite diagnosis? 1.VWF Ag
2.Factor IX assay 3.Factor XI assay 4.Inhibitor assay Inhibitor
assay
- Slide 26
- Case presentation Many works up was done to finding the cause
of her bleeding tendency Coagulation tests were: PT: 13 sec, INR: 1
PTT: 55 sec (mixing PTT:51 sec) Serum FVIII level: 0.14% Serum
FVIII inhibitor level: 145 BU Serum FIX inhibitor level: normal
Serum FX inhibitor level: normal ANA: neg dsDNA: neg
- Slide 27
- What is your definite diagnosis in this case? 1.Hemophilia A
2.Hemophilia B 3.Acquired Hemophilia A 4.VWD Acquired Hemophilia
A
- Slide 28
- What is treatment of bleeding in this case? 1.FVIII concentrate
2.IVIG 3.Recombinant FVIIa 4.FEIBA 5.3 and 4 6.All Recombinant
FVIIa & FEIBA Recombinant FVIIa & FEIBA
- Slide 29
- Case presentation (treatment) The patient admitted in the
hospital and the recombinant FVII 90 u/kg (every 4 hrs for three
times) with partial response So the frequency was changed to every
2 hrs for 24 hrs with complete response and then every 4-6 hours
for the second day The plasmapheresis was also done without any
response Immune suppressive treatment was started with prednisolon
1 mg/kg/d and cyclophosphamide 2 mg/kg/d at the same time. The
coagulation tests resulted to normalization after completion of
treatment
- Slide 30
- Case presentation (follow up) The bleeding symptom was stopped
after 2 days of acute treatment FVIII level: 30% FVIII inhibitor:
40 BU PTT: 45 sec The patient was discharged with continue
prednisolone and cyclophosphamide for a period of 6 weeks with
complete response
- Slide 31
- Thank you karimim@sums.ac.ir