10/15/2015

1

Anesthesia Considerations in Obstetric Hemorrhage

Jennifer Lucero, MDAssistant Professor

Division of Obstetric Anesthesia

Post-PartumHemorrhage

• Atony• Retained Placenta• Placenta accreta• Defects in Coagulation• Vaginal laceration• Uterine Inversion

Common Things Being CommonMost Common Cause of Maternal Mortality Worldwide.• In the US roughly 3% rate of PPH• Increasing rates of transfusion Obstetrics

– Increased Cesarean Delivery– Abnormal Placentation

• Atony 80% of causes of Severe PPH

WHO Analysis of Causes of Maternal Death Systematic Review

Khan KS, Wojdyla D, Say L, et.al., Lancet 2006; 367: 1066-74

DevelopedCountries

Africa AsiaLatin Am.Caribbean

Hemorrhage 13.4% 33.9% 30.8% 20.8%

HypertensiveDisorders

16.1% 9.1% 9.1% 25.7%

Infections 2.1% 9.7% 11.6% 7.7%

Abortion 8.2% 3.9% 5.7% 12.0%

Embolism 14.9% 2.0% 0.4% 0.6%

10/15/2015

2

Flood KM, et al. Am J Obstet Gynecol. 2009; 200: 632

Accreta and Peripartum Hysterectomy

Creanga AA, et al. Obstet Gynecol. 2015; 125: 5-12

Anesthesiology 2014; 121:450-8

10/15/2015

3

Graphic Source: CMQCC California Maternal Quality Care Collaborative

Source:www.cmqcc.org/ob_hemorrhage

• Developed a Tool Kit for OB services:– Set of Best Practices (short summaries of key aspects of OB

hemorrhage)– Checklist for managing OB hemorrhage– Flow-Chart and Table Chart Summaries of approach– Implementation tools such as sample policies, procedures,

charting examples, implementation hints• All resources on-line at:

www.cmqcc.org/ob_hemorrhage

CMQCC Hemorrhage Task Force:

Source: CMQCC California Maternal Quality Care Collaborative

10/15/2015

4

• Coagulopathy persisted at ICU admissionPre-ICU resuscitation:

9 ± 1 L crystalloid12 ± 1 units PRBC5 ± 0.4 units FFP

FFP was not given until after 6 units PRBCs• In the ICU during resuscitation, patients received 10 ± 1 units FFP for coagulopathy; the ratio of FFP:PRBC was 1:1. Mean INR < 1.4 within 8 hours

� Volume restoration is accomplished by using thawed plasma as a primary resuscitation fluid in at least a 1:1 or 1:2 ratio with PRBCs� Crystalloid is minimized and serves mainly as a carrier� The blood bank activates the massive transfusion protocol and

deliver 6 units of plasma, 6 units of PRBCs, 6 packs of platelets, and 10 units of cryoprecipitate � Recombinant FVIIa is occasionally used

� “Using the damage control resuscitation approach, the lack of intraoperative coagulopathic bleeding has been remarkable, allowing surgeons to focus on surgical bleeding.”

� “Patients treated in this fashion almost always arrive in the ICU warm, euvolemic, and nonacidotic, with a normal INR and minimal edema.”

10/15/2015

5

� “In the majority of patients the abnormalities of the lethal triad are absent.”

� “These patients appear to be easily ventilated and more quickly extubated than patients with similar blood loss treated with the standard crystalloid resuscitation volumes and blood component ratios.”

Borgman et al. J Trauma 2007; 63:805-13

2003-2005 Retrospective Data From Iraq War

Volume 50, February 2010 TRANSFUSION

Plasma:RBC product transfusion ratios effect on patient survival

Survival versus ratio. (Dark Gray ) 24-hour survival; (Light Gray ) 30-day survivalVolume 50, February 2010 TRANSFUSION

PLT:RBC product transfusion ratios effect on patient survival

Survival versus ratio. (Dark Gray ) 24-hour survival; (Light Gray ) 30-day survival

10/15/2015

6

Principles to Reducing Maternal Hemorrhage

• Screen and identify patients at high risk• Active management of 3rd stage• Ongoing quantification of blood loss• Ongoing evaluation of patient’s vital signs• Sequential use of medications & procedures• Timely request for blood products • Massive transfusion protocol and team• Periodic hemorrhage drills and simulations

Adapted from CMQCC California Maternal Quality Care Collaborative – OB Hemorrhage Task Force 22Graphic Source: CMQCC California Maternal Quality Care Collaborative

Blood Loss:1000-1500 ml

Stage 2

SequentiallyAdvance through

Medications &Procedures

Pre-Admission

Time of admission

Identify patients with special consideration:Placenta previa/accreta, Bleeding disorder, or those who decline blood products

Follow appropriate workups, planning, preparing

of resources, counseling and notification

Screen All Admissions for hemorrhage risk:Low Risk, Medium Risk and High Risk

Low Risk: Draw blood and hold specimenMedium Risk: Type & Screen, Review Hemorrhage ProtocolHigh Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage Protocol

All women receive active management of 3rd stageOxytocin IV infusion or 10 Units IM, 10-40 U infusion

Standard Postpartum Management

Fundal Massage

Vaginal Birth:Bimanual Fundal MassageRetained POC: Dilation and CurettageLower segment/Implantation site/Atony: Intrauterine BalloonLaceration/Hematoma: Packing, Repair as RequiredConsider IR (if available & adequate experience)

Cesarean Birth:Continued Atony: B-Lynch Suture/Intrauterine BalloonContinued Hemorrhage: Uterine Artery Ligation

To OR (if not there); Activate Massive Hemorrhage Protocol

Mobilize Massive Hemorrhage Team TRANSFUSE AGGRESSIVELY RBC:FFP:Plts 6:4:1 or 4:4:1

IncreasedPostpartum Surveillance

Definitive SurgeryHysterectomy

Conservative SurgeryB-Lynch Suture/Intrauterine BalloonUterine Artery LigationHypogastric Ligation (experienced surgeon only)Consider IR (if available & adequate experience)

Fertility

Strongly

Desired

Consider ICUCare; Increased

Postpartum Surveillance

Verify Type & Screen on prenatal record;

if positive antibody screen on prenatal or current labs (except low level anti-D from Rhogam), Type & Crossmatch 2

Units PBRCs

CALL FOR EXTRA HELPGive Meds: Hemabate 250 mcg IM -or-

Misoprostol 600-800 SL or PO

Cumulative Blood Loss>500 ml Vag; >1000 ml CS>15% Vital Sign change -or-

HR ≥ 110, BP ≤ 85/45

O2 Sat <95%, Clinical Sx

Ongoing Evaluation:

Quantification of blood loss and

vital signs

Unresponsive Coagulopathy:After 10 Units PBRCs and full

coagulation factor replacement,may consider rFactor VIIa

HEMORRHAGE CONTINUES

Blood Loss:>1500 ml

Stage 3

Activate Massive

Hemorrhage Protocol

Blood Loss: >500 ml Vaginal

>1000 ml CS

Stage 1Activate

Hemorrhage Protocol

NO

Stage 0All Births

Transfuse 2 Units PRBCs per clinical signs

Do not wait for lab valuesConsider thawing 2 Units FFP

YES

YES NO

Ong

oing

Cum

ulat

ive

Blo

od L

oss

Eva

luat

ion

Cumulative Blood Loss>1500 ml, 2 Units Given,

Vital Signs Unstable

YESIncrease IV Oxytocin RateMethergine 0.2 mg IM (if not hypertensive)Vigorous Fundal massage; Empty Bladder; Keep WarmAdminister O2 to maintain Sat >95%Rule out retained POC, laceration or hematomaOrder Type & Crossmatch 2 Units PRBCs if not already done

Activate Hemorrhage ProtocolCALL FOR EXTRA HELP

Continued heavy bleeding

Increased Postpartum Surveillance

NO

NO

CONTROLLED

INCREASED BLEEDING

California Maternal Quality Care Collaborative (CMQCC), Hemorrhage Taskforce (2009) visit: www.CMQCC.org for detailsThis project was supported by funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division

Obstetric Emergency Management Plan: Flow Chart Format Release 2.0 7/9/2014

23Graphic Source: CMQCC California Maternal Quality Care Collaborative

Blood Loss:1000-1500 ml

Stage 2

SequentiallyAdvance through

Medications &Procedures

Pre-Admission

Time of admission

Identify patients with special consideration:Placenta previa/accreta, Bleeding disorder, or those who decline blood products

Follow appropriate workups, planning, preparing

of resources, counseling and notification

Screen All Admissions for hemorrhage risk:Low Risk, Medium Risk and High Risk

Low Risk: Draw blood and hold specimenMedium Risk: Type & Screen, Review Hemorrhage ProtocolHigh Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage Protocol

All women receive active management of 3rd stageOxytocin IV infusion or 10 Units IM, 10-40 U infusion

Standard Postpartum Management

Fundal Massage

Vaginal Birth:Bimanual Fundal MassageRetained POC: Dilation and CurettageLower segment/Implantation site/Atony: Intrauterine BalloonLaceration/Hematoma: Packing, Repair as RequiredConsider IR (if available & adequate experience)

Cesarean Birth:Continued Atony: B-Lynch Suture/Intrauterine BalloonContinued Hemorrhage: Uterine Artery Ligation

To OR (if not there); Activate Massive Hemorrhage Protocol

Mobilize Massive Hemorrhage Team TRANSFUSE AGGRESSIVELY RBC:FFP:Plts 6:4:1 or 4:4:1

IncreasedPostpartum Surveillance

Definitive SurgeryHysterectomy

Conservative SurgeryB-Lynch Suture/Intrauterine BalloonUterine Artery LigationHypogastric Ligation (experienced surgeon only)Consider IR (if available & adequate experience)

Fertility

Strongly

Desired

Consider ICUCare; Increased

Postpartum Surveillance

Verify Type & Screen on prenatal record;

if positive antibody screen on prenatal or current labs (except low level anti-D from Rhogam), Type & Crossmatch 2

Units PBRCs

CALL FOR EXTRA HELPGive Meds: Hemabate 250 mcg IM -or-

Misoprostol 600-800 SL or PO

Cumulative Blood Loss>500 ml Vag; >1000 ml CS>15% Vital Sign change -or-

HR ≥ 110, BP ≤ 85/45

O2 Sat <95%, Clinical Sx

Ongoing Evaluation:

Quantification of blood loss and

vital signs

Unresponsive Coagulopathy:After 10 Units PBRCs and full

coagulation factor replacement,may consider rFactor VIIa

HEMORRHAGE CONTINUES

Blood Loss:>1500 ml

Stage 3

Activate Massive

Hemorrhage Protocol

Blood Loss: >500 ml Vaginal

>1000 ml CS

Stage 1Activate

Hemorrhage Protocol

NO

Stage 0All Births

Transfuse 2 Units PRBCs per clinical signs

Do not wait for lab valuesConsider thawing 2 Units FFP

YES

YES NO

Ong

oing

Cum

ulat

ive

Blo

od L

oss

Eva

luat

ion

Cumulative Blood Loss>1500 ml, 2 Units Given,

Vital Signs Unstable

YESIncrease IV Oxytocin RateMethergine 0.2 mg IM (if not hypertensive)Vigorous Fundal massage; Empty Bladder; Keep WarmAdminister O2 to maintain Sat >95%Rule out retained POC, laceration or hematomaOrder Type & Crossmatch 2 Units PRBCs if not already done

Activate Hemorrhage ProtocolCALL FOR EXTRA HELP

Continued heavy bleeding

Increased Postpartum Surveillance

NO

NO

CONTROLLED

INCREASED BLEEDING

California Maternal Quality Care Collaborative (CMQCC), Hemorrhage Taskforce (2009) visit: www.CMQCC.org for detailsThis project was supported by funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division

Obstetric Emergency Management Plan: Flow Chart Format Release 2.0 7/9/2014

Graphic Source: CMQCC California Maternal Quality Care Collaborative

CMQCC Obstetric Care Summary

10/15/2015

7

Holcomb et al. JAMA 2015; 313: 471-82

� Multisite, RCT, 12 Level 1 Trauma Centers � 680 Severely Injured Patients� August 2012 – December 2013� Outcomes 24-hour and 30-day mortality

Holcomb et al. JAMA 2015; 313: 471-82

Holcomb et al. JAMA 2015; 313: 471-82

Considerations in Massive Transfusion Protocol - Continued

• Consider arranging for blood salvage• Place large bore IVs (16G-14G)• Place invasive monitoring (a-line & CVP)• Repeat labs frequently (CBC, ABG, lytes, iCa, coags)• Fluid warmers & forced air warmer for patient• Prime rapid infusion pump or pressure bags• Point of care testing (Hb, blood gas, coags, lytes)• Direct communication with blood bank & central lab

Gallos G., et. al. Semin Perinatol 33: 116-123. 2009SFGH Massive Transfusion Policy No 2.06CMQCC Hemorrhage Task Force. www.cmqcc.org

10/15/2015

8

• Prepare for general anesthesia• Vasopressors immediately available • All uterotonics immediately available• Supply of calcium chloride to prevent low ionized

calcium levels from rapid transfusion• Foley to measure urine & SCDs• Reserve ICU bed

Gallos G., et. al. Semin Perinatol 33: 116-123. 2009SFGH Massive Transfusion Policy No. 2.06CMQCC Hemorrhage Task Force. www.cmqcc.org

Considerations in Massive Transfusion Protocol - Continued

• Request additional blood products as needed in “packs” of correct ratio (Prbcs:FFP:Plts)

• Consider cryoprecipitate (Fibrinogen < 100 mg/dL)• Consider factor VIIa (off-label hemostatic use)

– Only after approximately 10 units prbcs and factor replacement• Person for recording/tallying blood products & EBL• Bring “Code Cart” into OR• Plan for Blood Bank to prioritize Transfusion labs• Make time to debrief after event with all disciplines

Gallos G., et. al. Semin Perinatol 33: 116-123. 2009; SFGH Massive Transfusion Policy No. 2.06; CMQCC Hemorrhage Task Force. www.cmqcc.org

Considerations in Massive Transfusion Protocol - Continued

Consideration of Cell Salvage

• Cell salvage in obstetrics should be considered in cases at risk for severe hemorrhage or for individuals in whom allogenic blood can not be used…- Placenta accreta / increta / percreta- Massive uterine fibroids- Jehovah’s Witnesses- Difficult cross-matching

Opinion Statements• “If the diagnosis or strong suspicion of placenta accreta is

formed before delivery…Cell saver technology should be considered if available as well as the appropriate location and timing for delivery…”

(American College of Obstetricians and Gynecologists (ACOG), Practice Bulletin, No. 76, October 2006, Postpartum Hemorrhage)

10/15/2015

9

Opinion Statements• “Cell salvage is recommended for women in whom an

intraoperative blood loss of more than 1500 ml is anticipated. Cell salvage should only be used by healthcare teams who use it regularly and have the necessary expertise and experience. Consent should be obtained and its use in obstetric patients should be subject to audit and monitoring.””

(RCOG Guideline No. 27, October 2005 – Placenta Previa and Placenta Accreta)

TOOLS TO HELP? SOME NEW AND SOME OLD

Role of Interventional Radiology

Uterine Artery Catheterization

Pledgets

Slurry

Coils

n-Butyl Cyanoacrylate

Embolization Agents

10/15/2015

10

IR for AtonyClinical Success

Study Year n Success %Ornan D et al.Obstet Gynecol

2003 28 96%

Boulleret C et al.CVIR

2004 35 100%

Zwart JJ et al.Am J Obstet Gynecol

2009 114 85%

Kirby JM et al.JVIR

2009 43 79%

Obstet Gynecol 2009;113:992-9

• 100 patients over 13 years

• Outcomes– Clinical success in 89 patients (89%)– 7 of the 11 patients (64%) underwent hysterectomy– Buttock necrosis (1%)

– Puncture site hematoma (1%)

• Conclusion– Patients who failed embolization had higher rate of estimated

blood loss (more than 1,500 mL) and higher transfusion requirements (more than 5 units of PRBCs)

• 28 studies were included in the systematic review

• 460 out of 503 (91.45%) women resumed menstruation

• 168 women desired another pregnancy– 126 (75%) achieved conception following embolization

• Conclusion: Uterine-sparing radiological techniques do not appear to adversely affect the menstrual and fertility outcomes in most women; however, the number and quality of the available evidence is of concern

BJOG 2014;121:382-8

Interventional RadiologyInvasive Placenta

• Different disease process than uterine atony

• Requires a multidisciplinary team– Maternal fetal medicine (OB team)– Surgical gynecology (gyn onc)– Interventional radiology

– Diagnostic radiology (antenatal MRI)– Scheduled deliveries– Use of multidisciplinary team is associated with a significant

reduction in morbidity (p=0.005)

• Need randomized clinical trials/registry dataJ Obstet Gynaecol Can 2013; 35:417–425

10/15/2015

11

rFVIIaCost: ~ $5000.00

•A review of the FDA’s Reporting System from 1999 to 2004•A total of 431 AE reports for rFVIIa were found, of which 168 reports described 185 thromboembolic events•Unlabeled indications accounted for 151 of the reports, most with active bleeding (n=115)•In 36 (72%) of 50 reported deaths, the probable cause of death was the thromboembolic event•Conclusion: RCTs are needed to establish the safety and efficacy of rFVIIa in patients without hemophilia

� A 2008 review noted 118 cases of massive postpartum hemorrhage treated with rFVIIa.�Median dose was 71.6 mcg/kg� rFVIIa was reported to be effective in stopping or reducing bleeding in 90% of reported cases� Caution in interpreting results as they are from uncontrolled studies� RCTs needed to determine efficacy, dose, & safety

Review of Factor VIIa in Severe Obstetric PPH

Franchini M., et. al., Semin Thromb Hemost 2008; 34:104-112

Butwick et al. Curr Opin Anesthesiol 2015; 28;275-84

�Fibrinogen

10/15/2015

12

Charbit et al. J Thromb Haemost 2007; 5:266-273 Charbit et al. J Thromb Haemost 2007; 5:266-273

ThromboelastographyROTEM- Thromboelastometry (Germany)

ROTEM

10/15/2015

13

Butwick et al. Curr Opin Anesthesiol 2015; 28;275-84

PROTOCOL SUMMARY

FULL TITLE OF STUDY: Tranexamic acid for the treatment of postpartum haemorrhage: An international, randomised, double blind, placebo controlled trial

SHORT TITLE: WORLD MATERNAL ANTIFIBRINOLYTIC TRIAL

TRIAL ACRONYM: THE WOMAN TRIAL

PROTOCOL NUMBER: ISRCTN76912190

EUDRACT NUMBER: 2008-008441-38 CLINICALTRIALS.GOV ID: NCT00872469

10/15/2015

14

Summary• Recognition and Preparedness• Multidisciplinary Team • Good Communication and Team Work• Massive Transfusion Protocols• Role of Cell Salvage in Predictable

Hemorrhage• Potential Role of Devices and Pharmacologic

Interventions