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
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
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