obst hge

4/5/2012 Dr.Nesrine El-Refai 1

Updates in Management of

Obstetric Hemorrhage

By

Dr. Nesrine EL-Refai

•Professor of Anesthesia .Cairo University

•Member of Obstetric Anesthesia Committee of WFSA

4/5/2012 2

Objectives

Definition & Types of Obstetric

Hemorrhage.

Guidelines for Management of

Bleeding Parturient.

New trends in Obstetric Hge

management.

Introduction

• “Lots of people confuse destiny with bad management.”

-Kin Hubbard

• To avoid “bad management” We should know:• Risk factors

• Diagnostic criteria

• Obstetric management

• Anesthetic management


Parents’ Dream..

Obstetric Hemorrhage may change dream of safe labor into Nightmare!!!

Management of Obstetric

Hemorrhage

�Definition of Massive Obstetric

Hemorrhage:

1. Blood loss from the uterus or genital

tract >1500ml.

2. A decrease in haemaglobin of > 4 g/dl

3. Acute transfusion of > 4 units blood


Types of Obstetric Hemorrhage

I. Antepartum Haemorrhage

II. Intrapartum Haemorrhage.

III. Postpartum Haemorrhage.

Clinical Findings in Obstetric Hemorrhage. Blood Volume

LossBlood Pressure

(systolic)Symptoms and

SignsDegree of Shock

500-1000 mL(10-15%)

Normal Palpitations, tachycardia, dizziness

Compensated

1000-1500 mL(15-25%)

Slight fall (80-100 mm Hg)

Weakness, tachycardia, sweating

Mild

1500-2000 mL(25-35%)

Moderate fall (70-80 mm Hg)

Restlessness, pallor, oliguria

Moderate

2000-3000 mL(35-50%)

Marked fall (50-70 mm Hg)

Collapse, air hunger, anuria

Severe

( Int J Gynaecol Obstet. May 1997)

Obstetric Haemorrhage

1) Antepartum haemorrhage:

Placenta previa &

Abruptioplacentae


Types of Placenta Previa

Type 1 :lateral or low lying

Type2: Marginal

Type3: incomplete

centralis

(partial)

Type4:

Complete centralis

Varieties of Bleeding:

• Revealed

• Concealed

• Mixed


Intrapartum haemorrhage

(uterine rupture)

Increased mortality due to:

1) Haemorrhage.

2) DIC

3) Pulmonary embolism.

4) Sepsis.4/5/2012 Dr.Nesrine El-Refai 14


Post Partum Hemorrhage

Postpartum hemorrhage (PPH) is

responsible for around 25% of maternal

mortality worldwide (WHO, 2007),

Reaching as high as 60% in some countries.

Definition

PPH is defined as blood loss of more than

500 mL following vaginal delivery or more

than 1000 mL following cesarean delivery.

1ry or early: A loss of these amounts within

24 hours of delivery .

2ry or late :occurs 24 hours after delivery.

(John Smith,2012)

Causes of PPH

Tone: Uterine atony& uterine inversion.

Tissue : Retained placenta & Placenta

accreta.

Trauma: Genital tract lacerations.

Thrombin: Coagulation disorder.


Atony

Inversion

Retained placenta

Placenta accreta

• Genital tract laceration

Treatment of patients with PPH

2 major components:

(1) Resuscitation and management of

obstetric hemorrhage and shock .

(2) Identification and management of the

underlying cause(s) of the hemorrhage.

Placenta Accreta

–Accreta = adherent to endometrial cavity

–Increta = placental tissue invades

myometrium

–Percreta = placental tissue grows through

uterine wall



Uterine Inversion

Neurogenic ShockTreatment:

Reposition of the uterus.

G.A: with inhalational anesthetic.

Nitroglycerine

Fluid resuscitation

Uterotonic drugs after reposition.


Replacement of inversion


Uterine AtonyBimanual massage for atony


Uterine Atony versus Inversion

• Uterine Atony

1. Hemorrhagic shock (up to 1 liter blood.)

2. Management: Message Embolization laparotomy.

3. G.A. with TIVA.

• Uterine Inversion

1. Neurogenic shock

2. Management: Repositioning of

uterus. Nitroglycerine.

3. G.A. with volatile agent for reduction of the uterus.



How to manage Emergency Hge??

Methergine Vasopressin

Misoprostol Recombinant human factor VIIa*

BLOOD BANKING

Cryoprecipitate Platelets

Fresh-frozen plasma Red blood cells

SURGERY

Repair of lacerations Ligation of the hypogastric artery

B-Lynch suture Other uterine compression sutures

Hysterectomy, supracervical Pelvic packing

Hysterectomy, total Pelvic tourniquet

NONSURGICAL PROCEDURES

Bakri balloon Uterine packing

Uterine balloon tamponade

INTERVENTIONAL RADIOLOGY

Uterine artery balloons Uterine embolization

CONSULTATION

Anesthesiologist–intensivist Trauma surgeon

Gynecologic oncologist Urologist

Interventional radiologist

*Not approved by the FDA for this indication.

Shall We Discuss all these items?


Shall We Discuss all these

items?

Guidelines for Management of

Bleeding Parturient

I. Early during labour

II. Around time of delivery

III. Intraoperative

management


I. Early during labour

Early perinatal care.

Correction of coagulopathy: fibrinogen level detects PPH severity.

Preoperative autologous donation (PAD). OR Acute normovolemic

hemodilution.(ANH).

Prevention & early expectation of Hemorrhage!!


Uterotonic Drugs:

• 10 U of oxytocin in 500 mL of IV fluid.

• 200-250 mcg of ergonovine IM

• 250 mcg of 15-methyl prostaglandin IM.

• 100 microgram of oxytocin analogue

(carbetocin).

Management of Massive Haemorrhage

• Preparation• Identify patients at risk

• Large bore IV access x 3

• Blood available

• Avoid caval obstruction; supplemental O2

• Foetal monitoring

• Search for evidence of DIC

Peripheral blood smear

PT, PTT, Platelet counts, Fibrinogen level; D-dimer level

Specific factor analyses

Bedside coagulation testing (TEG)


Immediate aggressive volume replacement

– Crystalloid Vs Colloid ??

– Consider PRBC once blood loss > 2,000mL

Type specific or Type O blood availablity.

DIC ,once >80% of blood volume replaced

– Platelets - if < 20,000/mm3 or higher if bleeding

persisting

– FFP only to correct measured clotting

abnormalities

– Cryoprecipitate4/5/2012 Dr.Nesrine El-Refai 36

Volume Replacementnt

Uterine atony

Uterine Massage;

Oxytocin

Surgical exploration

Selective embolization of Uterine, internal iliac or internal

pudendal artery

Factor 7a

–Rescue therapy in severe haemorrhage


Specific Therapies

End Point Of Resuscitation

Cardiac Index =3 L/min/m2.

Systemic O2 delivery(DO2) >500ml/min/m2

Systemic O2 uptake (VO2)> 100ml /min/m2.

Arterial lactate <2mmol/L or base deficit >-

2mmol/L.


Management of Anesthesia

Stable hemodynamics : Regional anesthesia (T7)

Unstable hemodynamics :

G.A with TIVA with no or minimal inhalational anestheia.

Ketamine, Etomidate & Opioids.


Transfusion in obstetric haemorrhage:

ASA Guidelines and ACOG

recommendations:

Patients should be transfused when there

are signs of significant hypoperfusion.

PRBC administration is almost always

indicated when the hemoglobin level is

<=6g/dl.


Other indications for transfusion

If base deficit is >15, with ongoing blood loss.

O2 extraction of 50% can be used as an indication of

transfusion of erythrocytes.

Hb should be maintained between 6-10g/dl.

Platelet count maintained over 50,000/dl.

INR to be maintained <1.5 by using FFP @ 10-15ml/kg

body wt.

Cryoprecipitate should be used when fibrinogen levels

fall below 100mg/dl @ 1U/5-10kg body wt.


What`s new in transfusion medicine?

Recombinant factor VIIa. (rFVIIa)

1. Binds to exposed tissue factor &

directly activates factor IX & X.

2. Dose is 50-100mcg/kg every 2hrs

I.V until evidence of hemostasis.

3. Not effective when fibrinogen level

is less than 50mg/dl.4/5/2012 Dr.Nesrine El-Refai 42

II. Vasopressin

1. Used in hemorrhagic shock

unresponsive to conventional

vasopressors.

2. Infusion rate- 1-4mu/kg/min.

3. Has a potential to cause Myocardial

Ischemia.

III. Intraoperative cell salvage & acute

normovolemic hemodilution4/5/2012 Dr.Nesrine El-Refai 43

Acute Hemodilution


1. Acute isovolemic hemodilution•Withdraw 2-4u. of Blood

•Replace the volume with crystaloids

•Lower the pre-op Hct

•Replace the blood at end of surgery

2.- Acute hypervolemic hemodilutionAdmin 1500-2000cc Crystaloids .

Hemodilution (Lowers pre-op Hct)

PAD versus ANH

• PAD1. If risk of

transfusion 10-50%

2. 6 weeks before delivery.

3. 1 unit/week.

4. PAD is safe for both mother & fetus.

• ANH1. Pt initial Ht is

high

2. Dilution to Ht 0.28-0.20

3. Blood loss>2L.

4. Cheaper than PAD BUT

5) Safety is not yet established.


Types of Replacement Products

under research

• Oxygen Carrying Solutions–Hemoglobin Based Oxygen Carrying

Solutions (HBOCS)

–Perflourocarbons

• Other–Antigen Camouflage

–Recombinant Plasma Proteins

–Transgenic Therapeutic Proteins

–Platelet Substitutes4/5/2012 Dr.Nesrine El-Refai 46

New studies in WFSA 2012

Tranexemic acid may reduce PPH

& decreases mortality.

3gm fibrinogen given in severe

PPH induced hypofibrinogenemia.

When to Give rFVIIa ??

Guidance for the use of rFVIIa in major obstetric

haemorrhage

Use of rFVIIa should be considered in major

obstetric haemorrhage: which continues despite

optimal blood product replacement and obstetric

measures:

• Where uterine artery ligation/embolisation or

hysterectomy are considered,

• Clinical haemostatic failure

• Delay in the provision of blood products

• Refusal of blood transfusion.

Dose:

FV11a should be used judiciously for life-

threatening hemorrhage in patients who are

unresponsive to conventional therapy.

It is administered as a bolus injection in a dose

of 60 - 80mcq/kg.

Some authors suggested starting with 40mic/kg,

then repeat after 2h (half life is 2h).

A single standard dose should be kept in delivery

suite to facilitate rapid administration .

Use of rFVIIa should not be seen as an alternative to

surgical haemostasis or correction of coagulopathy with

blood products.

Before administration of rFVIIa, the following

laboratory indices are desirable;

• –Prothrombin time < 1.5 × upper limit of normal

• –Clauss fibrinogen > 1.0 g/L

• –Platelet count > 50 × 109/L

• pH > 7.1 is also desirable for optimal effect.

(IJOA,2007)

CONTROVERSIES IN OBSTETRIC ANAESTHESIA

Report of a debate

I agree with the authors of a recent

editorial,

that a trial of rFVIIa is “certainly

worth a try.”

The responsible clinician should

consider the use rFVIIa in the

treatment of MOH. (IJOA,2007)

4/5/2012Dr.Nesrine El-Refai 57

Opposer: M. Van de Velde MD,

Belgium(doi:10.1016/j.ijoa.2007.06.002)

However, rFVIIa is not without risks especially when

given too early in hypercoagulable patients.

Failure has been reported regularly.

It is wise to improve normal care before highly

expensive therapies are used liberally and

unnecessarily.

Clear guidelines are needed for

clinicians on when and how to use this

sometimes life-saving drug.4/5/2012 Dr.Nesrine El-Refai 58

Summary

Obstetric hemorrhage is a leading cause of maternal mortality.

Management includes surgical correction, treatment of coagulopathy & some new drugs.

Use rFVIIa when other measures fail.


Dr.Nesrine El-Refai

ReferencesJohn R Smith,2012 in Medscape.

Emergency medicine clinic of North America, Feb 2010, Vol 28.

AnaesthesiaUK - Emergency treatment of massive obstetric

haemorrhage

Scottish Obstetric Guidelines and Audit Project : The postt

partum hemorrhage

BJACEACCP - Massive haemorrhage in pregnancy.

Obstetric Anesthesia,widening Horizon. Indian Jour Anesth 2010.

Saving Mother’s lives, Br J Anesthesiology,2008.

WFSA Congress,2012.

SOAP meeting 2010.

http://ceaccp.oxfordjournals.org/cgi/content/extract/5/6/195




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