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1 Obstetrical Hemorrhage! Red is the new Black Marvin Williams, DO Associate Professor Interim Division Director Maternal Fetal Medicine “When determining a course of action, it often helps to know what you’re up against” Henry Kissinger Objectives Define and classify postpartum hemorrhage (PPH) Briefly review OB physiology State the common etiologies of PPH Discuss therapeutic interventions and management of PPH Review use of blood products

Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

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Page 1: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

1

Obstetrical Hemorrhage! Red is

the new Black

Marvin Williams, DOAssociate Professor

Interim Division Director

Maternal Fetal Medicine

“When determining a course of

action, it often helps to know

what you’re up against”

Henry Kissinger

Objectives

Define and classify postpartum hemorrhage

(PPH)

Briefly review OB physiology

State the common etiologies of PPH

Discuss therapeutic interventions and

management of PPH

Review use of blood products

Page 2: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

2

Definition?

Lack of agreement on blood loss

Blood loss greater than the “normal”estimates (Pritchard in 1962)

Vaginal delivery > 500cc

CD > 1,000cc

C-hysterectomy > 1,500cc

A 10% decrease in Hgb/HCT level

Need for blood transfusion

Definition?

Excessive bleeding that makes patient

symptomatic

Lightheadedness, vertigo, syncope

Results in signs of hypovolemia

Hypotension, tachycardia, or oligouria

Key: These changes will only occur after the patient

has lost a significant amount of blood

Incidence

Hemorrhage is the single most important

cause of maternal mortality worldwide

Accounts for 25-30% (PPH – 150,000 lives daily)

Of these, roughly half are ectopic-related

Developed regions <1%

Recent studies identified worrisome trends

US rate of PPH has increased steadily

3% of all births complicated by PPH

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3

Preventable Deaths (Clark et al 2008)

Retrospective study 1.5 mill. deliveries 2000-06

Examine the etiologies of maternal death

Preventable factors regarding the same

95 maternal deaths (6.5/100,000) in the cohort

Leading causes of death were due to complications

Preeclampsia

AFE

PPH

73% of postpartum hemorrhage deaths preventable

Clark el al. AJOG 2008

Preventing Maternal Death10 Clinical DiamondsClark and Hankins 2012

Angiographic embolization is not meant to be

used for acute, massive postpartum

hemorrhage

If more than a single dose of medication is

necessary to treat uterine atony, go to the

patient’s bedside until the atony has resolved

In the postpartum patient who is bleeding or

who recently has stopped bleeding and is

oliguric, furosemide is not the answer

Clark and Hankins, Preventing Maternal Death. Obstet Gynecol 2012;119(2 part

1):360-4.

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4

Preventing Maternal Death10 Clinical DiamondsClark and Hankins 2012

Never treat “PPH” without simultaneously

pursuing an actual clinical diagnosis

Any woman with placenta previa and one or

more CD should be evaluated and delivered in

a tertiary care medical center

If your L&D unit does not have a recently

updated massive transfusion protocol based on

established trauma protocols, get one today

Clark and Hankins, Preventing Maternal Death. Obstet Gynecol 2012;119(2 part 1):360-4.

CV and Heme. System

Harris, C. Obstetric Intensive Care Manual. 3rd Ed. Trauma in Pregnancy. p214

Blood Volume in Pregnancy ~100 cc/kg

The average pregnant woman increases blood volume by ~1200cc

Page 5: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

5

Hemodynamics of PPH

0

20

40

60

80

100

120

140

160

0% 10% 20% 30% 40%

Perc

en

t C

on

tro

l

Blood Volume Deficit

SVR

BP

CO

PPH Classification

Francois, K. Chapter 3. Obstetric Intensive Care Manual 2nd Ed.

©2007 by Lippincott Williams & Wilkins

Toledo P et al. Anesth Analg 2007;105:1736-1740

How much blood is in the drape on the left?

500 cc

Page 6: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

6

Quantification of Blood LossCalifornia Maternal Quality Care Collaborative

Visual estimates underestimate by 33-50%

Large volumes often over estimated

Small volumes often under estimated

No difference between in the accuracy of blood loss

estimation

No association between accuracy and years of training

or experience

Both improve with training

Dildy, G. Obstet Gynecol. 2004: 104:601-6

Toledo P et al. Anesth Analg 2007;105:1736-1740

Quantification of Blood LossCalifornia Maternal Quality Care Collaborative

Formally estimate blood loss by recording

percent (%) saturation

Visual cues such as pictures/posters

Formally measure blood loss by weighing

blood soaked pads/chux

Formally measure blood loss by collecting

blood in graduated measurement containers

Quantification of Blood LossCalifornia Maternal Quality Care Collaborative

Develop Training Tools: Visual aids displayed in L&D and/or

postpartum areas are guides for more accurate visual estimation

Page 7: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

7

Visual Pocket Card

Zuckerwise et al. OBG 2014;123(5)

Estimating Blood Loss With Simulation

OB providers (attendings, residents,

medical students) estimated blood loss at

“stations”

62% of subjects underestimated EBL by

20%

After 20 min didactic lecture

98% of participants accurately estimated the

blood loss

Dildy, G. Obstet Gynecol. 2004: 104:601-6

Etiologies of PPHRemember –PPH is not the diagnosis

Early (< 24hrs)

Uterine atony

Lower genital tract

lacerations

Retained placenta

Placental invasion

Uterine rupture

Uterine inversion

Coagulopathy

Late (>24hrs-

6wks)

Infection

Retained placenta

Placental site

subinvolution

Coagulopathy

Page 8: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

8

Risk Factors for OB Hemorrhage

“4 Ts” Pathophysiology

Abnormal uterine contractility

(TONE)

Over distended uterus

Uterine muscle fatigue

Chorioamnionitis

Uterine distortion/abnormality

Uterine relaxant

Retained products of conception

(TISSUE)

Accreta/Increta/Percreta

Retained placenta/membranes

Genital tract trauma

(TRAUMA)

Laceration of the cervix, vagina or perineum

Extension/laceration at cesarean section

Uterine rupture

Uterine inversion

Abnormalities of coagulation

(THROMBIN)

Preexisting clotting abnormalities (vWD ds,

hemophila)

Acquired in Pregnancy

DIC/HELLP/Anticoagulation

Team Work!

Multidiscipline effort

OBs, RNs, and Anesthesiologists

Organize early

Involve other services as necessary

Lab, blood bank, ICU

Allows for professionals to work in their

fields of expertise

Responsibilities

Assessment Refers constant awareness of the patient’s hemodynamic status

Evaluation to determine cause of bleeding

Breathing Admin. supplemental

Airway, anticipate difficulty with intubation

Circulation

IV access

Assess adequate circulating blood volume through resuscitation

Page 9: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

9

Responsibilities

Review ongoing fluid resuscitation and

pharmacotherapy and assume responsibility

for these

Place arterial line early if significant hemorrhage

present or anticipated

Send initial lab sample (hemoglobin, coagulation

status) if not already sent

Order blood and blood products as needed

Adequacy of analgesia

Therapeutic Care Plan for PPH

B Blood loss needs

L Loss estimation

E Etiology

E EBL replacement

D Drug therapy

I Intraoperative management

N Nonobstetrical services

G General complication assessment

Oxytocin

Short ½ life (3min) IV infusion required

Dosing 10-80 IU in 500 ml of crystalloid

Metabolized via renal and hepatic routes

Antidiuretic effect: Water toxicity

Large volumes in electrolyte free soln.

Rapid IV admin. of undiluted Oxytocin

Hypotension

Page 10: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

10

Oxytocin

Cesarean delivery

RCT comparing infusion of 10U vs 80U

oxytocin over 30 min after cord clamping

80 unit

Less uterine atony or PPH

Less need for additional uterotonic agents

Study did not find any difference in estimated

blood loss or change in hematocrit

Munn MB. Obstet Gynecol. 2001;98(3):386–390.

Oxytocin

Vaginal deliveries

Using 10, 40, and 80 units of oxytocin infused

over 60 min

No difference in PPH was noted between the

groups

The 80 unit group

Required less additional oxytocin

Less risk of a decline in hematocrit of 6% or more

compared to 10 units of oxytocin

Tita, A. Obstet Gynecol. 2012;119(2):293–300

Ergot Derivatives

Methylergonovine (Methergine)

IM injection of the standard 0.2 mg (q5min max 5

doses)

Acts within 2 minutes-5 minutes

Metabolism hepatic route

½ life is 30 minutes (clinical effect of approx. 3

hrs.

Side effects nausea, vomiting, and dizziness

Contraindications: HTN, Heart ds., PVD

Page 11: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

11

Carboprost (Hemabate)

0.25mg IM or intramyometrial injection

Smooth muscle stimulant

Second line agent

Peak plasma concentration (15min IM or 5 min

myometrial injection) repeat doses q15 min max

8 doses (2mg)

Side effects: GI, bronchospasm, and pyrexia

Contraindications: cardiac and pulmonary

Misoprostol

PG E1 analog

Onset of action 20-30 min

PO, sublingually, PV, PR, or direct IU

Usual dose 800 microgram

Hepatic metabolism

Protracted uterine bleeding

Side effects: GI and dose-dependent

Recombinant Activated Factor VIIa (Novoseven)

Enhances platelet aggregation

Promotes clotting through extrinsic pathway (binds to

tissue factor)

Complexes with tissue factor activates Factor IX

and X, and generates thrombin

Dose 40-60 mcg/Kg IV bolus, repeat in 15-30 minutes

Controls bleeding rapidly – 10 minutes!

Very few adverse effects reported < 1%

Short ½ life (2 hours)

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12

Recombinant Activated Factor VIIa (Novoseven)

Administration of rFVIIa:

Hemoglobin 9-10; Plts 70K; Fibrinogen 2g/L

FFP to goal of PT/PTT <1.5 times upper limit of

normal

Correct acidosis, hypothermia, low ionized

calcium, and rule out arterial bleeding

High Cost approx. $5000-10,000/dose

Transexamic Acid (Antifibrinolytic)

Transexamic Acid

Reduces blood loss during and after cesarean

delivery (pooled CD data)

Vaginal delivery

Two prospective studies (2000 subjects)

Treatment group:

PPH was significantly lower

Progression to severe PPH and blood transfusion was less

frequent than controls (P = 0.03, 0.07, and <0.001 respectively)

?Carries a risk of thrombosis?

Ducloy-Bouthors, et al. Crit Care. 2011;15:R117

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13

Intraoperative Cell Salvage in Obstetrics

Considered safe in obstetric

patients

>400 cases in OB literature

without AFE

Automated system can

provide 225 cc of washed,

saline suspended RBC with

Hct of 50% in 3 minutes

ACOG recommends

considering its use when

massive blood loss is

expected

Rh negative receive Rhogam

“Classic” (relative)

contraindications:

Malignancy

Amniotic fluid

contamination

Bacterial contamination

(abscess, bowel perf)

Betadine

Topical hemostatics

(Avitene, etc)

ACOG Practice Bulletin #76, 2006

Medical Therapy OptionsAgent Dose Route Dosing

Frequency

Side Effects Contraindications

Pitocin 10-80 U/L IV

(IM, IU)

Continuous N/V

Water

intoxication

None

Methergine

(Methyl-

ergonovine)

0.2 mg IM

(IU)

Q2-4hr HTN, N/V,

hypotension

HTN,

Preeclampsia

Hemabate

(PGF2)

0.25mg IM

(IU)

Q15-90min

Max = 8

N/V, F/C,

diarrhea

Active cardiac,

renal, liver, lung

disease

Dinoprostone

(PGE2)

20mg PR Q2hr N/V, F/C,

diarrhea, HA

Hypotension

Cytotec

(Misoprostol)

600-1000

mcg

PO

(PR)

Single dose Fever None

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14

Active Management of the 3rd

Stage of Labor

Three Key Components

Use uterotonic agent (Oxytocin)

Early clamping of the umbilical cord

Controlled traction

Cochrane Review

Comparison of Oxytocin, Placebo and ergot alkaloids

Oxytocin use associated with reduced risk of

hemorrhage (RR 0.5) and reduced need for therapeutic

uterotonics (RR 0.5)

Elbourne, CR. Cochrane Database Syst Rev 4:CD, 001808, 2001

ACOG Patient Safety

Checklist for Postpartum

hemorrhage

What should I order?

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Transfusion Therapy

Classic thinking:

Resuscitation using crystalloid and PRBCs

FFP, cryo, and plts only if hematologic parameters are

abn (plts<50K; FBG<100K; PT/aPTT<1.5XNL)

FAILED TO PREVENT COAGULOPATHY IN MASSIVE

HEMORRHAGE – DILUTIONAL COAGULOPATHY

New Concept

Limit early aggressive crystalloid use

Early admin. of FFP and PLTs (with pRBCs) ratio 1:1:1

Early use of fFVIIa

Massive Transfusion

Page 16: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

16

Principles of Massive Transfusion

Manage airway and breathing

Evaluate and address cause of

hemorrhage

Establish two large bore

peripheral intravenous lines

Consider central line and arterial

line placement

Administer crystalloid (1-2 L)

initially

Initiate massive transfusion

protocol, if available

Administer PRBCs, FFP, and

platelets in a timely fashion

Ratio FFP:PRBCs 1:1.5 - 1:1.8

Maintain core temperature

>35°C

Monitor CBC, PT, PTT, fibrinogen

every 30 min

Correct hypocalcemia

Correct hyperkalemia

Correct acidosis (pH = 7.4, normal

base deficit, normal lactate)

Continue product replacement until: hemodynamically

stable, platelet count >50,000, INR <1.5

Componen

t

Contents Indications Volume Shelf life Effect

PRBC’s RBC’s,

WBC’s,

plasma

Anemia 300 42 days Increase

Hgb 1g

Platelets Platelets,

plasma

Bleeding due

to low plts

50 5 days Increase

Plt count

7500/unit

FFP FBG,

plasma,

clotting

factors

DIC,

coagulation

disorder,

reverse

warfarin

250 12 mo

frozen

2 hr

thawed

Increase

FBG 10-15

Cryoppt FBG, factor

VIII, vWf,

XIII

DIC, von

Willebrands,

hemophilia A

40 4-6 h

thawed

Increase

FBG 10-15

Crystalloid Volume Duration

Colloid Dose (mL) Expansion Equivalent of Effect (hours)

Albumin

5% solution 500-700 similar to crystalloid 24

25% solution 100-200 3.5 times crystalloid 24

Hetastarch 500-1000 similar to crystalloid 24-36

Dextran 70 500 1050 mL over two hours 24

Colloid Solutions

Hydroxyethyl starch (Hespan®) banned in Europe. June 2013 FDA issued

black box warning against hetastarch.

Meta-analysis published early 2013 reports increased mortality, renal injury

and bleeding.

Zarychanski et al. JAMA 2013;309(7):678-688.

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17

Anticipate risk for

intraoperative

bleeding

Alison. Placenta Accreta, Increta, and Percreta Obstet Gynecol Clinics of North America 2013; 40(1):137

More Cesarean = More Invasion

CD and Placenta Previa

Clark et al 1985 Silver et al 2006

The majority of patients with accreta have a history

of prior cesarean delivery and previa

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18

Placenta previa, prior cesarean and accreta risk

-10

10

30

50

70

0 1 2 3 4 >5

Inc

ide

nc

e o

f a

cc

reta

(%

)

# prior sections

No previa

0

20

40

60

80

0 1 2 3 4 >5

Incid

en

ce o

f accre

ta (

%)

# prior sections

Previa

A placenta previa with no prior sections is associated

with a 3-4% risk of accreta.

Accreta risk is low without a previa until section # 4.

Conclusions

PPH is a common obstetrical event and a

major source of maternal morbidity and

mortality

Early recognition and treatment of PPH is

critical

Anticipation of potential need for blood

products is important

Page 19: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

19

QUESTIONS?

Page 20: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

20

STAT Blood Draw:

-Type and Screen (if

not previously drawn)-Hemoglobin/Hct

-DIC Panel

PT/INR, PTT

Fibrinogen, D-dimer

Platelet Count

Repeat Labs:

-H/H, platelet count, PT, PTT,

fibrinogen

-Ionized Calcium

Lab Results & Action (when available):

-If INR >1.5 give 2 units FFP

-If platelet count <100K, give 1 apheresis platelet unit-If fibrinogen <100 mg/dL, give 1 dose cryoprecipitate

(10 units)

No

Yes

Anticipate ongoing

bleeding?

Initial Blood package issued:

4 units RBC

4 units FFPStart thawing more FFP

(ready in 30-45 min)

OB/Anesthesia activates protocol

(clinical assessment/>4 RBCs in 1-2 hrs)

NOTIFICATION OF BLOOD BANK

Set-up rapid infuser

Deactivate Massive Transfusion Protocol

Criteria: Normalization of lab values

and/or no evidence of ongoing bleeding.Call Blood Bank.

Subsequent blood package issued:

4 units RBC and 4 units FFP

Every 2 packages or based on lab results:1 apheresis platelet unit

1 dose cryoprecipitate (10 units) – pooling initiated

at package pick-up; ready in 30 min.

Sample Massive Transfusion Protocol

Have an Operative Plan

Uterine curettage

Laceration repair Lower genital tract

Uterine

Arterial ligation/ embolization

B-Lynch suture

Packing

Hysterectomy

Arterial Ligation

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21

Arterial Ligation:Hypogastric Vessels

Reported success

rates variable

25-80%

Clark Obstet Gynecol 1985b;42:306

Stephen Surg Gynecol Obstet 1985;160:250

Wagaarachchi Hum Reprod 2000;15:1311

Sziller J Perinat Med 2007;35:187

Recent Results BHALTurkey

58 patients (1997-2008)

24 HELLP with

coagulopathy

25% complication rate

24 Uterine atony

12.5% complication rate

10 Massive hemorrhage

due to inadequate surgical

control or rupture

10% complication rate

1 death in each group

Complications

DIC

Hysterectomy

Relaparotomy

Wound infection

ATN

Unal J Mat Fet Med 2011;24(10):173

Before After

Suture placed 2-3 cm distal from bifurcation to ensure

placement distal to posterior division

Unal J Mat Fet Med 2011;24(10):173

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Arterial Embolization

Technique

Pelvic arteriogram in

order to identify

extravasation of blood

from pelvic vessels

Selective catheterization

of bleeding pelvic

vessels and

embolization of

Gelfoam, glue or coils

Arterial Embolization

Pros

Selectivity

Highly successful

>90%

Uterine preservation

Definitive surgical

therapy possible if

embolization fails

Cons Requires stable patient

Availability of interventional radiology

Complications

Fever/Pain

Infection

Procedure-related problems

B-Lynch Suture Technique

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Uterine Compression: SOS Bakri Tamponade Balloon

FDA approved for

temporary control of

postpartum uterine

bleeding: provides

compression

May be used vaginally or

at cesarean

Allows assessment of

ongoing bleeding

Remove after 24 hours

Uterine Compression: ebb™ Balloon

Hook port directly to IV fluid

bag: Fill uterine balloon in 250

cc increments up to 750 cc

Hook port directly to IV

fluid bag: Fill vaginal

balloon in up to 300 cc

Page 24: Obstetrical Hemorrhage! Red is the new Black · In the postpartum patient who is bleeding or ... Abnormal uterine contractility (TONE) ... Therapeutic Care Plan for PPH B Blood loss

24

Hysterectomy

Definitive therapy – don’t delay!

Refractory atony

Irreparable uterine rupture/vessel

lacerations

Placental invasion

Packing

Useful temporizing technique that controls

uterine bleeding or post-hysterectomy

bleeding from the vaginal cuff

Provides pressure to bleeding surfaces

until coagulation factors can be replaced

Packing Technique

Supplies

Sterile plastic bag

Packing gauze

IV bag for traction

Recommendations

Foley catheter

Prophylactic

antibiotics

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25

Concealed Abruption

Anticipate Blood Loss Needs

Establish large bore IV access

Type & crossmatch

PRBC, FFP, cryoprecipitate, platelets

Baseline laboratory assessment

CBC, platelets, fibrinogen, PT/PTT, BMP

Consider Cell Saver