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Postpartum HemorrhageSusan Leong-Kee, MD

Assistant ProfessorDirector of Simulation

Baylor College of MedicineDepartment of Obstetrics and Gynecology

I have no financial conflicts of interest to disclose

Agenda

Postpartum hemorrhage didactic overview Simulation skills training Debrief

Objectives

Review the incidence of pregnancy-related hemorrhage, specifically postpartum hemorrhage (PPH)

Review the pregnancy-related vascular changes that can lead to PPH

Identify risk factors for PPH Recognize prevention and develop

management skills

Incidence

Hemorrhage is one of the leading causes of maternal death worldwide

PPH: 27% of maternal mortality (WHO, 2014)

1 woman dies every 4 minutes due to PPH (ACOG, 2013)

28

27

14

8

11

9

Causes of maternal death worldwide by percentage (Source: WHO)

Pre-existing medical conditionsHemorrhagePregnancy related hypertensionAbortion complicationsInfections

Obstetric morbidity + mortality in the U.S.

Rate of maternal deaths has tripled from 6 per 100,000 in 1996 to 17 per 100,000 annual births in 1999

Blood transfusions increased 92% during delivery hospitalizations between 1997 and 2005

Annual Postpartum Hemorrhage Rates, United States, 1994-2006

7

Defining postpartum hemorrhage

Vaginal delivery: Greater than 500 mL blood loss

Cesarean section: Greater than 1000 mL blood loss

Hemodynamic changes of pregnancy

Plasma volume expansion Increase in red blood cell mass Cardiac output (SV X HR =CO) increases Pro-coagulant factors (i.e., fibrinogen)

increase

Classification of hemorrhage

Class Blood Loss Percentage Lost PhysiologicResponse

1 900 ml 15% Asymptomatic

2 1200-1500 ml 20-25% Tachycardia, tachypnea,

hypotension, delayed

hypothenar refill

3 1800-2100 ml 30-35% Tachycardia, tachypnea, cool

extremities

4 > 2400 ml 40% Shock, oliguria

Classification of PPH

Early (Primary) PPH: Occurs within 24 hours of delivery Occurs in 4-6% of pregnancies

Late (Secondary) PPH: Occurs between 24 hours of delivery and 6-12

weeks postpartum Occurs in 1% of pregnancies

Etiologies of postpartum hemorrhage

Postpartum hemorrhage etiologies

Early Uterine atonyLower genital tract lacerationsUpper genital tract lacerationsRetained products of conceptionAbnormal placentationUterine ruptureUterine inversionCoagulopathy

Late InfectionRetained products of conceptionPlacental site subinvolutionCoagulopathy

Most common causes of PPH

4 Ts: Tone Trauma Tissue -- Thrombin Tone = uterine atony Trauma = vagina/cervical lacerations Tissue = retained placenta; abnormal placentation Thrombin = coagulopathy

Risk factors History of postpartum hemorrhage Prolonged labor/precipitous labor Uterine over-distension (i.e., macrosomia,

multiple gestation, polyhydramnios) Operative delivery Episiotomy Medical conditions: Chorioamnionitis,

preeclampsia, clotting disorders Prolonged labor augmentation

Bimanual uterine massage

Uterotonic agents

DRUG DOSE FREQUENCY CONTRAINDICATIONS

Oxytocin IV: 10-40 U in 1 liter NS or LR

Continuous Drug hypersensitivity-rare

Methylergonovine IM: 0.2 mg Every 2-4 hours Hypertension

15-methyl PGF2 IM: 0.25 mg Every 15-90 minutes, 8 dosesmaximum

Asthma, hepatic, renal, cardiac disease

Dinoprostone Vaginal or rectal suppository: 20 mg

Every 2 hours Hypotension

Misoprostol Rectal: 800-1000 mcg

Once Drug hypersensitivity-rare

Active management of third stage of labor

Administration of oxytocin postpartum hemorrhage duration of third stage need for additional uterine tonic agents

Controlled cord traction Fundal massage after placenta delivery

Uterine tamponade

ACOG, Practice Bulletin 76

Selective uterine arterial embolization

Surgical intervention

OLeary stitch Compression-type sutures:

B-lynch Hayman Cho

OLeary Stitch

Bilateral uterine artery ligation

B-Lynch Suture

Hayman Suture

Cho Suture

Special scenarios

Genital tract lacerations Adequate VISUALIZATION and ANESTHESIA

Pelvic hematomas Results from lacerated vessels in the superficial

fascia of the anterior and/or posterior pelvic triangle

Special scenarios

Uterine inversion Occurs 1 in 2500 deliveries Risk factors: uterine over-distension, uterine

malformations, abnormal placentation, short umbilical cord, tocolysis, collagen disorders (i.e., Ehlers-Danlos)

Clinical findings: brisk vaginal bleeding, non-palpable fundus, maternal hemodynamic instability

Special scenarios

Management of uterine inversion

Special scenarios Coagulopathy

Risk factors: massive hemorrhage, sepsis, amniotic fluid embolism, preeclampsia, acute fatty liver of pregnancy

Laboratory studies: Type and screen, CBC, PT/PTT/INR, fibrinogen Management:

Replacement of clotting factors Goals: platelets > 50,000/L, fibrinogen > 100 mg/dl Massive transfusion protocol Intensive care unit

Volume resuscitation

Crystalloid resuscitation Initial management with a 3:1 ratio of

replacement to estimated blood loss

Colloid resuscitation: Albumin, hetastarch, dextran Blood products

Blood component therapy

ACOG, Practice Bulletin 76

Massive transfusion protocol

Establish hospital massive transfusion protocol Typically 1: 1 ratio of PRBC:FFP

Consider other supportive measures: ICU admission Fluid warmer Bear Hugger

Establishing Guidelines

Florida OHI algorithm

PPH/MTP Algorithms

Texas Childrens Hospital Pavilion for Women PPH and MTP Algorithm simulation training Total number of providers who completed

multi-disciplinary training 346 out of 406 (85.2% of targeted providers)

Result decrease the need for maternal transfusions of 4 units of PRBCs or more by 66% from 3/2012 12/2014

Conclusions

Review or help establish your hospitals postpartum hemorrhage protocol

Educate fellow team members (RNs, anesthesia, unit managers, etc.) on various approaches to PPH

Develop goals to improve ways to better estimate and quantify blood loss

References Argani CH, Eichelberger M, Deering S, Satin AJ. The case for simulation as

part of a comprehensive patient safety program. Am J Obstet Gynecol. 2012 Jun;206(6):451-5

Kramer MS, Berg C, Abenhaim H, Dahhou M, Rouleau J, Mehrabadi A, Joseph KS. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol. 2013 Nov;209(5):449.e1-7

Allam MS1, B-Lynch C. The B-Lynch and other uterine compression suture techniques. Int J Gynaecol Obstet. 2005 Jun;89(3):236-41. Epub 2005 Apr 19

Lyndon A, Lagrew D, Shields L, Main E, Cape V. Improving Health Care Response to ObstetricHemorrhage. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care)Developed under contract #11-10006 with the California Department of Public Health; Maternal,Child and Adolescent Health Division; Published by the California Maternal Quality CareCollaborative, 3/17/15

Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of bloodproducts. Am J Obstet Gynecol 2011;205:368.e1-8

http://health.usf.edu/publichealth/chiles/fpqc/ohi

Postpartum HemorrhageI have no financial conflicts of interest to discloseAgendaObjectivesIncidenceObstetric morbidity + mortality in the U.S.Annual Postpartum Hemorrhage Rates, United States, 1994-2006Defining postpartum hemorrhageHemodynamic changes of pregnancyClassification of hemorrhageClassification of PPHEtiologies of postpartum hemorrhageMost common causes of PPHRisk factorsBimanual uterine massageUterotonic agentsActive management of third stage of laborUterine tamponadeSelective uterine arterial embolizationSurgical interventionOLeary StitchB-Lynch SutureHayman SutureCho SutureSpecial scenariosSpecial scenariosSpecial scenariosSpecial scenariosVolume resuscitationBlood component therapyMassive transfusion protocolEstablishing GuidelinesFlorida OHI algorithmSlide Number 34PPH/MTP Algorithms ConclusionsReferences

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