vooruitstrevend in perioperatieve zorg afdeling Anesthesiologie

Postpartum Hemorrhage

(PPH)

Holger Baumann MD

AMC Anesthesiologie

Scenario I

39 yaar, unipara, 40 weken zwanger

6 uur durende bevalling

Retentio placentae – bloeding

GYN belt na 30 minuten

“Het bloedt meer dan normaal”

Scenario II

39 jaar, unipara, 40 weken zwanger

6 uren delivery

Retentio placentae – bloeding

GYN belt na 30 minuten

“Het bloedet meer dan normaal”

Bleek, duizelig, HR 94, SBP 110,

bloedverlies 1000-1500ml

Postpartum bloeding (PPH)

WHO BV > 500 ml bij vag. partus

BV > 1000 ml bij C-S

Australia BV > 500 ml bij vag. partus

BV > 750 ml bij C-S

Austria BV 500 – 1000ml

RCOG BV 500-1000ml “Minor PPH”

BV 1000-2000 ml “Moderate PPH”

BV >2000 ml “Severe PPH”

AMC Fluxus: BV >1000ml

Inschatten bloedverlies & PPH

30 - 50 % onderschatting

Bosse, BJOG 2006

Stafford Am J Obstet Gynecol 2008

Gabel, JOGNN 2012

There’s an App for it..

Scenario III 39 jaar, unipara, 40 weken zwanger

6 uren delivery

Retained placenta – bloeding

GYN belt na 30 minuten

Bleek, duizelig, HR 94, SBP 110, bloedverlies 1000-1500ml

GA after 1 hrs

SBP 70, HR 130

Manual placenta verwijdering

Bloedverlies continueert

Temp.: 34,2 C

Scenario IV

+ 30 min

Totaal bloedverlies 3500 ml

NaCl 0,9% 2000 ml, Colloids 2000ml

Transfusie gestart – RBC

En nu?

1. Crystalloids tot Hb 4,5, daarna RBC

2. Colloids/crystalloids tot Hb 4,5, daarna RBC

3. RBC:FFP:PLT ratio 1:1:1

4. RBC:FFP:PLT ratio 4:2:1

5. Anders

Dilutional coagulopathy?

Petroianu Anesth Anal 2000

>60%

>25%

>10%

If it does not clot or

carry oxygen…

we probably should not give it.

Richard P Dutton MD

Hemodilutie - Bloedprodukten Whole blood – 1:1:1 approach

650 ml koud spul

Hb 5.5 mmol/l (8.9 g/dl)

Thr. 75 * 109

Plasma factors 70 %

Fibrinogen: 0,5 -1 g (?)

Armand, Transf Medicine Reviews 2003

Como, Transfusion 2004

500 mL Warm

Hct: 38-50%

Plt: 150-400K

Coags: 100%

1500 mg

Fibrinogen

Massaal bloedtransfusie protocol @

MTP tot hemostasis is bereikt

MTP in PPH

……albeit based on limited prospective data. Massive

transfusion protocols could improve outcomes in the

bleeding patient not only due to early blood product

administration, but also secondarily to an early and

aggressive multidisciplinary intervention……..

Gutierrez, Int J Obstet Anes 2012

Pacheco, Am J Perinatal 2012

Conventioneel Lab. vs POC

Standard-Lab Point of Care (ROTEM/TEG)

Evaluatie voor bloeding NO YES

Tijd tot uitslag 30-60 min. 5-15 min.

Hyperfibrinolyse NO YES

Sterkte van stolsel NO YES

De Lange, Obstet Gynecol Surg 2012

Hysterektomie, En nu?

1. Fibrinogeen

2. Tranexaminezuur

3. rFVIIa

4. All

5. Other

Intrapartum

Obstetric bleeding

Prepartaal Postpartaal

Secondair

Primair (<24 hrs.)

Incidentie: 140.000 pa

Mortaliteit: 1:100.000 (developed countries)

Morbiditeit: 5:100

Ernstige (vitaal) PPH: 1:1000

BV > 1000ml: 3:100

Data:

Berg, Obstet Gynacol 2005 Dupont, Int J Obstet Anest 2009

Knight, BMC Pregnancy Child 2009 CEMACH

4 T’S Tone

Tissue

Trauma

Thrombin

Uterotonics, Macrosomia

Prior PPH, Multigestation, Adipositas

Retained placenta, Placenta previa,

Placenta acreata

C-Section, Laceratation, Rupture

Coagulopathy

TEAM Preparation & Communication

80% 5 T’S

Fluid resuscitation Maintain circulating BV

Tissue oxygenation Cristalloids / RBC

Cell Salvage

“Definitive intervention” Uterotonics

Arterial embolisation Hysterectomy

Hemostatic resuscitation Prevent Acidosis – Hypothermia - hypocalcemia

Treat/prevent Coagulopathy Monitor resucitation

Recognize PPH Identify cause

Start treatment Call “Resus” team

Woman with PPH

Modified from

McLintock, J Thromb Haemos 2011

Risk management in PPH

Underestimation of blood loss

Delay in diagnosis and treatment

Lack of easy-to use local protocols

Lack of adequate education and training

Poor communication

Deficiencies in organization

Upadhyay, Best Pract Res Clin Obstet 2008

Rath, Acta ObstetGynecol Scan 2011

Rath, Arch Gynecol Obstet 2012

3 D’s

Transport

Treatment

Diagnosis Delayed

Delayed

Delayed

Zorg voor heldere lokale protocollen.

Multidisciplinaire aanpak

Voorlichting en training

Behandel coagulopathieën • Basale behandeling

• TRX

• FFP/FIB

• MTP

• rFVIIa

Niet vergeten:

Interventie radiologie

Cell salvage

VROEGE TRANSPORT

A failure in planning is a plan for failure S03E08 Star Wars The Clone Wars

Blood Loss:

1000-1500 ml

Stage 2

Sequentially

Advance 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: Hold clot

Medium Risk: Type & Screen, Review Hemorrhage Protocol

High Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage

Protocol

All women receive active management of 3rd

stage

Oxytocin IV infusion or 10 Units IM

Vigorous fundal massage for 15 seconds minimum

Standard Postpartum

Management

Fundal Massage

Vaginal Birth:

Bimanual Fundal Massage

Retained POC: Dilation and Curettage

Lower segment/Implantation site/Atony: Intrauterine Balloon

Laceration/Hematoma: Packing, Repair as Required

Consider IR (if available & adequate experience)

Cesarean Birth:

Continued Atony: B-Lynch Suture/Intrauterine Balloon

Continued Hemorrhage: Uterine Artery Ligation

To OR (if not there);

Activate Massive Hemorrhage Protocol

Mobilize Massive Hemorrhage Team

TRANSFUSE AGGRESSIVELY

RBC:FFP:Plts à 6:4:1 or 4:4:1

Increased

Postpartum

Surveillance

Definitive Surgery

Hysterectomy

Conservative Surgery

B-Lynch Suture/Intrauterine Balloon

Uterine Artery Ligation

Hypogastric Ligation (experienced surgeon only)

Consider IR (if available & adequate experience)

Fertility Strongly Desired

Consider ICU

Care; 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 HELP

Give Meds: Hemabate 250 mcg IM -or-

Misoprostol 800-1000 mcg PR

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 0

All Births

Transfuse 2 Units PRBCs per clinical

signs

Do not wait for lab values

Consider thawing 2 Units FFP

YES

YES NO

On

go

ing

Cum

ula

tive

Blo

od

Lo

ss E

valu

ation

Cumulative Blood Loss

>1500 ml, 2 Units Given,

Vital Signs Unstable

YESIncrease IV rate (LR); Increase Oxytocin

Methergine 0.2 mg IM (if not hypertensive)

Continue Fundal massage; Empty Bladder; Keep Warm

Administer O2 to maintain Sat >95%

Rule out retained POC, laceration or hematoma

Order Type & Crossmatch 2 Units PRBCs if not already done

Activate Hemorrhage Protocol

CALL 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 details

This project was supported by Title V funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division

OBSTETRIC HEMORRHAGE CARE SUMMARY: FLOW CHART FORMAT v 1.4 5/7/2010

http://www.postpartum-hemorrhage.com/download/index.html

Stappenplan zonder ROTEM/TEG

1 Keep hemostasis happy Temp. > 34 C / pH > 7,2 / Ca2+ > 1,0mmol/l

2 RBC Hb> 6,2 mmol/l (massive bleeding)

3 Prevent/Treat Hyperfibrolysis Tranexamicacid 1-2 g + 1g/h over 8 hrs

4 Coagulation substrat FFP 30ml/kgBW 50mg Fibr./KG BW

5 Platelets Plts.> 100.000

6 Keep hemostasis happy

7 Thrombin burst 90micg/kg BW rFVIIa

Stappenplan met Point of Care

Hill Anaesth Intensive Care 2012

DeLoughery Hematology Am Soc 2010

En nu?

EXTRAS

Oxytocin in PPH

Hemodynamic effects of oxytocin in bolus

Dose-dependent

Tachycardia

Hypotension

ST depression

Myocardial ischaemia (chest pain)

Svanstrom, BJA 2008

Jonnson, BJOG 2010

Emergency Hysterectomy & PPH

Blood loss about 3000 ml

Mortality: ~2-5%

Morbidity: ~30-50%

Bloodflow in de uterus: 600-800ml/min

Geen autoregulatie

Rossi, Obstet Gynecol 2010

Machado, N AM J Med Sci 2011

Forna, Am J Obstet Gynecol 2004

Cellsaver

Recommended in cases of severe PPH

Patients at risk: e.g. abnormal placentation

No adverse outcome

Evidence low

AAGBI

CMACE

NICE Guidelines

McDonnell, Anaesth Intensiv Care 2010

Liumbruno, Transfusion 2011

Liumbruno, Blood Transf 2012

Peripartum hyperfibrinolysis

1. Trimenon 2. Trimenon 3. Trimenon Geboorte

Fibrinogeen

FVII, FIX, FX, FXII

FV

vWF

Fibrinolyse

Thrombocyten

Gerbasi, et al. Am J Obstet Gynecol 1990 Bremme, Best Prec Res Clin Haematol 2003

Hofer, Anaesthesist 2007

Antifibrinolytics in PPH I

Bloedverlies

Veilig

Novikova Cochrane review 2010

Peitsidis Expert Opin Pharmacother. 2011

WHO 2012

McCormack Drugs. 2012

Crash II Trial Lancet. 2010

Ducloy-Bouthors Crit Care 2011

Xu Arch Gynecol Obstet. 2012

Reduces bloodloss

Seems to be safe

WOMAN TRIAL

Shakur Trial 2010

http://www.womantrial.lshtm.ac.uk

AIM Effect of TXA on mortality, hysterectomy rate and other morbidity

Primary endpoint Proportion of woman who die or undergo hysterectomy

Sec. endpoints Surgical intervention Transfusion Thromboembolic events LOS Need for ventilation

Treatment 1gr TXA a.s.a.p. after randomization

Design Pragmatic randomized double blind trial

Inclusion criteria Vaginal delivery > 500ml, CS >1000ml, or hemodynamics

Monitoring hyperfibrinolysis

Thrombelastometrie-Thrombelastography

TRX in PPH

Preventive in high risk patients

Bloodloss > 1000 ml

1-2 gr. TRX

Ahonen, Acta Anaesthesiol Scand 2010

Fibrinogeen in PPH I

PPV 100% ≤ 2g/dl

NPV 79% ≥ 4g/dl

OR 2,63 [1,66-4,16] (per g/Fib.)

Charbit J Thrombosis Hemostasis 2007

Fibrinogeen in PPH II

Cortet M, Br. J. Anaesth. 2012

“The fibrinogen level at PPH diagnosis is a marker of the risk of aggravation

and should serve as an alert to clinician.”

Fibrinogeen in PPH III

Huissoud BJOG 2009

Fibrinogeen in PPH IV:

coming next to PubMed

RCT

Primary outcome: need for transfusion

Wikkelsoe, TRIALS 2012

The FIB-PPH trial: fibrinogen concentrate as

initial treatment for postpartum haemorrhage:

study protocol for a randomised controlled trial

En hoe?

Doel?

Monitoring:

Substraat:

Fibrinogeen level ?

Conventioneel - ROTEM/TEG

FFP - Fibrinogeen

Fibrinogen: >2g/l

30ml/kg BW FFP 50mg/kg BW Fib.

after TRX

How do u sweet’n your coffee?

rFVIIa in PPH

No guideline, No RCT

Variability in timing and dosing

Effective in reducing bloodloss (in about 85%)

Given too late: avg. bloodloss > 3000ml

No monitoring

Expensive

Safety? Bouma, Eur J Obstet Gynecol 2008

Franchini Clin Obstet Gynecol 2010

Levi, NEJM 2010

Ahonen, Curr Opin Anesthsiol 2012

rFVIIa in PPH

Consider rFVIIa after “conventional” therapy,

if

SOP University Heidelberg

rFVIIa(Novoseven): 90micg/kg BW

pH > 7,2

Temp. > 35,0C

Fibrinogen > 100 mg/dl or FIBTEM >12 mm

Thrombocytes > 50/nl or Extem > 45mm

Hyperfibrinolysis ruled out/therapy

No surgical/IR therapy