Walters - Postpartum Hemorrhage USAFP (FILEminimizer)

7/27/2019 Walters - Postpartum Hemorrhage USAFP (FILEminimizer)

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Postpartum Hemorrhage:

What Does The Evidence

Show?

MAJ Katrina Walters

4 A ril 2011


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The Impact of PPH

Worldwide a woman dies every 4 minutesfrom PPH

Top 5 reasons for maternal morbidity

Affects 1 to 19% of deliveries

Incidence is increasing in high resourcecountries(BMC Pregnancy & Childbirth 2009; 9:55.)


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Complications of PPH

Anemia

PP Depression(J Nutr 2003 DEC; 133(12):4139)

Acute Renal Failure, Myocardial Infarction,ARDS, Shock

Transfusions/ Surgery

Sheehans Syndrome Death


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Outline

Definitions

Etiology/ Risk Factors

Prevention through Active Management

Initial Management

Advanced Techniques

Blood Product Utilization

Summary


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Definitions (1 of 2)

Multiple andproblematic

Traditional

> 500ml forVaginal Delivery

> 1000ml EBL

Cesareansection

Excess bleeding +s/sx hypovolemia Gabbe, CH 18


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Definitions (2 of 2)

Drop in Hct of 10% after delivery

Hct not a clear indicator of acute status

Primary vs. Secondary

Early vs. Late

Severe PPH

Recognition may be hampered by occult

bleeding


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Etiology

Bleeding from Placental Implantation Site

Trauma to Genital Tract

Coagulation Defects


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The 4 Ts of PPH

CAUSE INCIDENCE

(APPROX)

TONE Atony 70%

TRAUMA Lacerations,hematoma, inversion,rupture

20%

TISSUE Retained placenta,invasive placenta

10%

THROMBIN Coagulopathies 1%

Am Fam Physician 2007; 75:875.


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Bleeding from Placentation Site(Risk Factors)

Uterine Atony

Halogenated hydrocarbon GETA

Hypotension

Overdistended uterus

Exhausted myometrium

Prior Uterine atony

Retained Placental Tissue

Abnormal placentation

Succenturiate (Extra) Lobe


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Trauma to Genital Tract(Risk Factors)

Episiotomy/Lacerations

Instrumented

Delivery Compound Fetal

Presentation

Surgical Delivery Hematomas

Uterine Inversion

Uterine Rupture

Prior uterine scar

High parity

Hyperstimulation

Obstructed labor

Midforceps rotation

Intrauterinemanipulation


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Coagulation Defects(Risk Factors)

Abruption

Prolonged retention of dead fetus

Amniotic fluid embolism

Massive transfusions

Severe Pre-eclampsia/ Eclampsia

Congenital Coagulopathies

Anticoagulant Rx

Sepsis

Saline Induced Abortions

Placental Abruption


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Other Risk Factors (1 of 2)

Previous PPH

14.8% with 2nd Pregnancy

21.7% with 3rd Pregnancy

10.2% with 3rd if PPH in 1st but not 2ndpregnancy(Med J Aust 2007 Oct 1; 187(7):391)

Prolonged 3rd Stage


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Other Risk Factors (2 of 2)

Small Maternal Blood Volume

Small Stature

Hypervolemic constricted states (Pre-eclampsia)

Obesity

Native Americans, Hispanics, Asians

Epidural Anesthesia

Nulliparity

Women with female genital mutilation(Lancet 2006JUN3; 367 (9525):1835)


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Risk Factor Identification

Small proportion with RF develop PPH and

many women without RF have PPH

Consider early Type and Screen/Cross for RF


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P ti th h A ti


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Prevention through ActiveManagement of Third Stage

(2 of 3) Prophylactic Pitocin (SOR A)(Cochrane Database Sys Rev 2001; 4: CD001808)

Does timing matter?

(Cochrane Database Sys Rev 2010; 8: CD006173)

Are other uterotonics as effective? (SOR B)(Cochrane Database Sys Rev 2007; 2:CD005456.)

Cord Traction(Am J Obstet Gynecol 1997 Oct;177(4):770, Repro Health 2009; 6:2)

Uterine Massage after Placenta Delivery(Cochrane Database Syst Rev 2008 Jul16; 3:CD006431)

P ti th h A ti


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Prevention through ActiveManagement of Third Stage

(3 of 3) Early Cord Clamping(Pediatrics 2006 APR; 117(4):e779)

Cord Drainage

(Cochrane Database Sys Rev 2005; 4: CD004665.)

Fundal Pressure vs. Cord Traction(Cochrane Database Sys Rev 2007; 4: CD005462)


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Other Prevention Stategies

Tranexamic Acid(Cochrane Database Sys Rev 2010 JUL7; 7: CD007872)

Avoid Routine Episiotomy (SOR A)(Cochrane Database Sys Rev 1999;3:CD000081)

Continuous Presence of Midwives

Xuesaitong(Zhongguo Zhong Xi Yi Jie He Za Zhi 2002 MAR; 22(3):182 [Chinese])


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Initial Management of PPH(1 of 2)

Recognize PPH

Delay in initial care increases risk of severePPH(Obstet Gynecol 2011 JAN;117(1):21)

Fundal Massage

Intravenous Access

Follow local protocols if available (SOR B)(BJOG 2004 May; 111:495, BJOG 2010; 117:1278)


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Initial Management of PPH(2 of 2)

Treat Uterine Atony since this is mostcommon cause for PPH

Uterotonics (SOR C)

Pitocin

Ergot Alkaloids

Prostaglandins


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Uterotonics

Pitocin(Obstet Gynecol 2001; 98:386)

Methergine

Hemabate(AM J Obstet Gynecol 1990 JAN;162(1):205)

Misoprostol (SOR B)

Route?(BJOG 2004;112:547)

Is it effective?(Cochrane Database Syst Rev 2007;1:CD003249)

Does the order matter?


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Pitocin

Dose/

Route

Cost Mechanism Contra-

Indications

Onset Duration

10U IM

10-40Uin 1LNSover

10min

$85 IncreasedcontractionsbyincreasingintracellularCalcium

3-5 min IM

IVImmediate

2-3 hours

1 hour


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Methergine

Dose/

Route


indications

Onset Duration

0.2mgIM Q2-4hours

Oral0.2mg

$11 perampule

$1.60per tab

UterineSmoothmusclecontraction >Vasoconstrict

Hypertension

Scleroderma,Raynauds

IM-2-5 min

Oral-5-10min

3 hours


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Hemabate

Dose/

Route


Indications

Onset Duration

0.25 mgIM

Q15minto maxdose of2mg

$49per

dose

Prostaglandinaffect on

myometrium,also affectsarterioles andbronchioles

Asthma 2-5 min 2 hours


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Cytotec

Dose/

Route


Indications

Onset Duration

200

1000mcg

OralSLPR

Vaginal

$0.60

per tab

Prostaglandin

affects inmyometrium

SL >

Oral >Vaginal /Rectal

Vaginal/

Rectal >SL/Oral

3-6 hours


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Unresponsive to Uterotonics

Bimanual Uterine compression

HELP! (OB, Anesthesia, Nursing, OR)

2nd Large Bore IV

Fluids + Blood Products

Anderson JM, AFP 2007


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Unresponsive to Uterotonics

Look for other causes! (SOR C)

Explore uterus for retained products

Inspect cervix and vagina

Incise and Evacuate Large Hematomas(SOR B)(South Med J 1987 AUG;80(8):991)

Consider Type and Cross Place a Foley catheter to monitor Is/ Os

Labs for coagulopathy


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Uterine Tamponade

Bakri Balloon

Foley, BT-Cath,Sengstaken-

Blakemore Tube Gauze Packing

(Obstet Gynecol Survey 2007; 62(8): 540)

Jacobs AJ, Up to Date 2009


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Shorter time to bleeding stopped

Decreased units of blood transfused

Decreased need for additional uterotonics

No increased morbidity or mortality(J Obstet Gynaecol Res 2009 JUN;35(3):453)

External Aortic CompressionDevice


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Uterine Artery Embolization

Requires available facilities/ personnel

Hemodynamically Stable Patient

Temporizing measure en route to OR

Fertility Effects(Obstet Gynecol Survey 2007; 62(8): 540, Obstet Gynecol 2009MAY;113(5):992)


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Surgical Intervention (1 of 4)

Gabbe, Ch 18


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Gabbe, Ch 18


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Recombinant Activated Factor VII

Initiates coagulation at site of tissue injury viatissue factor

Used for massive hemorrhage

$$$

Observational reports of 80% success ratebut only used when all other measures short

of hysterectomy failed(Obstet Gynecol 2007; 110:1270)

SOR C


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Local protocols are helpful

Dont wait for lab abnormalities if actively

bleeding!

Massive hemorrhage without replacement ofcoagulation factors (FFP) will result incoagulation abnormalities


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Product Contents Volume Effect

Whole Blood 500ml Hct 3%

PRBCs RBCs, WBCs, few

plasma proteins

300ml Hct 3%, less

fever

Platelets Pooledconcentrate

1 unit = 6 pack

50ml PLT 5-10K

FFP Fibrinogen, ATIII,

clotting factors,plasma

250ml fibrinogen 5-

10mg/dl

Cryoprecipitate Fibrinogen,Factor VIII, XIII,vWF

40ml fibrinogen 5-10mg/dl



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Active Bleeding and Hct < 25 = PRBCs

PLT < 100K or massive transfusion =Platelets

Fibrinogen < 125 = cryoprecipitate/ FFP

Massive bleeding or INR > 1.5 = Fresh frozenplasma

No consensus on ratio of RBC:FFP:PLT(J Trauma 2007; 62:307, J Trauma 2006; 60:S51)


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Refusal of Blood Products

Jehovahs Witnesses 44-fold increased risk ofdeath(Am J Obstet Gynecol 2001 Oct;185(4):893)

Intraoperative Blood Salvage andAutotransfusion

Optimize pre-delivery Hgb

Gluten as volume expander

Hyperbaric Oxygen


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Summary

Active Management of Third Stage of Labor isimperative

Always be prepared for PPH, risk factors are

not always present and prevention doesntalways work

Focus on the basics, dont forget fluid/ blood

product replacement

Bakri Balloon and Uterine Artery Embolizationmay be temporizing measures available onthe way to the OR

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Walters - Postpartum Hemorrhage USAFP (FILEminimizer)