2 Overview of Postpartum Hemorrhage Old Problem – Consistent Thoughts
3 Definition… Arbitrary and problematic Traditionally: (Baskett, 1999) EBL >=500 cc after vaginal deliveryEBL >=1000 cc after a cesarean sectionExcessive blood loss that makes the patient symptomatic (ie lightheadedness, vertigo, syncope) +/-signs of hypovolemia (ie hypotension, tachycardia, or oliguria)
4 Incidence… Affects 5-15% of women giving birth Two categories: Early (primary) hemorrhage: occurs within the first 24 hours postpartumLate (secondary) hemorrhage: occurs after 24 hours postpartum
5 Be Prepared… Risk Factors: Macrosomia Labor induction and augmentation Prolonged second stageChorioamnionitisMagnesium sulfate usePrevious PPH(Jackson, 2001)
6 Be Prepared…Risk FactorORCIRetained placenta3.5Failure to progress during the second stage of labor3.4Placenta accreta3.3Lacerations2.4Instrumental delivery2.3Large for gestational age (LGA) newborn1.9Hypertensive disorders1.7Induction of labor1.4Augmentation of labor with oxytocinSheiner et al 2005
7 Prevention Active management of the 3rd stage of labor uterotonic administration (preferably oxytocin) immediately upon delivery of the baby (or shoulders)early cord clamping and cuttinggentle cord traction with uterine countertraction when the uterus is well contracted (ie, Brandt-Andrews maneuver).
8 Benefits of Active Management Vs Physiological management OutcomeCtrl rateRRCIPPH > 500ml14 %0.38PPH > 1000ml2.6%0.33Hgb < 9 g/dl6.1%0.4Blood transfusions2.3%0.44Therapeutic Uteretonics17%0.2Prendiville, 2000
10 Clinical findings in Ob PPH… Blood LossSBPSymptoms and signsDegree of shockmL (10-15%)NormalPalpitations, tachycardia, dizzinessCompensatedmL (15-25%)Slight fall ( mm Hg)Weakness, tachycardia, sweatingMildmL(25-35%)Moderate fall (70-80 mm Hg)Restlessness, pallor, oliguriaModeratemL (35-50%)Marked fall (50-70 mm Hg)Collapse, air hunger, anuriaSevere
11 Two important facts…1. Caregivers consistently underestimate visible blood loss by as much as 50%. The volume of any clotted blood represents half of the blood volume required to form the clots. 2. Most women giving birth are healthy and compensate for blood loss very well. This, combined with the fact that the most common birthing position is some variant of semirecumbent with the legs elevated, means that symptoms of hypovolemia may not develop until a large volume of blood has been lost
12 Quantified Blood Loss 25 ml peripad 50 ml peripad 100 ml peripad A saturated 4x4 12-ply sponge = 5 mlOther methods of quantification:WeightDirect Measurement100 ml chux250 ml chux350 ml chux500 ml chuxDry25 ml50 ml75 ml100 ml18x18 laps: 25 ml approx 50%; 50 ml approx 75%;75 ml entire surface; 100 ml saturated and dripping
13 Treatment… Two major components: Resuscitation and management of obstetric hemorrhage and, possibly, hypovolemic shockIdentification and management of the underlying cause(s) of the hemorrhage
14 Philadelphia Delivery Centers ProtocolPhiladelphia Delivery Centers
15 Organize the team…Call for help ( Attending, nurse , anesthesiologist)Designate a nurse to record vital signs, urine output, fluids and drugs administeredAssess the vital signs every 5-10min
16 Resuscitation… Administer 5-7L/min of Oxygen by face mask Place 2 large bore IV linesInitial Blood work:Type and cross match,CBC,PT/PTT/INR,Fib, FSP,Cr,S-8Fluid Resusciation with NS or LR to maintain BP at 90 mm/HgBlood transfusion using Massive Transfusion ProtocolCorrect coagulopathy if present
17 Massive Transfusion Protocol “1:1:1” Consider activation of a MT protocol when patient actively bleeding and any of the following:Systolic blood pressure < 90 mmHgPh < 7.1Base deficit > 6 meq/LTemperature below 34°CINR > 2.0Platelet count < 50,000/mm³Once activated, the blood bank will send 6 units of PRBC, 6 units of FFP, 6 units of platelets, and 10 units of cryoprecipitate. After this, if the patient remains bleeding (the protocol has not being inactivated), 6 more units of PRBC and FFP will be prepared along with 20 units of cryoprecipitate. The latter product is given in order to elevate the fibrinogen level since the next step of the protocol is toRecombinant Activated factor VII administer.At any point, if the patient’s hemorrhage stops, the blood bank should be notified so that the protocol can be terminated.If bleeding persists, the sequence is started again.
18 Blood Products General considerations Keep the platelet count > 50,000. If less than that, administer units initiallyIf surgical intervention is necessary, maintain Plt count > ,000.Cryoprecipate may be used along with FFP for fibrinogen levels <100, give in 6-12 unit doses
19 Blood Component Therapy ProductVolContentsEffectPRBCs240RBC, WBC, plasmaIncrease hematocrit 3 percentage points, hemoglobin by 1 g/dLPlatelets50Platelets, RBC, WBC, plasmaIncrease platelet count 5,000– 10,000/mm3 per unitFFP250Fibrinogen, antithrombin III, factors V and VIIIIncrease fibrinogen by 10 mg/dLCryoprecipitate40Fibrinogen, factors VIII and XIII, von Willebrand factor
20 Targets after Transfusion… Fibrinogen > 100mg/dlHematocrit >21%Hemoglobin >7g/dlPlatelet count >50,000PT/PTT <1.5 times control
21 Response to Resuscitation… Pay attention to pt’s level of consciousnessMonitor BPMaintain BP around 90 mm/Hg SystolicMonitor RRFrequent auscultation of lung fieldsStart Blood if BP cannot be maintained or when Bleeding is controlled
22 Work up… Exam Patient- DR or in OR Imaging Studies: bedside U/S Uterine ToneGenital LacerationsPlacentaBleeding SitesLab Studies: Type and cross match, CBC, PT/PTT/INR, Fib, FSP, Cr, S-8Imaging Studies: bedside U/S
23 Initial Management… Empty bladder Vigorous bimanual Uterine massage Manual exploration of uterine cavity. (Use U/S to r/o retained placenta)UterontonicsCareful inspection of cervix, vagina, vulva and perianal area for lacerations and/or hematomas in ORConsider coagulopathy if no other cause identified
24 Medical Management…UTEROTONICS…Pitocin: 40 units in 1 liter NS or LR IV rapid infusion or 10 units IM (Avoid undiluted IV push)Methergine: 0.2mg IM q2-4hr, max 5 doses (Contraindicated with HTN)Hemabate: 0.25mg IM or intramyometrial q 20-90min, max 8 doses (Contraindicated with Asthma)Cytotec: mcg PR or SL (not per vagina)
26 Management Monitor CBC, Coagulation studies, ABG Monitor pulse oximetryMonitor Urine output with indwelling catheterCorrect coagulopathyFFP- preferred because of volumeCryoprecipitate
27 If PPH hemorrhage continues after uterotonics… Shift to ORExam under anesthesia: carefully re-inspect the cervix, vagina, vulva and perianal areas for lacerations and /or hematomasPerform D&E to make sure that there is no retained placental tissue (“Banjo” curette)
28 Packing and Tamponade… If PPH still continues….Packing: 4 inch gauze pack into uterus using a sponge stick. If thrombin available, soak gauze with 5,000 units thrombin in 5cc sterile salineSOS Bakri Tamponade Balloon: Insert balloon, instill cc salineFoley catheters: if Bakri balloon unavailable. Insert one or more bulbs, instilled with 60-80cc of NSS
30 Intractable PPH at vaginal delivery Uterine Artery Embolization No coagulopathy Hemodynamically stable to go to Radiology suite Interventional Radiologist available
31 UAE: special considerations… If patient is relatively stable, not coagulopathic and an intervention radiologist is available; consider arterial embolization before proceeding to exploratory laprotomy. Temporizing measures like packing and SOS Bakri balloon tamponade can be used in the meanwhile.
32 Intractable PPH at Vaginal delivery LaparotomyMake midline vertical abdominal incisionBegin with bilateral uterine art ligation-Figure of 8’sIf unsuccessful, consider…B-Lynch suture or square compression sutureVicryl 1Hpogastric artery ligationHysterctomy (supracervical)
34 PPH at cesarean delivery Aggressive resuscitationDirect bimanual compressionDirect intramyometrial injection of Hemabate may be undertakenRetained placenta can be removed under direct visualizationCompression sutures may be placedLUS can be packed with end in the vagina for hrsHypogastric Artery LigationSupracervical Hysterectomy
35 Post Op care… Continue resuscitation Monitor vital signs and urine outputMonitor vaginal bleedingRepeat labs as indicatedDisposition: ?ICUMonitor for coagulopathyMonitor for complications: anemia, ARDS, ATN being most common
36 Documentation… Infusion type and rate Massive Transfusion Protocol (1:1:1)BloodPlateletsFibrinogenMedications administeredPatient responseVital signs and urine outputNursing and Physician notes
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