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Old Problem – Consistent Thoughts Definition… Arbitrary and problematic Traditionally: ( Baskett, 1999)  EBL >=500 cc after vaginal delivery  EBL >=1000.

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Presentation on theme: "Old Problem – Consistent Thoughts Definition… Arbitrary and problematic Traditionally: ( Baskett, 1999)  EBL >=500 cc after vaginal delivery  EBL >=1000."— Presentation transcript:

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2 Old Problem – Consistent Thoughts

3 Definition… Arbitrary and problematic Traditionally: ( Baskett, 1999)  EBL >=500 cc after vaginal delivery  EBL >=1000 cc after a cesarean section Excessive 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 postpartum  Late (secondary) hemorrhage: occurs after 24 hours postpartum

5 Be Prepared… Risk Factors: Macrosomia Labor induction and augmentation Prolonged second stage Chorioamnionitis Magnesium sulfate use Previous PPH (Jackson, 2001)

6 Risk Factor ORCI Retained placenta Failure to progress during the second stage of labor Placenta accreta Lacerations Instrumental delivery Large for gestational age (LGA) newborn Hypertensive disorders Induction of labor Augmentation of labor with oxytocin Sheiner et al 2005 Be Prepared …

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 cutting  gentle cord traction with uterine countertraction when the uterus is well contracted (ie, Brandt-Andrews maneuver).

8 Benefits of Active Management Vs Physiological management OutcomeCtrl rateRRCI PPH > 500ml14 % PPH > 1000ml2.6% Hgb < 9 g/dl6.1% Blood transfusions2.3% Therapeutic Uteretonics 17% Prendiville, 2000

9 Etiologies (4T’s)… Tone: uterine atony (80%) Tissue: retained placental tissue Trauma: uterine, cervical or vaginal lacerations Thrombin: dilutional coagulopathy, consumptive coagulopathy and coagulation disorders

10 Clinical findings in Ob PPH… Blood LossSBPSymptoms and signs Degree of shock mL (10-15%) NormalPalpitations, tachycardia, dizziness Compensated mL (15-25%) Slight fall ( mm Hg) Weakness, tachycardia, sweating Mild mL (25-35%) Moderate fall (70-80 mm Hg) Restlessness, pallor, oliguria Moderate mL (35-50%) Marked fall (50-70 mm Hg) Collapse, air hunger, anuria Severe

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

12 100 ml peripad 250 ml chux 350 ml chux500 ml chux 18x18 laps: 25 ml approx 50%; 50 ml approx 75%; 75 ml entire surface; 100 ml saturated and dripping 25 ml50 ml75 ml100 ml A saturated 4x4 12-ply sponge = 5 ml 50 ml peripad25 ml peripad 100 ml chux Dry Other methods of quantification: Weight Direct Measurement

13 Treatment… Two major components: Resuscitation and management of obstetric hemorrhage and, possibly, hypovolemic shock Identification and management of the underlying cause(s) of the hemorrhage

14 Philadelphia Delivery Centers

15 Organize the team… Call for help ( Attending, nurse, anesthesiologist) Designate a nurse to record vital signs, urine output, fluids and drugs administered Assess the vital signs every 5-10min

16 Resuscitation… Administer 5-7L/min of Oxygen by face mask Place 2 large bore IV lines Initial Blood work: Type and cross match, CBC, PT/PTT/INR, Fib, FSP, Cr, S-8 Fluid Resusciation with NS or LR to maintain BP at 90 mm/Hg Blood transfusion using Massive Transfusion Protocol Correct coagulopathy if present

17 Consider activation of a MT protocol when patient actively bleeding and any of the following: Systolic blood pressure < 90 mmHg Ph < 7.1 Base deficit > 6 meq/L Temperature below 34°C INR > 2.0 Platelet count < 50,000/mm³ Once 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 to Recombinant 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. Massive Transfusion Protocol “1:1:1”

18 Blood Products General considerations Keep the platelet count > 50,000. If less than that, administer units initially If 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 ProductVolContentsEffect PRBCs240RBC, WBC, plasmaIncrease hematocrit 3 percentage points, hemoglobin by 1 g/dL Platelets50Platelets, RBC, WBC, plasma Increase platelet count 5,000– 10,000/mm3 per unit FFP250Fibrinogen, antithrombin III, factors V and VIII Increase fibrinogen by 10 mg/dL Cryoprecipitate40Fibrinogen, factors VIII and XIII, von Willebrand factor Increase fibrinogen by 10 mg/dL

20 Targets after Transfusion… Fibrinogen > 100mg/dl Hematocrit >21% Hemoglobin >7g/dl Platelet count >50,000 PT/PTT <1.5 times control

21 Response to Resuscitation… Pay attention to pt’s level of consciousness Monitor BP Maintain BP around 90 mm/Hg Systolic Monitor RR Frequent auscultation of lung fields Start Blood if BP cannot be maintained or when Bleeding is controlled

22 Work up… Exam Patient- DR or in OR Uterine Tone Genital Lacerations Placenta Bleeding Sites Lab Studies: Type and cross match, CBC, PT/PTT/INR, Fib, FSP, Cr, S-8 Imaging 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) Uterontonics Careful inspection of cervix, vagina, vulva and perianal area for lacerations and/or hematomas in OR Consider 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 min, max 8 doses (Contraindicated with Asthma) Cytotec: mcg PR or SL (not per vagina)

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26 Management Monitor CBC, Coagulation studies, ABG Monitor pulse oximetry Monitor Urine output with indwelling catheter Correct coagulopathy FFP- preferred because of volume Cryoprecipitate

27 If PPH hemorrhage continues after uterotonics… Shift to OR Exam under anesthesia: carefully re-inspect the cervix, vagina, vulva and perianal areas for lacerations and /or hematomas Perform 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 saline SOS Bakri Tamponade Balloon: Insert balloon, instill cc saline Foley catheters: if Bakri balloon unavailable. Insert one or more bulbs, instilled with 60-80cc of NSS

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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 Laparotomy Make midline vertical abdominal incision Begin with bilateral uterine art ligation-Figure of 8’s If unsuccessful, consider… B-Lynch suture or square compression suture Vicryl 1 Hpogastric artery ligation Hysterctomy (supracervical)

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34 PPH at cesarean delivery Aggressive resuscitation Direct bimanual compression Direct intramyometrial injection of Hemabate may be undertaken Retained placenta can be removed under direct visualization Compression sutures may be placed LUS can be packed with end in the vagina for hrs Hypogastric Artery Ligation Supracervical Hysterectomy

35 Post Op care… Continue resuscitation Monitor vital signs and urine output Monitor vaginal bleeding Repeat labs as indicated Disposition: ?ICU Monitor for coagulopathy Monitor for complications: anemia, ARDS, ATN being most common

36 Documentation… Infusion type and rate Massive Transfusion Protocol (1:1:1) Blood Platelets Fibrinogen Medications administered Patient response Vital signs and urine output Nursing and Physician notes

37 Management of Post Partum Hemorrhage

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39 Post Partum Hemorrhage Box

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41 Post Partum Hemorrhage Meds

42 H.A.E.M.O.S.T.A.S.I.S Hask for help AAssess (VS, EBL) and resuscitate EEstablish etiology, ensure availability of blood, ecbolics MMassage uterus OOxytocin/Methergine/Hemabate/Cytotec S SShift to OR TTamponade balloon, uterine packing AApply compression sutures SSystematic pelvis devascularization IInterventional radiologist – UAE SSubtotal/total abdominal Hysterectomy

43 Thank-you from the Chairs of Ob/Gyn in Philadelphia


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