1. Management of Obstetrical Hemorrhage Jeffrey Stern, M.D.

2. Management of Obstetrical Hemorrhage Fundal massage VS q 15 minutes, O2 sat’s > 94%, oxygen by mask 10 liter/min. 1st IV, LR w/Pitocin 20-40 units at 1000 ml/ 30 minutes Start 2nd 18 G IV warm LR and administer wide open Obtain hemogram, fibrinogen, PT/PTT, platelets, T&C 4 u of PRBCs Initiate monitoring of I&O, urinary Foley catheter Get help, including Interventional Radiology, Anesthesia, etc.

3. Management of Obstetrical Hemorrhage LR or NS replaces blood loss at 3:1 Volume expander 1:1 (albumin, hetastarch, dextran) Administer uterotonic medications Anticipate DIC Verify complete removal of placenta, may require ultrasound Inspect for bleeding, episiotomy, laceration, hematomas, inversion, rupture Emperic transfusion: 2 u PRBC; FFP 1-2 u/4-5 u PRBC; cryo 10 u, uncrossed (O neg.) PRBC Warm blood products and infusion to prevent hypothermia, coagulopathy, arrhythmias

4. Treatment of Uterine Atony Oxytocin – 90% success –10-40 units in 1 liter NS or LR rapid infusion Methylergonovine (Methergine) - 90% success –0.2 mg IM q 2-4 hours max. 5 doses; avoid with hypertension Prostaglandin F2 Alpha (Hemabate) - 75% success –250 micrograms IM; intramyometrial, repeat q 20-90 min; max 8 doses. –Avoid if asthma/Hi BP. Prostaglandin E2 suppositories (Dinoprostone, Prostin E2) - 75% success –20 mg per rectum q 2 hours; avoid with hypotension Prostaglandin PGE 1 Misoprostol (Cytotec) - 75% to 100% success –1000 microgram per rectum or sublingual (100 or 200 microgram tabs)

5. Target Values Invasive monitoring Maintain systolic BP>90 mmHg Maintain urine output > 0.5 ml per kg per hour Hct > 21% Platelets > 50,000/ul Fibrinogen > 100 mg/dl PT/PTT < 1.5 times control Repeat labs as needed – every 30 minutes

6. Blood Component Therapy FFP (45 minutes to thaw) : –INR > 1.5 - 2u FFP –INR 2-2.5 - 4u FFP –INR > 2.5 - 6u FFP Cryoprecipitate (1 hour to thaw) : –Fibrinogen < 100 mg/dl – 10u cryo –Fibrinogen < 50 mg/dl – 20u cryo Platelets (5 minutes when in stock) : –Plt. ct. < 100,000 – 1u plateletpheresis –Plt. ct. < 50,000 – 2u plateletpheresis

7. Blood Component Therapy Blood CompContentsVolume (ml) Effect ( Per u) Packed RBCsRBC, Plasma300Inc. Hgb by 1 g/dl PlateletsPlatelets, Plasma300Inc. count by 7500 FFP Fibrinogen, antithrombin III, clotting factors, plasma 250Inc. Fibrinogen 10 mg/dl Cryoprecipitate Fibrinogen, antithrombin III, clotting factors, plasma 40Inc. Fibrinogen 10 mg/dl

8. Prepare for Laparotomy General anesthesia usually best Allen or yellowfin stirrups Uterine cavity manual exploration with ultrasound present Uterine inversion: Magnesium sulfate, Halothane, Terbutoline, NTG. Uterine packing (treatment vs. temporizing) – remove in 24-28 h –4” gauze Kerlex soaked in 5000 u of thrombin in 5ml of sterile saline –24 Fr. Foley with 30ml balloon with 30-80 ml of saline (1 or more as needed) –Bakri (intrauterine) balloon - 500 cc –Antibiotics

9. Intraoperatively Consider vertical incision General anesthesia usually best Get Help! Avoid compounding problems by making major mistakes Direct manual uterine compression / uterotonics Direct aortic compression Modified B-Lynch stitch (#2 chromic) for atony Ligation of uterine and utero-ovarian vessels (#1 chromic)

10. Intraoperatively Internal iliac artery ligation ( 50% success) –Desirous of children –Experience of surgeon –Palpate common iliac bifurcation –Ligate at least 2-3 cm from bifurcation –#1 silk. Do not divide Interventional Radiology: uterine artery embolization (catheters placed pre-op) Hysterectomy/ subtotal hysterectomy (put ring forceps on lip of cervix) Cell saver: investigational (amniotic fluid problems)

11. Post-Hysterectomy Bleeding Patient usually has DIC – Rx with whole blood, FFP, platelets, etc. Military Anti-Shock Trousers (MAST) –Increases pelvic and abdominal pressure to reduce bleeding –Can use at any point in the procedure Transvaginal or transabdominal (pelvic) pressure pack –Bowel bag with opening pulled through vagina cuff –Stuff with Kerlex gauze tied end-to-end until pelvis packed tight –Tie to 10-20 lbs. weight –Hang weights over edge of bed to help keep constant pressure May have to leave clamps or accept ligation of ureter or a major side wall vessel Interventional Radiology

12. Arterial Embolization

13. Selective Artertial Embolization by Angiography Clinically stable patient – Try to correct coagulopathy Takes approximately 1-6 hours to work Often close to shock, unstable, require close attention Can be used for expanding hematomas Can be used preoperatively, prophylactically for patients with accreta Analgesics, anti-nausea medications, antibiotics

14. Selective Artertial Embolization by Angiography Real time X-Ray (Fluoroscopy) Access right common iliac artery Single blood vessel best Embolize both uterine or hypogastric arteries Sometimes need a small catheter distally to prevent reflux into non- target vessels May need to treat entire anteriordivision or even all of the internal iliac artery. Risks: Can embolize nearby organs and presacral tissue, resulting in necrosis Technique –Gelfoam pads – Temporary, allows recanalization –Autologous blood clot or tissue –Vasopressin, dopamine, Norepinephrine –Balloons, steel coils

16. Evaluate for Ovarian Collaterals May need to embolize

17. Mid-Embolization “Pruned Tree Vessels”

18. Post Embolization

19. Pre EmboPost Embo