1. { Postpartum Hemorrhage (PPH) What to know and do Dr. Bruno C. R. Borges Hamilton Health Sciences McMaster University OMA Anesthesia Meeting 2014

2.  Most common cause of maternal morbidity in developed countries  Most common cause of maternal mortality worldwide (150, 000 women per year - approximately 1 every 3-4 minutes)  Now complicates up to 6% of deliveries (has been steadily increasing over the past 10 years) Postpartum Hemorrhage BJOG: 2013;120:853–62.

3.  Authors of recent PPH related articles  Anesthesiologist and Obstetrician in the Maternal and Perinatal Death Review Committee (Office of Coroner Chief of Ontario)  Anesthesiologists with vast experience in transfusion medicine, who build hemorrhage protocols  Simulator instructors of PPH scenarios  Colleagues with obstetrical anesthesia interest and/or fellowships Experts I reached out to:

6. We May Be Ignoring Risk Factors Dutton RP et al. Massive Hemorrhage: A Report from the Anesthesia Closed Claims Project. Anesthesiology, Sep 2014. “Among the 43 obstetric claims, 74% presented with at least one risk factor for hemorrhage”

7.  Tone – Uterine Atony – prolonged labor, protracted labor, pre-term labor, large uterus, use of oxytocin during labor, etc.  Trauma - Lacerations, Hematomas, Uterine Inversion, Rupture  Tissue (Placenta) – Retained, Invasive Placenta  Thrombin – Coagulopathies, abruption, amniotic fluid embolus Know the Risk Factors The 4 T’s of PPH

8. Ontarian Risk Factors? Dutton RP et al. Massive Hemorrhage: A Report from the Anesthesia Closed Claims Project. Anesthesiology, Sep 2014.

9.  Minimum of 1 or 2 extra large bore IVs  “PPH kit”  Blood (G+S)  Have a device to push/warm blood products – youtube video  Surgical Checklist – “This patient is high risk for PPH because of ” Risk Factor? Prepare. https://www.youtube.com/watch?v=1PaQgD4ir2g

10. Diagnose Quicker...Common features : lack of timely diagnosis...Anesthesia care contributed to poor outcome in most claims.” “A timely diagnosis of hemorrhage was judged to have occurred in only 31% of the claims” Inform your team Dutton RP et al. Massive Hemorrhage: A Report from the Anesthesia Closed Claims Project. Anesthesiology, Sep 2014. and Expert emails

11. Treat Atony More Aggressively Dutton RP et al. Massive Hemorrhage: A Report from the Anesthesia Closed Claims Project. Anesthesiology, Sep 2014. “…often caregivers wait too long to intervene hoping things will get better instead of actively making them better.” Quick “escalation is key ” – Think airway algorithm… “Bring the PPH Kit!”

12. Have a PPH Kit  Oxytocin 10U/mL x3 vials;  Ergonovine 0.25 mg/mL one vial;  Misoprostol 100mcg tabs x10;  Hemabate/carboprost 250mcg vials x3;  Tranexamic acid 100mg/mL vials total of 2g.

13. Ideally  OBs, Nurses and Anesthesiologists know what the sequence of steps are  In-services  Combined Rounds  Checklists  Simulation

14. Oxytocin  2 maternal deaths reported in UK after 10U push  ED90 bolus dose for elective C- sections, non-laboring women: 0.3U  Higher requirements for prolonged labor (builds resistance)  40U Oxytocin + Ergot in 1L Bag. J Obstet Gynaecol Can 2009;31:980–93.

15. Ergonovine  Alpha adrenergic effects  Contraindicated for hypertensive disorders  Dose for prolonged labor (builds resistance)  How to give:  IV in 1L bag  IM  Slow 1ml/10s, 20mL syringe

16. Prostaglandins and Tran. Acid  Bronchospasm with hemabate (carboprost) – case report  For asthmatics, use PR/PO misoprostol (600-1000mcg) instead (bronchodilator)  Potential Additive Effect  Give Tranexamic Early: Bolus 1g  WOMAN trial

17. Engage the Team “Everyone, this is PPH!” “Start the Massive Hemorrhage Protocol!” “Call the blood bank!” Dutton RP et al. Massive Hemorrhage: A Report from the Anesthesia Closed Claims Project. Anesthesiology, Sep 2014.

18. Blood Products  Start early. Limit Cristaloids  Ask for 6 PRC + 4 FFP + PLTs  Start with a ratio of 2 RPC:1 FFP or 1:1  It pre-eclamptic, give PLT, Cryo and FFP early.  Calcium: 1mg of CaCl 2 for every mL of FFP transfused

19. Blood Products  Permissive Hypotension

20. Non-anesthetic interventions  Intrauterine Balloon  Interventional Radiology J Obstet Gynaecol Can 2009;31:980–93.

21. Non-anesthetic interventions  Interventional Radiology  Embolization of uterine arteries  For hemodynamically stable patients J Obstet Gynaecol Can 2009;31:980–93.

22. What now?  Transfer to tertiary center  Deal with PPH onsite

23. Questions to be answered first: Blood bank output capability Logistics issues Is your OB comfortable with hysterectomy? Do you have backup OBs/surgeons? Do you have backup anesthesia people? How close are you to big centers? Design a Emergency Fan Out list Call Obstetric team from tertiary center in?

24. Factor VIIa  Last resource before hysterectomy  90mcg/kg, repeat at 20 minutes if no response  Be aware of potential thrombotic complications

25.  PPH is on the rise  Look for and be aware of risk factors  In the Moment:  Diagnose Quicker  Communicate diagnosis loudly  Treat Aggressively  Short Term (in the next month):  Have a PPH drug kit  Have a plan for when things don’t work  Long term (next year):  Have a massive hemorrhage protocol  Simulate Take Home Messages For other resources and this presentation, go to http://obanesthesiaatmac.com