1. Jennifer L. Thompson, MD Assistant Professor Maternal Fetal Medicine
Critical Care Obstetrics: Severe Postpartum Hemorrhage and Blood Transfusion
Jennifer L. Thompson, MD
Assistant Professor
Maternal Fetal Medicine

2. Outline Learning Objectives Background Management / Treatment Summary
References

3. Learning Objectives
Appreciate the significant impact of obstetric hemorrhage on maternal morbidity and mortality
Understand the most common risk factors for obstetric hemorrhage
Be confident initiating early, aggressive treatment for postpartum hemorrhage
Utilize a staged approach to treating severe obstetric hemorrhage
By the end of the course we hope you are able :
- Appreciate the significant impact of obstetric hemorrhage on maternal morbidity and mortality
- Understand the most common risk factors for obstetric hemorrhage
- Be confident initiating early, aggressive treatment for postpartum hemorrhage
- Utilize a staged approach to treating severe obstetric hemorrhage

4. BACKGROUND

5. PPH Background
Obstetric hemorrhage affects 4-6% of births in the US and is a leading cause of maternal morbidity and mortality.
Failure to recognize excessive blood loss is a major contributor to maternal morbidity and mortality.
Lack of early recognition and intervention is common in woman who die from obstetric hemorrhage.
I don’t need to remind this audience of the importance and significant morbidity associated with PPH. It affects 4-6% of births in the US and is a leading cause of maternal morbidity and mortality. Failure to recognize excessive blood loss is a major contributor to this morbidity and mortality. Furthermore lack of early recognition and intervention is a common thread in woman who die from obstetric hemorrhage.
With timely diagnosis, appropriate resources, and appropriate management, however, PPH may be the most preventable cause of maternal mortality.

6. 123(5): , May 2014
Recognition of maternal morbidity and mortality has become of national importance over the last five years. In 2010 the Joint Commission issued a sential alert entitled “Preventing Maternal Death”. Within that publication they suggested various initiatives to help reduce maternal mortality including simulation training. After that publication ACOG and other organizations worked together identifying priorities for maternal safety. Out of those meetings The national partnership for maternal safety was established to develop a safety program for every birthing center in the US to help recognize and prevent the most common causes of maternal mortality. The partnership recognized three areas in which to focus: obstetric hemorrhage, severe hypertension and peripartum venous thromboembolism. The first they chose to address was obstetric hemorrhage.

7. 126(1): , July 2015
In July the National Partnership on Maternal Safety issued their consensus bundle on obstetric hemorrhage. This bundle outlines clinical practices that are recommended to be implemented in every maternity unit. The bundle is organized into 4 areas: Readiness ,Recognition and Prevention, Response and Reporting and system learning. Within each of these areas they outlined what should be in place and how to manage an obstetric hospital.
Readiness – Every unit : hemorrhage cart, access to hemorrhage medications, establish a response team, establish massive and emergency release transfusion protocols, unit education on protocols and drills
Recognition and preventions – Every patient: assessment of hemorrhage risk, measurement of cumulative blood loss, active management of the 3rd stage
Response – Every hemorrhage – unit standard, stage based obstetric hemorrhage emergency plan with checklists, support program for patients, families and staff
Reporting and Systems learning: Establish a culture of huddles and postevent debriefs, multidisciplinary review of serious hemorrhages for systems issues, monitor outcomes and process metrics in quality improvement committee
ACOG Practice Activities Division
June 2011

8. Risk Factors for PPH Prolonged or augmented labor Prior PPH Obesity
Retained/Abnormal placentation
Lacerations
Operative vaginal delivery
Macrosomic infant
Abruption
Hypertensive disorders
Prior PPH
Obesity
High parity
Asian/Hispanic
Precipitous labor
Uterine over distention
Uterine infection
Drugs that cause uterine relaxation
There are many risks factors for PPH and these are just a few. There can be both pregnancy and personal factors that contribute to developing PPH. This can include retained or abnormal placentation, lacerations, operative vaginal delivery, abruption, personal hx of PPH, high parity, rapid labor, uterine over distention, infection or medications causing uterine relaxation -= general anesthesia/magnesium

9. Risk Assessment Low Medium High No previous uterine surgery
Prior cesarean or uterine surgery
Placenta previa/low lying placenta
Singleton
Multiple gestation
Suspected placenta accrete, increate, percreta
≤ 4 previous vaginal deliveries
> 4 previous vaginal deliveries
Hematocrit <30 and other risk factors
No known bleeding disorder
Chorioamnionitis
Platelets <100k
No history of PPH
History of PPH
Active bleeding at admission
Large fibroids
Known coagulopathy
Risk assessment should continue throughout admission and labor process – if anything changes need to increase risk assessment

10. Causes of PPH Uterine Atony Trauma Retained Placenta
Coagulation Disorders
Uterine Inversion
Abnormal Placentation
Uterine atony is the number one cause of postpartum hemorrhage accounting for approximately 80% of hemorrhages and occurring in nearly 1:20 births
Trauma includes genital tract lacerations such as cervical lacerations, uterine rupture or extensions of the hysterotomy at the time of CD.

11. Definition
ACOG nomenclature consensus conference (reVITALize) recently revised:
Early postpartum hemorrhage: cumulative blood loss of >=1000ml OR blood loss accompanied by signs/symptoms of hypovolemia within 24 hours
Cumulative blood loss of ml alone should trigger increased supervision and potential interventions as clinically indicated 
In order for us to be able to recognize PPH and treat it we need to know how we define it. In 2014 ACOG set to standardize their definitions of common things given the use of electronic medical records to allow for better communication among individuals caring for patients.
Menard MK, Main EK, Currigan SM. Executive summary of the reVITALize Initiative: Standardizing obstetric data definitions. Obstet Gynecol 2014;124(1):150-3.
The definition of early PPH was revised and is now defined as cumulative blood loss of >/= 1000ml OR blood loss accompanied by signs/sx of hypovolemia within 24 hrs. There is no distinction made between vaginal or cesarean delivery.
It is important to realize however that, a cumulative blood loss of ml alone should trigger increased supervision and potential interventions as clinically indicated.

12. MANAGEMENT / TREATMENT

13. Dry Weight (approximate wt)
Diagnosis
Depends on accurate assessment of blood loss which must be:
As quantitative as possible
Cumulative
Item
Dry Weight (approximate wt)
Cloth under pad
639 gms
Blue Plastic Chux
10 gms
Delivery Pad
15 gms
Peripad
20 gms
Large Peripad
65 gms
Ice Pack
220 gms
Mesh Panties
0 gms
Lap Sponges
Large Lap Sponges
Blue/Green Towels
80 gms
1 gm weight =
1 ml of blood loss
Determining accurate assessment of blood loss requires us to be as quantitative as possible and cumulative. Quantifying blood loss is one way to determine this. ****Anyone currently using quantitative blood loss? Have you seen a change in your assessment of this patient?
QBL involves obtaining an accurate assessment of blood loss by using graduated drapes, as well as weighing wet items and subtracting the dry weight to get the total EBL. 1 gram of weight is equal to 1 ml of blood. This assessment needs to continue into the postpartum evaluation for the first 24 hours.
California Maternal Quality Care Collaborative Obstetric hemorrhage toolkit 2.0

14. Initial Management
Goal is early recognition, supportive care, treat the etiology and stop the bleeding.
Unit-standard, stage-based obstetric hemorrhage emergency response plan.
In the initial management of PPH the goal is early recognition, supportive care, treat the underlying etiology and stop the bleeding. There should be a unit standard, stage based approach to managing these patients. We will look at specific protocols later in the talk however when we think of how stages are broken down this usually is related to amount of blood loss, vital signs of the patient or need for escalating interventions.

15. Initial Management Supportive care: Assess resources
Vitals, O2 saturation, empty bladder, fundal massage
Ensure IV access, increase fluids
Type and cross
Escalate through stages
First assess your resources – is there another nurse available to help, do you have residents available to evaluate the patient.
Obtain vital signs – this includes BP and HR (Is she hypovolemic, is she tachycardic, are her vitals stable) is she conscious, what is her oxygen saturation, has her bladder been emptied if not empty bladder a full bladder can keep the uterus from being able to contract down empty the bladder.
Is her uterus boggy? Are there retained products? Start fundal massage
Ensure you have IV access and start IV fluid
Make sure she has a type and screen sent and if needed get blood available
As she continues to bleed make sure to escalate the level of care as things worsen. Many protocols base stages on degree of blood loss – once EBL >1500 need to move to OR to reassess bleeding, make sure all resources are available etc.

16. Initial Management Based on etiology: Medical therapy (atony)
Tamponade (balloon/packing)
Surgical therapy (based on etiology)
You initial management is going to depend on the cause of the bleeding.
Is it from atony – use medical therapy if not successful consider an intrauterine balloon
Is it due from laceration – repair the lacerations
Do they need surgical repair

17. Medications
Uterotonic available for the medical treatment of PPH include:
Oxytocin – IU/L IV or 10 units IM if no IV access
Methergine .2 mg IM – can repeat every 2-4 hours
Hemabate 250 mcg IM can repeat q15 minutes – max 8 doses
Misoprostol mcg rectally

18. Nonpharmacological Management of PPH
Repair of lacerations
Uterine curettage for retained placenta
Tamponade devices
Nonmedical therapy can be divided into two categories – nonsurgical and surgical. First we will discuss nonsurgical management.

19. Laceration Repair
These can occur in any portion of the genital tract and can lead to PPH
Very common
Adequate visualization and systematic inspection are essential
Genital tract lacerations are a common cause of PPH – if bleeding persists following delivery with a firm uterus inspection of the genital tract for a laceration is needed. Lacerations can be seen more often after operative vaginal delivery, delivery of a macrosomic infant and precipitous delivery. Adequate visualization is essential to ensure ability to repair the laceration – in some cases this requires moving the patient to the operating room is necessary.

20. Uterine Curettage
Hemorrhage rates have found to be increased if the length of the 3rd stage of labor is >30min
Examine placenta
Bedside ultrasound
Uterine curettage under ultrasound guidance using a large, blunt curette
Studies have shown that there is an increased risk of PPH with increasing length of the 3rd stage of labor with increased rates seen once the 3rd stage exceeds 30min. In addition once the placenta is removed it should be inspected to ensure it was removed in its entirety and no portion was left behind. Bedside ultrasound can be used to assist in the diagnosis of retained products – Shen et al evaluated a cohort of pts using bedside abd ultrasound and found that the sensitivity of 93.8% and specificity of 73.9% of predicting retained products. If suspicion is high that PPH is caused by retained products – uterine curettage is indicated. A large, blunt curette is used in order to assist in removing retained products with less likelihood of uterine perforation.

21. Uterine Tamponade Uterine Packing Initially described in 1887
Packing material distending the uterine cavity providing pressure against the uterine walls
Risk of concealed hemorrhage and continued bleeding
Uterine packing was initially described in 1887 as a way to control uterine bleeding. Packing have been considered an unfavorable way to treat PPH in the past because of the risk of infection and the possibility of concealing continued hemorrhage. It is considered a method of tamponade by distending the uterine cavity and providing pressure against the uterine walls. Variety of instruments can be used but the cavity needs to be packed completely. It is recommended to leave packing in from 24-36hrs.

22. Intrauterine Balloon Initially described in 1999
Balloon catheter placed inside the uterus
Used in both vaginal and cesarean deliveries
After placement of balloon – pack vagina as well
The use of a interuterine balloon was initially described in Several different types of balloons are available for use. Benefit of balloon over packing it is easier to place and allows filling of the uterus. Two hypothesis regarding mechanism of action have been proposed these include 1)Works by exerting an inward to outward pressure that is thought to be greater than the systemic arterial pressure 2)hydrostatic pressure effect of the balloon on the uterine arteries is what causes hemostasis. The balloon catheter can be used in both vaginal and cesarean deliveries. The Bakri balloon which we are most familiar with was initially described as being used only in causes of atony, however a subsequent report stated that successful use in lower uterine segment bleeding as well. Intrauterine balloon can be used alone or in combination with surgical methods. Overall success rate of uterine tamponade has been reported to be between %
Uterine tamponade is a safe and effective method and should be considered before proceeding with laparotomy.

23. Intrauterine Balloon
Applies inward to outward hydrostatic pressure against the uterine wall
Compression reduces blood flow and facilitates clotting
Success rates range from %
Indications include atony and bleeding from abnormal placentation
There are several different types of balloons available – Bakri, Ebb, BT-catheter.

24. Surgical Management of PPH: Uterine Sparing Techniques
B- Lynch Suture
Uterine Artery Ligation
Uterine Devascularization
Hypogastric Artery Ligation
Now we will review the various uterine sparing surgical methods of treating PPH

25. B-Lynch Suture Described in 1997
Compression suture to control PPH due to atony at time of cesarean
Preformed prior to closer of the uterine incision
First I’d like to discuss the B- Lynch compression suture. It was initially described by B-Lynch and colleagues in 1997 described as a compression suture to control uterine bleeding related to atony at the time of c/s. Since then various modifications on the technique have been described. This technique allows for exploration of the uterine cavity and doesn’t interfere with uterine drainage. An open hysterotomy incision is necessary to perform the B-Lynch suture. Prior to placing the sutures manual compression is done to test the efficacy of the sutures.

26. B-Lynch Suture Technique
When placing the B-Lynch suture the suture material of choice is 1-0 or 0 Vicryl. The first suture is placed 3cm below the transverse hysterotomy incision on the right and is then passed through the uterine cavity above the incision to a spot 4cm from the lateral border of the uterus where it is then passed through the anterior uterine wall. The suture is then taken over the fundus while the uterus continues to be compressed manually. The suture is then passed through the posterior wall at the level of the incision and the uterosacral ligaments. The suture is now located inside the cavity and is taken to the left side of the uterus and passed back through the posterior wall on the left – it is again taken over the fundus and down the left side to 4cm from the lateral side where it is then passed through the uterine wall into the cavity. The suture is then brought out of the cavity inferior to the incision and the two ends are tied.
These sutures can be placed following a vaginal delivery however, a hysterotomy incision is necessary in order to not obstruct the cervix or the uterine cavity.

27. B- Lynch Technique
Benefit of this suture technique is the ease of placement.

28. Hayman Modification of B-Lynch Technique
Doesn’t require a hysterotomy
Several modifications have been made to the B-Lynch technique – One in particular that I would like to mention is the Hayman technique described in 2002 – this is a similar technique however it doesn’t require a hysterotomy which makes this technique more useful in pts who delivered vaginally. In this technique 2 sutures of 2-0 Vicryl are placed (2 on each side) at similar locations to the B-Lynch sutures. The first suture is placed posterior to anterior through the entire thickness of the uterus at a level where a low transverse incision would be – the sutures are tied down over the fundus while manual compression is held. This is then repeated on the other side.
Overall success of this type of suture in controlling hemorrhage and avoiding hysterectomy has been found to be %
Complications that have been described in the literature include uterine necrosis and pyometria
Ghezzi F, . BJOG 2007

29. Uterine Artery Ligation
Described in 1966 by O’Leary and O’Leary
Uterine artery is ligated at the level of the internal os
2002 – Vaginal approach described
Uterine artery ligation was initially described by O’Leary and O'Leary in 1966 as a method to control PPH. This technique ligates the uterine artery at the level of the internal os using 1-0 chromic. 2-3cm of myometrium should be included in the suture which is then passed through the avascular space of the broad ligament. The sutures are placed below the level of the transverse incision. The uterine arteries account for 90% of uterine blood flow during pregnancy and these sutures have been found to decrease blood loss in cases of PPH due both to atony and abnormal placentation.
Success rates have been described as high as 85%. Complications associated with uterine artery ligation include arterial injury, hematomas and ureteral injury.
In 2002 Hebisch and Huch described a transvaginal approach for uterine artery ligation – The cervix is grasp with a ring forceps and a horizontal incision in made in the anterior cervix 1cm beneath the vaginocervical fold. Bladder is reflected using a sponge stick. Then traction is placed to pull the uterus down and lateral to maximize access. A stitch of 2-0 Vicryl is then placed around the uterine artery. After the first suture is placed another one or two sutures are recommended to ensure adequate ligation – this is not a widely used technique secondary to concerns regarding ureteral injury.
Uterine Artery
O’Leary & O’Leary. Obstet Gynecol. 1974

30. Uterine Devascularization
AdbRabbo in 1994
Extension of the O’Leary technique involving ligation of more of the uterine vascular supply
Complications
Ovarian failure
Synechiae
Necrotic uterus
Uterine devascularization was described by AdbRabbo in 1994 as another option for controlling PPH and avoiding hysterectomy. This technique involves ligation of the uterine artery at two locations as well as ligation of the ovarian vessels. The first stitch is placed similar to the O’Leary stitch at the level of the internal os using the same technique- this is represented by the letter C on the image. The next stitch is then placed lower on the uterine artery closer to the insertion point of the uterine artery this is represented by the letter D. This requires a well developed bladder flap and incorporation of 2cm of myometrium which is brought through the broad ligament. The next stitches involve ligation of the ovarian vessel. In the initially description of the technique it was reported that ovarian function is preserved due to collateral blood supply – Other authors have described ligation of the utero-ovarian anastomosis which is depicted by letters A and B and not the actual ovarian artery as was initially described.
Complications associated with this method include ovarian failure, synechiae or necrotic uterus

31. Hypogastric Artery Ligation
Described as early as 1888 to control hemorrhage associated with gynecologic malignancy
Requires thorough knowledge of pelvic anatomy
Exposure is essential
Controls hemorrhage by reducing pulse pressure which allows hemostasis to be achieved more quickly
Hypogastric artery ligation has been described as early as 1888 as a method to control gyn malignancies. This technique requires the surgeon to have a thorough knowledge of the pelvic anatomy as well as adequate exposure. Control of hemorrhage is achieved by a reduction in the pulse pressure, which allows hemostasis to be achieved more quickly by clot formation. Initially effectiveness was described in the 1980s as ranging from 25-40%. A more recent study described 100% success in controlling hemorrhage, however within their population of 117 pts only 13 did not proceed to hysterectomy. ACOG in its 2006 practice bulletin states that the procedure has been found to be less successful than previously thought – however no recommendation is made regarding use of the technique

32. Hypogastric Artery Ligation
In order to identify the hypogastric artery the peritoneum is incised at the level of the common iliac artery. Dissection is carried to the level of the bifurcation of the internal and external iliac. Internal iliac is then dissected out and is ligated – placement of suture should be distal to bifurcation by 3cm to avoid incorporating the posterior division in the ligation.
Complications include: injury to adjacent veins, ureters and ligation of the external iliac artery leading to devascularzation of the lower limbs – ligation of the posterior division leading to ischemia, intermittent claudication of the gluteal region
Porreco R et al. Clinical Obstetrics andGynecology 2010

33. Uterine Artery Embolization

34. Uterine Artery Embolization
Described in 1979 for control of vaginal lacerations
1980 successful use in uterine atony
Success rates as high as 95%
Complications – ischemia, neuropathy, uterine necrosis, vessel aneurysm, late rebleeding, fever
Initially described by Brown et al in 1979 as a means to control bleeding related to vaginal lacerations that were unable to be controlled with surgical management. Pais et al in 1980 described embolization as treatment for PPH secondary to atony. If pt is hemodynamiclly stable they are transferred to the radiology suite where under fluoroscopy. A femoral catheter is placed and threaded to the hypogastric artery and then embolized. The material that is used for the embolization are pledgets of gelatin sponge or gelatin sponge slurry – these agents are used because they cause a temporary occlusion that allows recannualization of the vessel within a few weeks. The use of non-resorbable materials has been associated with ischemia and necrosis.
Of note in cases where a significant blood loss is expected – occlusive uterine balloons can be placed prior to delivery in the hypogastric artery and if significant bleeding is experienced the balloons can be inflated to reduce uterine perfusion.
SIDE NOTE: COILS NOT USED TO CONTROL PPH GIVEN THEY ARE CONSIDERED INSUFFICIENT TO CONTROL BLEEDING

35. Uterine Artery Embolization
These images are of a 27yo with PPH undergoing an embolization. The first image is a selective left internal iliac angiogram showing abnormal area of increased vascularity in left pelvis. The second image depicts extravisation in area of defect. The third image is following injection of the Gelform slurry shows no more extravasation.
The arrow is marking truncation of the superior gluteal artery.

36. Peripartum Hysterectomy
When all other options fail

37. Peripartum Hysterectomy
Definitive surgical management
Incidence 1/1000
Indications
Atony
Abnormal placentation
Risk Factors
Prior cesarean
Peripartum hysterectomy is indicated if all other methods have failed and definitive treatment is necessary for control of PPH. Estimated incidence of peripartum hysterectomy is 1/1000 deliveries or less. Most common indications for hysterectomy are uterine atony and abnormal placentation. Abnormal placentation has now become the most frequently reason for peripartum hysterectomy – thought to be caused by the increasing rate of cesarean sections. Other indications include uterine rupture, extension of the incision, infection, leiomyoma, and DIC.
Maternal fetal medicine units network evaluated 30,132 women who underwent c/s delivery and found that the major risk factor for peripartum hysterectomy was number of prior sections with risk increasing proportionally with two prior section risk being 0.42% up to 2.41% with a 4th prior section.

38. Peripartum Hysterectomy Technique
Similar to traditional hysterectomy
Increased pedicle size
“Clamp-cut-drop” technique
A peripartum hysterectomy occurs in the same manner as a hysterectomy in the nonpregnant patent. However the difference is larger pedicle size based on increased peripartum edema and hypertrophy which leads to needing to take pedicles with two bites rather than just one. Emergent hysterectomy differs from one planned for abnormal placentation in that advanced preparations can be made to improve outcome and help minimize morbidity – this includes availability of blood prior to start of procedure, placement of central access for hemodynamic monitoring such as an A line and possibility of balloon catheters placed in the hypogastric artery.
One technique described in proceeding with an emergent hysterectomy is a “clamp-cut-drop” technique in which the pedicles are clamped and cut but not ligated until the uterine blood supply is controlled in order to expedite the procedure. If bleeding is severe you can start by clamping the uterine arteries before returning to the round ligaments.
Shah M & Wright J. Semin Perinatol 2009

39. The cervix: Take it or leave it?
Surgeon preference
Supracervical may be completed faster
May need total in order to control bleeding
No difference in complication rates, operating time, blood loss or transfusion between two techniques
The decision to perform a total versus supracervical hysterectomy is dependent on surgeon preference at the time of the operation. A supracervical hysterectomy may be able to be completed faster, however a total hysterectomy may be needed in order to control bleeding especially if the bleeding is due to abnormal placentation. In reviewing two studies looking at peripartum hysterectomy a supracervical was preformed 50% of the time or less. Studies have also found that there was no difference in the complication rates, operating time, blood loss or transfusion requirements between supracervical and total hysterectomy.
Chandraharan E & Arulkumaran S. Best Pract Res Clin Obstet Gynaecol 2008

40. Peripartum Hysterectomy – Maternal Outcomes
Complications
Percentage
Death
0.5-6%
ICU admission %
Reoperation %
Mechanical Ventilation
7-13%
Cystotomy
6-28%
Blood Transfusion
83%
Several studies have looked at complications related to peripartum hysterectomy. Studies were conducted in industrialized countries including UK, USA and Netherlands – found that maternal mortality occurs in 0.5-6% of peripartum hysterectomies. Most women require large volume blood transfusions – one study looking at academic medical centers found that 83% of patents required blood transfusions with greater than 30% requiring products in addition to PRBC. Kwee and associated found that in the Netherlands 38% of their pts required greater than 20 units of PRBC. The most common morbidity is postoperative fever occurring 11-34%. The most common intraoperative injury is cystotomy occurring in 6-28% of pts. Reoperation is necessary in 4-13% of patients. Reoperation was necessary for control of intra-abdominal hemorrhage in 2/3 of cases and the other 1/3 was for repair of other organs damaged at the time of hysterectomy.
Shah M & Wright J. Semin Perinatol 2009
Shellhaas C et al Obstet Gynecol 2009

41. MASSIVE TRANSFUSION

42. Classification of Hemorrhage
Hemorrhage Class
Acute Blood Loss
Percent Loss
Symptoms 1
900ml 15
None, palpitations, dizziness, mild tachycardia 2 ml
20-25
Mild tachycardia, tachypnea, diaphoresis, weakness 3
30-35
Overt hypotension, tachycardia, tachypnea, pallor, oliguria 4
2400ml 40
Hypovolemic shock
Before proceeding with discussion of blood transfusion I want to review the classification of hemorrhage based on the American College of Surgeons’ classification scheme. Early stages of blood loss lead to hypoprofusion which causes an increase in circulating catecholamines leading to tachycardia and low-normal blood pressure. Then HR increases in a response to increase O2 delivery to the tissue, pulse pressure decreases, and hypotension develops. As you can see class one hemorrhage results from a 900ml blood loss that equates to 15% of blood volume and symptoms can be none to very mild – in contrast to class 3 and 4 – which would be a patient whose had a severe postpartum hemorrhage and needing a life saving hysterectomy – they have lost 30-40% of their blood volume and have significant symptoms related to that.

43. Blood Products Product Volume (mL) Content Effect Packed Red Cells 240
RBC, WBC, plasma
Increase Hct by 3%; hgb by 1g/dL
Platelets 50
Platelets, RBC, WBC, plasma
Increase platelet count by 5,000 – 10,000/mm3 per unit
Fresh Frozen Plasma
250
Fibrinogen, antithrombin III, Factors V and VIII
Increase fibrinogen by 10mg/dL
Cryoprecipitate 40
Fibrinogen, factors VIII and XIII, von Willebrand factor
RBC – 240ml, RBC/WBC/plasma, increase hct 3%, hgb 1g/dL
Platelets – 50, platelets/RBC/WBC/plasmas, increase 5-10k
FFP – 250, fibrinogen, ATIII, Factor V and VIII, increase fibrinogen by 10mg/dL
Cryo – 40, fibrinogen, factor VIII, XIII, VWF, increase by 10

44. Massive Transfusion Hemorrhage Red Cell Transfusion Coagulopathy
Acidosis
Hypothermia
Massive transfusion is defined at administration of greater than 10 units of packed RBC. Massive transfusion protocols involve early utilization of blood products in resuscitation of patients with obstetrical hemorrhage. Use of clotting factors is recommended early to help attenuate the cycle of acidosis, hypothermia and coagulopathy. In hemorrhages large enough to require massive transfusion – hemorrhage can be worsened by coagulopathy that is associated with metabolic acidosis and core hypothermia.
Transfusion of PRBC can worsen the coagulopathy by diluting platelets and clotting factors leading to a worsening of the hypothermia and acidosis.

45. Massive Transfusion Protocol
Preset ratio of RBC:FFP:platelets
Automatic release and replenishment
Avoid dilution coagulopathy
Avoid acidosis, hypocalcemia and hyperkalemia
Additional agents available for hemorrhage unresponsive to adequate blood product replacement
Massive transfusion protocols have an established preset ratio – usually 6 RBC :4 FFP: 1 platelet which is the most common ratio. This was initiated to replace 70% of the total RBC volume and 60% of the circulating plasma in a 70kg individual.
There is an automatic release of products once the protocol is activated and requires a multidisciplinary approach involving OB, anesthesia, blood bank and possible hematology. Products continue to be released in the preset ratio until the MTP is canceled or the patient dies. The theory behind use of MTP is that when resuscitation is done primary with crystalloid hypovolemia is corrected however there is a worsening of dilution coagulopathy, enhances fibrinolysis and contributes to acidosis and hypothermia.
 Inadequate tissue perfusion in patients with hypovolemic shock due to bleeding leads to metabolic (lactic) acidosis, which can be exacerbated by excessive chloride and component blood administration.
Additional agents available such as recombinant factor VII, fibrinogen concentrate or tranexamic acid (TXA)
Acidosis causes demonstrable clotting dysfunction in experimental models at pH<7.2 by interfering with the assembly of coagulation factor complexes involving calcium and negatively-charged phospholipids [12-15]. As an example, the activity of the factor Xa/Va/phospholipid/prothrombin (“prothrombinase”) complex is reduced by 50, 70, and 90 percent at a pH of 7.2, 7.0, and 6.8, respectively. However, correction of acidosis alone does not always correct the associated coagulopathy, indicating that tissue injury causes coagulopathy via additional mechanism

46. Massive Transfusion Protocol
Must ascertain:
Guidelines for escalation/activation/blood transport
How additional blood products/platelets will be obtained
Mechanism for obtaining serial labs to ensure transfusion targets achieved
When developing a massive transfusion protocol needs to set:
Guidelines for escalation/activation/blood transport – who can activate it? How are we getting the blood to the patient? How do we escalate?
How additional blood products/platelets will be obtained – what if we need something different how is that obtained?
Mechanism for obtaining serial labs to ensure transfusion targets achieved – what labs, where do they go, what is our turn around time?
All of these factors are important to know in developing a MTP

47. Lets discuss the PPH checklist
Lets discuss the PPH checklist. There are several different checklists available this is the check list from district II. Important that you are familiar with your checklist and know how to use it. Stage one – Blood loss >500 SVD or >1000 CD. Vital signs, empty bladder, identify etiology, fundal massage, uterotonic – type and screen

48. Stage 2 continued bleeding up to 1500ml or if requiring >2 uterotonics – send labs, continue medications, if atony consider the balloon or surgical intervention, start MTP

49. Stage 3 >1500ml, ?2 units given, - transfusion,

50. Cardiovascular collapse – surgical intervention, replacement, and hemostasis.
Post hemorrhage management

51. Recurrence Risk Pregnancy Risk PPH 1st 5.8% 2nd with PPH in 1st 14.8%
3rd with 2 prior PPH
21.7%
3rd without PPH in 2nd
10.2%
In a population based study out of Australia evaluating 125,295 women – Ford et al looked at the recurrence risk of PPH. Their results demonstrated that 5.8% of women had a hemorrhage with their first pregnancy. The rate of recurrence in a second pregnancy was found to be 14.8% a 3 fold increase. In women who had had two consecutive PPH, 21.7% had a PPH with their third pregnancy. What about those who have had a PPH but don’t in a second pregnancy. Their risk was found to be 10.2% in a third pregnancy. Based on this study women with a prior hemorrhage are at an increased risk of hemorrhaging in a subsequent pregnancy.
Ford et al. Med J Aust. 2007; 187

52. SUMMARY
ACOG Simulation Committee

53. Obstetric Hemorrhage Best Practices
Management varies depending on etiology and available treatment options
Multidisciplinary approach is required
Uterotonics are first-line treatment for atony

54. Obstetric Hemorrhage Best Practices
When uterotonics fail (even with vaginal delivery), exploratory laparotomy is the next step.
In the presence of conditions associated with placenta accreta, the obstetric care provider must have a high clinical suspicion and take appropriate precautions.

55. Obstetric Hemorrhage Clinical Diamonds
Angiographic embolization is not meant to be used for acute, massive PPH.
Never treat “PPH” without simultaneously pursuing an actual clinical diagnosis.
In the PP patient who is bleeding or who recently has stopped bleeding and is oliguric, Furosemide is not indicated and will exacerbate the situation.

56. Obstetric Hemorrhage Clinical Diamonds
Any woman with placental previa and 1 or more cesarean deliveries should be evaluated and delivered in a tertiary care medical center.
If your labor and delivery unit does not have a recently updated massive transfusion protocol based on established trauma protocols, get one today.
With timely diagnosis, appropriate resources, and appropriate management, however, PPH may be the most preventable cause of maternal mortality.

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62. References & Resources
Safe Motherhood Initiative Bundles