Bleeding Complications During Pregnancy - HTRS · severe postpartum hemorrhage following an...
Transcript of Bleeding Complications During Pregnancy - HTRS · severe postpartum hemorrhage following an...
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Outline
• Epidemiology and causes of maternal mortality
• Placental structure and relation to hematologic disease in pregnancy
• Maternal mortality/morbidity due to bleeding
• Life threatening bleeding disorders
• Von Willebrand disease in pregnancy
http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html
Pregnancy-Related Death in the United States
Q1: Postpartum Hemorrhage
You are called to see a 24 year old woman who has developed severe postpartum hemorrhage following an extended labor and delivery. Her pregnancy had been previously uncomplicated. On further questioning she has had mild epistaxis about once every year or two, usually in the winter. She had previously undergone tonsillectomy as a child and said she bled afterwards but does not recall needing transfusions. She also underwent a laparoscopic appendectomy without excessive bleeding. Her obstetricians want to know whether she has an underlying coagulopathy.
Definitions and Causes of Postpartum Hemorrhage
Abdul-Kadir et al: Transfusion, 2014
Bateman et al: Anesth Analg, 2010
Massive Obstetric Hemorrhage/Disseminated Intravascular Coagulation
• Amniotic fluid embolism
• Placental abruption
• Placenta previa
• Placenta accreta
• Retained products of conception
ISTH Scoring System for DIC: Relevance to Pregnancy
Taylor FB et al: JTH, 2001Charbit G; JTH, 2007
Réger et al; Thromb Res 2013
Amniotic Fluid Embolism• Misnomer—“anaphylactoid syndrome of pregnancy”
• Incidence: 1/40,000
• Risk factors--controversial
– No risk factor identified that justifies prospective alterations of clinical practice
• Early clinical signs and symptoms
– Hypotension
– Dyspnea
– Cyanosis
– Loss of consciousness
– Cardiac arrest
• Fulminant coagulopathy (DIC)-diffuse bleeding from uterus, incisions, intravenous sites
• Consequences
– Maternal mortality in 60% if all classic signs and symptoms are present
– If cardiac arrest, mortality increases to 90%
– Severe fetal morbidity/mortality if not delivered urgently
Amniotic Fluid Embolism
https://www.studyblue.com/notes/note/n/vascular-disorders-_atlas-images/deck/8094977
Kanayama and Tamura J Obstet Gynec Res 40: 1507, 2014
Placental Abruption• Partial or complete separation of normally implanted placenta before delivery
• Incidence: 0.4-1.0% of pregnancies
– Highest incidence at 24-26 weeks
• Risk factors
– Advanced maternal age (>35 years)
– Smoking
– Chronic hypertension
– Vaginal bleeding during pregnancy
– PROM/chorioamnionitis
– Obstetrical history (preeclampsia, C-section, stillbirth, abruption)
– Thrombophilia?
• Clinical manifestations
– Hypovolemic shock, renal failure
– Fulminant DIC in severe cases
– Neonatal compromise
– Maternal mortality < 1%
http://umm.edu/health/medical/pregnancy/labor-and-delivery/placenta-abruptio
Algorithm for Management After Dx
of Amniotic Fluid Embolism
Balinger et al. Curr Opin Obstet Gynec 27:398, 2015
Treatment Algorithm for DIC Management in Obstetric Syndromes
Cunningham and Nelson Obstet Gynec 126:999, 2015
Management of Severe Postpartum Hemorrhage
• Uterine massage/uterotonics– Syntocinon
– Ergometrine/Syntometrine
– PGF2 alpha/Misoprostol
• Interventional approaches
– Uterine tamponade
– B-lynch suture
– Uterine artery/internal iliac artery embolization
– Hysterectomy
• Aggressive transfusion, platelet, coagulation factor replacement
• Recombinant factor VIIa (rVIIa)
Su et al: Best Prac Clin Res Obstet Gyn, 2012
Massive Transfusion in Obstetrical Bleeding
Pacheco LD et al: Am J Perinatol, 2013
Burtelow M et al: Transfusion, 2007
rVIIa in Obstetrical Hemorrhage
Leighton et al: Anesthesiology, 2011
Kobayashi et al: Int J Hematolol, 2012
Tranexamic Acid in Postpartum Hemorrhage
TXA: 4 gm over 1 hour, then 1 gm/hr infusion, IV Ducloy-Bouthors et al: Crit Care, 2011
Effect of TA on Postpartum Blood Loss: Systematic Analysis
Alam and Choi, Transf Med Rev 29:231-241, 2015
Case 2: VWD in Pregnancy
• 32 yo woman with VWD
• Menorrhagia
• Epistaxis, once per year, usually in winter
• Lab• PTT 36 sec (< 32 sec)
• RCOF 31% (>35%)
• CBA 42% (>41%)
• VWF ag 44% (>50%)
• All multimers reduced
• Presents in week 28 of uncomplicated pregnancy
Hemostatic Disorders in Pregnancy:vWD
Sadler JE: JTH, 2006
Castaman G: Med J Hematol Inf Dis, 2013Huq et al: Haemophilia, 2012
Management of Type I VWD at Delivery
• Most patients achieve normal levels of VWF by mid second trimester
• Vaginal or C-section is safe if RCof and FVIII levels are > 50%
• DDAVP can be used in pregnancy if invasive procedures needed before increase in VWF
• VWF levels begin to drop by day 3 and return to baseline by day 14—mean time at presentation for hemorrhage in VWF patients is 15.7 days
• Patient should be counseled to consult physician at any sign of increased bleeding: treatment options include DDAVP, factor concentrates, tranexamic acid
Neff and Sidonio. Am Soc Hematol Educ Prog 2014(1): 536-41
Summary• With respect to coagulation, pregnancy is a closely regulated
state, disruption of which can cause profound derangement of hemostasis
• The most common cause of post-partum bleeding is uterine atony
• Placental abruption is a cytokine/SIRS driven process, in which profound DIC follows the initial insult and may lead to life-threatening hemorrhage
• The normal increases in VWF during pregnancy in patients with Type I VWD are usually sufficient to enable safe delivery, but bleeding can occur in the post-partum period.