Postpartum Hemorrhage

Gayle Olson, M.D.

Department of Obstetrics and Gynecology

University of Texas Medical Branch

Galveston, Texas USA.

Texas 2Step. 2013

Objectives

• Define hemorrhage

• Diagnose postpartum hemorrhage

• Strategies to prevent hemorrhage

• Discuss management options

Maternal Mortality

• Every minute a woman dies

• 529,000 women per year

• 20 suffer injury, infection or disease

• 10 million women per year

www.who.int accessed 2011

Direct Complications of

Childbirth

• Account for 70% mortality

• Fateful Five

• Hemorrhage (25%)

• Infection (15%)

• Unsafe abortion (13%)

• Eclampsia (12%)

• Obstructed labor (8%)

www.who.int accessed Fall 2011

Causes Maternal Death

Asia/Africa

Morbidity Percentage

Haemorrhage 31

Anemia 12.8

Other indirect causes of

deaths 12.5

Sepsis/infection 11.6

Obstructed labour 9.4

Hypertensive disorders 9.1

Khan KS et al. WHO analysis of causes of maternal death: a

systematic review. Lancet, 2006, 367:1066–1074

Causes Maternal Death

Developed Countries

Morbidity Percentage

Other direct causes of

deaths 21.3

Hypertensive disorders 16.1

Embolism 14.9

Other indirect causes of

deaths 14.4

Haemorrhage 13.4

Abortion 8.2

Khan KS et al. WHO analysis of causes of maternal death: a

systematic review. Lancet, 2006, 367:1066–1074

Impact of Hemorrhage on

HealthCare

• 3% of all deliveries.

• Transfusion increased

• 2.4 per 1,000 in 1998-1999

• 4.6 per 1,000 in 2004-2005

• Hysterectomy increased 15%

• Responsible for 10-13% of all deaths

Causes and Predisposing Factors of

Hemorrhage

Placentation

Previa, Accreta,

Percreta

Abruption

Ectopic pregnancy

Hydatidiform mole

Other

Obesity

Previous PPH

Severe preeclampsia,

sepsis,

renal insufficiency

AFE

Von Willebrand

Causes and Predisposing Factors of

Hemorrhage

Trauma

CD or hysterectomy

Episiotomy, forceps,

vacuum, cervical tear

Atony

Overdistended uterus,

LGA, multiples, clots

Induction

Halogenated agents

Exhausted

myometrium

Postpartum Hemorrhage

Definitions

• One or both:

• 10% change in Hct between admission and

postpartum

• need for erythrocyte transfusion

• EBL ≥500 mL for SVD: ≥1000 mL for CD

• Early (within 24 hrs) versus late (24 hrs to

6 weeks)

ACOG Educational Bulletin # 243; 1998

Rath. Acta Obstetricia et Gynecol Scandinavica 2011

Early vs Late PPH

Primary, Early or Acute

Within 24h PP

90% cases

Associated with more bleeding

Secondary or Late

24h – 12 wks pp

1-3% of deliveries

Infection

Retained products

Abnormal uterine involution

Failures in Treatment:

• Lack of consensus for PPH definition

• Lack of local ease-to-use action plans

(protocols)

• Underestimating the extent of hemorrhage

• Delay in blood transfusion/coagulation

factors (or not available)

• Lack of adequate education and training

Rath. Acta Obstetricia et Gynecol Scandinavica 2011

Mistakes Identified by Simulation

Error Percent

Underestimate blood loss 95

Unfamiliar with prostaglandin administration 82

Late transition to the operating room 82

Delayed administration of blood products 66

Unfamiliar dosing of ergot myometrial contractors 60

Essential blood tests carried out 44

Under detection of consumption coagulopathy 36

Source of bleeding not explored 35

Urinary bladder not drained 32

Maslovitz et al. Obstet Gynecol 2007;109:1295-300

Blood Volume in Pregnancy

Parameter % change

Blood volume Increase 45

Plasma volume Increase 55

RBC volume Increase 30

Estimated total blood volume 95mL/Kg during pregnancy

Compared to 75mL/Kg for non-pregnant adult women

An average increase of approx 1250 mL

Replacement considered at 15-20% loss of EBV

A Practical Approach to Obstetric Anesthesia 2009

Allowable Blood Loss (ABL)

EBV x (Hi - Hf)

Hi = ABL Hi = initial Hct

Hf = final lowest acceptable Hct

95 mL/Kg Assume 70kg EBV 6,650

6650 x (30 - 24)

30

= 1,330 mL (20%)

Estimating Blood Loss

4x4 hold ~ 10 mL blood

Ray-techs ~ 10-20 mL blood

Lap sponges ~ 100 mL blood

25 mL 50 mL 75 mL 100 mL

A B C D

Clinical Staging of Postpartum Hemorrhage

Severity Findings SBP % loss Blood Volume

Normal Palpitations,

dizziness,

tachycardia

Normal 10-15 500-1000ml

Mild HR < 100 bpm

Vasoconstriction

Slightly low 15-20% 1000-1500ml

Moderate

HR= 100-120 bpm

Restlessness

Oliguria

70-80

25-35% 1500-2000ml

Severe

HR > 120 bpm

Consciousness

Anuria, air hunger

< 60

≥ 35% 2000-3000ml

Management

Prevent

Mechanical

Medical

Surgical

Impact and Action

• California -2002 and 2003

• 10 of 98 pregnancy-related deaths,

• 70% preventable with improved care

• Maternal Quality Care Collaborative

(CMQCC)

The CMQCC Staged

Approach

• Stage 0 – Active management 3rd stage

• Stage 1 – EBL limits exceeded, stable

• Stage 2 – Continued bleeding, unstable

• Stage 3 – Major obstetric hemorrhage

• EBL > 1500, unstable, coagulopathy

Mhyre J. Anesth 2011

Modified Early Obstetric Warning Scores (MEOWS)1

Contact a physician for early intervention if the patient scores ≥2 at any time

Score 2 1 0 1 2

Pulse ≤40 41-50 51-100 101-120 or

10-20%

increase

>120 or >20%

increase

SBP ≤85 or

>20% decrease

85-100 101-150 151-160 >160

DBP <45 45-80 81-100 >100

SpO2 <95% 95-100%

RR ≤10 11-20 21-30

Temp ≤35.0 35.1-

35.9

36.0-37.9 ≥38.0

CNS Normal Responds Pain response

Anesthesiology 2011, ASA Annual Meeting

Rath. Acta Obstetricia et Gynecol Scandinavica 2011

Prevention

AMTSL

• Prophylactic oxytocin

• Controlled cord traction

• Uterine massage

Mechanical

Bimanual Compression

Operative Obstetrics 1995

Use of AMTSL Tsu VD. J Obstet Gynaecol Res 2006

Outcomes AMTSL Districts Control Districts

Number N=1,236 N=2,371

Bleeding - normal 81.0 81.0

Bleeding-high normal 15.6 14.6

Moderate hemorrhage 2.7 3.8

Severe hemorrhage 0.7 0.5

Third stage > 30 min 1.1 4.6

Third stage > 15 min 5.4 46.7

Effects of AMTSL on PPH and duration of the third stage of labor

Prophylactic Oxytocin Cotter AM et al. Cochrane Database of Systematic Reviews

2001

Oxytocin vs no uterotonics RR 0.50 [95% CI 0.43-0.59]

RR 0.60 [95% CI 0.44-0.87]

RR 0.50 [95% CI 0.39-0.64]

Oxytocin vs ergot alkaloids Little evidence to support

using one drug over the

other

Oxytocin + ergometrine vs

ergot alkaloids

Little evidence to support a

synergist effect

Medical Management Uterotonic Agents

Drug Route Dose NTK

Oxytocin IV, IM, IMM 10-40 U in LR Ø bolus, water

intoxication

Methylergonovine IM, IMM 0.2 mg

Ø IV, hypertension,

coronary insufficiency

Hemabate (15-methyl-PGF2 ) IM, IMM

0.25 mg

Every 15-90 min

max 8 doses

Ø cardiac, pulmonary,

renal or hepatic diseases

Dinoprostone (Prostin E2, PGE2)

rectal,

vaginal

20 mg, every 2

hours

Ø hypotension

Misoprostol (PGE1) rectal,

sublingual

400 – 800 g oral

routes, 800-1000

rectal routes.

Shivering, fever, diarrhea,

increasing with dose

Route of administration Misoprostol (PGE1)

Chong YS. European J Obstet Gyn Reprod Buil 2004

Uterine Packing

Operative Obstetrics 1995

Late - Mechanical Aortic Compression

20 normal non-bleeding parturients

Aortic compression with closed fist at umbilicus

Leg blood pressure

obliterated in 55%

significantly reduced in 10%

Femoral pulse obliterated in all

Systemic blood pressure not significantly affected

Riley & Burgess. Anaesth Intensive Care 1994;22:571-5

SOS Bakri

Tamponade Balloon Catheter

Cook OB/GYN (www.cookmedical.com)

The ebb™ Complete Tamponade System

Uterine Balloon Tamponade Alone Doumouchtsis et al. Obstet Gynecol Surv 2007;62:540-7

Surgical Management of

PPH

D&C if retained products

Repair of lacerations

Uterine compression sutures

Arterial ligation

• Uterine, tubo-ovarian, hypogastric

Pelvic embolization

Hysterectomy

B. Sibai

Uterine Compression Suturing Techniques

• B-Lynch Brace

• Hayman (vertical sutures)

• Cho (multiple square)

• Ouahba et al (2 transverse & 2 lateral)

B. Sibai

•Technique: #2

chromic on a 75 mm

heavy round bodied

needle

•Test: bleeding controlled

by bimanual compression

B-Lynch Suture

B-Lynch C. Br J Obstet Gynecol 1997;104:372-375.

B. Sibai

Zheng J, etal. BJOG 2010

Uterine Compression Suture Alone Doumouchtsis et al. Obstet Gynecol Surv 2007;62:540-7

Uterine Sandwich Nelson & O’Brien. Am J Obstet Gynecol 2007

Blood Supply to Uterus, Cervix, & Vagina

• Uterine fundus

• Uterine arteries (90%)

• Ovarian arteries (10%)

• From aorta

• Internal iliac artery

• Uterine artery

• Cervical branches

• Vaginal branches

• Multiple collaterals

B. Sibai

Postpartum Hemorrhage Hypogastric Artery Ligation

• Pulse pressure 85%

• Blood flow 48%

• Convert arterial flow to venous-like flow

• Allows hemostasis by clot formation

Uterine Artery Ligation

Efficacy of Reported Methods to Control PPH

(mainly uterine atony)

%

Uterine Balloon tamponade 77-88

Uterine compression sutures 84-95

Uterine devascularization 50-60

Uterine Arteries

Utero-ovarian vessels

Hypogastric 50-90

Uterine artery embolization 70-90

Hysterectomy ~100

Placenta Accreta

Placenta Accreta Predisposing Factors

• Placenta previa (by far the most important)

• Uterine scar (previous cesarean section,

myomectomy, metroplasty)

• Advanced maternal age

• Placenta overlying uterine scar

• Multiparity (95 % occurred in multiparae)

• Previous uterine curettage

Ultrasound Findings Suggestive of Accreta

Placental lacunae

• Loss of retroplacental hypoechoic zone

Previous cesarean & previa

• Low-lying gestational sac

• Intraplacental lakes with turbulent flow

• Absent decidua basalis

— Myometrial thickness < 1 mm

Loss of smooth interface with bladder

Focal nodular projections into bladder

• Percreta

B. Sibai

Massive Transfusion Protocol

Activation

• Active bleeding

• SBP < 90 mmHg

• Ph < 7.1

• Base deficit > 6 meq/L

• Temperature < 34º C

• INR > 2

• Platelets < 50,000/mm3

Massive Transfusion Protocol

• Adopts Hemostatic Resuscitation

concepts

• Limits aggressive crystalloids

• Introduces early use of FFP

• Ratio of PRBC:FFP 1:1

• Early use of rFVIIa

rFVIIa

Optimize Factor VII action

Hgb ≥ 7 g/dL

Fibrinogen > 50 -100 mg/dL

Pt & PT < 1.5 x mean control

Platelet count > 50,000 mm3

Normal ionized calcium levels

Serum K+ < 5 mEg/L

Temperature > 32º C and pH > 7.2

B. Sibai

Massive Transfusion Protocol

Obstetrics

PRBC FFP Platelets Cryoprecipitate

Round 1 6 units 6 units 6 units 10 units

Round 2 6 units 6 units 20 units

Round 3 Recombinant activated Factor VII (40 mg/kg)

Round 4 6 units 6 units 6 units 10 units

Round 5 6 units 6 units 10 units

Round 6 Recombinant activated Factor VII (40 mg/kg)

UTMB Blood Bank

Complications from Massive Transfusion

PRBCs

• DIC (dilutional)

• Hypothermia (blood stored at 1-6°C)

• Acidosis (pH of PRBC 6.9-7.0)

• Hypocalcemia (citrate binds to Ca++)

• Hyperkalemia (K+ leaves RBC in stored blood)

• Transfusion-related acute lung injury (TRALI)

B. Sibai

Abdominal Compartment

Syndrome • Third spacing colloids/crystalloids

• Bowel edema, ascites, ileus

• Increased intrabdominal pressure

• Compression abd and retroperitoneal

vessel

• Drop in CO, ↓ BP, oliguria, hypoxemia

• Intraabdominal pressure > 20mmHg + organ

compromise

• Surgical decompression

Assess blood loss & vital signs

Call for help and avoid Chaos

Large bore IV access + fluids

Obtain blood/products

Retained tissues

Previa-accreta

Lacerations

· Cervical/vag

· Perineal

· Extension at c/s

Uterine rupture

Coagulopathy

• Abruptio

• AFE/AFLP

• Anticoagulation

• Bleeding

• VW disease

Atony inversion

• Blood products

•Surgery

• Resuscitation

• Supportive care

30 y/o, 39 weeks, Prev CD x 3, ultrasound

report normal, for repeat, its you, scub tech,

anesthesia, small hospital-USA, you find

Summary

Suspicion of Hemorrhage

• Avoid Chaos

• Transfer to a tertiary care center

• Multidisciplinary team: Anesthesia,

blood bank, Interventional Radiology,

Pediatrics

• Surgical planning, OR preparation

• Postpartum diligence

Thank You

Also Consider:

Thromboelastogram

• Whole blood

hemostasis testing

• Measures

mechanical

properties of a clot

• Time to fibrin

formation

• Strength of the clot

• Fibrinolysis Haemonetics

Femoral Balloons

Prophylactic Balloon Catheters Zacharias et al. Am J Obstet Gynecol 2004

Cases Controls P

Estimated blood loss (ml) 3450 3320 NS

Transfused units of

PRBCs (median)

3 3 NS

Minutes in operating room 180 135 NS

Intensive care unit 33% 14% NS

Postoperative day

discharged (median)

6 5 NS

Acute Normovolemic

Hemodilution

• Presumption of bleeding

• Hemoglobin > 10g/dL

• No evidence of cardiovascular disease

• Remove 500-1000 mL whole blood

• Colloid 1:1 ratio replacement

• Crystalloid 3:1 ratio replacement

• Stable when stored for up to 6 hours

Intraoperative Cell Salvage

• Collects blood aspirated from the

surgical site

• Filters and concentrates PRBC

• Hematocrit 55-80%

• No current evidence of iatrogenic AFE

Ligasure

LigaSure

• Pressure +energy for tissue fusion

• Permanently fuses vessels to 7mm

• Seal cycle 2-4 seconds

• Automatically stops when seal complete

• RCT of TXA for PPH

• Ongoing

• Enrollment 15,000