Management of Obstetrical Hemorrhage

Jeffrey Stern, M.D.

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.

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

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)

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

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

Blood Component Therapy

Blood Comp Contents Volume (ml)

Effect ( Per u)

Packed RBCs RBC, Plasma 300 Inc. Hgb by 1 g/dl

Platelets Platelets, Plasma 300 Inc. count by 7500

FFPFibrinogen, antithrombin III,

clotting factors, plasma250 Inc. Fibrinogen 10 mg/dl

CryoprecipitateFibrinogen, antithrombin III,

clotting factors, plasma40 Inc. Fibrinogen 10 mg/dl

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

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)

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)

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

Arterial Embolization

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

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

Evaluate for Ovarian Collaterals

May need to embolize

Mid-Embolization “Pruned Tree Vessels”

Post Embolization

Post Embolization

Pre Embo Post Embo