THE SAFE MOTHERHOOD INITIATIVE: ADDRESSING CURRENT ...
Transcript of THE SAFE MOTHERHOOD INITIATIVE: ADDRESSING CURRENT ...
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THE SAFE MOTHERHOOD INITIATIVE:
ADDRESSING CURRENT PRACTICE PATTERNS IN
HEMORRHAGE, HYPERTENSION, & VTE
Mary E. D’Alton MD, FACOGSMI Co‐ChairWillard C. Rappleye Professor and ChairDepartment of Obstetrics and GynecologyColumbia University Medical Center
Cynthia Chazotte, MD, FACOGSMI Co‐ChairProfessor and Vice Chair, Department ofObstetrics and GynecologyAlbert Einstein College of Medicine/Montefiore Medical Center
CONFLICT OF INTEREST DISCLOSURE STATEMENT
We don’t have financial interest or other relationships with the industry relative to the
topics being discussed.
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Learning Objectives
1. Determine the appropriate use of oxytocin in the setting of obstetric hemorrhage and its indicated dosing schedule
2. Describe the term “persistent hypertension of pregnancy” and when to treat based on this definition
3. Identify the indicated use of heparin as a form ofchemoprohylaxis for pregnant patients at risk for VTE
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Obstetric Hemorrhage
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Risk Assessment: Prenatal
• Suspected previa/accreta/increta/percreta*
• Pre‐pregnancy BMI >50
• Clinically significant bleeding disorder
• Other significant medical/surgical risk (consider patients who decline transfusion)
Transfer to appropriate level of care for delivery **
* See supplemental guidance document on morbidly adherent placenta
** Review availability of medical/surgical, blood bank, ICU, and interventional radiology support
EXAMPLE
Risk Assessment:Patients Who Decline Blood Products
Antepartum period
• Discuss the blood product form/list
• Discuss how to maximize their HB/Hct, etc. in the event of blood loss
Labor & delivery admission
• Antepartum as outlined above, plus
• Complete blood product form
• Alert hemorrhage team
Alert the hemorrhage team
• Admission to labor & delivery
• Prior to surgery if risks factors for PPH present
• For any patient with PPH
EXAMPLE
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Universal Active Management of 3rd Stage of Labor
• Increase IV Oxytocin rate, 500mL/hour of 10‐40 units/500‐1000mL solution
• Titrate infusion rate to uterine tone, up to 500mL as needed
EXAMPLE
Blood Bank: Massive Transfusion Protocol
1.In order to provide safe obstetric care institutions must:
• Have a functioning Massive Transfusion Protocol (MTP)
• Have a functioning Emergency Release Protocol (a minimum of 4 units of O‐negative/uncrossmatched RBCs)*
• Have the ability to obtain 6 units PRBCs and 4 units FFP (compatible or type specific) for a bleeding patient
• Have a mechanism in place to obtain platelets and additional products in a timely fashion
EXAMPLE
Blood transfusion or crossmatching should not be used as a negative quality marker &is warranted for certain obstetric events.
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Statement on the Use of Blood Products
Blood transfusion or crossmatching should not be used as a negative quality marker and is warranted for certain obstetric events. In cases of severe obstetric hemorrhage, ≥4 units of blood products may be necessary to save the life of a maternity patient.
Hospitals are encouraged to coordinate efforts with their laboratories, blood banks, and quality improvement departments to determine the appropriateness of transfusion and quantity of blood products necessary for these patients.
EXAMPLE
Recommended Instruments Medication Kit(for rapid access to medications)
[ ] Pre‐mixed Oxytocin (Pitocin) 10‐40 units / 500‐1000mL solution 2 bags
[ ] Oxytocin (Pitocin) 10 units 2 vials
[ ] 15‐methyl PGF2α (Hemabate) 250 micrograms/milliliters 1 ampule *
[ ] Misoprostol (Cytotec) 200 microgram tablets 5 tabs
[ ] Methylergonovine (Methergine)0.2 milligrams/milliliters 1 ampule *
* Needs refrigeration
EXAMPLE
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NEW FORMAT
Hemorrhage Checklist
RECOGNITION
Call for assistance (appropriate obstetric hemorrhage team)
Designate
Team leader
Checklist reader/recorder
Identify primary RN
Announce
Cumulative blood loss
Vital signs
Determine stage
EXAMPLE
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Checklist: STAGE 1 Blood loss >500 mL vaginal OR blood loss >1000 mL
cesarean WITH NORMAL VITAL SIGNS and LAB VALUES
• Record VS, O2 saturation every 5 minutes
• Record cumulative blood loss
• Insert Foley catheter
• IV access: at least 16 gauge if possible
• Increase intravenous fluid (crystalloid: estimated blood loss in 2:1 ratio without oxytocin)
• Fundal massage
• Determine and treat etiology (4 Ts ‐Tone, Trauma, Tissue, Thrombin)
• Blood bank: Type & crossmatch 2 units PRBCs
EXAMPLE
Checklist: STAGE 1 Blood loss >500 mL vaginal OR blood loss >1000 mL cesarean
WITH NORMAL VITAL SIGNS and LAB VALUES
INITIAL STEPS
Ensure 16G or 18G IV access
Increase IV fluid (crystalloid: estimated blood loss in 2:1 ratio without oxytocin)
Insert indwelling urinary catheter
Fundal massage
MEDICATIONS
Increase oxytocin, other uterotonics
BLOOD BANK
Type & crossmatch for 2 units RBCs
ACTION
Determine etiology & treat
Prepare OR if clinically indicated
(i.e., optimal visualization & examination)
EXAMPLE
Oxytocin (Pitocin)10‐40 international units/liter intravenously
Methylergonovine (Methergine)0.2 milligram intramuscularly (may repeat)
15‐methyl PGF2α (Hemabate, Carboprost)250 micrograms intramuscularly (may repeat)
Misoprostol (Cytotec)800‐1000 micrograms rectally
Tone (i.e., atony) Tissue (i.e., retained products)Trauma (i.e., laceration) Thrombin (i.e., coagulation dysfunction)
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Checklist: STAGE 2Continued bleeding EBL up to 1500 mL OR any patient requiring ≥2 uterotonics WITH NORMAL VITAL SIGNS and LAB VALUES
• 2nd IV access (16 gauge if possible)
• STAT labs, with coags & fibrinogen
• Warming blanket
• For uterine atony Consider intrauterine balloon or surgical interventions
• Blood bank: DO NOT wait for labs. Transfuse per clinical signs/symptoms.
– Notify of OB hemorrhage, bring 2 units PRBCs to bedside, thaw 2 units FFP
• Medications: Continue medications from Stage 1
• Consider moving patient to OR (better exposure, potential D&C)
• Mobilize additional team members as necessary
EXAMPLE
Checklist: STAGE 2Continued bleeding EBL up to 1500 mL OR any patient requiring >2 uterotonics WITH NORMAL VITAL SIGNS and LAB VALUES
INITIAL STEPS
Mobilize additional help
Place 2nd IV (16‐18G)
Draw STAT labs (CBC, coags, fibrinogen)
Prepare OR
MEDICATIONS
Continue Stage 1 medications
BLOOD BANK
Obtain 2 units RBCs, thaw 2 units FFP (DO NOT wait for labs. Transfuse per clinical signs/symptoms)
ACTION
Escalate therapy with goal of hemostasis
EXAMPLE
Guidance document to be created on theprocesses for measuring blood loss:> eyeballing technique> semi‐quantitative> quantitative
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Surgical Management
• Uterine curettage
• Placental bed suture
• Uterine artery ligation
• Uteroovarian ligation
• Repair uterine rupture
• B‐Lynch suture, multiple square sutures
• Hysterectomy
Images used with permission from:FEMALE PELVIC SURGERY VIDEO ATLAS SERIES Mickey Karam, Series Editor
Management of Acute Obstetric Emergencies Baha Sibai, MD [Copyright 2011 by Saunders]
B‐Lynch suture B‐Lynch suture
Hayman uterine compression suture
Surgical ligation locations of uterine blood supply
EXAMPLEGuidance document to be created for the use of
embolization vs. ligation
Checklist: STAGE 3Continued bleeding with EBL >1500 mL OR >2 units PRBCs given
OR Patient at risk for occult bleeding (post‐cesarean, coagulopathy) OR Any patient with abnormal vital signs/labs/oliguria
• Outline management plan Serial re‐evaluation Communicate with hemorrhage team
• Replacement RBC‐FFP‐Platelets in a 6:4:1 ratio (trigger Massive Transfer Protocol ‐MTP) If coagulopathic, add cryopreciptate. Consider consultation for alternative agents
• If unclear, identify etiology for bleeding Rule out lacerations (exam), coagulopathy (labs), occult bleeding (imaging)
• Hemostasis Initiate immediately, interventions based on etiology. If poor response, adopt additional measures.
EXAMPLE
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Checklist: STAGE 3Continued bleeding with EBL >1500 mL OR >2 units RBCs given
OR Patient at risk for occult bleeding/coagulopathy OR any patient with abnormal vital signs/labs/oliguria
EXAMPLE
INITIAL STEPS
Mobilize additional help
Move to OR
Announce clinical status (vital signs, cumulative blood loss, & etiology)
Outline & communicate plan
MEDICATIONS
Continue Stage 1 medications
BLOOD BANK
Initiate massive transfusion protocol (If clinical coagulopathy: add cryoprecipitate, consult for additional agents)
ACTION
Achieve hemostasis, interventions based on etiology
Checklist: STAGE 4Cardiovascular (CV) Collapse
• For patients with cardiovascular collapse in setting of massive hemorrhage:
– Profound hypovolemic shock (blood loss not replaced)
– AFE (sudden CV collapse followed by heavy uterine bleeding from uterine relaxation and associated coagulopathy)
• In these situations, immediate surgical intervention to ensure hemostasis (hysterectomy) is suggested. This should take place with simultaneous aggressive blood and factor replacement and medical interventions regardless of patient’s coagulation status. Expeditious hemostasis is the only step that will maximize survival rates for these critical patients.
EXAMPLE
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Checklist: STAGE 4Cardiovascular Collapse (massive hemorrhage, profound hypovolemic shock or
amniotic fluid embolism)
INITIAL STEPS
Mobilize additional resources
MEDICATIONS
ACLS
BLOOD BANK
Simultaneous aggressive massive transfusion
ACTION
Immediate surgical intervention to ensure hemostasis (hysterectomy)
EXAMPLE
Severe Hypertension in Pregnancy
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Severe Blood Pressure Values &“Persistent” Hypertension
When a Severe BP is Obtained
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NEW!
First Line Therapies
First Line Therapy Algorithm: Labetalol
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First Line Therapy Algorithm: Hydralazine
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Revised Hypertension Bundle Checklists