Post Partum Hemorrhage Protocol

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Post Partum Hemorrhage Protocol
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Overview of Postpartum Hemorrhage

• Old Problem Consistent Thoughts

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Definition

• Arbitrary and problematic
• Traditionally (Baskett, 1999)
• EBL gt500 cc after vaginal delivery
• EBL gt1000 cc after a cesarean section
• Excessive blood loss that makes the patient
  symptomatic (ie lightheadedness, vertigo,
  syncope) /-signs of hypovolemia (ie hypotension,
  tachycardia, or oliguria)

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Incidence

• Affects 5-15 of women giving birth
• Two categories
• Early (primary) hemorrhage occurs within the
  first 24 hours postpartum
• Late (secondary) hemorrhage occurs after 24
  hours postpartum

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Be Prepared

• Risk Factors
• Macrosomia
• Labor induction and augmentation
• Prolonged second stage
• Chorioamnionitis
• Magnesium sulfate use
• Previous PPH
• (Jackson, 2001)

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Be Prepared
Risk Factor OR CI
Retained placenta 3.5 2.1-5.8
Failure to progress during the second stage of labor 3.4 2.4-4.7
Placenta accreta 3.3 1.7-6.4
Lacerations 2.4 2.0-2.8
Instrumental delivery 2.3 1.6-3.4
Large for gestational age (LGA) newborn 1.9 1.6-2.4
Hypertensive disorders 1.7 1.2-2.1
Induction of labor 1.4 1.1-1.7
Augmentation of labor with oxytocin 1.4 1.2-1.7
Sheiner et al 2005
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Prevention

• Active management of the 3rd stage of labor
• uterotonic administration (preferably oxytocin)
  immediately upon delivery of the baby (or
  shoulders)
• early cord clamping and cutting
• gentle cord traction with uterine countertraction
  when the uterus is well contracted (ie,
  Brandt-Andrews maneuver).

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Benefits of Active Management Vs Physiological
management
Outcome Ctrl rate RR CI
PPH gt 500ml 14 0.38 0.32-0.46
PPH gt 1000ml 2.6 0.33 0.21-0.51
Hgb lt 9 g/dl 6.1 0.4 0.29-0.55
Blood transfusions 2.3 0.44 0.22-0.53
Therapeutic Uteretonics 17 0.2 0.17-0.25
Prendiville, 2000
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Etiologies (4Ts)

• Tone uterine atony (80)
• Tissue retained placental tissue
• Trauma uterine, cervical or vaginal lacerations
• Thrombin dilutional coagulopathy, consumptive
  coagulopathy and coagulation disorders

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Clinical findings in Ob PPH
Blood Loss SBP Symptoms and signs Degree of shock
500-1000 mL (10-15) Normal Palpitations, tachycardia, dizziness Compensated
1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness, tachycardia, sweating Mild
1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness, pallor, oliguria Moderate
2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse, air hunger, anuria Severe
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Two important facts

• 1. Caregivers consistently underestimate visible
  blood loss by as much as 50. The volume of any
  clotted blood represents half of the blood volume
  required to form the clots.
• 2. Most women giving birth are healthy and
  compensate for blood loss very well. This,
  combined with the fact that the most common
  birthing position is some variant of
  semirecumbent with the legs elevated, means that
  symptoms of hypovolemia may not develop until a
  large volume of blood has been lost

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Quantified Blood Loss
100 ml peripad
50 ml peripad
25 ml peripad
A saturated 4x4 12-ply sponge 5 ml

• Other methods of quantification
• Weight
• Direct Measurement

250 ml chux
100 ml chux
350 ml chux
500 ml chux
Dry
25 ml
50 ml
75 ml
100 ml
18x18 laps 25 ml approx 50 50 ml approx 75
75 ml entire surface 100 ml saturated and
dripping
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Treatment

• Two major components
• Resuscitation and management of obstetric
  hemorrhage and, possibly, hypovolemic shock
• Identification and management of the underlying
  cause(s) of the hemorrhage

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Protocol

• Philadelphia Delivery Centers

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Organize the team

• Call for help ( Attending, nurse ,
  anesthesiologist)
• Designate a nurse to record vital signs, urine
  output, fluids and drugs administered
• Assess the vital signs every 5-10min

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Resuscitation

• Administer 5-7L/min of Oxygen by face mask
• Place 2 large bore IV lines
• Initial Blood work
• Type and cross match,
• CBC,
• PT/PTT/INR,
• Fib, FSP,
• Cr,
• S-8
• Fluid Resusciation with NS or LR to maintain BP
  at 90 mm/Hg
• Blood transfusion using Massive Transfusion
  Protocol
• Correct coagulopathy if present

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Massive Transfusion Protocol111

• Consider activation of a MT protocol when patient
  actively bleeding and any of the following
• Systolic blood pressure lt 90 mmHg
• Ph lt 7.1
• Base deficit gt 6 meq/L
• Temperature below 34C
• INR gt 2.0
• Platelet count lt 50,000/mm³
• Once activated, the blood bank will send 6 units
  of PRBC, 6 units of FFP, 6 units of platelets,
  and 10 units of cryoprecipitate. After this, if
  the patient remains bleeding (the protocol has
  not being inactivated), 6 more units of PRBC and
  FFP will be prepared along with 20 units of
  cryoprecipitate. The latter product is given in
  order to elevate the fibrinogen level since the
  next step of the protocol is to
• Recombinant Activated factor VII administer.
• At any point, if the patients hemorrhage stops,
  the blood bank should be notified so that the
  protocol can be terminated.
• If bleeding persists, the sequence is started
  again.

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Blood Products

• General considerations
• Keep the platelet count gt 50,000. If less than
  that, administer 10-12 units initially
• If surgical intervention is necessary, maintain
  Plt count gt 80-100,000.
• Cryoprecipate may be used along with FFP for
  fibrinogen levels lt100, give in 6-12 unit doses

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Blood Component Therapy
Product Vol Contents Effect
PRBCs 240 RBC, WBC, plasma Increase hematocrit 3 percentage points, hemoglobin by 1 g/dL
Platelets 50 Platelets, RBC, WBC, plasma Increase platelet count 5,000 10,000/mm3 per unit
FFP 250 Fibrinogen, antithrombin III, factors V and VIII Increase fibrinogen by 10 mg/dL
Cryoprecipitate 40 Fibrinogen, factors VIII and XIII, von Willebrand factor Increase fibrinogen by 10 mg/dL
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Targets after Transfusion

• Fibrinogen gt 100mg/dl
• Hematocrit gt21
• Hemoglobin gt7g/dl
• Platelet count gt50,000
• PT/PTT lt1.5 times control

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Response to Resuscitation

• Pay attention to pts level of consciousness
• Monitor BP
• Maintain BP around 90 mm/Hg Systolic
• Monitor RR
• Frequent auscultation of lung fields
• Start Blood if BP cannot be maintained or when
  Bleeding is controlled

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Work up

• Exam Patient- DR or in OR
• Uterine Tone
• Genital Lacerations
• Placenta
• Bleeding Sites
• Lab Studies Type and cross match, CBC,
  PT/PTT/INR, Fib, FSP, Cr, S-8
• Imaging Studies bedside U/S

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Initial Management

• Empty bladder
• Vigorous bimanual Uterine massage
• Manual exploration of uterine cavity. (Use U/S
  to r/o retained placenta)
• Uterontonics
• Careful inspection of cervix, vagina, vulva and
  perianal area for lacerations and/or hematomas in
  OR
• Consider coagulopathy if no other cause identified

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Medical Management

• UTEROTONICS
• Pitocin 40 units in 1 liter NS or LR IV rapid
  infusion or 10 units IM (Avoid undiluted IV push)
• Methergine 0.2mg IM q2-4hr, max 5 doses
  (Contraindicated with HTN)
• Hemabate 0.25mg IM or intramyometrial q
  20-90min, max 8 doses (Contraindicated with
  Asthma)
• Cytotec 800-1000mcg PR or SL (not per vagina)

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Management

• Monitor CBC, Coagulation studies, ABG
• Monitor pulse oximetry
• Monitor Urine output with indwelling catheter
• Correct coagulopathy
• FFP- preferred because of volume
• Cryoprecipitate

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If PPH hemorrhage continues after uterotonics

• Shift to OR
• Exam under anesthesia carefully re-inspect the
  cervix, vagina, vulva and perianal areas for
  lacerations and /or hematomas
• Perform DE to make sure that there is no
  retained placental tissue (Banjo curette)

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Packing and Tamponade

• If PPH still continues.
• Packing 4 inch gauze pack into uterus using a
  sponge stick. If thrombin available, soak gauze
  with 5,000 units thrombin in 5cc sterile saline
• SOS Bakri Tamponade Balloon Insert balloon,
  instill 300-500 cc saline
• Foley catheters if Bakri balloon unavailable.
  Insert one or more bulbs, instilled with 60-80cc
  of NSS

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Intractable PPH at vaginal delivery

• Uterine Artery Embolization
• No coagulopathy
• Hemodynamically stable to go to Radiology suite
• Interventional Radiologist available

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UAE special considerations

• If patient is relatively stable, not
  coagulopathic and an intervention radiologist is
  available consider arterial embolization before
  proceeding to exploratory laprotomy.
• Temporizing measures like packing and SOS Bakri
  balloon tamponade can be used in the meanwhile.

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Intractable PPH at Vaginal delivery

• Laparotomy
• Make midline vertical abdominal incision
• Begin with bilateral uterine art ligation-Figure
  of 8s
• If unsuccessful, consider
• B-Lynch suture or square compression suture
• Vicryl 1
• Hpogastric artery ligation
• Hysterctomy (supracervical)

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PPH at cesarean delivery

• Aggressive resuscitation
• Direct bimanual compression
• Direct intramyometrial injection of Hemabate may
  be undertaken
• Retained placenta can be removed under direct
  visualization
• Compression sutures may be placed
• LUS can be packed with end in the vagina for
  24-30 hrs
• Hypogastric Artery Ligation
• Supracervical Hysterectomy

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Post Op care

• Continue resuscitation
• Monitor vital signs and urine output
• Monitor vaginal bleeding
• Repeat labs as indicated
• Disposition ?ICU
• Monitor for coagulopathy
• Monitor for complications anemia, ARDS, ATN
  being most common

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Documentation

• Infusion type and rate
• Massive Transfusion Protocol (111)
• Blood
• Platelets
• Fibrinogen
• Medications administered
• Patient response
• Vital signs and urine output
• Nursing and Physician notes

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Management ofPost Partum Hemorrhage
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Post Partum Hemorrhage Box
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Post Partum Hemorrhage Box
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Post Partum Hemorrhage Meds
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H.A.E.M.O.S.T.A.S.I.S

• H ask for help
• A Assess (VS, EBL) and resuscitate
• E Establish etiology, ensure availability of
  blood, ecbolics
• M Massage uterus
• O Oxytocin/Methergine/Hemabate/Cytotec
• S Shift to OR
• T Tamponade balloon, uterine packing
• A Apply compression sutures
• S Systematic pelvis devascularization
• I Interventional radiologist UAE
• S Subtotal/total abdominal Hysterectomy

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Thank-you from the Chairs of Ob/Gyn in
Philadelphia