describe analyze identify postpartum hemorrhage …
TRANSCRIPT
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POSTPARTUM HEMORRHAGE AND TRANEXAMIC ACID
Gregory Collins, DNP, CRNA
DESCRIBE ANALYZE IDENTIFY
…the impact,
incidence, and
consequences
of acute
postpartum
hemorrhage
(PPH).
…the patho-
physiology of
acute PPH
and routes of
potential
intervention.
...mechanism
of action for
tranexamic
acid (TXA)
and the role
for treatment
of acute PPH.
“Maternal hemorrhage…remains the leading cause of maternal mortality worldwide.”
“Hemorrhage that leads to blood transfusion is the leading cause of severe maternal morbidity in
the United States…”
ACOG Practice Bulletin No. 183: Postpartum Hemorrhage.Obstetrics & Gynecology. 2017;130(4):e168-e186.
Cairoli G, Cuesta C, Abalos E, Gulmezaglu A. Epidemiology of postpartum haemorrhage: A systematic review. Best Practice & Research Clinical
Obstetrics and Gynaecology. 2008;22(6):999-1012.
EPIDEMIOLOGY
4-6% PPH
1.86% PPHSEVERE
125,000/YR*MATERNAL DEATHS
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ETIOLOGY
Evensen A, Anderson J, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. American Family Physician. April 1, 2017;95(7):442-449.
TONETRAUMATISSUETHROMBIN
70%
20%
10%
~1%
CONSEQUENCES
RENAL FAILURE / INSUFFICIENCY
BLOOD TRANSFUSION
PROLONGED ANEMIA
LOSS OF FERTILITY
POSTPARTUM DEPRESSION
RESPIRATORY FAILURE / ARDS
COAGULOPATHY
PITUITARY ISCHEMIA / NECROSIS
Baird E. Identification and management of obstetric hemorrhage. Anesthesiology Clinics. 2017;35:15-34.
HEMOSTASISMANAGEMENT OF
COAGULA
TION
FIBRIN
OLYSIS
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IN PREGNANCYHEMOSTASIS
Hellgren M. Hemostasis during normal pregnancy and puerperium. Seminars in Thrombosis and Hemostasis. 2003;29(2):125-130.
LARGE VOLUME INCREASE IN CLOTTING FACTORS: VII, VIII, X, XII, vWF
UP TO 200% INCREASE
IN FIBRINOGEN LEVELS
PROTEIN C RESISTANCE
DECREASED LEVELS OF PROTEIN S
INCREASE IN PLASMINOGEN, tPA, uPA
MARKED INCREASE IN
PLASMINOGEN INHIBITORS
vWF
VIIVIII
PIs
XIIvWF
FIBPLASMINOGEN
tPA uPAX
FIBRINOLYSIS
PLASMINOGEN
PLASMIN
tPA/uPA
FSPsD-DIMER
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FIBRINOLYSIS
PLASMIN
PLASMINOGEN
tPA uPAPAI-1 / PAI-2 / A2AP
COAGULA
TION
FIBRINOLY
SIS
COAGULATION
FIBRINOLYSIS
CO
NSU
MPT
ION
DIL
UTI
ON
AC
TIVATION
PLASMINO
GEN / tPATRAUMA!
COAGULA
TION
FIBRIN
OLYSIS
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PIs
PLASMINOGEN
tPA uPA
!
VIIVIII FIB
XIIvWF
X
"COAGULA
TION
FIBRIN
OLYSIS
HYPERFIBRINOLYSIS
https://www.rotem.de/en/methodology/result-interpretation-rotem-delta-und-sigma/
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https://www.rotem.de/en/methodology/result-interpretation-rotem-delta-und-sigma/
INTERVENTIONPHARMACOLOGICAL
BINDS PLASMINOGEN LYSINE RECEPTOR, INHIBITS
CONVERSION TO PLASMIN, INHIBITS FIBRINOLYSIS
1000 mg IVMAY REPEAT
IN 30-60 MINUTES
CYKLOKAPRON
SYNTHETIC DERIVITAVE OF AMINO ACID LYSINE
NO TRUE CONTRAINDICATIONS(EXTREME CAUTION IN
SUSPECTED DIC)
HYPOTENSION, VISUAL ABNORMALITIES,N/V/D, SEIZURE
TRANEXAMIC ACID
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Glymph DC, Tubog TD, Vedenikina M. Use of Tranexamic Acid in Preventing Postpartum Hemorrhage. AANA Journal. 2016;84(6):427-438.
FIBRINOLYSIS
PLASMINOGEN
PLASMIN
tPA/uPA
FSPsD-DIMER
WOMAN TRIALWORLD MATERNAL ANTIFIBRINOLYTIC 193
HOSPITALS20,000+
PATIENTS23
COUNTRIES
Shakur H, Roberts I, Fawole B et al. Effect of early tranexamic acid administration on mortality,hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN):
an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017;389(10084):2105-2116.
UPON DX:1000 mg TXA IV OVER 10 min OR PLACEBO
PRIMARY OUTCOME MEASURES: MATERNAL DEATHHYSTERECTOMY
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OVERALL REDCUTION1.5% VS 1.9%
p=0.045
< 3hr OF DELIVERY1.2% VS 1.7%
p=0.008
Shakur H, Roberts I, Fawole B et al. Effect of early tranexamic acid administration on mortality,hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN):
an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017;389(10084):2105-2116.
DEATH DUE TO BLEEDING SIGNIFICANTLY REDUCED
< 3hr OF DELIVERY1.2% VS 1.7%
p=0.008
OVERALL REDCUTION1.5% VS 1.9%
p=0.045
NO SIGNIFICANT INCREASE IN ADVERSE EVENTS
“Tranexamic acid reduces death due to bleeding in women with
post-partum hemorrhage with no adverse effects. When used as a
treatment for postpartum hemorrhage, tranexamic acid should be given as soon as
possible after bleeding onset.”
Shakur H, Roberts I, Fawole B et al. Effect of early tranexamic acid administration on mortality,hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN):
an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017;389(10084):2105-2116.
“Tranexamic acid reduces death due to bleeding in women with
post-partum hemorrhage with no adverse effects. When used as a
treatment for postpartum hemorrhage, tranexamic acid should be given as soon as
possible after bleeding onset.”
TRANEXAMIC ACID
BLOODCOMPONENT THERAPY
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MTP PRBCsOXYHEMOGLOBIN
HEMATOCRITTRIGGERS?
GOALS?
ERYTHROCYTES, PRESERVATIVES,
ANTICOAGULANTS
ESSENTIAL ELEMENT FOR NEUROMUSCULAR
FUNCTION/HOMEOSTASIS
1-2 g SLOW IVEVERY 2-4 UNITS PRBCMAINTAIN iCa >1.0-2.0
Calcium Chloride / Calcium Gluconate
MINERAL, ELECTROLYTE
NO TRUECONTRAINDICATIONS
ARRHYTHMIA, HYPOTENSION, N/V
CALCIUM
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Dyer RA, van Dyk D, Dresner A. The use of uterotonic drugs during caesarean section. International Journal of Obstetric Anesthesia. 2010;19:313-319. https://www.memorangapp.com/flashcards/77608/Cardiac+Physiology+Lectures+4-6/
FFPVOLUME
CLOTTING FACTORS
TRIGGERS?
NONCELLULAR FRACTION OF BLOOD, ALBUMIN,
COAGULATION ENZYMES
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FFPVOLUME
CLOTTING FACTORS
TRIGGERS?GOALS?
NONCELLULAR FRACTION OF BLOOD, ALBUMIN,
COAGULATION ENZYMES PLTSHEMOSTASIS
BRICKSTRIGGERS?
THROMBOCYTES, DONOR PLASMA,
SCANT ERYTHROCYTES
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PLTSHEMOSTASIS
BRICKSTRIGGERS?
GOALS?
THROMBOCYTES, DONOR PLASMA,
SCANT ERYTHROCYTES CRYOFIBRINOGEN!
CLOTTING FACTORS(VII, VWF, XIII, FIB),
PLT MICROPARTICLES
FIBRINOGEN
McDonnell NJ, Browning R. How to replace fibrinogen in postpartum haemorrhage situations?.International Journal of Obstetric Anesthesia. 2018;33:4-7.
POSITIVE PREDICTIVE VALUE FOR PROGRESSION
TO SEVERE PPH
100%FIBRINOGEN < 200 mg/dl
FIBRINOGEN >400…79% NEGATIVE PREDICTIVE VALUE FOR PROGRESSION TO SEVERE PPH
CRYOFIBRINOGEN!
MORTAR
TRIGGERS?
CLOTTING FACTORS(VII, VWF, XIII, FIB),
PLT MICROPARTICLES
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CRYOFIBRINOGEN!
MORTAR
TRIGGERS?GOALS?
CLOTTING FACTORS(VII, VWF, XIII, FIB),
PLT MICROPARTICLES
pH
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PREPARE
PRACTICE
PREACH
ACOG Practice Bulletin No. 183: Postpartum Hemorrhage.Obstetrics & Gynecology. 2017;130(4):e168-e186.
PREPARE
PRACTICE
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PREPARE
PRACTICE
PREACH
QUESTIONS
REFERENCESACOG Practice Bulletin No. 183. Obstetrics & Gynecology. 2017;130(4):e168-e186.
Cairoli G, Cuesta C, Abalos E, Gulmezaglu A. Epidemiology of postpartum haemorrhage: A systematic review. Best Practice & Research Clinical Obstetrics and Gynaecology. 2008;22(6):999-1012.
Evensen A, Anderson J, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. American Family Physician. April 1, 2017;95(7):442-449.
Baird E. Identification and management of obstetric hemorrhage. Anesthesiology Clinics. 2017;35:15-34.
Hellgren M. Hemostasis during normal pregnancy and puerperium. Seminars in Thrombosis and Hemostasis. 2003;29(2):125-130.
https://www.rotem.de/en/methodology/result-interpretation-rotem-delta-und-sigma/
Glymph DC, Tubog TD, Vedenikina M. Use of Tranexamic Acid in Preventing Postpartum Hemorrhage. AANA Journal. 2016;84(6):427-438.
4/14/19
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REFERENCESShakur H, Roberts I, Fawole B et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage(WOMAN): an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017;389(10084):2105-2116.
Sahu J, Mishra N. Role of intravenous tranexamic acid in reducing blood loss during caesarean section: Study at tribal-dominated area hospital in Chhattisgarh, India. Journal of Obstetrics and Gynaecology Research. 2019. doi:10.1111/jog.13915
Dyer RA, van Dyk D, Dresner A. The use of uterotonic drugs during caesarean section. International Journal of Obstetric Anesthesia. 2010;19:313-319.
Osoti A, Vogel J, Oladapo O, Qureshi Z, Gülmezoglu A. Tranexamic acid for treatment of postpartum haemorrhage. Obstetrics, Gynaecology & Reproductive Medicine. 2019.