Arnold W. Cohen, MD,

ChairmanDepartment of

Obstetrics & Gynecology

Albert Einstein Medical Center

Professor of Ob/GynJefferson Medical

CollegePhiladelphia, PA.

Old Problem – Consistent Thoughts

Definition…Arbitrary and problematicTraditionally: (Baskett, 1999) EBL >=500 cc after vaginal delivery EBL >=1000 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)

Incidence…Affects 5-15% of women giving birthTwo categories: Early (primary) hemorrhage: occurs within the first

24 hours postpartum Late (secondary) hemorrhage: occurs after 24 hours

postpartum

Be Prepared…Risk Factors:

MacrosomiaLabor induction and augmentationProlonged second stage Chorioamnionitis Magnesium sulfate usePrevious PPH

(Jackson, 2001)

Risk Factor OR CIRetained placenta 3.5 2.1-5.8Failure to progress during the second stage of labor

3.4 2.4-4.7

Placenta accreta 3.3 1.7-6.4Lacerations 2.4 2.0-2.8Instrumental delivery 2.3 1.6-3.4Large for gestational age (LGA) newborn

1.9 1.6-2.4

Hypertensive disorders 1.7 1.2-2.1Induction of labor 1.4 1.1-1.7Augmentation of labor with oxytocin 1.4 1.2-1.7

Sheiner et al 2005

Be Prepared…

PreventionActive 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).

Benefits of Active Management Vs Physiological management

Outcome Ctrl rate RR CI

PPH > 500ml 14 % 0.38 0.32-0.46

PPH > 1000ml 2.6% 0.33 0.21-0.51

Hgb < 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

Etiologies (4T’s)…Tone: uterine atony (80%)Tissue: retained placental tissueTrauma: uterine, cervical or vaginal lacerations Thrombin: dilutional coagulopathy, consumptive

coagulopathy and coagulation disorders

Clinical findings in Ob PPH…Blood Loss SBP Symptoms

and signsDegree 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

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

100 ml peripad

250 ml chux

350 ml chux 500 ml chux

18x18 laps: 25 ml approx 50%; 50 ml approx 75%; 75 ml entire surface; 100 ml saturated and dripping

25 ml 50 ml 75 ml 100 ml

A saturated 4x4 12-ply sponge = 5 ml

50 ml peripad25 ml peripad

100 ml chux

Dry

Other methods of quantification:•Weight•Direct Measurement

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

Philadelphia Delivery Centers

Organize the team…Call for help ( Attending, nurse ,

anesthesiologist)Designate a nurse to record vital signs, urine

output, fluids and drugs administeredAssess the vital signs every 5-10min

Resuscitation…Administer 5-7L/min of Oxygen by face maskPlace 2 large bore IV linesInitial 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

Consider activation of a MT protocol when patient actively bleeding and any of the following:

Systolic blood pressure < 90 mmHg Ph < 7.1 Base deficit > 6 meq/L Temperature below 34°C INR > 2.0 Platelet count < 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 patient’s hemorrhage stops, the blood

bank should be notified so that the protocol can be terminated.

If bleeding persists, the sequence is started again.

Massive Transfusion Protocol“1:1:1”

Blood Products

General considerations Keep the platelet count > 50,000. If less than

that, administer 10-12 units initiallyIf surgical intervention is necessary, maintain

Plt count > 80-100,000.Cryoprecipate may be used along with FFP

for fibrinogen levels <100, give in 6-12 unit doses

Blood Component TherapyProduct Vol Contents EffectPRBCs 240 RBC, WBC,

plasmaIncrease 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

Targets after Transfusion…Fibrinogen > 100mg/dlHematocrit >21%Hemoglobin >7g/dlPlatelet count >50,000PT/PTT <1.5 times control

Response to Resuscitation…Pay attention to pt’s level of consciousnessMonitor BP

Maintain BP around 90 mm/Hg SystolicMonitor RRFrequent auscultation of lung fieldsStart Blood if BP cannot be maintained or

when Bleeding is controlled

Work up…Exam Patient- DR or in OR

Uterine ToneGenital LacerationsPlacentaBleeding Sites

Lab Studies: Type and cross match, CBC, PT/PTT/INR, Fib, FSP, Cr, S-8

Imaging Studies: bedside U/S

Initial Management…Empty bladder Vigorous bimanual Uterine massage Manual exploration of uterine cavity. (Use

U/S to r/o retained placenta)UterontonicsCareful inspection of cervix, vagina, vulva and

perianal area for lacerations and/or hematomas in OR

Consider coagulopathy if no other cause identified

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)

ManagementMonitor CBC, Coagulation studies, ABGMonitor pulse oximetryMonitor Urine output with indwelling

catheterCorrect coagulopathy

FFP- preferred because of volumeCryoprecipitate

If PPH hemorrhage continues after uterotonics…

Shift to ORExam under anesthesia: carefully re-inspect

the cervix, vagina, vulva and perianal areas for lacerations and /or hematomas

Perform D&E to make sure that there is no retained placental tissue (“Banjo” curette)

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

Intractable PPH at vaginal delivery

Uterine Artery EmbolizationNo coagulopathyHemodynamically stable to go to Radiology suiteInterventional Radiologist available

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.

Intractable PPH at Vaginal delivery

LaparotomyMake midline vertical abdominal incisionBegin with bilateral uterine art ligation-

Figure of 8’sIf unsuccessful, consider…B-Lynch suture or square compression

sutureVicryl 1

Hpogastric artery ligationHysterctomy (supracervical)

PPH at cesarean deliveryAggressive resuscitationDirect bimanual compressionDirect intramyometrial injection of Hemabate

may be undertakenRetained placenta can be removed under

direct visualizationCompression sutures may be placedLUS can be packed with end in the vagina for

24-30 hrsHypogastric Artery LigationSupracervical Hysterectomy

Post Op care…Continue resuscitationMonitor vital signs and urine outputMonitor vaginal bleedingRepeat labs as indicatedDisposition: ?ICUMonitor for coagulopathyMonitor for complications: anemia, ARDS,

ATN being most common

Documentation…Infusion type and rateMassive Transfusion Protocol (1:1:1)

BloodPlateletsFibrinogen

Medications administeredPatient responseVital signs and urine outputNursing and Physician notes

Management ofPost Partum Hemorrhage

Post Partum Hemorrhage Box

Post Partum Hemorrhage Box

Post Partum Hemorrhage Meds

H.A.E.M.O.S.T.A.S.I.SH ask for helpA Assess (VS, EBL) and resuscitateE Establish etiology, ensure availability of

blood, ecbolics M Massage uterusO Oxytocin/Methergine/Hemabate/CytotecS SShift to ORT Tamponade balloon, uterine packingA Apply compression suturesS Systematic pelvis devascularizationI Interventional radiologist – UAES Subtotal/total abdominal Hysterectomy