Post on 06-May-2019
vooruitstrevend in perioperatieve zorg afdeling Anesthesiologie
Postpartum Hemorrhage
(PPH)
Holger Baumann MD
AMC Anesthesiologie
Scenario I
39 yaar, unipara, 40 weken zwanger
6 uur durende bevalling
Retentio placentae – bloeding
GYN belt na 30 minuten
“Het bloedt meer dan normaal”
Scenario II
39 jaar, unipara, 40 weken zwanger
6 uren delivery
Retentio placentae – bloeding
GYN belt na 30 minuten
“Het bloedet meer dan normaal”
Bleek, duizelig, HR 94, SBP 110,
bloedverlies 1000-1500ml
Postpartum bloeding (PPH)
WHO BV > 500 ml bij vag. partus
BV > 1000 ml bij C-S
Australia BV > 500 ml bij vag. partus
BV > 750 ml bij C-S
Austria BV 500 – 1000ml
RCOG BV 500-1000ml “Minor PPH”
BV 1000-2000 ml “Moderate PPH”
BV >2000 ml “Severe PPH”
AMC Fluxus: BV >1000ml
Inschatten bloedverlies & PPH
30 - 50 % onderschatting
Bosse, BJOG 2006
Stafford Am J Obstet Gynecol 2008
Gabel, JOGNN 2012
There’s an App for it..
Scenario III 39 jaar, unipara, 40 weken zwanger
6 uren delivery
Retained placenta – bloeding
GYN belt na 30 minuten
Bleek, duizelig, HR 94, SBP 110, bloedverlies 1000-1500ml
GA after 1 hrs
SBP 70, HR 130
Manual placenta verwijdering
Bloedverlies continueert
Temp.: 34,2 C
Scenario IV
+ 30 min
Totaal bloedverlies 3500 ml
NaCl 0,9% 2000 ml, Colloids 2000ml
Transfusie gestart – RBC
En nu?
1. Crystalloids tot Hb 4,5, daarna RBC
2. Colloids/crystalloids tot Hb 4,5, daarna RBC
3. RBC:FFP:PLT ratio 1:1:1
4. RBC:FFP:PLT ratio 4:2:1
5. Anders
Dilutional coagulopathy?
Petroianu Anesth Anal 2000
>60%
>25%
>10%
If it does not clot or
carry oxygen…
we probably should not give it.
Richard P Dutton MD
Hemodilutie - Bloedprodukten Whole blood – 1:1:1 approach
650 ml koud spul
Hb 5.5 mmol/l (8.9 g/dl)
Thr. 75 * 109
Plasma factors 70 %
Fibrinogen: 0,5 -1 g (?)
Armand, Transf Medicine Reviews 2003
Como, Transfusion 2004
500 mL Warm
Hct: 38-50%
Plt: 150-400K
Coags: 100%
1500 mg
Fibrinogen
Massaal bloedtransfusie protocol @
MTP tot hemostasis is bereikt
MTP in PPH
……albeit based on limited prospective data. Massive
transfusion protocols could improve outcomes in the
bleeding patient not only due to early blood product
administration, but also secondarily to an early and
aggressive multidisciplinary intervention……..
Gutierrez, Int J Obstet Anes 2012
Pacheco, Am J Perinatal 2012
Conventioneel Lab. vs POC
Standard-Lab Point of Care (ROTEM/TEG)
Evaluatie voor bloeding NO YES
Tijd tot uitslag 30-60 min. 5-15 min.
Hyperfibrinolyse NO YES
Sterkte van stolsel NO YES
De Lange, Obstet Gynecol Surg 2012
Hysterektomie, En nu?
1. Fibrinogeen
2. Tranexaminezuur
3. rFVIIa
4. All
5. Other
Intrapartum
Obstetric bleeding
Prepartaal Postpartaal
Secondair
Primair (<24 hrs.)
Incidentie: 140.000 pa
Mortaliteit: 1:100.000 (developed countries)
Morbiditeit: 5:100
Ernstige (vitaal) PPH: 1:1000
BV > 1000ml: 3:100
Data:
Berg, Obstet Gynacol 2005 Dupont, Int J Obstet Anest 2009
Knight, BMC Pregnancy Child 2009 CEMACH
4 T’S Tone
Tissue
Trauma
Thrombin
Uterotonics, Macrosomia
Prior PPH, Multigestation, Adipositas
Retained placenta, Placenta previa,
Placenta acreata
C-Section, Laceratation, Rupture
Coagulopathy
TEAM Preparation & Communication
80% 5 T’S
Fluid resuscitation Maintain circulating BV
Tissue oxygenation Cristalloids / RBC
Cell Salvage
“Definitive intervention” Uterotonics
Arterial embolisation Hysterectomy
Hemostatic resuscitation Prevent Acidosis – Hypothermia - hypocalcemia
Treat/prevent Coagulopathy Monitor resucitation
Recognize PPH Identify cause
Start treatment Call “Resus” team
Woman with PPH
Modified from
McLintock, J Thromb Haemos 2011
Risk management in PPH
Underestimation of blood loss
Delay in diagnosis and treatment
Lack of easy-to use local protocols
Lack of adequate education and training
Poor communication
Deficiencies in organization
Upadhyay, Best Pract Res Clin Obstet 2008
Rath, Acta ObstetGynecol Scan 2011
Rath, Arch Gynecol Obstet 2012
3 D’s
Transport
Treatment
Diagnosis Delayed
Delayed
Delayed
Zorg voor heldere lokale protocollen.
Multidisciplinaire aanpak
Voorlichting en training
Behandel coagulopathieën • Basale behandeling
• TRX
• FFP/FIB
• MTP
• rFVIIa
Niet vergeten:
Interventie radiologie
Cell salvage
VROEGE TRANSPORT
A failure in planning is a plan for failure S03E08 Star Wars The Clone Wars
Blood Loss:
1000-1500 ml
Stage 2
Sequentially
Advance through
Medications &
Procedures
Pre-
Admission
Time of
admission
Identify patients with special consideration:
Placenta previa/accreta, Bleeding disorder, or
those who decline blood products
Follow appropriate workups, planning, preparing of
resources, counseling and notification
Screen All Admissions for hemorrhage risk:
Low Risk, Medium Risk and High Risk
Low Risk: Hold clot
Medium Risk: Type & Screen, Review Hemorrhage Protocol
High Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage
Protocol
All women receive active management of 3rd
stage
Oxytocin IV infusion or 10 Units IM
Vigorous fundal massage for 15 seconds minimum
Standard Postpartum
Management
Fundal Massage
Vaginal Birth:
Bimanual Fundal Massage
Retained POC: Dilation and Curettage
Lower segment/Implantation site/Atony: Intrauterine Balloon
Laceration/Hematoma: Packing, Repair as Required
Consider IR (if available & adequate experience)
Cesarean Birth:
Continued Atony: B-Lynch Suture/Intrauterine Balloon
Continued Hemorrhage: Uterine Artery Ligation
To OR (if not there);
Activate Massive Hemorrhage Protocol
Mobilize Massive Hemorrhage Team
TRANSFUSE AGGRESSIVELY
RBC:FFP:Plts à 6:4:1 or 4:4:1
Increased
Postpartum
Surveillance
Definitive Surgery
Hysterectomy
Conservative Surgery
B-Lynch Suture/Intrauterine Balloon
Uterine Artery Ligation
Hypogastric Ligation (experienced surgeon only)
Consider IR (if available & adequate experience)
Fertility Strongly Desired
Consider ICU
Care; Increased
Postpartum
Surveillance
Verify Type & Screen on prenatal
record;
if positive antibody screen on prenatal
or current labs (except low level anti-D
from Rhogam), Type & Crossmatch 2
Units PBRCs
CALL FOR EXTRA HELP
Give Meds: Hemabate 250 mcg IM -or-
Misoprostol 800-1000 mcg PR
Cumulative Blood Loss
>500 ml Vag; >1000 ml CS
>15% Vital Sign change -or-
HR ≥110, BP ≤85/45
O2 Sat <95%, Clinical Sx
Ongoing
Evaluation:
Quantification of
blood loss and
vital signs
Unresponsive Coagulopathy:
After 10 Units PBRCs and full
coagulation factor replacement,
may consider rFactor VIIa
HEMORRHAGE CONTINUES
Blood Loss:
>1500 ml
Stage 3
Activate
Massive
Hemorrhage
Protocol
Blood Loss:
>500 ml Vaginal
>1000 ml CS
Stage 1Activate
Hemorrhage
Protocol
NO
Stage 0
All Births
Transfuse 2 Units PRBCs per clinical
signs
Do not wait for lab values
Consider thawing 2 Units FFP
YES
YES NO
On
go
ing
Cum
ula
tive
Blo
od
Lo
ss E
valu
ation
Cumulative Blood Loss
>1500 ml, 2 Units Given,
Vital Signs Unstable
YESIncrease IV rate (LR); Increase Oxytocin
Methergine 0.2 mg IM (if not hypertensive)
Continue Fundal massage; Empty Bladder; Keep Warm
Administer O2 to maintain Sat >95%
Rule out retained POC, laceration or hematoma
Order Type & Crossmatch 2 Units PRBCs if not already done
Activate Hemorrhage Protocol
CALL FOR EXTRA HELP
Continued heavy
bleeding
Increased
Postpartum
Surveillance
NO
NO
CONTROLLED
INCREASED BLEEDING
California Maternal Quality Care Collaborative (CMQCC), Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details
This project was supported by Title V funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division
OBSTETRIC HEMORRHAGE CARE SUMMARY: FLOW CHART FORMAT v 1.4 5/7/2010
Stappenplan zonder ROTEM/TEG
1 Keep hemostasis happy Temp. > 34 C / pH > 7,2 / Ca2+ > 1,0mmol/l
2 RBC Hb> 6,2 mmol/l (massive bleeding)
3 Prevent/Treat Hyperfibrolysis Tranexamicacid 1-2 g + 1g/h over 8 hrs
4 Coagulation substrat FFP 30ml/kgBW 50mg Fibr./KG BW
5 Platelets Plts.> 100.000
6 Keep hemostasis happy
7 Thrombin burst 90micg/kg BW rFVIIa
Stappenplan met Point of Care
Hill Anaesth Intensive Care 2012
DeLoughery Hematology Am Soc 2010
En nu?
EXTRAS
Oxytocin in PPH
Hemodynamic effects of oxytocin in bolus
Dose-dependent
Tachycardia
Hypotension
ST depression
Myocardial ischaemia (chest pain)
Svanstrom, BJA 2008
Jonnson, BJOG 2010
Emergency Hysterectomy & PPH
Blood loss about 3000 ml
Mortality: ~2-5%
Morbidity: ~30-50%
Bloodflow in de uterus: 600-800ml/min
Geen autoregulatie
Rossi, Obstet Gynecol 2010
Machado, N AM J Med Sci 2011
Forna, Am J Obstet Gynecol 2004
Cellsaver
Recommended in cases of severe PPH
Patients at risk: e.g. abnormal placentation
No adverse outcome
Evidence low
AAGBI
CMACE
NICE Guidelines
McDonnell, Anaesth Intensiv Care 2010
Liumbruno, Transfusion 2011
Liumbruno, Blood Transf 2012
Peripartum hyperfibrinolysis
1. Trimenon 2. Trimenon 3. Trimenon Geboorte
Fibrinogeen
FVII, FIX, FX, FXII
FV
vWF
Fibrinolyse
Thrombocyten
Gerbasi, et al. Am J Obstet Gynecol 1990 Bremme, Best Prec Res Clin Haematol 2003
Hofer, Anaesthesist 2007
Antifibrinolytics in PPH I
Bloedverlies
Veilig
Novikova Cochrane review 2010
Peitsidis Expert Opin Pharmacother. 2011
WHO 2012
McCormack Drugs. 2012
Crash II Trial Lancet. 2010
Ducloy-Bouthors Crit Care 2011
Xu Arch Gynecol Obstet. 2012
Reduces bloodloss
Seems to be safe
WOMAN TRIAL
Shakur Trial 2010
http://www.womantrial.lshtm.ac.uk
AIM Effect of TXA on mortality, hysterectomy rate and other morbidity
Primary endpoint Proportion of woman who die or undergo hysterectomy
Sec. endpoints Surgical intervention Transfusion Thromboembolic events LOS Need for ventilation
Treatment 1gr TXA a.s.a.p. after randomization
Design Pragmatic randomized double blind trial
Inclusion criteria Vaginal delivery > 500ml, CS >1000ml, or hemodynamics
Monitoring hyperfibrinolysis
Thrombelastometrie-Thrombelastography
TRX in PPH
Preventive in high risk patients
Bloodloss > 1000 ml
1-2 gr. TRX
Ahonen, Acta Anaesthesiol Scand 2010
Fibrinogeen in PPH I
PPV 100% ≤ 2g/dl
NPV 79% ≥ 4g/dl
OR 2,63 [1,66-4,16] (per g/Fib.)
Charbit J Thrombosis Hemostasis 2007
Fibrinogeen in PPH II
Cortet M, Br. J. Anaesth. 2012
“The fibrinogen level at PPH diagnosis is a marker of the risk of aggravation
and should serve as an alert to clinician.”
Fibrinogeen in PPH III
Huissoud BJOG 2009
Fibrinogeen in PPH IV:
coming next to PubMed
RCT
Primary outcome: need for transfusion
Wikkelsoe, TRIALS 2012
The FIB-PPH trial: fibrinogen concentrate as
initial treatment for postpartum haemorrhage:
study protocol for a randomised controlled trial
En hoe?
Doel?
Monitoring:
Substraat:
Fibrinogeen level ?
Conventioneel - ROTEM/TEG
FFP - Fibrinogeen
Fibrinogen: >2g/l
30ml/kg BW FFP 50mg/kg BW Fib.
after TRX
How do u sweet’n your coffee?
rFVIIa in PPH
No guideline, No RCT
Variability in timing and dosing
Effective in reducing bloodloss (in about 85%)
Given too late: avg. bloodloss > 3000ml
No monitoring
Expensive
Safety? Bouma, Eur J Obstet Gynecol 2008
Franchini Clin Obstet Gynecol 2010
Levi, NEJM 2010
Ahonen, Curr Opin Anesthsiol 2012
rFVIIa in PPH
Consider rFVIIa after “conventional” therapy,
if
SOP University Heidelberg
rFVIIa(Novoseven): 90micg/kg BW
pH > 7,2
Temp. > 35,0C
Fibrinogen > 100 mg/dl or FIBTEM >12 mm
Thrombocytes > 50/nl or Extem > 45mm
Hyperfibrinolysis ruled out/therapy
No surgical/IR therapy