14 Postpartum Hemorrhage on Labor and Delivery.pdf - Vtr

<strong>Postpartum</strong> <strong>Hemorrhage</strong> on
Labor and Delivery
Learning Objectives:
As a result of completing this activity, the participant
will be able to
Identify women at risk for major obstetric hemorrhage
List the options available to control and mitigate
the consequences of obstetric hemorrhage
Discuss how contemporary transfusion practices
apply in the obstetric setting
Draw from published guidelines and protocols to
inform both individual clinical practice and systems
solutions in the preparation for these emergencies
Author Disclosure Information:
Dr. Mhyre has disclosed that she has no financial
interests in or significant relationship with any commercial
companies pertaining to this educational activity.
Obstetric hemorrhage is the leading indication for
intensive care unit admission in the peripartum
period, and a leading cause of maternal death. 1,2 Unfortunately,
postpartum hemorrhage rates appear to be increasing
due to changes in demographics and obstetric
practice. This chapter reviews the available data on epidemiology,
management, and systems solutions to predict,
prevent, and mitigate the consequences of postpartum
hemorrhage.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are available in both the HTML and PDF
versions of this article. Links to the digital files are provided in the HTML and
PDF text of this article on the Journal’s Web site (www.asa-refresher.com).
Jill Mhyre, MD
Department of Anesthesiology
Division of Obstetric Anesthesia
University of Michigan Health System
Ann Arbor, Michigan
105
DEFINITION AND EPIDEMIOLOGY
<strong>Postpartum</strong> hemorrhage is most commonly defined by an
estimated blood loss (EBL) Z500 mL for a vaginal delivery
and Z1,000 mL for a cesarean. 3 However, blood loss estimation
is notoriously inaccurate 4 —bleeding may be
concealed within the uterus, the drapes, or in the retroperitoneal
space, and the physiologic impact of hemorrhage
depends on the mother’s initial blood volume,
hematocrit, and the speed of blood loss. 5 Primary postpartum
hemorrhage develops within 24 hours of delivery
and is due to uterine atony; retained placenta; genital tract
trauma; placenta accreta, increta, or percreta; uterine inversion;
or coagulopathy. Coagulopathy may be inherited
or may result from a range of disorders in pregnancy, with
amniotic fluid embolism being the most severe. 6 Secondary
postpartum hemorrhage is relatively infrequent, develops
more than 24 hours after delivery, and is ascribed to subinvolution
of the placental site, retained products of conception,
infection, or inherited coagulation defects.
Blood loss estimation is notoriously inaccurate—
bleeding may be concealed within the uterus,
the drapes, or in the retroperitoneal space, and
the physiologic impact of hemorrhage depends
on the mother’s initial blood volume, hematocrit,
and the speed of blood loss.

106 Mhyre
While the incidence of antepartum hemorrhage appears
to be relatively stable, postpartum hemorrhage is increasing
in developed countries around the globe. 7–11 In the
United States between 1994 and 2006, rates of postpartum
hemorrhage increased 30%, almost entirely attributable to
increases in postpartum uterine atony. The proportion of
all US deliveries complicated by the need for a blood
transfusion increased 90% between 1998 and 2005 to
0.5% of all deliveries. 10 Exposure to blood products is
only one of a number of hemorrhage-related morbidities,
including anemia, disseminated intravascular coagulopathy,
myocardial ischemia, respiratory failure, renal failure,
secondary surgical procedures, fertility loss, and
delayed functional recovery postpartum. 12
Peripartum hysterectomy increased 15% in the United
States between 1994 and 2007, to a rate of 1 in 1,200
deliveries. 13 Placenta accreta, with or without placenta
previa, leads to approximately half of all peripartum hysterectomies,
and rates have increased in conjunction with
the burgeoning population of pregnant women with previous
cesarean deliveries. Hysterectomy attributed to uterine
atony more than doubled, and currently accounts for
one third of all peripartum hysterectomies. Meanwhile,
hysterectomies due to uterine rupture have become vanishingly
rare as the rates of vaginal birth after cesarean
delivery have plummeted.
The shift toward cesarean birth, up to 33% of all births
in 2009, underlies the increasing rates of abnormal placentation,
uterine atony, and postpartum hemorrhage. <strong>14</strong>
Other factors include: (1) increasing population rates of
obesity, 15 multiple gestation, 11 and advanced maternal age;
(2) increasing rates of induction of labor 16 ; and (3) increasing
use of oxytocin for induction and/or augmentation
of labor. Between 1990 and 2006, inductions of labor increased
from 10% to 22% of all US births 17 and may be as
high as 44% among women attempting to deliver vaginally.
18 Prolonged exposure to oxytocin infusions downregulates
oxytocin receptors in the lower uterine segment. 19
There appears to be a dose–response relationship between
the oxytocin area under the curve and the risk of postpartum
hemorrhage attributed to uterine atony. 20
Globally, hemorrhage is the leading cause of maternal
mortality, accounting for 25% of all maternal deaths, or an
estimated 100,000 deaths per year. 21,22 In the United
States, over the past 25 years, cause-specific mortality attributed
to obstetric hemorrhage has declined 30% from
2.6 to 1.8 per 100,000 live births, 2 and currently accounts
for 13% of all maternal deaths.
While hemorrhage is no longer the leading cause of
maternal death in the United States, it remains among the
most preventable. 23 In California, between 2002 and
2003, hemorrhage accounted for just 10% of pregnancyrelated
deaths, but in 70% of these cases, improved clinical
care would have had a good or strong chance to alter the
fatal outcome. 5 This rate of potential preventability was
higher than for any other condition and established hemorrhage
as a top priority for the California Maternal
Quality Care Collaborative (CMQCC). Consequently,
CMQCC developed the Obstetric <strong>Hemorrhage</strong> Toolkit
and deployed a statewide campaign ‘‘to improve California
hospital capabilities and resources for responding
to obstetric hemorrhage by increasing the use of protocols
and drills and by improving availability of and training in
standard and state-of-the-art medical, surgical and blood
replacement options.’’ 5
ANTICIPATED HEMORRHAGE
Antenatal risk assessment and targeted preparation are
crucial. Even with the physiological anemia of pregnancy,
a hematocrit less than 32% should be treated with oral
iron, intravenous iron, or even erythropoietin to reduce the
possible need for postpartum blood transfusion. It is important
to identify patients with special considerations,
including: (1) women with abnormal placentation; (2)
those with inherited coagulation disorders; and (3) those
who refuse blood products.
Even with the physiological anemia of
pregnancy, a hematocrit less than 32% should
be treated with oral iron, intravenous iron, or
even erythropoietin to reduce the possible
need for postpartum blood transfusion.
Special Considerations
Placenta Accreta. With placenta accreta, the decidua
basalis is absent, and the placenta adheres to a floor of
uterine myometrium. With placenta increta, chorionic villi
invade into the myometrium. With percreta, the placenta
penetrates the uterine serosa and may even grow into other
pelvic structures, most commonly the bladder. Decidual
deficiency increases vulnerability to abnormal placental
adherence and is most commonly observed at the site of a
uterine scar, in the lower uterine segment around the internal
cervical os, and over a uterine fibroid. As a result,
prior cesarean delivery, especially in the setting of an anterior
placenta or placenta previa, is the most important
risk factor for placenta accreta. 24 It is less commonly seen
after other uterine surgeries, advanced maternal age, grand
multiparity, uterine fibroids, or in vitro fertilization. Frank
hematuria in pregnancy is most often due to urinary tract
infection or nephrolithiasis, but in the setting of these other
risk factors, should be considered to be placenta percreta
invading the bladder until imaging proves otherwise.
Optimal surgical management of placenta accreta is
directed toward delivering the neonate, then closing the
uterus with the placenta left in situ, followed by planned
peripartum hysterectomy. When the area of accreta is
small, a trial of spontaneous placental separation may be

<strong>Postpartum</strong> <strong>Hemorrhage</strong> on Labor and Delivery
attempted followed by deep myometrial sutures, a uterine
compression suture (e.g., B-Lynch), and/or intrauterine
balloon tamponade (e.g., with a Bakri balloon). 25,26 Endovascular
sheaths may be inserted antepartum to facilitate
uterine artery balloon placement or postpartum
embolization. Because of limitations in efficacy due to device
displacement or collateral circulation, and risk for
complications (insertion site hematoma, abscess, tissue
infection, lower extremity necrosis), the Society for Maternal-Fetal
Medicine recommends reserving the use of
prophylactic uterine artery balloon catheters for women
who strongly desire fertility preservation, those who decline
blood products, and in women with unresectable
placenta percreta. 27
While general anesthesia is preferred for cases with anticipated
massive blood loss, a neuraxial catheter can
provide analgesia for endovascular sheath placement, may
be extended and re-dosed for prolonged surgery, allows the
mother to be awake for the delivery, limits fetal exposure
to anesthetic, and may decrease blood loss compared with
general anesthesia (Supplemental Digital Content 1, http://
links.lww.com/ASA/A130). 10,28,29 The decision between
general or neuraxial anesthesia will depend upon the
magnitude of anticipated blood loss, the availability of
additional anesthesia staff to assist with an unplanned
conversion to general anesthesia, and the anticipated risk
of a difficult airway. In some cases, elective conversion to
general anesthesia just after delivery allows for participation
in the birth plus a secure airway for any massive
hemorrhage that may follow. Beyond selection of the primary
anesthetic, optimal management ensures sufficient
venous access and blood products to respond to massive
hemorrhage (generally anticipate Z10 L blood loss), 28
hemodynamic and hemostatic monitoring capability (e.g.,
central venous and peripheral arterial access), thermoregulation,
and compression stockings to prevent venous
thromboembolism. 27 Pulmonary embolism complicates
approximately 1.5% of all peripartum hysterectomies. 24
Management techniques for massive postpartum hemorrhage
are discussed below.
Inherited Coagulation Disorders. Von Willebrand
disease, hemophilia A and B, and factor XI deficiency account
for approximately 90% of inherited bleeding disorders.
29–31 Inherited platelet disorders (e.g., Bernard
Soulier syndrome, Glanzmann thrombasthenia) are rare.
Given the clinical heterogeneity within each diagnosis,
consultation with a hematologist and blood bank personnel
will help to clarify optimal management. Sixteen percent
of women who have von Willebrand disease will
experience postpartum hemorrhage within 24 hours of
delivery, and 29% will experience delayed postpartum
bleeding. 32 A familial history of inherited coagulopathy,
postpartum or perioperative hemorrhage, significant
menorrhagia, gingivorrhagia, or epistaxis may help to
identify patients at increased risk for disordered hemostasis
with delivery. 30,32,33
Women Who Refuse Blood Products, Including
Jehovah’s Witnesses. The antepartum consultant
should review a comprehensive list of blood products, alternatives,
and blood conservation strategies to determine
acceptability of each intervention for the patient. 5 Neuraxial
anesthesia is generally preferred for operative anesthesia
both to minimize blood loss, 11,34,35 and because an
awake patient may change her mind in the face of impending
death.
Volume replacement with crystalloid or colloid can decrease
viscosity of the blood and improve peripheral perfusion
while maintaining oxygen delivery (by increasing
oxygen extraction in the periphery), and minimizing cardiac
work. However, excessive fluid resuscitation can contribute
to dilutional coagulopathy and decreased oncotic pressure.
Cell-saver autotransfusion with a continuous circuit technique
is often acceptable for patients who would otherwise
refuse blood products. 36 With massive blood loss and profound
anemia (Hgbr4 g/dL), prolonged postoperative sedation,
intubation, thermoregulation, and paralysis may be
required to limit oxygen consumption while erythropoietin
and iron are used to restore the patient’s red cell mass. Erythropoietin
requires 48 to 72 hours for a significant reticulocyte
response in peripheral blood, and 10 to <strong>14</strong> days to
increase hemoglobin levels. Laboratory testing should be
minimized, using pediatric tubes and finger-stick testing
when possible. 37
Risk-stratified Blood Product Preparation
Patients usually receive a type and screen as part of routine
prenatal care to determine blood type, the requirement for
RhoGAM, and the presence of minor antibodies. This result
in combination with antepartum risk factors can help
determine the optimal blood tests that should be submitted
at the time of admission to the labor and delivery unit.
Risk-stratified blood testing has been shown to reduce
excess cost associated with testing for low-risk women, to
focus attention and resources on high-risk patients, and to
reduce inconsistencies in transfusion ordering. 5,38 Nevertheless,
specific algorithms vary among centers, and are
largely based on expert opinion supported by limited empirical
data. Recommendations in Table 1 synthesize algorithms
from the CMQCC, 5 Stanford University, 5,38 and
Northwestern University (C. A. Wong, written communication,
October 2011; Supplemental Digital Content 2,
http://links.lww.com/ASA/A131).
UNANTICIPATED POSTPARTUM HEMORRHAGE
107
Clear multidisciplinary guidelines and regular skills training
(multidisciplinary drills) reduce the incidence of massive
postpartum hemorrhage, 45–48 and are recommended for all
units by the Centre for Maternal and Child Enquiries in the
United Kingdom. 23 Simulation-based training for obstetric
hemorrhage can reveal specific management deficits, and
thereby facilitate targeted quality improvement and staff
education. 49

108 Mhyre
Table 1. Recommendations for Blood Product
Preparation Based on the Level of Risk for Blood
Transfusion
Risk Level and
Recommendations Conditions
Low risk*
A clotted sample can be sent to
the blood bank at the time of
admission for delivery 39–41
Risko 5%
Either a type and screen or clot
only, depending on institutional
resources
Risk 5–10%
At least a type and screen
Risk >10%
A type and crossmatch of
Z2 U PRBC
Highest risk
A type and crossmatch of
Z6 U PRBC
Z6 U FFP and
Z6 single donor units of
plateletsz
Elective CD with no prior uterine
surgery
Admitted for labor with fewer than
five prior VB
No known bleeding disorder
No history of PPH
Second through fourth elective CD 35
More than four prior VB
Multiple gestation 35
Prior PPH
Uterine fibroids
Fetal macrosomia
Maternal obesity
Unplanned CD in labor without
additional risk factors 35
Antenatal observation for placenta
previa without active bleeding
Chorioamnionitis
Elective CD with prior myomectomy
or fundal surgery
Trial of labor after any uterine
surgery
Use of general anesthesia 38,42
A history of RhoGAM therapy†
Severe anemia (antepartum
Hcto 25%) 35
Mild anemia (Hcto 30%) in the
presence of other risk factors
Thrombocytopenia (platelets

<strong>Postpartum</strong> <strong>Hemorrhage</strong> on Labor and Delivery
Table 2. Stages of <strong>Postpartum</strong> <strong>Hemorrhage</strong>
Antepartum Up to Time of Delivery
Stage 0 All births postpartum
Stage 1 4 500 mL vaginal delivery or >1,000 mL cesarean
delivery
Brisk bleeding, large gush, large or multiple clots
Boggy uterus
Vital sign triggers
AND
o 1,500 mL cumulative blood loss
Stage 2 Continued bleeding despite stage 1 maneuvers
Continued vital sign instability
Symptomatic
AND
o 1,500 mL cumulative blood loss
Stage 3 Cumulative blood loss >1,500 mL
Z2 U PRBCs given
Coagulopathy suspected
Insufficient response to prior actions
Adapted from California Maternal Quality Care Collaborative. 5
PRBCs ¼ packed red blood cells.
One of the cardinal recommendations from the
CMQCC is to establish the standard of structured assessments
of blood loss, vital signs, fundal height, and uterine
tone after all deliveries, and to define specific triggers for
action to limit the risk for denial and delay. Accurate blood
loss estimation is improved by the use of calibrated drapes
and formal staff training. 5,63–66 Blood contained in absorbing
materials (e.g., pads, sponges) can be quantified by
weighing all items, subtracting the dry weight of each, and
assuming 1 g weight ¼ 1 mL blood. 5 Immediately after
delivery, the team should routinely tabulate fluid volume in
suction canisters, calibrated drapes, and absorbing materials;
any subsequent volume is assumed to be blood, not
amniotic fluid.
Because hemorrhage is so often concealed or underestimated,
monitoring protocols with clear triggers for escalating
care are essential. 5,23 A Modified Obstetric
Early Warning Scoring (MEOWS) system adapted from
the Saving Mothers’ Lives report is presented
in Table 3. 5,23,67,68 A recent prospective evaluation in a
delivery center in the United Kingdom suggests that
Modified Obstetric Early Warning Scoring triggers are
89% sensitive (95% confidence interval: 81 to 95%), 79%
specific (95% confidence interval: 76 to 82%), with a
positive predictive value of 39% (95% confidence interval:
32 to 46%) and a negative predictive value of 98% (95%
confidence interval: 96 to 99%) to predict severe obstetric
morbidity. 69 Thirteen percent of women in this sample
developed some morbidity, including 5.5% with hemorrhage,
4% with preeclampsia, and 2.5% with infection.
The study found that hypotension was the least specific
criterion in predicting severe morbidity. But this was based
on a threshold of 90 to 100 mmHg to define mild hypotension
and

110 Mhyre
Table 3. A Scoring System Adapted From the Modified Early Obstetric Warning Score
Warning Score 2 1 0 1 2
Heart rate (beats/min) r40 41–50 51–100 101–120 4 120
Systolic blood pressure
(mmHg)
o 85 or >20% decrease 85–94 95–150 151–160 4 160
Diastolic blood pressure
(mmHg)
— — Z90 91–100 4 100
Oxygen saturation (%) o 95 — 95–100 — —
Respiratory rate r10 — 11–20 21–30 4 30
Temperature (1C) r35.0 35.1–35.9 36.0–37.9 — Z38.0
Neurological responses — — Alert and conscious Responds only to voice Responds only to pain or unresponsive
After measuring each parameter, assign the score located at the top of the column for each corresponding physiologic parameter. Sum the individual assigned values to
obtain a total score for the patient. If the total score is Z2, consult a physician for evaluation and intervention.
Data adapted from CEMACH, 68 Singh. 69
requesting additional blood products, activating a massive
transfusion protocol, converting to general anesthesia, initiating
cell salvage, and establishing invasive hemodynamic
monitoring depend on the ongoing state of the
patient, the rate of blood loss, and the degree to which
obstetricians are effective in controlling the source of
bleeding.
Following manual exploration and repair of lacerations,
stepwise escalation of surgical therapy includes dilatation
and curettage, intrauterine balloon insertion (e.g., Bakri
balloon), placement of a uterine compression suture (e.g.,
B-Lynch, O’Leary, multiple squares), selective embolization,
peripartum hysterectomy, and abdominal packing.
Stage 3
Stage 3 qualifies as major obstetric hemorrhage (Supplemental
Digital Content 6, http://links.lww.com/ASA/
A135). In the event of unanticipated massive hemorrhage,
an interosseous needle may be rapidly inserted in the
proximal humerus and used to initiate fluid resuscitation
while additional intravenous access is established. 71 Temporizing
maneuvers include leg elevation, manual compression
of the aorta at the umbilicus, and a nonpneumatic
antishock garment. 72,73 This last device is a Neoprene
garment secured with Velcro that has been found to
be helpful based on randomized trials conducted in the
developing world. Permissive hypotension (MAP
50 mmHg) 37 may help to limit bleeding, but is not well
studied in the postpartum patient.
While a hemoglobin transfusion threshold of 6 to 7 g/dL
is generally appropriate, laboratory results are inaccurate
in the face of major ongoing hemorrhage, and transfusion
for these patients should proceed empirically without
waiting for laboratory results. Failure to maintain adequate
hematocrit during acute obstetric hemorrhage has
been associated with end-organ dysfunction. 74 Based on
the trauma literature, for patients who require >6 U PRBC
in the first 24 hours, outcomes are improved when transfusion
is initiated earlier and when a PRBC-to-FFP-to-
platelet ratio of 1:1:1 is used (e.g., 4 PRBC, 4 FFP, 1 fivepack
platelets). 75 Massive transfusion protocols can be
established to treat life-threatening obstetric hemorrhage.
For example, at Stanford University, upon activation of the
massive transfusion protocol, the blood bank provides a
standard pack to initiate resuscitation (e.g., 6 U O-negative
blood, 4 U FFP, and 1 apheresis platelet unit [5-pack]). 76
Subsequent matched blood products are continuously
prepared to maintain blood product availability, and the
protocol is automatically discontinued once additional
blood products have not been requested for at least 1 hour.
To direct therapy, a full panel of laboratory values (i.e.,
CBC/PLTS, ionized Ca, K, PT/aPTT, fibrinogen, ABG)
should be sent every 30 to 60 minutes to establish trends
and to tailor the transfusion ratios as well as electrolyte
supplementation. Serial coagulation tests are more helpful
than single time point measurements in assessing the
quality of resuscitation and development of coagulopathy.
6 Blood product transfusion thresholds are listed
in Table 4. 6
Plasma contains six times the citrate concentration as a
unit of packed cells, and rapid transfusion of blood and
plasma may lead to profound hypocalcemia, hyperkalemia,
and pulseless electrical activity arrest. When the
rate of plasma infusion exceeds 0.25 mL/kg/min, accelerate
serial electrolyte measurements and infuse calcium
chloride through a central line. 77
Point-of-care viscoelastic monitors are an alternate strategy
to facilitate goal-directed therapy. A thromboelastography
treatment algorithm was introduced to a trauma service in
Denmark in 2003 (Table 5), and among patients receiving
Z10 U of blood, 30-day mortality declined from 31.5 to
20.4%. 79 Corresponding treatment thresholds for women
experiencing a postpartum hemorrhage have not been established.
Women are usually slightly hypercoagulable at
the moment of delivery, and need to lose more blood and
experience greater hemodilution to arrive at these thromboelastographic
parameters. The algorithm recommends
tranexamic acid if clot lysis at 30 minutes exceeds 8%.

<strong>Postpartum</strong> <strong>Hemorrhage</strong> on Labor and Delivery
Table 4. Blood Product Transfusion Thresholds
Product Goal
PRBC HctZ21–25%*
FFP PT and PTT r1.5 normal
Platelets Platelet >25,000–50,000/mm 3 *
Cryoprecipitate Fibrinogen >1–2 g/L*
Data obtained from Thachil and Toh, 6 Goodnough et al., 38 Burtelow et al. 76
*The higher values reflect goals appropriate for ongoing major blood loss.
FFP ¼ fresh-frozen plasma; Hct ¼ hematocrit; PRBC ¼ packed red blood cells;
PT ¼ prothrombin time; PTT ¼ partial thromboplastin time.
Tranexamic acid is an antifibrinolytic agent recommended
by the World Health Organization to treat postpartum
hemorrhage if bleeding continues despite a full
complement of uterotonics (1 g administered over 1 minute,
repeated once after 30 minutes). 80 A trial from eight
delivery centers in France randomized <strong>14</strong>4 women who
had vaginal deliveries associated with >800 mL EBL to
receive either tranexamic acid or a placebo, and demonstrated
a modest reduction in median EBL in the 6 hours
following randomization (173 mL [interquartile range 59,
277] versus 221 mL [interquartile range 105 to 564],
P ¼ 0.04). The World Maternal Antifibrinolytic Trial is
enrolling 20,000 women with Stage 1 postpartum hemorrhage
to compare the dose recommended by the World
Health Organization versus placebo on the risk of death or
peripartum hysterectomy. 81 Results are expected in 2015.
Preliminary evidence suggests that the early coagulopathy
in postpartum hemorrhage is driven by the consumption
of fibrinogen, which appears to fall before any
other clotting factor. 70 Fibrinogen is traditionally replaced
using cryoprecipitate, but small quantities of fibrinogen
are present in all blood products (Table 6). Alternatively,
lyophilized fibrinogen concentrate of 2 to 4 g has been reported
to be helpful in obstetric patients. 83 The main advantage
of fibrinogen concentrate over cryoprecipitate is
that it can be given rapidly and does not need to be thawed.
It was approved for use in the United States by the Food
and Drug Administration in 2009 to treat congenital hypofibrinogenemia,
but might be considered for off-label
use in the event of severe obstetric hemorrhage.
Table 5. Thromoelastography Treatment Algorithm
Thromoelastography Variable Treatment
R 11–<strong>14</strong> minutes 10 mL/kg FFP
R ><strong>14</strong> minutes 20 mL/kg FFP
MA 46–50 mm 10 mL/kg PC
MA 8% Tranexamic acid
Adapted from Johansson and Stensballe. 78 Copyright r 2010 by American
Association of Blood Banks.
FFP ¼ fresh-frozen plasma; Ly30 ¼ lysis (in percent) 30 minutes after MA is
reached; MA ¼ maximum amplitude; PC ¼ platelet concentrate; R ¼ reaction time.
Cell-salvaged blood can be processed from the surgical
field and is another strategy that may limit the need for
autologous blood donation. It increasingly appears to be
safe, based on more than 400 published cases of its use in
obstetric patients. Newer machines in combination with
leukocyte reduction filters have demonstrated effective
clearance of fetal squamous cells, phospholipid lamellar
bodies, plasma heparin, cytokines, and other coagulopathic
mediators. Cell-salvaged blood does contain up to
2% fetal erythrocytes; Rhesus-negative women will require
dose-adjusted RhoGAM administration. Emergency
cell salvage services may be most appropriate in institutions
where cell saver devices are routinely used as
they offer dedicated technicians to set up the equipment. 84
Recombinant Factor VIIa
Registries of recombinant factor VIIa report an overall
80% success rate in controlling hemorrhage when other
interventions have failed, with reported doses r90 mg/
kg. 85 Temperature, acid–base balance, calcium, platelets,
and fibrinogen should first be optimized for maximal hemostatic
effect. For women with refractory hemorrhage in
the setting of amniotic fluid embolism, recombinant factor
VIIa has been associated with a high rate of thrombotic
complications. 86
CONCLUSIONS
Given the complexity of maternal hemorrhage management,
multidisciplinary postpartum hemorrhage drills
allow the entire care team to integrate individual management
components, to improve teamwork and communication,
and to ensure the entire system will perform well
in the event of a hemorrhagic emergency. In situ simulation
on the labor and delivery unit has been shown to be
effective for identifying and correcting latent hazards. 87,88
Sample scenarios, evaluation forms, and debriefing guides
are available on the CMQCC website. 5
<strong>Postpartum</strong> hemorrhage rates are increasing, and will
likely continue to increase as a function of shifting demographics
and increasing reliance on induction of labor and
cesarean delivery. Continuing medical education is only
the first step toward ensuring optimal clinical management.
Anesthesiologists have particular skills in recognizing
impending illness and managing resuscitation, but may
exert the greatest influence on maternal outcomes by
Table 6. Fibrinogen Content in Blood Products
Fibrinogen Volume (mL)
1 U PRBC o 100 mg 350
1 U FFP 400 mg 200–250
One 5-pack platelets 80 mg 5 ¼ 400 mg 250
One 10-donor unit cryoprecipitate
Adapted from Stinger et al.
2,500 mg 150
82
FFP ¼ fresh-frozen plasma; PRBC ¼ packed red blood cells.
111

112 Mhyre
marshaling institutional resources to develop and implement
systems solutions to prepare, on a hospital level, for
postpartum hemorrhagic emergencies.
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