14 Postpartum Hemorrhage on Labor and Delivery.pdf - Vtr

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%.