14 Postpartum Hemorrhage on Labor and Delivery.pdf - Vtr

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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
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