obstetric haemorrhageNiamh Hayes
Rotunda Hospital, Dublin
obstetric haemorrhage
• haemorrhage is a leading cause of maternal death
• mortality not decreasing in resource-rich countries
• common cause of maternal morbidity
• common cause of obstetric critical care admission
obstetric haemorrhage
APH PPH
APH
placental abruption
placenta praevia
😦
uterine rupture
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😨
PPH
≥ 1000ml?
≥ 1500ml? “S”PPH
≥ 40g.L-1 Hb drop ≥ 4ū RCC
transfusion
IR/surgery required?
minor PPH 500 - 1000ml; major PPH > 1000ml (& “moderate” or “severe” if > 2000ml loss)
😳
APH PPH
NHS Maternity Statistics 2012 - 2013
PPH incidence increasing
Knight M et al. Trends in PPH in high resource countries… BMC Pregnancy and Childbirth 2009;9:55-65All PPH
Atonic PPH
• prolonged, augmented labours• maternal obesity• labour management (20 & 30)
PPH: aetiology
Tissue Trauma
Thrombin
Tone
obstetric haemorrhage is a very real problem
haemorrhage management
mobilise
think
act
haemorrhage management
• “Medical, Midwifery & Theatre” team
• Laboratory team
• Radiology/specialist Surgical team
mobilise
haemorrhage managementact
stop the bleeding resuscitate patient
uterotonic Rx mechanical Tx
haemorrhage managementact
stop the bleeding resuscitate patient
uterotonic Rx mechanical Tx
haemorrhage managementact
stop the bleeding
uterotonic Rx mechanical Tx
uterotonic Rx mechanical Tx
PG F2𝑎hemabate
PG E1misoprostol
oxytocin
ergometrine
Grotegut CA et al. Oxytocin exposure during labor among women with postpartum hemorrhage
secondary to uterine atony. AJOG 2011;204:1(56)e1-6
Phaneuf S et al. Desensitisation of oxytocin receptor in human myometrium.
Human Reprod Update 1998;4(5):625-33
PPH: don’t delay in moving through pharmacologic treatment algorithm…
uterotonic Rx mechanical Tx
expel clots/“rub up”
recheck placenta
bimanual compression
*advanced intervention
uterotonic Rx mechanical Tx
*advanced intervention
balloon tamponnade of uterus
compression sutures to uterus
devascularisation of uterus
uterotonic Rx mechanical Tx
*advanced intervention
interventional radiology?
stepwise surgical devasularisation
emergency peripartum hysterectomy…SOONER RATHER THAN LATER!
devascularisation of uterus
Machato LSM. Emergency peripartum hysterectomy: incidence, indications, risk factors
and outcome. N Am J Med Sci 2011;3(8):358-61
uterotonic Rx mechanical Tx
escalate pharmacologic and mechanical therapies quickly… while
they are still likely to be effective…
haemorrhage managementact
stop the bleeding resuscitate patient
uterotonic Rx mechanical Tx
haemorrhage managementresuscitate patient
avoid bloody vicious cycle
haemorrhage managementavoid bloody vicious cycle
hypothermia
acidosishaemodilution
haemorrhage management
slows enzyme kinetics of coagulation cascade
reduces synthesis of coagulation factors
increases fibrinolysis
platelet adherence/activation ⬇
avoid bloody vicious cycle
hypothermia
haemorrhage managementavoid bloody vicious cycle
hypothermia
Polderman KH. Hypothermia and coagulation. Crit Care 2012;16:A20
Rajagopalan S et al. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology 2008;108:71-7
hypothermia
2000ml @ 200C
3000ml @ 370C << 350C↔ ↔
all resuscitation fluid should be warmed
haemorrhage managementavoid bloody vicious cycle
hypothermia
acidosishaemodilution
acidosis
Martini WZ. Coagulopathy by hypothermia and acidosis: mechanisms of thrombin generation and fibrinogen availability. J Trauma Acute Care Surg 2009;67:202-9
Dirkmann D et al. Hypothermia and acidosis synergistically impair coagulation in human whole blood. A&A 2008;106:1627-32
acidosis amplifies effects of hypothermia
synergistically impairs clotting times with hypothermia
not immediately reversed with correction of pH
getting out of trouble…?
staying out of trouble…?
fluid resuscitation targets
haemodynamic profile: MAP ≥ 65mmHg
perfusion profile: minimise lactate/acidosis
value of giving blood/blood products if ⬇ T0/pH
haemorrhage managementavoid bloody vicious cycle
hypothermia
acidosishaemodilution
think
haemodilution
think
• Hct a determinant of coagulation…
• rheological effects of platelet margination: “near-wall concn”
• coagulopathy develops before compromise of O2 delivery…
haemodilution
think
red cell storage defect:
TACO/TRALI/acute haemolytic & non-haemolytic reactions…
looking at cell salvage in obstetrics at every opportunity?
Hb ≥ 80g.L-1
appropriate target
haemorrhage managementhaemodilution
fibrinogen deficiency is the primary problem with haemodilution
other coagulation factor washout less pronounced than fibrinogen
fibrinogen replacement corrects clotting (thromboelastometry)
Bollinger D et al. Finding the optimal concentration range for fibrinogen replacement after severe haemodilution: an in vitro model. BJA 2009;102:793-9
haemodilution & consumption
haemorrhage managementhaemodilution:
PPH
fibrinogen level best correlated with increasing volume PPH
fibrinogen most useful marker of developing coagulopathy
guidelines for FFP use in PPH not followed (vide infra)
de Lloyd L et al. Standard haemostatic tests following major obstetric haemorrhage. IJOA 2011;20:135-41
haemodilution & consumption
haemorrhage managementhaemodilution:
PPH
fibrinogen level associated with severe PPH
PPV of fibrinogen ≤ 2g.L-1 ➡ severe PPH = 100%
for each ⬇ fibrinogen 1g.L-1, OR 2.63 for severe PPH
Charbit B et al. The decrease of fibrinogen is an early predictor of severity of postpartum haemorrhage. J Thromb Haem 2007;5:266-73
haemodilution & consumption
haemorrhage management
significant consumptive coagulopathy in abruption & AFE
think
fibrinogen ≥ 1g.L-1
2.0 - 4.5 g.L-1
4.5 - 5.8 g.L-1
minimal fibrinogen should be 2g.L-1 to improve clot formation, and 2.5g.L-1 to fully optimise coagulation
in vitro dilutional model: does not consider
consumption/fibrinolysis
fibrinogen >> 1g.L-1?
appropriate target for fibrinogen?
best replacement product?
fibrinogen >> 1g.L-1?
goal-directedproduct replacement
'empiric blood
product replacement
(
coagF X%
dilution of plasma
steady infusion of “coagF”
bolus infusion of “coagF”
enough coagulation product to generate
(stable) clot
key issues• haemorrhage a key problem
• mobilise, act and think - quickly!
• maintain homeostasis (stay out of trouble)
• choose appropriate targets for blood products
• enough coagulation substrate to generate clot