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Coagulation Changes in Pregnancy, Ante and Post-Partum Hemorrhage, FVIIa

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Lavinia Lin M.D. CA-3 Dec.9, 2008 Hypercoagulable state probably a protective adaptation to limit blood loss at delivery Marked increase in Factors VII and ... – PowerPoint PPT presentation

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Title: Coagulation Changes in Pregnancy, Ante and Post-Partum Hemorrhage, FVIIa


1
Coagulation Changes in Pregnancy, Ante and
Post-Partum Hemorrhage, FVIIa
  • Lavinia Lin M.D.
  • CA-3
  • Dec.9, 2008

2
Coagulation Changes in Pregnancy
  • Hypercoagulable state probably a protective
    adaptation to limit blood loss at delivery
  • Marked increase in Factors VII and fibrinogen and
    modest increase VIII, IX, X, XII
  • (only)Decrease Factor XI
  • Platelet count decreases 10 during 3rd trimester

3
Antepartum Hemorrhage
  • PLACENTA PREVIA
  • 5 of pregnancies
  • Risk factors previous C-sxn or uterine
    myomectomy, multiparity, advanced maternal age,
    large placenta
  • May partially or completely cover cervical os,
    anterior lying placenta previa incr risk of
    excess bleed for Csxn

4
Placenta Previa (cont)
  • Presents as painless vaginal bleed
  • Dx with Ultrasound, never vaginal exam
  • Before 37wks gestaton mild-moderate bleed-gt bed
    rest obs
  • After 37wks, deliver via Csxn
  • Anesthetic technique
  • -If pt stable fluid resuscitated-gtconsider
    regional
  • -If active bleed or unstable-gt GA

5
Placenta Previa-Additional Complications
  • H/o previous previa or Csxn -gt increased risk of
    placenta adhering to surface (placenta accreta),
    muscle (placenta increta), or penetrating
    myometrium (placenta percreta).
  • Placenta becomes difficult or impossible to
    separate from uterus
  • May produce life-threatening hemorrhage
  • Usually requires hysterectomy

6
Antepartum Hemorrhage
  • ABRUPTIO PLACENTA (premature separation of
    placenta)
  • 1-2 or pregnancies, most common cause of
    intrapartum fetal death
  • Risk factors HTN, trauma, short umbilical cord,
    multiparity, prolonged PROM, EtOH or cocaine
    abuse
  • Symptoms painFUL vaginal bleed uterine
    tenderness
  • Dx U/S

7
Abruptio Placenta (cont)
  • Vaginal delivery if mild-mod abruption w/ fetus
    gt37wks gestation
  • Csxn if signs of fetal distress
  • Bleeding can be concealed inside uterus cause
    underestimation of blood loss
  • If fetal demise-gt possible severe coagulopathy
    d/t activation of circulating plasminogen
    (fibrinolysis) release of tissue
    thromboelastins that precipitate DIC
  • Mod abruption fibrinogen level 150-250mg/dL
    (mildy reduced)
  • Fetal demise fibrinogen lt150mg/dL

8
Antepartum Hemorrhage
  • UTERINE RUPTURE
  • Relatively uncommon (11000-3000)
  • Si/Sx frank hemorrhage, fetal distress, loss of
    uterine tone, hypotension w/ occult bleed, even
    with working epidural rupture often heralded by
    abrupt onset of continuous abdominal pain
    hypotension.
  • TX volume resuscitation GA for immediate
    laparotomy

9
Postpartum Hemorrhage
  • A major cause of maternal morbidity, with
    sequelae such as shock, renal failure, ARDS,
    coagulopathy, and Sheehans syndrome (postpartum
    hypopituitarism)
  • Incidence 1-5 of deliveries
  • Definitions (many)
  • -best defined dx clinically as excessive
    bleeding that makes the pt symptomatic
    (lightheadedness, syncope) and/or results in
    signs of hypovolemia(hypotension, tacycardia)

10
Postpartum Hemorrhage Definition (cont)
  • -most common definition postpartum blood loss
    gt500mL after vaginal birth or gt1000mL after
    C-sxn, but clinicians frequently underestimate
    volume of blood loss.
  • -another classic definition10 decline in
    postpartum Hb from prepartum levels, but this
    is not clinically useful and large fall in Hb
    from preeclampsia or dehydration may present in
    absence of excess blood loss.

11
PPH-Etiology and Risk Factors
  • Causes deficient contraction of myometrium
    (atony), defective decidual hemostasis associated
    w/ indadequate decidualization (ie.placenta
    accreta) or bleeding diatheses (ie. factor
    deficiency or thrombocytopenia)
  • ATONY most common cause 1 in 20 births
    responsible for gt80 of PPH related to
    overdistention (multiple gestation,
    polyhydramnios, macrosomia), uterine

12
Uterine Atony (cont)
  • infection drugs (uterine relaxants), uterine
    fatigue after prolonged or induced labor,
    uterine inversion, retained placenta
  • TRAUMA d/t lacerations (esp. after instrumental
    delivery), incisions (episiotomy) or uterine
    rupture
  • COAG DEFECTS Acquired causes include severe
    preecampsia, HELLP syndrome, Abruptio placenta,
    Fetal demise, Amniotic fluid embolism, Sepsis.
    Consumptive coagulopathy may develop after severe
    hemorrhage.

13
PPH Risk Factors
  • Study of 154,311 deliveries compared 666 cases of
    PPH to controls w/o hemorrhage. Factors
    significantly assoc w/hemorrhage
  • -Retained placenta (OddsRatio 3.5, 95CI 2.1-5.8)
  • -Failure to progress(OR 3.4, 95CI 2.4-4.7)
  • -Placenta accreta (OR3.3, 95CI 1.7-6.4)
  • -Lacerations (OR 2.4, 95CI 2-2.8)
  • -Instrumental delivery (OR2.3, 95CI 1.6-3.4)
  • -Augmented labor w/oxytocin (OR1.4, 95CI1.2-1.7)

14
Sequential Steps in Management of Post-Partum
Hemorrhage
  • Uterine massage
  • Uterotonic drugs (oxytocin, methergine,
    carboprost tromethamine(Hemabate), misoprostol)
  • Inspect for lacerations, repair as necessary
  • Transarterial embolization-if woman is stable and
    there is time for personnel to mobilize
  • Uterine tamponade (Bakri or Sengstaken-Blakemore
    tube, Foley, Packing) if medical therapy fails
    and while preparing for surgery
  • Laparotomy if above measures fail
  • Ligation of bleeding sites

15
Management of Post-Partum Hemorrhage (cont)
  • B-Lynch stitch envelops and compress uterus
    to manal massage, limited f/u show no adverse
    effects on future pregnancy
  • Hysterectomy- last resort, but should not be
    delayed in women in DIC who require prompt
    control to prevent death
  • Recombinant Factor VIIa

16
Anesthesiologists roles in post-partum hemorrhage
  • Obtain large bore iv access
  • Send off for CBC, coags, DIC panel
  • Management of vaginal, cervical, uterine exam,
    laceration repairs may be done under local
    infiltration or pudendal nerve blocks add
    nitrous oxide or opioid to residual anesthetic
    from prior epidural or spinal.
  • However, induction of spinal or epidural
    anesthesia in presence of hypovolemia is
    contraindicated
  • GA usually required for bimanual uterine massage,
    extraction of retained placenta, reversion of
    inverted uterus or repair of major laceration
  • Early ligation of internal iliac arteries may
    reduce blood loss (and help avoid hysterectomy)

17
Pharmocologic tx for uterine atony
  • Oxytocin 40units/L NS iv or 10units IM
    (including directly into myometrium). Relaxation
    of vascular smooth muscles
  • S/E transient systemic hypotension, reflex
    tachycardia
  • Methylergonovine 0.2mg IM (incl. directly into
    myometrium NEVER IV) may repeat at 2-4hr
    intervals. Constricts vascular smooth muscle to
    cause intense, prolonged uterine contraction
    c/i HTN, raynauds phenomenon, scleroderma

18
Pharmocologic tx for uterine atony (cont)
  • Carboprost tromethamine (PGF2alpha) (Hemabate)
    250mcg IM (incl. directly into myometrium)
    q15-90min, prn to total of 2mg c/i asthma
  • Misoprostol (PGE1) data is limited and optimum
    route dose unclear 800-1000mcg rectally,
    200mcg orally 400mcg sublingual can use in HTN
    or asthma but monitor temp as pyrexia gt40degree C
    can occur

19
FACTOR VIIa
  • Human recombinant factor VIIa approved by FDA for
    bleeding related to Hemophilia A B congenital
    fVII deficiency.
  • Used successfully OFF-LABEL for control of
    bleeding in postpartum uterine atony, placenta
    accreta, or uterine rupture.
  • Doses of 16.7 to 120mcg/kg as single bolus
    injection over a few minutes q 2hr until
    hemostasis achieved, usually controls bleeding
    w/in 10-40minutes of first dose.
  • VERY expensive 1/mcg so 70kg woman approx
    1200-8400! May incr risk of thromboembolism

20
Blood replacement products
21
Transfusion
  • No consensus on optimal ratio of blood product
    replacement
  • Standford University medical center lab studies
    q30minutes to direct replacement therapy.
  • GOALS
  • Hb gt21
  • Plt gt50,000
  • Fibrinogen gt100mg/dL
  • PT PTT lt1.5x control (ex. 4FFP given for INR
    gt1.5, 1 plt pack for plt lt50K, 10 bags cryo for
    fibrinogen lt100mg/dL.

22
Practice Questions
  • 1) Place in order from highest to lowest cause
    for maternal death in the U.S.
  • a)General Anesthesia (failed intubation or
    aspiration)
  • b) Hemorrhage
  • c) Pulmonary emoblism
  • d) Pregnanacy-induced HTN
  • e) Infection
  • f) cardiomyopathy

23
ANSWER
  • Causes from highest to lowest
  • 1) Hemorrhage (29)
  • 2) PE (20)
  • 3) PIH (18)
  • 4) Infection (13)
  • 5) Cardiomyopathy (6)
  • 6) GA (3)

24
Practice Questions
  • 2) Match the side-effects of these uterotonic
    drugs.
  • -Oxytocin?
  • -Methergen?
  • -Hemabate?
  • Bronchospasm
  • HTN
  • Hypotension
  • (Know these. Was on ITE last year!)

25
ANSWER
  • Oxytocin -gt hypotension
  • Methergen -gt HTN
  • Hemabate -gt bronchospasm

26
Practice Questions
  • 3) Which of the following conditions is LEAST
    likely to develop DIC?
  • PIH
  • Placenta abruption
  • Placenta previa
  • Amniotic fluid embolism
  • Dead fetus syndrome

27
Answer C (placenta previa)
  • Lab dx of DIC is based on consumption of
    procoagulants (decr. in fibrinogen plt,
    prolongation of PT/PTT, incr. fibrin-fibrinogen
    degradation products. DIC is assoc w/ the
    following OB conditions placental abruption,
    dead fetus, AFE, gram-neg. sepsis, severe PIH.
    Placental abruption is MOST common cause of DIC
    in preg pt.
  • Placenta previa blood loss does NOT induce a
    coagulopathy

28
Practice Questions
  • 4) Which of the signs/sxs is NOT assoc with
    amniotic fluid embolism?
  • a) Dyspnea
  • b) HTN
  • c) Bleeding
  • d) Hypoxemia
  • e) Seizures

29
Answer B (HTN)
  • Amniotic Fluid embolism is a very rare
    (120,000-30,000 deliveries) but serious
    complication. For this to occur, placental
    membranes must be ruptured and abnormal open
    sinusoids at the uteroplacental site or
    lacerations of endocervical veins must exist.
    Onset of AFE is assoc w/ dyspnea, severe
    hypotension hypoxmenia. DIC occurs in as many
    as 40 of pts. Altered mental status
    characterized as seizure or coma.

30
Practice Questions
  • 5) Which of the following pt is most likely to
    need an emergency hysterectomy for uncontrolled
    bleeding at time of delivery?
  • a) pt w/placenta abruption
  • b) pt undergoing VBAC
  • c) pt w/quadruplets
  • d) pt w/placenta previa (not bleeding) for
    elective repeat C-sxn
  • e) pt w/ abdominal pregnancy

31
Answer D (pt w/placenta previa for repeat Csxn)
  • Pt w/ placenta previa and previous scar has very
    high chance of uncontrolled bleed b/c of placenta
    accreta (abnormally adherent placenta).
  • Incidence of placenta accreta in pt w/previa and
  • no previous Csxn is 5-7
  • one previous Csxn is 10-30
  • 2 or more Csxn is 40-70
  • 2/3 of pt w/accreta require hysterectomy
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