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Post Partum Hemorrhage Protocol

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PPH at cesarean delivery Aggressive resuscitation Direct bimanual compression Direct intramyometrial injection of Hemabate may be undertaken Retained placenta can be ... – PowerPoint PPT presentation

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Title: Post Partum Hemorrhage Protocol


1
Post Partum Hemorrhage Protocol
2
Overview of Postpartum Hemorrhage
  • Old Problem Consistent Thoughts

3
Definition
  • Arbitrary and problematic
  • Traditionally (Baskett, 1999)
  • EBL gt500 cc after vaginal delivery
  • EBL gt1000 cc after a cesarean section
  • Excessive blood loss that makes the patient
    symptomatic (ie lightheadedness, vertigo,
    syncope) /-signs of hypovolemia (ie hypotension,
    tachycardia, or oliguria)

4
Incidence
  • Affects 5-15 of women giving birth
  • Two categories
  • Early (primary) hemorrhage occurs within the
    first 24 hours postpartum
  • Late (secondary) hemorrhage occurs after 24
    hours postpartum

5
Be Prepared
  • Risk Factors
  • Macrosomia
  • Labor induction and augmentation
  • Prolonged second stage
  • Chorioamnionitis
  • Magnesium sulfate use
  • Previous PPH
  • (Jackson, 2001)

6
Be Prepared
Risk Factor OR CI
Retained placenta 3.5 2.1-5.8
Failure to progress during the second stage of labor 3.4 2.4-4.7
Placenta accreta 3.3 1.7-6.4
Lacerations 2.4 2.0-2.8
Instrumental delivery 2.3 1.6-3.4
Large for gestational age (LGA) newborn 1.9 1.6-2.4
Hypertensive disorders 1.7 1.2-2.1
Induction of labor 1.4 1.1-1.7
Augmentation of labor with oxytocin 1.4 1.2-1.7
Sheiner et al 2005
7
Prevention
  • Active management of the 3rd stage of labor
  • uterotonic administration (preferably oxytocin)
    immediately upon delivery of the baby (or
    shoulders)
  • early cord clamping and cutting
  • gentle cord traction with uterine countertraction
    when the uterus is well contracted (ie,
    Brandt-Andrews maneuver).

8
Benefits of Active Management Vs Physiological
management
Outcome Ctrl rate RR CI
PPH gt 500ml 14 0.38 0.32-0.46
PPH gt 1000ml 2.6 0.33 0.21-0.51
Hgb lt 9 g/dl 6.1 0.4 0.29-0.55
Blood transfusions 2.3 0.44 0.22-0.53
Therapeutic Uteretonics 17 0.2 0.17-0.25
Prendiville, 2000
9
Etiologies (4Ts)
  • Tone uterine atony (80)
  • Tissue retained placental tissue
  • Trauma uterine, cervical or vaginal lacerations
  • Thrombin dilutional coagulopathy, consumptive
    coagulopathy and coagulation disorders

10
Clinical findings in Ob PPH
Blood Loss SBP Symptoms and signs Degree of shock
500-1000 mL (10-15) Normal Palpitations, tachycardia, dizziness Compensated
1000-1500 mL (15-25) Slight fall (80-100 mm Hg) Weakness, tachycardia, sweating Mild
1500-2000 mL (25-35) Moderate fall (70-80 mm Hg) Restlessness, pallor, oliguria Moderate
2000-3000 mL (35-50) Marked fall (50-70 mm Hg) Collapse, air hunger, anuria Severe
11
Two important facts
  • 1. Caregivers consistently underestimate visible
    blood loss by as much as 50. The volume of any
    clotted blood represents half of the blood volume
    required to form the clots.
  • 2. Most women giving birth are healthy and
    compensate for blood loss very well. This,
    combined with the fact that the most common
    birthing position is some variant of
    semirecumbent with the legs elevated, means that
    symptoms of hypovolemia may not develop until a
    large volume of blood has been lost

12
Quantified Blood Loss
100 ml peripad
50 ml peripad
25 ml peripad
A saturated 4x4 12-ply sponge 5 ml
  • Other methods of quantification
  • Weight
  • Direct Measurement

250 ml chux
100 ml chux
350 ml chux
500 ml chux
Dry
25 ml
50 ml
75 ml
100 ml
18x18 laps 25 ml approx 50 50 ml approx 75
75 ml entire surface 100 ml saturated and
dripping
13
Treatment
  • Two major components
  • Resuscitation and management of obstetric
    hemorrhage and, possibly, hypovolemic shock
  • Identification and management of the underlying
    cause(s) of the hemorrhage

14
Protocol
  • Philadelphia Delivery Centers

15
Organize the team
  • Call for help ( Attending, nurse ,
    anesthesiologist)
  • Designate a nurse to record vital signs, urine
    output, fluids and drugs administered
  • Assess the vital signs every 5-10min

16
Resuscitation
  • Administer 5-7L/min of Oxygen by face mask
  • Place 2 large bore IV lines
  • Initial Blood work
  • Type and cross match,
  • CBC,
  • PT/PTT/INR,
  • Fib, FSP,
  • Cr,
  • S-8
  • Fluid Resusciation with NS or LR to maintain BP
    at 90 mm/Hg
  • Blood transfusion using Massive Transfusion
    Protocol
  • Correct coagulopathy if present

17

Massive Transfusion Protocol 111
  • Consider activation of a MT protocol when patient
    actively bleeding and any of the following
  • Systolic blood pressure lt 90 mmHg
  • Ph lt 7.1
  • Base deficit gt 6 meq/L
  • Temperature below 34C
  • INR gt 2.0
  • Platelet count lt 50,000/mm³
  • Once activated, the blood bank will send 6 units
    of PRBC, 6 units of FFP, 6 units of platelets,
    and 10 units of cryoprecipitate. After this, if
    the patient remains bleeding (the protocol has
    not being inactivated), 6 more units of PRBC and
    FFP will be prepared along with 20 units of
    cryoprecipitate. The latter product is given in
    order to elevate the fibrinogen level since the
    next step of the protocol is to
  • Recombinant Activated factor VII administer.
  • At any point, if the patients hemorrhage stops,
    the blood bank should be notified so that the
    protocol can be terminated.
  • If bleeding persists, the sequence is started
    again.

18
Blood Products
  • General considerations
  • Keep the platelet count gt 50,000. If less than
    that, administer 10-12 units initially
  • If surgical intervention is necessary, maintain
    Plt count gt 80-100,000.
  • Cryoprecipate may be used along with FFP for
    fibrinogen levels lt100, give in 6-12 unit doses

19
Blood Component Therapy
Product Vol Contents Effect
PRBCs 240 RBC, WBC, plasma Increase hematocrit 3 percentage points, hemoglobin by 1 g/dL
Platelets 50 Platelets, RBC, WBC, plasma Increase platelet count 5,000 10,000/mm3 per unit
FFP 250 Fibrinogen, antithrombin III, factors V and VIII Increase fibrinogen by 10 mg/dL
Cryoprecipitate 40 Fibrinogen, factors VIII and XIII, von Willebrand factor Increase fibrinogen by 10 mg/dL
20
Targets after Transfusion
  • Fibrinogen gt 100mg/dl
  • Hematocrit gt21
  • Hemoglobin gt7g/dl
  • Platelet count gt50,000
  • PT/PTT lt1.5 times control

21
Response to Resuscitation
  • Pay attention to pts level of consciousness
  • Monitor BP
  • Maintain BP around 90 mm/Hg Systolic
  • Monitor RR
  • Frequent auscultation of lung fields
  • Start Blood if BP cannot be maintained or when
    Bleeding is controlled

22
Work up
  • Exam Patient- DR or in OR
  • Uterine Tone
  • Genital Lacerations
  • Placenta
  • Bleeding Sites
  • Lab Studies Type and cross match, CBC,
    PT/PTT/INR, Fib, FSP, Cr, S-8
  • Imaging Studies bedside U/S

23
Initial Management
  • Empty bladder
  • Vigorous bimanual Uterine massage
  • Manual exploration of uterine cavity. (Use U/S
    to r/o retained placenta)
  • Uterontonics
  • Careful inspection of cervix, vagina, vulva and
    perianal area for lacerations and/or hematomas in
    OR
  • Consider coagulopathy if no other cause identified

24
Medical Management
  • UTEROTONICS
  • Pitocin 40 units in 1 liter NS or LR IV rapid
    infusion or 10 units IM (Avoid undiluted IV push)
  • Methergine 0.2mg IM q2-4hr, max 5 doses
    (Contraindicated with HTN)
  • Hemabate 0.25mg IM or intramyometrial q
    20-90min, max 8 doses (Contraindicated with
    Asthma)
  • Cytotec 800-1000mcg PR or SL (not per vagina)

25
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26
Management
  • Monitor CBC, Coagulation studies, ABG
  • Monitor pulse oximetry
  • Monitor Urine output with indwelling catheter
  • Correct coagulopathy
  • FFP- preferred because of volume
  • Cryoprecipitate

27
If PPH hemorrhage continues after uterotonics
  • Shift to OR
  • Exam under anesthesia carefully re-inspect the
    cervix, vagina, vulva and perianal areas for
    lacerations and /or hematomas
  • Perform DE to make sure that there is no
    retained placental tissue (Banjo curette)

28
Packing and Tamponade
  • If PPH still continues.
  • Packing 4 inch gauze pack into uterus using a
    sponge stick. If thrombin available, soak gauze
    with 5,000 units thrombin in 5cc sterile saline
  • SOS Bakri Tamponade Balloon Insert balloon,
    instill 300-500 cc saline
  • Foley catheters if Bakri balloon unavailable.
    Insert one or more bulbs, instilled with 60-80cc
    of NSS

29
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30
Intractable PPH at vaginal delivery
  • Uterine Artery Embolization
  • No coagulopathy
  • Hemodynamically stable to go to Radiology suite
  • Interventional Radiologist available

31
UAE special considerations
  • If patient is relatively stable, not
    coagulopathic and an intervention radiologist is
    available consider arterial embolization before
    proceeding to exploratory laprotomy.
  • Temporizing measures like packing and SOS Bakri
    balloon tamponade can be used in the meanwhile.

32
Intractable PPH at Vaginal delivery
  • Laparotomy
  • Make midline vertical abdominal incision
  • Begin with bilateral uterine art ligation-Figure
    of 8s
  • If unsuccessful, consider
  • B-Lynch suture or square compression suture
  • Vicryl 1
  • Hpogastric artery ligation
  • Hysterctomy (supracervical)

33
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34
PPH at cesarean delivery
  • Aggressive resuscitation
  • Direct bimanual compression
  • Direct intramyometrial injection of Hemabate may
    be undertaken
  • Retained placenta can be removed under direct
    visualization
  • Compression sutures may be placed
  • LUS can be packed with end in the vagina for
    24-30 hrs
  • Hypogastric Artery Ligation
  • Supracervical Hysterectomy

35
Post Op care
  • Continue resuscitation
  • Monitor vital signs and urine output
  • Monitor vaginal bleeding
  • Repeat labs as indicated
  • Disposition ?ICU
  • Monitor for coagulopathy
  • Monitor for complications anemia, ARDS, ATN
    being most common

36
Documentation
  • Infusion type and rate
  • Massive Transfusion Protocol (111)
  • Blood
  • Platelets
  • Fibrinogen
  • Medications administered
  • Patient response
  • Vital signs and urine output
  • Nursing and Physician notes

37
Management of Post Partum Hemorrhage
38
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39
Post Partum Hemorrhage Box
40
Post Partum Hemorrhage Box
41
Post Partum Hemorrhage Meds
42
H.A.E.M.O.S.T.A.S.I.S
  • H ask for help
  • A Assess (VS, EBL) and resuscitate
  • E Establish etiology, ensure availability of
    blood, ecbolics
  • M Massage uterus
  • O Oxytocin/Methergine/Hemabate/Cytotec
  • S Shift to OR
  • T Tamponade balloon, uterine packing
  • A Apply compression sutures
  • S Systematic pelvis devascularization
  • I Interventional radiologist UAE
  • S Subtotal/total abdominal Hysterectomy

43
Thank-you from the Chairs of Ob/Gyn in
Philadelphia
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