Transcript Postpartum Hemorrhage

Kimberlee McKay, M.D.
AMG OB/Gyn
Objectives:
•Why a protocol?
•Key points to implement
•Massive transfusion
Disclosures:
1.
2.
3.
This is not a talk on the academics of PPH
This is not a talk about replacing clinical judgment with an algorithm.
This talk is brought to you by Diet Coke.
1.
2.
3.
See one.
Do one.
Teach one.
Olden days: Postpartum
Hemorrhage
Give
Medication
Get lab
•Wait
•Wait
DIC!
Hysterectomy
Cultural
Assumptions:
•Real World Experience
•Required Intelligence and “good
doctoring.”
•Sacred Calling
What about when:
1.
2.
3.
You are tired.
You are busy.
Or both.
Patient care depends on:
1. Their Disease.
2. The Diagnosis AND Treatment for it.
3. The implementation of that plan.
Why a protocol?
•Help bring out human expertise.
•Support interaction, coordination, and role
articulation.
Who is this guy??
Who is this guy??
Postpartum Hemorrhage:
1.
2.
3.
Major source of maternal morbidity and mortality.
Complicates 3-5% of all births.
Has risen steadily since the 90s.
Post Partum Hemorrhage:
Causes
1.
2.
3.
4.
5.
Uterine atony
Retained Placenta
Lacerations
Abnormal placentation
Other
Comprehensive maternal
hemorrhage protocols improve
patient safety and reduce
utilization of blood product.
Shields, L., Smalarz, K., et al. AJOG: 268.e1-8
Does it work?
Review of 3200 deliveries
Identified incidence, causes, “near-miss” events.
No obvious labor and delivery risks identified
Deviation from hospital guidelines was almost universal.
Guidelines were revised, disseminated to staff and
taken into simulation.
Goal was 100% adherence to the protocol.
Riszvi, F. et al. BJOG:May 2004 (211). 495-498
Total EBL
1999
No.
%
2002
No.
%
>1500
28
52
5
33
>2000
15
28
0
0
>2500
10
19
0
0
>3000
7
13
1
6.7
**3300 deliveries followed over 6 months in 2002.
Riszvi, F. et al. BJOG:May 2004 (211). 495-498
Maternal Morbidit
1999
2002
No.
%
No
%
Any transfusion
26
48
5
33
Blood
transfusion>6U
9
17
0
0
ICU admit
25
46
2
13
Exam under
anesthesia
6
11
5
33
Postpartum hyst
3
5.6
0
0
Riszvi, F. et al. BJOG:May 2004 (211). 495-498
Testing the California Protocol
5800 deliveries followed during the study period
Goal was to evaluate whether early intervention
increased the number of patients successfully treated in
stage 1 hemorrhage
Indirectly, they hypothesized that blood product use
would be less and DIC would be less
Shields, L., Smalarz, K., et al. AJOG: 268.e18
Changes in stage of hemorrhage before and
after protocol initiation.
PPH stage
Pre
protocol
Post
period 1
Post
period 2
Post
period 3
1
35%(22)
51%(25)
69%(27)
82%(49)
2
53%(33)
45%(22)
18%(7)
10%(6)
3
11%(7)
4%(2)
13%(5)
10%(6)
Shields, L., Smalarz, K., et al.
AJOG: 268.e1-8
Changes in average number of blood products
transfused per month.
Preprotocol=16.7 U/month
Postprotocol=6.3 U/month.
Shields, L., Smalarz, K., et al.
AJOG: 268.e1-8
Who Bleeds?
Not everyone has the same risk.
Low
Medium
High
Situational Awareness: Assessing
the Risk on Admission
Low Risk: Type and Screen Recommended; BB Hold
(Minimum)
•No prior uterine incision
•Singleton
•<4 Vaginal deliveries
•No history of PPH
•No bleeding disorder.
•Negative Antibody screen on PN lab
Situational Awareness: Assessing
the risk on admission
Medium Risk: Type and Screen
•Prior C/S or uterine surgery
•Multiple gestations
•>4 vaginal deliveries
•H/O PPH
•Large uterine fibroids
•EFW> 4k
•BMI>35
Situational Awareness: Assessing
the risk on admission
High Risk: Type and Cross for 2 U pRBCs and hold.
•Placenta Previa, Low-lying placenta
•Suspected Accreta/Increta/Percreta
•Hct<30 AND other RF
•Plt < 100k
•Active Bleeding
•Known Coagulopathy
Situational Awareness: Assessing
the risk
On-going Risk Assessment:
•Prolonged 2nd stage
•Prolonged Oxytocin use
•Active bleeding
•Chorioamnionitis
•Magnesium Sulfate treatment
Situational Awareness: Team
Huddle
Medium
risk:
Review PPH
protocol
High Risk
Review PPH
protocol
Anesthesia
consult
Prevention: Active management
of the third stage
Oxytocin 30 mU in 500 cc tra 250cc q hr X 2 hrs.IV or
10 U IM delivery of anterior shoulder
•Has not been shown to increase retained placenta
Gentle cord traction (+/-)
•DO NOT PULL TOO HARD
Immediate cord clamping within 2 minutes of delivery.
Vigorous fundal massage (15 sec) during uterine
contraction.
PPH Protocol
Key
Concepts
•Reduce delay.
•Follow a plan.
•Move steadily through
the algorithm.
PPH Protocol
Key
Concepts
•Should be used with
the “Typical” PPH
patient.
•No meant to replace
clinical judgment.
STAGE I Hemorrhage:
EBL>500cc vaginal or > 1000cc cs
Nursing
interventions
MD/CNMW
•IV access
•On-going assessment: ARE VS UNSTABLE??
•Calculating blood loss
•TYPE and CROSS (if BB Hold, will delay 20-30
minutes)
•Keep patient warm and oxygenated
•Place a foley
•Find cause for bleeding
•MANUAL EXAM OF UTERUS: if you cannot
reach the fundus, CALL LABORIST
•Give medications
•TYPE and CROSS
•ARE VS UNSTABLE???:
Manual Exam of the Uterus
•It’s cheap.
•It’s effective!
•It can hurt.
PPH resulting from Uterine
Atony After Vaginal Delivery
4550 patients with PPH following vaginal delivery
Looked at PPH severity as it related to PPH management
and organizational characteristics of maternity units.
Study cohort was selected from the Pithagore6 trial
population which consisted of 6 perinatal networks and 106
French maternity units (initial cohort of 146,000 with PPH
rate of 6.4%.
Driessen, M. et al. Ob Gyn 2011;117(1):21-31
Severe PPH
20.9% of patients (n=952)
Factors associated with severity
Primiparity
Previous PPH
Previous CS
Cervical ripening
Prolonged labor
Episiotomy
Driessen, M. et al. Ob Gyn 2011;117(1):21-31
Severe PPH
Factors associated with severity:
Administration of oxytocin >10 min after dx
24.6% vs 20.5 %, adjusted OR 1.38, 95% CI
MEU >20 minutes after dx
28.2% vs 20.7 %, adjusted OR 1.83m 95% CI
Delay in calling for assistance >10 min after dx
29.8 vs. 24.8, adjusted OR 1.61, 95%CI
Driessen, M. et al. Ob Gyn 2011;117(1):21-31
Epidural!!
•Potective as these patients tended to have an
MEU performed sooner.
PPH: Definition of unstable VS
HR > 110
BP < 85/45
Unstable VS
O2 Sat < 95%
VS >15% change
Stage I hemorrhage: Medications
• Usually first line—onset action within 5 minutes
• Contraindicated with HTN
Methergine
• Little or no response to 1st dose then MOVE ON
0.2 mg IM
• Usually works within 2 doses
Hemeabat • Contraindicated in ASTHMA/HTN**
e 0.25 mg • No response after the 2nd dose then MOVE ON
IM
Cytotec
800-1000
mcg pr
• Onset of action usually 30-60 minutes PR
• SL dose 400mcg-600mcg onset within 11 minutes
STAGE 2: Continued bleeding or
Unstable VS or EBL 1000-1500 cc
Nursing
interventions
MD/CNM
interventions
• Request Laborist/OB consult if not
present
• Move patient to OR
• Notify Anesthesia
• Move to OR
• Continued uterotonic use
• Request anesthesia
• 1500 CC EBL with ongoing bleeding--Start transfusing (do not wait for lab
results)
STAGE 2: Continued
bleeding or Unstable VS or
EBL > 1500 cc
Vaginal
Delivery
Cesarean
Section
• D&C, Laceration repair
• Bakri Balloon
• Interventional radiology
• B-Lynch
• O’Leary stitches
• Uterine/internal iliac ligation
• Bakri Balloon placement
Stage 3: EBL>1500cc, > 2U
PRBCs given, unstable VS or
Suspect DIC
Nursing
interventions:
• Continued monitoring of EBL
• SUGGEST MTP activation
• Manage activation of MTP
Anesthesia
interventions
• Consider CVP or Art line
• Manage Blood products
Stage 3: EBL>1500cc, > 2U
PRBCs given, unstable vs or
Suspect DIC
OB MD
interventions
• MTP activation
•Call in back-up OR Gyn Onc
•Transfuse 2 U FFP
•Keep transfusion ration 4:4:1
(PRBCS:FFP:PLT)
•Laparotomy/Gyn Onc
•B-Lynch
•Uterine/ internal iliac
artery ligation
•Hysterectomy
Massive transfusion
Classic transfusion therapy:
Crystalloid administration
PRBCs
FAILED to prevent coagulopathy!!
Dilutional; Increased hydrostatic pressure and clot
dislodgement at endothelial injury sites
DIC: early hypoperfusion leads to up-regulation of the
Protein C pathway and inhibition of factors Vs and VIIIa
and enhanced fibrinolyisis.
Parameters:
•INR>1.5
•Plt<50k
•Hgb<7.5
•Fibrinogen< 100
Massive Transfusion
Iraq Data
Casualties who received less than 1U of plasma for every
4U PRBCs were associated with a 65% mortality
Casualties who received 2U of plasma for every 3U of
PRBCs were associated with a 19% mortality.
SpinellaPC, Holcomb JB. Resuscitation and
transfusion principles for traumatic
hemorrhagic shock. Blood Rev. 2009;23:231240.
Massive Transfusion Protocols
Higher intra-operative product use.
Lower 24-hour component use.
Lower utilization of PLT
Post operative PTT and PLT significantly improved.
Lower Crystalloid use.
Colton, BA. Gunter OL Isbell J, et al. Damage control
hematology: The impact of a trauma exsanguination protocol on
survival and blood product utilization. J Trauma. 2008; 64:11771183
Massive Transfusion Protocols
Purpose:
Structured system-wide process for early and efficient
delivery of specific ratios of blood product,
4 U PRBCs/4U FFP/ 1 Aphoresis pack PLT
PPH treated with MTP
Lab data of OB patient receiving blood products from MTP
Baseline
Most Extreme
Post-MTP
Hgb (g/dl)
11.9 (1.3)
7.1 (1.7)
10.3(2.4)
PLT
192 (56)
103 (75)
124 (44)
INR
1.2 [1.3-2.1]
2.0 [1.3-2.1]
1.3 [1.2-1.4]
aPTT
29.3 [12.9-15.8]
46.2 [31.5-53.7]
30.9 [30.2-35]
Fibrinogen
405 [302-533]
229 (170)
325 (125)
( )=mean AND [
]=interquartile
range
Gutierrez MD et al. PPH treates with MTP at a tertiary ob center: a
retrospective study; Int J of Ob Anesth 2012 (21): 230-35.
“Analysis of the initial management
of postpartum hemorrhage
demonstrated that delayed care
increased the risk of severe
postpartum hemorrhage”
Postpartum Hemorrhage: Becoming more evidence based.
Carolyn M. Zelop, M.D.
Obstetrics and Gynecology 117(1): 3-5.
PPH Protocol
Key
Concepts
•Reduce delay.
•Follow a plan.
•Move steadily through
the algorithm.
Medicine is the last high-risk
industry that expects people to
perform perfectly in complex, rare
emergencies but does not support
them with high-quality training and
practice throughout their careers”
Paul Preston, MD
Safety and QI Leader
CMQCC