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

😨

😨

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