Postpartum hemorrhage- dr beckerman

Postpartum hemorrhage

Transcript

1. Rutgers, The State University of New Jersey Marc Beckerman, MD, MBS (Mohammed Faysal Malik, MD) May 1, 2020 Postpartum Hemorrhage
2. Learning Objectives Upon completion of this presentation, participants will be able to • Define different types of obstetric hemorrhage • Be able to describe contributing factors to postpartum hemorrhage • Prioritize treatments for postpartum hemorrhage
3. Obstetric Hemorrhage Classification • Antepartum (before the onset of labor) • Intrapartum (during labor and delivery) • Postpartum (after delivery of the placenta) 3
4. Case Report • 25 y.o. G6P3A3 no significant PMHx • Delivered at home after a fast labor associated with abdominal expression and minimal traction of the umbilical cord at delivery. The newborn is a female of undefined weight. • Two hours later, and following the stage of expulsion, the parturient reports continued bleeding. • BIBEMS. Initial GE found a conscious and agitated patient. • Vitals - BP 100/70, HR 100, RR 20, T 38.6 • DDx? 4
5. Case Report cont. • PE - extremely sensitive, necrosed mass exteriorized by the vulva • Pelvic U/S - did not show a uterus in the pelvis, diagnosis of Uterine inversion was attained • Tx Plan? 5
6. Case report cont. • Broad-spectrum antibiotic therapy was given • Blood transfusion initiated • A manual reduction was attempted under General A without obtaining any positive results. • Converted to laparotomy, allowing progressive reduction using the Huntington technique • Considering the gangrene and infectious context, hysterectomy with ovaries conservation was performed 6
7. Postpartum Hemorrhage (PPH) • Maternal mortality after PPH approximately 2% • Wide variations worldwide depending on both the overall health + resources for treatment • Death rates vary from 0.6 percent in the United Kingdom to 20 percent in parts of Africa • From 1:100,000 deliveries in the United Kingdom to 1:1000 deliveries in developing world 7 World Health Organization. WHO Recommendations for the Prevention of Postpartum Haemorrhage. Geneva, WHO, 2007. Ford JB, Roberts CL, Bell JC, et al. Postpartum haemorrhage occurrence and recurrence: A population-based study. Med J Aust 2007; 187:391-3.
8. PPH definition • Classic: >500 mL after vaginal delivery, >1000 mL after C/S • Current: Bleeding that is greater than expected and results in signs and/or symptoms of hypovolemia 8
9. Alternate PPH definitions 9 1° PPH: first 24 hrs 2° PPH: 24 hrs - 6 weeks
10. Physiologic Mechanisms that limit PPH • Contraction of the myometrium -> compresses the blood vessels supplying the placental bed + causes mechanical hemostasis • Local decidual hemostatic factors -> tissue factor, type-1 plasminogen activator inhibitor, systemic coag factors (eg, platelets, circulating clotting factors) • Most remaining d/t loss of intact vasculature (ie, trauma) • Consistent potential for massive hemorrhage in late pregnancy -> uterine artery blood flow is 500 to 700 mL/min and accounts for approximately 15 percent of cardiac output 10
11. Risk Factors • In a study including over 154,000 deliveries that compared 666 cases of PPH vs controls, associated risk factors were: • Retained placenta/membranes (odds ratio [OR] 3.5, 95% CI 2.1-5.8) • Failure to progress during the second stage of labor (OR 3.4, 95% CI 2.4-4.7) • Laceration (OR 2.4, 95% CI 2.0-2.8) • Large for gestational age (eg, >4000 g) (OR 1.9, 95% CI 1.6-2.4) • Hypertensive disorders (preeclampsia, eclampsia, HELLP (OR 1.7, 95% CI 1.2-2.1) • Induction of labor (OR 1.4, 95% CI 1.1-1.7) 11 Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M J Matern Fetal Neonatal Med. 2005;18(3):149.
12. Risk Factors cont. • Scar (prior C/S, hysterotomy/curettage) • Overdistended uterus (macrosomia, multiparity, multiple gestation, polyhydramnios) • Infection (chorioamnionitis) • Labor (precipitous, prolonged, stimulated) • Embolism, amniotic fluid • Demise, fetal 12 Mayer DC, Smith K. Antepartum and Postpartum hemorrhage. Chestnut's Obstetric Anesthesia Principles and Practice. 4th ed. Philadelphia, PA: Mosby Elsevier; 2009:825.
13. Question? • A 36 yo G4P3 presents at 38 Weeks Gestational Age presents for elective C-Section for history of 3 prior C Sections. Her past OB history is significant for preclampsia. A combined spinal epidural is placed in the OR without complication and immediately after delivery of the fetus you start an oxytocin infusion. However, blood loss continues and has reached 800ml in the past 5mins and is continuing. What is the most likely cause of her bleeding? A. Placenta accreta B. Cervical laceration C. Uterine atony D. Retained placenta • 13
14. Causes of PPH • “The Five T’s” 1. Tone – uterine tone* 2. Tissue – retained placenta 3. Tissue – placenta accreta 4. Trauma – genital trauma 5. Turned inside out — uterine inversion 14
15. Uterine Atony • Contraction of the uterus critical to controlling blood loss • Maternal oxytocin + prostaglandins contract uterus • Failure to adequately contract following delivery = uterine atony • Most common indication for blood transfusion • Most common cause of both intrapartum + postpartum hemorrhage 15 World Health Organization. Reducing the global burden: Postpartum hemorrhage: Making pregnancy safer. World health Organization Hot Topics Issue April 2007; 4:1-8
16. Uterine Atony - Risk Factors • Overdistended uterus • Macrosomia • Multiple gestation • Polyhydramnios • Cesarean • Prolonged rupture of membranes • Grand multiparity • Retained placenta • General anesthesia 16
17. Uterine Atony - Diagnosis • Soft and boggy postpartum uterus • Vaginal bleeding • Uterus may contain over 1000 mL of blood! • Absence of bleeding does not exclude Dx 17
18. Uterine Atony - Management • Call for help • Bimanual uterine compression • Confirm oxytocin administration • Address IV access if blood transfusion needed • Explore uterine cavity for retained placenta fragments • Inspect cervix + vagina for lacerations • Insert Foley to monitor UOP • Begin volume resuscitation, re-consider blood product transfusion 18 Alexander James M, Wortman Alison C. Intrapartum Hemorrhage. Obstet Gynecol Clin N Am 2013; 40:15-26
19. Question? • A 24 yo G1P0 with a past medical history of well controlled asthma, is being taken back for an urgent C section for failure to progress. She has been on an oxytocin infusion for the past 8hours for augmentation. Her epidural is titrated to achieve surgical anesthesia for the C-section and a healthy baby boy is delivered. However the Ob residents looks over and says to you that her uterus looks boggy can you give her some utertonic agents. Which of the following agents are relatively contraindicated? A. Oxytocin 20 Units infusion B. Methylergonovine 200mcg im C. Prostaglandin E1 100mcg per rectum D. 15 Methyl Prostaglandin F 2 Alpha 250mcg im • 19
20. Uterine Atony - Medical management 20 Obstetrical Society of Philadelphia. Management of Post-partum hemorrhage
21. Retained Placenta • 0.1-3.3% of deliveries • ↑ risk if delivery of placenta > 30 min 1. Trapped or incarcerated - placenta is trapped behind a partially closed cervix 2. Placenta adherans – placenta adheres to the endometrial lining, manually separates 3. Placenta accreta – placenta is abnormally adherent to the myometrium, no signs of separation 21 Magann EF, Evans S, Chauhan SP, et al. The length of the third stage of labor and the risk of postpartum hemorrhage. Obstet Gynecol 2005; 105 (2): 290-293
22. Retained Placenta - Risk Factors • History of retained placenta • Small or low-lying placenta • Uterine scar • Placenta accreta • Age over 35 • Early labor • Infection • Preeclampsia 22
23. Retained Placenta - Management • Obstetric Management: • Manual extraction, oxytocin, monitoring, alert anesthesia team • Anesthetic Management: 1. Airway assessment 2. Non-particulate antacid 3. Neuraxial anesthesia (epidural, spinal) 4. N 2 O (40-50%) 5. Ketamine (10-mg boluses), fentanyl (50-100 mcgs) 6. Nitroglycerin (40-200 mcgs) 7. GA/RSI (1.5 MAC) 23 Carroli G, Laros RK Jr. Umbilical vein injection for management of retained placenta. Cochrane Database Syst Rev 2001; (4): CD001337. Yoo K, Lee JC, Yoon MH, et al. The effects of volatile anesthetics on spontaneous contractility of isolated human pregnant uterine muscle: A comparison amo sevoflurane, desflurane, isoflurane, and halothane. Anesth Analg 2006; 103:443-7.
24. Abnormal Placental Implantation • Placenta accreta vera • adherence onto myometrium • Placenta increta • invasion into myometrium • Placenta percreta • invasion of the uterine serosa and other pelvic structures 24
25. Placenta Accreta • Risk Factors • Previous C/S • Previous or current placenta previa • Diagnosis • Antepartum • US and/or MRI • Intrapartum • Difficulty separating placenta • Examination of uterus during laparotomy 25 Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107:1226-32
26. Placenta Accreta - Antepartum Management • Probable hysterectomy to avoid large blood loss • Placenta percreta • greatest risk of morbidity and mortality • Preparatory measures (ACOG) • Patient counseling on need for hysterectomy • Preoperative anesthesia consultation • Adequate IV access • Blood product (PRBCs, platelets, FFP, other clotting factors) immediate availability • Cell saver consideration 26
27. Placenta Accreta - Intrapartum Management • Discovered at delivery: prompt recognition and hysterectomy • Preparation is a key to better outcome • IR consultation • Adequate IV access • Blood product immediate availability 27
28. Vaginal + Cervical Laceration • Spontaneous delivery associated with injury to the vagina and cervix • Bleeding should be identified promptly and immediately • Anesthetic technique? 28
29. Vaginal + Cervical Laceration - Management • Large cervical lacerations • Uterine segments • Uterine artery • Extend retroperitoneal • Vaginal Injury • Vaginal arteries injury can cause vaginal hematomas • Larger or expanding hematomas can be associated with significant blood loss • Anesthetic management? • Estimated blood loss? • Location of injury? • Patient stability? 29
30. Uterine Inversion • 1:2,500 – 1:20,000 • Risk factors: • Uterine atony • Short umbilical cord • Excessive umbilical cord traction • Inappropriate fundal pressure • Fundal location of placenta • Diagnosis • Most cases are obvious (mass in introitus + massive hemorrhage) 30 You WB, Zahn CM. Postpartum hemorrhage: Abnormally adherent placenta, uterine inversion, and puerperal hematomas. Clin Obstet Gynecol 2006; 49:184-97.
31. Uterine Inversion - Management • Obstetric Management • Immediately replace the uterus! • Terbutaline • Nitroglycerin (IV, SL) • Magnesium sulfate • Ecbolic agents • Oxytocin • Prostaglandins • Ergot alkaloids 31 You WB, Zahn CM. Postpartum hemorrhage: Abnormally adherent placenta, uterine inversion, and puerperal hematomas. Clin Obstet Gynecol 2006; 49:184-97.2.
32. Uterine Inversion - Management • If previous treatment fails, GA/ RSI is necessary. • Volatile agents are ideal • Rapid relaxation • Minimal side effects • Short duration of action 32
33. General Principles • Delivery complicated by hemorrhage • Stable ! may proceed with existing CSE or epidural • Existing single shot spinal is unlikely to provide sufficient duration for complicated surgery and GA should be considered • Unstable with existing neuraxial anesthesia ! GA should be strongly considered 33
34. Evaluation Blood Loss • EBL is commonly only ½ of actual • Vital signs may be a poor indicator • Decreased UOP? • Significant Bleeding • Adequate IV Access (peripheral vs Central vs IO) • Rapid infusion of blood products and crystalloids • foley catheter • Medical vs surgical treatment 34 Alexander James M, Wortman Alison C. Intrapartum Hemorrhage. Obstet Gynecol Clin N Am 2013; 40:15-26
36. Invasive Treatment Options • Cesarean or hysterectomy • Uterine compression sutures • Intrauterine balloon tamponade • Angiographic arterial embolization • Bilateral surgical ligation 36 Allam MS, B-Lynch C. The B-Lynch and other uterine compression suture techniques. Int J Gynaecol Obstet 2005; 89:236-41 Doumouchtsis SK, Papageorghiou AT, Aruklumaran S. Systematic review of conservative management of postpartum hemorrhage: What do to when medical treatment fails. Obstet Gynecol Surv 2007; 62:540-7
37. WOMAN Trial • World Maternal Antifibrinolytic Trial - tranexamic acid for the treatment of PPH (2017) • Clinical question - Does the early administration of tranexamic acid (TXA), compared with placebo, reduce death from bleeding in women with post-partum haemorrhage (PPH)? • Design - large, multicentre, Double-blinded, RCT • Population - 16+, clinical diagnosis PPH, 20,060 enrolled • Intervention - Tranexamic Acid (n=10036), 1g (10mg/ml) IV over 10 min 37
38. WOMAN Trial - Outcomes 38
39. PPH Summary • Be alert for the 5 “T’s” of Postpartum Hemorrhage 1. Tone – uterine tone* 2. Tissue – retained placenta 3. Tissue – placenta accreta 4. Trauma – genital trauma 5. Turned Inside Out – uterine inversion 1. Ensure adequate IV access (PIV vs IO vs CVC) 2. Administer uterotonics 3. Assess blood loss and transfuse as indicated 4. Call for help and initiate the Massive Transfusion Protocol 39 Treatment