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Post Partum Hemorrhage Protocol

Post Partum Hemorrhage Protocol. Overview of Postpartum Hemorrhage. Old Problem – Consistent Thoughts. Definition…. Arbitrary and problematic Traditionally: ( Baskett, 1999) EBL >=500 cc after vaginal delivery EBL >=1000 cc after a cesarean section

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Post Partum Hemorrhage Protocol

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  1. Post Partum Hemorrhage Protocol

  2. Overview of Postpartum Hemorrhage Old Problem – Consistent Thoughts

  3. Definition… • Arbitrary and problematic • Traditionally: (Baskett, 1999) • EBL >=500 cc after vaginal delivery • EBL >=1000 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… 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 Prendiville, 2000

  9. Etiologies (4T’s)… • 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…

  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 25 ml peripad 50 ml peripad 100 ml peripad A saturated 4x4 12-ply sponge = 5 ml • Other methods of quantification: • Weight • Direct Measurement 100 ml chux 250 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 Resusciationwith NS or LR to maintain BP at 90 mm/Hg • Blood transfusion using Massive Transfusion Protocol • Correct coagulopathy if present

  17. Massive Transfusion Protocol“1:1:1” • Consider activation of a MT protocol when patient actively bleeding and any of the following: • Systolic blood pressure < 90 mmHg • Ph < 7.1 • Base deficit > 6 meq/L • Temperature below 34°C • INR > 2.0 • Platelet count < 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 patient’s 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 > 50,000. If less than that, administer 10-12 units initially • If surgical intervention is necessary, maintain Plt count > 80-100,000. • Cryoprecipate may be used along with FFP for fibrinogen levels <100, give in 6-12 unit doses

  19. Blood Component Therapy

  20. Targets after Transfusion… • Fibrinogen > 100mg/dl • Hematocrit >21% • Hemoglobin >7g/dl • Platelet count >50,000 • PT/PTT <1.5 times control

  21. Response to Resuscitation… • Pay attention to pt’s 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. Management • Monitor CBC, Coagulation studies, ABG • Monitor pulse oximetry • Monitor Urine output with indwelling catheter • Correct coagulopathy • FFP- preferred because of volume • Cryoprecipitate

  26. 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 D&E to make sure that there is no retained placental tissue (“Banjo” curette)

  27. 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

  28. Intractable PPH at vaginal delivery Uterine Artery Embolization No coagulopathy Hemodynamically stable to go to Radiology suite Interventional Radiologist available

  29. 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.

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

  31. 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

  32. 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

  33. Documentation… • Infusion type and rate • Massive Transfusion Protocol (1:1:1) • Blood • Platelets • Fibrinogen • Medications administered • Patient response • Vital signs and urine output • Nursing and Physician notes

  34. Management ofPost Partum Hemorrhage

  35. Post Partum Hemorrhage Box

  36. Post Partum Hemorrhage Box

  37. Post Partum Hemorrhage Meds

  38. 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

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

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