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Hematologic management of massive PPH. Mehran Karimi Professor of Pediatric Hematology- Oncology Shiraz University of Medical Science 29 Khordad,Shiraz. postpartum hemorrhage (PPH). PPH is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby

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hematologic management of massive pph

Hematologic management of massive PPH

MehranKarimi

Professor of Pediatric Hematology- Oncology Shiraz University of Medical Science

29 Khordad,Shiraz

postpartum hemorrhage pph
postpartum hemorrhage (PPH)
  • PPH is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby
  • PPH can be minor (500–1000 ml) or major (more than 1000 ml)
  • PPH is the most common cause of maternal death worldwide
  • PPH is responsible for 25% of the deaths of an estimated 358000 women world-wide each year

WHO guidelines for the management of postpartum haemorrhage and retained placenta, 2009

severe pph
Severe PPH
  • Pale, sweating
  • PR > systolic blood pressure
  • Blood loss: watery, non clot
  • Decreased Hb more than 2-4 gr/dl from baseline (anemia is a risk factor for PPH)
  • Decreased HR + decreased BP when blood loss > 1500 mls
hematological changes in pregnancy
Hematological Changesin Pregnancy
  • Non pregnant: < 1% of her cardiac output flows through her uterus but at the end of pregnancy uterine blood flow accounts for 15% of CO
  • 40% expansion of blood volume by 30 weeks
  • 600 ml/min of blood flows through intervillous space
  • Appreciable increase in concentration of Factors I (fibrinogen), VII, VIII, IX, X
  • Plasminogen appreciably increased
  • Plasmin activity decreased
  • Decreased colloid oncotic pressure secondary to 25% reduction in serum albumin
blood products utilization
Blood Products Utilization
  • Local protocols are helpful
  • Don’t wait for lab abnormalities if actively bleeding!
  • Massive hemorrhage without replacement of coagulation factors (FFP) will result in coagulation abnormalities
causes and treatment of massive pph
Causes and treatment of massive PPH

Causes

Treatment

Massage, remove clot, uterotonic agent, uterine tamponade

Surgical repaire

Factor replacement

  • Uterine atony: The most common cause of PPH that bleeding leading to coagulopathy
  • Incisions and lacerations
  • Hemostatsis defect
  • Early hysterectomy indications : 1- Placenta accreta
  • 2- Uterine rupture
goals in management of a postpartum hemorrhage
Goals in management of a postpartum hemorrhage

Journal of Thrombosis and Haemostasis, 2011; 9: 1441–1451

blood components for prevention of massive bleeding
Blood components for prevention of massive bleeding
  • Whole blood and RBC
  • Fresh frozen plasma (FFP)
  • Cryopercipitate
  • Platelets
  • Fibrinogen
  • rFVIIa
blood components
blood components
  • When the blood loss reaches about 4.5 liters (80% of blood volume) and large volumes of replacement fluids have been given, there will be clotting factor defects and blood components should be given
  • transfusion of coagulation factors, up to 1 liter of FFP and 10 units of cryoprecipitate may be prevent bleeding
  • Critical levels of fibrinogen rich after a loss only 140% of the calculated blood volume
  • Critical levels of prothrombin, FV, FVII and PLT rich after a loss only 200% of the calculated blood volume
fluid therapy and blood products transfusion
Fluid therapy and blood products transfusion
  • FFP/RBC ratio mortality: 1/4: 19%, 2/5: 34%,1/8: 65%
fibrinogen concentrate
Fibrinogen concentrate
  • Acquired hypofibrinogenaemia develops early in relation to fluid resuscitation, imbalanced transfusion of blood components and bleeding
  • This state of impaired hemostasis also develops in relation to PPH
  • Fibrinogen concentrate is a commercially available drug produced from human plasma
  • It seems that early fibrinogen substitution in cases of PPH is benefit in prevention PPH
  • The FIB-PPH trial is investigator-initiated and aims to provide an evidence-based platform for the recommendations of the early use of fibrinogen concentrate in PPH (Wikkelsoe et al. Trials 2012, 13:110)
  • If fibrinogen less than 2 gr/lit severe PPH
fluid replacement
Fluid replacement
  • By consensus, total volume of 3.5 liters of clear fluids (up to 2 liters of warmed Hartmann’s solution as rapidly as possible, followed by up to a further 1.5 liters of warmed colloid if blood still not available) comprises the maximum that should be infused while awaiting compatible blood
  • The choice of fluid to be infused is controversial but of greater importance is rapid administration and warming of the infusion
  • The woman needs to be kept warm using appropriate measures
blood transfusion
Blood transfusion
  • If fully cross-matched blood is unavailable by the time that 3.5 liters of clear fluid have been infused, the best available alternative should be given to restore oxygen-carrying capacity
  • Group O RhD-negative blood may be the safest way to avoid a mismatched transfusion in an acute emergency
antifibrinolytic agents tranexamic acid
Antifibrinolytic agents (Tranexamic acid)
  • Treatment with TXA is effective in reducing blood loss in patients undergoing CS
  • Although the study was not adequately powered to address safety issues, the observed side effects were mild and transient
  • TXA given in the dose of 0.5 to 1 g intravenously was effective in reducing postpartum haemorrhage after vaginal birth and caesarean section with minimal side effects

Arch GynecolObstet 2012 Oct 13

2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

slide17

Tranexamic acid

TA and Pregnancy & Post-partum – Systematic review

6 RCT, 7 Observational studies

Peitsidis et al 2011

  • Reduction of amount of blood loss
  • TXA seems to be safe and effective
  • Lack of prospective trial
slide18

Tranexamic acid

  • Blood loss – significantly less
  • Duration of bleeding less
  • BT – significantly less
  • Less interventions required to stop the bleeding
  • Loading 4 gr over 1 hr then infusion of 1 gr/hr over 6 hrs

Ducloy-Bouthers et al 2011

recombinant activated factor vii rfviia
Recombinant activated factor VII (rFVIIa)
  • rFVIIawas developed for the treatment of haemophilia
rfviia
rFVIIa
  • North European Registry – 2000-2004
  • 128 women – 33 hysterectomy prior rFVIIa
  • 80% improvement after rFVIIa – 13(14%) required hysterectomy
  • 4 cases of VTE + one myocardial infarction
  • Death – 5 cases - none due to VTE
  • Australian and New Zealand Registry – 2002-2008
  • 110 cases - 78% of cases single dose (median dose 92 µg/kg
  • 76% positive response
  • Hysterectomy 41% before rFVIIa
  • 21% required hysterectomy after rFVIIa
  • 2 cases of VTE
  • Death – 9 cases - none related directly to rFVIIa
rfviia1
rFVIIa
  • rVIIa – should be considered in management of massive PPH
  • Timing ?
  • Prior to hysterectomy – unless bleeding surgical
  • Optimal dose ?
  • – 90mcg/Kg – two doses 15-30 minutes apart
  • Ensure
  • Platelet > 50 and Fibrinogen > 2gm/l

Grade C-IV evidence

algorithm approach of rfviia in pph
Algorithm approach of rFVIIa in PPH

P/E: R/O GYN problem

If : -PLT > 50000

- FIB> 1 gr/dl

- Normal PT

- PH ≥ 7.2

- Temp ≥35

Hematology consult :

rFVIIa: 40-60 μg/kg

*By: MOH

conclusion
Conclusion
  • Severe bleeding because of placenta accreta or uterine rupture cause early hysterectomy (HST)
  • Before early hysterectomy: compression suture or balloon tomponade is indicated
  • Uterine Atony: bleeding persist in spite of correction:
  • Coagulopathy
  • Hypothermia rFVIIa (max: 2 doses)
  • Acidosis and hypocalcemia90 µg/kg before HST
case presentation
Case presentation
  • The patient was a 37 years old women
  • She had normal first vaginal delivery without history of coagulation disorders
  • Three months after second normal vaginal delivery she developed severe skin ecchymosis and bleeding of right upper and lower extremities (compartment syndrome)
what is your next evaluation for definite diagnosis
What is your next evaluation for definite diagnosis?
  • VWF Ag
  • Factor IX assay
  • Factor XI assay
  • Inhibitor assay

Inhibitor assay

case presentation1
Case presentation
  • Many works up was done to finding the cause of her bleeding tendency
  • Coagulation tests were:
  • PT: 13 sec, INR: 1
  • PTT: 55 sec (mixing PTT:51 sec)
  • Serum FVIII level: 0.14%
  • Serum FVIII inhibitor level: 145 BU
  • Serum FIX inhibitor level: normal
  • Serum FX inhibitor level: normal
  • ANA: neg
  • dsDNA: neg
what is your definite diagnosis in this case
What is your definite diagnosis in this case?
  • Hemophilia A
  • Hemophilia B
  • Acquired Hemophilia A
  • VWD

Acquired Hemophilia A

what is treatment of bleeding in this case
What is treatment of bleeding in this case?
  • FVIII concentrate
  • IVIG
  • Recombinant FVIIa
  • FEIBA
  • 3 and 4
  • All

Recombinant FVIIa

&

FEIBA

case presentation treatment
Case presentation (treatment)
  • The patient admitted in the hospital and the recombinant FVII 90 u/kg (every 4 hrs for three times) with partial response
  • So the frequency was changed to every 2 hrs for 24 hrs with complete response and then every 4-6 hours for the second day
  • The plasmapheresis was also done without any response
  • Immune suppressive treatment was started with prednisolon 1 mg/kg/d and cyclophosphamide 2 mg/kg/d at the same time.
  • The coagulation tests resulted to normalization after completion of treatment
case presentation follow up
Case presentation (follow up)
  • The bleeding symptom was stopped after 2 days of acute treatment
  • FVIII level: 30%
  • FVIII inhibitor: 40 BU
  • PTT: 45 sec
  • The patient was discharged with continue prednisolone and cyclophosphamide for a period of 6 weeks with complete response
slide31

Thank you

karimim@sums.ac.ir