DESCRIBE ANALYZE IDENTIFY POSTPARTUM HEMORRHAGE …

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POSTPARTUM HEMORRHAGE AND TRANEXAMIC ACID

Gregory Collins, DNP, CRNA

DESCRIBE ANALYZE IDENTIFY

…the impact,

incidence, and

consequences

of acute

postpartum

hemorrhage

(PPH).

…the patho-

physiology of

acute PPH

and routes of

potential

intervention.

...mechanism

of action for

tranexamic

acid (TXA)

and the role

for treatment

of acute PPH.

“Maternal hemorrhage…remains the leading cause of maternal mortality worldwide.”

“Hemorrhage that leads to blood transfusion is the leading cause of severe maternal morbidity in

the United States…”

ACOG Practice Bulletin No. 183: Postpartum Hemorrhage.Obstetrics & Gynecology. 2017;130(4):e168-e186.

Cairoli G, Cuesta C, Abalos E, Gulmezaglu A. Epidemiology of postpartum haemorrhage: A systematic review. Best Practice & Research Clinical

Obstetrics and Gynaecology. 2008;22(6):999-1012.

EPIDEMIOLOGY

4-6% PPH

1.86% PPHSEVERE

125,000/YR*MATERNAL DEATHS

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ETIOLOGY

Evensen A, Anderson J, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. American Family Physician. April 1, 2017;95(7):442-449.

TONETRAUMATISSUETHROMBIN

70%

20%

10%

~1%

CONSEQUENCES

RENAL FAILURE / INSUFFICIENCY

BLOOD TRANSFUSION

PROLONGED ANEMIA

LOSS OF FERTILITY

POSTPARTUM DEPRESSION

RESPIRATORY FAILURE / ARDS

COAGULOPATHY

PITUITARY ISCHEMIA / NECROSIS

Baird E. Identification and management of obstetric hemorrhage. Anesthesiology Clinics. 2017;35:15-34.

HEMOSTASISMANAGEMENT OF

COAGULA

TION

FIBRIN

OLYSIS

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IN PREGNANCYHEMOSTASIS

Hellgren M. Hemostasis during normal pregnancy and puerperium. Seminars in Thrombosis and Hemostasis. 2003;29(2):125-130.

LARGE VOLUME INCREASE IN CLOTTING FACTORS: VII, VIII, X, XII, vWF

UP TO 200% INCREASE

IN FIBRINOGEN LEVELS

PROTEIN C RESISTANCE

DECREASED LEVELS OF PROTEIN S

INCREASE IN PLASMINOGEN, tPA, uPA

MARKED INCREASE IN

PLASMINOGEN INHIBITORS

vWF

VIIVIII

PIs

XIIvWF

FIBPLASMINOGEN

tPA uPAX

FIBRINOLYSIS

PLASMINOGEN

PLASMIN

tPA/uPA

FSPsD-DIMER

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FIBRINOLYSIS

PLASMIN

PLASMINOGEN

tPA uPAPAI-1 / PAI-2 / A2AP

COAGULA

TION

FIBRINOLY

SIS

COAGULATION

FIBRINOLYSIS

CO

NSU

MPT

ION

DIL

UTI

ON

AC

TIVATION

PLASMINO

GEN / tPATRAUMA!

COAGULA

TION

FIBRIN

OLYSIS

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PIs

PLASMINOGEN

tPA uPA

!

VIIVIII FIB

XIIvWF

X

"COAGULA

TION

FIBRIN

OLYSIS

HYPERFIBRINOLYSIS

https://www.rotem.de/en/methodology/result-interpretation-rotem-delta-und-sigma/

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INTERVENTIONPHARMACOLOGICAL

BINDS PLASMINOGEN LYSINE RECEPTOR, INHIBITS

CONVERSION TO PLASMIN, INHIBITS FIBRINOLYSIS

1000 mg IVMAY REPEAT

IN 30-60 MINUTES

CYKLOKAPRON

SYNTHETIC DERIVITAVE OF AMINO ACID LYSINE

NO TRUE CONTRAINDICATIONS(EXTREME CAUTION IN

SUSPECTED DIC)

HYPOTENSION, VISUAL ABNORMALITIES,N/V/D, SEIZURE

TRANEXAMIC ACID

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Glymph DC, Tubog TD, Vedenikina M. Use of Tranexamic Acid in Preventing Postpartum Hemorrhage. AANA Journal. 2016;84(6):427-438.

FIBRINOLYSIS

PLASMINOGEN

PLASMIN

tPA/uPA

FSPsD-DIMER

WOMAN TRIALWORLD MATERNAL ANTIFIBRINOLYTIC 193

HOSPITALS20,000+

PATIENTS23

COUNTRIES

Shakur H, Roberts I, Fawole B et al. Effect of early tranexamic acid administration on mortality,hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN):

an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017;389(10084):2105-2116.

UPON DX:1000 mg TXA IV OVER 10 min OR PLACEBO

PRIMARY OUTCOME MEASURES: MATERNAL DEATHHYSTERECTOMY

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OVERALL REDCUTION1.5% VS 1.9%

p=0.045

< 3hr OF DELIVERY1.2% VS 1.7%

p=0.008



DEATH DUE TO BLEEDING SIGNIFICANTLY REDUCED

< 3hr OF DELIVERY1.2% VS 1.7%

p=0.008

OVERALL REDCUTION1.5% VS 1.9%

p=0.045

NO SIGNIFICANT INCREASE IN ADVERSE EVENTS

“Tranexamic acid reduces death due to bleeding in women with

post-partum hemorrhage with no adverse effects. When used as a

treatment for postpartum hemorrhage, tranexamic acid should be given as soon as

possible after bleeding onset.”



“Tranexamic acid reduces death due to bleeding in women with

post-partum hemorrhage with no adverse effects. When used as a

treatment for postpartum hemorrhage, tranexamic acid should be given as soon as

possible after bleeding onset.”

TRANEXAMIC ACID

BLOODCOMPONENT THERAPY

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MTP PRBCsOXYHEMOGLOBIN

HEMATOCRITTRIGGERS?

GOALS?

ERYTHROCYTES, PRESERVATIVES,

ANTICOAGULANTS

ESSENTIAL ELEMENT FOR NEUROMUSCULAR

FUNCTION/HOMEOSTASIS

1-2 g SLOW IVEVERY 2-4 UNITS PRBCMAINTAIN iCa >1.0-2.0

Calcium Chloride / Calcium Gluconate

MINERAL, ELECTROLYTE

NO TRUECONTRAINDICATIONS

ARRHYTHMIA, HYPOTENSION, N/V

CALCIUM

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Dyer RA, van Dyk D, Dresner A. The use of uterotonic drugs during caesarean section. International Journal of Obstetric Anesthesia. 2010;19:313-319. https://www.memorangapp.com/flashcards/77608/Cardiac+Physiology+Lectures+4-6/

FFPVOLUME

CLOTTING FACTORS

TRIGGERS?

NONCELLULAR FRACTION OF BLOOD, ALBUMIN,

COAGULATION ENZYMES

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FFPVOLUME

CLOTTING FACTORS

TRIGGERS?GOALS?

NONCELLULAR FRACTION OF BLOOD, ALBUMIN,

COAGULATION ENZYMES PLTSHEMOSTASIS

BRICKSTRIGGERS?

THROMBOCYTES, DONOR PLASMA,

SCANT ERYTHROCYTES

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PLTSHEMOSTASIS

BRICKSTRIGGERS?

GOALS?

THROMBOCYTES, DONOR PLASMA,

SCANT ERYTHROCYTES CRYOFIBRINOGEN!

CLOTTING FACTORS(VII, VWF, XIII, FIB),

PLT MICROPARTICLES

FIBRINOGEN

McDonnell NJ, Browning R. How to replace fibrinogen in postpartum haemorrhage situations?.International Journal of Obstetric Anesthesia. 2018;33:4-7.

POSITIVE PREDICTIVE VALUE FOR PROGRESSION

TO SEVERE PPH

100%FIBRINOGEN < 200 mg/dl

FIBRINOGEN >400…79% NEGATIVE PREDICTIVE VALUE FOR PROGRESSION TO SEVERE PPH

CRYOFIBRINOGEN!

MORTAR

TRIGGERS?


PLT MICROPARTICLES

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CRYOFIBRINOGEN!

MORTAR

TRIGGERS?GOALS?


PLT MICROPARTICLES

pH

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PREPARE

PRACTICE

PREACH

ACOG Practice Bulletin No. 183: Postpartum Hemorrhage.Obstetrics & Gynecology. 2017;130(4):e168-e186.

PREPARE

PRACTICE

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PREPARE

PRACTICE

PREACH

QUESTIONS

[email protected]

REFERENCESACOG Practice Bulletin No. 183. Obstetrics & Gynecology. 2017;130(4):e168-e186.

Cairoli G, Cuesta C, Abalos E, Gulmezaglu A. Epidemiology of postpartum haemorrhage: A systematic review. Best Practice & Research Clinical Obstetrics and Gynaecology. 2008;22(6):999-1012.

Evensen A, Anderson J, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. American Family Physician. April 1, 2017;95(7):442-449.

Baird E. Identification and management of obstetric hemorrhage. Anesthesiology Clinics. 2017;35:15-34.

Hellgren M. Hemostasis during normal pregnancy and puerperium. Seminars in Thrombosis and Hemostasis. 2003;29(2):125-130.


Glymph DC, Tubog TD, Vedenikina M. Use of Tranexamic Acid in Preventing Postpartum Hemorrhage. AANA Journal. 2016;84(6):427-438.

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REFERENCESShakur H, Roberts I, Fawole B et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage(WOMAN): an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017;389(10084):2105-2116.

Sahu J, Mishra N. Role of intravenous tranexamic acid in reducing blood loss during caesarean section: Study at tribal-dominated area hospital in Chhattisgarh, India. Journal of Obstetrics and Gynaecology Research. 2019. doi:10.1111/jog.13915

Dyer RA, van Dyk D, Dresner A. The use of uterotonic drugs during caesarean section. International Journal of Obstetric Anesthesia. 2010;19:313-319.

Osoti A, Vogel J, Oladapo O, Qureshi Z, Gülmezoglu A. Tranexamic acid for treatment of postpartum haemorrhage. Obstetrics, Gynaecology & Reproductive Medicine. 2019.

DESCRIBE ANALYZE IDENTIFY POSTPARTUM HEMORRHAGE …

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