obstetric haemorrhage - OAA webcast · obstetric haemorrhage ... obstetric haemorrhage APH PPH. APH...
Transcript of obstetric haemorrhage - OAA webcast · obstetric haemorrhage ... obstetric haemorrhage APH PPH. APH...
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obstetric haemorrhageNiamh Hayes
Rotunda Hospital, Dublin
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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
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obstetric haemorrhage
APH PPH
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APH
placental abruption
placenta praevia
😦
uterine rupture
😨
😨
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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)
😳
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APH PPH
NHS Maternity Statistics 2012 - 2013
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PPH incidence increasing
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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)
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PPH: aetiology
Tissue Trauma
Thrombin
Tone
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obstetric haemorrhage is a very real problem
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haemorrhage management
mobilise
think
act
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haemorrhage management
• “Medical, Midwifery & Theatre” team
• Laboratory team
• Radiology/specialist Surgical team
mobilise
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haemorrhage managementact
stop the bleeding resuscitate patient
uterotonic Rx mechanical Tx
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haemorrhage managementact
stop the bleeding resuscitate patient
uterotonic Rx mechanical Tx
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haemorrhage managementact
stop the bleeding
uterotonic Rx mechanical Tx
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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…
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uterotonic Rx mechanical Tx
expel clots/“rub up”
recheck placenta
bimanual compression
*advanced intervention
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uterotonic Rx mechanical Tx
*advanced intervention
balloon tamponnade of uterus
compression sutures to uterus
devascularisation of uterus
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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
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uterotonic Rx mechanical Tx
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escalate pharmacologic and mechanical therapies quickly… while
they are still likely to be effective…
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haemorrhage managementact
stop the bleeding resuscitate patient
uterotonic Rx mechanical Tx
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haemorrhage managementresuscitate patient
avoid bloody vicious cycle
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haemorrhage managementavoid bloody vicious cycle
hypothermia
acidosishaemodilution
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haemorrhage management
slows enzyme kinetics of coagulation cascade
reduces synthesis of coagulation factors
increases fibrinolysis
platelet adherence/activation ⬇
avoid bloody vicious cycle
hypothermia
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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
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hypothermia
2000ml @ 200C
3000ml @ 370C << 350C↔ ↔
all resuscitation fluid should be warmed
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haemorrhage managementavoid bloody vicious cycle
hypothermia
acidosishaemodilution
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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
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getting out of trouble…?
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staying out of trouble…?
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fluid resuscitation targets
haemodynamic profile: MAP ≥ 65mmHg
perfusion profile: minimise lactate/acidosis
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value of giving blood/blood products if ⬇ T0/pH
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haemorrhage managementavoid bloody vicious cycle
hypothermia
acidosishaemodilution
think
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haemodilution
think
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• Hct a determinant of coagulation…
• rheological effects of platelet margination: “near-wall concn”
• coagulopathy develops before compromise of O2 delivery…
haemodilution
think
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red cell storage defect:
TACO/TRALI/acute haemolytic & non-haemolytic reactions…
looking at cell salvage in obstetrics at every opportunity?
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Hb ≥ 80g.L-1
appropriate target
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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
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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
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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
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haemodilution & consumption
haemorrhage management
significant consumptive coagulopathy in abruption & AFE
think
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fibrinogen ≥ 1g.L-1
2.0 - 4.5 g.L-1
4.5 - 5.8 g.L-1
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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
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fibrinogen >> 1g.L-1?
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appropriate target for fibrinogen?
best replacement product?
fibrinogen >> 1g.L-1?
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goal-directedproduct replacement
'empiric blood
product replacement
(
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coagF X%
dilution of plasma
steady infusion of “coagF”
bolus infusion of “coagF”
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enough coagulation product to generate
(stable) clot
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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
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