POSTPARTUM HEMORRHAGE

MASSIVE TRANSFUSION

Professor

Vice Chairman of Quality & Patient Safety

Director, Division of Maternal-Fetal Medicine

Department of Obstetrics & Gynecology

Chief Quality Officer

Obstetrics & Gynecology

Gary A. Dildy, M.D.

Disclosures

Gary A. Dildy, M.D. is co-inventor of the

Belfort-Dildy Obstetrical Tamponade System;

assigned to B&D Medical Development LLC

of Park City, UT of which he is a Manager;

manufactured and marketed by Clinical

Innovations in Salt Lake City as the ebbTM

Complete Tamponade System for use in

treating postpartum hemorrhage.

BLOOD COMPONENT THERAPY

Abbreviations

ATLS Advanced Trauma Life Support

aPLT Apheresis Platelets

BCT Blood Component Therapy

Cryo Cryoprecipitate

CT Component Therapy

FFP Fresh Frozen Plasma

LP Liquid Plasma

MT Massive Transfusion

PPH Postpartum Hemorrhage

PRBC Packed Red Blood Cells

WFWB Warm Fresh Whole Blood

PREVENTABLE MATERNAL MORTALITY

DUE TO POSTPARTUM HEMORRHAGE

Berg 2005

500,000+ deliveries

NC 1995-1999

Studied 108 MM

PPH #2 cause (14%)

93% preventable

Clark 2008

1,461,270 deliveries

USA 2000-2006 (HCA)

Studied 95 MM

PPH #3 cause (12%)

73% preventable

Berg CJ, Harper MA, Atkinson SM, Bell EA, Brown HL, Hage ML, Mitra AG,

Moise KJ Jr, Callaghan WM. Preventability of pregnancy-related deaths: results

of a state-wide review. Obstet Gynecol 2005;106:1228-34.

Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GDV.

Maternal death in the 21st century: causes, prevention and relationship to

cesarean delivery. Am J Obstet Gynecol 2008;199(1):36.e1-5.

PPH protocols in US academic

obstetric anesthesia units

Hospital

Characteristics

PPH Protocol

Yes

N = 40

PPH Protocol

No

N = 20

P

Annual delivery volume (n) 3900 (2550-5200) 2300 (1900-3600) 0.002

Annual cesarean rate (%) 30 (29-36) 31 (29-39) 0.73

PPH rate (%) 5 (3-7) 5 (3-7) 0.69

Kacmar RM, Mhyre JM, Scavone BM, Fuller AJ, Toledo P. The use of postpartum hemorrhage

protocols in United States academic obstetric anesthesia units. Anesth Analg 2014;119:906-10.

Sentinel Event Alert Issue 44

26 January 2010

“Preventing Maternal Death”

2. Identify specific triggers for responding to changes

in the mother’s vital signs and clinical condition and

develop and use protocols and drills for responding

to changes, such as hemorrhage and pre-

eclampsia. Use the drills to train staff in the

protocols, to refine local protocols, and to identify

and fix systems problems that would prevent optimal

care.

Knight et al. BMC Pregnancy and Childbirth 2009

All PPH Atonic PPH

SEVERE POSTPARTUM HEMORRHAGE

McLintock & James . Obstetric hemorrhage. J Thromb Haemost. 2011;9(8):1441-51.

BLOOD COMPONENT THERAPY

In A Nut Shell

WHOLE BLOOD (500 mL)

Packed Red Cells (1U = 200-250 mL) 1U increases Hematocrit 3%

Platelets (1U = 50 mL) 6 pooled U increases platelet count 30K/uL

* Plateletpheresis (1U = 6-8 pooled singles = 250 mL)

Fresh Frozen Plasma (1U = 200-300 mL) 1U increases fibrinogen 7-10 mg/dL

Cryoprecipitate (1U = 20 mL)

Factor I, VIII, XIII, vWF, fibronectin 10 pooled U increases fibrinogen 70 mg/dL

Temp

(C)

1 to 6

20 to 24

-18

-18

TRANSFUSION

Recent Practice

Traditional strategies based on ATLS guidelines Start resuscitation with crystalloid followed by PRBCs

Use of other blood products based on laboratory tests

Massive Transfusion (MT) Replacement of > 50% of blood volume in 12-24 hours

Transfusion of > 10 U PRBC in 24 hours

Recent MT protocols at many centers Have not recommended the infusion FFP until after 4-10

U of PRBCs have been given

Many guidelines do not include recommendations for PLTs pending laboratory data

Feldbuch der Wundarznei by Hans von Gersdorff (1517)

http://en.wikipedia.org/wiki/Battlefield_medicine

Quick

Review

of the

Literature

MASSIVE TRANSFUSION

Combat & Trauma Experience

Series Setting N CT Studied Findings

Borgman 2007 Combat 246 FFP:RBC 1:1

Gonzalez 2007 Civilian 97 FFP:RBC 1:1

Sperry 2008 * Civilian 415 FFP:PRBC >=1:1.5

Holcomb 2008 Civilian 467 FFP:RBC

PLT:RBC

1:2

1:2

Maegele 2008 Civilian 713 pRBC : FFP <0.9

Spinella 2009 Combat 354 WFWB v CT WFWB > CT

Perkins 2009 Combat 694 aPLT:RBC 1:8

Zink 2009 Civilian 466 FFP:RBC

PLT:RBC

Higher ratios

MASSIVE TRANSFUSION

Combat Casualties

In patients with combat-related

trauma requiring massive

transfusion, a FFP:RBC ratio is

independently associated with

improved survival, primarily by

decreasing death from hemorrhage.

Concluded that MT protocols

should utilize 1:1 ratio of FFP:RBC

for hypocoagulable patients with

traumatic injuries.

Borgman et al. The ratio of blood products transfused affects

mortality in patients receiving massive transfusions at a combat

support hospital. J Trauma 2007;63(4):805-13.

Retrospective chart review

of 246 patients at a US

Army combat support

hospital in Iraq received MT

MASSIVE TRANSFUSION

16 Civilian Level I Trauma Centers

Review of 466 MT trauma cases during 2005-2006

Survival was increased in patients transfused high FFP:RBC (≥1:2)

high PLT:RBC (≥1:2)

No change in deaths due to MSOF

Holcomb et al. Increased plasma and platelet to red blood cell ratios

improves outcome in 466 massively transfused civilian trauma

patients. Ann Surg 2008; 248:447.

MASSIVE TRANSFUSION

16 Civilian Level I Trauma Centers

Zink et al. A high ratio of plasma and platelets to packed red blood

cells in the first 6 hours of massive transfusion improves outcomes

in a large multicenter study. Am J Surg 2009;197(5):565-70.

466 MT cases

during 2005-2006

TRAUMA & COAGULOPATHY

Military Approach

Rapid identification of coagulopathic patients

Frequent use of recombinant human factor VIIa

Rapid treatment of acidosis

Avoidance of hypothermia

Prompt initiation of 1:1:1 resuscitation ratios with RBCs, prethawed universal donor AB plasma,

and apheresis platelets

with conversion to fresh whole blood as soon as this can be obtained

Hess, JR. Blood and coagulation support in trauma care. Hematology Am

Soc Hematol Educ Program 2007;187-91.

Holcomb et al. Damage control resuscitation: directly addressing the early

coagulopathy of trauma. J Trauma 2007; 62:307-310.

BLOOD COMPONENT THERAPY

Massive Transfusion

Military

Battlefield

Level I

Trauma Center

L & D

?

MASSIVE TRANSFUSION

Postpartum Hemorrhage

Stanford Univ Med Ctr

Blood products 6 U PRBC

4 U FFP or LP

1 U aPLT

Lab assessment CBC & PLT

PT / PTT / Fibrinogen

Recombinant Factor VIIa

Burtelow et al. How we treat: management of life-threatening

primary postpartum hemorrhage with a standardized massive

transfusion protocol. Transfusion 2007;47:1564-72.

Massive Transfusion Protocol

Pack A

4 U PRBC

4 U FFP

Pack B

4 U PRBC

4 U FFP

1 U PLT

1-10 U Cryo

SMH 2010

Massive Transfusion Protocol

SMH 2010

When to activate the MTP in

Obstetrics

Hemorrhage expected to be massive (>50% BV within 2 hours)

Bleeding continues after 4 U PRBC within e.g. 1-2 hrs

Systolic BP <90 mmHg & P >120 bpm c uncontrolled bleeding

Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GD. An update

on the use of massive transfusion protocols in obstetrics. Am J Obstet

Gynecol 2016;214:340-4.

The MTP in Obstetrics

Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GD. An update on the use of

massive transfusion protocols in obstetrics. Am J Obstet Gynecol 2016;214:340-4.

POINT OF CARE

Handheld Analyzers

https://www.abbottpointofcare.com/products-services/istat-handheld

http://www.alere.com/us/en/product-details/epoc-blood-analysis-system.html

i-STAT® epoc®

Blood Gases (pH, Hgb)

Electrolytes (K, iCa)

Chemistries

Coagulation (PT)

Hematology (Hgb & Hct)

Glucose

Cardiac markers

Thromboelastography

Thromboelastography [TE] 1948 Hartert

Clot development, stabilization and

dissolution…reflects in vivo hemostasis

Thromboelastography (TEG®)

Haemonetics Corporation

http://www.haemonetics.com/

Thromboelastometry (ROTEM®)

Tem International GmbH

https://www.rotem.de/en/

htt

p:/

/ww

w.u

pto

da

te.c

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/

r-TEG criteria for Transfusion

Activated clotting time (ACT) time to beginning of clot formation (seconds)

Correlated with coagulation factor activity and thrombin generation

ACT > 110 treated with plasma

Angle (α) rate of clot strength increase (degrees)

Correlated with fibrinogen concentration and function

Angle < 66° treated with cryoprecipitate

Maximum amplitude (MA) maximal clot strength achieved (millimeters)

Correlated with platelet–fibrinogen interactions

MA < 54 mm treated with platelets

Percent clot lysis (LY30) 30 minutes after MA is achieved (%)

Correlated with fibrinolysis

LY30 > 3% treated with tranexamic acid (TXA)

Einersen PM, Moore EE, Chapman MP, Moore HB, Gonzalez E, Silliman CC,

Banerjee A, Sauaia A. Rapid-thrombelastography (r-TEG) thresholds for goal-directed

resuscitation of patients at risk for massive transfusion. J Trauma Acute Care Surg

2016 Oct 31. [Epub ahead of print] PubMed PMID: 27805995.

Online Resources

POSPTARTUM HEMORRHAGE

Blood Transfusion…Conclusions

PPH is a major cause of maternal mortality

Most maternal deaths due to PPH are preventable

Many preventable deaths are due to inadequate BCT

New MTP data from military & civilian trauma centers

Limited published experience with MTP in L&D for PPH

Lethal Triad of coagulopathy, hypothermia, & acidosis

Don’t forget hyperkalemia and hypocalcemia

Have, practice (Sim) and use PPH and MTP guidelines