4/5/2012
Dr.Nesrine El-Refai
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Updates in Management of Obstetric Hemorrhage By
Dr. Nesrine EL-Refai
4/5/2012
•Professor of Anesthesia . Cairo University •Member of Obstetric Anesthesia Committee of WFSA
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Objectives Definition & Types of Obstetric Hemorrhage. Guidelines for Management of Bleeding Parturient. New trends in Obstetric Hge management.
Introduction • “Lots of people confuse destiny with bad management.” -Kin Hubbard • To avoid “bad management” We should know: • Risk factors • Diagnostic criteria • Obstetric management • Anesthetic management 4/5/2012
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Parents’ Dream..
Obstetric Hemorrhage may change dream of safe labor into Nightmare!!!
Management of Obstetric Hemorrhage •efinition of Massive Obstetric D Hemorrhage: 1. Blood loss from the uterus or genital tract >1500ml. 2. A decrease in haemaglobin of > 4 g/dl 3. Acute transfusion of > 4 units blood 4/5/2012
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Types of Obstetric Hemorrhage I.
Antepartum Haemorrhage
II.
Intrapartum Haemorrhage.
III. Postpartum Haemorrhage.
Clinical Findings in Obstetric Hemorrhage. Blood Volume Loss
Blood Pressure (systolic)
Symptoms and Signs
Degree of Shock
500-1000 mL (10-15%)
Normal
Palpitations, tachycardia, dizziness
Compensated
1000-1500 mL (15-25%)
Slight fall (80100 mm Hg)
Weakness, tachycardia, sweating
Mild
1500-2000 mL (25-35%)
Moderate fall (70-80 mm Hg)
Restlessness, pallor, oliguria
Moderate
2000-3000 mL (35-50%)
Marked fall (50- Collapse, air 70 mm Hg) hunger, anuria
Severe
( Int J Gynaecol Obstet. May 1997)
Obstetric Haemorrhage
1) Antepartum haemorrhage:
Placenta previa & Abruptioplacentae 4/5/2012
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Types of Placenta Previa
Type 1
Type2:
:lateral
Marginal
or low lying
Type3: incomplete centralis (partial)
Type4: Complete centralis
Varieties of Bleeding: • Revealed
• Concealed
• Mixed 4/5/2012
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Intrapartum haemorrhage
(uterine rupture) Increased mortality due to: 1) Haemorrhage. 2) DIC 3) Pulmonary embolism. 4) Sepsis. 4/5/2012
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Post Partum Hemorrhage Postpartum hemorrhage (PPH) is responsible for around 25% of maternal mortality worldwide (WHO, 2007), Reaching as high as 60% in some countries.
Definition PPH is defined as blood loss of more than 500 mL following vaginal delivery or more than 1000 mL following cesarean delivery. 1ry or early: A loss of these amounts within 24 hours of delivery . 2ry or late :occurs 24 hours after delivery. (John Smith,2012)
Causes of PPH Tone: Uterine atony& uterine inversion. Tissue : Retained placenta & Placenta accreta.
Trauma: Genital tract lacerations. Thrombin: Coagulation disorder. 4/5/2012
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Atony
Inversion
Retained placenta Placenta accreta
• Genital tract laceration
Treatment of patients with PPH 2 major components: (1) Resuscitation and management of obstetric hemorrhage and shock . (2) Identification and management of the underlying cause(s) of the hemorrhage.
Placenta Accreta –Accreta = adherent to endometrial cavity –Increta = placental tissue invades myometrium –Percreta = placental tissue grows through uterine wall 4/5/2012
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Uterine Inversion
Neurogenic Shock Treatment: Reposition of the uterus. G.A: with inhalational anesthetic. Nitroglycerine Fluid resuscitation Uterotonic drugs after reposition. 4/5/2012
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Replacement of inversion
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Uterine Atony Bimanual massage for atony
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Uterine Atony versus Inversion • Uterine Atony
• Uterine Inversion
1. Hemorrhagic shock (up to 1 liter blood.)
1. Neurogenic shock
2. Management:
2. Management:
Message Embolization laparotomy.
3. G.A. with TIVA.
3.
4/5/2012
Repositioning of uterus. Nitroglycerine. G.A. with volatile agent for reduction of the uterus.
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How to manage Emergency Hge??
Methergine Misoprostol
Vasopressin Recombinant human factor VIIa*
BLOOD BANKING
Cryoprecipitate Fresh-frozen plasma
Platelets Red blood cells
SURGERY Repair of lacerations B-Lynch suture Hysterectomy, supracervical Hysterectomy, total
Ligation of the hypogastric artery Other uterine compression sutures Pelvic packing Pelvic tourniquet
NONSURGICAL PROCEDURES Bakri balloon Uterine balloon tamponade
Uterine packing
INTERVENTIONAL RADIOLOGY Uterine artery balloons
Uterine embolization
CONSULTATION Anesthesiologist–intensivist Gynecologic oncologist Interventional radiologist
*Not approved by the FDA for this indication.
Trauma surgeon Urologist
Shall We Discuss all these items?
4/5/2012
Shall We Discuss all these Dr.Nesrine El-Refai items?
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Guidelines for Management of Bleeding Parturient
I. Early during labour II. Around time of delivery III. Intraoperative management 4/5/2012
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I.
Early during labour
Early perinatal care. Correction of coagulopathy: fibrinogen level detects PPH severity. Preoperative autologous donation (PAD). OR Acute normovolemic hemodilution.(ANH).
Prevention & early expectation of Hemorrhage!! 4/5/2012
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Uterotonic Drugs: • • • •
10 U of oxytocin in 500 mL of IV fluid. 200-250 mcg of ergonovine IM 250 mcg of 15-methyl prostaglandin IM. 100 microgram of oxytocin analogue (carbetocin).
Management of Massive Haemorrhage • Preparation •
Identify patients at risk
•
Large bore IV access x 3
•
Blood available
•
Avoid caval obstruction; supplemental O2
•
Foetal monitoring
• Search for evidence of DIC Peripheral blood smear PT, PTT, Platelet counts, Fibrinogen level; D-dimer level
Specific factor analyses Bedside coagulation testing (TEG) 4/5/2012
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Volume Replacementnt Immediate aggressive volume replacement
– Crystalloid Vs Colloid ?? – Consider PRBC once blood loss > 2,000mL Type specific or Type O blood availablity. DIC ,once >80% of blood volume replaced – Platelets - if < 20,000/mm3 or higher if bleeding persisting
– FFP only to correct measured clotting abnormalities – Cryoprecipitate 4/5/2012
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Specific Therapies Uterine atony Uterine Massage; Oxytocin
Surgical exploration Selective embolization of Uterine, internal iliac or internal pudendal artery
Factor 7a –Rescue therapy in severe haemorrhage
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End Point Of Resuscitation Cardiac Index =3 L/min/m2.
Systemic O2 delivery(DO2) >500ml/min/m2 Systemic O2 uptake (VO2)> 100ml /min/m2. Arterial lactate <2mmol/L or base deficit >2mmol/L. 4/5/2012
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Management of Anesthesia
Stable hemodynamics : Regional anesthesia (T7)
Unstable hemodynamics : ď&#x192;ź G.A with TIVA with no or minimal inhalational anestheia. ď&#x192;źKetamine, Etomidate & Opioids. 4/5/2012
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Transfusion in obstetric haemorrhage: ASA Guidelines and ACOG recommendations: ď&#x192;&#x2DC; Patients should be transfused when there are signs of significant hypoperfusion. ď&#x192;&#x2DC;PRBC administration is almost always indicated when the hemoglobin level is <=6g/dl.
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Other indications for transfusion If base deficit is >15, with ongoing blood loss. O2 extraction of 50% can be used as an indication of transfusion of erythrocytes. Hb should be maintained between 6-10g/dl. Platelet count maintained over 50,000/dl. INR to be maintained <1.5 by using FFP @ 10-15ml/kg body wt. Cryoprecipitate should be used when fibrinogen levels fall below 100mg/dl @ 1U/5-10kg body wt. 4/5/2012
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What`s new in transfusion medicine?
Recombinant factor VIIa. (rFVIIa) 1. Binds to exposed tissue factor & directly activates factor IX & X. 2. Dose is 50-100mcg/kg every 2hrs I.V until evidence of hemostasis. 3. Not effective when fibrinogen level is less than 50mg/dl. 4/5/2012
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II. Vasopressin
1. Used in hemorrhagic shock unresponsive to conventional vasopressors. 2. Infusion rate- 1-4mu/kg/min. 3. Has a potential to cause Myocardial Ischemia. III. Intraoperative cell salvage & acute normovolemic hemodilution 4/5/2012
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Acute Hemodilution 1. Acute isovolemic hemodilution •Withdraw 2-4u. of Blood •Replace the volume with crystaloids •Lower the pre-op Hct •Replace the blood at end of surgery
2.- Acute hypervolemic hemodilution Admin 1500-2000cc Crystaloids . Hemodilution (Lowers pre-op Hct) 4/5/2012
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PAD versus ANH • PAD 1. If risk of transfusion 1050% 2. 6 weeks before delivery. 3. 1 unit/week. 4. PAD is safe for both mother & fetus. 4/5/2012
• ANH 1. Pt initial Ht is high 2. Dilution to Ht 0.28-0.20 3. Blood loss>2L. 4. Cheaper than PAD BUT
5) Safety is not yet established.
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Types of Replacement Products under research • Oxygen Carrying Solutions – Hemoglobin Based Oxygen Carrying Solutions (HBOCS) – Perflourocarbons
• Other – Antigen Camouflage – Recombinant Plasma Proteins – Transgenic Therapeutic Proteins – Platelet Substitutes 4/5/2012
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New studies in WFSA 2012 Tranexemic acid may reduce PPH & decreases mortality. 3gm fibrinogen given in severe PPH induced hypofibrinogenemia.
When to Give rFVIIa ??
Guidance for the use of rFVIIa in major obstetric haemorrhage Use of rFVIIa should be considered in major obstetric haemorrhage: which continues despite optimal blood product replacement and obstetric measures: • Where uterine artery ligation/embolisation or hysterectomy are considered, • Clinical haemostatic failure • Delay in the provision of blood products • Refusal of blood transfusion.
Dose: FV11a should be used judiciously for lifethreatening hemorrhage in patients who are unresponsive to conventional therapy. It is administered as a bolus injection in a dose of 60 - 80mcq/kg. Some authors suggested starting with 40mic/kg, then repeat after 2h (half life is 2h).
A single standard dose should be kept in delivery suite to facilitate rapid administration . Use of rFVIIa should not be seen as an alternative to surgical haemostasis or correction of coagulopathy with blood products.
• • • •
Before administration of rFVIIa, the following laboratory indices are desirable; –Prothrombin time < 1.5 × upper limit of normal –Clauss fibrinogen > 1.0 g/L –Platelet count > 50 × 109/L pH > 7.1 is also desirable for optimal effect. (IJOA,2007)
CONTROVERSIES IN OBSTETRIC ANAESTHESIA Report of a debate
I agree with the authors of a recent editorial, that a trial of rFVIIa is “certainly worth a try.” The responsible clinician should consider the use rFVIIa in the treatment of MOH. (IJOA,2007) 4/5/2012
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Opposer: M. Van de Velde MD, Belgium(doi:10.1016/j.ijoa.2007.06.002) However, rFVIIa is not without risks especially when given too early in hypercoagulable patients. Failure has been reported regularly. It is wise to improve normal care before highly expensive therapies are used liberally and unnecessarily.
Clear guidelines are needed for clinicians on when and how to use this sometimes life-saving drug. 4/5/2012
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Summary Obstetric hemorrhage is a leading cause of maternal mortality. Management includes surgical correction, treatment of coagulopathy & some new drugs. Use rFVIIa when other measures fail.
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Dr.Nesrine El-Refai
References John R Smith,2012 in Medscape. Emergency medicine clinic of North America, Feb 2010, Vol 28. AnaesthesiaUK - Emergency treatment of massive obstetric haemorrhage Scottish Obstetric Guidelines and Audit Project : The postt partum hemorrhage BJACEACCP - Massive haemorrhage in pregnancy. Obstetric Anesthesia,widening Horizon. Indian Jour Anesth 2010. Saving Motherâ&#x20AC;&#x2122;s lives, Br J Anesthesiology,2008. WFSA Congress,2012. SOAP meeting 2010.