Postpartum HemorrhageSusan Leong-Kee, MD

Assistant ProfessorDirector of Simulation

Baylor College of MedicineDepartment of Obstetrics and Gynecology

I have no financial conflicts of interest to disclose

Agenda

• Postpartum hemorrhage didactic overview• Simulation skills training• Debrief

Objectives

• Review the incidence of pregnancy-related hemorrhage, specifically postpartum hemorrhage (PPH)

• Review the pregnancy-related vascular changes that can lead to PPH

• Identify risk factors for PPH• Recognize prevention and develop

management skills

Incidence

• Hemorrhage is one of the leading causes of maternal death worldwide

• PPH: 27% of maternal mortality (WHO, 2014)

• 1 woman dies every 4 minutes due to PPH (ACOG, 2013)

28

27

14

8

11

9

Causes of maternal death worldwide by percentage (Source: WHO)

Pre-existing medical conditionsHemorrhagePregnancy related hypertensionAbortion complicationsInfections

Obstetric morbidity + mortality in the U.S.

• Rate of maternal deaths has tripled from 6 per 100,000 in 1996 to 17 per 100,000 annual births in 1999

• Blood transfusions increased 92% during delivery hospitalizations between 1997 and 2005

Annual Postpartum Hemorrhage Rates, United States, 1994-2006

7

Defining postpartum hemorrhage

• Vaginal delivery:– Greater than 500 mL blood loss

• Cesarean section:– Greater than 1000 mL blood loss

Hemodynamic changes of pregnancy

• Plasma volume expansion• Increase in red blood cell mass• Cardiac output (SV X HR =CO) increases• Pro-coagulant factors (i.e., fibrinogen)

increase

Classification of hemorrhage

Class Blood Loss Percentage Lost PhysiologicResponse

1 900 ml 15% Asymptomatic

2 1200-1500 ml 20-25% Tachycardia, tachypnea,

hypotension, delayed

hypothenar refill

3 1800-2100 ml 30-35% Tachycardia, tachypnea, cool

extremities

4 > 2400 ml 40% Shock, oliguria

Classification of PPH

• Early (Primary) PPH:– Occurs within 24 hours of delivery– Occurs in 4-6% of pregnancies

• Late (Secondary) PPH:– Occurs between 24 hours of delivery and 6-12

weeks postpartum– Occurs in 1% of pregnancies

Etiologies of postpartum hemorrhage

Postpartum hemorrhage etiologies

Early Uterine atonyLower genital tract lacerationsUpper genital tract lacerationsRetained products of conceptionAbnormal placentationUterine ruptureUterine inversionCoagulopathy

Late InfectionRetained products of conceptionPlacental site subinvolutionCoagulopathy

Most common causes of PPH

• 4 Ts: Tone – Trauma – Tissue -- Thrombin– Tone = uterine atony– Trauma = vagina/cervical lacerations– Tissue = retained placenta; abnormal placentation– Thrombin = coagulopathy

Risk factors• History of postpartum hemorrhage• Prolonged labor/precipitous labor• Uterine over-distension (i.e., macrosomia,

multiple gestation, polyhydramnios)• Operative delivery• Episiotomy• Medical conditions: Chorioamnionitis,

preeclampsia, clotting disorders• Prolonged labor augmentation

Bimanual uterine massage

Uterotonic agents

DRUG DOSE FREQUENCY CONTRAINDICATIONS

Oxytocin IV: 10-40 U in 1 liter NS or LR

Continuous Drug hypersensitivity-rare

Methylergonovine IM: 0.2 mg Every 2-4 hours Hypertension

15-methyl PGF2α IM: 0.25 mg Every 15-90 minutes, 8 dosesmaximum

Asthma, hepatic, renal, cardiac disease

Dinoprostone Vaginal or rectal suppository: 20 mg

Every 2 hours Hypotension

Misoprostol Rectal: 800-1000 mcg

Once Drug hypersensitivity-rare

Active management of third stage of labor

• Administration of oxytocin– postpartum hemorrhage– duration of third stage– need for additional uterine tonic agents

• Controlled cord traction• Fundal massage after placenta delivery

Uterine tamponade

ACOG, Practice Bulletin 76

Selective uterine arterial embolization

Surgical intervention

• O’Leary stitch• Compression-type sutures:

– B-lynch– Hayman– Cho

O’Leary Stitch

• Bilateral uterine artery ligation

B-Lynch Suture

Hayman Suture

Cho Suture

Special scenarios

• Genital tract lacerations– Adequate VISUALIZATION and ANESTHESIA

• Pelvic hematomas– Results from lacerated vessels in the superficial

fascia of the anterior and/or posterior pelvic triangle

Special scenarios

• Uterine inversion– Occurs 1 in 2500 deliveries– Risk factors: uterine over-distension, uterine

malformations, abnormal placentation, short umbilical cord, tocolysis, collagen disorders (i.e., Ehlers-Danlos)

– Clinical findings: brisk vaginal bleeding, non-palpable fundus, maternal hemodynamic instability

Special scenarios

• Management of uterine inversion

Special scenarios• Coagulopathy

– Risk factors: massive hemorrhage, sepsis, amniotic fluid embolism, preeclampsia, acute fatty liver of pregnancy

– Laboratory studies:– Type and screen, CBC, PT/PTT/INR, fibrinogen– Management:

• Replacement of clotting factors• Goals: platelets > 50,000/μL, fibrinogen > 100 mg/dl• Massive transfusion protocol• Intensive care unit

Volume resuscitation

• Crystalloid resuscitation – Initial management with a 3:1 ratio of

replacement to estimated blood loss

• Colloid resuscitation:– Albumin, hetastarch, dextran– Blood products

Blood component therapy

ACOG, Practice Bulletin 76

Massive transfusion protocol

• Establish hospital massive transfusion protocol– Typically 1: 1 ratio of PRBC:FFP

• Consider other supportive measures:– ICU admission– Fluid warmer– Bear Hugger®

Establishing Guidelines

Florida OHI algorithm

PPH/MTP Algorithms

• Texas Children’s Hospital Pavilion for Women• PPH and MTP Algorithm simulation training• Total number of providers who completed

multi-disciplinary training – 346 out of 406 (85.2% of targeted providers)

• Result – decrease the need for maternal transfusions of 4 units of PRBCs or more by 66% from 3/2012 – 12/2014

Conclusions

• Review or help establish your hospital’s postpartum hemorrhage protocol

• Educate fellow team members (RNs, anesthesia, unit managers, etc.) on various approaches to PPH

• Develop goals to improve ways to better estimate and quantify blood loss

References• Argani CH, Eichelberger M, Deering S, Satin AJ. The case for simulation as

part of a comprehensive patient safety program. Am J Obstet Gynecol. 2012 Jun;206(6):451-5

• Kramer MS, Berg C, Abenhaim H, Dahhou M, Rouleau J, Mehrabadi A, Joseph KS. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol. 2013 Nov;209(5):449.e1-7

• Allam MS1, B-Lynch C. The B-Lynch and other uterine compression suture techniques. Int J Gynaecol Obstet. 2005 Jun;89(3):236-41. Epub 2005 Apr 19

• Lyndon A, Lagrew D, Shields L, Main E, Cape V. Improving Health Care Response to ObstetricHemorrhage. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care)Developed under contract #11-10006 with the California Department of Public Health; Maternal,Child and Adolescent Health Division; Published by the California Maternal Quality CareCollaborative, 3/17/15

• Shields LE, Smalarz K, Reffigee L, et al. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of bloodproducts. Am J Obstet Gynecol 2011;205:368.e1-8

• http://health.usf.edu/publichealth/chiles/fpqc/ohi