Postpartum Hemorrhage

Dawn Palaszewski, MD Assistant Professor Department of Obstetrics and Gynecology University of South Florida Morsani College of Medicine I have no financial conflicts of interest to disclose Objectives

• Review the incidence of - 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 Causes of maternal death worldwide by percentage (Source: WHO) • Hemorrhage is one 9 of the leading 11 28 causes of maternal death worldwide 8 • PPH: 27% of maternal mortality 14 (WHO, 2014) 27 • 1 woman dies every 4 minutes due to Pre-existing medical conditions PPH (ACOG, 2013) Hemorrhage Pregnancy related hypertension 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 • According to the WHO report “Trends in Maternal Mortality: 1990 to 2013” the U.S. matrnal mortality rate from 1990 to 2013 increased by 136% Annual Postpartum Hemorrhage Rates, United States, 1994-2006

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Defining postpartum hemorrhage

• : – 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 Physiologic Response

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 • 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

Uterine atony Early Lower genital tract lacerations Upper genital tract lacerations Retained products of conception Abnormal placentation Uterine rupture Uterine inversion Coagulopathy

Infection Late Retained products of conception Placental site subinvolution Coagulopathy Most common causes of PPH

• 4 Ts: Tone – Trauma – Tissue -- Thrombin – Tone = – Trauma = /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 • • Medical conditions: Chorioamnionitis, preeclampsia, clotting disorders • Prolonged labor augmentation Bimanual uterine massage agents

DRUG DOSE FREQUENCY CONTRAINDICATIONS

Oxytocin IV: 10-40 U in 1 liter Continuous Drug hypersensitivity-rare NS or LR

Methylergonovine IM: 0.2 mg Every 2-4 hours Hypertension

15-methyl PGF2α IM: 0.25 mg Every 15-90 minutes, 8 Asthma, hepatic, renal, cardiac doses maximum disease

Dinoprostone Vaginal or rectal Every 2 hours Hypotension suppository: 20 mg

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

Sengstaken Blakemore tube

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 • Florida Department of Health PAMR website http://www.floridahealth.gov/statistics-and-data/PAMR/index.html