ObstetricObstetric HemorrhageHemorrhage SUNYSUNY StonyStony BrookBrook EducationEducation Module:Module: ThirdThird Edition,Edition, JanuaryJanuary 20052005 DesignedDesigned toto promotepromote aa systemizedsystemized andand standardstandard responseresponse toto ObstetricalObstetrical HemorrhageHemorrhage Author: Paul L. Ogburn, MD ObstetricObstetric HemorrhageHemorrhage StonyStony BrookBrook UniversityUniversity HospitalHospital hashas implementedimplemented aa systemsystem forfor dealingdealing withwith obstetricalobstetrical hemorrhagehemorrhage toto decreasedecrease thethe riskrisk ofof maternalmaternal mortality.mortality. TheThe componentscomponents ofof thethe systemsystem include:include: 1.1. EducationEducation 2.2. PreparationPreparation 3.3. VigilanceVigilance 4.4. PersistencePersistence 5.5. ContinuousContinuous improvementimprovement ObstetricObstetric HemorrhageHemorrhage 1. Education – includes this educational CD. 2. Preparation – includes: a. standard admission orders for labor/delivery; b. standard orders for obstetrical hemorrhage emergency; c. a system developed to maintain obstetrical continuity with Maternal Fetal Medicine supervision for 24 hours after initiation of the obstetrical hemorrhage emergency; d. appropriate equipment for labor and delivery; e. appropriate training for physicians and nurses. ObstetricObstetric HemorrhageHemorrhage 3.3. VigilanceVigilance -- isis maintainedmaintained byby virtuevirtue ofof thethe systemsystem ofof orders,orders, training,training, andand monitoringmonitoring whichwhich includesincludes thethe educationeducation andand preparationpreparation mentionedmentioned above.above. 4.4. PersistencePersistence -- occursoccurs forfor eacheach individualindividual patientpatient byby virtuevirtue ofof thethe mandatedmandated 2424 hourhour monitoringmonitoring (supervised(supervised byby thethe perinatalperinatal andand obstetricalobstetrical teams)teams) followingfollowing thethe acuteacute hemorrhagehemorrhage event.event. 5.5. FormalFormal trainingtraining -- concerningconcerning obstetricalobstetrical hemorrhagehemorrhage willwill occuroccur forfor physiciansphysicians andand nursesnurses andand willwill includeinclude thisthis instructionalinstructional programprogram (with(with additionaladditional practicalpractical drills).drills). ObstetricObstetric HemorrhageHemorrhage InIn thethe thirdthird trimestertrimester ofof pregnancy,pregnancy, bloodblood flowflow toto thethe uterusuterus isis increasedincreased toto aboutabout 600600 cccc perper minute.minute. MostMost ofof thisthis bloodblood flowsflows toto thethe undersideunderside ofof thethe placentaplacenta wherewhere itit bathesbathes thethe coteledonscoteledons.. TheThe humanhuman placentalplacental isis hemochorialhemochorial.. ThisThis meansmeans thatthat anyany lossloss inin integrityintegrity inin thethe uteroutero--placentalplacental sealseal cancan allowallow leakageleakage ofof virtuallyvirtually allall ofof thethe maternalmaternal bloodblood flowingflowing toto thethe uterus.uterus. InjuryInjury toto thethe birthbirth canalcanal oror uterusuterus oror failurefailure ofof thethe uterusuterus toto contractcontract properlyproperly afterafter deliverydelivery cancan havehave thethe samesame hemorrhagichemorrhagic effects.effects. ObstetricObstetric HemorrhageHemorrhage andand MaternalMaternal DeathsDeaths AbruptioAbruptio placentaplacenta –– 1919 percentpercent UterineUterine rupturerupture –– 1616 percentpercent UterineUterine atonyatony –– 1515 percentpercent CoagulationCoagulation disorderdisorder –– 1414 percentpercent PlacentaPlacenta previaprevia –– 77 percentpercent PlacentaPlacenta accretaaccreta –– 66 percentpercent RetainedRetained placentaplacenta –– 44 percentpercent ChichakiChichaki,, etet al,al, 19991999 CausesCauses ofof MaternalMaternal DeathsDeaths duedue toto HemorrhageHemorrhage InadequateInadequate resourcesresources andand personnelpersonnel –– forfor example,example, homehome deliverydelivery attempts.attempts. FailureFailure toto prepareprepare forfor obstetricobstetric hemorrhagehemorrhage ––forfor example,example, nono IVIV sitesite startedstarted onon admission.admission. DelayDelay inin recognitionrecognition ofof hemorrhage.hemorrhage. DelayDelay inin treatmenttreatment ofof hemorrhage.hemorrhage. TreatmentTreatment failures.failures. AntepartumAntepartum HemorrhageHemorrhage AbruptioAbruptio placentaplacenta PlacentaPlacenta previaprevia UterineUterine rupturerupture DefinitiveDefinitive treatmenttreatment isis cesareancesarean sectionsection forfor eacheach ofof thesethese conditions.conditions. SimultaneousSimultaneous preparationpreparation forfor transfusiontransfusion shouldshould occuroccur asas needed.needed. IfIf heavyheavy bleedingbleeding continuescontinues afterafter thethe cesareancesarean section,section, treattreat asas postpartumpostpartum hemorrhage.hemorrhage. PostpartumPostpartum Hemorrhage:Hemorrhage: ““ObstetricsObstetrics isis BloodyBloody BusinessBusiness””* *Cunningham, et. al: Williams Obstetrics, 21st ed., 2001 Postpartum Hemorrhage Etiology is linked to Risk Factors Bleeding from Hypotonic myometrium—uterine atony Placental Some general anesthetics Implantation Site Poorly perfused myometrium Over distended uterus Prolonged labor Very rapid labor Oxytocin-induced or augmented labor High parity Uterine atony in previous pregnancy Chorioamnionitis Retained placental tissue Avulsed cotyledon, succenturiate lobe Abnormally adherent—accreta, increta, percreta Postpartum Hemorrhage Etiology is linked to Risk Factors Trauma to the Large episiotomy, including extensions Genital Tract Lacerations of perineum, vagina or cervix Ruptured uterus Coagulation Defects Intensify all of the above Postpartum Hemorrhage DODO NOTNOT UNDERESTIMATEUNDERESTIMATE BLOODBLOOD LOSSLOSS Clinical Features of Shock System Early Shock Late Shock CNS Altered mental states Obtunded Cardiac Tachycardia Cardiac failure Orthostatic hypotension Arrhythmias Hypotension Renal Oliguria Anuria Respiratory Tachypnea Tachypnea Respiratory failure Hepatic No change Liver failure Gastrointestinal No change Mucosal bleeding Hematological Anemia Coagulopathy Metabolic None Acidosis Hypocalcemia Hypomagnesemia Postpartum Hemorrhage CategorizationCategorization ofof AcuteAcute HemorrhageHemorrhage Class 1 Class 2 Class 3 Class 4 Blood loss 15% 15%-30% 30%-40% >40% (% blood volume) Pulse rate <100 >100 >120 >140 Pulse pressure Normal Decreased Decreased Decreased Blood pressure Normal or Decreased Decreased Decreased increased Postpartum Hemorrhage GoalsGoals ofof TherapyTherapy •• MaintainMaintain thethe following:following: SystolicSystolic pressurepressure >90mm>90mm HgHg UrineUrine outputoutput >0.5>0.5 mLmL/kg/hr/kg/hr NormalNormal mentalmental statusstatus •• EliminateEliminate thethe sourcesource ofof hemorrhagehemorrhage •• AvoidAvoid overzealousoverzealous volumevolume replacementreplacement thatthat maymay contributecontribute toto pulmonarypulmonary edemaedema Postpartum Hemorrhage ManagementManagement ProtocolProtocol To be undertaken simultaneously with management of hypovolemic shock • ExamineExamine thethe uterusuterus toto rulerule outout atonyatony • ExamineExamine thethe vaginavagina andand cervixcervix toto rulerule outout lacerations;lacerations; repairrepair ifif presentpresent • ExploreExplore thethe uterusuterus andand performperform curettagecurettage toto rulerule outout retainedretained placentaplacenta Postpartum Hemorrhage ManagementManagement ProtocolProtocol (cont’d.) •• For uterine atony: • Firm bimanual compression • Oxytocin infusion, 40 units in 1 liter of D5RL • 15-methyl prostglandin F2a, 0.25 to 0.50 mg intramuscularly; may be repeated • Methergine 0.2 mg IM, PGE1 200 mg, or PGE2 20 mg are second line drugs in appropriate patients • Bilateral uterine artery ligation • Bilateral hypogastric artery ligation (if patient is clinically stable and future childbearing is of great importance) • Hysterectomy Postpartum Hemorrhage Management of Hypovolemic Shock • Insert at least two large catheters. Start saline infusion. Apply compression cuff to infusion pack. Monitor central venous pressure (CVP) and arterial pressure. • Alert blood bank. Take samples for transfusion and coagulation screen. Order at least 6 units of red cells. Do not insist on cross matched blood if transfusion is urgently needed • Place patient in the Trendelenburg position • Warm the resuscitation fluids • Call extra staff, including consultant anesthesiologist and obstetrician. • Rapidly infuse 5% dextrose in lactated Ringer’s solution while blood products are obtained. Postpartum Hemorrhage Management of Hypovolemic Shock (cont’d) • Transfuse red cells as soon as possible. Until then: •crystalloid, maximum of 2 liters •colloid, maximum of 1.5 liters • Restore normovolaemia as priority, monitor red cell replacement with Hematocrit or Hemoglobin • Use coagulation screens to guide and monitor use of blood components • If massive bleeding continues, give FFP 1 unit, cryoprecipitate 10 units while awaiting coagulation results • Monitor pulse rate, blood pressure, CVP, blood gases, acid- base status and urinary output (catheterization) Consider adding oxygen by mask. EmergencyEmergency ObstetricsObstetrics HemorrhageHemorrhage OrdersOrders TransfuseTransfuse twotwo unitsunits ofof packedpacked redred bloodblood cellscells immediately.immediately. UseUse crosscross matchedmatched bloodblood ifif available;available; otherwiseotherwise useuse typetype specificspecific oror OO negativenegative packedpacked