management of postpartum hemorrhage · is necessary to treat uterine atony, go to the patient’s...
TRANSCRIPT
2/25/2019
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Management of Postpartum Hemorrhage
Rachel G. Sinkey, MD
Progress 2019
Disclosures
• No conflicts of interest.
Objectives
1. Review management of postpartum hemorrhage.
2. Highlight the need for a multidisciplinary hospital-based massive transfusion protocol.
3. Discuss emerging uses of tranexamic acid.
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Case One• 25 year old G7P4115 @ 38 + 5
• Presents in active labor
• Delivers – unmedicated – within 2 hours of arrival
• The nurse calls you one hour after delivery: “Ms. Jones is
bleeding more than I’d like.”
• What do you do?
Management of postpartum hemorrhage
1. Recognize the hemorrhage
Management of Postpartum Hemorrhage
1. Recognize the hemorrhage
2. Simultaneously:
• Assess need for resuscitation
• Identify the reason
• Treat the underlying cause
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Management of Postpartum Hemorrhage
1. Tamponade
2. Medical management
3. Surgical management
Management of Postpartum Hemorrhage
1. Tamponade
a. Bimanual Massage
b. Intrauterine balloon tamponade
2. Medical management
3. Surgical management
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Management of Postpartum Hemorrhage
1. Tamponade
2. Medical management
3. Surgical management
Management of Postpartum Hemorrhage
1. Tamponade
2. Medical management
3. Surgical management
a. Temporizing measures
a. Compression sutures, devascularize the uterus
b. Embolization
c. Definitive treatment – hysterectomy
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Gilmandyar et al, Seminars in Perinatology, February 2019
Anti-shock garment
https://www.viaglobalhealth.com/product/non-pneumatic-anti-shock-garment/
NASG vs Standard Care to prevent maternal mortality
Pileggi-Castro et al., 2015
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Case Two• 37 year old G4P1112 @ 392 presents for scheduled rCS
• Uncomplicated delivery of infant
• Placenta “feels a little stuck”, but delivers with manual effort
• Exteriorize the uterus
• The uterus looks like a floppy pancake & very thin at fundus
• What do you do?
Cases
• Despite correctly managing both patients, they continue to
bleed
• Hypotensive
• Tachycardic
Access
• Two large bore IVs
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Massive Transfusion
• Do you have a protocol?
• Is your blood bank onsite?
Massive Transfusion Considerations
• Each obstetric unit should have a multidisciplinary massive
transfusion protocol
• If resources allow, consider having 1-2 coolers of emergency
blood available at all times
• Use simulation to troubleshoot barriers before an actual
emergency
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Example of massive transfusion protocol
WOMAN Trial
WOMAN Trial•Randomized, placebo-controlled trial
•20,060 women
• TXA, n= 10,051; Death, n = 155 (1.5%)
• Placebo, n = 10,009; Death, n = 191 (1.9%)
• RR 0.81, 95% CI 0.65 – 1.00, p = 0.045
•VTE events similar between groups
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TXA Mechanism
• Fibrinolytic antagonist
• Binds to lysine residues in plasminogen and plasmin
preventing plasmin activation
MFMU Tranexamic Acid Trial
• Tranexamic acid for the prevention of obstetrical
hemorrhage after cesarean
• RCT of 11,000 women to assess whether TXA prophylaxis
reduces the risk of PPH among women undergoing cesarean
delivery
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Preventing Maternal Death
• Of the 10 clinical diamonds, 6 involve postpartum
hemorrhage
Preventing Maternal Death
•Angiographic embolization is not meant to
be used for acute, massive postpartum
hemorrhage.
Preventing Maternal Death
•If more than a single dose of medication
is necessary to treat uterine atony, go to
the patient’s bedside until the atony has
resolved.
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Preventing Maternal Death
•Never treat “postpartum hemorrhage”
without simultaneously pursing an
actual clinical diagnosis.
Preventing Maternal Death
•In the postpartum patient who is
bleeding or who recently has stopped
bleeding and is oliguric, furosemide is
not the answer.
Preventing Maternal Death
•Any woman with placenta previa and
one or more cesarean deliveries should
be evaluated and delivered in a tertiary
care medical center.
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Preventing Maternal Death
•If your labor and delivery unit does not
have a recently updated massive
transfusion protocol based on
established trauma protocols, get one
today.
Blood component processing, Kogutt et al, Seminars in Perinatology, February 2019
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https://www.smfm.org/data/mortality-map