Robin Jankiewicz CRNA DNP Compose a plan of

Robin Jankiewicz CRNA, DNP

§Compose a plan of your own for antepartum and postpartum hemorrhage §Case review discussions § Discuss disseminated intravascular coagulation within the parturient

§ American College of Obstetricians and Gynecologists places the estimate at 140, 000 maternal deaths per year or 1 woman every 4 minutes. § The direct pregnancy-related maternal mortality rate in the United States is approximately 7 -10 women per 100, 000 live births. National statistics suggest that approximately 8% of these deaths are caused by PPH. § In industrialized countries, PPH usually ranks in the top 3 causes of maternal mortality, along with embolism and hypertension.

§ Half a million women world wide die annually from postpartum hemorrhage - TOP 3 RD CAUSE § Uterine contraction is the main means by which hemorrhage is contained § Myometrium surgery and previous C-section increased risk 6. 5% § Vaginal delivery is associated with a 50% reduction in hemorrhage risk – 4% § 1 -5% of all vaginal deliveries have bleeding greater than 1000 ml with a corresponding 3 -4 gm hemoglobin decrease. § Underestimation of postpartum bleeding is common

Blood loss > 500 ml at vaginal delivery > 1000 ml at Cesarean ACOG 10% drop in hematocrit Need for blood transfusion Severe PPH > 1000 ml loss at vaginal delivery

§ Early cumulative EBL > 1000 ml § Occurs unpredictably in normal deliveries § Complications of Postpartum hemorrhage include: § Hypovolemic shock & Tachycardia § Hepatic failure § Renal failure § Denial and delay – Masked in the maternal changes of pregnancies § Obstet Gynecol 2015; 125: 938 -47

§ Retained placenta (OR 3. 5, 95% CI 2. 1 -5. 8) § Failure to progress during the second stage of labor (OR 3. 4, 95% CI 2. 4 -4. 7) § Placenta accreta (OR 3. 3, 95% CI 1. 7 -6. 4) § Lacerations (OR 2. 4, 95% CI 2. 0 -2. 8) § Instrumental delivery (OR 2. 3, 95% CI 1. 6 -3. 4) § Large-for-gestational-age (LGA) newborn (OR 1. 9, 95% CI 1. 6 -2. 4) § Hypertensive disorders (OR 1. 7, 95%CI 1. 2 -2. 1) § Induction of labor (OR 1. 4, 95%CI 1. 1 -1. 7) § Augmentation of labor with oxytocin

§ Recognition and prevention § Assessment of risk § Precise measurement of EBL § Active management of 3 rd stage by OB § Anesth Analg 2015; 121: 142 -48

§ Problem 1: Almost 50% of deliveries lose >500 ml of blood. § Problem 2: Estimated blood loss is often less than half the actual blood loss. § Problem 3: Most of the serious causes of “PPH” have origins prior to the end of the 3 rd Stage of labor. § Problem 4: PPH, as defined, is technically misdiagnosed and clinically irrelevant.

§ Underestimation leads to delayed intervention. § Visual estimated amounts of blood loss are far from accurate by as much as 30 -50%: especially for very large amounts. § Old methods for estimating blood loss tend to be complex. § weighing soaked clothes and pads, collection into pans etc. , § Acid haematin techniques § Spectrophometric technics and measuring plasma volume changes

CAUSES OF PPH FOUR “ T”S TONE TRUAMA TISSUE RETENSION THROMBIN

§- Uterine over distension § Polyhydramnios, Multiple gestations, Macrosomia § Prolonged labor: “uterine fatigue” § Precipitous labor § High parity § Chorioamnionitis § Retained products of conception § Halogenated anesthetic – it’s always us!

Uterine Rupture - Lacerations of the Birth Canal - Operative Trauma Cesarean sections Episiotomies Forceps, Vacuums, Rotations

§ Placenta Previa - Abruptio Placentae - Accreta, increta, percreta - Vasa previa

- Sepsis - Amniotic Fluid Embolism - Abruptio Placentae associated coagulopathy - HELLP Syndrome - Dilutional Coagulopathy - Inherited Clotting Disorders - Anticoagulant Therapy

§ Oxytocin – with delivery or post § Cord traction – continuous tension & gentle pull with contractions § Uterine massage

§ Hemorrhage cart § Hemorrhage meds – immediate access § Response team § Transfusion protocol § Unit based drills

§ Arterial line early – BP, pulse pressure, respiratory variation & serial sampling – ABG w/Hct, T&C, Coags, TEG § Temperature – warming blanket & fluid warming measures § Vasopressor support § Rapid infuser – pressure bags & Level 1 § 2 Large bore IV’s – Consider IO’s

§ California Maternal Quality Care Collaborative, identified obstetric hemorrhage as the leading cause of maternal mortality in California (2002 -2004) and a cause of death with significant prevention potential. § System level readiness § Carts, Kits, and Trays * § Simulation and Drills (includes debriefing) * § Sample Massive Transfusion Protocol * § Sample Emergency Transfusion Protocol * § Education * § Patient level readiness § Placenta Accreta and Percreta § Coagulation Disorders § Planning for women (Jehovah’s Witness and others) who may decline transfusion

§Stage 0 Every woman in labor/giving birth §Stage 1 Blood loss: > 500 ml vaginal or >1000 ml Cesarean, or VS changes (by >15% or HR ≥ 110, BP ≤ 85/45, O 2 sat <95%) §Stage 2 Continued bleeding with total blood loss under 1500 ml §Stage 3 Total blood loss over 1500 ml, or >2 units PRBCs given or VS unstable or suspicion of DIC

§ Low Risk: § �� No previous uterine incision § �� Singleton Pregnancy § �� < 4 previous vaginal births § �� No known bleeding disorder § �� No history of PPH § Hold Specimen Medium Risk: �� Prior c/s or uterine surgery �� Multiple gestation �� > 4 previous vaginal births �� Chorioamnionitis �� History of previous PPH �� Large uterine fibroids Type and Screen High Risk: �� Placenta Previa, or low lying �� Suspected accreta or percreta �� HCT < 30 AND other risk factors �� Platelets < 100, 000 �� Active bleeding on admit �� Known coagulopathy

q. Readiness: (every unit) q Hemorrhage Cart / with Procedural Instructions (balloons, qcompression stiches) q Rapid access to hemorrhage medications (kit or equivalent) q Establish a response team: multiple partnerships // unit education, drills, debriefs q Establish MTP and 0 -neg/uncross matched transfusion protocols

q Recognition: (every patient) q Assessment of hemorrhage risk (prenatal, on admission, ongoing in labor & PP) q Measurement of CUMMULATIVE blood loss q Active Management of 3 rd Stage (oxytocin after birth)

Active management with oxytocin infusion of 10 -40 units/5001000 m. L titrated; or 10 units IM § Action § �� Quantitative evaluation of cumulative blood loss: use of graduated containers, visual comparisons, and weighing blood soaked materials after delivery of placenta. 1 gm = 1 m. L § �� Ongoing evaluation of vital signs per hospital protocol; more if needed per patient condition. § ��

§ Continued bleeding and Blood loss: > 500 ml vaginal or > 1000 ml C/S, OR VS changes (by >15% or HR > 110, BP < 85/45) sat < 95% OR increased bleeding during recovery period. § Mobilize § �� Notify OB/CNM § �� Notify Charge RN § �� Notify Anesthesia provider § Actions § Establish 16 g IV Infuse oxytocin 500 m. L/hr. (10 -40 units/500 -1000 m. L) § Weigh and calculate blood loss Administer 02 to keep sats >95% § Empty bladder – foley with urimeter Type and Cross for 2 units PRBCs § Keep patient warm Vigorous fundal massage § Administer 2 nd uterotonic Vital signs including 02 sat q 5 minutes

§ Continued bleeding or Vital Sign instability, and < 1500 m. L cumulative blood loss § Mobilize § �� OB/CNM at bedside; 2 nd OB or perinatologist & anesthesiologist called to assist; § �� Charge nurse: assign recorder and runner, notify nursing supervisor, call radiology to prepare for IR if available, and call for second anesthesiologist § �� Notify Rapid Response Team § �� Assign a 2 nd RN to communicate with blood bank and offer family support § Actions § �� Administer hemabate or misoprostil § �� Move to OR § �� Transfuse 2 U PRBC (do not wait for lab results); blood warmer; request for blood bank to thaw FFP § �� Order STAT CBC/plts, Chem 12, Coag panel, and ABG § �� Start 2 nd IV § �� Weigh & calculate cumulative blood loss § �� Announce vital signs § �� Ready essential equipment.

§ Cumulative blood loss > 1500 m. L, > 2 U PRBCs given, VS unstable or suspect DIC § Mobilize § �� Activate Massive Transfusion Protocol § �� Notify GYN/Onc Surgeon § �� Call in OR staff (anesthesia assist) § �� Call in supervisor, CNS, Manager § �� Blood bank to stay ahead of blood products § Actions § �� Announce VS and cumulative blood loss § �� Assist anesthesiologist with art line, PA or § CVP line, or intubation. § �� Use fluid warmer and/or rapid infuser § �� Keep patient warm. § �� Apply sequential. compression stockings to lower extremities. § �� Repeat labs q 30 -60 minutes.

§ Packed Red Blood Cells (PRBCs) Best first line product 1 unit = 200 ml volume �If antibody positive, may take § § § 1 -24 hrs for crossmatch Fresh Frozen Plasma (FFP) Approximately 35 -45 min to thaw �� Highly desired if > 2 units PRBCs given, or for prolonged PT, PTT �� 1 unit = 18 ml volume Platelets (PLTs) �� Priority for women with platelets < 50, 000 �� Single—donor apheresis unit (= 6 units of platelet concentrates) provides 40 -50 K transient increase in platelets Cryoprecipitate (CRYO) �� Approximately 35 -45 min to thaw �� Priority for women with Fibrinogen levels< 80 �� 10 unit pack raises Fibrinogen 80 -100 mg/dl �� Best for DIC with low Fibrinogen and don't need volume replacement �� Caution: 10 units come from 10 different donors, so infection risk is proportionate �� Warm upper body with blankets or warming device �� Sequential compression stockings

§ In an OB hemorrhage event the blood bank needs to have the following available: § Six units of blood, Four units of FFP and One unit of apheresis platelets § 6: 4: 1 rule replaces approximately 70% of total RBC § volume and 60% of the total circulating plasma volume of a 70 kg adult § Approximates whole blood with a HCT of 40%

§ Results from the disruption in homeostasis § Activated clotting cascade § Widespread thrombosis § Depleted coagulation factors and platelets § Excessive thrombolysis § Hemorrhage – thrombosis – multi-organ failure

§ Prevalence: § Pregnancy is not an independent predictor of DIC § Complications in pregnancy are predictors of DIC § Aminonic fluid embolism (66%) § HELLP (21%) § Placntal abruption (37%) § Postpartum hemorrhage (29%) § Acute fatty liver of pregnancy (8%) § Fetal demise

§ Systemic hemostasis in DIC § Elevated coagulation factors § Decreased anticoagulation factors § Specific pathology § Placental decidual cells lining the endothelium § Tissue factor release thrombin generation fibrin formation clotting § DIC: Excess thrombin formation wide spread fibrinolysis § Depletion of coagulation facotrs and platlets

§ Amniotic fluid & fetoplacental tissue § Increased procoagulation and anticoagulants § Injurious states: HELLP/Pre-clampsia/Fatty liver § Hemorrhage alone does not cause DIC § Injury § Disease § Elevated response to coagulants/anticoagulants

§ Parturient with complications § Severe bleeding § Signs of shock § Organ dysfunction

§ Thrombocytopenia § Prolonged PT/a. PTT/INR § Decreased fibrinogen § Increased D-dimer § Prolonged thrombin time § Assessing DIC – serial testing – CBC, Coags, Chemistry & LFT’s § Fluid loss – UOP & EBL

§ Point system assessments: § ISTH – The International Society of Thrombosis & Haemostasis § JAAM – The Japanese Association of Acute Medicine § 93 -98% Sensitivity/Specificity for DIC § PLT § D-Dimer § PT § Fibrinogen

§ Balance decision based on welfare of the fetus vs. delivery § Identify & treat contributing factors § Communicate concerns/call for help § OR § Rapid response § ICU § Trauma team § Anesthesia § Blood Bank

§ Emergency release blood products vs. crossmatch products § Blood product administration § PRBCs, FFP, PLT, Cryoprecipitate § Initial crystalloid fluid resuscitation § Prepare for massive transfusion

§ Massive transfusion considerations § Ratio: 1: 1: 1 for RBC, FFP, PLT § Products: § PRBC: acute anemia/hypovolemia § PLT: thrombocytopenia § <100 K vs. <50 K § FFP: hypovolemia / elevated coagulation values § INR>1. 5 § Cryoprecipitate: decreased fibrinogen § <200 mg/dl with supporting clinical information § <100 mg/dl

§ Normothermia § Invasive monitoring § Ventilation support § ICU

§ DIC profile may last days ( fatty liver of pregnancy) § Appropriate treatment – rapid improvement in coagulopathy § Significant morbidity with prolonged resuscitation § Neurological deficits

§ 30 y. o. – 38 weeks, G 3 P 2 § Hx. of SVDx 2 without complications § Found by good Samaritan as patient was collapsed in her garden § Brought to small (CAH) hospital § Found to have fetal demise and possible placental abruption § Life flight from tertiary center summoned & responded § Initial resuscitation started in transport

§ Life flight crew communication – 2 units of PRBCs given § Patient to OB – direct entry to operating room from ED § Patient evaluated in OR – prep for immediate induction § MSMAID § 1 -18 g & 1 -20 g IV § Belmont repid transfusion device § Cross matched: 4 - PRBC, 4 – FFP & PLT (shortage) § GETA with RSI/CCP without difficulties

§ Surgical incision: complete uterine rupture and fetal demise confirmed § Labs drawn & IV fluid/blood products initiated § Help provided by 2 ICU RNs for blood product “running” & other assistance § Labs: 19> 10/30 <104 Chem: 137/4. 6 – 114/16 – 14/0. 9<82 § IVF: § NS 3000 LR: 500 § PRBC: 2 units § FFP: 4 units § Labs redrawn

§ Clinical significance: § VS stable § Surgical field “oozing” § Pt normothermic and skin was pale throughout the case § Case completion: § Pt hemodynamically stable § ICU attending /report – fibrinogen <35 mg? dl with cryoprecipitate ordered § Surgical hemostatis noted / JP drains § Pt extubated & transported to ICU