SCCM Resource Library-Obstetric Hemorrhage for the Intensivist: Stopping the Major Cause of Global Maternal Mortality

Video Transcription

Welcome to the 51st Critical Care Congress of Society of Critical Care Medicine 2022. I'm going to talk about Obstetric Hemorrhage for the Intensivist.  I'm Dr. Raja Ram, Professor of Medicine at Sydney Camel Medical College of Thomas Jefferson University and a Critical Care Intensivist Lead at Morristown Medical Centre.  So Obstetric Hemorrhage for the Intensivist, how to stop the major cause of this global maternal mortality. Obstetric Hemorrhage worldwide.  So Obstetric Hemorrhage is a major cause of maternal mortality in developing countries mainly and it accounts for more than 50% of 300,000 maternal deaths globally.  One death occurs every seven minutes because of Obstetric Hemorrhage and the blood loss is very difficult to accurately estimate, especially in the developing countries.  And accurate incidence and prevalence reporting is all very difficult due to lack of standard definitions worldwide.  So the most common etiology is uterine atony for postpartum hemorrhage and main part of the Obstetric Hemorrhage.  There are increased number of cesarean deliveries nowadays, which has led to the dramatic increase in morbidly adherent placenta or placenta accreta.  Because of the number of cesarean deliveries has increased, the hemorrhage has increased. And placenta accreta, which confers a high risk of hemorrhage and emergency hysterectomies  as well. Let's talk about some definitions here. So what is postpartum hemorrhage? It's more than 1000 ml of blood loss regardless of the route of delivery or if a blood loss  is accompanied by signs and symptoms of hypovolemia, then you call it as postpartum hemorrhage. So postpartum hemorrhage, which occurs within the first 24 hours of delivery.  There are secondary postpartum hemorrhage, which can occur up to 12 weeks from 24 hours to 12 weeks, almost three months of postpartum, which accounts for about one to three percent  of the postpartum hemorrhage. And you call it as a major hemorrhage if your blood loss is more than 1500 ml.  Okay, let's try and understand some physiology and pathophysiology of a utero placental unit, which is very important.  So when placenta invades the endometrium, there are average of 120 spiral arteries, which penetrate through the myometrium to perfuse the placenta.  So during a normal birth, the placenta, which separates from the uterus because of the myometrial  contraction, which compresses and provides a tamponade effect of the spiral arteries, you don't have major hemorrhage.  Many factors are also activated normally and effectively plug these spiral arteries. So this subsequent uterine remodeling, which eliminates the spiral arteries over the course  of several weeks from a normal delivery. So what can go wrong in this utero placental unit? There are four major abnormalities.  The four T's we call it as Tone, Tissue, Thrombin, and Trauma. So what are the four T's, Tone, Tissue, Thrombin, and Trauma?  The most common cause of the postpartum hemorrhage is deficiency in the tone or failure of the uterine contraction to compress and tamponade the spiral arteries, so uterine atony.  Number two is the retained placental membrane tissue, which impairs the myometrial contraction. Number three is the deficiency in the clotting factors or thrombin.  And the fourth one is the trauma from childbirth. There are large lacerations can happen of the cervix or vagina, which can cause excessive blight loss.  And very rarely other causes such as uterine inversion, arteriovenous malformations, or other structural abnormalities, which may contribute to postpartum hemorrhage.  So in summary of this utero placental units, which is part of the normal postpartum mechanism, the placenta is removed and exposes the spiral arteries and bleeding starts.  And the uterine myometrial compression, which causes mechanical tamponade and clots are formed to occlude these spiral arteries.  And the uterine remodeling and apoptosis, that is a programmed cell death of the spiral arteries happens and hemorrhage comes to a halt.  So let's talk about the obstetric hemorrhage now. The postpartum hemorrhage, which is called as accumulative blood loss of more than 1000  ml, blood loss, or even more than 500 ml in vaginal delivery should be considered abnormal.  Or any blood loss, which is over 500 ml, which is accompanied by signs and symptoms of hypovolemia,  blood loss, within the first 24 hours after birth is called postpartum hemorrhage. And which is the leading cause of maternal mortality worldwide.  And the incidence is about 4 to 6% in normal deliveries, up to 10% in cesarean deliveries.  So the obstetric hemorrhage, the four Ts associated with this postpartum hemorrhage is the most common cause of hemorrhage, as well as some antepartum causes of hemorrhage.  Let's start with the antepartum hemorrhage diagnosis. So how do you diagnose is antepartum hemorrhage is mainly by ultrasound.  So this, the first trimester antepartum hemorrhage, common cause is ectopic pregnancy or pregnancy outside the uterus, which complicates about 1 to 3% of pregnancies.  So the ectopic pregnancy, you develop hemoperitoneum or hemorrhagic shock. Patient present with amenorrhea, abdominal pain, and vaginal bleeding, you do an ultrasound  and beta HCG levels quantitatively to help in your diagnosis. And surgery is the gold standard of therapy or expected management with methotrexate may  be considered in selected cases. Antepartum hemorrhage during advanced pregnancy, what happens?  This is after first trimester, there's abnormal placentation is a major cause of antepartum hemorrhage.  Placenta previa, that means placenta is located over or near the internal cervical loss or  placental abruption, that is premature separation of the placenta from the uterus, typically occurs after a traumatic event.  The timing of delivery, a course of antenatal steroids and antenatal transfusion and antepartum  admissions are crucial in the management of this antepartum hemorrhage during advanced pregnancy.  So in obstetric hemorrhage, let's talk about the etiology and a summary, both antepartum and postpartum causes.  Antepartum causes obviously placental abruption, placenta previa, those are in advanced pregnancies  and first trimester ectopic pregnancy, trauma can happen anytime, especially in advanced pregnancy, cause uterine rupture.  Postpartum causes, uterine atony is the most common cause, tissue, the retained products  of conception, thrombin, which is coagulopathy, and trauma, especially genital tract lacerations and other causes such as uterine inversion and AV malformations can cause postpartum  hemorrhage. So what are the clinical presentations of this obstetric hemorrhage? You can present antepartum, intrapartum or postpartum or during vaginal delivery or operative  vaginal delivery, cesarean delivery or postpartum up to three months during readmissions. So summary of early pregnancy hemorrhage, five major causes at the end for bleeding  during early pregnancy is ectopic pregnancy, early pregnancy loss with threatened or impending  abortions, physiological related to implantation of the pregnancy, cervical vaginal or uterine  pathology can cause bleeding such as polyps, any inflammation or infection can result in early pregnancy hemorrhage or gestational trophoblastic disease.  So ruptured ectopic pregnancy can result in severe hemorrhage and death. So transvaginal ultrasound is the cornerstone of the evaluation of bleeding in early pregnancy.  As pregnancy advances, the causes are you can have a bloody show associated with labor.  By definition, labor occurs after 20 weeks of gestation or less commonly from a cervical insufficiency.  Pregnancy loss, which is defined as loss between 14 and 20 weeks of gestation or placenta previa. The clinical features are absence of abdominal pain and uterine contractions.  So you diagnose it with vaginal ultrasound. Placental abruption, which is premature separation of a normally implanted placenta prior to birth.  So the risk factors for placental abruptions are prior abruption during pregnancies or history of  trauma or smoking history, cocaine use, hypertension, preterm, pre-labor and rupture of membranes are risk factors. Uterine rupture is very rare, can happen during trauma.  And vasoprevia is also a very rare cause of obstetric hemorrhage. Fetal blood vessels, which are present in the membranes of the internal os, cervical os,  and rupture of these vasoprevia lead to fetal death and exsanguination of the fetus. So the risk factors for this vasoprevia is multiple gestation or in vitro fertilization.  So these are other causes of obstetric hemorrhage.  This is a slide which is summarizing the risk factors. So uterine atony, if you have prolonged oxytocin or high parity,  chorioamnionitis, inflammation or infection, general anesthesia use or fibroids or uterine  overdistension with multiple gestation, polyhydramniosis or macrosomia can be high risk factors for uterine atony.  Retained placenta, if you have a succentuate lobe or previous uterine surgery is a risk factor.  Trauma, obviously, is operative vaginal delivery or during a PCOTomy or if you have a precipitous delivery, uterine rupture, these are traumatic incidences.  And coagulopathy, when you have placental abruption, you can have coagulopathy, preeclampsia or severe infection or inherited coagulopathies are risk factors.  And uterine inversion, which is fundal placenta and excessive cotraction can be a risk factor for  uterine inversion. So how do you diagnose this? There are some early maternal warning criteria. If your systolic blood pressure drops less than 90 or even more than 160 or diastolic  blood pressure more than 100, that's hypertension, preeclampsia, heart rate goes less than 50 or more  than 120. If your breathing rate goes less than 10 or more than 30, oxygen saturation on room air  or at sea level drops below 95 percent. Or if you develop low urine output, oliguria,  for more than two hours, less than 35 ml per hour, that's oliguria. Or if you develop maternal agitation, confusion or unresponsiveness in patients, especially with preeclampsia,  they are reporting non-remitting headaches, shortness of breath. Those are early maternal  warning signs. So evaluation is very important. We must mobilize the obstetric hemorrhage team  and we should determine the etiology of the hemorrhage. General evaluation, especially insert  a Foley catheter, evaluate the vital signs, heart rate, blood pressure and pulse oximetry and pelvic and genital examinations. We should identify the site and the severity of the  bleeding. Initiate interventions to control bleeding. Digital examination of the cervix should be avoided in patients presenting with bleeding in the second half of the pregnancy  until placenta previa has been excluded by an ultrasound exam. Digital examination of this placenta previa can cause immediate and severe hemorrhage. Evaluation and disposition are  essential. So in evaluation, we're going to do hemoglobin, hematopoietin, platelet counts,  coagulation profile, electrolyte panels, arterial blood gas, type and cross-match for blood products  and consider thromboelastometry, lactic acid and ionized calcium if available,  an abdominal ultrasound or performing digital exploration of the uterus for any products of conception during advanced pregnancy. If you have an endometrial stripe more than two  centimeters on the ultrasound in the surgical plane, that is suggestive of products of conception  and adequate monitoring and disposition either to a surgical unit or surgery or interstitial care  unit are paramount important. So the key points in evaluations are obtaining vital signs and attempt  to estimate the blood loss. In cases of postpartum hemorrhage, we must call for an obstetric rapid  response team as intensivist and perform pelvic and general physical exams, order the lab test,  abdominal ultrasound and provide monitoring and appropriate disposition either patient goes to the  operating room or intensive care unit. This is an important slide, how to evaluate the hemorrhage.  Degree of hemorrhage is one, if you have estimated blood loss is about 500 to 1000 ml,  15% of the blood is lost from the person and you don't get any signs sometimes, so just  rarely palpitations can happen. If you have stage two hemorrhage, about 1200 to 1500 ml blood is  lost, about 20 to 25% of the blood is lost, patient develop minor tachycardia, tachypnea,  narrow pulse pressure and postural hypotension. When you advance to stage three, about 1800 to  2100 ml blood is lost, that means 30 to 35% of the blood is lost, patient develop hypotension,  tachycardia, more than 120 beats per minute, tachypnea, cold extremities and oliguria develops.  We have a major fourth degree hemorrhage that more than 2400 ml blood is lost,  40% of the blood is lost, profound shock and altered mental status or consciousness happens.  These are some examples of definitions of postpartum hemorrhage worldwide, WHO says more than 500 ml within 24 hours after birth and if it's severe blood loss more than  1000 ml within the same time frame. American College of Obstetricians and Gynecologists has  a similar, a little different definition and Royal College of Obstetricians and Gynecologists and  International Expert Panel and Society of OBGYN of Canada and California Maternal Quality Care  Collaborative all have these definitions almost coming up to the similar staging type and the  amount of blood loss which you could review. Let's talk about some laboratory studies, hemoglobin, hematocrit and platelets are essential, coagulation profile is very important,  electrolyte panels must be sent, type and cross match of the blood products, ionized calcium and lactate measures are very helpful and you could consider thromboelastography  if it is available. This is a sample of the thromboelastogram if it is available,  it gives you the clotting time, clot formation time and the amplitude within 10 minutes after  the clotting time and maximum clot firmness and lysis index and maximum lysis all can be  seen in this thromboelastogram. So the thromboelastography or TEG method is a method of  testing the efficiency of the blood coagulation especially during the hemorrhage time. These are  a variety of pictures of the characteristics of the TEG waveform and the amplitude in minutes  and the firmness of the clots and how to interpret the TEG tracing and also the TEG values help to  help the clinicians to transduce appropriate blood products. If the TEG ACT is more than 140,  you could give FFP or R time is more than 10, give FFP, K time is more than 3, give cryoprecipitate.  If your alpha angle is less than 53, give cryoprecipitate plus or minus platelets  and MA is less than 50, give platelets and then LY30 is more than 3 percent, you can use  10-hexamic acid. These are some recommended transfusion strategies based on the TEG,  just be aware of it. This tool is available in certain parts of the world.  So this is a picture of the retained products of conception and you can see that the uterine wall  is here and the retained products of conceptions are here and ultrasound or sagittal or transverse  planes looking for retained products of conceptions. If you see more than two centimeters of the uterine  content, if you find it in the ultrasound, a digital or instrumented removal of these products  are essential to prevent bleeding. If ultrasound is not readily available, digital exploration of  the uterine cavity should be performed. Just a summary of the differential diagnosis, so uterine atony, 80 percent of the cases of postpartum hemorrhage is responsible  for uterine atony and a physical exam of the genital tract trauma, a thorough inspection of  the uterus, cervix and vagina and repair of the bleeding lacerations and ligation of the vessels  are essential. Ultrasound which helps you diagnose retained placental products and lab studies,  coagulopathy, correction of the fibrinogen and coagulation factors are very essential.  Thromboelastography may help in the diagnosis of coagulopathy and guide expedited therapy.  Let's move on to the management. The management is a multidisciplinary team approach. The ABCD interventions are essential, airway breathing circulation, disposition and delivery,  evaluation and expert interventions are crucial. So you ensure and maintain a patent airway,  oxygen at high flow can be used, IV access above the diaphragm have at least two peripheral veins  with a large bovine catheters, at least 16 to 18 gauge IVs during hemorrhage, IV fluids,  ringers lactate, lactated ringer solution or normal selene and transfusion of blood products.  You can administer cross-matched blood and if cross-matched blood is not readily available,  give type O RH negative packed RBC red blood cells and there's massive hemorrhage institute  massive transfusion protocol. So if you have signs of hypovolemia, you should activate the massive transmission protocol.  If you look at the placenta and uncontracted uterus, and there is blood from the severe vessels of the placenta, this is postpartum hemorrhage.  Patient developed tachycardia, hypotension, mental status changes, and considerable blood loss has occurred.  If you have 25% of the maternal blood volume is lost, about 1500 ml, then you should activate the massive transfusion protocol. So what is massive transfusion protocol?  If you have a blood loss more than 1500 ml, if you have signs of hypovolemia, coagulopathy and ongoing bleeding, you have to activate the MTP or massive transfusion protocol.  Fluid and transfusions. So crystalloid IV fluids and avoid starches, that's very important. Excessive fluid resuscitation also may cause coagulopathy state and renal failure.  So you need to be careful. IV crystalloid boluses are recommended, 500 cc to 1000 ml. The goal is to maintain your systolic blood pressure more than 80 mmHg or mean arterial  pressure more than 60 mmHg.  And the urine output goal is to maintain more than 0.5 ml of urine per kg per hour and normal level of consciousness. These are the goals for crystalloid volume resuscitation.  And the transfusion goal is transfuse the patient in 1 to 1 to 1 ratio. What it means is one unit of PRBC, one unit of plasma, and one unit of platelets in that ratio.  And also correct the patient's hypothermia, coagulopathy, acidosis, and hypocalcemia. Massive transfusion protocols in obstetric patients, the evidence shows there's improved  survival and reduction in the multiple organ failure. So again, our resuscitation goal should be stop the bleeding as quickly as possible with  the systolic blood pressure above 80 or MAP above 60, heart rate less than 120 per minute, and temperature more than 35 or 95 degrees Fahrenheit.  Hemoglobin goal above 7 mg per deciliter with a hematocrit goal above 21%, and a platelet goal above 50,000 per microliter.  And your international NINR ratio is less than 1.5, and the fibrinogen level is more than 200 mg per deciliter, and pH more than 7.2 to correct the acidosis, and correct the  ionized calcium to more than 1 millimoles per liter, and get the lactate levels below 2 millimoles per liter. These are our ultimate resuscitation goals.  So the optimal resuscitation strategy in major hemorrhage is if you have grade 3 or grade 4 hemorrhage, patients can die from multiple organ failure.  Early aggressive resuscitation is crucial, and fluids to maintain tissue perfusion and bleeding site control and blood products are key.  Crystalloids are effective in restoring the volume, but crystalloids can contribute to hemodilution and can decrease the oxygen transportation.  So crystalloids are not effective in prevention and correction of coagulopathy. So the restricted crystalloid strategy and early administration of blood products are important.  There's something called a permissive hypotension in postpartum hemorrhage only, which has improved  patients' outcomes, compared to conventional aggressive resuscitation with the fluids until the bleeding site is under control.  Increase in intravascular hydrostatic pressure associated with the rapid infusion of fluids can loosen the fresh blood clots.  That's where the permissive hypotension or restricted crystalloid strategy is important.  What are other strategies to tackle the main cause of postpartum hemorrhage, which is uterine atony? Active management of the third stage of labor can prevent hemorrhage.  Uterine contraction is paramount to tamponade the intramyo-material arterioles that perfuse the placenta.  So you could use medications to manage the uterine atony, such as oxytocin, methyl ergonovine, and prostaglandin 2-alpha.  Methylpropylene E2 and mesopristol are commonly used off-label uses for postpartum hemorrhage. This is a summary slide for medical management of the uterine atony.  So if you look at oxytocin, which can be used 10 units IM or 10 to 40 units in half a liter  of saline or ring-elacted solution as infusions at 125 ml per hour, can be used continuously. No contraindications, it can cause nausea, vomiting, or water intoxication as some side  effects. Methylergonovine, 0.2 mg IM, every 2 to 4 hours can be used. And contraindications are hypertension and preeclampsia, because the side effects can  be hypertension or hypotension and nausea, vomiting. Prostaglandin F2-alpha is 0.25 mg IM, can be used every 15 to 90 minutes, maximum doses about 8 doses.  And contraindication in asthma patients, nausea, vomiting, diarrhea, fever, headaches, and other side effects.  Prostaglandin E2 is 20 mg suppository, either vaginal or rectal suppository, can be used every 2 hours.  Hypotension is a contraindication, again nausea, vomiting, diarrhea, fever, shivering, and headaches can happen as side effects.  Misoprostol is 800 to 100 mg rectal dose, single dose, no real contraindications, shivering and fever, diarrhea can happen.  Just a summary slide about fluid management, lactator ringer solution as the initial fluid  of choice, resuscitate to our goals we discussed, and allow permissive hypotension until hemostasis or postpartum hemorrhage only in this one, not for antepartum hemorrhage.  And avoid over resuscitation with crystalloids, which leads to fluid overload complications as well as dilution coagulopathy. And early transfusion as necessary is important.  So what are the complications of this fluid overload? In brain it can cause edema and altered level of consciousness, in heart it can cause conduction  disturbances, diastolic dysfunction and worsen the contractility, lungs obviously edema and increase the respiratory load, in liver change in the synthesis and cholestasis, kidneys  it can increase in the venous pressure, edema, reduced blood flow to the kidneys and reduced filtration rate, increased interstitial fluid pressure and uremia can develop, intestine  poor absorption and leaks can develop, subcutaneous tissue obviously edema, change in the lymphatic  drainage, change in scarring and injury and infection can happen with fluid overload. So hemostatic resuscitation, the interventions are designed to restore the intravascular  volume, maximize the oxygen transportation ability and to correct the coagulopathy. So it consists of three fundamental aspects.  We should limit aggressive use of crystalloid in resuscitation, taking into account permissive hypotension to the goals of resuscitation.  This is mainly postpartum hemorrhage and administer fresh frozen plasma early in conjunction with  red blood cells and platelets of pharesis at a ratio of 1 to 1 to 1 ratio and consider use of hemostatic agents such as tranexamic acid and factor VIIa in refractory hemorrhage.  So what is tranexamic acid which is a synthetic antifibrinolytic which does not require cold  storage or refrigeration. It's shown to reduce death from postpartum hemorrhage. The dose is  about one gram intravenously given, can be repeated if bleeding continues or resumes within  24 hours. This is from the women's trial studied about 20,000 women in 193 hospitals over 21 countries and that study found a one-third decrease in deaths from postpartum hemorrhage  compared to 1.2 percent compared to 1.7 percent in addition compared to the placebo groups. So use of tranexamic acid did not prevent hysterectomies because in many low-income  countries or poor resource nation countries do not have access to blood or intensive care unit  or full array of pharmacopoeia so it makes the hysterectomy as far more aggressive compared to  high-income countries. That brings us to surgical management. So when medical management fails or  of bleeding is secondary to another reason and you need definitive control of the bleeding and you attempted minimally invasive interventions with sequential escalation  to more invasive interventions and least to most invasive a sequential approach is recommended  when the patient's hemodynamic stability and the clinician surgical capacity permits,  the surgical management or this approach results in shorter surgical times, less bleeding during  the procedure and fewer overall complications like a sequential approach towards surgical  management. So the success rates for surgical procedures if you look at that balloon temponade which is about 84 percent successful the complications are cervical laceration and  extension compression sutures 91.7 percent success rate rare complications uterine artery  ligation is 89 percent successful rare complications that can happen hypogastic artery ligation 40 to  60 percent success rate infertility injury to the pelvic or other vessels ureteral injury can happen  and uterine artery embolization 90 percent successful but infertility is possible and subsequent pregnancy may be complicated. This is an example of the intrauterine balloon  for temponade. So the top is inflated and the bottom is deflated and most have a port to release  the intrauterine blood also so it's important it should be filled with water or isotonic saline  and do not fill with air that's important this is the intrauterine balloon for temponade.  This is an example of uterine temponade balloon or Bakri balloon you can see that the blood can  accumulate above there around the uterus and the success depends on a positive temponade.  So the commonly this balloon maximum inflation is about 500 ml and we use ultrasound for placement  tension on the distal end and left in place for 12 to 24 hours. In resource poor countries a  Foley catheter was used as a tool for uterine temponade also which is very successful.  I just want to bring it to the attention to the intensive it that's important to have a hemorrhage  cart in postpartum hemorrhage or antepartum hemorrhage. So this cart should contains blood tubing, vaginal instruments for retraction, suction, scales to weigh items for estimated  blood loss, Foley catheters, laparotomy sponges. So all those can be included in the cart to be  ready to take care of the patient. What about hysterectomy? So hysterectomy has the highest rates of complications blood loss and surgery time. So establish whether the patient is  hemodynamically unstable. Such patients cannot tolerate intervention failure or wasted time.  So subtotal hysterectomy rather than total hysterectomy which we shorten the surgical time.  Subtotal means uterine corpus is removed but the cervix is left in place. It may be associated  with less potential for bladder and urethral injury although data are equivocal. So subtotal  hysterectomy may not control bleeding completely especially in cases of placenta previa. The  placenta is implanted over the cervix. Hysterectomy may result in urinary tract complications,  cystotomy in about 60 to 29 percent of cases and urethral lesions about seven percent of cases.  The hysterectomy is considered as a last resort in many high-income nations but it's unlikely in  and it's considered quickly in under-resourced areas because of lack of full blood bank capabilities and variety of medications and personal availability. Based on that it's  more used in resource poor areas. So in summary hysterectomy highest rate of complications blood  loss and surgery time. It's necessary in uterine rupture. If possible operate when resuscitated and  hemodynamically stable patients. Subtotal hysterectomy rather than total hysterectomy which shortens the surgical time may reduce the rates of operative injury to the surrounding  structures. The complication rates about 60 to 29 percent bladder injury and seven percent  urethral injury. Coming back to the principles of transfusing these blood products. The blood  products are similar to non-pregnant women. So you need to restore the blood volume, improve the  tissue oxygenation, oxygen transportation and tissue perfusions, enable the clot formation, provide clotting factors and remain in intravascular space without significant third  space. Transfusion of these blood products if you go through the red blood cells those are erythrocytes  about 300 ml per unit transfused increase the hemoglobin by one gram per deciliter which will  increase the hematocrit by three to four percent. Fresh frozen plasma which is plasma proteins and  coagulation factors 250 ml per unit which will increase the fibrinogen to seven to ten milligrams  per deciliter and coagulation factors by five to seven percent. Platelets which is suspended in  plasma give platelets as well as some red cells and leukocytes associated with it. 50 ml per unit  it will increase the platelets by five to ten thousand per millimeter cube. Cryoprecipitate has fibrinogen factor 5, 8, 13 and 1 wilbrin factor given as 40 ml per unit will increase  the factors by 10 to 15 milligrams per deciliter. Fibrinogen concentrate can be given purely  provide fibrinogen which is about two to four grams depending on the plasma fibrinogen level  and factor 7a which is very effective 90 micrograms per kg intravenously given in three to five  minutes. You can repeat it in every 20 minutes to reduce the bleeding in 85 percent of the cases  factor 7a. Those are the blood products we generally transfuse. So institutional massive transfusion protocols you should consider initiating for active hemorrhage or in the  following situations such as blood pressure is less than 80 millimeter mercury, pH is less than  7.2, base deficit less than 6 and temperature less than 35 degree centigrade or 95 degree Fahrenheit,  INR or international normalized ratio more than 2 or platelet count less than 50 000 per cubic  millimeter and transfusion protocols have demonstrated improvement in survival and then reducing the multiple organ failure in trauma patients. So your blood product management as a  sample transfusion protocol usually at first round is 1 is to 1 is to 1 means 6 units of packed RBC,  6 units of plasma and 6 unit of platelets with 10 units cryoprecipitate. You can do round 2 again 6 units RBC, 6 units FFP and 6 unit platelets with 20 units cryoprecipitate.  So in other words it's equal ratios of packed RBCs, fresh frozen plasma, platelets and platelets  are apheresis packs and not standard packs and some institutions give factor 7a at a third round  balance. You need to balance of course availability and the risk of thrombosis with factor 7a.  So our resuscitation aims with these blood products is to maintain your hemoglobin more than 7 grams per deciliter. You can give additional RBC depending on the bleeding  control hemodynamics and co-morbidities and platelets called more than 50 000 per cubic millimeter and your fibrinogen goal is about 200 milligrams per deciliter.  So in important things to talk about factor 7a as a blood product management. So factor 7a  is used for refractory hemorrhage when you have hematocrit more than 24 percent, platelets more  than 50 000 per millimeter mercury and fibrinogen more than 200 milligrams per deciliter and patient  is still bleeding. The dose is about 90 micrograms per kg in 3 to 5 minutes. If bleeding has not  stopped a second dose can be used about 90 micrograms per kg and use of antifibrinolytics and correction of severe acidosis, severe hypothermia and hypocalcemia are essential.  Factor 7a carries a very high risk of intravascular clotting. For example you can develop deep vein thrombosis pulmonary embolism or arterial thrombosis because you're trying to  stop the bleeding and you can clot more. Factor 7a should be used in emergency cases  where other measures have failed. Antifibrinolytic therapy has been used in some trials to aid in reduction of this postpartum hemorrhage. So these agents are really  contraindicated if you have an ongoing pregnancy because of the clotting risk.  So what are the complications of massive hemorrhage and transfusions? So obviously with the hemorrhage you can develop anemia, you can develop infections, shock,  tubular necrosis in the kidneys, you can have increased hospital length of stay and ICU length of stay, transfusion associated circulatory overload,  transfusion associated lung injury, allergic reactions with the blood products, hemolysis can happen and psychological sequelae of the mother and delirium can happen with  transfusion protocols. So final key points of obstetric hemorrhage. Obstetric hemorrhage is the principal cause of maternal death and warrants a rapid multidisciplinary approach.  Uterine atony is the cause of 80% of postpartum hemorrhage. Fibromyalgia less than 200 milligrams  per deciliter is predictive of severe obstetric hemorrhage and requiring major blood transfusions  and surgical interventions. Hemostatic resuscitation consists of interventions designed to restore the intravascular volume and to maximize the oxygen transportation.  Institutions should establish protocols for the response to major obstetric hemorrhage  and for massive transfusion protocols in obstetrics. Early aggressive care will usually reduce complications of hemorrhage. Thank you for the opportunity. We discussed obstetric  hemorrhage for the intensivist, stopping the major cause of global maternal mortality.  The superimposed phenomena was chorioamnionitis, disseminated intravascular coagulation and many more we discussed. Thank you.

Video Summary

Obstetric hemorrhage is a major cause of maternal mortality, particularly in developing countries. It accounts for more than 50% of the 300,000 maternal deaths globally. The most common cause of obstetric hemorrhage is uterine atony, which refers to the failure of the uterus to contract and compress the spiral arteries, leading to excessive bleeding.<br /><br />There are several risk factors for obstetric hemorrhage, including cesarean deliveries, which can increase the risk of placenta accreta and emergency hysterectomies. Other causes include retained placental tissue, coagulopathy, and trauma.<br /><br />Management of obstetric hemorrhage involves a multidisciplinary approach. Medical interventions such as the use of uterotonic medications like oxytocin, methylergonovine, and prostaglandins can help manage uterine atony. In severe cases, surgical interventions like balloon tamponade, uterine artery ligation, or hysterectomy may be necessary.<br /><br />Fluid resuscitation is important to restore blood volume, and blood products like packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate may be transfused to correct coagulopathy.<br /><br />Early recognition and aggressive management of obstetric hemorrhage can significantly reduce maternal mortality and complications. It is crucial to establish protocols and coordinate care between obstetricians, intensivists, and other healthcare professionals to ensure prompt and effective treatment.

Asset Subtitle

Obstetrics, Hematology, 2022

Asset Caption

Physiologic changes in blood volume and hemostasis that accompany pregnancy mitigate the risk of maternal hemorrhage; however, these adaptive mechanisms can be overcome in superimposed pathophysiologic states. Uterotonic and hemostatic adjuncts constitute the first line of defense in combatting postpartum hemorrhage. Familiarity with the indications, contraindications, and pharmacokinetics of these agents is critical for the continued successful management of hemorrhage in the ICU. Early recognition and management are therefore critical because failure to treat potential contributors to hemorrhage can lead to adverse outcomes.

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Content Type Presentation

Knowledge Area Obstetrics

Knowledge Area Hematology

Knowledge Level Advanced

Membership Level Select

Tag Obstetrics

Tag Hemorrhage

Year 2022

Keywords

Obstetric hemorrhage

maternal mortality

developing countries

uterine atony

risk factors

management

medical interventions

surgical interventions

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