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Management of Obstetrical Hemorrhage

Management of Obstetrical Hemorrhage. Jeffrey Stern, M.D. Management of Obstetrical Hemorrhage. Fundal massage VS q 15 minutes, O2 sat’s > 94%, oxygen by mask 10 liter/min. 1st IV, LR w/Pitocin 20-40 units at 1000 ml/ 30 minutes Start 2nd 18 G IV warm LR and administer wide open

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Management of Obstetrical Hemorrhage

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  1. Management of Obstetrical Hemorrhage Jeffrey Stern, M.D.

  2. Management of Obstetrical Hemorrhage • Fundal massage • VS q 15 minutes, O2 sat’s > 94%, oxygen by mask 10 liter/min. • 1st IV, LR w/Pitocin 20-40 units at 1000 ml/ 30 minutes • Start 2nd 18 G IV warm LR and administer wide open • Obtain hemogram, fibrinogen, PT/PTT, platelets, T&C 4 u of PRBCs • Initiate monitoring of I&O, urinary Foley catheter • Get help, including Interventional Radiology, Anesthesia, etc.

  3. Management of Obstetrical Hemorrhage • LR or NS replaces blood loss at 3:1 • Volume expander 1:1 (albumin, hetastarch, dextran) • Administer uterotonic medications • Anticipate DIC • Verify complete removal of placenta, may require ultrasound • Inspect for bleeding, episiotomy, laceration, hematomas, inversion, rupture • Emperic transfusion: 2 u PRBC; FFP 1-2 u/4-5 u PRBC; cryo 10 u, uncrossed (O neg.) PRBC • Warm blood products and infusion to prevent hypothermia, coagulopathy, arrhythmias

  4. Treatment of Uterine Atony • Oxytocin – 90% success • 10-40 units in 1 liter NS or LR rapid infusion • Methylergonovine (Methergine) - 90% success • 0.2 mg IM q 2-4 hours max. 5 doses; avoid with hypertension • Prostaglandin F2 Alpha (Hemabate) - 75% success • 250 micrograms IM; intramyometrial, repeat q 20-90 min; max 8 doses. • Avoid if asthma/Hi BP. • Prostaglandin E2 suppositories (Dinoprostone, Prostin E2) - 75% success • 20 mg per rectum q 2 hours; avoid with hypotension • Prostaglandin PGE 1 Misoprostol (Cytotec) - 75% to 100% success • 1000 microgram per rectum or sublingual (100 or 200 microgram tabs)

  5. Target Values • Invasive monitoring • Maintain systolic BP>90 mmHg • Maintain urine output > 0.5 ml per kg per hour • Hct > 21% • Platelets > 50,000/ul • Fibrinogen > 100 mg/dl • PT/PTT < 1.5 times control • Repeat labs as needed – every 30 minutes

  6. Blood Component Therapy • FFP (45 minutes to thaw) : • INR > 1.5 - 2u FFP • INR 2-2.5 - 4u FFP • INR > 2.5 - 6u FFP • Cryoprecipitate (1 hour to thaw) : • Fibrinogen < 100 mg/dl – 10u cryo • Fibrinogen < 50 mg/dl – 20u cryo • Platelets (5 minutes when in stock) : • Plt. ct. < 100,000 – 1u plateletpheresis • Plt. ct. < 50,000 – 2u plateletpheresis

  7. Blood Component Therapy

  8. Prepare for Laparotomy • General anesthesia usually best • Allen or yellowfin stirrups • Uterine cavity manual exploration with ultrasound present • Uterine inversion: Magnesium sulfate, Halothane, Terbutoline, NTG. • Uterine packing (treatment vs. temporizing) – remove in 24-28 h • 4” gauze Kerlex soaked in 5000 u of thrombin in 5ml of sterile saline • 24 Fr. Foley with 30ml balloon with 30-80 ml of saline (1 or more as needed) • Bakri (intrauterine) balloon - 500 cc • Antibiotics

  9. Intraoperatively • Consider vertical incision • General anesthesia usually best • Get Help! • Avoid compounding problems by making major mistakes • Direct manual uterine compression / uterotonics • Direct aortic compression • Modified B-Lynch stitch (#2 chromic) for atony • Ligation of uterine and utero-ovarian vessels (#1 chromic)

  10. Intraoperatively • Internal iliac artery ligation ( 50% success) • Desirous of children • Experience of surgeon • Palpate common iliac bifurcation • Ligate at least 2-3 cm from bifurcation • #1 silk. Do not divide • Interventional Radiology: uterine artery embolization (catheters placed pre-op) • Hysterectomy/ subtotal hysterectomy (put ring forceps on lip of cervix) • Cell saver: investigational (amniotic fluid problems)

  11. Post-Hysterectomy Bleeding • Patient usually has DIC – Rx with whole blood, FFP, platelets, etc. • Military Anti-Shock Trousers (MAST) • Increases pelvic and abdominal pressure to reduce bleeding • Can use at any point in the procedure • Transvaginal or transabdominal (pelvic) pressure pack • Bowel bag with opening pulled through vagina cuff • Stuff with Kerlex gauze tied end-to-end until pelvis packed tight • Tie to 10-20 lbs. weight • Hang weights over edge of bed to help keep constant pressure • May have to leave clamps or accept ligation of ureter or a major side wall vessel • Interventional Radiology

  12. Arterial Embolization

  13. Selective Artertial Embolization by Angiography • Clinically stable patient – Try to correct coagulopathy • Takes approximately 1-6 hours to work • Often close to shock, unstable, require close attention • Can be used for expanding hematomas • Can be used preoperatively, prophylactically for patients with accreta • Analgesics, anti-nausea medications, antibiotics

  14. Selective Artertial Embolization by Angiography • Real time X-Ray (Fluoroscopy) • Access right common iliac artery • Single blood vessel best • Embolize both uterine or hypogastric arteries • Sometimes need a small catheter distally to prevent reflux into non-target vessels • May need to treat entire anteriordivision or even all of the internal iliac artery. • Risks: Can embolize nearby organs and presacral tissue, resulting in necrosis • Technique • Gelfoam pads – Temporary, allows recanalization • Autologous blood clot or tissue • Vasopressin, dopamine, Norepinephrine • Balloons, steel coils

  15. Evaluate for Ovarian Collaterals May need to embolize

  16. Mid-Embolization “Pruned Tree Vessels”

  17. Post Embolization

  18. Post Embolization Pre Embo Post Embo

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