Download 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
• 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.
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
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)
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
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
Blood Component Therapy
Blood Comp
Contents
Volume
(ml)
Effect ( Per u)
Packed RBCs
RBC, Plasma
300
Inc. Hgb by 1 g/dl
Platelets
Platelets, Plasma
300
Inc. count by 7500
FFP
Fibrinogen, antithrombin III,
clotting factors, plasma
250
Inc. Fibrinogen 10 mg/dl
Cryoprecipitate
Fibrinogen, antithrombin III,
clotting factors, plasma
40
Inc. Fibrinogen 10 mg/dl
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
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)
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)
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
Arterial Embolization
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
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 nontarget 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
Evaluate for
Ovarian Collaterals
May need to embolize
Mid-Embolization “Pruned Tree Vessels”
Post Embolization
Post Embolization
Pre Embo
Post Embo