Anesthesia Considerations in Placenta accreta Obstetric Hemorrhage - - PowerPoint PPT Presentation

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Anesthesia Considerations in Obstetric Hemorrhage

Jennifer Lucero, MD Assistant Professor Division of Obstetric Anesthesia

Post-Partum Hemorrhage

• Atony
• Retained Placenta
• Placenta accreta
• Defects in Coagulation
• Vaginal laceration
• Uterine Inversion

Common Things Being Common

Most Common Cause of Maternal Mortality Worldwide.

• In the US roughly 3% rate of PPH
• Increasing rates of transfusion Obstetrics

– Increased Cesarean Delivery – Abnormal Placentation

• Atony 80% of causes of Severe PPH

WHO Analysis of Causes of Maternal Death Systematic Review

Khan KS, Wojdyla D, Say L, et.al., Lancet 2006; 367: 1066-74 Developed Countries

Africa Asia Latin Am. Caribbean Hemorrhage 13.4% 33.9% 30.8% 20.8% Hypertensive Disorders 16.1% 9.1% 9.1% 25.7% Infections 2.1% 9.7% 11.6% 7.7% Abortion 8.2% 3.9% 5.7% 12.0% Embolism 14.9% 2.0% 0.4% 0.6%

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Flood KM, et al. Am J Obstet Gynecol. 2009; 200: 632

Accreta and Peripartum Hysterectomy

Creanga AA, et al. Obstet Gynecol. 2015; 125: 5-12

Anesthesiology 2014; 121:450-8

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Graphic Source: CMQCC California Maternal Quality Care Collaborative

Source:www.cmqcc.org/ob_hemorrhage

• Developed a Tool Kit for OB services:

– Set of Best Practices (short summaries of key aspects of OB hemorrhage) – Checklist for managing OB hemorrhage – Flow-Chart and Table Chart Summaries of approach – Implementation tools such as sample policies, procedures, charting examples, implementation hints

• All resources on-line at:

www.cmqcc.org/ob_hemorrhage

CMQCC Hemorrhage Task Force:

Source: CMQCC California Maternal Quality Care Collaborative

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• Coagulopathy persisted at ICU admission

Pre-ICU resuscitation:

9 ± 1 L crystalloid 12 ± 1 units PRBC 5 ± 0.4 units FFP FFP was not given until after 6 units PRBCs

• In the ICU during resuscitation, patients received 10 ± 1

units FFP for coagulopathy; the ratio of FFP:PRBC was 1:1. Mean INR < 1.4 within 8 hours

Volume restoration is accomplished by using thawed plasma as a primary resuscitation fluid in at least a 1:1 or 1:2 ratio with PRBCs Crystalloid is minimized and serves mainly as a carrier The blood bank activates the massive transfusion protocol and deliver 6 units of plasma, 6 units of PRBCs, 6 packs of platelets, and 10 units of cryoprecipitate Recombinant FVIIa is occasionally used

“Using the damage control resuscitation approach, the lack of intraoperative coagulopathic bleeding has been remarkable, allowing surgeons to focus on surgical bleeding.” “Patients treated in this fashion almost always arrive in the ICU warm, euvolemic, and nonacidotic, with a normal INR and minimal edema.”

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“In the majority of patients the abnormalities of the lethal triad are absent.” “These patients appear to be easily ventilated and more quickly extubated than patients with similar blood loss treated with the standard crystalloid resuscitation volumes and blood component ratios.”

Borgman et al. J Trauma 2007; 63:805-13

2003-2005 Retrospective Data From Iraq War

Volume 50, February 2010 TRANSFUSION

Plasma:RBC product transfusion ratios effect on patient survival

Survival versus ratio. (Dark Gray ) 24-hour survival; (Light Gray ) 30-day survival

Volume 50, February 2010 TRANSFUSION

PLT:RBC product transfusion ratios effect on patient survival

Survival versus ratio. (Dark Gray ) 24-hour survival; (Light Gray ) 30-day survival

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Principles to Reducing Maternal Hemorrhage

• Screen and identify patients at high risk
• Active management of 3rd stage
• Ongoing quantification of blood loss
• Ongoing evaluation of patient’s vital signs
• Sequential use of medications & procedures
• Timely request for blood products
• Massive transfusion protocol and team
• Periodic hemorrhage drills and simulations

Adapted from CMQCC California Maternal Quality Care Collaborative – OB Hemorrhage Task Force 22

Graphic Source: CMQCC California Maternal Quality Care Collaborative

Blood Loss: 1000-1500 ml

Stage 2

Sequentially Advance through Medications & Procedures

Pre- Admission Time of admission

Identify patients with special consideration: Placenta previa/accreta, Bleeding disorder, or those who decline blood products Follow appropriate workups, planning, preparing

• f resources, counseling and notification

Screen All Admissions for hemorrhage risk: Low Risk, Medium Risk and High Risk Low Risk: Draw blood and hold specimen Medium Risk: Type & Screen, Review Hemorrhage Protocol High Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage Protocol All women receive active management of 3rd stage Oxytocin IV infusion or 10 Units IM, 10-40 U infusion Standard Postpartum Management Fundal Massage Vaginal Birth: Bimanual Fundal Massage Retained POC: Dilation and Curettage Lower segment/Implantation site/Atony: Intrauterine Balloon Laceration/Hematoma: Packing, Repair as Required Consider IR (if available & adequate experience) Cesarean Birth: Continued Atony: B-Lynch Suture/Intrauterine Balloon Continued Hemorrhage: Uterine Artery Ligation To OR (if not there); Activate Massive Hemorrhage Protocol Mobilize Massive Hemorrhage Team TRANSFUSE AGGRESSIVELY RBC:FFP:Plts 6:4:1 or 4:4:1 Increased Postpartum Surveillance Definitive Surgery Hysterectomy Conservative Surgery B-Lynch Suture/Intrauterine Balloon Uterine Artery Ligation Hypogastric Ligation (experienced surgeon only) Consider IR (if available & adequate experience) Fertility Strongly Desired Consider ICU Care; Increased Postpartum Surveillance Verify Type & Screen on prenatal record; if positive antibody screen on prenatal

• r current labs (except low level anti-D

from Rhogam), Type & Crossmatch 2 Units PBRCs CALL FOR EXTRA HELP Give Meds: Hemabate 250 mcg IM -or- Misoprostol 600-800 SL or PO Cumulative Blood Loss >500 ml Vag; >1000 ml CS >15% Vital Sign change -or- HR ≥ 110, BP ≤ 85/45 O2 Sat <95%, Clinical Sx Ongoing Evaluation: Quantification of blood loss and vital signs Unresponsive Coagulopathy: After 10 Units PBRCs and full coagulation factor replacement, may consider rFactor VIIa HEMORRHAGE CONTINUES

Blood Loss: >1500 ml

Stage 3

Activate Massive Hemorrhage Protocol Blood Loss: >500 ml Vaginal >1000 ml CS

Stage 1

Activate Hemorrhage Protocol NO

Stage 0

All Births Transfuse 2 Units PRBCs per clinical signs Do not wait for lab values Consider thawing 2 Units FFP YES YES NO Ongoing Cumulative Blood Loss Evaluation Cumulative Blood Loss >1500 ml, 2 Units Given, Vital Signs Unstable YES Increase IV Oxytocin Rate Methergine 0.2 mg IM (if not hypertensive) Vigorous Fundal massage; Empty Bladder; Keep Warm Administer O2 to maintain Sat >95% Rule out retained POC, laceration or hematoma Order Type & Crossmatch 2 Units PRBCs if not already done Activate Hemorrhage Protocol CALL FOR EXTRA HELP Continued heavy bleeding Increased Postpartum Surveillance NO NO CONTROLLED INCREASED BLEEDING California Maternal Quality Care Collaborative (CMQCC), Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details This project was supported by funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division

Obstetric Emergency Management Plan: Flow Chart Format

Release 2.0 7/9/2014

23

Graphic Source: CMQCC California Maternal Quality Care Collaborative

Blood Loss: 1000-1500 ml

Stage 2

Sequentially Advance through Medications & Procedures

Pre- Admission Time of admission

Identify patients with special consideration: Placenta previa/accreta, Bleeding disorder, or those who decline blood products Follow appropriate workups, planning, preparing

• f resources, counseling and notification

Screen All Admissions for hemorrhage risk: Low Risk, Medium Risk and High Risk Low Risk: Draw blood and hold specimen Medium Risk: Type & Screen, Review Hemorrhage Protocol High Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage Protocol All women receive active management of 3rd stage Oxytocin IV infusion or 10 Units IM, 10-40 U infusion Standard Postpartum Management Fundal Massage Vaginal Birth: Bimanual Fundal Massage Retained POC: Dilation and Curettage Lower segment/Implantation site/Atony: Intrauterine Balloon Laceration/Hematoma: Packing, Repair as Required Consider IR (if available & adequate experience) Cesarean Birth: Continued Atony: B-Lynch Suture/Intrauterine Balloon Continued Hemorrhage: Uterine Artery Ligation To OR (if not there); Activate Massive Hemorrhage Protocol Mobilize Massive Hemorrhage Team TRANSFUSE AGGRESSIVELY RBC:FFP:Plts 6:4:1 or 4:4:1 Increased Postpartum Surveillance Definitive Surgery Hysterectomy Conservative Surgery B-Lynch Suture/Intrauterine Balloon Uterine Artery Ligation Hypogastric Ligation (experienced surgeon only) Consider IR (if available & adequate experience) Fertility Strongly Desired Consider ICU Care; Increased Postpartum Surveillance Verify Type & Screen on prenatal record; if positive antibody screen on prenatal

• r current labs (except low level anti-D

from Rhogam), Type & Crossmatch 2 Units PBRCs CALL FOR EXTRA HELP Give Meds: Hemabate 250 mcg IM -or- Misoprostol 600-800 SL or PO Cumulative Blood Loss >500 ml Vag; >1000 ml CS >15% Vital Sign change -or- HR ≥ 110, BP ≤ 85/45 O2 Sat <95%, Clinical Sx Ongoing Evaluation: Quantification of blood loss and vital signs Unresponsive Coagulopathy: After 10 Units PBRCs and full coagulation factor replacement, may consider rFactor VIIa HEMORRHAGE CONTINUES

Blood Loss: >1500 ml

Stage 3

Activate Massive Hemorrhage Protocol Blood Loss: >500 ml Vaginal >1000 ml CS

Stage 1

Activate Hemorrhage Protocol NO

Stage 0

All Births Transfuse 2 Units PRBCs per clinical signs Do not wait for lab values Consider thawing 2 Units FFP YES YES NO Ongoing Cumulative Blood Loss Evaluation Cumulative Blood Loss >1500 ml, 2 Units Given, Vital Signs Unstable YES Increase IV Oxytocin Rate Methergine 0.2 mg IM (if not hypertensive) Vigorous Fundal massage; Empty Bladder; Keep Warm Administer O2 to maintain Sat >95% Rule out retained POC, laceration or hematoma Order Type & Crossmatch 2 Units PRBCs if not already done Activate Hemorrhage Protocol CALL FOR EXTRA HELP Continued heavy bleeding Increased Postpartum Surveillance NO NO CONTROLLED INCREASED BLEEDING California Maternal Quality Care Collaborative (CMQCC), Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details This project was supported by funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division

Obstetric Emergency Management Plan: Flow Chart Format

Release 2.0 7/9/2014

Graphic Source: CMQCC California Maternal Quality Care Collaborative

CMQCC Obstetric Care Summary

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Holcomb et al. JAMA 2015; 313: 471-82

Multisite, RCT, 12 Level 1 Trauma Centers 680 Severely Injured Patients August 2012 – December 2013 Outcomes 24-hour and 30-day mortality

Holcomb et al. JAMA 2015; 313: 471-82 Holcomb et al. JAMA 2015; 313: 471-82

Considerations in Massive Transfusion Protocol - Continued

• Consider arranging for blood salvage
• Place large bore IVs (16G-14G)
• Place invasive monitoring (a-line & CVP)
• Repeat labs frequently (CBC, ABG, lytes, iCa, coags)
• Fluid warmers & forced air warmer for patient
• Prime rapid infusion pump or pressure bags
• Point of care testing (Hb, blood gas, coags, lytes)
• Direct communication with blood bank & central lab

Gallos G., et. al. Semin Perinatol 33: 116-123. 2009 SFGH Massive Transfusion Policy No 2.06 CMQCC Hemorrhage Task Force. www.cmqcc.org

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• Prepare for general anesthesia
• Vasopressors immediately available
• All uterotonics immediately available
• Supply of calcium chloride to prevent low ionized

calcium levels from rapid transfusion

• Foley to measure urine & SCDs
• Reserve ICU bed

Gallos G., et. al. Semin Perinatol 33: 116-123. 2009 SFGH Massive Transfusion Policy No. 2.06 CMQCC Hemorrhage Task Force. www.cmqcc.org

Considerations in Massive Transfusion Protocol - Continued

• Request additional blood products as needed in “packs” of

correct ratio (Prbcs:FFP:Plts)

• Consider cryoprecipitate (Fibrinogen < 100 mg/dL)
• Consider factor VIIa (off-label hemostatic use)

– Only after approximately 10 units prbcs and factor replacement

• Person for recording/tallying blood products & EBL
• Bring “Code Cart” into OR
• Plan for Blood Bank to prioritize Transfusion labs
• Make time to debrief after event with all disciplines

Gallos G., et. al. Semin Perinatol 33: 116-123. 2009; SFGH Massive Transfusion Policy No. 2.06; CMQCC Hemorrhage Task Force. www.cmqcc.org

Considerations in Massive Transfusion Protocol - Continued

Consideration of Cell Salvage

• Cell salvage in obstetrics should be considered in cases

at risk for severe hemorrhage or for individuals in whom allogenic blood can not be used…

• Placenta accreta / increta / percreta
• Massive uterine fibroids
• Jehovah’s Witnesses
• Difficult cross-matching

Opinion Statements

• “If the diagnosis or strong suspicion of placenta accreta is

formed before delivery…Cell saver technology should be considered if available as well as the appropriate location and timing for delivery…”

(American College of Obstetricians and Gynecologists (ACOG), Practice Bulletin, No. 76, October 2006, Postpartum Hemorrhage)

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Opinion Statements

• “Cell salvage is recommended for women in whom an

intraoperative blood loss of more than 1500 ml is

• anticipated. Cell salvage should only be used by healthcare

teams who use it regularly and have the necessary expertise and experience. Consent should be obtained and its use in

• bstetric patients should be subject to audit and

monitoring.”” (RCOG Guideline No. 27, October 2005 – Placenta Previa and Placenta Accreta)

TOOLS TO HELP? SOME NEW AND SOME OLD Role of Interventional Radiology

Uterine Artery Catheterization

Pledgets Slurry Coils n-Butyl Cyanoacrylate

Embolization Agents

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IR for Atony Clinical Success

Study Year n Success %

Ornan D et al. Obstet Gynecol 2003 28 96% Boulleret C et al. CVIR 2004 35 100% Zwart JJ et al. Am J Obstet Gynecol 2009 114 85% Kirby JM et al. JVIR 2009 43 79%

Obstet Gynecol 2009;113:992-9

• 100 patients over 13 years
• Outcomes

– Clinical success in 89 patients (89%) – 7 of the 11 patients (64%) underwent hysterectomy – Buttock necrosis (1%) – Puncture site hematoma (1%)

• Conclusion

– Patients who failed embolization had higher rate of estimated blood loss (more than 1,500 mL) and higher transfusion requirements (more than 5 units of PRBCs)

• 28 studies were included in the systematic review
• 460 out of 503 (91.45%) women resumed menstruation
• 168 women desired another pregnancy

– 126 (75%) achieved conception following embolization

• Conclusion: Uterine-sparing radiological techniques do

not appear to adversely affect the menstrual and fertility

• utcomes in most women; however, the number and

quality of the available evidence is of concern

BJOG 2014;121:382-8

Interventional Radiology Invasive Placenta

• Different disease process than uterine atony
• Requires a multidisciplinary team

– Maternal fetal medicine (OB team) – Surgical gynecology (gyn onc) – Interventional radiology – Diagnostic radiology (antenatal MRI) – Scheduled deliveries – Use of multidisciplinary team is associated with a significant reduction in morbidity (p=0.005)

• Need randomized clinical trials/registry data

J Obstet Gynaecol Can 2013; 35:417–425

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rFVIIa

Cost: ~ $5000.00

• A review of the FDA’s Reporting System from 1999 to 2004
• A total of 431 AE reports for rFVIIa were found, of which 168 reports

described 185 thromboembolic events

• Unlabeled indications accounted for 151 of the reports, most with active

bleeding (n=115)

• In 36 (72%) of 50 reported deaths, the probable cause of death was the

thromboembolic event

• Conclusion: RCTs are needed to establish the safety and efficacy of rFVIIa

in patients without hemophilia

A 2008 review noted 118 cases of massive postpartum hemorrhage treated with rFVIIa. Median dose was 71.6 mcg/kg rFVIIa was reported to be effective in stopping or reducing bleeding in 90% of reported cases Caution in interpreting results as they are from uncontrolled studies RCTs needed to determine efficacy, dose, & safety

Review of Factor VIIa in Severe Obstetric PPH

Franchini M., et. al., Semin Thromb Hemost 2008; 34:104-112 Butwick et al. Curr Opin Anesthesiol 2015; 28;275-84

Fibrinogen

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Charbit et al. J Thromb Haemost 2007; 5:266-273 Charbit et al. J Thromb Haemost 2007; 5:266-273

Thromboelastography

ROTEM- Thromboelastometry (Germany)

ROTEM

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Butwick et al. Curr Opin Anesthesiol 2015; 28;275-84

PROTOCOL SUMMARY

FULL TITLE OF STUDY: Tranexamic acid for the treatment of postpartum haemorrhage: An international, randomised, double blind, placebo controlled trial SHORT TITLE: WORLD MATERNAL ANTIFIBRINOLYTIC TRIAL TRIAL ACRONYM: THE WOMAN TRIAL PROTOCOL NUMBER: ISRCTN76912190 EUDRACT NUMBER: 2008-008441-38 CLINICALTRIALS.GOV ID: NCT00872469

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Summary

• Recognition and Preparedness
• Multidisciplinary Team
• Good Communication and Team Work
• Massive Transfusion Protocols
• Role of Cell Salvage in Predictable

Hemorrhage

• Potential Role of Devices and Pharmacologic

Interventions