Surgical Considerations for Obstetrical Hemorrhage Lee-may Chen, MD - - PowerPoint PPT Presentation

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Surgical Considerations for Obstetrical Hemorrhage

10/16/15

Lee-may Chen, MD Division of Gynecologic Oncology UCSF Helen Diller Family Comprehensive Cancer Center Department of Obstetrics, Gynecology and Reproductive Sciences

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I have no financial disclosures

Audience Response

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Have you been involved in a postpartum hemorrhage in the last 6 months?

• A. Yes
• B. No

Have you diagnosed a placenta accreta/percreta in the last year?

• A. Yes
• B. No
• Have you performed a postpartum hysterectomy in the last year?
• A. Yes
• B. No

Learning Objectives

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To describe patterns of pregnancy related mortality, and the impact

• f postpartum hemorrhage

To recognize patients at risk for postpartum hemorrhage, including preoperative and intraoperative management strategies To describe the role of multidisciplinary teams in the management

• f C-section deliveries for abnormal placentation

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Pregnancy-related Mortality

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CDC Pregnancy Mortality Surveillance System: 16.0 deaths per 100,000 live births

Obstetrical Hemorrhage

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26% 10% 10% 3% 12% 2% 2% 16% 19% Ruptured ectopic Uterine rupture or laceration Placental abruption Placenta previa Accreta/increta/percreta Retained products Coagulopathy Atony Other/unspecified

Hemorrhage accounts for 11% of pregnancy related mortality

Obstetrical Hemorrhage

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26% increase in postpartum hemorrhage, primary due to atony

Obstetrical Hemorrhage

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26% increase in postpartum hemorrhage, primary due to atony

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A California Toolkit

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National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage

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Main et al, Obstet Gynecol 2015 Main et al, Anesth Analg 2015 Main et al, J Midwifery Womens Health 2015 Main et al, J Obstet Gynecol Neonatal Nurs 2015

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Readiness: Establish a Response Team

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Anesthesia Blood bank Pharmacy Advanced gynecologic surgery Critical Care Medicine Operating room Interventional radiology Nursing (Tissue banking) (Pathology)

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Recognition and Prevention: Common Errors

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Failure to identify at risk patients Delayed response from medical team

• Protocols for activating response teams

Underestimation of blood loss

• Quantitative versus estimated

Delay in blood product administration Lack of readily accessible or working equipment Need for organized and standardized team approach

Access to hemorrhage medications, blood products

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Oxytocin 10-40 units per 500-1000mL IV infusion Methylergonivine 0.2mg IM (not IV) q 2-4 hours 15-methyl PG F2a 250mcg IM or intramyometrial (not IV) Misoprostol 600-800mcg sublingual or PO Packed red blood cells: longer to crossmatch with antibodies Fresh frozen plasma: especially if > 2 units PRBCs Platelets: especially if < 50K Cryoprecipitate: especially if Fib < 80

Uterine tamponade

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Internal balloons may be used where uterotonics not effective or not available (2012 WHO guidelines)

• Fill with 500-750mL fluid
• 60-80% success in 20-30 minutes
• Maximum dwell 24 hours

Uterine packing may be an option in poor resource settings

Uterine tamponade

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Compression sutures with 1-Chromic or 1-Monocryl

• Manually squeeze the uterus from top to bottom
• May combine with intrauterine balloon
• May also be used for focal accretas

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Uterine artery ligation

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O’Leary stitches

• Include part of the myometrium
• May also ligate utero-ovarian vessels

Kominiarek, Hospital Physician 2008

Uterine artery occlusion

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Hypogastric artery ligation N=110 women with PPH underwent hypogastric artery ligation 39% required hysterectomy None required re-operation; 1 iliac vein injury Joshi et al, Br J Obstet Gynecol 2007

Uterine artery occlusion

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Interventional Radiology techniques

• Vaso-occlusive balloons

‒ Better EBL and less transfusion in prophylaxis for percreta ‒ Complications of pseudoaneurysm, vessel rupture, thrombus

• Embolization

Cali et al, Eur J Obstet Gynecol Reprod Biol 2014 Bishop et al, Int J Obsetet Anesth 2011 Urquia et al, ECR 2012

Cell Saver

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Commencement after removal of fetoplacental unit Minimal contamination of fetal elements Higher postoperative hemoglobin concentrations Shorter hospital stay Requires set up time Rainaldi et al, Br J Anesth 1998

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Readiness: Multidisciplinary Team

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The invasive placenta, a spectrum of abnormal adherence 1/533 incidence Associated with prior C-section, other uterine surgery Concurrent placenta previa in 90% Possible defect of trophoblastic function leading to invasion Leading cause of C-hysterectomy

Invasive Placenta

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Ultrasound is primary screening tool

• Prominent placental lacunae
• Loss of space between uterus & placenta
• Interruption of bladder-myometrium interface
• Increased vascularity
• Aberrant surface vessels
• Sensitivity: 77-93%
• Specificity: 71-96%

Invasive Placenta

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MRI is used for preoperative planning

• Abnormal uterine bulging
• Heterogeneous placental signal

intensity

• Dark intraplacental bands
• Sensitivity: 80-88%
• Specificity; 65-100%

Invasive Placenta

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Bladder involvement Complete previa & percreta

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Invasive Placenta

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Traditional therapy is hysterectomy

• Typically admitted after bleeding.
• Steroids for fetal lung maturity
• MRI for surgical planning
• MFM, Gyn Onc, IR, Neonatal consults

Schedule delivery @ 34-35 weeks

• Unscheduled patients deliver earlier, more likely to have vaginal

bleeding, uterine activity Preoperative considerations Bowman et al, Am J Obstet Gynecol 2014

Invasive Placenta

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Schedule delivery @ 34-35 weeks ‒ Arrange for cell saver ‒ T&C 6 units PRBCs, 2 units FFP

• Lithotomy position, 3 way Foley
• Regional anesthetic general
• Consider vertical skin incision, uterine incision based on fetal

position

• Consider vascular balloon occlusion
• Consider ureteral stent placement
• Consider internal iliac ligation

Intraoperative considerations

Readiness: Multidisciplinary Team

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Gynecologic Oncology Maternal Fetal Medicine Obstetrical Anesthesia Radiology Interventional Radiology Nursing Pathology UCSF Multidisciplinary Abnormal Placentation Service (MAPS)

Readiness: Multidisciplinary Team

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3 Tertiary care hospitals between 2000-2013 Multidisciplinary management introduced in 2011 90 patients with placenta accreta Multidisciplinary group, n= 57, versus 33 historical controls More percreta cases Less EBL Less likely to be delivered emergently Retrospective Cohort Study Shamshirasaz et al, Am J Obset Gyncol 2015

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Silver et al, Am J Obset Gyncol 2015 Consider referral/delivery at accreta center for: Suspicious for accreta on ultrasound Placenta previa with abnormal ultrasound Placenta previa with > 3 prior C-section deliveries h/o classical C-section & anterior placenta h/o endometrial ablation or RT

Centers of Excellence for Placenta Accreta Centers of Excellence for Placenta Accreta

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Delay uterine incision if findings abnormal Set up OR team Consider transfer to Teritary Center if stable Close hysterotomy, leaving placenta in situ If percreta is discovered at laparotomy Silver et al, Am J Obset Gyncol 2015

Conclusions

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Early recognition Elective delivery pre-term Don’t delay intervention—transfusions, activation of surgical teams Review and debrief for quality improvement