I have no financial disclosures Surgical Considerations for Obstetrical Hemorrhage Lee-may Chen, MD Division of Gynecologic Oncology UCSF Helen Diller Family Comprehensive Cancer Center Department of Obstetrics, Gynecology and Reproductive Sciences 10/16/15 Surgical Considerations for Obstetrical Hemorrhage 2 10/16/15 Audience Response Learning Objectives � Have you been involved in a postpartum hemorrhage in the last 6 months? � To describe patterns of pregnancy related mortality, and the impact A. Yes of postpartum hemorrhage B. No � Have you diagnosed a placenta accreta/percreta in the last year? � To recognize patients at risk for postpartum hemorrhage, including A. Yes preoperative and intraoperative management strategies B. No Have you performed a postpartum hysterectomy in the last year? � � To describe the role of multidisciplinary teams in the management A. Yes of C-section deliveries for abnormal placentation B. No Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 3 4 10/16/15 10/16/15 1 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 10/16/2015 AND HANDOUTS]
Pregnancy-related Mortality Obstetrical Hemorrhage Hemorrhage accounts for 11% of pregnancy related mortality CDC Pregnancy Mortality Surveillance System: 16.0 deaths per 100,000 live births Ruptured ectopic Uterine rupture or laceration 19% Placental abruption 26% Placenta previa 16% 10% Accreta/increta/percreta Retained products 10% 12% 3% Coagulopathy 2% 2% Atony Other/unspecified Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 5 6 10/16/15 10/16/15 Obstetrical Hemorrhage Obstetrical Hemorrhage 26% increase in postpartum hemorrhage, primary due to atony 26% increase in postpartum hemorrhage, primary due to atony Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 7 8 10/16/15 10/16/15 2 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 10/16/2015 AND HANDOUTS]
A California Toolkit National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage 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 Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 9 10 10/16/15 10/16/15 Readiness: Establish a Response Team � Anesthesia � Blood bank � Pharmacy � Advanced gynecologic surgery � Critical Care Medicine � Operating room � Interventional radiology � Nursing � (Tissue banking) � (Pathology) Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 11 12 10/16/15 10/16/15 3 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 10/16/2015 AND HANDOUTS]
Recognition and Prevention: Common Access to hemorrhage medications, blood Errors products � Failure to identify at risk patients � Oxytocin 10-40 units per 500-1000mL IV infusion � Delayed response from medical team � Methylergonivine 0.2mg IM (not IV) q 2-4 hours • Protocols for activating response teams � 15-methyl PG F2a 250mcg IM or intramyometrial (not IV) � Underestimation of blood loss � Misoprostol 600-800mcg sublingual or PO • Quantitative versus estimated � Delay in blood product administration � Packed red blood cells: longer to crossmatch with antibodies � Lack of readily accessible or working equipment � Fresh frozen plasma: especially if > 2 units PRBCs � Need for organized and standardized team approach � Platelets: especially if < 50K � Cryoprecipitate: especially if Fib < 80 Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 13 14 10/16/15 10/16/15 Uterine tamponade Uterine tamponade � Internal balloons may be used where uterotonics not effective or � Compression sutures with 1-Chromic or 1-Monocryl not available (2012 WHO guidelines) • Manually squeeze the uterus from top to bottom • Fill with 500-750mL fluid • May combine with intrauterine balloon • 60-80% success in 20-30 minutes • May also be used for focal accretas • Maximum dwell 24 hours � Uterine packing may be an option in poor resource settings Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 15 16 10/16/15 10/16/15 4 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 10/16/2015 AND HANDOUTS]
Uterine artery ligation Uterine artery occlusion � O’Leary stitches � Hypogastric artery ligation • Include part of the myometrium N=110 women with PPH underwent hypogastric artery ligation • May also ligate utero-ovarian vessels 39% required hysterectomy None required re-operation; 1 iliac vein injury Kominiarek, Hospital Physician 2008 Joshi et al, Br J Obstet Gynecol 2007 Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 17 18 10/16/15 10/16/15 Uterine artery occlusion Cell Saver � Interventional Radiology techniques � Commencement after removal of fetoplacental unit • Vaso-occlusive balloons � Minimal contamination of fetal ‒ Better EBL and less transfusion in prophylaxis for percreta elements ‒ Complications of pseudoaneurysm, vessel rupture, thrombus � Higher postoperative hemoglobin concentrations • Embolization � Shorter hospital stay � Requires set up time Cali et al, Eur J Obstet Gynecol Reprod Biol 2014 Bishop et al, Int J Obsetet Anesth 2011 Rainaldi et al, Br J Anesth 1998 Urquia et al, ECR 2012 Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 19 20 10/16/15 10/16/15 5 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 10/16/2015 AND HANDOUTS]
Readiness: Multidisciplinary Team Invasive Placenta � The invasive placenta, a spectrum of abnormal adherence � Ultrasound is primary screening tool � 1/533 incidence • Prominent placental lacunae � Associated with prior C-section, other uterine surgery • Loss of space between uterus & placenta � Concurrent placenta previa in 90% • Interruption of bladder-myometrium interface � Possible defect of trophoblastic function leading to invasion • Increased vascularity � Leading cause of C-hysterectomy • Aberrant surface vessels • Sensitivity: 77-93% • Specificity: 71-96% Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 21 22 10/16/15 10/16/15 Invasive Placenta Invasive Placenta Bladder involvement � MRI is used for preoperative planning Complete previa & percreta • Abnormal uterine bulging • Heterogeneous placental signal intensity • Dark intraplacental bands • Sensitivity: 80-88% • Specificity; 65-100% Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 23 24 10/16/15 10/16/15 6 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 10/16/2015 AND HANDOUTS]
Invasive Placenta Invasive Placenta Preoperative considerations Intraoperative considerations � Traditional therapy is hysterectomy � Schedule delivery @ 34-35 weeks • Typically admitted after bleeding. ‒ Arrange for cell saver • Steroids for fetal lung maturity ‒ T&C 6 units PRBCs, 2 units FFP • MRI for surgical planning • Lithotomy position, 3 way Foley • MFM, Gyn Onc, IR, Neonatal consults • Regional anesthetic � general • Consider vertical skin incision, uterine incision based on fetal position � Schedule delivery @ 34-35 weeks • Consider vascular balloon occlusion • Unscheduled patients deliver earlier, more likely to have vaginal bleeding, uterine activity • Consider ureteral stent placement • Consider internal iliac ligation Bowman et al, Am J Obstet Gynecol 2014 Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 25 26 10/16/15 10/16/15 Readiness: Multidisciplinary Team Readiness: Multidisciplinary Team UCSF Multidisciplinary Abnormal Placentation Service (MAPS) Retrospective Cohort Study � Gynecologic Oncology 3 Tertiary care hospitals between 2000-2013 � Maternal Fetal Medicine Multidisciplinary management introduced in 2011 � Obstetrical Anesthesia 90 patients with placenta accreta � Radiology � Interventional Radiology Multidisciplinary group, n= 57, versus 33 historical controls � Nursing More percreta cases � Pathology Less EBL Less likely to be delivered emergently Shamshirasaz et al, Am J Obset Gyncol 2015 Surgical Considerations for Obstetrical Hemorrhage Surgical Considerations for Obstetrical Hemorrhage 27 28 10/16/15 10/16/15 7 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 10/16/2015 AND HANDOUTS]
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