management of postpartum hemorrhage · is necessary to treat uterine atony, go to the patient’s...

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Management of Postpartum Hemorrhage

Rachel G. Sinkey, MD

Progress 2019

Disclosures

• No conflicts of interest.

Objectives

1. Review management of postpartum hemorrhage.

2. Highlight the need for a multidisciplinary hospital-based massive transfusion protocol.

3. Discuss emerging uses of tranexamic acid.

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Case One• 25 year old G7P4115 @ 38 + 5

• Presents in active labor

• Delivers – unmedicated – within 2 hours of arrival

• The nurse calls you one hour after delivery: “Ms. Jones is

bleeding more than I’d like.”

• What do you do?

Management of postpartum hemorrhage

1. Recognize the hemorrhage


1. Recognize the hemorrhage

2. Simultaneously:

• Assess need for resuscitation

• Identify the reason

• Treat the underlying cause

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1. Tamponade

2. Medical management

3. Surgical management


1. Tamponade

a. Bimanual Massage

b. Intrauterine balloon tamponade



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1. Tamponade




1. Tamponade



a. Temporizing measures

a. Compression sutures, devascularize the uterus

b. Embolization

c. Definitive treatment – hysterectomy

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Gilmandyar et al, Seminars in Perinatology, February 2019

Anti-shock garment

https://www.viaglobalhealth.com/product/non-pneumatic-anti-shock-garment/

NASG vs Standard Care to prevent maternal mortality

Pileggi-Castro et al., 2015

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Case Two• 37 year old G4P1112 @ 392 presents for scheduled rCS

• Uncomplicated delivery of infant

• Placenta “feels a little stuck”, but delivers with manual effort

• Exteriorize the uterus

• The uterus looks like a floppy pancake & very thin at fundus

• What do you do?

Cases

• Despite correctly managing both patients, they continue to

bleed

• Hypotensive

• Tachycardic

Access

• Two large bore IVs

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Massive Transfusion

• Do you have a protocol?

• Is your blood bank onsite?

Massive Transfusion Considerations

• Each obstetric unit should have a multidisciplinary massive

transfusion protocol

• If resources allow, consider having 1-2 coolers of emergency

blood available at all times

• Use simulation to troubleshoot barriers before an actual

emergency

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Example of massive transfusion protocol

WOMAN Trial

WOMAN Trial•Randomized, placebo-controlled trial

•20,060 women

• TXA, n= 10,051; Death, n = 155 (1.5%)

• Placebo, n = 10,009; Death, n = 191 (1.9%)

• RR 0.81, 95% CI 0.65 – 1.00, p = 0.045

•VTE events similar between groups

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TXA Mechanism

• Fibrinolytic antagonist

• Binds to lysine residues in plasminogen and plasmin

preventing plasmin activation

MFMU Tranexamic Acid Trial

• Tranexamic acid for the prevention of obstetrical

hemorrhage after cesarean

• RCT of 11,000 women to assess whether TXA prophylaxis

reduces the risk of PPH among women undergoing cesarean

delivery

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Preventing Maternal Death

• Of the 10 clinical diamonds, 6 involve postpartum

hemorrhage


•Angiographic embolization is not meant to

be used for acute, massive postpartum

hemorrhage.


•If more than a single dose of medication

is necessary to treat uterine atony, go to

the patient’s bedside until the atony has

resolved.

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•Never treat “postpartum hemorrhage”

without simultaneously pursing an

actual clinical diagnosis.


•In the postpartum patient who is

bleeding or who recently has stopped

bleeding and is oliguric, furosemide is

not the answer.


•Any woman with placenta previa and

one or more cesarean deliveries should

be evaluated and delivered in a tertiary

care medical center.

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•If your labor and delivery unit does not

have a recently updated massive

transfusion protocol based on

established trauma protocols, get one

today.

Blood component processing, Kogutt et al, Seminars in Perinatology, February 2019

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https://www.smfm.org/data/mortality-map

management of postpartum hemorrhage · is necessary to treat uterine atony, go to the patient’s...

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