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Hemorrhagic shock… An obstetric perspective

Hemorrhagic shock… An obstetric perspective. Christopher T. Lang, MD Staff Perinatologist Mount Carmel Health Dept. of Obstetrics and Gynecology Division of Maternal-Fetal Medicine 6 February, 2016. Today’s presentation… Objectives.

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Hemorrhagic shock… An obstetric perspective

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  1. Hemorrhagic shock…An obstetric perspective Christopher T. Lang, MD Staff Perinatologist Mount Carmel Health Dept. of Obstetrics and Gynecology Division of Maternal-Fetal Medicine 6 February, 2016

  2. Today’s presentation…Objectives • Review the scope of obstetric hemorrhagic shock and potential sources • Discuss clinical presentation and diagnosis as well as the potential pitfalls • Discuss management strategies particularly with respect to fluid and blood product replacement

  3. The battlefield medic……and the obstetrician • Similarities • Hemorrhage in a young, healthy individual • Unpredictable • Get your hands bloody – you are “in the trenches” • More than 1 patient at 1 time • Differences • Battlefield hemorrhage = usually obvious (e.g. limb amputation, penetrating trauma) / Obstetric hemorrhage = not always obvious (e.g. concealed placental abruption) • Medic = control hemorrhage and not get shot / Obstetrician = just control hemorrhage

  4. Blood-banking CDC, Vital and Health Statistics (2007)

  5. Lewis G, et al. CEMACH 6th Report Why Mothers Die 2000-2002

  6. Chang J, et al. MMWR (2003): 52: 1-8

  7. Chang J, et al. MMWR (2003): 52: 1-8

  8. Chichakli LO, et al. Obstet Gynecol 1999; 94: 721-5

  9. Chichakli LO, et al. Obstet Gynecol 1999; 94: 721-5

  10. Maternal death Near-hit morbidity Severe morbidity Action/Inaction Physician / System / Patient

  11. Maternal physiology…Prepared for hemorrhage (1)

  12. Maternal physiology…Prepared for hemorrhage (2)

  13. Obstetric hemorrhagic shock…Pathophysiology 1 3 2 10 4 7 7 5 6 9 8 7 7 8 Multiple organ dysfunction Cohen WR. J Perinat Med 2006; 34: 263-71

  14. Obstetric hemorrhagic shock…Categorization (1) www.modernmedicine.com

  15. Obstetric hemorrhagic shock…Categorization (2) • Dr. Lang’s categories… • Typical • “Happy housekeeper” • Not typical • “Unhappy housekeeper”

  16. Obstetric hemorrhagic shock…Diagnostic pitfalls (1)

  17. Obstetric hemorrhagic shock…Diagnostic pitfalls (2) • Blood loss is always more than you estimate • Is it typical blood loss or not? • What is the source?

  18. Obstetric hemorrhagic shock…Diagnostic pitfalls (3)

  19. Obstetric hemorrhagic shock…Diagnostic pitfalls (4) Hemorrhage ≠

  20. Obstetric hemorrhagic shock…Diagnostic pitfalls (5) Hemorrhage =

  21. Obstetric hemorrhagic shock…Diagnostic pitfalls (6) cc 600 1200 1800 2400 3000

  22. Obstetric hemorrhagic shock…Management issues • Defining hemorrhage • Differential diagnosis • Don’t forget the fetus • Fluid resuscitation • “Damage control resuscitation” and transfusion principles • The “deadly triad” • Surgical approaches specific to the obstetric patient (and others)

  23. Obstetric hemorrhagic shock…Fluid resuscitation (1) • Maintenance vs. replacement fluid therapy • Hemorrhage = water and electrolyte deficits • Isotonic fluids (i.e. LR, 0.9 NS) • Keep fluid intravascular • Ultimately, a losing battle • Traditional 3:1 replacement • Lessons from Vietnam • 60-80 mL/kg per hr  SBP 80-90 mmHg • Initial volume 1-2 L LR quickly  initial attempts to restore perfusion • Goal = expand intravascular volume, preload  improved BP, urine output • Keep fluid therapy in perspective – product replacement must get priority

  24. Obstetric hemorrhagic shock…Fluid resuscitation (2) • What’s in LR anyway? • 130 mEq Na, 109 mEq Cl, 28 mEq lactate, 4 mEq K, 3 mEq Ca • pH 6.5, but an alkalizing solution • Advantages vs. NS • Reduced hyperchloremic metabolic acidosis • Reduced mortality when large volumes required • Treatment for acidosis

  25. Obstetric hemorrhagic shock…Fluid resuscitation (3) • What about hypertonics? Colloids? • To make a long story short, no benefit over isotonics and increased mortality suggested in meta-analyses of both

  26. Obstetric hemorrhagic shock…General modern-day principles (1) Cohen WR. J Perinat Med 2006; 34: 263-71

  27. 1 unit PRBCs… 250 mL Hct 50-80% 42.5 – 80 g Hb Avg 50 mL plasma 147 – 278 mg Fe Increase Hb by 1 g/dL, Hct 3% Obstetric hemorrhagic shock…General modern-day principles (2)

  28. 1 unit FFP… 250 mL 220 u each coag factor 4-pack increases most factors by approx 10%, each unit increases fibrinogen by 10-15 mg/dL Buffer – improved acidosis Must be thawed prior to use – select trauma centers keeping thawed plasma in 4°C refrigerators available for immediate use (last up to 5 days) 1 unit cryo… Cold, insoluble precipitate of 1 u of FFP 15 mL 100 IU factor VIII, 250 mg fibrinogen, vWF, factor XIII 1 u/10 kg body weight increases fibrinogen by approx 50 mg/dL, or each unit increases fibrinogen by 7 mg/dL Obstetric hemorrhagic shock…General modern-day principles (3)

  29. 1 unit platelets… 50 mL 8 x 1010 platelets Avg 50 mL plasma Increase platelets by approx 7-10,000 Obstetric hemorrhagic shock…General modern-day principles (4)

  30. Operations Iraqi and Enduring Freedom Challenge to traditional teaching that e.g. coagulopathy is iatrogenic (i.e. “give FFP only when so many units of PRBCs transfused”) The severely injured / unstable obstetric patient (?) has physiologic derangements which must be corrected promptly Multi-organ dysfunction is irreversible Obstetric hemorrhagic shock…“Damage control resuscitation” (1)

  31. Who might benefit? SBP < 80 mmHg Base deficit > 6 INR ≥ 1.5 Platelets < 100,000 Hct < 30% Fibrinogen < 100 mg/dL Obstetric hemorrhagic shock…“Damage control resuscitation” (2) Hess JR, et al. Transf 2008; 48: 1763-5

  32. Damage control resuscitation…Can obstetric patients fit the bill? • Absolutely… • with the potential advantage of deterioration happening right in front of you, rather than prior to arrival on the battlefield or at the accident scene • Anecdotal cases • Immediate intraoperative postpartum hemorrhage secondary to uterine atony, etc • Obstetric hemorrhage “shows no mercy”

  33. Obstetric hemorrhagic shock…FFP:PRBC ratios (1)

  34. Obstetric hemorrhagic shock…FFP:PRBC ratios (2) • Retrospective, combat • N = 246 • Massive transf • 3 cohorts FFP:PRBC • 1:8 • 1:2.5 • 1:1.4 Hemorrhagic mortality, esp early Median interval to death = 2 hrs Borgman MA, et al. J Trauma 2007; 63: 805-13

  35. Obstetric hemorrhagic shock…FFP:PRBC ratios (3) • Retrospective, combat • N = 246 • Massive transf • 3 cohorts FFP:PRBC • 1:8 • 1:2.5 • 1:1.4 Borgman MA, et al. J Trauma 2007; 63: 805-13

  36. Obstetric hemorrhagic shock…FFP:PRBC ratios (4) • Retrospective, civilian • N = 415 • Massive transf • 2 cohorts FFP:PRBC • ≥1.5 • <1.5 mortality, esp early Sperry JL, et al. J Trauma 2008; 65: 986-93

  37. Obstetric hemorrhagic shock…Importance of coagulopathy (1) • Retrospective, civilian • N = 97 (of 200) • Massive transf, pre-ICU • 1:6 FFP:PRBC • 1:1 FFP:PRBC • Post-ICU Gonzalez EA, et al. J Trauma 2007; 62: 112-9

  38. Obstetric hemorrhagic shock…Importance of coagulopathy (2) • Retrospective, civilian • N = 97 (of 200) • Massive transf pre-ICU • 1:6 FFP:PRBC • 1:1 FFP:PRBC • Post-ICU Gonzalez EA, et al. J Trauma 2007; 62: 112-9

  39. Obstetric hemorrhagic shock…Whole blood (1) • Retrospective, combat • N = 354 • Massive transf • 2 cohorts • WFWB • CT Spinella PC, et al. J Trauma 2009; 66: S69-76

  40. Obstetric hemorrhagic shock…Whole blood (2) • Retrospective, combat • N = 354 • Massive transf • 2 cohorts • WFWB • CT Spinella PC, et al. J Trauma 2009; 66: S69-76

  41. Obstetric hemorrhagic shock…Whole blood (3) • OSUMC blood bank does not keep any WFWB • Grant MC blood bank does not keep any WFWB • “Damage control resuscitation” with component therapy 1:1

  42. Obstetric hemorrhagic shock…Platelets (1) • Prophylactic platelet administration during massive transfusion • Prospective, randomized, double-blind clinical study; civilian • N = 33 • Massive transf (WFWB) • 2 interventions • Proph plts:WFWB 6:12 • Proph FFP:WFWB 2:12 } No diff in microvascular bleeding (DIC) Reed RL, et al. Ann Surg 1986; 203: 40-8

  43. Obstetric hemorrhagic shock…Platelets (2) Endogenous plt release Reed RL, et al. Ann Surg 1986; 203: 40-8

  44. Obstetric hemorrhagic shock…The “deadly triad” • Coagulopathy • Hypothermia • Acidosis

  45. Obstetric hemorrhagic shock…The “deadly triad” - hypothermia • < 32-34°C • Clotting factors don’t work well when you are cold • Keep patient warm by whatever means necessary

  46. Obstetric hemorrhagic shock…The “deadly triad” - acidosis • Clotting factors also don’t work well in an acidic environment • Platelets lose their ability to aggregate • Stop hemorrhage, restore perfusion = reverse acidosis • In meantime, don’t make it worse  maintain ventilation, use LR

  47. Obstetric hemorrhagic shock…Recombinant factor VIIa • Suffice it to say… • When this is considered, the patient is in serious trouble • It may reduce PRBC requirements and save lives when nothing else will • The “ideal” patient to receive this therapy is unknown, as is when to give it • Thromboembolic complications are a potential risk

  48. Damage control at its finest…Surgical approaches (1)

  49. Damage control at its finest…Surgical approaches (2)

  50. Damage control at its finest…Surgical approaches (3)

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