Postpartum Hemorrhage:
Diagnosis, Treatment and The Michigan Approach
July 2021
Conflicts of Interest
Department of
Anesthesiology
Department of Anesthesiology
I have no conflicts of interest to disclose.
Tom Klumpner, MD
Clinical Assistant Professor
Anesthesiology and Obstetrics and Gynecology
Assistant Director, Informatics and Systems Improvement
Maternal Mortality Rates Per 100,000 Live Births
Department of
Anesthesiology
Department of Anesthesiology
GBD 2015 Maternal Mortality
Collaborators. Global, regional, and
national levels of maternal mortality,
1990-2015: a systematic analysis for
the Global Burden of Disease Study
2015. Lancet 388, 1775–1812 (2016)
Figure adapted from NPR.org.
https://www.npr.org/2017/05/12/528098
789/u-s-has-the-worst-rate-of-maternal-
deaths-in-the-developed-world
Accessed: July 31, 2019
Maternal Mortality Rates Per 100,000 Live Births
Department of
Anesthesiology
Department of Anesthesiology
CDC. Pregnancy Mortality Surveillance
System.
https://www.cdc.gov/reproductivehealth/
maternal-mortality/pregnancy-mortality-
surveillance-system.htm
Accessed: June 15, 2021
Maternal Mortality Rates Per 100,000 Live Births
Department of
Anesthesiology
Department of Anesthesiology
Deadly Deliveries. USA Today. Accessed: July 2019
Maternal Mortality
Department of
Anesthesiology
Department of Anesthesiology
• Postpartum
hemorrhage
(PPH) is a
leading cause
of maternal
death
cdc.gov
https://www.cdc.gov/reproductivehe
alth/maternalinfanthealth/pregnancy
-mortality-surveillance-system.htm
Maternal Mortality
Department of
Anesthesiology
Department of Anesthesiology
• Postpartum
hemorrhage
(PPH) is a
leading cause
of maternal
death in
Michigan
https://www.michigan.gov/document
s/mdhhs/MMMS_2012-
2016_Fact_Sheet_1.23.2020_6794
78_7.pdf
Preventable Maternal Mortality
Department of
Anesthesiology
Department of Anesthesiology
• Death from
postpartum
hemorrhage is
often
preventable
Main, E. et al. Pregnancy-Related
Mortality in California: Causes,
Characteristics, and Improvement
Opportunities. Obstetrics &
Gynecology. 125(4):938–947, Apr
2015
Preventable Maternal Mortality
Department of
Anesthesiology
Department of Anesthesiology
• Death from
postpartum
hemorrhage is
often
preventable
and is often
related to
delayed and
ineffective care.
Main, E. et al. Pregnancy-Related
Mortality in California: Causes,
Characteristics, and Improvement
Opportunities. Obstetrics &
Gynecology. 125(4):938–947, Apr
2015
Department of
Anesthesiology
Department of Anesthesiology
We are at a turning point.
Outline
Department of
Anesthesiology
Department of Anesthesiology
• Epidemiology and definition
• Risk Factors
• Diagnosis
• Early Identification
• Pathogenesis
• Treatment
• Transfusion Management
• Preparation
Health.mil
Incidence
Department of
Anesthesiology
Department of Anesthesiology
• In the US: 3%
• Worldwide: 6-11%
Marshall, A.L. et. al. The impact of postpartum hemorrhage on hospital length of stay and inpatient mortality: a National Inpatient Sample-based analysis. Am J Obstet Gynecol. 2017 Sep;217(3):344.e1-344.e6
John M. Eisenberg Center for Clinical Decisions and Communications Science. Comparative Effectiveness Review Summary Guides for Clinicians [Internet]. Rockville (MD): Agency for Healthcare Research
and Quality (US); 2007-. AHRQ Comparative Effectiveness Reviews. 2016 Jul 12.
Incidence
Department of
Anesthesiology
Department of Anesthesiology
• In the US: 3%
• Worldwide: 6-11%
• Incidence is increasing
• 26% increase in US between 1994-
2006
• Severity is also increasing
John M. Eisenberg Center for Clinical Decisions and Communications Science. Comparative Effectiveness Review Summary Guides for Clinicians [Internet]. Rockville (MD): Agency for Healthcare Research
and Quality (US); 2007-. AHRQ Comparative Effectiveness Reviews. 2016 Jul 12.
CDC. Data on Selected Pregnancy Complications in the United States. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-complications-data.htm Accessed: July 2019
Risk Factors
Department of
Anesthesiology
Department of Anesthesiology
Before Pregnancy
• Maternal Age <19
• Maternal Age >35
• Grand Multiparity (≥ 5 births)
• Prior Cesarean Delivery
Antepartum
• Hypertensive Disease of Pregnancy
• Diabetes
• Polyhydramnios
• Infection
• Placenta Previa/Abruption
• Multiple Gestation
• Macrosomia (>4,000g)
• Fibroids
Intra/Post-partum
• Medical Induction of Labor
• Instrumental Vaginal Delivery
• Cesarean Delivery
M.S. Kramer, C. Berg, H. Abenhaim, et al. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol, 209
(2013), pp. 449.e1-449.e7
Risk Factors
Department of
Anesthesiology
Department of Anesthesiology
M.S. Kramer, C. Berg, H. Abenhaim, et al. Incidence, risk factors, and temporal trends in severe postpartum
hemorrhage. Am J Obstet Gynecol, 209 (2013), pp. 449.e1-449.e7
• Not all risk factors are equal
Risk Factors
Department of
Anesthesiology
Department of Anesthesiology
M.S. Kramer, C. Berg, H. Abenhaim, et al. Incidence, risk factors, and temporal trends in severe postpartum
hemorrhage. Am J Obstet Gynecol, 209 (2013), pp. 449.e1-449.e7
• Not all risk factors are equal
• Multiple Gestation – OR 2.8 (2.6 - 3.0)
• Amnionitis – OR 2.9 (2.5 - 3.4)
• Preeclampsia – OR 3.1 (2.9 - 3.3)
• Eclampsia – OR 5.1 (4.3 - 6.2)
Risk Factors
Department of
Anesthesiology
Department of Anesthesiology
M.S. Kramer, C. Berg, H. Abenhaim, et al. Incidence, risk factors, and temporal trends in severe postpartum
hemorrhage. Am J Obstet Gynecol, 209 (2013), pp. 449.e1-449.e7
• Risk factors are not completely predictive
Risk Factors
Department of
Anesthesiology
Department of Anesthesiology
Main, Elliott K. MD; Goffman, Dena MD; Scavone, Barbara M. MD; Low, Lisa Kane PhD, CNM; Bingham, Debra
DrPH, RN; Fontaine, Patricia L. MD, MS; Gorlin, Jed B. MD; Lagrew, David C. MD; Levy, Barbara S. MD National
Partnership for Maternal Safety, Obstetrics & Gynecology: July 2015 - Volume 126 - Issue 1 - p 155-162
• Risk factors are not completely predictive
• 40% of PPH occurs in low risk
women
Department of
Anesthesiology
Department of Anesthesiology
Diagnosis
Definition
Department of
Anesthesiology
Department of Anesthesiology
• Traditionally:
• Vaginal Delivery: 500cc of blood lost
• Cesarean Delivery: 1000cc of blood lost
• Recently:
• 1000cc blood lost
OR
• Blood loss accompanied by signs or symptoms of
hypovolemia
Borovac-Pinheiro, A. et. al. Postpartum hemorrhage: new insights for definition and diagnosis. American Journal of Obstetrics & Gynecology, Volume 219, Issue 2, 162 – 168
Menard MK, Main EK, Currigan SM. Executive summary of the reVITALize initiative: standardizing obstetric data definitions. Obstet Gynecol 2014;124:150–3.
Maxpixel.net
Diagnosis
Department of
Anesthesiology
Department of Anesthesiology
• Visual Estimation of Blood Loss
• Most frequently practiced
• Most people receive no formal training
in estimating EBL
• Training might not improve estimation
• Often underestimates blood loss
• Underestimation increases as blood
loss increases
• Quantitative Methods
• More sensitive
• Not always rapidly available
Toledo P et al. The accuracy of blood loss estimation after simulated vaginal delivery. Anesth Analg. 2007 Dec;105(6):1736-40.
W Prasertcharoensuk, et. al. Accuracy of the blood loss estimation in the third stage of labor. Int J Gyn Obst. Vol 71. Iss 1. pg 69-70. Oct. 2000
Hancock A., et. al. Is accurate and reliable blood loss estimation the 'crucial step' in early detection of postpartum haemorrhage: an integrative review of the literature. BMC Pregnancy Childbirth. 2015; 15: 230.
Toledo et. al.
Diagnosis
Department of
Anesthesiology
Department of Anesthesiology
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
R. Collis, E. Guasch. Managing major obstetric haemorrhage: Pharmacotherapy and transfusion. Best Practice &
Research Clinical Anaesthesiology 31 (2017) 107-124
• Signs or symptoms of hypovolemia with
blood loss
• Increased blood volume in pregnancy limits
sensitivity
Diagnosis
Department of
Anesthesiology
Department of Anesthesiology
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
R. Collis, E. Guasch. Managing major obstetric haemorrhage: Pharmacotherapy and transfusion. Best Practice &
Research Clinical Anaesthesiology 31 (2017) 107-124
• Signs or symptoms of hypovolemia with
blood loss
• Increased blood volume in pregnancy limits
sensitivity
Estimated Blood Loss Clinical Signs
<1000cc
--
>1000-1500cc
tachycardia, tachypnea,
slight ↓ systolic blood
pressure
>1500cc
↑ tachycardia, ↑ tachypnea,
systolic blood pressure < 80
mmHg, altered mental
status
Diagnosis
Department of
Anesthesiology
Department of Anesthesiology
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
R. Collis, E. Guasch. Managing major obstetric haemorrhage: Pharmacotherapy and transfusion. Best Practice &
Research Clinical Anaesthesiology 31 (2017) 107-124
• Signs or symptoms of hypovolemia with
blood loss
• Increased blood volume in pregnancy limits
sensitivity
• Early recognition is key!
Estimated Blood Loss Clinical Signs
<1000cc
--
>1000-1500cc
tachycardia, tachypnea,
slight ↓ systolic blood
pressure
>1500cc
↑ tachycardia, ↑ tachypnea,
systolic blood pressure < 80
mmHg, altered mental
status
Diagnosis
Department of
Anesthesiology
Department of Anesthesiology
Mhyre J. et. al. The Maternal Early Warning Criteria A Proposal From the National Partnership for Maternal Safety.
Obstet Gynecol 2014;124:782–6
Department of
Anesthesiology
Department of Anesthesiology
Pathogenesis
Pathogenesis – The Four T’s
Department of
Anesthesiology
Department of Anesthesiology
Tone
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
Pathogenesis – The Four T’s
Department of
Anesthesiology
Department of Anesthesiology
Tone
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
Traum
a
Pathogenesis – The Four T’s
Department of
Anesthesiology
Department of Anesthesiology
Tone
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
Traum
a
Tissue
Pathogenesis – The Four T’s
Department of
Anesthesiology
Department of Anesthesiology
Tone
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
Traum
a
Tissue
Thrombi
n
Pathogenesis – The Four T’s
Department of
Anesthesiology
Department of Anesthesiology
Tone
Uterine Atony: Overdistention,
Muscle Fatigue, GA, Chorioamnionitis
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
Traum
a
Tissue
Thrombi
n
Pathogenesis – The Four T’s
Department of
Anesthesiology
Department of Anesthesiology
Tone
Uterine Atony: Overdistention,
Muscle Fatigue, GA, Chorioamnionitis
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
Traum
a
Genital Tract Laceration, Uterine Inversion,
Surgical Misadventure
Tissue
Thrombi
n
Pathogenesis – The Four T’s
Department of
Anesthesiology
Department of Anesthesiology
Tone
Uterine Atony: Overdistention,
Muscle Fatigue, GA, Chorioamnionitis
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
Traum
a
Genital Tract Laceration, Uterine Inversion,
Surgical Misadventure
Tissue
Retained Placenta, Invasive Placenta,
Placental Abruption
Thrombi
n
Pathogenesis – The Four T’s
Department of
Anesthesiology
Department of Anesthesiology
Tone
Uterine Atony: Overdistention,
Muscle Fatigue, GA, Chorioamnionitis
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
Traum
a
Genital Tract Laceration, Uterine Inversion,
Surgical Misadventure
Tissue
Retained Placenta, Invasive Placenta,
Placental Abruption
Thrombi
n
Placental Abruption, Pre-Eclampsia,
Coagulopathy
Pathogenesis – The Four T’s
Department of
Anesthesiology
Department of Anesthesiology
Tone
Uterine Atony: Overdistention,
Muscle Fatigue, GA, Chorioamnionitis
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
Pathogenesis – The Four T’s
Department of
Anesthesiology
Department of Anesthesiology
Tone
Uterine Atony: Overdistention,
Muscle Fatigue, GA, Chorioamnionitis
E. Mavrides, S. Allard, E. Chandraharan, et al., on behalf of the Royal College of Obstetricians and Gynaecologists
Prevention and management of postpartum haemorrhage. BJOG (2016)
Uterine atony causes 80% of PPH
Department of
Anesthesiology
Department of Anesthesiology
Treatment
Management of Postpartum Hemorrhage
Department of
Anesthesiology
Department of Anesthesiology
EBL>1000cc, brisk
bleeding, or signs of
hypovolemia
Resuscitate
Determine Cause
and Treat
Management of Postpartum Hemorrhage
Department of
Anesthesiology
Department of Anesthesiology
Resuscitate
Determine Cause
and Treat
• Call for help
• Establish (multiple) large-bore IV access
• Obtain baseline laboratory studies: CBC, INR,
fibrinogen, viscoelastometric testing (if available)
• Type and Screen/Type and Cross
• Correct hypovolemia
• Escalate monitoring
• Monitor urine output
• Move to the OR quickly
• Maintain normothermia, electrolyte management,
etc
Management of Postpartum Hemorrhage
Department of
Anesthesiology
Department of Anesthesiology
Resuscitate
Determine Cause
and Treat
Tone
Trauma
Tissue
Thrombi
n
• Call for help
• Establish (multiple) large-bore IV access
• Obtain baseline laboratory studies: CBC, INR,
fibrinogen, viscoelastometric testing (if available)
• Type and Screen/Type and Cross
• Correct hypovolemia
• Escalate monitoring
• Monitor urine output
• Move to the OR quickly
• Maintain normothermia, electrolyte management,
etc
Treatment
Department of
Anesthesiology
Department of Anesthesiology
Determine Cause
and Treat
Tone
Trauma
Tissue
Thrombin
• Oxytocin
• First line therapy
• Methylergonovine (Methergine)
• Judicious use in patients with HTN
• Carboprost (Hemabate)
• Judicious use in patients with reactive airway
disease
• Misoprostol (Cytotec)
Wikimedia Commons
Treatment
Department of
Anesthesiology
Department of Anesthesiology
Determine Cause
and Treat
Tone
Trauma
Tissue
Thrombin
• Uterine massage
• Intrauterine balloon tamponade
• Uterine compression sutures
utahmed.com
Treatment
Department of
Anesthesiology
Department of Anesthesiology
Determine Cause
and Treat
Tone
Trauma
Tissue
Thrombin
• Evaluation by obstetric team
• Laceration repair
• Uterine exploration
• Manual removal of placenta
• Curettage
Wikimedia Commons
Treatment
Department of
Anesthesiology
Department of Anesthesiology
Determine Cause
and Treat
Tone
Trauma
Tissue
Thrombi
n
• Evaluation of clotting
• Replace clotting factors, platelets
• Hematology consult for congenital
clotting disorders to target treatment
Flickr
Management of Postpartum Hemorrhage
Department of
Anesthesiology
Department of Anesthesiology
Resuscitate
Determine Cause
and Treat
Tone
Trauma
Tissue
• Call for help
• Establish (multiple) large-bore IV access
• Obtain baseline laboratory studies: CBC, INR,
fibrinogen, viscoelastometric testing (if available)
• Type and Screen/Type and Cross
• Correct hypovolemia
• Escalate monitoring
• Monitor urine output
• Move to the OR quickly
• Maintain normothermia, electrolyte management,
etc
Thrombi
n
Department of
Anesthesiology
Department of Anesthesiology
Transfusion Management
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
pRBC : FFP - Fixed ratio?
1:1?
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
pRBC : FFP - Fixed ratio?
1:1?
More than 80% of institutions report using 1:1 ratio
Treml, A. et. al. Massive Transfusion Protocols: A Survey of Academic Medical Centers in the United States.
Anesthesia & Analgesia 124 (1):277-281, January 2017.
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Hypofibrinogenemia is associated with PPH
Collins PW, et. al. Management of postpartum haemorrhage: from research into practice, a narrative review of the literature and
the Cardiff experience. Int J Obstet Anesth. 2019 Feb;37:106-117.
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Collins PW, et. al. Management of postpartum haemorrhage: from research into practice, a narrative review of the literature and
the Cardiff experience. Int J Obstet Anesth. 2019 Feb;37:106-117.
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
From Carlo Pancaro, MD, used with permission.
Coagulation impairment after 1-2 liters blood loss
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Collins et al Theoretical modeling of fibrinogen supplementation with therapeutic plasma, cryoprecipitate, or fibrinogen concentrate. BJA 113:585-95 2014.
Abbassi-Ghanavati, M. et. al. Pregnancy and Laboratory Studies. Obstet Gynecol 2009;114:1326–31
Effect of empiric FFP administration in PPH
2 2.5
3
0
5
10
Units
Plasma fibrinogen g/L
1 L FFP
Abruption
Fibrinogen <200 mg/dL
Uterine Atony/Surgical
Bleeding
Fibrinogen 400 mg/dL
0
5
10
Units
Plasma fibrinogen g/L
3 4 5
3.5
4.5
1 L FFP
*Normal fibrinogen (third trimester) = 373 - 619mg/dL
FFP
contains
about
200-250
mg/dL
fibrinogen
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Collins et al Theoretical modeling of fibrinogen supplementation with therapeutic plasma, cryoprecipitate, or fibrinogen concentrate. BJA 113:585-95 2014.
Abbassi-Ghanavati, M. et. al. Pregnancy and Laboratory Studies. Obstet Gynecol 2009;114:1326–31
Effect of empiric FFP administration in PPH
2 2.5
3
0
5
10
Units
Plasma fibrinogen g/L
1 L FFP
Abruption
Fibrinogen <200 mg/dL
Uterine Atony/Surgical
Bleeding
Fibrinogen 400 mg/dL
0
5
10
Units
Plasma fibrinogen g/L
3 4 5
3.5
4.5
1 L FFP
*Normal fibrinogen (third trimester) = 373 - 619mg/dL
FFP
contains
about
200-250
mg/dL
fibrinogen
Department of
Anesthesiology
Department of Anesthesiology
Using Viscoelastometric Testing to Guide Transfusion
Therapy
Viscoelastometric Testing
Department of
Anesthesiology
Department of Anesthesiology
Görlinger K., Dirkmann D., Hanke A.A.
(2016) Rotational Thromboelastometry
(ROTEM®). In: Gonzalez E., Moore H.,
Moore E. (eds) Trauma Induced
Coagulopathy. Springer, Cham
Viscoelastometric Testing
Department of
Anesthesiology
Department of Anesthesiology
haemoview.com.au
Viscoelastometric Testing
Department of
Anesthesiology
Department of Anesthesiology
• INTEM
• Intrinsic system screening test
• EXTEM
• Extrinsic system screening test
• FIBTEM
• Isolated fibrinogen contribution to clot firmness
Görlinger K., Dirkmann D., Hanke A.A. (2016) Rotational Thromboelastometry (ROTEM®). In: Gonzalez E., Moore H., Moore E. (eds) Trauma Induced Coagulopathy. Springer, Cham
link.springer.com
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Viscoelastic fibrinogen testing correlates with severity of PPH
Collins PW, et. al. Management of postpartum haemorrhage: from research into practice, a narrative review of
the literature and the Cardiff experience. Int J Obstet Anesth. 2019 Feb;37:106-117.
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Collins et. al. Viscoelastometric-guided early fibrinogen concentrate
replacement during postpartum haemorrhage: OBS2, a double-blind
randomized controlled trial. BJA, 119 (3): 411–21 (2017)
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
• No difference in outcome
when a goal:
– FIBTEM A5 > 16mm (300
mg/dL) used as threshold.
– FIBTEM A5 > 12mm (200
mg/dL) used as threshold.
• No benefit to treat fibrinogen
level > 200 mg/dL
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Anaesthesia. 2015 Feb;70(2):166-75
• EBL > 1500cc with coagulopathy
• 2011-2012: “shock pack”
• Emphasis on early transfusion
• 2012-2013: “fibrinogen phase”
• Emphasis on ROTEM guidance
• Use of fibrinogen concentrate
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Anaesthesia. 2015 Feb;70(2):166-75
• EBL > 1500cc with coagulopathy
• 2011-2012: “shock pack”
• Emphasis on early transfusion
• 2012-2013: “fibrinogen phase”
• Emphasis on ROTEM guidance
• Use of fibrinogen concentrate
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Anaesthesia. 2015 Feb;70(2):166-75
• EBL > 1500cc with coagulopathy
• 2011-2012: “shock pack”
• Emphasis on early transfusion
• 2012-2013: “fibrinogen phase”
• Emphasis on ROTEM guidance
• Use of fibrinogen concentrate
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Snegovskikh, D. et. al. Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage. Journal of Clinical Anesthesia 44 (2018) 50–56.
• Retrospective cohort study: 2011-2015
• Before and after study
• standard massive transfusion protocol vs.
point-of-care ROTEM-based protocol
• ROTEM-guided administration of:
• Cryoprecipitate (FIBTEM)
• FFP (CT)
• Platelets (MCF)
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Snegovskikh, D. et. al. Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage. Journal of Clinical Anesthesia 44 (2018) 50–56.
• Reduction in:
• pRBC, FFP and platelet administration
• Length of hospital stay
• ICU admissions
• Reduction in hysterectomies
Transfusion Management
Department of
Anesthesiology
Department of Anesthesiology
Snegovskikh, D. et. al. Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage. Journal of Clinical Anesthesia 44 (2018) 50–56.
Department of
Anesthesiology
Department of Anesthesiology
Tranexamic Acid
Department of
Anesthesiology
Department of Anesthesiology
Lancet. 2017 May 27;389(10084):2105-2116
• Randomized controlled trial, 2010-
2016
• 193 hospitals, 21 countries, 20,060
women
• 1g tranexamic acid vs. placebo at
clinical diagnosis of hemorrhage
Department of
Anesthesiology
Department of Anesthesiology
Lancet. 2017 May 27;389(10084):2105-2116
• Randomized controlled trial, 2010-
2016
• 193 hospitals, 21 countries, 20,060
women
• 1g tranexamic acid vs. placebo at
clinical diagnosis of hemorrhage
Department of
Anesthesiology
Department of Anesthesiology
Lancet. 2017 May 27;389(10084):2105-2116
• Tranexamic acid mortality:
155/10036 - 1.5 %
• Placebo mortality:
191/9985 - 1.9%
• Mortality in USA for PPH:
1.7 per 100,000 births
Department of
Anesthesiology
Department of Anesthesiology
The Michigan Medicine PPH Transfusion Protocol
Department of
Anesthesiology
Department of Anesthesiology
Department of
Anesthesiology
Department of Anesthesiology
Department of
Anesthesiology
Department of Anesthesiology
Department of
Anesthesiology
Department of Anesthesiology
Preparation and Response
Preparation and Response
Department of
Anesthesiology
Department of Anesthesiology
Maternal Early
Warning System
Preparation and Response
Department of
Anesthesiology
Department of Anesthesiology
Mhyre J. et. al. The Maternal Early Warning Criteria A Proposal From the National Partnership for Maternal Safety.
Obstet Gynecol 2014;124:782–6
Preparation and Response
Department of
Anesthesiology
Department of Anesthesiology
Maternal Early
Warning System
Preparation and Response
Department of
Anesthesiology
Department of Anesthesiology
Maternal Early
Warning System
Respond
Monitor
Identify Trigger
Alert
Evaluate
Diagnose
Preparation and Response
Department of
Anesthesiology
Department of Anesthesiology
Klumpner TT, Kountanis JA,
Langen ES, Smith RD, Tremper
KK. Use of a novel electronic
maternal surveillance system to
generate automated alerts on the
labor and delivery unit. BMC
Anesthesiol. 2018;18(1):78.
Preparation and Response
Department of
Anesthesiology
Department of Anesthesiology
Klumpner TT, Kountanis JA,
Langen ES, Smith RD, Tremper
KK. Use of a novel electronic
maternal surveillance system to
generate automated alerts on the
labor and delivery unit. BMC
Anesthesiol. 2018;18(1):78.
Preparation and Response
Department of
Anesthesiology
Department of Anesthesiology
Health.mil
Preparation and Response
Department of
Anesthesiology
Department of Anesthesiology
Simulation Training
Preparation and Response
Department of
Anesthesiology
Department of Anesthesiology
Marshall NE, et. al. Impact of simulation and team training on postpartum hemorrhage management in non-academic centers. J Matern Fetal Neonatal Med. 2015 Mar;28(5):495-9.
• Effect of simulation and team
training on response to
simulated hemorrhage
• 6 rural and urban non-
academic centers
• Simulated PPH followed by
didactic
Preparation and Response
Department of
Anesthesiology
Department of Anesthesiology
Marshall NE, et. al. Impact of simulation and team training on postpartum hemorrhage management in non-academic centers. J Matern Fetal Neonatal Med. 2015 Mar;28(5):495-9.
• Improvement in:
• Recognition of PPH
• Time to use oxytocin
• Time to perform uterine massage
• Time to use a secondary uterotonic
Preparation and Response
Department of
Anesthesiology
Department of Anesthesiology
Postpartum Hemorrhage
Protocols
Preparation and Response – PPH Protocol
Department of
Anesthesiology
Department of Anesthesiology
Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-e186.
• Use of a postpartum
hemorrhage management
protocol is recommended
by ACOG
Preparation and Response – PPH Protocol
Department of
Anesthesiology
Department of Anesthesiology
Shields, LE. et. al. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol. 2015 Mar;212(3):272-80.
• Comprehensive PPH protocol across 29 hospitals comprising 60,000
births annually.
• 2010-2012
Preparation and Response – PPH Protocol
Department of
Anesthesiology
Department of Anesthesiology
Shields, LE. et. al. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol. 2015 Mar;212(3):272-80.
• PPH protocol:
– hemorrhage risk assessment
– early escalation of care and
monitoring
– sending laboratory studies
– uterotonic administration
– transfusion guidance
• 26% reduction in blood
product administration.
STAGE 2
OB Hemorrhage
Ongoing bleeding and/or vital sign instability, and < 1500 ml cumulative blood loss (EBL/QBL)
Cumulative blood loss (EBL/QBL) > 1500 ml, > 2units PRBCS given, VS unstable or suspicion for DIC?
Proceed to STAGE 3
MOBILIZE
Primary Nurse:
❏ Activate OB
Hemorrhage Protocol
❏ Call/Birth Center
Page Team Leader
and Anesthesiology to
room
Team Leader or designee:
❏ Bring Hemorrhage
Cart to patient’s
location if not in OR
❏ Notify Charge Nurse
❏ Assign designees to
continue Blood Bank
communication
❏ Designate a provider,
nurse, or SW as family
support person
OR Team Leader:
❏ Prepare OR & staff for
patient transfer if not
already there
ACT
OB/Nurse/Anesthesia Team Leaders
❏ Continue IV oxytocin, IV crystalloid, uterine massage
❏ Obtain and document quantitative blood loss q 10 minutes
❏ Continue uterotonic medication per protocol (Virtual Hemorrhage Pack in
Pyxis)*
Second nurse or OR techs:
❏ Obtain portable light and OB procedure tray
❏ Assist with transfer to OR (if indicated)
❏ Administer methergine 0.2 mg IM (if not hypertensive);
may repeat dose q 2 hr
❏ Administer misoprostol 800 mcg buccal or rectal
❏ Administer hemabate 0.25 mg IM (if not asthmatic); may
repeat dose q 15 min
Give once, if
no response,
move to next
agent
❏ Vital signs, including O2 sat & level of consciousness (LOC) q 5 minutes
❏ Administer oxygen to maintain O2 sats at > 95% & keep patient warm
❏ Empty bladder; straight cath or place Foley with urimeter
❏ Transfusion
❏ Bring 2 units PRBCs to bedside (mobile refrigerator on unit or blood bank)
❏ Consider activation of Massive Transfusion Protocol
❏ Transfuse PRBCs based on clinical signs & response; don’t wait for lab
results
❏ Order labs STAT (CBC, CMP, Coag/Fibrinogen, Point-of-care labs)
Don’t delay other interventions while waiting for response. Consider move to OR.
THINK
Once stabilized:
❏ Postpartum Debrief
❏ Update Postpartum Risk
Assessment: Modified postpartum
management with increased
surveillance
Vaginal birth
• Trauma (vaginal, cervical, or uterine)
🡪 Visualize & repair
• Retained placenta 🡪 D&C
• Uterine atony/LUS bleeding 🡪 Bakri
• Other 🡪 Arterial embolization (IR)
Cesarean Section
• Atony 🡪 B-Lynch, Intrauterine Balloon
• Uterine Inversion 🡪 Anesthesia &
uterine relaxation for manual
reduction
• Amniotic Fluid Embolism 🡪
Maximally aggressive respiratory,
vasopressor, and blood product
support
• VS worse than blood loss 🡪 consider
uterine rupture or broad ligament tear
with internal bleeding 🡪 move to
laparotomy
STAGE 2
OB Hemorrhage
Ongoing bleeding and/or vital sign instability, and < 1500 ml cumulative blood loss (EBL/QBL)
Cumulative blood loss (EBL/QBL) > 1500 ml, > 2units PRBCS given, VS unstable or suspicion for DIC?
Proceed to STAGE 3
MOBILIZE
Primary Nurse:
❏ Activate OB
Hemorrhage Protocol
❏ Call/Birth Center
Page Team Leader
and Anesthesiology to
room
Team Leader or designee:
❏ Bring Hemorrhage
Cart to patient’s
location if not in OR
❏ Notify Charge Nurse
❏ Assign designees to
continue Blood Bank
communication
❏ Designate a provider,
nurse, or SW as family
support person
OR Team Leader:
❏ Prepare OR & staff for
patient transfer if not
already there
ACT
OB/Nurse/Anesthesia Team Leaders
❏ Continue IV oxytocin, IV crystalloid, uterine massage
❏ Obtain and document quantitative blood loss q 10 minutes
❏ Continue uterotonic medication per protocol (Virtual Hemorrhage Pack in
Pyxis)*
Second nurse or OR techs:
❏ Obtain portable light and OB procedure tray
❏ Assist with transfer to OR (if indicated)
❏ Administer methergine 0.2 mg IM (if not hypertensive);
may repeat dose q 2 hr
❏ Administer misoprostol 800 mcg buccal or rectal
❏ Administer hemabate 0.25 mg IM (if not asthmatic); may
repeat dose q 15 min
Give once, if
no response,
move to next
agent
❏ Vital signs, including O2 sat & level of consciousness (LOC) q 5 minutes
❏ Administer oxygen to maintain O2 sats at > 95% & keep patient warm
❏ Empty bladder; straight cath or place Foley with urimeter
❏ Transfusion
❏ Bring 2 units PRBCs to bedside (mobile refrigerator on unit or blood bank)
❏ Consider activation of Massive Transfusion Protocol
❏ Transfuse PRBCs based on clinical signs & response; don’t wait for lab
results
❏ Order labs STAT (CBC, CMP, Coag/Fibrinogen, Point-of-care labs)
Don’t delay other interventions while waiting for response. Consider move to OR.
THINK
Once stabilized:
❏ Postpartum Debrief
❏ Update Postpartum Risk
Assessment: Modified postpartum
management with increased
surveillance
Vaginal birth
• Trauma (vaginal, cervical, or uterine)
🡪 Visualize & repair
• Retained placenta 🡪 D&C
• Uterine atony/LUS bleeding 🡪 Bakri
• Other 🡪 Arterial embolization (IR)
Cesarean Section
• Atony 🡪 B-Lynch, Intrauterine Balloon
• Uterine Inversion 🡪 Anesthesia &
uterine relaxation for manual
reduction
• Amniotic Fluid Embolism 🡪
Maximally aggressive respiratory,
vasopressor, and blood product
support
• VS worse than blood loss 🡪 consider
uterine rupture or broad ligament tear
with internal bleeding 🡪 move to
laparotomy
STAGE 2
OB Hemorrhage
Ongoing bleeding and/or vital sign instability, and < 1500 ml cumulative blood loss (EBL/QBL)
Cumulative blood loss (EBL/QBL) > 1500 ml, > 2units PRBCS given, VS unstable or suspicion for DIC?
Proceed to STAGE 3
MOBILIZE
Primary Nurse:
❏ Activate OB
Hemorrhage Protocol
❏ Call/Birth Center
Page Team Leader
and Anesthesiology to
room
Team Leader or designee:
❏ Bring Hemorrhage
Cart to patient’s
location if not in OR
❏ Notify Charge Nurse
❏ Assign designees to
continue Blood Bank
communication
❏ Designate a provider,
nurse, or SW as family
support person
OR Team Leader:
❏ Prepare OR & staff for
patient transfer if not
already there
ACT
OB/Nurse/Anesthesia Team Leaders
❏ Continue IV oxytocin, IV crystalloid, uterine massage
❏ Obtain and document quantitative blood loss q 10 minutes
❏ Continue uterotonic medication per protocol (Virtual Hemorrhage Pack in
Pyxis)*
Second nurse or OR techs:
❏ Obtain portable light and OB procedure tray
❏ Assist with transfer to OR (if indicated)
❏ Administer methergine 0.2 mg IM (if not hypertensive);
may repeat dose q 2 hr
❏ Administer misoprostol 800 mcg buccal or rectal
❏ Administer hemabate 0.25 mg IM (if not asthmatic); may
repeat dose q 15 min
Give once, if
no response,
move to next
agent
❏ Vital signs, including O2 sat & level of consciousness (LOC) q 5 minutes
❏ Administer oxygen to maintain O2 sats at > 95% & keep patient warm
❏ Empty bladder; straight cath or place Foley with urimeter
❏ Transfusion
❏ Bring 2 units PRBCs to bedside (mobile refrigerator on unit or blood bank)
❏ Consider activation of Massive Transfusion Protocol
❏ Transfuse PRBCs based on clinical signs & response; don’t wait for lab
results
❏ Order labs STAT (CBC, CMP, Coag/Fibrinogen, Point-of-care labs)
Don’t delay other interventions while waiting for response. Consider move to OR.
THINK
Once stabilized:
❏ Postpartum Debrief
❏ Update Postpartum Risk
Assessment: Modified postpartum
management with increased
surveillance
Vaginal birth
• Trauma (vaginal, cervical, or uterine)
🡪 Visualize & repair
• Retained placenta 🡪 D&C
• Uterine atony/LUS bleeding 🡪 Bakri
• Other 🡪 Arterial embolization (IR)
Cesarean Section
• Atony 🡪 B-Lynch, Intrauterine Balloon
• Uterine Inversion 🡪 Anesthesia &
uterine relaxation for manual
reduction
• Amniotic Fluid Embolism 🡪
Maximally aggressive respiratory,
vasopressor, and blood product
support
• VS worse than blood loss 🡪 consider
uterine rupture or broad ligament tear
with internal bleeding 🡪 move to
laparotomy
STAGE 2
OB Hemorrhage
Ongoing bleeding and/or vital sign instability, and < 1500 ml cumulative blood loss (EBL/QBL)
Cumulative blood loss (EBL/QBL) > 1500 ml, > 2units PRBCS given, VS unstable or suspicion for DIC?
Proceed to STAGE 3
MOBILIZE
Primary Nurse:
❏ Activate OB
Hemorrhage Protocol
❏ Call/Birth Center
Page Team Leader
and Anesthesiology to
room
Team Leader or designee:
❏ Bring Hemorrhage
Cart to patient’s
location if not in OR
❏ Notify Charge Nurse
❏ Assign designees to
continue Blood Bank
communication
❏ Designate a provider,
nurse, or SW as family
support person
OR Team Leader:
❏ Prepare OR & staff for
patient transfer if not
already there
ACT
OB/Nurse/Anesthesia Team Leaders
❏ Continue IV oxytocin, IV crystalloid, uterine massage
❏ Obtain and document quantitative blood loss q 10 minutes
❏ Continue uterotonic medication per protocol (Virtual Hemorrhage Pack in
Pyxis)*
Second nurse or OR techs:
❏ Obtain portable light and OB procedure tray
❏ Assist with transfer to OR (if indicated)
❏ Administer methergine 0.2 mg IM (if not hypertensive);
may repeat dose q 2 hr
❏ Administer misoprostol 800 mcg buccal or rectal
❏ Administer hemabate 0.25 mg IM (if not asthmatic); may
repeat dose q 15 min
Give once, if
no response,
move to next
agent
❏ Vital signs, including O2 sat & level of consciousness (LOC) q 5 minutes
❏ Administer oxygen to maintain O2 sats at > 95% & keep patient warm
❏ Empty bladder; straight cath or place Foley with urimeter
❏ Transfusion
❏ Bring 2 units PRBCs to bedside (mobile refrigerator on unit or blood bank)
❏ Consider activation of Massive Transfusion Protocol
❏ Transfuse PRBCs based on clinical signs & response; don’t wait for lab
results
❏ Order labs STAT (CBC, CMP, Coag/Fibrinogen, Point-of-care labs)
Don’t delay other interventions while waiting for response. Consider move to OR.
THINK
Once stabilized:
❏ Postpartum Debrief
❏ Update Postpartum Risk
Assessment: Modified postpartum
management with increased
surveillance
Vaginal birth
• Trauma (vaginal, cervical, or uterine)
🡪 Visualize & repair
• Retained placenta 🡪 D&C
• Uterine atony/LUS bleeding 🡪 Bakri
• Other 🡪 Arterial embolization (IR)
Cesarean Section
• Atony 🡪 B-Lynch, Intrauterine Balloon
• Uterine Inversion 🡪 Anesthesia &
uterine relaxation for manual
reduction
• Amniotic Fluid Embolism 🡪
Maximally aggressive respiratory,
vasopressor, and blood product
support
• VS worse than blood loss 🡪 consider
uterine rupture or broad ligament tear
with internal bleeding 🡪 move to
laparotomy
Department of
Anesthesiology
Department of Anesthesiology
https://safehealthcareforeverywoman.org/wp-content/uploads/safe-health-care-for-every-woman-Obstetric-Hemorrhage-Bundle.pdf
Department of
Anesthesiology
Department of Anesthesiology
https://soap.org/
Department of
Anesthesiology
Department of Anesthesiology
https://www.acog.org/
Preparation and Response – Quality Measures?
Department of
Anesthesiology
Department of Anesthesiology
Department of
Anesthesiology
Department of Anesthesiology
Take Home Points
Conclusion
Department of
Anesthesiology
Department of Anesthesiology
• Maternal mortality in the US is rising, while it is decreasing in
other developed countries.
• Improving our response to PPH may reverse this trend.
• Early identification of PPH is important.
• Get involved early.
• Quickly escalate care.
• Consider viscoelastic testing/send labs early.
• PPH protocols improve outcomes.
Department of
Anesthesiology
Department of Anesthesiology
Please join us for the OB panel.
