Acute Resuscitation in Catastrophic

Uncontrolled Obstetric Haemorrhage in

the Peripartum Period
PIT X Fetomaternal
Batu-Malang, 11th March 2009
Agrowisata, Batu

Associate Professor Stephen Gatt, OAM, MOM, KM, KHS, JP; MD, LRCP, DCH, CHE, MASCH, MRACMA, MRCS, AFACHSE, FFARACS, FANZCA, FICANZCA
Director of Anaesthesia, Prince of Wales Hospital,
Head of Division, Anaesthesia and Intensive Care, Prince of Wales & Sydney Childrens Hospitals.
Senior Staff Specialist (and, previously, Director of Anaesthesia & Acute Care), Royal Hospital for Women.
President, Obstetric Anaesthesia Society of Asia and Oceania (OASAO).

Kensington & Randwick, Sydney, Australia

Order of Battle a Learning

Objective
Catastrophic haemorrhage
definitions
action plan
Overwhelming transfusion
management
Role of recombinant factor
Haemorrhage
timing
optimised performance
Massive Transfusion Protocol

VIIa in Massive

Syllabus Objectives Management of Severe

Haemorrhage

Immediate volume replacement

rVIIa do not wait too long before using
Immediate management training in and
activation of the haemorrhage drill
Pre-preparation of a massive transfusion
trolley or box with pressure bags, large
cannulae, Level 1 blood warmers, blood
pumps, etc.
Activation of the Massive Transfusion Protocol

What is a massive, catastrophic,

critical or extreme transfusion?
Arbitrary
Transfusion of patients entire red cell mass
within 24 hrs
Often ~10 units RCC in adults
Perhaps management of massive transfusion
should be re-named management of critical
bleeding (Isbister J 2005)

Typical catastrophic bleeding profile

Blood products used in the 24 hrs to infusion (units)

16

Coagulation profile prior to infusion

Packed cells 30
Platelets
16
FFP
20
Cryoprecipitate

Platelet count
83 x 109/l
INR
1.6
APTT 75 secs
Fibrinogen 2.3 g/l

Mean dose/kg infused: 113 g

He who sees things

from the beginning has
the finest view of them
Aristotle 384-322, BC

ASSESSING SEVERITY

500-1000
1000-1500
1500-2000
2000-3000

BP
Appearance
Normal
SAP 80-90
Pallor, sweating
SAP 60-80
Clammy, uo<30
SAP<50 Anuria
Unconscious

Heart Rate
Resp
Usually fast
>100
>100
Tachypnoea
>110
Tachypnoea
HR may be low
Air hunger

Extreme Haemorrhage: Type of Delivery

Massive Haemorrhage: Causes

atony
+
a
t
n
e
c
la
tained p
e
r
=
r
e
h
t
O
auses
c

d
e
ix
m
and other

What do CEPOD
and now the WMD
and Maternal Death
Enquiries teach us
about
Haemorrhage?

Leading causes of direct deaths

reported to CEMD, 2000-02
Thromboembolism
Haemorrhage
Hypertension
Sepsis
Ectopic
Other early pregnancy deaths
Amniotic fluid embolism
Other direct
0
Source: Confidential enquiries into maternal deaths, Figure 1.2

10

15

20

Rate per million maternities

Massive Bleeding requiring rVIIa:

Cases by Presentation - overall
Total cases = 2029

Indo Rupiah
141,000,000,000,000

Position: May 2008

Obstetric: 5%

Patients requiring rVIIa: Obstetric

makes up 3-5%

Will we see more bleeding?

(% of deliveries in NSW for each category in NSW in 2004)

Massive Haemorrhage
Massive haemorrhage continues to be a anxiety producing
challenge for medical staff especially junior doctors
Will we see it more often?
Management involves ANTICIPATION, DIAGNOSIS,
MANAGEMENT
Diagnosis requires vigilance and awareness of confounders
Management is through team-work and good
communication with obstetricians, JMOs, surgeons,
midwives, haematologists and radiologists.

Principles Underpinning Massive

Obstetric Haemorrhage
Gravid uterus receives up to 15% of maternal CO (from
2%)
>600ml/min
Placental haemorrhage represents >1 unit blood loss/min

Low resistance placental circulation lacks autoregulation

Uterine myometrial contraction primarily responsible for
cessation of bleeding

Improved Outcomes
Lower mortality
Less morbidity
Fewer complications
Renal failure
Sheehans syndrome

Retained reproductive function

Smaller reliance on radiological

embolisation procedures

Making a diagnosis
Placenta complete/incomplete
Vaginal bleeding
Uterus soft or contracted
Uterus palpation and uterine position
Abdominal pain or shoulder tip pain
Additional bleeding from other
wound sites

SEVERE HAGE RECOGNISED

CALL FOR HELP
SENIOR
MIDWIVES

PORTERS

ICU

OBSTETRICIANS

ANAESTHETIST

HAEMATOLOGIST

GYNAE ONCOLOGIST

ANAESTHETIC
REGISTRARS

BLOOD BANK

5 Step Plan for Managing PPH

I.

Identify Source of Bleeding; Give Uterotonics

II.

Apply Pressure to Uterus; Transfuse

III.

Control Blood Supply to Uterus, Give Blood

Products

IV.

Place Uterine Compression Sutures

V.

Perform Hysterectomy

Uterine Bleeding
Drug

Dose

Side effects

Syntocinon

-5U slow IV bolus

-30-40U in 1L titrated

-Hypotension
-Reflex tachycardia/arrhythmias
-weak ADH like effect

Ergometrine

-250ug IM or
-125ug slowly IV

-n/v (common)
-HT (can be severe)
-coronary spasm/ ischaemic pain

Carboprost
PG F2

-0.25mg
intramyometrially or
IM repeated to max
2mg

-n/v/diarrhoea
-severe bronchospasm
-hypoxia (alter pulm shunt fraction)

m
o
r
f

d
F
e
i
O
d
M
l
Al DS/
MO

Crystalloid + Colloid + Packed

Cells as per Massive
Transfusion Protocol
Packed Cells + Platelets +
Cryporecipitate + Fresh
Frozen Plasma + rVIIa

How well do I do fluid

resuscitation?

Massive transfusion protocol

(email to staff 9/05, 11/06 final, 12/08 widespread
distribution across the state)

Protocol
-

Activation of MTP by communication with blood bank

Blood bank supplies initial 4U PRBC
MTP pack

1. 4U PRBCs, 4U FFP, 4U platelets (1pooled)

Alternating with
2. 4U PRBC, 4U FFP, 10U Cryo
3. Suggest additional products in certain circumstances - rFVIIa

POWH protocol
First 4 units RCC
Then 4 units FFP and 4 units platelets
Then 4 units RCC, 4 units plasma, 8 units
cryoprecipitate
Continue to alternate until MTP ceased or
lab results suggest other therapies

Postpartum Hemorrhage Process Map

Patient has Post Partum Hemorrhage, stay calm
note time T0 and call for help,
announcing Post Partum Hemorrhage

Hemorrhage
Alert
Potential for PPH

Notify NIC & Unit

Coordinator about
Hemorrhage Alert -potential for PPH.
Alert others as needed.

If pati
ent sy
mptom
atic

Inform patient/family of
potential for pp hemorrhage

I. Ob provider and/or Nurse begin uterine massage

II. a) Nurse calls for help and request Beeper 300 team for PPH
Keep track of time

II. b) Obtain IV access; Bolus IV fluids, crystalloids & pitocin;

draw labs; call Blood Bank-4u PRBCs; give 0 2
time subtotal = X min

Announce minutes from T0

III. Give Uterotonics-cytotec or methergine or hemabate or prostin
NIC arrives and Event Manager assigned
time subtotal = X min
Announce minutes from T0
IV. Review differential dx; Examine vagina, cervix, placenta;
transfuse as needed, Cryoprecipitate if bleeding massive

Remember Uterotonics

Active Management of 3
Stage of Labor
Give uterotonics before
placenta delivers; note
time placenta delivers

rd

time subtotal = X min

Call Off PPH alert

Announce Surgical Variance-Stage I, then Stage II

V. Pack or Tamponade Uterine Cavity Balloon or packing;

Consider Uterine Artery Embolization; Transfuse-stay ahead
Surgical Variance Stage III
Grand Total Time = X min

VI.
Uterus contracts
without problem

Remember Foley, I & Os

Proceed with AGGRESSIVE SURGICAL MANEUVERS

LAPAROTOMY
a)
Ligate bleeders
b)
Uterine Artery Ligation OLeary Sutures
c)
B-Lynch or Modified B-Lynch Sutures
d)
Hysterectomy
e)
Pack Pelvis
f)
Mast Suit as needed

Finish
Surgery
Check
perineum
Count
instruments
& sponges

Document
&
Talk with
Family

BWH CLB Obstetric Surgical Variance

Unexpected, Emergent
Peripartum Event

Vaginal Delivery

Patient Stable
Remain in CLB room

Primary Ob Care Team

Manages Event
Page Beeper 300
as needed

Patient
Unstable

C-Section Deviation from Expecte

STAGE I S.V.
Patient
Unstable

Call for Help

Beeper
300,

Move to OR

Announce Surgical
Variance
Page the NIC
STAGE II AHOD
Resources w/in Labor & Delivery

Advanced Surgical
Procedure(s)
STAGE III
Resources outside of L & D

Additional Surgical Procedure(s)

? Hysterectomy

Introduction of an obstetricspecific medical emergency

team for obstetric crises:
implementation and
experience
Gabriella G. Gosman, MD; Marie R.
Baldisseri, MD; Karen L. Stein, RN,
MSED; Trish A. Nelson, RN, MHRM;
Susan H. Pedaline, MS, BSN; Jonathan H.
Waters, MD; Hyagriv N. Simhan, MD,
MSCR
Magee-Womens Hospital, Pittsburgh, PA, 2007.

POW-SCH-RHW-POWPH

PACE

Drop in Blood Product Usage

PRODUCT

% Reduction % Reduction % Reduction

in Use
in Use Areain Use at
Statewide
wide
Randwick
Campus

Red cells

6.2

9.1

9.2

Platelets

12.0

8.5

16.8

FFP

15.0

13.0

39.1

ARCBS Data to 30th March 2008 (3rd quarter): reduced usage with increased
clinical activity: Responsible use of blood product data.

Randwick Quarterly Usage Fresh

Blood Components Targets
Target 2007/08

5,600
[current usage Mar 08: 5,000]

Target 2008/09

4,800

Target 2009/10

4,000

Data: Network Targets & Trends, Area Transfusion Committee

rFVIIa boosts thrombin generation on activated platelets

Per 100,000 head of population

NumberofCasesofrVIIabyPopulation
Australia:

20,434,176

USA:

299,396,484

Indonesia:

280,124,646

X 15

Effect on
Bleeding

Outcome at
28 Days

n = 27

Haemostasis Registry: rVIIa: First 27 POW/SCH: Jan 2007

Outcome & Effect on Bleeding

Randwick Campus vs. Total Registry

Dose
Number of patients = 2029
Total number of doses = 3003
Median dose = 7.2 mg (IQR: 4.8-9.6)
Median dose = 90.6 g/kg (IQR: 71.5-102.5)

Number of Doses

Effect on Bleeding vs Outcome

Number of cases

Total cases = 1735

22 = 318, p < 0.001

Outcome
at 28 days

Effect on Bleeding vs Outcome

Obstetrics

Causes of rVIIa failure

Fibrinogen <0.8 g/L
Platelets <50 x 10 /L
9

Low pH acidaemia
Low body temp

DJARUM AD, BATU-MALANG, 2009

Temp and Effect on Bleeding

Total cases = 1.307

214 = 44, p < 0.001

pH and Effect on Bleeding

Total cases = 1,182

216 = 199, p < 0.001

pH and
Temperature
n = 1,169

decreasing decreasing
temp
pH

pH, Temperature & Effect on Bleeding

n = 1,034

In haemorrhage,
rVIIa is
DYNAMITE
(but do not waste it)

Fulfilment of Syllabus Objectives in the

Management of Catastrophic
Haemorrhage

Volume replacement
rVIIa the Haemostasis Registry
Australia & New Zealand
Haemorrhage fire drills Asia perspective
Massive transfusion box
Massive Transfusion Protocol Australian
perspective

Joint OASAO SOAP Meeting

So much
more to
haemorrhage

Stephen Gatt,

MD

Terima Kasih Atas

Perhatian Anda

Adverse Events - Trauma

Definitely Linked
Probably Linked
Possibly Linked
Sub Total

0
0
1
1 = 2.2%

Unlikely to be Linked
Not Linked

4
9

Unable to Assess
Causality

07/06 Ob
Definitely Linked
0
Probably Linked
0
Possibly Linked
0
Unlikely to be Linked
4
Not Linked
7
Unable to assess causality

51y.o. male with previous history of

chronic alcoholic liver disease suffered
blunt assault including liver lacerations.
AE = DIC, <6 hours post rFVIIa
administration.
Deceased Day 12
Cause of Death - unknown (awaiting
coroners report)
38y.o. male with no significant medical
history suffered MBA. Injuries included
open-book pelvic # and abdominal
haematoma
AE= multiple pulmonary emboli at Day
24, treated with heparin

Discharged to rehab Day 97

Randwick Campus Cumulative

Expenditure
$1,602,000
1,200,000
$1,031,000

1,000,000

August 2007

800,000

+5 years

600,000
February 2006

400,000
200,000

Aug 02

Aug 03

Aug 04

Aug 05

Aug 06

Aug 07

Economic Aspects

Survival?
Intensive care unit
cost?
Days in hospital?

Cost of drug?

Obstetrics & rFVIIa

Units of Packed Cells

0
4
7
>0 <5
2 13
6 - 10
2
1
11 - 15
8
15 - 20
2
21 - 25
0
26 - 30
1
> 30
3
0
Totals 22

Before rFVIIa

2
1
1

22

After Dose2

After Dose3

1
0
0

0
0
0
1
0

After Dose1

0
0
1
0

0
0
0
0

Position on 24.vii.06: B Tx before & after VIIa

n=22

Economic Considerations
What

is the cost of a life?

What is the cost of a fatherless or
motherless family?
What is the cost of saved blood & blood
products?
What is the cost of ICU stay? Of return to
O/R?

LEUCODEPLETION TARGETS
Leucodepletion Targets
100% universal leucodepletion by 1st.
October 2008 to Council of Europe
Guidelines
Cost extra: $100/unit
? Second WBC bedside filter (to reduce
further log WBC)

Delivering Blood from Blood Bank

Pneumatic Tube
System (SCUD)

Porter delivered

12 units broken
Additional after-hours
(1.1.08-30.4.08)
porter
Decontamination
Additional blood
($20,000 /episode)
fridges ($14,000
Blood splash to 1 staff
each)
Wasted units in fridge

B. Tx & VIIa - Costs

80%

of blood & blood product costs lie

in administration not in acquisition.
The overall cost of blood
administration may be as high as
$3billion p.a. in Australia
Cost of acquisition and distribution of
blood products (up to out of blood
bank stage) is ~$A740 million p.a.
nationally.