1. Kimberlee McKay, M.D. AMG OB/Gyn

2. Objectives: Why a protocol? Key points to implement Massive transfusion

3. Disclosures: 1. This is not a talk on the academics of PPH 2. This is not a talk about replacing clinical judgment with an algorithm. 3. This talk is brought to you by Diet Coke.

4. 1. See one. 2. Do one. 3. Teach one.

5. Olden days: Postpartum Hemorrhage Wait Give Medication Wait Get lab

6. DIC! Hysterectomy

7. Cultural Assumptions: Real World Experience Required Intelligence and “good doctoring.” Sacred Calling

9. What about when: 1. You are tired. 2. You are busy. 3. Or both.

10. Patient care depends on: 1. Their Disease. 2. The Diagnosis AND Treatment for it. 3. The implementation of that plan. 1. Their Disease. 2. The Diagnosis AND Treatment for it. 3. The implementation of that plan.

11. Why a protocol? Help bring out human expertise. Support interaction, coordination, and role articulation.

12. Who is this guy??

14. Postpartum Hemorrhage: 1. Major source of maternal morbidity and mortality. 2. Complicates 3-5% of all births. 3. Has risen steadily since the 90s.

15. Post Partum Hemorrhage: Causes 1. Uterine atony 2. Retained Placenta 3. Lacerations 4. Abnormal placentation 5. Other

16. Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood product. Shields, L., Smalarz, K., et al. AJOG: 268.e1-8

17. Does it work? Review of 3200 deliveries Identified incidence, causes, “near-miss” events. No obvious labor and delivery risks identified Deviation from hospital guidelines was almost universal. Guidelines were revised, disseminated to staff and taken into simulation. Goal was 100% adherence to the protocol. Riszvi, F. et al. BJOG:May 2004 (211). 495-498

18. 1999 No.% 2002 No.% >15002852533 >2000152800 >2500101900 >300071316.7 **3300 deliveries followed over 6 months in 2002. Total EBL Riszvi, F. et al. BJOG:May 2004 (211). 495-498

19. Maternal Morbidit 19992002 No.%No% Any transfusion2648533 Blood transfusion>6U 91700 ICU admit2546213 Exam under anesthesia 611533 Postpartum hyst35.600 Riszvi, F. et al. BJOG:May 2004 (211). 495-498

22. Testing the California Protocol 5800 deliveries followed during the study period Goal was to evaluate whether early intervention increased the number of patients successfully treated in stage 1 hemorrhage Indirectly, they hypothesized that blood product use would be less and DIC would be less Shields, L., Smalarz, K., et al. AJOG: 268.e1- 8

23. PPH stagePre protocol Post period 1 Post period 2 Post period 3 135%(22)51%(25)69%(27)82%(49) 253%(33)45%(22)18%(7)10%(6) 311%(7)4%(2)13%(5)10%(6) Changes in stage of hemorrhage before and after protocol initiation. Shields, L., Smalarz, K., et al. AJOG: 268.e1-8

24. Changes in average number of blood products transfused per month. Preprotocol=16.7 U/month Postprotocol=6.3 U/month. Shields, L., Smalarz, K., et al. AJOG: 268.e1-8

25. Who Bleeds? Not everyone has the same risk. Low Medium High

26. Situational Awareness: Assessing the Risk on Admission Low Risk : Type and Screen Recommended; BB Hold (Minimum) No prior uterine incision Singleton <4 Vaginal deliveries No history of PPH No bleeding disorder. Negative Antibody screen on PN lab

27. Situational Awareness: Assessing the risk on admission Prior C/S or uterine surgery Multiple gestations >4 vaginal deliveries H/O PPH Large uterine fibroids EFW> 4k BMI>35 Medium Risk : Type and Screen

28. Situational Awareness: Assessing the risk on admission High Risk : Type and Cross for 2 U pRBCs and hold. Placenta Previa, Low-lying placenta Suspected Accreta/Increta/Percreta Hct<30 AND other RF Plt < 100k Active Bleeding Known Coagulopathy

29. Situational Awareness: Assessing the risk Prolonged 2 nd stage Prolonged Oxytocin use Active bleeding Chorioamnionitis Magnesium Sulfate treatment On-going Risk Assessment:

30. Situational Awareness: Team Huddle Medium risk: Review PPH protocol High Risk Review PPH protocol Anesthesia consult

31. Prevention: Active management of the third stage Has not been shown to increase retained placenta Oxytocin 30 mU in 500 cc tra 250cc q hr X 2 hrs.IV or 10 U IM delivery of anterior shoulder DO NOT PULL TOO HARD Gentle cord traction (+/-)Immediate cord clamping within 2 minutes of delivery. Vigorous fundal massage (15 sec) during uterine contraction.

32. PPH Protocol Key Concepts Reduce delay. Follow a plan. Move steadily through the algorithm.

33. PPH Protocol Key Concepts Should be used with the “Typical” PPH patient. No meant to replace clinical judgment.

34. STAGE I Hemorrhage: EBL>500cc vaginal or > 1000cc cs IV access On-going assessment: ARE VS UNSTABLE?? Calculating blood loss TYPE and CROSS (if BB Hold, will delay 20-30 minutes) Keep patient warm and oxygenated Place a foley Nursing interventions Find cause for bleeding MANUAL EXAM OF UTERUS: if you cannot reach the fundus, CALL LABORIST Give medications TYPE and CROSS ARE VS UNSTABLE???: MD/CNMW

35. Manual Exam of the Uterus It’s cheap. It’s effective! It can hurt.

36. PPH resulting from Uterine Atony After Vaginal Delivery 4550 patients with PPH following vaginal delivery Looked at PPH severity as it related to PPH management and organizational characteristics of maternity units. Study cohort was selected from the Pithagore6 trial population which consisted of 6 perinatal networks and 106 French maternity units (initial cohort of 146,000 with PPH rate of 6.4%. Driessen, M. et al. Ob Gyn 2011;117(1):21-31

37. Severe PPH 20.9% of patients (n=952) Factors associated with severity Primiparity Previous PPH Previous CS Cervical ripening Prolonged labor Episiotomy Driessen, M. et al. Ob Gyn 2011;117(1):21-31

38. Severe PPH Factors associated with severity: Administration of oxytocin >10 min after dx 24.6% vs 20.5 %, adjusted OR 1.38, 95% CI MEU >20 minutes after dx 28.2% vs 20.7 %, adjusted OR 1.83m 95% CI Delay in calling for assistance >10 min after dx 29.8 vs. 24.8, adjusted OR 1.61, 95%CI Driessen, M. et al. Ob Gyn 2011;117(1):21-31

39. Epidural!! Potective as these patients tended to have an MEU performed sooner.

40. PPH: Definition of unstable VS HR > 110BP < 85/45 O2 Sat < 95%VS >15% change Unstable VS

41. Stage I hemorrhage: Medications Methergine 0.2 mg IM Usually first line—onset action within 5 minutes Contraindicated with HTN Little or no response to 1 st dose then MOVE ON Hemeabat e 0.25 mg IM Usually works within 2 doses Contraindicated in ASTHMA/HTN** No response after the 2 nd dose then MOVE ON Cytotec 800-1000 mcg pr Onset of action usually 30-60 minutes PR SL dose 400mcg-600mcg onset within 11 minutes

42. STAGE 2: Continued bleeding or Unstable VS or EBL 1000-1500 cc Request Laborist/OB consult if not present Move patient to OR Notify Anesthesia Nursing interventions Move to OR Continued uterotonic use Request anesthesia 1500 CC EBL with ongoing bleeding--- Start transfusing (do not wait for lab results) MD/CNM interventions

43. STAGE 2: Continued bleeding or Unstable VS or EBL > 1500 cc D&C, Laceration repair Bakri Balloon Interventional radiology Vaginal Delivery B-Lynch O’Leary stitches Uterine/internal iliac ligation Bakri Balloon placement Cesarean Section

44. Stage 3: EBL>1500cc, > 2U PRBCs given, unstable VS or Suspect DIC Continued monitoring of EBL SUGGEST MTP activation Manage activation of MTP Nursing interventions : Consider CVP or Art line Manage Blood products Anesthesia interventions

45. Stage 3: EBL>1500cc, > 2U PRBCs given, unstable vs or Suspect DIC MTP activation Call in back-up OR Gyn Onc Transfuse 2 U FFP Keep transfusion ration 4:4:1 (PRBCS:FFP:PLT) Laparotomy/Gyn Onc B-Lynch Uterine/ internal iliac artery ligation Hysterectomy OB MD interventions

46. Massive transfusion Classic transfusion therapy: Crystalloid administration PRBCs FAILED to prevent coagulopathy!! Dilutional; Increased hydrostatic pressure and clot dislodgement at endothelial injury sites DIC: early hypoperfusion leads to up-regulation of the Protein C pathway and inhibition of factors Vs and VIIIa and enhanced fibrinolyisis.

47. Parameters: INR>1.5 Plt<50k Hgb<7.5 Fibrinogen< 100

48. Massive Transfusion Iraq Data Casualties who received less than 1U of plasma for every 4U PRBCs were associated with a 65% mortality Casualties who received 2U of plasma for every 3U of PRBCs were associated with a 19% mortality. SpinellaPC, Holcomb JB. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. 2009;23:231- 240.

49. Massive Transfusion Protocols Higher intra-operative product use. Lower 24-hour component use. Lower utilization of PLT Post operative PTT and PLT significantly improved. Lower Crystalloid use. Colton, BA. Gunter OL Isbell J, et al. Damage control hematology: The impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma. 2008; 64:1177- 1183

50. Massive Transfusion Protocols Purpose: Structured system-wide process for early and efficient delivery of specific ratios of blood product, 4 U PRBCs/4U FFP/ 1 Aphoresis pack PLT

51. PPH treated with MTP BaselineMost ExtremePost-MTP Hgb (g/dl)11.9 (1.3)7.1 (1.7)10.3(2.4) PLT192 (56)103 (75)124 (44) INR1.2 [1.3-2.1]2.0 [1.3-2.1]1.3 [1.2-1.4] aPTT29.3 [12.9-15.8]46.2 [31.5-53.7]30.9 [30.2-35] Fibrinogen405 [302-533]229 (170)325 (125) ( )=mean AND [ ]=interquartile range Lab data of OB patient receiving blood products from MTP Gutierrez MD et al. PPH treates with MTP at a tertiary ob center: a retrospective study; Int J of Ob Anesth 2012 (21): 230-35.

52. “Analysis of the initial management of postpartum hemorrhage demonstrated that delayed care increased the risk of severe postpartum hemorrhage” Postpartum Hemorrhage: Becoming more evidence based. Carolyn M. Zelop, M.D. Obstetrics and Gynecology 117(1): 3-5.

53. PPH Protocol Key Concepts Reduce delay. Follow a plan. Move steadily through the algorithm.

54. Medicine is the last high-risk industry that expects people to perform perfectly in complex, rare emergencies but does not support them with high-quality training and practice throughout their careers” Paul Preston, MD Safety and QI Leader CMQCC