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. Physician / System / Patient
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… Pathophysiology1 3 2 10 4 7 7 5 6 9 8 7 7 8
Multiple organ dysfunction
Cohen WR. J Perinat Med 2006; 34:

14. Obstetric hemorrhagic shock… Categorization (1)

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 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:

27. Obstetric hemorrhagic shock… General modern-day principles (2)
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%

28. Obstetric hemorrhagic shock… General modern-day principles (3)
1 unit FFP…
250 mL
220 u each coag factor
4-pack increases most factors by approx 10%, each unit increases fibrinogen by 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

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

30. Obstetric hemorrhagic shock… “Damage control resuscitation” (1)
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

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

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:

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:

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:

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
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)

51. Damage control at its finest… Surgical approaches (4)

52. Damage control at its finest… Surgical approaches (5)

53. Conclusions (1)
Hemorrhage is a potential challenge facing the obstetrician, as well as many other healthcare professionals
It remains a major source of maternal mortality in the US
The diagnosis of hemorrhagic shock must be confident and prompt, accompanied by an appreciation for the physiologic responses of otherwise healthy patients

54. Conclusions (2)
There are multiple lessons learned from the management of battlefield casualties
Conventional, component therapy is clearly the standard among obstetric patients, but “damage control resuscitation” and aggressive product replacement likely has its time and place
Not necessarily predicted or planned – just happens as management moves forward
Surgical intervention is frequently the most integral component to “damage control” in the obstetric patient

55. My take… When I manage an obstetric hemorrhage… Run isotonic fluids
Transfuse 1-2 units PRBC when bleeding appears “atypical” and if difficulty controlling bleeding
Transfuse 2 units FFP as soon as thawed, regardless of coags
Transfuse platelets based on clinical picture and/or labs
Anticipate “damage control”
Anesthesia’s role
“Barometer” of progress or lack thereof
Frequent, direct communication – “manage as we go”
Ongoing transfusion (strive for 1:1) based on vitals, urine output, labwork, and my ability to control hemorrhage

56. Questions? Comments? My email… Clang@phy.mchs.com