PPH simulation

Question 1

What is meant by “physiologic anemia of pregnancy”? How does HTN affect this phenomenon?

Answer 1

Maternal plasma volume expands by 42%, but RBC volume only by 24% - so proportionally fewer RBCs

With hypertensive disorders: plasma volume expansion is diminished - so women are less able to tolerate hemorrhage and are at increased risk for hemorrhage

Question 2

What is the average blood loss volume/percentage of total blood volume for vaginal delivery, operative vaginal delivery, C-section, elective C-hyst, and emergency C-hyst?

Answer 2

Vaginal delivery: 500 ml/10%
note that 3rd and 4th degree lacs can have as much bleeding as a C/s

Operative vaginal delivery: 1000 ml/25%

Cesarean delivery: 1000 ml/25%

Elective C-hyst: 1500 ml/33%

Emergency C-hyst: 3500 ml/75%

Question 3

What are the volumes per unit of blood products for transfusions?

Answer 3

pRBCs: 300 ml/unit 
Whole blood: 450-500 ml/unit 
FFP: 250-300 ml/unit
Platelets: 40-50 ml/unit 
Cryoprecipitate: 10-12 ml/unit

Question 4

What is the average blood volume in an adult?

Answer 4

Male 5 L, female 4.5 L

Question 5

How much does a transfusion of 1U pRBCs raise Hb and Hct?

Answer 5

Hb: 1 g/dL
Hct: 3%

Question 6

What is the definition of a postpartum hemorrhage? How common are they?

Answer 6

PPH: 10% drop in Hb or Hct, or need for blood transfusion

Can be primary (1st 24h after delivery) or secondary (>24h after delivery up to 6w postpartum)

Represents 4% of vaginal deliveries and 6% of C-sections; 1/20 women

Question 7

What are the 4Ts that are commonly the cause of PPH?

Answer 7

Tone: atonic uterus (70%)

Trauma: lacerations, hematomas, inversion, rupture (20%)

Tissue: retained tissue, invasive placenta (10%)

Thrombin: coagulopathies (1%)

Question 8

What are risk factors for PPH that are identifiable in the prenatal period?

Answer 8

Suspected previa, accreta, increta, percreta

Pre-pregnancy BMI > 50

Clinically significant bleeding disorder

Other significant medical/surgical risk (including pts who decline transfusion)

Question 9

When should you plan to deliver patients with accreta, previa, prior classical C-section, or myomectomy?

Answer 9

Placenta accreta: 34w0d to 35w6d

Previa: 36w0d to 37w6d

Prior classical: 36w0d to 37w6d

Prior myomectomy: 37w0d to 38w6d

If extensive myomectomy: 36-37w

Question 10

What risk factors on L and D admission put patients at medium risk for PPH?

Answer 10

Prior c/s, uterine surgery, multiple laparotomies

Multiple gestation

> 4 prior births

Prior obstetric hemorrhage

Large myomas

EFW>4000g

Obesity BMI>40

Hct<30% with other risk

Type and SCREEN

Question 11

What risk factors on L and D admission put patients at high risk for PPH?

Answer 11

Placenta previa/low lying

Suspected accreta/percreta

Platelet count <70,000

Active bleeding

Known coagulopathy

2+ medium risk factors

Type and CROSS

Question 12

What intrapartum risk factors put patients at medium vs. high risk for PPH?

Answer 12

Medium: chorioamnionitis, pitocin >24h, prolonged 2nd stage, magnesium sulfate

High: new active bleeding, 2+ medium risk factors

Question 13

What medications are useful for management of obstetric hemorrhage?

Answer 13

Pitocin: 10-40 IU/L IV

Hemabate (15-methyl PGF2a): 250 mcg IM (can repeat dosing) - can cause bronchospasm in asthma, contraindicated in acute PID

Cytotec (misoprostol): 800-1000 mcg per rectum or 600 mcg PO or 800 mcg PL

Methergine (methylergonovine): 0.2 mg IM (can repeat dosing) - contraindicated in HTN or preE

Question 14

What are the stages of PPH?

Answer 14

Stage 1: blood loss >500 ml vaginal or >1000 c-section with normal VS and lab values

Stage 2: continued bleeding up to 1500 ml or >2 uterotonics with normal VS and lab values

Stage 3: continued bleeding with EBL >1500 ml or >2u pRBCs given or patient at risk for occult bleeding/coagulopathy or any pt with abnormal VS, labs, oliguria

Stage 4: cardiovascular collapse (massive hemorrhage, profound hypovolemic shock, amniotic fluid embolism)

Question 15

How should a stage 1 PPH be managed (>500 ml NSVD, >1000 ml C/S with VSS)?

Answer 15

First steps: ensure 16 or 18G IV access, increase IV fluid (crystalloid without oxytocin), insert Foley, perform fundal massage

Meds: increase oxytocin, add on uterotonics

Blood bank: type and cross 2U RBCs

Action: determine etiology, prepare OR if needed

Question 16

How should a stage 2 PPH be managed (EBL up to 1500 ml OR 2+ uterotonics with VSS)?

Answer 16

First steps: get additional help, place 2nd 16-18G IV, draw stat labs (CBC, coags, fibrinogen), prep OR

Meds: continue stage 1 meds (oxytocin, miso, hemabate, methergine)

Blood bank: get 2U RBCs (do not wait for labs, transfuse as needed), that 2U FFP

Action: escalate therapy with goal of hemostasis

Question 17

How is a PPH managed surgically?

Answer 17

Uterine curettage, placental bed suture, uterine artery ligation, uteroovarian ligation, repair uterine rupture (if present), B-Lynch suture, multiple square sutures, hysterectomy

Question 18

How should a stage 3 PPH be managed (>1500 ml EBL OR >2U pRBCs given OR pt at risk for occult bleed or coagulopathy OR abnormal VS/labs/oliguria)?

Answer 18

First steps: get additional help, move to OR, announce clinical status (VS, cumulative blood loss, etiology), outline plan

Meds: continue stage 1 meds (pitocin, miso, hembate, methergine)

Blood bank: initiate massive transfusion protocol (if clinical coagulopathy, add cryoprecipitate)

Action: achieve hemostasis, interventions based on etiology

Question 19

How should a stage 4 PPH be managed (cardiovascular collapse)?

Answer 19

Get additional resources on board, ACLS, simultaneous aggressive massive transfusion, immediate surgical intervention to ensure hemostasis (hysterectomy)