6. How do you assess the patient once PPH is identified?
OBG Management: How do you assess the patient after hemorrhage begins?
Dr. Brown: We recheck the hemoglobin and hematocrit levels and monitor vital signs for hypotension and tachycardia. We also begin fluid resuscitation and type and cross-match blood and blood products.
A delayed response to hemorrhage raises the risk of maternal morbidity and death.
We notify the anesthesia team when it seems likely that a surgical approach to the hemorrhage will be needed. And we notify interventional radiology if the bleeding may respond to uterine artery embolization.
7. Why is it important to replace blood products?
OBG Management: You’ve been known to say, “The more blood a patient loses, the more blood she loses.” What do you mean by that?
Dr. Brown: Excessive bleeding leads to a loss of critical clotting factors that are made in the liver. Once the clotting factors are depleted, the woman is at risk of coagulopathy or disseminated intravascular coagulation. This depletion potentiates the cycle of hemorrhage. When that occurs, the hemorrhage can be controlled only with transfusion of red blood cells (RBCs) and replacement of clotting factors with fresh frozen plasma, platelets, and cryoprecipitate, along with prompt correction of the process that is causing the bleeding.
OBG Management: What blood products do you administer to a patient with hemorrhage, and when?
Dr. Brown: The first line of defense for blood loss requiring transfusion is packed RBCs. Each unit of packed cells increases the hematocrit by 3% and hemoglobin by 1 g/dL, assuming bleeding is under control. After that, consider:
- Platelets. Depending on the severity of the hemorrhage and the level of platelets once the coagulation status is checked, platelets can be given. A 50-mL unit can raise the platelet count 5,000–10,000/mm3. Platelets should be considered if the count is below 50,000/mm3.
- Fresh frozen plasma should be given to replace clotting factors. Fresh frozen plasma contains fibrinogen, antithrombin III, factor V, and factor VIII. Each unit of fresh frozen plasma increases the fibrinogen level by 10 mg/dL.
- Cryoprecipitate contains fibrinogen, factors VIII and XIII, and von Willebrand factor. Each unit of cryoprecipitate increases fibrinogen by 10 mg/dL.
- Factor VII can be given if the hemorrhage is still active, but it should only be given after fresh frozen plasma and cryo-precipitate have been given to replace clotting factors. Factor VII is ineffective without clotting factor replacement prior to its administration. This medication is associated with a high risk of thromboembolism. It is also expensive.
- Synthetic fibrinogen (RiaSTAP) is available for use in the United States, but it has FDA approval only for the treatment of acute bleeding in patients who have congenital fibrinogen deficiency. It may have potential for use during PPH when essential clotting factors have been depleted.
Is your patient obese? She requires extra attention
A woman who is obese has additional risk factors for hemorrhage. Obesity itself is associated with prolonged labor and large-for-gestational-age infants, which, in turn, lead to poor contractility of the uterus and the potential for early postpartum hemorrhage.
Begin by ensuring that the obese or morbidly obese woman has appropriate intravenous access at the time of labor and receives early regional anesthesia (epidural). also alert anesthesia to the risk and assess baseline hemoglobin and hematocrit levels, including a type and screen.
An obese woman undergoing cesarean delivery has a heightened risk of uterine laceration, difficult extraction of the fetus, and uterine atony, especially if prolonged labor preceded the cesarean. Second-stage arrest and prolonged pushing before the cesarean may make extraction of the infant difficult and lead to poor uterine contractility once the placenta is removed.
All obese women, as well as other women at risk of postpartum uterine atony, should have oxytocin infused before the placenta is removed, especially at the time of cesarean delivery. Expressing the placenta at the time of cesarean delivery—as opposed to manual removal—is associated with lower blood loss and allows the uterus to begin contracting before the placenta is removed.—HAYWOOD L. BROWN, MD
8. When do you use the intrauterine balloon?
OBG Management: When is the intrauterine balloon a management option?
Dr. Brown: The balloon offers a way to actively manage hemorrhage and has been associated with decreasing morbidity and a reduced need for surgical intervention, including hysterectomy. It works through a tamponade effect. Once the balloon is inflated with 300 to 500 mL of saline, it compresses the uterine cavity until the uterus develops predelivery tone. It can be left in place as long as 24 hours, need be.