After vaginal delivery, the standard postpartum hemorrhage algorithm includes:
- administration of uterotonics
- fundal massage
- placement of an additional large-bore IV catheter
- volume replacement
- insertion of an arterial line
- moving the patient from a labor room to a fully equipped operating room.
Procedures that might need to be performed include:
- a sonogram to determine whether retained products are in the uterus or if free fluid is in the peritoneal cavity
- a dilatation and curettage to remove retained products of conception
- placement of an intrauterine tamponade balloon
- repair of vaginal and cervical lacerations
- uterine artery embolization.
After vaginal delivery and postpartum hemorrhage, additional surgical procedures that might be necessary include:
- exploratory laparotomy
- uterine compression stitches
- sequential devascularization of the uterus with O’Leary stitches
- hypogastric artery ligation
- hysterectomy.
Additional steps in the postpartum hemorrhage protocol often include recruiting additional staff to the OR, including an advanced general surgeon or gyn surgeon; an additional anesthesiologist; and the director of the blood bank.
Lyophilized fibrinogen concentrate: Another source of fibrinogen
In hospitals that provide OB services but have a blood bank with limited transfusion products, stocking RiaSTAP (lyophilized fibrinogen concentrate [human]; CSL Behring) may provide a reliable source of fibrinogen for transfusion.
In many OB cases marked by coagulopathy, a major contributor to the disorder is hypofibrinogenemia. At hospitals with limited blood bank resources, the in-house supply of fresh frozen plasma and cryoprecipitate might be depleted before an obstetrical patient’s coagulopathy is fully corrected. RiaSTAP can provide a stable, readily available alternative source of fibrinogen for transfusion.1
One major disadvantage of RiaSTAP: It is a more expensive source of fibrinogen than FFP and cryoprecipitate.
Reference
Bell SF, Rayment R, Collins PW, Collis RE. The use of fibrinogen concentrate to correct
hypofibrinogenaemia rapidly during obstetric hemorrhage. Int J Obstet Anesth. 2010;19(2):218–223.
Blood product transfusion protocol. An additional key feature of the emergency hemorrhage protocol is activation of a standardized blood product transfusion protocol. Rapid replacement of blood products is essential to support effective surgical management (see “Lyophilized fibrinogen concentrate: Another source of fibrinogen,” above, and the TABLE).
Modern transfusion guidelines in a case of massive hemorrhage after trauma call for transfusing fresh frozen plasma (FFP) at a ratio of FFP to red blood cells (RBCs) of >1:1.5.5-7 At my hospital (Brigham and Women’s Hospital), the blood bank is alerted to activate the protocol when a clinician announces that an “emergency obstetric hemorrhage” is in progress. The blood bank emergently transports 2 units of FFP and 2 units of RBCs to the delivery suite and begins to prepare a cooler with 6 units of RBCs, 2 units of FFP, and 1 dose of cryoprecipitate.
Because a postpartum coagulopathy is not a common occurrence, it is of great value to practice the OB hemorrhage protocol using simulation exercises.
The clinical impact of various blood replacement products1-3
| Product | How provided | Clinical effect |
|---|---|---|
| Red blood cells | 1 unit (bag) contains 300–350 mL | 1 unit raises the hemoglobin concentration by 1 g/dL and the hematocrit by 3% |
| Fresh frozen plasma (all clotting factors) | 1 unit (bag) contains 200–300 mL | 1 unit raises the fibrinogen level by 7 to 10 mg/dL |
| Cryoprecipitate (fibrinogen, factor VIII, factor XIII, and von Willebrand factor) | 1 dose (as provided by the Red Cross) comprises 2 120–158 mL bags of 5 units each; 1 dose contains protein precipitate from 10 units of fresh plasma | 1 dose raises the fibrinogen level by 70 mg/dL in a 70-kg person |
| Platelets | 1 unit (bag) contains 300 mL, from 6 units of whole blood or one apheresis donor | 1 unit raises the platelet count by 30 × 103/μL in an adult whose surface area is 2 m2 |
| References | ||
CASE Resolved
You recognize the diffuse oozing and failure of the oozing to stop after a laceration is properly sutured as a sign of a developing coagulopathy.
You decide to send a blood specimen for a stat set of coagulation studies. You discontinue repair of the lacerations and pack the vagina with three laparotomy sponges tied together.
The patient is moved to the OR, and you activate the emergency transfusion protocol. You immediately receive 2 units of FFP, which you transfuse.
The blood bank sends a cooler with 4 units of FFP; 8 units of RBCs; and 2 bags of cryoprecipitate to the OR. The anesthesiologists begin the transfusion of these products.
The pretransfusion coagulation profile eventually returns: hemoglobin, 9.8 g/dL; platelet count, 79 X 103 μL; PT, 23.1 sec; International Normalized Ratio (INR), 2.0; PTT, 49 sec; and fibrinogen, 60 mg/dL.
After transfusing 4 units of FFP and the bag of cryoprecipitate, you remove the vaginal packs and note that diffuse bleeding has stopped. You resume repair of cervical and vaginal lacerations. During the course of the repair, all products in the cooler and 2 bags of platelets are transfused.