CLINICAL OBSTETRICS AND GYNECOLOGY Volume 57, Number 4, 791–796 r 2014, Lippincott Williams & Wilkins
Obstetric Hemorrhage: Recent Advances ANTONIO SAAD, MD, and MAGED M. COSTANTINE, MD Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The University of Texas Medical Branch, Galveston, Texas
Abstract: Hemorrhage is the most common cause of maternal mortality worldwide, and represents the third most common obstetrical cause of maternal death in the United States. Although uterine atony was previously a major cause of peripartum hemorrhage, more recently, it appears that abnormal placentation is the leading etiology and the main indication of peripartum hysterectomy. Early identification and aggressive management of obstetrical hemorrhage is of utmost importance to prevent maternal morbidities and mortality. Key words: obstetrical hemorrhage, massive transfusion, placenta accreta
Introduction According to the Centers for Disease Control, about 650 women die each year in the United States as a result of pregnancy-related complications, with obstetric hemorrhage being a top tier leading etiology of maternal mortality.1 Worldwide, hemorrhage remains the #1 cause of Correspondence: Maged M. Costantine, MD, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX. E-mail: [email protected] The authors declare that they have nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
/
maternal mortality and the most common form of shock in obstetrical practice.1 Traditionally, uterine atony had been the major cause for peripartum hysterectomy; however, recently abnormal placentation has surpassed it in the developed world.2,3 This may be because of the current trends in obstetrical patients and practice including advanced maternal age at time of conception, higher obesity rates, and increasing cesarean delivery rates. These may have resulted in increased prevalence of placental abnormalities including placenta previa and placental accretism (accreta, increta, or percreta). It is estimated that placental accretism complicates 1 in 533 pregnancies; a rate that represents a sharp increase from 1 in 4027 pregnancies in the 1970s.4 In recent years, novel pathways thought to play crucial role in the pathogenesis of hemorrhage have been identified. In addition, the standard transfusion guidelines currently in place have been questioned, with a push to make hemostatic resuscitation (early aggressive blood product replacement) and massive transfusion protocols essential elements VOLUME 57
/
NUMBER 4
/
DECEMBER 2014
www.clinicalobgyn.com | 791
792
Saad and Costantine
in these guidelines.3 In this paper, we will review the diagnosis and management of placental accretism, as well as, discuss advances in the medical management of obstetrical hemorrhage. These topics have been recently the subject of many extensive reviews by Pacheco and colleagues.5–7
and its effects on the fetus remains uncertain. Therefore, use of paramagnetic contrast media during pregnancy may be undertaken only after evaluating the risk benefit ratio of such approach, and if the improved accuracy of the study is expected to significantly improve patient care and guide essential therapeutic interventions.
DIAGNOSIS OF PLACENTA ACCRETA
In the majority of cases, an ultrasound performed by an experienced and trained sonographer has good sensitivity and specificity to diagnose placental accretism (sensitivity of 77% to 87%, specificity of 96% to 98%, and negative predictive value of 98%).8,9 Traditional sonographic clues suggestive of placental accretism include loss of the normal retroplacental hypoechoic space, increased vascularity with uterine wall vessel invasion on color Doppler, and the presence of placental lacunae giving a ‘‘moth-eaten or Swiss cheese’’ appearance, which is the most predictive sonographic sign with sensitivity of 79% and positive predictive value of 92%. Although an ultrasound may be enough in the majority of patients, magnetic resonance imaging (MRI) may be useful in patients suspected of having placental accretism to evaluate the depth of invasion, especially for posterior placentas, as well as to better discriminate the involvement of adjacent organs when a placenta percreta is suspected.10 Bulging of the lower uterine segment, the presence of a heterogeneous placenta, and dark intraplacental linear bands on T2weighed MRI images are suggestive of placental accretism.11 In general, the accuracy of ultrasound and MRI in diagnosing placenta accretism is similar.5,12 Of note, although the use of paramagnetic contrast media (gadolinium) would likely improve the diagnostic performance of MRI by enhancing the outer placental surface relative to the myometrium; however, the agent readily crosses the placenta www.clinicalobgyn.com
ANTEPARTUM CARE AND TIMING OF DELIVERY
To ensure optimal care, it is recommended that patients with suspected placental accretism or at risk for peripartum hemorrhage should be referred to a tertiary center and managed by a multidisciplinary team including specialists in maternal fetal medicine, urology, vascular surgery, interventional radiology, blood bank, and neonatology. Such an approach has been shown to decrease maternal morbidity.5,13 The use of serial ultrasound examinations to monitor fetal growth is not recommended in patients with isolated placenta previa without accretism, as the latter was not found to be associated with fetal growth restriction.14 However, when placental accretism is suspected or present, serial sonographic follow-up every 3 to 4 weeks is recommended to assess fetal growth, and the depth of placental invasion. Patients with suspected placental accretism or at risk for peripartum hemorrhage need to have their hemoglobin levels optimized before delivery. It is common to start these patients on iron and/or folic acid supplements, and occasionally, intravenous iron and/or recombinant erythropoietin may be needed as adjuvant therapy. Preoperative autologous blood donation may be considered in select patients, such as those with rare blood types and/or alloimmunization to rare antibodies. Patients [with hemoglobin >10 g/dL, and within 42 d of surgery, the maximum accepted time to maintain packed red
Systolic Blood Pressure blood cells (RBC) in the blood bank] may donate their own blood units during pregnancy, and these will be later used intraoperatively if needed. Disadvantages of such approach is that it has not been shown to be cost-effective, is not well studied in pregnancy, and may not be acceptable by Jehovah’s Witnesses patients.15 Regarding timing of delivery, the Society of Maternal Fetal Medicine recommends that patients with placenta previa should be delivered at 36 to 37 weeks, and those with suspected placental accretism at 34 to 35 weeks.16 Testing for fetal lung maturity before delivery is not thought to not provide any additional benefit, and thus is not recommended.17 The decision to deliver a pregnant woman with suspected accretism between 34 and 37 weeks should be individualized depending on the patient obstetrical history, pregnancy complications, and risk of preterm labor and/or vaginal bleeding.5,18 PERIOPERATIVE INTERVENTIONS
Although a complete sympathectomy (eg, spinal anesthesia) may impair the patient’s ability to vasoconstrict and increase systemic vascular resistances and thus may put the patient at risk from the hypovolemia associated with acute blood loss; a continuous epidural technique is safe and may be appropriate for patients with placental accretism.19,20 However, in emergent situations of massive bleeding, general anesthesia may be more appropriate. In contrast, permissive hypotension (with systolic blood pressure of 80 to 100 mm Hg) may be discussed with the anesthesia team and considered in patients with postpartum hemorrhage. No data are available on its safety before delivery of the fetus as it may compromise uterine perfusion.5,6 Although acute normovolemic hemodilution may be considered in certain patients (those with hemoglobin level >10 g/dL and no history of
793
cardiovascular disease), there is minimal evidence that it alone reduces significantly the need for transfusion. This technique involves collecting 500 to 1000 mL of blood from the patient and replacing it with either colloid (1:1 ratio) or crystalloid (3:1 ratio) fluids to maintain hemodynamics.15 After surgical bleeding is controlled, the patient is transfused the previously collected blood. This technique is acceptable for some Jehovah’s Witnesses as long as the collection bag is connected to the central venous line at all times, without any ‘‘circuit’’ disconnections.15 Another safe and effective technique that may be accepted by Jehovah’s Witnesses patients is intraoperative cell salvage.5,6 After collecting and filtering aspirated blood from the surgical field, sterile filters will separate tissue factor, afetoprotein, platelets, and circulating procoagulants.21 The collected blood is then reinfused to the patient after its reaches a hematocrit concentration >55%. A Kleihauer-Betke stain and appropriate administration of anti-D immunoglobulin is required for prevention of alloimmunization in Rh-negative blood type patients.15 Moreover, there is no evidence of increased risk of amniotic fluid embolism with the use of this technique in the 400 plus cases described in the obstetric literature.22 Another therapy that is being more frequently used in obstetric hemorrhage is recombinant factor VII a (rFVIIa). Traditionally, this therapy has been approved for patients with hemophilia and inhibitory alloantibodies.23 However, it has been used off-label in various clinical scenarios including trauma, cardiovascular surgery, and obstetrical hemorrhage; and is being added to many massive transfusion protocols. The agent has a short half-life (2 to 6 h), requires multiple administrations, and its use is associated with increased risk of arterial thromboembolism. rFVIIa is not the first line www.clinicalobgyn.com
794
Saad and Costantine
FIGURE 1. Massive transfusion protocol in obstetrics. Once activated, blood bank personnel will continue preparing blood products until the protocol is inactivated by the surgical team. After 2 sequences of rounds 1 to 3, if not inactivated, the protocol will start again from round 1. *The utilized dose of recombinant activated factor VII is based on local expert opinion. ^If bleeding is not controlled the sequence is repeated. FFP indicates fresh frozen plasma; pRBC, packed red blood cells. Adapted from Pacheco et al.7
of treatment for massive hemorrhage and should only be used after surgical bleeding has been controlled, with a combination of various blood products, and only after meeting multiple prerequisites including platelet count >50,000/mm3, fibrinogen >50 to 100 mg/dL, temperature >321C, pH>7.2, and normal ionized calcium.24 Multiple, nonobstetric, randomized controlled trials have been published where rFVIIa has been used to control bleeding, and none showed that its use improves survival. However, 4 of 17 studies concluded that it reduced transfusion requirements or blood loss.25 The optimal dose of rFVIIa, especially in pregnancy, is unknown, but the majority of reports in obstetrical hemorrhage have used a dose of 40 to 90 mg/kg.6,7 Acute coagulopathy remains a major complication in the setting of massive hemorrhage, most commonly secondary to ‘‘dilutional coagulopathy.’’ Traditional resuscitative maneuvers are heavily www.clinicalobgyn.com
based on massive administration of crystalloids, colloids and packed RBC, with the use of fresh frozen plasma (FFP), cryoprecipitates, and platelets limited to low fibrinogen (1.5 normal), and thrombocytopenia (platelet count 20 mm Hg and dysfunction of at least 1 organ, and these patients are managed with fluid restriction, enteral feeding, but most will need surgical decompression.32
Summary Obstetrical hemorrhage remains among the major causes of maternal morbidity and mortality, with placental accretism representing the major cause and the most common indication for a cesarean hysterectomy in the developed world. Early identification of placental accretism and patient transfer to a tertiary care center with multidisciplinary team approach, improves maternal and fetal outcomes. Various strategies have been identified that may assist in management of these patients including, normovolemic hemodilution, intraoperatively use of cellsaver, hemostatic resuscitation, and the use of massive transfusion protocols.
References 1. Kung HC, Hoy DL, Murphy SL. Deaths: Final Data for 2005. Volume 56, No. 10. Hyattsville, MD: National Center for Health Statistics; 2008. 2. Kwee A, Bots ML, Visser GH, et al. Emergency peripartum hysterectomy: a prospective study in The Netherlands. Eur J Obstet Gynecol Reprod Biol. 2006;124:187–192. 3. Smith J, Mousa HA. Peripartum hysterectomy for primary postpartum haemorrhage: incidence and maternal morbidity. J Obstet Gynaecol. 2007; 27:44–47. 4. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol. 2005;192:1458–1461.
www.clinicalobgyn.com
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5. Pacheco LD, Gei AF. Controversies in the management of placenta accrete. Obstet Gynecol Clin North Am. 2011;38:313–322. 6. Pacheco LD, Saade GR, Gei AF, et al. Cuttingedge advances in the medical management of obstetrical hemorrhage. Am J Obstet Gynecol. 2011;205:526–532. 7. Pacheco LD, Saade GR, Costantine MM, et al. The role of massive transfusion protocols in obstetrics. Am J Perinatol. 2013;30:1–4. 8. Warshak CR, Eskander R, Hull AD, et al. Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. Obstet Gynecol. 2006;108:573–581. 9. Comstock CH, Love JJ Jr, Bronsteen RA, et al. Sonographic detection of placenta accreta in the second and third trimesters of pregnancy. Am J Obstet Gynecol. 2004;190:1135–1140. 10. Baughman WC, Corteville JE, Shah RR. Placenta accreta: spectrum of US and MR imaging findings. Radiographics. 2008;28:1905–1916. 11. Teo TH, Law YM, Tay KH, et al. Use of magnetic resonance imaging in evaluation of placental invasion. Clin Radiol. 2009;64:511–516. 12. Dwyer BK, Belogolovkin V, Tran L, et al. Prenatal diagnosis of placenta accreta: sonography or magnetic resonance imaging? J Ultrasound Med. 2008;27:1275–1281. 13. Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. 2011;117:331–337. 14. Harper LM, Odibo MO, Macones GA, et al. Effect of placenta previa on fetal growth. Am J Obstet Gynecol. 2010;203:330.e1–330.e5. 15. Catling S. Blood conservation techniques in obstetrics: a UK perspective. Inter J Obstet Anesth. 2007;16:241–249. 16. Spong CY, Mercer BM, D’Alton M, et al. Timing of indicated late-preterm and early-term birth. Obstet Gynecol. 2011;118:323–333. 17. Robinson BK, Grobman WA. Effectiveness of timing strategies for delivery of individuals with placenta previa and accreta. Obstet Gynecol. 2010;116:835–842. 18. Stafford IA, Dashe JS, Shivvers SA, et al. Ultrasonographic cervical length and risk of hemorrhage in pregnancies with placenta previa. Obstet Gynecol. 2010;116:595–600.
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19. Parekh N, Husaini SW, Russell IF. Caesarean section for placenta previa: a retrospective study of anaesthetic management. Br J Anaesth. 2000;84:725–730. 20. Ioscovich A, Mirochnitchenko E, Halpern S, et al. Perioperative anaesthetic management of high order repeat caesarean section: audit of practice in a university affiliated medical center. Int J Obstet Anesth. 2009;18:314–319. 21. Tawes RL Jr. Clinical applications of autotransfusion. Semin Vasc Surg. 1994;7:89–90. 22. Rainaldi MP, Tazzari PL, Seagliarini G, et al. Blood salvage during cesarean section. Br J Anaesth. 1998;80:196–198. 23. Stanworth SJ, Birchall J, Doree CJ, et al. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev. 2007;18: CD005011. 24. Spahn DR, Cerny V, Coats TJ, et al. Management of bleeding following major trauma: a European guideline. Crit Care. 2007;11:R17. 25. Johansson PI, Ostrowski SR, Secher NH. Management of major blood loss: an update. Acta Anaesthesiol Scand. 2010;54:1039–1049. 26. Nascimento B, Callum J, Rubenfeld G, et al. Clinical review: fresh frozen plasma in massive bleedings-more questions than answers. Crit Care. 2010;14:202. 27. Ickx BE. Fluid and blood transfusion management in obstetrics. Eur J Anaesthesiol. 2010;27: 1031–1035. 28. Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: mechanism, identification, and effect. Curr Opin Crit Care. 2007;13: 680–685. 29. Cotton 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: 1177–1182. 30. Snyder CW, Weinberg JA, McGwin G, et al. The relationship of blood product ratio to mortality: survival benefit or survival bias? J Trauma. 2009;66:358–362. 31. Scalea TM, Bochicchio KM, Lumpkins K, et al. Early aggressive use of fresh frozen plasma does not improve outcome in critically injured trauma patients. Ann Surg. 2008;248:578–584. 32. Cheatham ML. Abdominal compartment syndrome. Curr Opin Crit Care. 2009;15:154–162.
Obstetric Hemorrhage: Recent Advances ANTONIO SAAD, MD, and MAGED M. COSTANTINE, MD Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The University of Texas Medical Branch, Galveston, Texas
Abstract: Hemorrhage is the most common cause of maternal mortality worldwide, and represents the third most common obstetrical cause of maternal death in the United States. Although uterine atony was previously a major cause of peripartum hemorrhage, more recently, it appears that abnormal placentation is the leading etiology and the main indication of peripartum hysterectomy. Early identification and aggressive management of obstetrical hemorrhage is of utmost importance to prevent maternal morbidities and mortality. Key words: obstetrical hemorrhage, massive transfusion, placenta accreta
Introduction According to the Centers for Disease Control, about 650 women die each year in the United States as a result of pregnancy-related complications, with obstetric hemorrhage being a top tier leading etiology of maternal mortality.1 Worldwide, hemorrhage remains the #1 cause of Correspondence: Maged M. Costantine, MD, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX. E-mail: [email protected] The authors declare that they have nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
/
maternal mortality and the most common form of shock in obstetrical practice.1 Traditionally, uterine atony had been the major cause for peripartum hysterectomy; however, recently abnormal placentation has surpassed it in the developed world.2,3 This may be because of the current trends in obstetrical patients and practice including advanced maternal age at time of conception, higher obesity rates, and increasing cesarean delivery rates. These may have resulted in increased prevalence of placental abnormalities including placenta previa and placental accretism (accreta, increta, or percreta). It is estimated that placental accretism complicates 1 in 533 pregnancies; a rate that represents a sharp increase from 1 in 4027 pregnancies in the 1970s.4 In recent years, novel pathways thought to play crucial role in the pathogenesis of hemorrhage have been identified. In addition, the standard transfusion guidelines currently in place have been questioned, with a push to make hemostatic resuscitation (early aggressive blood product replacement) and massive transfusion protocols essential elements VOLUME 57
/
NUMBER 4
/
DECEMBER 2014
www.clinicalobgyn.com | 791
792
Saad and Costantine
in these guidelines.3 In this paper, we will review the diagnosis and management of placental accretism, as well as, discuss advances in the medical management of obstetrical hemorrhage. These topics have been recently the subject of many extensive reviews by Pacheco and colleagues.5–7
and its effects on the fetus remains uncertain. Therefore, use of paramagnetic contrast media during pregnancy may be undertaken only after evaluating the risk benefit ratio of such approach, and if the improved accuracy of the study is expected to significantly improve patient care and guide essential therapeutic interventions.
DIAGNOSIS OF PLACENTA ACCRETA
In the majority of cases, an ultrasound performed by an experienced and trained sonographer has good sensitivity and specificity to diagnose placental accretism (sensitivity of 77% to 87%, specificity of 96% to 98%, and negative predictive value of 98%).8,9 Traditional sonographic clues suggestive of placental accretism include loss of the normal retroplacental hypoechoic space, increased vascularity with uterine wall vessel invasion on color Doppler, and the presence of placental lacunae giving a ‘‘moth-eaten or Swiss cheese’’ appearance, which is the most predictive sonographic sign with sensitivity of 79% and positive predictive value of 92%. Although an ultrasound may be enough in the majority of patients, magnetic resonance imaging (MRI) may be useful in patients suspected of having placental accretism to evaluate the depth of invasion, especially for posterior placentas, as well as to better discriminate the involvement of adjacent organs when a placenta percreta is suspected.10 Bulging of the lower uterine segment, the presence of a heterogeneous placenta, and dark intraplacental linear bands on T2weighed MRI images are suggestive of placental accretism.11 In general, the accuracy of ultrasound and MRI in diagnosing placenta accretism is similar.5,12 Of note, although the use of paramagnetic contrast media (gadolinium) would likely improve the diagnostic performance of MRI by enhancing the outer placental surface relative to the myometrium; however, the agent readily crosses the placenta www.clinicalobgyn.com
ANTEPARTUM CARE AND TIMING OF DELIVERY
To ensure optimal care, it is recommended that patients with suspected placental accretism or at risk for peripartum hemorrhage should be referred to a tertiary center and managed by a multidisciplinary team including specialists in maternal fetal medicine, urology, vascular surgery, interventional radiology, blood bank, and neonatology. Such an approach has been shown to decrease maternal morbidity.5,13 The use of serial ultrasound examinations to monitor fetal growth is not recommended in patients with isolated placenta previa without accretism, as the latter was not found to be associated with fetal growth restriction.14 However, when placental accretism is suspected or present, serial sonographic follow-up every 3 to 4 weeks is recommended to assess fetal growth, and the depth of placental invasion. Patients with suspected placental accretism or at risk for peripartum hemorrhage need to have their hemoglobin levels optimized before delivery. It is common to start these patients on iron and/or folic acid supplements, and occasionally, intravenous iron and/or recombinant erythropoietin may be needed as adjuvant therapy. Preoperative autologous blood donation may be considered in select patients, such as those with rare blood types and/or alloimmunization to rare antibodies. Patients [with hemoglobin >10 g/dL, and within 42 d of surgery, the maximum accepted time to maintain packed red
Systolic Blood Pressure blood cells (RBC) in the blood bank] may donate their own blood units during pregnancy, and these will be later used intraoperatively if needed. Disadvantages of such approach is that it has not been shown to be cost-effective, is not well studied in pregnancy, and may not be acceptable by Jehovah’s Witnesses patients.15 Regarding timing of delivery, the Society of Maternal Fetal Medicine recommends that patients with placenta previa should be delivered at 36 to 37 weeks, and those with suspected placental accretism at 34 to 35 weeks.16 Testing for fetal lung maturity before delivery is not thought to not provide any additional benefit, and thus is not recommended.17 The decision to deliver a pregnant woman with suspected accretism between 34 and 37 weeks should be individualized depending on the patient obstetrical history, pregnancy complications, and risk of preterm labor and/or vaginal bleeding.5,18 PERIOPERATIVE INTERVENTIONS
Although a complete sympathectomy (eg, spinal anesthesia) may impair the patient’s ability to vasoconstrict and increase systemic vascular resistances and thus may put the patient at risk from the hypovolemia associated with acute blood loss; a continuous epidural technique is safe and may be appropriate for patients with placental accretism.19,20 However, in emergent situations of massive bleeding, general anesthesia may be more appropriate. In contrast, permissive hypotension (with systolic blood pressure of 80 to 100 mm Hg) may be discussed with the anesthesia team and considered in patients with postpartum hemorrhage. No data are available on its safety before delivery of the fetus as it may compromise uterine perfusion.5,6 Although acute normovolemic hemodilution may be considered in certain patients (those with hemoglobin level >10 g/dL and no history of
793
cardiovascular disease), there is minimal evidence that it alone reduces significantly the need for transfusion. This technique involves collecting 500 to 1000 mL of blood from the patient and replacing it with either colloid (1:1 ratio) or crystalloid (3:1 ratio) fluids to maintain hemodynamics.15 After surgical bleeding is controlled, the patient is transfused the previously collected blood. This technique is acceptable for some Jehovah’s Witnesses as long as the collection bag is connected to the central venous line at all times, without any ‘‘circuit’’ disconnections.15 Another safe and effective technique that may be accepted by Jehovah’s Witnesses patients is intraoperative cell salvage.5,6 After collecting and filtering aspirated blood from the surgical field, sterile filters will separate tissue factor, afetoprotein, platelets, and circulating procoagulants.21 The collected blood is then reinfused to the patient after its reaches a hematocrit concentration >55%. A Kleihauer-Betke stain and appropriate administration of anti-D immunoglobulin is required for prevention of alloimmunization in Rh-negative blood type patients.15 Moreover, there is no evidence of increased risk of amniotic fluid embolism with the use of this technique in the 400 plus cases described in the obstetric literature.22 Another therapy that is being more frequently used in obstetric hemorrhage is recombinant factor VII a (rFVIIa). Traditionally, this therapy has been approved for patients with hemophilia and inhibitory alloantibodies.23 However, it has been used off-label in various clinical scenarios including trauma, cardiovascular surgery, and obstetrical hemorrhage; and is being added to many massive transfusion protocols. The agent has a short half-life (2 to 6 h), requires multiple administrations, and its use is associated with increased risk of arterial thromboembolism. rFVIIa is not the first line www.clinicalobgyn.com
794
Saad and Costantine
FIGURE 1. Massive transfusion protocol in obstetrics. Once activated, blood bank personnel will continue preparing blood products until the protocol is inactivated by the surgical team. After 2 sequences of rounds 1 to 3, if not inactivated, the protocol will start again from round 1. *The utilized dose of recombinant activated factor VII is based on local expert opinion. ^If bleeding is not controlled the sequence is repeated. FFP indicates fresh frozen plasma; pRBC, packed red blood cells. Adapted from Pacheco et al.7
of treatment for massive hemorrhage and should only be used after surgical bleeding has been controlled, with a combination of various blood products, and only after meeting multiple prerequisites including platelet count >50,000/mm3, fibrinogen >50 to 100 mg/dL, temperature >321C, pH>7.2, and normal ionized calcium.24 Multiple, nonobstetric, randomized controlled trials have been published where rFVIIa has been used to control bleeding, and none showed that its use improves survival. However, 4 of 17 studies concluded that it reduced transfusion requirements or blood loss.25 The optimal dose of rFVIIa, especially in pregnancy, is unknown, but the majority of reports in obstetrical hemorrhage have used a dose of 40 to 90 mg/kg.6,7 Acute coagulopathy remains a major complication in the setting of massive hemorrhage, most commonly secondary to ‘‘dilutional coagulopathy.’’ Traditional resuscitative maneuvers are heavily www.clinicalobgyn.com
based on massive administration of crystalloids, colloids and packed RBC, with the use of fresh frozen plasma (FFP), cryoprecipitates, and platelets limited to low fibrinogen (1.5 normal), and thrombocytopenia (platelet count 20 mm Hg and dysfunction of at least 1 organ, and these patients are managed with fluid restriction, enteral feeding, but most will need surgical decompression.32
Summary Obstetrical hemorrhage remains among the major causes of maternal morbidity and mortality, with placental accretism representing the major cause and the most common indication for a cesarean hysterectomy in the developed world. Early identification of placental accretism and patient transfer to a tertiary care center with multidisciplinary team approach, improves maternal and fetal outcomes. Various strategies have been identified that may assist in management of these patients including, normovolemic hemodilution, intraoperatively use of cellsaver, hemostatic resuscitation, and the use of massive transfusion protocols.
References 1. Kung HC, Hoy DL, Murphy SL. Deaths: Final Data for 2005. Volume 56, No. 10. Hyattsville, MD: National Center for Health Statistics; 2008. 2. Kwee A, Bots ML, Visser GH, et al. Emergency peripartum hysterectomy: a prospective study in The Netherlands. Eur J Obstet Gynecol Reprod Biol. 2006;124:187–192. 3. Smith J, Mousa HA. Peripartum hysterectomy for primary postpartum haemorrhage: incidence and maternal morbidity. J Obstet Gynaecol. 2007; 27:44–47. 4. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol. 2005;192:1458–1461.
www.clinicalobgyn.com
796
Saad and Costantine
5. Pacheco LD, Gei AF. Controversies in the management of placenta accrete. Obstet Gynecol Clin North Am. 2011;38:313–322. 6. Pacheco LD, Saade GR, Gei AF, et al. Cuttingedge advances in the medical management of obstetrical hemorrhage. Am J Obstet Gynecol. 2011;205:526–532. 7. Pacheco LD, Saade GR, Costantine MM, et al. The role of massive transfusion protocols in obstetrics. Am J Perinatol. 2013;30:1–4. 8. Warshak CR, Eskander R, Hull AD, et al. Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. Obstet Gynecol. 2006;108:573–581. 9. Comstock CH, Love JJ Jr, Bronsteen RA, et al. Sonographic detection of placenta accreta in the second and third trimesters of pregnancy. Am J Obstet Gynecol. 2004;190:1135–1140. 10. Baughman WC, Corteville JE, Shah RR. Placenta accreta: spectrum of US and MR imaging findings. Radiographics. 2008;28:1905–1916. 11. Teo TH, Law YM, Tay KH, et al. Use of magnetic resonance imaging in evaluation of placental invasion. Clin Radiol. 2009;64:511–516. 12. Dwyer BK, Belogolovkin V, Tran L, et al. Prenatal diagnosis of placenta accreta: sonography or magnetic resonance imaging? J Ultrasound Med. 2008;27:1275–1281. 13. Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. 2011;117:331–337. 14. Harper LM, Odibo MO, Macones GA, et al. Effect of placenta previa on fetal growth. Am J Obstet Gynecol. 2010;203:330.e1–330.e5. 15. Catling S. Blood conservation techniques in obstetrics: a UK perspective. Inter J Obstet Anesth. 2007;16:241–249. 16. Spong CY, Mercer BM, D’Alton M, et al. Timing of indicated late-preterm and early-term birth. Obstet Gynecol. 2011;118:323–333. 17. Robinson BK, Grobman WA. Effectiveness of timing strategies for delivery of individuals with placenta previa and accreta. Obstet Gynecol. 2010;116:835–842. 18. Stafford IA, Dashe JS, Shivvers SA, et al. Ultrasonographic cervical length and risk of hemorrhage in pregnancies with placenta previa. Obstet Gynecol. 2010;116:595–600.
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