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Editorial


Planning reduces the risk of maternal death. This tool helps.

Developing—and practicing—standardized clinical responses to massive obstetric hemorrhage reduce the risk of this major cause of maternal death

August 2009 · Vol. 21, No. 08

Obstetric hemorrhage is a major cause of maternal death worldwide. Clinical research conducted in major trauma units shows that mortality can be reduced by:

  • developing and practicing standardized processes for responding to massive hemorrhage
  • defining, beforehand, the transfusion approach to massive hemorrhage—the so-called massive transfusion protocol, or MTP.

Take a look at California’s OB hemorrhage guideline

Leaders in obstetrics in California have developed and released a guideline for managing massive obstetric hemorrhage and improving outcomes that involves four ascending stages of response1:

Stage 0. Assess women for risk factors for hemorrhage. Actively manage the third stage of labor by administering oxytocin and performing fundal massage.

Stage 1. Activate the hemorrhage protocol when blood loss exceeds what would be considered a normal volume. Immediately:

  • assemble appropriate personnel (head nurse, anesthesiologist, additional obstetricians if available)
  • establish large-bore intravenous access
  • increase the rate of oxytocin infusion
  • perform fundal massage
  • administer methergine (if the mother is not hypertensive)
  • prepare to transfuse 2 units of packed red blood cells (RBCs).

Stage 2. If bleeding continues, assemble the OB rapid response team. Also:

  • assess coagulation status
  • administer additional uterotonic agents, such as misoprostol and carboprost tromethamine (Hemabate)
  • move to an operating room
  • consider dilation and curettage
  • place an intrauterine balloon
  • consider interventional radiology and uterine artery embolization
  • consider laparotomy and either uterine compression stitches or hysterectomy.

Stage 3. If bleeding persists and exceeds a predetermined volume:

  • activate the MTP
  • mobilize additional gyn surgical resources and an additional anesthesiologist
  • repeat all laboratory tests
  • perform laparotomy and consider hysterectomy.

(Note: This guideline for managing OB hemorrhage is summarized in the California Maternal Quality Care Collaborative’s TABLE.)


Obstetric Hemorrhage Care Summary: Table Chart Format

A massive transfusion protocol is invaluable

Evidence from trauma centers demonstrates that an MTP reduces the risk of death and morbidity from major hemorrhage.2-5 MTPs vary by center, but their common feature is rapid delivery of multiple units of blood, fresh frozen plasma (FFP), and platelets to the operating room (OR) where the mother has been brought.

It’s not an exaggeration to say that, in the past, a clinician managing a massive bleed had to beg the blood bank to release adequate blood products. In the new MTP approach, the blood bank sends a standardized amount of products to the OR immediately after the MTP is triggered.

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The MTP at Brigham and Women’s Hospital. Our MTP calls for 2 units of RBCs and 2 units of FFP to be delivered by pneumatic tube within a few minutes. Additional products—4 more units of RBCs and 2 more units each of FFP and platelets—are delivered shortly thereafter.

There are alternatives: For example, an MTP can call for 6 units of RBCs, 4 units of FFP, and 6 units of platelets to be sent to the OR.

MTPs also emphasize the standardized transfusion ratio of units of RBCs to FFP of roughly 1:1, or 2:1 until coagulation status can be adequately assessed. Some MTPs also define the ratio of units of RBCs to platelets that should be utilized—for example, 5:1.

Common coagulation targets of MTPs are:

  • hematocrit, ≥21%
  • international normalized ratio (INR), ≤1.5
  • platelets, ≥50K/μL
  • fibrinogen, ≥100 mg/dL.

Trauma centers have more experience with MTPs, but major obstetric units have also discovered that they help clinicians and patients.6

RiaSTAP to the rescue for small OB units?

Many smaller obstetric hospitals do not have adequate blood products immediately available to deal with massive OB hemorrhage. In many cases of OB hemorrhage, all endogenous fibrinogen is consumed, and a key to saving the life of the mother is to replace fibrinogen rapidly.

Recently, the FDA approved a lyophilized fibrinogen concentrate (RiaSTAP) for congenital hypofibrinogenemia. Although RiaSTAP is expensive, it is stable and could be stocked by the blood bank of a small hospital for (off-label) use in massive hemorrhage.

Unlike cryoprecipitate, a commonly used source of fibrinogen that can take 30 minutes or longer to thaw, RiaSTAP can be quickly reconstituted with sterile water.

RiaSTAP might be apppropriate when it would take longer than 30 minutes to thaw cryoprecipitate and fibrinogen infusion is needed sooner. Combining RiaSTAP with FFP would provide most of the critical proteins in the coagulation cascade.

Saving lives worldwide with a balloon catheter

The intrauterine balloon is now widely recognized as a simple intervention that can often resolve massive OB bleeding.7,8 Two FDA-approved intrauterine balloons are available:

  • the Bakri Postpartum Balloon (Cook Medical)
  • the BT-Cath (Utah Medical Products).

The Bakri Postpartum Balloon has been widely utilized; clinicians should be familiar with its use. I discussed this device in my February 2009 Editorial.

The balloon of the BT-Cath has a graded shape that conforms to the lower uterine segment. This feature may reduce the frequency with which the balloon protrudes through the cervix and into the vagina.

In some case series, the intrauterine balloon resulted in resolution of more than 80% of cases of OB hemorrhage.9-11 It is likely that the worldwide use of an intrauterine balloon could significantly reduce maternal mortality caused by hemorrhage.

Practice, practice, practice!

Firemen practice their response to fire scenarios. Pilots practice their response to various midair catastrophic events. Cardiovascular code teams practice their response to standard cardiac and respiratory arrest scenarios. OBs, OB anesthesiologists, and nurses would be wise to practice their team response to massive obstetric hemorrhage. A standardized plan, including an MTP, will reduce the associated morbidity and mortality.

References

1. CMQCC Hemorrhage Task Force. OB hemorrhage protocol. OB hemorrhage care guidelines: table chart format. California Maternal Quality Care Collaborative Web site. Available at: http://www.cmqcc.org/resources/ob_hemorrhage/ob_hemorrhage_protocol_tools_release_1_2. Accessed July 31, 2009.

2. Dente CJ, Shaz BH, Nicholas JM, et al. Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of a massive transfusion protocol in a civilian level I trauma center. J Trauma. 2009;66:1616-1624.

3. Bormanis J. Development of a massive transfusion protocol. Transfus Apher Sci. 2008;38:57-63.

4. Gunter OL, Au BK, Isbell JM, Mowery NT, Young PP, Cotton BA. Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival. J Trauma. 2008;65:527-534.

5. Cotton BA, Au BK, Nunez TC, Gunter OL, Robertson AM, Young PP. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma. 2009;66:41-48.

6. Burtelow M, Riley E, Druzin M, Fontaine M, Viele M, Goodnough LT. How we treat: management of life-threatening primary postpartum hemorrhage with a standardized massive transfusion protocol. Transfusion. 2007;47:1564-1572.

7. Georgiou C. Balloon tamponade in the management of postpartum hemorrhage: a review. BJOG. 2009;116:748-757.

8. Barbieri RL. You should add the Bakri balloon to your treatments for OB bleeds. OBG Management. 2009;21(2):6-7, 10.

9. Doumouchtsis SK, Papageorghiou AT, Vernier C, Arulkumaran S. Management of postpartum hemorrhage by uterine balloon tamponade: prospective evaluation of effectiveness. Acta Obstet Gynecol Scand. 2008;87:849-855.

10. Condous GS, Arulkumaran S, Symonds I, Chapman R, Sinha A, Razvi K. The “tamponade test” in the management of massive postpartum hemorrhage. Obstet Gynecol. 2003;101:767-772.

11. Dabelea V, Schultze PM, McDuffie RS, Jr. Intrauterine balloon tamponade in the management of postpartum hemorrhage. Am J Perinatol. 2007;24:359-364.

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