Management of Hemorrhage
Management of Hemorrhage
Management of Hemorrhage
A prudent rule is that any time blood loss is considered more than average by an
experienced team member, then the hema- tocrit is determined and plans are made
for close observation for physiological deterioration. Urine output is one of the
most important “vital signs” with which to monitor the woman with obstetrical
hemorrhage. Renal blood flow is especially sensitive to changes in blood volume.
Unless diuretic agents are given— and these are seldom indicated with active
bleeding—accurately measured urine flow reflects renal perfusion, which in turn
reflects perfusion of other vital organs. Urine flow of at least 30 mL, and
preferably 60 mL, per hour or more should be maintained. With potentially
serious hemorrhage, an indwelling bladder catheter is inserted to measure hourly
urine flow.
■ Hypovolemic Shock
Shock from hemorrhage evolves through several stages. Early in the course of
massive bleeding, there are decreases in mean arterial pressure, stroke volume,
cardiac output, central venous pressure, and pulmonary capillary wedge pressure.
Increases in arteriovenous oxygen content difference reflect a relative increase in
tissue oxygen extraction, although overall oxygen consumption falls.
The pathophysiological events just described lead to the important but often
overlooked extracellular fluid and electro- lyte shifts involved in both the genesis
and successful treatment of hypovolemic shock. These include changes in the
cellular transport of various ions such as sodium and water into skel- etal muscle
and potassium loss. Replacement of extracellular fluid and intravascular volume
are both necessary. Survival is enhanced in acute hemorrhagic shock if blood plus
crystalloid solu- tion is given compared with blood transfusions alone.
Whenever there is suggestion of excessive blood loss in a preg- nant woman, steps
are simultaneously taken to identify the source of bleeding and to begin
resuscitation. If she is undeliv- ered, restoration of blood volume is beneficial to
mother and fetus, and it also prepares for emergent delivery. If she is post-
partum, it is essential to immediately identify uterine atony, retained placental
fragments, or genital tract lacerations. At least one and preferably more large-bore
intravenous infusion systems are established promptly with rapid administration
of crystalloid solutions, while blood is made available. An operat- ing room,
surgical team, and anesthesia providers are assembled immediately. Specific
management of hemorrhage is further dependent on its etiology. For example,
antepartum bleeding from placenta previa is approached somewhat differently
than that from postpartum atony.
Fluid Resuscitation
Blood Replacement
There is considerable debate regarding the hematocrit level or hemoglobin
concentration that mandates blood transfusion. Cardiac output does not
substantively decrease until the hemo- globin concentration falls to approximately
7 g/dL or hemato- crit of 20 volume percent. At this level the Society of Thoracic
Surgeons (2011) recommends consideration for red-cell trans- fusions. Also,
Military Combat Trauma Units in Iraq used a target hematocrit of 21 volume
percent (Barbieri, 2007). In general, with ongoing obstetrical hemorrhage, we
recommend rapid blood infusion when the hematocrit is 25 volume per- cent.
This decision is dependent on whether the fetus has been delivered, surgery is
imminent or ongoing operative blood loss is expected, or acute hypoxia, vascular
collapse, or other factors are present.
Scant clinical data elucidate these issues. In a study from the Canadian Critical
Care Trials Group, nonpregnant patients were randomly assigned to restrictive red
cell transfusions to maintain hemoglobin concentration 7 g/dL or to liberal
trans- fusions to maintain the hemoglobin level at 10 to 12 g/dL. The 30-day
mortality rate was similar—19 versus 23 percent in the restrictive versus liberal
groups, respectively (Hebert, 1999). In a subanalysis of patients who were less ill,
the 30-day mor- tality rate was significantly lower in the restrictive group—9
versus 26 percent. In a study of women who had suffered post- partum
hemorrhage and who were now isovolemic and not actively bleeding, there were
no benefits of red cell transfusions when the hematocrit was between 18 and 25
volume percent (Morrison, 1991). The number of units transfused in a given
woman to reach a target hematocrit depends on her body mass and on
expectations of additional blood loss.
There are reports that support the preferable use of whole blood for massive
hemorrhage, including our experiences at Parkland Hospital (Alexander, 2009;
Hernandez, 2012). Of more than 66,000 deliveries, women with obstetrical
hemor- rhage treated with whole blood had significantly decreased incidences of
renal failure, acute respiratory distress syndrome, pulmonary edema,
hypofibrinogenemia, ICU admissions, and maternal death compared with those
given packed red cells and component therapy. Freshly donated whole blood has
also been used successfully for life-threatening massive hemorrhage at combat
support hospitals in Iraq (Spinella, 2008).
Thrombocytopenia is the most frequent coagulation defect found with blood loss
and multiple transfusions (Counts, 1979). In addition, packed red cells have very
small amounts of soluble clotting factors, and stored whole blood is deficient in
platelets and in factors V, VIII, and XI. Massive replacement with red cells only
and without factor replacement can also cause hypofibrinogenemia and
prolongation of the prothrom- bin and partial thromboplastin times. Because many
causes of obstetrical hemorrhage also cause consumptive coagulopathy, the
distinction between dilutional and consumptive coagulopa- thy can be confusing.
Fortunately, treatment for both is similar.
A few studies have assessed the relationship between massive transfusion and
resultant coagulopathy in civilian trauma units and military combat hospitals
(Bochicchio, 2008; Borgman, 2007; Gonzalez, 2007; Johansson, 2007). Patients
undergoing massive transfusion—defined as 10 or more units of blood—had
much higher survival rates as the ratio of plasma to red cell units was near 1.4,
that is, one unit of plasma given for each 1.4 units of packed red cells. By way of
contrast, the highest mortality group had a 1:8 ratio. Most of these studies found
that component replacement is rarely necessary with acute replacement of 5 to 10
units of packed red cells.
From the foregoing, when red cell replacement exceeds five units or so, a
reasonable practice is to evaluate the platelet count, clotting studies, and plasma
fibrinogen concentration. In the woman with obstetrical hemorrhage, the platelet
count should be maintained above 50,000/μL by the infusion of platelet con-
centrates. A fibrinogen level 100 mg/dL or a sufficiently pro- longed
prothrombin or partial thromboplastin time in a woman with surgical bleeding is
an indication for replacement. Fresh- frozen plasma is administered in doses of 10
to 15 mL/kg, or alternatively, cryoprecipitate is infused (see Table 41-8).
Type and Screen versus Crossmatch. A blood type and antibody screen should
be performed for any woman at sig- nificant risk for hemorrhage. Screening
involves mixing mater- nal serum with standard reagent red cells that carry
antigens to which most of the common clinically significant antibodies react.
Crossmatching involves the use of actual donor eryth- rocytes rather than the
standardized red cells. Clinical results show that the type-and-screen procedure is
amazingly efficient. Indeed, only 0.03 to 0.07 percent of patients identified to
have no antibodies are subsequently found to have antibod- ies by crossmatch
(Boral, 1979). Importantly, administration of screened blood rarely results in
adverse clinical sequelae.
Packed Red Blood Cells. One unit of packed erythrocytes is derived from one
unit of whole blood to have a hematocrit of 55 to 80 volume percent, depending
on the length of gen- tle centrifugation. Thus one unit contains the same volume
of erythrocytes as one whole blood unit. It will increase the hematocrit by 3 to 4
volume percent depending on patient size. Packed red blood cell and crystalloid
infusion are the mainstays of transfusion therapy for most cases of obstetrical
hemorrhage.
Importantly, the donor plasma in platelet units must be compatible with recipient
erythrocytes. Further, because some red blood cells are invariably transfused
along with the plate- lets, only units from D-negative donors should be given to
D-negative recipients. If necessary, however, adverse sequelae are unlikely. For
example, transfusion of ABO-nonidentical platelets in nonpregnant patients
undergoing cardiovascular surgery had no clinical effects (Lin, 2002).
One major concern with rFVIIa use is arterial—and to a lesser degree venous—
thrombosis. In a review of 35 random- ized trials with nearly 4500 subjects,
arterial thromboembolism developed in 55 percent (Levi, 2010a). A second
concern is that it was found to be only marginally effective in most of these
studies (Pacheco, 2011). In obstetrics, recombinant FVIIa has also been used to
control severe hemorrhage in women with and without hemophilia (Alfirevic,
2007; Franchini, 2007). It has been used with uterine atony, lacerations, and
placental abruption or previa. In approximately a third of cases, hysterec- tomy
was required. Importantly, rFVIIa will not be effective if the plasma fibrinogen
level is 50 mg/dL or the platelet count is 30,000/μL.
Autologous Transfusion. Patient phlebotomy and autolo- gous blood storage for
transfusion has been disappointing. Exceptions are women with a rare blood type
or with unusual antibodies. In one report, three fourths of women who began such
a program in the third trimester donated only one unit (McVay, 1989). This is
further complicated in that the need for transfusion cannot be predicted (Reyal,
2004). For these and other reasons, most have concluded that autologous
transfusions are not cost effective (Etchason, 1995; Pacheco, 2011, 2013).
Cell Salvage. To accomplish autotransfusion, blood lost intra- operatively into the
surgical field is aspirated and filtered. The red cells are then collected into
containers with concentrations similar to packed red cells and are infused as such.
Intraoperative blood salvage with reinfusion is considered to be safe in obstetri-
cal patients (Pacheco, 2011; Rainaldi, 1998). That said, Allam and associates
(2008) reported the lack of prospective trials but also found no reports of serious
complications.
Complications with Transfusions. During the past sev- eral decades, substantial
advances have been achieved in blood transfusion safety. Although many risks are
avoided or miti- gated, the most serious known risks that remain include errors
leading to ABO-incompatible blood transfusion, transfusion- related acute lung
injury (TRALI), and bacterial and viral trans- mission (Lerner, 2010).
Red Cell Substitutes. Use of these artificial carriers of oxy- gen has been
abandoned (Ness, 2007; Spiess, 2009). Three that have been studied include
perfluorocarbons, liposome-encapsu- lated hemoglobin, and hemoglobin-based
oxygen carriers.