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Fibrinogen, haemostasis and postpartum haemorrhage
Ove KarlssonSahlgrenska University Hospital
Gothenburg, Sweden
No conflict of interests
• Gothenburg, Sweden• 10-11.000 deliveries• 3 labour wards
• 2 normal• 1 special
0
100
200
300
400
500
600
700
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
2016 7.2%
Vaginal deliveries with bleeding >1000 ml, Sahlgrenska University Hospital
0
10
20
30
40
50
60
70
80
90
100
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
1500 - 1999
2000 - 2999
3000 - 3999
>4000
Bleeding during operation
2010 20161-2 L 8.1% 4.2%>2 L 1.3% 0.76%
• Better routine• Better cooperation• Better knowledge
of haemostasis
0
100
200
300
400
500
600
700
800
2009 2010 2011 2012 2013 2014 2015 2016
Erytrocyter Plasma Trombocyter
Reduced blood transfusions with 39.5%
8.5 per 100.000 maternities
MBRRACE-UK 2012-2014
In all patients with mortality due to haemorrhage, improvements in care may have made a difference to the outcome (MBRRACE-UK 2009-2012)
Treatment of large postpartum haemorrhage:
1. Prophylaxis against postpartum haemorrhage
2. Initial treatment
3. Pharmacological treatment
4. Surgical treatment
5. Haemostasis
6. Anaesthesia
7. And more
Initial treatment
• Aorta compression• Alt. bimanually uterus compression• Call staff• Lower head and Oxygen 5-10 L/min• Blood pressure and pulse• Intravenous access• Hb, screen• Coagulation screen• Warm fluids
• Crystalloid (avoid excessive use)• Colloid (restricted)• Adverse effects of haemostasis
• Catheter• Keep patient warm• Inj Tranexamic acid 2 g iv
Farmacological therapy of atony
• Inj Oxytocin (Syntocinon®)– Bolus 8,3 ug/ml 1 ml iv under 1 min– Oxytocin 8,3 ug/ml = 5 E/ml– Vid elektivt snitt under 5 minuter– Infusion 66,4 ug/ml 120 ml/t
• Inj Metylergometrin (Methergin®)– 0,2 mg iv alt im, långsamt– Kan upprepas 4 ggr
• Inj Karboprost (Prostinfenem®)– 0,25 mg im– Kan upprepas 8 ggr
• T Misoprostol (Cytotec®)– 200 mg 3 st rektalt
Obstetrical interventions
• Inspection of placenta
• Exploration of uterus
• Inspection of cervix/vagina
• Balloon tamponade
• Compression sutures
• Hysterectomy
Goals during on-going bleeding:
• Hb > 90 g/l• Platelets > 100 x 109/l• PK(INR) < 1.5• APTT normal• Fibrinogen > 2.0-2.5 g/l• Temp > 36.5 °C• pH > 7.2• Ionised Ca2+ >1.0• Point-of-Care devices• Repeat sampling!
• Review• Several randomised studies• Reduced bleeding volume• Large RCT required
• 20.000 patients, 21 countries, 193 hospital• Randomised, double-blind, placebo controlled• Inj Tranexamic acid 1g, a second dose possible• Reduced mortality due to reduced bleeding
Transfusion strategy
Bleeding < ½ blood volume
and bleeding will stop
• Transfusion strategy
– As little as possible
– Goal-directed therapy
– Packed red blood cells, until acceptable Hb
Bleeding > ½ blood volume
and bleeding will continue
• Transfusion strategy
– Blood/plasma/platelets
–4:4:1
Try to assess if the bleeding will:
• The risk for severe PPH was 2.63-fold higher for each 1 g/L decrease of fibrinogen
• Positive predictive value of fibrinogen ≤2 g/L was 100%
• A simple fibrinogen can anticipate the risk of severe bleeding in PPH.
• Multicentre, d-blinded, randomized• Study group vs control group
• EBL 1493 (±489) vs 1426 (±463)• Fib 4.5 (±1.1) vs 4.5 (±1.3)• 2 g fibrinogen or saline• Total EBL 1700 vs 1700
• No difference transfusion or (total) estimated blood loss (EBL)
Study group Control groupBleeding, L 2.5 (2.0-3.7) 0.4 (0.2-0.6)Fibrinogen g/L 3.0 (2.7-3.3) 4.8 (4.6-5.0)
range 1.0-5.0 range 3.6-6.7
• Faster clot initiation• Reduced clot strength• TEG, faster results• Strongest correlation
• Fibrinogen - TEG-MA• EBL - Fibrinogen• EBL – TEG-MA
• Fibrinogen concentration mean 5.3 g/L• Interval 2.9 – 8.8 g/L
r = 0.9
p < 0.0001
r = 0.003
p < 0.9
• Fibrinogen does not decrease during labour• Fibrinogen does not predict severe PPH• Predictors of PPH:
• Exploration of uterus postpartum• Caesarean section• Instrumental delivery• Oxytocin stimulation
• >2.0 g/L, improved coagulation• 2.5 g/L, optimized coagulation• Still not stable to fibrinolysis
• Review about fibrinogen• Plasma contains 1-3 g/L• Fibrinogen concentrate 15-20 g/L• Obstetric haemorrhage 1 g,
median increase of 0.36 g/L
American Journal of Obstetrics & Gynecology 2015
• Urgent treatment• Treat the cause• Give it all at once
• Blood/Plasma/Platelets• Fibrinogen• Tranexamic acid
• Repeat sampling
• Off label use• Case reports, obstetric bleeding• No randomised studies• In some guidelines
• No studies, postpartum haemorrhage• Other studier, no difference in bleeding• Indication profylaxis
• von Willebrand• Hemofili A• Platelet dysfunction
• Risk for water intoxication
Work against:• Hypothermia• Hypocalcaemia• Acidosis
Anaesthesia and obstetric complications
Regional anaesthesia
• Less bleeding
• Less transfusions
• Less mortality
• Less morbidity
• Contraindication– Large on-going bleeding
General anaesthesia
• Increased bleeding
• Increased transfusions
• Increased mortality
• Increased morbidity
• Indication– Large on-going bleeding
• Volatile anaesthetics• Dose dependent relaxation• Uterine muscles
• Change volatile anaesthetics• Propofol infusion• Optimize O2/N2O/fentanyl
Bleeding (median and range)• Study group 1400 mL (400-3000)• Control group 8000 mL (2300-40.000)