Postpartum Hemorrhage and Tranexamic Acid

Copyright 2019. Gregory Collins, DNP CRNA, Dawn Lewellen, MHS, CRNA.All Rights Reserved.

DISCLOSURE STATEMENT

▪ We have no financial relationships with any commercial interestrelated to the content of this activity.

▪ We will not discuss off-label use during our presentation.

LEARNER OUTCOMES

Identify indications for tranexamic acid (TXA) use inwomen with postpartum hemorrhage.

List mechanisms of action and possible side effects from TXA use.

Describe the patient safety bundle for obstetricalhemorrhage and how to implement the guidelines with your facility.

MATERNAL MORTALITY & PPH

100,000 DEATHS PER YEAR1

MATERNAL MORTALITY & PPH

7 /100,0003

1,570 /100,0003

1.938 /100,0002

EPIDEMIOLOGY & ETIOLOGY

4-6%

1.86%

PPH

PPHSEVERE

ETIO

LOG

Y: TONETRAUMATISSUETHROMBIN

20%70%

10%~1%

CASE STUDY: PPH, ROTEM, AND TXA

PPH CASE STUDY▪ 24 YO G1P1A0 presented at 39w2d with PROM, thin meconium,

positive cocaine, amphetamine, cannabinoids

▪ Induction with Pitocin

▪ After 24 hours, to OR for ASAP C/S under epidural. 1000 mL EBL

▪ After skin closure, patient became tachycardic, HR 150s, SBP 90

▪ 500 mL on sheets

▪ Carboprost (Hemabate) X3, pitocin, and 2 units PRBCs

▪ Uterine atony continued, reopened incision and converted to GETA

▪ EBL 1500 mL

▪ Uterine atony

▪ ABG: pH 7.25, PaCO2 53, PaO2 99, HCO3 23, BE -4, Lactate 2

▪ 80/50, HR 130’s

▪ Proceeded to hysterectomy

▪ Massive Transfusion Protocol (MTP)

▪ ROTEM sent

TIME POINT 1: 20 MIN AFTER RE-OPENING

▪ Determine phases of clotting of WHOLE blood

▪ POC, fast turnaround

▪ Allows for targeted resuscitation of coagulation deficiencies (yellow stuff: platelets, plasma, or cryo)

▪ Alleviate (in part) blind blood component resuscitation therapy.

▪ Rapid TEG another option available

ROTEM Thromboelastrography

11

Normal Trace

– Short CT (stem)

– Wide MCF (body)

Red Wine Glass

Used with permission from https://www.rotem.de/en/methodology/result-interpretation-rotem-delta-und-sigma/

Amplitudein (mm)

The greater the amplitude the firmer the clot

Time in Minutes

ROTEM Interpretation

ROTEM IN TERM PREGNANCY

▪ A10EX on EXTEM is 32 (>45)

– Needs either cryo or platelets

▪ A10FIB is 21 (>16)

▪ Prolonged clotting time 177 (<80)

– Needs FFP/Plasma

▪ Maximum Lysis 72%!! (<15%)

– Needs TXA

Time Point 1: 1st ROTEM

▪ TXA Tranexamic acid 1 gram

▪ Continued MTP

– 5 PRBCs

– 3 FFP

Time Point 1: TREATMENT

HYPERFIBRINOLYSIS

▪ HR 130s, 102/70, Temp 36.1

▪ ABG: pH 7.38, PaCO2 36, PaO2 185, HCO3 22, BE -4

▪ Lactate 3.4

▪ Fibrinogen <60

▪ Calcium 3.7++

– Banked blood has citrate, binds calcium

– Hypocalcemia: low BP, decreased clotting, decreased contractility

Time Point 2: 90 MIN AFTER RE-OPENING

Time Point 2: 2nd ROTEM

Time Point 2: TREATMENT

▪ Cryoprecipitate 2 bags (10 units)▪ MTP shipment #2 completed (10 PRBCs, 6 FFP, 1 platelets)

▪ HR 120 BP 110/70

▪ pH 7.36, CO2 41, O2 180, HCO 3 24, BE -2,

▪ Lactate 2.9

▪ Calcium 2.7++

▪ Fibrinogen 226

2.5 HR AFTER RE-OPENING

▪ Intubated in ICU

(extubated 7 hours later)

▪ VSS

▪ Totals:

– Crystalloids 5300 mL

– PRBCs 13

– FFP 6

– Cryo 2

– Platelets 1

4 HR AFTER RE-OPENING: ICU Admission

CASE SUMMARY▪ Prompt recognition of hyperfibrinolysis (only 1500 mL loss

reported at this time)

▪ TXA given

▪ Resolution of hyperfibrinolysis

▪ Only 3 shipments of MTP required for EBL 7000

▪ Patient extubated 7 hours after ICU arrival and discharged 6 days later

FIBRINOLYSIS

PLASMINOGEN

PLASMIN

tPA/uPAFSP

D DIMER

TRANEXAMIC ACID5

EVIDENCE

WOMAN TRIALWORLD MATERNAL ANTIFIBRINOLYTIC

WOMAN TRIAL1

20,000+ 193 23PATIENTS HOSPITALS COUNTRIES

1000mg TXA PLACEBO

DEATH DUE TO BLEEDINGHYSTERECTOMY

WOMAN TRIAL1

MATERNAL DEATH

OVERALL < 3 HR1.5% vs 1.9% 1.2% vs 1.7%

DUE TO PPH

p=0.045 p=0.008

NO SIGNIFICANT

INCREASE IN ADVERSE

EVENTS

RECOMMENDATIONS

1000mg TXA IV OVER 10min

MAY REPEAT x1 IN 30min

IMMEDIATELY UPON DX OF PPH

FUTURE OF TXA & PPH6

7

▪ Utilizes straight forward, evidence-based recommendations that improve outcomes

▪ Bundles aid implementation and consistency of practice

▪ Denial and Delay common

MATERNAL SAFETY BUNDLE for PPH

MATERNAL SAFETY BUNDLE for PPH

▪ Hemorrhage cart

▪ Hemorrhage kit (Pyxis) (uterotonics, TXA)

▪ Response team (anesthesia, pharmacy, critical care, main OR)

▪ Massive transfusion protocol (MTP)

▪ Drills in situ

MATERNAL SAFETY BUNDLE for PPH

Resources

▪ ROTEM PPH Algorithm, Trauma Algorithm, and MTP: https://drive.google.com/open?id=19dYOCp2wm7QBs-5q55bKrFfYEm4QSo4T

▪ https://www.cmqcc.org/resources-tool-kits/toolkits

▪ https://dshs.texas.gov/mch/Obstetric-Hemorrhage-Bundle.aspx

▪ UptoDate– Anesthesia for the patient with

peripartum hemorrhage– Postpartum hemorrhage: Medical and

minimally invasive management

https://www.cmqcc.org/resources-tool-kits/toolkits

California

https://dshs.texas.gov/mch/Obstetric-Hemorrhage-Bundle.aspx

Texas

Steve Davis CRNA

References1. Shakur H, Roberts I, Fawole B et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. The Lancet. 2017;389(10084):2105-2116. doi:10.1016/s0140-6736(17)30638-4

2. Creanga A, Syverson C, Seed K, Callaghan W. Pregnancy-Related Mortality in the United States, 2011–2013. Obstetrics & Gynecology. 2017;130(2):366-373. doi:10.1097/aog.0000000000002114

3. Raimann F, Jennewein L, Sonntagbauer M et al. Influence of the WOMAN trial on national wide standard operating procedures for treatment of postpartum hemorrhage. J Gynecol Obstet Hum Reprod. 2019;48(4):269-273. doi:10.1016/j.jogoh.2019.01.010

4. Carroli G, Cuesta C, Abalos E, Gulmezoglu A. Epidemiology of postpartum haemorrhage: a systematic review. Best Practice & Research Clinical Obstetrics & Gynaecology. 2008;22(6):999-1012. doi:10.1016/j.bpobgyn.2008.08.004

5. Glymph D, Tubog T, Vedenikina M. Use of Tranexamic Acid in Preventing Postpartum Hemorrhage. AANA J. 2016;84(6):427-438.

6. Saccone G, Della Corte L, D’Alessandro P et al. Prophylactic use of tranexamic acid after vaginal delivery reduces the risk of primary postpartum hemorrhage. The Journal of Maternal-Fetal & Neonatal Medicine. 2019:1-9. doi:10.1080/14767058.2019.1571576

7. Sadek S, Kayaalp E, Movva V, Dad N. 398: Prophylactic tranexamic acid usage in prevention of postpartum hemorrhage a pilot study. Am J Obstet Gynecol. 2018;218(1):S244. doi:10.1016/j.ajog.2017.10.334

References

▪ Scavone BM, Sullican JT. Tranexamic Acid in Obstetric Hemorrhage. Anesthesia Patient Safety Foundation Newsletter. 2017;32(2); 54-55. Retrieved from https://www.apsf.org/article/tranexamic-acid-in-obstetric-hemorrhage/

▪ Main EK, Goffman D, Scavone BM, et al. National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage. Anesthesia & Analgesia. 2015;121:142-148. Retrieved from https://journals.lww.com/anesthesia-analgesia/Pages/ArticleViewer.aspx?year=2015&issue=07000&article=00022&type=Fulltext#pdf-link

▪ Cochrane: Shakur H, Beaumont D, Pavord S, Gayet‐Ageron A, Ker K, MousaHA. Antifibrinolytic drugs for treating primary postpartum haemorrhage. Cochrane Database of Systematic Reviews 2018, Issue 2. Art. No.: CD012964. DOI: 10.1002/14651858.CD012964.

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