Fibrinogen, haemostasis and postpartum haemorrhage. Ove Karlsson Sahlgrenska University Hospital Gothenburg, Sweden

Transcription

1 Fibrinogen, haemostasis and postpartum haemorrhage Ove Karlsson Sahlgrenska University Hospital Gothenburg, Sweden

2 No conflict of interests

3 Gothenburg, Sweden deliveries 3 labour wards 2 normal 1 special

4 Vaginal deliveries with bleeding >1000 ml, Sahlgrenska University Hospital %

5 Bleeding during operation L 8.1% 4.2% >2 L 1.3% 0.76% > Better routine Better cooperation Better knowledge of haemostasis

6 Reduced blood transfusions with 39.5% Erytrocyter Plasma Trombocyter

7 8.5 per maternities

8 MBRRACE-UK In all patients with mortality due to haemorrhage, improvements in care may have made a difference to the outcome (MBRRACE-UK )

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10 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

11 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

12 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

13 Obstetrical interventions Inspection of placenta Exploration of uterus Inspection of cervix/vagina Balloon tamponade Compression sutures Hysterectomy

14 Goals during on-going bleeding: Hb > 90 g/l Platelets > 100 x 10 9 /l PK(INR) < 1.5 APTT normal Fibrinogen > g/l Temp > 36.5 C ph > 7.2 Ionised Ca 2+ >1.0 Point-of-Care devices Repeat sampling!

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17 patients, 21 countries, 193 hospital Randomised, double-blind, placebo controlled Inj Tranexamic acid 1g, a second dose possible Reduced mortality due to reduced bleeding Review Several randomised studies Reduced bleeding volume Large RCT required

18 Transfusion strategy Try to assess if the bleeding will: Bleeding < ½ blood volume and bleeding will stop Bleeding > ½ blood volume and bleeding will continue Transfusion strategy As little as possible Goal-directed therapy Packed red blood cells, until acceptable Hb Transfusion strategy Blood/plasma/platelets 4:4:1

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20 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.

21 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)

22 Study group Control group Bleeding, L 2.5 ( ) 0.4 ( ) Fibrinogen g/l 3.0 ( ) 4.8 ( ) range range

23 Faster clot initiation Reduced clot strength TEG, faster results Strongest correlation Fibrinogen - TEG-MA EBL - Fibrinogen EBL TEG-MA

24 Fibrinogen concentration mean 5.3 g/l Interval g/l

25 r = 0.9 p <

26 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 r = p < 0.9

27 >2.0 g/l, improved coagulation 2.5 g/l, optimized coagulation Still not stable to fibrinolysis

28 Review about fibrinogen Plasma contains 1-3 g/l Fibrinogen concentrate g/l Obstetric haemorrhage 1 g, median increase of 0.36 g/l

29 American Journal of Obstetrics & Gynecology 2015 Urgent treatment Treat the cause Give it all at once Blood/Plasma/Platelets Fibrinogen Tranexamic acid Repeat sampling

30 No studies, postpartum haemorrhage Other studier, no difference in bleeding Indication profylaxis von Willebrand Hemofili A Platelet dysfunction Risk for water intoxication Off label use Case reports, obstetric bleeding No randomised studies In some guidelines

31 Work against: Hypothermia Hypocalcaemia Acidosis

32 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

33 Volatile anaesthetics Dose dependent relaxation Uterine muscles Change volatile anaesthetics Propofol infusion Optimize O 2 /N 2 O/fentanyl

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35 Bleeding (median and range) Study group 1400 ml ( ) Control group 8000 ml ( )

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