Postpartum Hemorrhage Management Guide

[Dr. Christopher Beck]
Once you know you have postpartum hemorrhage, you're working through your differential. I think it's easiest to talk about an atomic uterus. By far and away, the most common. We talked about starting oxytocin. We talked about the other medications that you have potentially at your disposal. Can you talk about what other options that you have, or at least let's talk about first, the conservative side like what you're doing for conservative management, and then what you're thinking of in terms of getting this patient ready for escalated level of, I don't know, care or treatment. Do you know what I mean by this?

[Dr. Anthony Shanks]
I'd love to hear your opinions on this, Roxane. We're blowing past the atonic uterus. We've gone through our medication algorithms. What are you guys doing next?

[Dr. Roxane Rampersad]
In my mind, the things I'm thinking about is what stage of hemorrhage I am and what the medications I'm going to need, and potentially what other, I think, actions I need to get done. If we start with the medications like you mentioned, Tony, and I'm not getting any response and I have ongoing bleeding, then I'm going down in my head, "What else am I supposed to do?"

The next thing for me to do in addition to the medications that we use to make the uterus more contractile that I'm thinking about TXA, the addition of TXA to help. Then if TXA is not helping, I'm thinking about tamponade, so introducing balloon tamponade, the uterus. Tamponade, the sites that are bleeding inside the uterus. For us, that's a Bakri balloon.

[Dr. Christopher Beck]
Roxane, I'm sorry to interrupt, but I don't know what TXA is. I suspect a couple of other people don't.

[Dr. Roxane Rampersad]
Yes, so that's tranexamic acid.

[Dr. Christopher Beck]
Okay, got you.

[Dr. Roxane Rampersad]
We use it not only in the OB world but also in the GYN world. When a hysterectomy is with ongoing bleeding, we can use TXA. GYN is not my world anymore. Tony, remind me. I think people also use TXA for heavy menstrual bleeding, don't they?

[Dr. Anthony Shanks]
Yes. In terms of how it actually works, it prevents that fibrinogen getting broken down by plasminogen. It works on that coagulation pathway. Technically, you can make these people hypercoagulable with that. There is a lot of studies that come out with TXA. I think people use it for the postpartum hemorrhage after three hours if you're still having ongoing bleeding.

I have come across in preparing for this talk. They have had some studies where they've done it prophylactically as part of bundles for people that they're anticipating being at risk and that they may show some potential benefits. I suspect that we'll continue to see more studies with TXA. I wanted to hear, Roxane, about the Bakri balloon because I mentioned to her. We're doing something called Jada at our institution. Tell us what the Bakri is, Roxane.

[Dr. Christopher Beck]
Sure. One of the things I want to talk about with TXA just for some of the IR listeners, TXA is something to keep on your radar if your institution uses it or it's part of their algorithm. If you do end up taking a patient back and you're going to be working in the blood vessels knowing the patient is on TXA can create issues with basically inducing thrombus in areas that we don't want to put it there, so we go in femoral access or radial access. TXA makes people hypercoagulable.

You can have more clot formation in areas you do not want the clot. Now, we're getting to the point where either the balloons aren't working, the meds aren't working, and you're now at a point where you either have to take them back to the OR or you take them back to the IR suite. What's going on in your head as to how patients get triaged to different spots? Just because you're going to the operating room doesn't mean it's hysterectomy, right? There are some other maneuvers you can do, but will you talk about how that decision tree happens?

[Dr. Roxane Rampersad]
I'll tell you, for me, what allows me to decide whether the patients go into the IR or the operating suite is really the amount of blood. Persistent bleeding in someone that's hemodynamically stable, I'm going to take that patient to the interventional radiology suite. If that patient is not hemodynamically stable, they're unstable and they have more brisk bleeding, their vital signs are abnormal, they're hypotensive, then I'm going to the operating room and I'm going to think about more operative maneuvers.

You mentioned there are other things besides hysterectomy. A B-Lynch suture is one of those things that we can do. Essentially, we're compressing the uterus on itself to try to stop the bleeding. We can sometimes ligate the vessels, the uterine arteries going to the uterus, or we can ligate a little bit higher. A hypogastric ligation is the next thing. Then if those things are not working and bleeding ensues and that patient becomes unstable and it's becoming coagulopathic from that blood loss, then we're thinking about hysterectomy is my mind. Tony, what do you think?

[Dr. Anthony Shanks]
I think the word that you mentioned about stability is the big one. We would never want to send a hemodynamically unstable patient off the floor to interventional radiology where they cannot be surgically reopened quickly. I think that would probably be the unsafe thing to do. That's reserved for the person that has maybe that persistent low-level bleed. If you have a Bakri balloon and you continue to see blood come out, the patient's vital signs are otherwise stable, but you're not really addressing the bleeding.

That's a good person for that. I also think certainly C-sections. If you have a complicated C-section and they're hemodynamically unstable, going back in, seeing where you actually closed off your hysterotomy, that makes sense because sometimes you can have those extensions and that's where you're bleeding from. Not necessarily hysterectomy, but just reapproximating those areas first.

[Dr. Christopher Beck]
One of the things I want to dig in on though is you guys are super high-level operators at big institutions, do a lot of those work, but not every OBGYN is created equal or not all resources available. Just not every IR is created equal, not every OBGYN is created equal. Can you speak to that a little bit? Are there some operators who would feel uncomfortable with unstable patients? Sometimes I'll hear from OBGYN colleagues like they're very nervous about taking a patient back because they're like, "Oh, I just feel like it's going to be a hostile pelvis." Things like this come up into, I think, people's decision tree. Can different obstetricians end up in different places?

[Dr. Anthony Shanks]
Yes, I would never want an obstetrician or really any physician do something that they're uncomfortable with. I was specifically thinking about hysterectomies, a cesarean hysterectomy. I think the planning stages are very important because, at our institution, we actually have GYN oncologists. Those are the people that do the most surgery. Typical day for Roxane and myself, we are not in the OR all day.

We're seeing patients. We're doing ultrasound. We like having people that are really good at knowing surgical planes and distorted anatomy because that's what it is at the time of a c-hyst. Planning is great. Certainly, there are going to be times when the instability happens and they're not there like it happens. You want to make sure your labor and delivery is covered by staff that is capable of doing that. What do you think, Roxane?

[Dr. Roxane Rampersad]
We take a lot of transfers, and so this comes up definitely. For most obstetricians out in smaller areas and small institutions, I think the thing that they worry about mostly is their blood bank, is that they are not equipped to transfuse someone sometimes more than six units. It's really unfathomable to me because we have this big blood bank and we have massive transfusion protocols. I think that's what most of those obstetricians are thinking about.

[Dr. Anthony Shanks]
Sure.

[Dr. Roxane Rampersad]
They may have the balloon tamponades, but they may not have interventional radiology also. For them, hysterectomy is the-- The end-point is removing that. Then we often get a lot of those patients transferred to us because they can still have ongoing bleeding even after hysterectomy, and so they need to come to these quaternary centers like what we have. It's definitely something to think about when you're in a smaller area and a smaller hospital.