SE M I N A R S I N P E R I N A T O L O G Y 40 (2016) 99–108

Available online at www.sciencedirect.com

Seminars in Perinatology

www.seminperinat.com

Care bundles for management of

obstetrical hemorrhage
Adiel Fleischer, MDn, and Natalie Meirowitz, MD
Department of Obstetrics and Gynecology, Hofstra North Shore—LIJ School of Medicine, 270-05 76th Ave, Suite 400,
New Hyde Park, NY 11040

article info abstra ct

Keywords: Peripartum hemorrhage is one of the most preventable causes of maternal mortality
Maternal Mortality worldwide. Much effort has been directed toward creating programs that address deficits in
Peripartum hemorrhage maternity care responsible for preventable hemorrhage-related morbidity and mortality.
Hemorrhagic shock To have a significant impact on outcomes, such programs must address both providers and
Massive transfusion processes involved in the delivery of maternity care. At the core of a successful program,
are standardized care bundles integrating medical and surgical techniques for managing
hemorrhage with principles of transfusion medicine and critical care. In this article, we
review the components of the safety bundle for obstetric hemorrhage developed by ACOG
District II Safe Motherhood Initiative.
& 2016 Elsevier Inc. All rights reserved.

Introduction medicine specialists, obstetricians and gynecologists, obstetrical

Peripartum hemorrhage continues to be a major contributor
to maternal morbidity and mortality. Over the last 10 years,
the incidence of PPH and transfusions (including that of
massive transfusion) has increased considerably.1,2 Most
reviews of maternal mortality from hemorrhage suggest that
the majority of these cases are preventable.3–5 A comprehen-
sive protocol addressing the issue of accurate and realistic
diagnosis, as well as timely and adequate interventions, is
likely to have a positive impact on the morbidity and mortal-
ity associated with this obstetrical complication.
Approximately 2 years ago, a group of Obstetricians and
Gynecologists in NYS under the leadership of ACOG District II
launched a patient safety initiative to address several clinical
entities responsible for maternal morbidity and mortality (Safe
Motherhood Initiative). One of the three clinical entities chosen
for this intervention was peripartum hemorrhage. The group
was multidisciplinary in nature, including maternal–fetal
nurses, certified nurse midwives, and anesthesiologists. During
regular meetings, we build a consensus around the major
elements of a standardized clinical protocol concerning the
diagnosis and management of peripartum hemorrhage.
Elements of the standardized clinical protocol for peripar-
tum hemorrhage are as follows:

Risk assessment and measures to modify that risk

General (universal) preparations for managing any PPH
episodes

Diagnosis
○ Establish a more objective process for measuring
blood loss
○ Define the stages of hemorrhage based on the clinical
consequences of blood loss

Management algorithms

Logistics and communication

n
Corresponding author.
E-mail address: afleischer@lij.edu (A. Fleischer).

http://dx.doi.org/10.1053/j.semperi.2015.11.015
0146-0005/& 2016 Elsevier Inc. All rights reserved.

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100 S E M I N A R S I N

Hemostatic intervention

Replacement therapy
Risk assessment
Ideally, risk assessment for peripartum hemorrhage, should
start in the antepartum period to allow time for diagnosis and
delivery planning. Although all women should be considered at
risk for hemorrhage, further classification into medium and
high risk allow for targeted interventions. Examples of ante-
natal interventions include treatment of maternal anemia,
diagnosis of abnormal placentation, and management of coa-
gulopathies. Advance planning and multidisciplinary coordina-
tion of care is needed to minimize the risk of life threatening
hemorrhage and increase the margin of safety for patients with
these conditions. The most common conditions that benefit
from such interventions in the antepartum period are:

Placenta previa

Placenta accreta

Previous classical cesarean section

History of myomectomy

Refusal of blood transfusion

Bleeding disorder

Current anticoagulation (therapeutic)

Significant cardiopulmonary and hematologic morbidities
For patients with prior uterine surgery and abnormal pla-
centation, the most critical element in management is timing
the delivery before the onset of labor. In such cases, the risk of
neonatal prematurity is outweighed by the significant risk of
profound maternal hemorrhage should labor occur spontane-
ously. The group’s recommendation in this regard is entirely
consistent with ACOG guidelines concerning these entities.6
Condition for which timing of delivery is critical
Placenta accreta 340/7–356/7
Placenta previa 360/7–376/7
Prior classical C/S 360/7–376/7
Previous myomectomy 370/7–386/7
If extensive 360/7–376/7
In addition, for patients with placenta accreta, transfer to a
facility for delivery that has the resources to manage such
complex cases is critical. Those include blood bank resources,
experienced surgical support, anesthesia resources, the abil-
ity to provide vascular embolization, urology services, and
critical care support.
Blood transfusion acceptance
Another category of high-risk patients that benefit from
antenatal discussion are those refusing blood transfusions.
It is important for the provider to discuss and document
which specific replacement products are acceptable to the
patient in the event of hemorrhage. We suggest using a blood
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P E R I N A T O L O G Y 40 (2016) 99–108
product acceptance list that can be completed and signed by
the patient in the antepartum period (Table). Some patients,
such as those with religious objections, are familiar with the
various products, but others are unfamiliar and require
detailed counseling. It is best to introduce such discussions
privately between the patient and the physician, and include
family members only if requested by the patient. The dis-
cussion should address the surgical measures that can be
anticipated if hemorrhage occurs, including need for hyster-
ectomy. This is especially critical for these patients as the
decision for surgical intervention here should be made earlier
in the course of bleeding compared with patients who will
accept transfusion. If the blood transfusion acceptance form
has not been completed in the antepartum period, it should
be accomplished upon admission to Labor & Delivery.
It is also preferable to identify patients that refuse blood
products in the antepartum period, so that hemoglobin can
be optimized (with oral or intravenous iron) well before
admission for delivery. Patients with inherited or acquired
coagulopathy as well as those who are fully anticoagulated
are best co-managed with hematology and/or Maternal–Fetal
Medicine, and their coagulation status carefully monitored in
the peripartum period.
General (universal) preparations
Optimal care of the high-risk patient involves an organized team
approach, so it is important that team members (obstetrician,
anesthesiologist, nursing, neonatology, etc.) are aware when a
high-risk patient is admitted to Labor & Delivery. One effective
method of standardizing such communication is the Perinatal
Huddle, which enhances situational awareness and allows team
members to prepare for potential hemorrhage and develop an
organized management plan. The exchange of clinical informa-
tion that occurs with the Perinatal Huddle has become more
valuable given the increasing frequency of provider cross cover-
age in obstetrical care. As part of general measures, women who
are at high risk for peripartum hemorrhage should have a type
and cross-match submitted on admission to L&D.
weeks
weeks Familiarity with blood bank protocols
weeks
weeks It is important to be familiar with the institution’s blood bank
weeks protocols to respond to peripartum hemorrhage in an adequate
and timely manner. Collaboration between Obstetrics and
Transfusion Medicine (blood bank) to develop guidelines for
blood product replacement is mutually beneficial. Such guide-
lines must address the following key elements critical for
successfully managing obstetrical hemorrhage:

Emergency blood release

Massive transfusion protocol (MTP)

Hemorrhage cart/medical kit

Hemorrhage team (different then the primary team)
Emergency blood release
Unanticipated hemorrhage can occur before the availability of
cross-matched blood. Under these circumstances, emergency
 SE M I N A R S I N P E R I N A T O L O G Y 40 (2016) 99–108 101

Table – Blood product acceptance list.

Category I Will accept Will not accept May accept under certain circumstances
Red blood cells
Fresh frozen plasma
Platelets
Autologous banked blood
Cryoprecipitate

Category II (contains human plasma)

Albumin
Fibrin glue
Fibrinogen concentrate (RiaSTAP)
RhoGAM
Plasma protein fractions/plasmanate
Human immunoglobulin
Factor 8/vWF concentrate (Humate-P and Wilate)
Prothrombin complex concentrate
Bebulin (3 factors)
Kcenta (4 factors)

Category II (does not contain human plasma)

Factor 7A (Novo 7)
Factor 8 recombinant
Factor 9 recombinant
Factor 13 recombinant (Tretten)

Category III (no blood component)

Tranexamic acid
Amicar
DDAVP
Erythropoietin—recombinant
Hetastarch
Balanced salt solutions

Category IV
Isovolemic hemodilution
Hypervolemic hemodilution
Cell saver

Date: _______________ Time: ______________

Signature: ____________________________________________
Witness: ______________________________________________

release of O-negative or type specific blood (where type is known)
becomes necessary. Although cross-matched blood is preferable,
successful transfusion using type specific or O-negative blood
approaches 99%. In a large review of trauma patients, 5810 units
of uncross-matched blood were administered to 161 patients.
There were no acute hemolytic transfusion reactions observed in
these patients.7 In general, a successful transfusion of type
specific blood is reported as high as 99.8%.8 Similarly, emergency
release of FFP includes ability to release AB plasma on an urgent
basis. Given the scarcity of AB plasma low titer Type A plasma
has become acceptable as a general donor of FFP.9,10
Massive transfusion protocol (MTP)
An institution’s MTP is used to standardize the response to
massive uncontrolled hemorrhage. It outlines exactly how
the blood bank will release large amounts of blood and blood
products as well as the order and ratio with which they
should be administered. Newer data extrapolated from the
trauma literature endorses early administration of FFP and
higher ratio of FFP:RBC. While no one specific ratio is
endorsed above others, ratios between 1:1 and 1:2 (FFP:RBC)
seem to be beneficial when compared to lower ratios. Time to
achieve these ratios is important as well, and early admin-
istration of these (FFP:RBC) rates appears to be associated
with lower mortality and massive transfusion rates.11,12
Hemorrhage cart/medical kit
The construction of a hemorrhage cart and medical kit allows
easy access to equipment and medications used to control
hemorrhage. It should be accessible to all areas of the
hospital where peripartum hemorrhage may be anticipated
(Labor & Delivery, Postpartum Unit, Antepartum Unit, Triage
Unit, etc.). The suggested components of the hemorrhage
cart/medication kit are detailed in Figure 1.
Hemorrhage team
The concept of a hemorrhage team, separate from the
primary obstetrician/surgeon, is another critical component

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102 S E M I N A R S I N
Hemorrhage Cart Supplies
Vaginal Delivery
Vaginal retractors
Long weighted speculum
Long instruments
Intrauterine balloon
Banjo Curette
Bright task light/Head lamp
Procedure diagrams
Fig. 1 – Contents of Hemorrhage Cart.
of PPH management. It is well known, that delays in surgical
intervention and inadequate replacement therapy are major
contributors to maternal morbidity and mortality. Successful
treatment of massive hemorrhage requires surgical and
critical care resources that are generally not available or
necessary for routine obstetrical care. Owing to the infre-
quency of such events, staffs are often unfamiliar with their
institution’s resources and do not know who or when to call
for help with catastrophic hemorrhage. Creation of an obstet-
rical hemorrhage team, provides a simple mechanism for
amplifying resources when they are needed, and dictating
objective triggers that call for a response from the hemor-
rhage team. A hemorrhage team should consist of experts
that can provide surgical support (Gynecologic Oncology,
MFM, Generalist OB, General Surgery, etc.), anesthesia sup-
port, critical care, nursing care, and logistical support (blood
bank and laboratory).
Recommended indications for calling the hemorrhage team
include:

Before delivery for patients refusing blood transfusions
with an additional risk factor(s) for PPH

Before delivery for patients with high index of suspicion
for placenta accreta

Before delivery for patients with fully anticoagulated
requiring surgery

Any PPH diagnosed as Stage 3

Any PPH in patients refusing blood transfusions
Diagnosis of PPH
Classically, the diagnosis of PPH is made on the basis of the
provider’s impression of excessive blood loss or suspicion of
intra-abdominal bleeding related to clinical, hemodynamic,
or laboratory abnormalities. This approach for estimating
blood loss is notoriously inaccurate (overwhelmingly under
estimated), particularly with cases in the upper range of
blood loss.13 To make this process more objective, we suggest
that estimation of blood loss (EBL) intraoperatively be ini-
tiated by the circulating nurse, based on a visual quantitative
accounting of the number of blood soaked laps, chucks, 4  4
pads, and contents of the suction bottle (Fig. 2). Once
quantified by the nurse, the EBL is communicated to the
surgeon and anesthesiologist. With their input, a consensus
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P E R I N A T O L O G Y 40 (2016) 99–108
Medication Kit
Cesarean Delivery
Hysterectomy tray Pitocin 20u/l 1bag
Reloadable straight needle for B- Pitocin 10u 2vials
Lynch suture
Intrauterine balloon Carboprost 250 microgram/ml
Procedure diagrams Misoprostol 200microgram/tablet
Methergine 0.2 mg/ml
is reached regarding blood loss, which is hopefully more
objective and accurate.
Hemodynamic changes
Hemodynamic evaluation refers to standard monitoring of
BP, heart rate (HR), urinary output, and oxygen saturation.
Traditionally, hemodynamic changes have been heavily
relied upon for assessment and management of obstetrical
hemorrhage. Unfortunately, despite having a good positive
predictive value, they have a rather poor negative predictive
value for ruling out significant blood loss. Relevant changes in
vital signs, especially a drop in systolic blood pressure (SBP)
appears late in the course of hemorrhage. Compensatory
physiological changes characteristic of early hemorrhagic
shock, mask the drop in circulating blood volume. In the
initial phase, cardiac output is maintained by an increase in
heart rate, thus maintaining blood pressure at baseline levels.
Even with further blood loss and a modest drop in cardiac
output, blood pressure can be maintained by a marked
increase in systemic vascular resistance.
Blood pressure ¼ Cardiac output ðstroke volume
 heart rateÞ  systemic vascular resistance
Large retrospective studies in trauma patients have dem-
onstrated that high mortality rates can be seen despite only
minimal changes in vital signs. Data regarding mortality with
hemorrhagic shock from the National Trauma Data Bank
(115,830)14 show that hypotension defined as SBP o 90 mmHg
is only reached in the most severe cases of hemorrhagic
shock, (Base deficit 420 and mortality 450%). Less severe
Estimating Blood Loss
4X4 gauze pad = 5 mL
Full & dripping purple chux = 800 mL
Full & dripping blue chux = 300 mL
Fully soaked peripad = 70-100 mL
Partially soaked peripad = 50 mL
Full & dripping lap pad (half pad) used in vaginal delivery = 40-45 mL
Full lap pad (half pad) used in vaginal delivery (not dripping) = 30 mL
Full & dripping lap pad used in surgery = 100 mL
Full lap pad used in surgery (not dripping) = 60-75 mL
12 ounce soda can = 355 mL
Fist or baseball size clot = 60 mL
Fig. 2 – A visual, quantitative method for estimating
blood loss.
 SE M I N A R S I N
cases of hemorrhage that still resulted in considerably high
mortality rates (15% and 33%) had mean SBP on admission of
123 and 111 mmHg respectively. In summary, normal vital
signs are not reliable indicators of the severity of blood loss;
however, abnormal vital signs suggest an advanced stage of
hypovolemic shock.
Other physiologic parameters have been proposed to iden-
tify early stages of hemorrhagic shock. One such variable is
the shock index, which is simply the ratio of HR to SBP. As HR
and SBP are expected to change in the opposite direction with
hypovolemia, the ratio is a more sensitive marker for signifi-
cant hemorrhage than either individual parameter. A number
of clinical studies have confirmed the value of the shock
index in identifying patients with significant blood loss that
require immediate intervention to insure hemostasis.15,16 In a
review of 48000 trauma patients, massive transfusion and
mortality rates increased significantly when shock index
41.1. A shock index between 1.1 and 1.3 was associated with
a 3-fold increase in massive transfusion and mortality rates
(mean SBP for this group was 107 mmHg) while a shock index
41.3 had a five-fold increase in massive transfusion and
mortality rates (mean SBP for this group was 102 mmHg).16 It
appears that a shock index 41.1 can identify patients with
significant blood loss, while changes in the SBP were not
clinically informative.
In conclusion, there appears to be sufficient evidence to
suggest that the shock index is a suitable parameter for early
identification of significant blood loss. As such, shock index
should be used to guide care in cases of hemorrhage in which
BP and HR are considered “within the normal range”.
Laboratory changes
Hemoglobin and hematocrit (Hb/Hct)
In the acute phase of hemorrhage Hb/Hct changes tend to lag,
and normal values have a poor negative predictive value. A low
initial Hb/Hct (o25%), or a drop greater than 5 points on repeat
measurements identified only 20–25% of patients that went on
to require significant intervention to manage their hemorrhage.
On the other hand, abnormal values had a high positive
predictive value for identifying the majority (75%) of patients
with severe hemorrhage.17 Therefore, values in the normal
range cannot be considered reassuring, but abnormal values
denote severe hemorrhage requiring aggressive intervention.
Coagulation changes
In the setting of hemorrhage, abnormal coagulation studies
(fibrinogen, PT, PTT, and hyperfibrinolysis), are strongly
associated with increased mortality rates. The earliest and
most consistent finding in hemorrhage-induced coagulop-
athy is an abnormal fibrinogen level. Only later in the course
of bleeding are changes seen in PT, PTT, and INR. Conse-
quently, fibrinogen levels should always be included in the
coagulation profile. In the initial evaluation of women diag-
nosed with postpartum hemorrhage, fibrinogen level was
found to be the best predictor of severe hemorrhage, defined
as decreased in hemoglobin 44 g, transfusion of more than
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P E R I N A T O L O G Y 40 (2016) 99–108 103
four units RBC, or hysterectomy within the first 24 h. Platelet
count, PTT, and INR did not predict which patients would
eventually progress to severe hemorrhage.18
Acid base changes
Since hemorrhagic shock results in tissue hypoxia and a shift
from aerobic to anaerobic metabolism, measurement of
serum lactate, the byproduct of this shift, is critical for
assessing the effects of blood loss, and the response to
resuscitative efforts. The presence of metabolic acidosis
(elevated based deficit, low pH, and elevated lactic acid) is a
strong predictor of morbidity and mortality.19,20 A group of
patients with hemorrhage secondary to abdominal trauma
were classified based on their lactate level on admission to
the hospital. Compared to those with normal initial lactate,
patients with lactic acidemia (47.5 mol) had significantly
increased transfusion rates (4.8% vs. 42.3%), and mortality
rates (2.4% vs. 26.7%.).20
Staging hemorrhage
The aim of the classification system is to standardize the
clinical evaluation and response to hemorrhage. Given the
high positive predictive value of hemodynamic laboratory
and clinical changes, we proposed a modification of the
American College of Surgeons’ classification of hemorrhage
(Fig. 3). Estimated blood loss retains its role in classifying the
stage of hemorrhage only as long as there are no changes in
other clinical parameters (hemodynamic, laboratory findings,
and clinical manifestations). Once a patient exhibits changes
in clinical parameters, the stage of hemorrhage is raised,
regardless of the estimated blood loss (Stage 3).
Management
The management of peripartum hemorrhage should be
tailored to the clinical scenario (including the cause of
bleeding) and the severity of blood loss (stage of hemorrhage).
Hemostasis
Hemostatic interventions should be tailored to the etiology of
hemorrhage, and the timing and extent of interventions
individualized. Factors to be considered include the rate of
ongoing bleeding, patient acceptance of blood products,
availability of resources (i.e., Interventional Radiology), and
desire for future childbearing. Uterine atony, the most com-
mon cause of obstetrical hemorrhage should be managed in a
stepwise fashion, progressing without delay if hemostasis is
not achieved (Figs. 4 and 5).
Replacement therapy
The main goal of resuscitation after hemorrhage is to restore
O2 delivery to the tissues in order to support aerobic metab-
olism. The main determinants of oxygen delivery are cardiac
104 S E M I N A R S I N
Fig. 3 – Stages of Hemorrhage (modified after ACS).
output, arterial oxygen saturation, and hemoglobin
concentration.
O2 Delivery ¼ C.O.  SaO2  Hb%
Fluid management
Maintaining cardiac output is accomplished initially by
administrating IV fluids, the most common of which are
Ringer’s lactate and normal saline. In the short run, this
strategy maintains BP at a level needed to support oxygen
delivery. However, recent data show that in the long term,
large volumes of crystalloid are detrimental, associated with
cardiopulmonary complications, coagulopathy, further blood
loss and higher mortality rates.21,22 The lethal trial of acido-
sis, hypothermia and coagulopathy, long associated with
severe hemorrhagic shock, has been shown to be exacerbated
by large volume crystalloid based resuscitation. Based on
data accumulated from management of trauma-related hem-
orrhage, a new paradigm emerged, Damage Control Resusci-
tation (DCR).23,24 The three tenets of this approach are;
limitation of crystalloid resuscitation, transfusion of blood
products in ratios similar to whole blood, and permissive
hypotension (target blood pressure for resuscitation are lower
than an individual’s baseline blood pressure). Fluid admin-
istration in a 1:1 or 2:1 ratio to the EBL or 1–1.5 L of crystalloid
for every unit of RBC transfused appears to be associated with
the lowest morbidity and mortality rates. Larger amounts of
crystalloid (43:1 to EBL or 41.5 L 1RBC) may increase rates of
re-bleeding, multiple organ failure, and death.21,24–27 Further-
more, the use of permissive hypotension, by limiting the
volume of fluid and blood products infused, should improve
outcome after hemorrhage by decreasing transfusion and
morbidity rates (lower rates for ARDS and MOF).28–30
O2 administration
O2 administration significantly increases the amount of O2
dissolved in plasma. At low Hb concentrations (o7 g), O2
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P E R I N A T O L O G Y 40 (2016) 99–108
dissolved in plasma becomes the main contributor (450%) to
O2 supply. The difference in the contribution of plasma
dissolved O2 between room air and hyperoxic ventilation is
the equivalent to the amount of O2 released by 2.9 g of
hemoglobin.31 Therefore, administering O2 at low Hg levels,
allows one to safely increase the time interval before which
hemoglobin levels are augmented.32
RBC transfusion
There is no consensus on a specific Hb level to be achieved in
cases of peripartum hemorrhage. Based on existing data, once
bleeding is controlled in an otherwise healthy individual there
is little justification for transfusing RBCs above a Hb level of 7–
8 g.33 In older individuals or those with significant cardiopul-
monary co-morbidities a higher Hb target may be considered.
This principle does not apply to patients with ongoing bleeding.
Coagulopathy
The most effective intervention to prevent and/or treat
coagulopathy is early administration of FFP. In cases of
massive blood loss, FFP should be given in a 1:1 or 1:2 ratio
to RBC. This principle, derived from trauma-related hemor-
rhage is not universally accepted, and supporting studies are
criticized as resulting from “survival bias.” A recent report
addressed this specific concern using data obtained from the
“Inflammation and the Host Response to Injury” study a large-
scale collaborative program, of 620 patients receiving massive
transfusion (Z10 U RBC in 24 h). When controlled for degree of
hemorrhage, a high FFP:RBC ratio achieved early in the
process (within 6 h of admission) was associated with lower
mortality rates (3.9% vs. 9%) and lower RBC requirements
during the first 24 h (18 vs. 23 U).11 The survival advantage of a
high FFP:RBC ratio is not confined to patients with abnormal
coagulation profiles. In a study of trauma patients requiring
massive transfusion, a high FFP:RBC ratio appeared to be
beneficial even for patients with a normal initial INR as well.12
Fibrinogen, is the first coagulation parameter to become
abnormal in massive hemorrhage, and should be replaced
early in the course of hemorrhage. Low fibrinogen in these
situations have been strongly associated with severity of
hemorrhage and mortality rates.34,35 In-vitro coagulation
studies evaluating speed and quality of clot formation sug-
gested fibrinogen levels of 250–300 mg% were required to
normalize all coagulation parameters comparable to con-
trol.36,37 Animal models of dilutional coagulopathy support
the importance of fibrinogen replacement. Blood loss and
mortality rates were significantly lower in the group that
received fibrinogen replacement compared with controls (240
vs. 1900 ml and 0% vs. 80%).38 In the past, fibrinogen replace-
ment was recommended empirically for levels below 100%.39
Revised guidelines recommend that replacement for fibrino-
gen concentration of o200 mg%.40 This change is supported
by data suggesting that concentrations 4200 mg% are
required to produce effective clot formation.
As the concentration of coagulation factors in FFP is
relatively low, large volumes may be required to correct the
coagulopathy. Under these circumstances, more concen-
trated products should be considered to replace factors using
 SE M I N A R S I N P E R I N A T O L O G Y 40 (2016) 99–108 105

Fig. 4 – Management of severe PPH (>1500cc) at the time of delivery.

lower fluid volumes. Such products currently available Prothrombin Complex Concentrate (PCC)—are plasma derived
include the following: products containing vitamin K dependent clotting factors: FII,
Fibrinogen—cryoprecipitate, fibrinogen concentrate FVII, FIX, and FX. They are classified as 3 or 4 factor PCC.

Fig. 5 – Management of PPH in the postpartum period.

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106 S E M I N A R S I N P E R I N A T O L O G Y 40 (2016) 99–108

Fig. 6 – Management of patients suspected of intrabdominal bleeding in the postpartum period.

Recent data identifies increased fibrinolysis as a major risk

Contains Name Dose factor for massive transfusion and mortality rates.41,42 As
such, considerable data from the surgical literature support
3 Factor FII, FIX, FX Bebulin 25–50 u/kg
the use of antifibrinolytics both prophylactically in high risk
PCC (little FVII)
patients and as treatment for heavy bleeding:43–47 Prophy-
4 Factor FII, FIX, FX, FVII Kcentra 25–50 u//kg
lactic administration of tranexamic acid reduces surgical
PCC
blood loss by approximately 30% and administration of
tranexamic acid in the presence of significant bleeding
decreases transfusion, and mortality rates without increas-
Antifibrinolytics ing rates of thromboembolic disease. Tranexamic acid is
administered intravenously (1 g over 10 min) at the start of
Hyperfibrinolysis is another contributor to the disturbed surgery (for prophylactic use) or at the onset of heavy
coagulation process characteristic of massive hemorrhage. bleeding.

Fig. 7 – Patients: cardio-vascular collapse in the setting of hemorrhage.

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 SE M I N A R S I N
Suggested indications for the prophylactic use of tranexamic
acid for delivery

Patients refusing blood products with risk factors for PPH

Patients fully anticoagulated

Patients at significant risk for massive PPH, i.e., placenta
previa/accreta
Suggested indications for therapeutic use of tranexamic acid
in the setting of peripartum hemorrhage

Any patient diagnosed with stage 3 hemorrhage
Clinical algorithms
We have designed management algorithms that are specific
to common scenarios during which peripartum hemorrhage
is likely to be encountered:
– Increased bleeding in the operating room/labor room
during the delivery or immediately postpartum (Fig. 4)
– Increased vaginal bleeding during the postpartum period
(PACU or postpartum floor (Fig. 5)
– Suspected intrabdominal bleeding on the basis of unex-
pected clinical, laboratory, or hemodynamic changes sug-
gestive of hypovolemia (Fig. 6)
In the most severe form, that of cardio-vascular collapse in
the setting of hemorrhage we suggest an agressive surgical
intervention in paralell with medical resuscitation and
replacement therapies (Fig. 7).
re fe r en ces
1. Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum
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