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Hematologic Challenges in the Critically Ill: Obstetrics

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Hematologic Challenges in the Critically Ill

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Abstract

Hemorrhage is a major cause of maternal morbidity and mortality worldwide. Other hematologic challenges associated with pregnancy include the hypercoagulable state, potential for disseminated intravascular coagulation, and exacerbation of disease states such as sickle-cell disease. This chapter will consider the epidemiology and management considerations for many of these hematologic challenges in critically ill pregnant women, with a focus on hemorrhage.

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References

  1. Katz D, Beilin Y. Disorders of coagulation in pregnancy. Br J Anaesth. 2015;115(Suppl 2):ii75–88.

    Article  Google Scholar 

  2. Brenner B. Haemostatic changes in pregnancy. Thromb Res. 2004;114:409–14.

    Article  CAS  Google Scholar 

  3. Thornton P, Douglas J. Coagulation in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2010;24:339–52.

    Article  Google Scholar 

  4. El Kady D. Perinatal outcomes of traumatic injuries during pregnancy. Clin Obstet Gynecol. 2007;50:582–91.

    Article  Google Scholar 

  5. Petrone P, Jiménez-Morillas P, Axelrad A, Marini CP. Traumatic injuries to the pregnant patient. A critical literature review. Eur J Trauma Emerg Surg. 2017;0(0):1–10.

    Google Scholar 

  6. Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ. Trauma in pregnancy: an updated systematic review. Am J Obstet Gynecol. 2013;209:1–10.

    Article  Google Scholar 

  7. Sela HY, Weiniger CF, Hersch M, Smueloff A, Laufer N, Einav S. The pregnant motor vehicle accident casualty: adherence to basic workup and admission guidelines. Ann Surg. 2011;254:346–52.

    Article  Google Scholar 

  8. Pacheco LD, Saade GR, Gei AF, Hankins GD. Cutting-edge advances in the medical management of obstetrical hemorrhage. Am J Obstet Gynecol. 2011;205:526–32.

    Article  Google Scholar 

  9. Savage SA, Zarzaur BL, Brewer BL, Lim GH, Martin AC, Magnotti LJ, Croce MA, Pohlman TH. 1: 1 transfusion strategies are right for the wrong reasons. J Trauma Acute Care Surg. 2017;82:845–52.

    Article  Google Scholar 

  10. Schochl H, Maegele M, Voelckel W. Fixed ratio versus goal-directed therapy in trauma. Curr Opin Anaesthesiol. 2016;29:234–44.

    Article  Google Scholar 

  11. El Kady D, Gilbert WM, Xing G, Smith LH. Association of maternal fractures with adverse perinatal outcomes. Am J Obstet Gynecol. 2006;195:711–6.

    Article  Google Scholar 

  12. Boulet SL, Okoroh EM, Azonobi I, Grant A, Craig Hooper W. Sickle cell disease in pregnancy: maternal complications in a Medicaid-enrolled population. Matern Child Health J. 2013;17:200–7.

    Article  Google Scholar 

  13. Yawn BP, Buchanan GR, Afenyi-Annan AN, Ballas SK, Hassell KL, James AH, Jordan L, Lanzkron SM, Lottenberg R, Savage WJ, Tanabe PJ, Ware RE, Murad MH, Goldsmith JC, Ortiz E, Fulwood R, Horton A, John-Sowah J. Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members. JAMA. 2014;312:1033–48.

    Article  Google Scholar 

  14. Pregnancy. G-tGMoscdi: Management of sickle cell disease in pregnancy, London: Royal College of Obstetricians and Gynaecologists 2011.

    Google Scholar 

  15. Stuart MJ, Nagel RL. Sickle-cell disease. Lancet. 2004;364:1343–60.

    Article  Google Scholar 

  16. Parrish MR, Morrison JC. Sickle cell crisis and pregnancy. Semin Perinatol. 2013;37:274–9.

    Article  Google Scholar 

  17. Danzer BI, Birnbach DJ, Thys DM. Anesthesia for the parturient with sickle cell disease. J Clin Anesth. 1996;8:598–602.

    Article  CAS  Google Scholar 

  18. Oteng-Ntim E, Meeks D, Seed PT, Webster L, Howard J, Doyle P, Chappell LC. Adverse maternal and perinatal outcomes in pregnant women with sickle cell disease: systematic review and meta-analysis. Blood. 2015;125:3316–25.

    Article  CAS  Google Scholar 

  19. Friedman AM, D’Alton ME. Venous thromboembolism bundle: risk assessment and prophylaxis for obstetric patients. Semin Perinatol. 2016;40:87–92.

    Article  Google Scholar 

  20. Leffert L, Butwick A, Carvalho B, Arendt K, Bates SM, Friedman A, Horlocker T, Houle T, Landau R, Dubois H, Fernando R, Houle T, Kopp S, Montgomery D, Pellegrini J, Smiley R, Toledo P. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the anesthetic management of pregnant and postpartum women receiving thromboprophylaxis or higher dose anticoagulants. Anesth Analg 2018;126(3):928–44.

    Article  Google Scholar 

  21. Sentilhes L, Vayssiere C, Deneux-Tharaux C, Aya AG, Bayoumeu F, Bonnet MP, Djoudi R, Dolley P, Dreyfus M, Ducroux-Schouwey C, Dupont C, Francois A, Gallot D, Haumonte JB, Huissoud C, Kayem G, Keita H, Langer B, Mignon A, Morel O, Parant O, Pelage JP, Phan E, Rossignol M, Tessier V, Mercier FJ, Goffinet F. Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF): in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR). Eur J Obstet Gynecol Reprod Biol. 2016;198:12–21.

    Article  Google Scholar 

  22. Prevention and management of postpartum haemorrhage: Green-top guideline no. 52. BJOG 2017; 124: e106-e149.

    Google Scholar 

  23. Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) consult series #44: management of bleeding in the late preterm period. Am J Obstet Gynecol. 2018;218(1):B2–B8.

    Article  Google Scholar 

  24. Collis RE, Collins PW. Haemostatic management of obstetric haemorrhage. Anaesthesia. 2015;70(Suppl 1):78–86, e27–8.

    Article  Google Scholar 

  25. Sharp HT, Johnson JV, Lemieux LA, Currigan SM. executive summary of the reVITALize initiative: standardizing gynecologic data definitions. Obstet Gynecol. 2017;129(4):603–7.

    Article  Google Scholar 

  26. Abdul-Kadir R, McLintock C, Ducloy AS, El-Refaey H, England A, Federici AB, Grotegut CA, Halimeh S, Herman JH, Hofer S, James AH, Kouides PA, Paidas MJ, Peyvandi F, Winikoff R. Evaluation and management of postpartum hemorrhage: consensus from an international expert panel. Transfusion. 2014;54:1756–68.

    Article  Google Scholar 

  27. Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, Gulmezoglu AM, Temmerman M, Alkema L. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2:e323–33.

    Article  Google Scholar 

  28. Main EK, Goffman D, Scavone BM, Low LK, Bingham D, Fontaine PL, Gorlin JB, Lagrew DC, Levy BS. National partnership for maternal safety: consensus bundle on obstetric hemorrhage. Anesth Analg. 2015;121:142–8.

    PubMed  Google Scholar 

  29. National Blood Authority. Patient Blood Management Guidelines: Module 5 - Obstetrics and Maternity. © National Blood Authority, 2015. ISBN 978-0-9924971-2-5. https://www.blood.gov.au/system/files/documents/20180426-Module5-WEB.pdf.

  30. Leduc D, Senikas V, Lalonde AB. CLINICAL PRACTICE OBSTETRICS COMMITTEE. Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage: No. 235 October 2009 (Replaces No. 88, April 2000). Int J Gynaecol Obstet 2010; 108: 258–267.

    Google Scholar 

  31. Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG. 2006;113:919–24.

    Article  CAS  Google Scholar 

  32. Hancock A, Weeks AD, Lavender DT. Is accurate and reliable blood loss estimation the ‘crucial step’ in early detection of postpartum haemorrhage: an integrative review of the literature. BMC Pregnancy Childbirth. 2015;15:230.

    Article  Google Scholar 

  33. Gutierrez G, Reines HD, Wulf-Gutierrez ME. Clinical review: hemorrhagic shock. Crit Care. 2004;8:373–81.

    Article  Google Scholar 

  34. Arora KS, Shields LE, Grobman WA, D’Alton ME, Lappen JR, Mercer BM. Triggers, bundles, protocols, and checklists--what every maternal care provider needs to know. Am J Obstet Gynecol. 2016;214:444–51.

    Article  Google Scholar 

  35. Le Bas A, Chandraharan E, Addei A, Arulkumaran S. Use of the “obstetric shock index” as an adjunct in identifying significant blood loss in patients with massive postpartum hemorrhage. Int J Gynaecol Obstet. 2014;124:253–5.

    Article  Google Scholar 

  36. Dennis AT. Transthoracic echocardiography in obstetric anaesthesia and obstetric critical illness. Int J Obstet Anesth. 2011;20:160–8.

    Article  CAS  Google Scholar 

  37. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: rapid ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010;28:29–56. vii

    Article  Google Scholar 

  38. Liu XH, Jiang YM, Shi H, Yue XA, Wang YF, Yang H. Prospective, sequential, longitudinal study of coagulation changes during pregnancy in Chinese women. Int J Gynaecol Obstet. 2009;105:240–3.

    Article  Google Scholar 

  39. Shaylor R, Weiniger CF, Austin N, Tzabazis A, Shander A, Goodnough LT, Butwick AJ. National and international guidelines for patient blood management in obstetrics: a qualitative review. Anesth Analg. 2017;124:216–32.

    Article  Google Scholar 

  40. de Lloyd L, Bovington R, Kaye A, Collis RE, Rayment R, Sanders J, Rees A, Collins PW. Standard haemostatic tests following major obstetric haemorrhage. Int J Obstet Anesth. 2011;20:135–41.

    Article  Google Scholar 

  41. Cortet M, Deneux-Tharaux C, Dupont C, Colin C, Rudigoz RC, Bouvier-Colle MH, Huissoud C. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. Br J Anaesth. 2012;108:984–9.

    Article  CAS  Google Scholar 

  42. Green L, Knight M, Seeney F, Hopkinson C, Collins PW, Collis RE, Simpson NA, Weeks A, Stanworth SJ. The haematological features and transfusion management of women who required massive transfusion for major obstetric haemorrhage in the UK: a population based study. Br J Haematol. 2016;172:616–24.

    Article  CAS  Google Scholar 

  43. Ekelund K, Hanke G, Stensballe J, Wikkelsoe A, Albrechtsen CK, Afshari A. Hemostatic resuscitation in postpartum hemorrhage - a supplement to surgery. Acta Obstet Gynecol Scand. 2015;94:680–92.

    Article  Google Scholar 

  44. No PB. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017;130:e168–86.

    Article  Google Scholar 

  45. Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, del Junco DJ, Brasel KJ, Bulger EM, Callcut RA, Cohen MJ, Cotton BA, Fabian TC, Inaba K, Kerby JD, Muskat P, O’Keeffe T, Rizoli S, Robinson BR, Scalea TM, Schreiber MA, Stein DM, Weinberg JA, Callum JL, Hess JR, Matijevic N, Miller CN, Pittet JF, Hoyt DB, Pearson GD, Leroux B, van Belle G. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313:471–82.

    Article  CAS  Google Scholar 

  46. Bonnet MP, Deneux-Tharaux C, Bouvier-Colle MH. Critical care and transfusion management in maternal deaths from postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol. 2011;158:183–8.

    Article  Google Scholar 

  47. Cotton BA, Dossett LA, Au BK, Nunez TC, Robertson AM, Young PP. Room for (performance) improvement: provider-related factors associated with poor outcomes in massive transfusion. J Trauma. 2009;67:1004–12.

    Article  Google Scholar 

  48. Bawazeer M, Ahmed N, Izadi H, McFarlan A, Nathens A, Pavenski K. Compliance with a massive transfusion protocol (MTP) impacts patient outcome. Injury. 2015;46:21–8.

    Article  CAS  Google Scholar 

  49. Kacmar RM, Mhyre JM, Scavone BM, Fuller AJ, Toledo P. The use of postpartum hemorrhage protocols in United States academic obstetric anesthesia units. Anesth Analg. 2014;119:906–10.

    Article  Google Scholar 

  50. Brookfield KF, Goodnough LT, Lyell DJ, Butwick AJ. Perioperative and transfusion outcomes in women undergoing cesarean hysterectomy for abnormal placentation. Transfusion. 2014;54:1530–6.

    Article  Google Scholar 

  51. Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive maternal hemorrhage protocols reduce utilization of blood products and improve patient safety. Am J Obstet Gynecol. 2011;205(4):368.e1–8.

    Google Scholar 

  52. Rizvi F, Mackey R, Barrett T, McKenna P, Geary M. Successful reduction of massive postpartum haemorrhage by use of guidelines and staff education. BJOG. 2004;111:495–8.

    Article  Google Scholar 

  53. Butwick AJ, Goodnough LT. Transfusion and coagulation management in major obstetric hemorrhage. Curr Opin Anaesthesiol. 2015;28:275–84.

    Article  CAS  Google Scholar 

  54. Chang R, Holcomb JB. Optimal fluid therapy for traumatic hemorrhagic shock. Crit Care Clin. 2017;33:15–36.

    Article  Google Scholar 

  55. Tuncalp O, Souza JP, Gulmezoglu M. New WHO recommendations on prevention and treatment of postpartum hemorrhage. Int J Gynaecol Obstet. 2013;123:254–6.

    Article  Google Scholar 

  56. Klein AA, Arnold P, Bingham RM, Brohi K, Clark R, Collis R, Gill R, McSporran W, Moor P, Rao Baikady R, Richards T, Shinde S, Stanworth S, Walsh TS. AAGBI guidelines: the use of blood components and their alternatives 2016. Anaesthesia. 2016;71:829–42.

    Article  CAS  Google Scholar 

  57. Duffield A, McKenzie C, Carvalho B, Ramachandran B, Yin V, El-Sayed YY, Riley ET, Butwick AJ. Effect of a high-rate versus a low-rate oxytocin infusion for maintaining uterine contractility during elective cesarean delivery: a prospective randomized clinical trial. Anesth Analg. 2017;124:857–62.

    Article  CAS  Google Scholar 

  58. Butwick AJ, Carvalho B, Blumenfeld YJ, El-Sayed YY, Nelson LM, Bateman BT. Second-line uterotonics and the risk of hemorrhage-related morbidity. Am J Obstet Gynecol. 2015;212:642.e1–7.

    Article  Google Scholar 

  59. WOMAN Trial Collaborators. 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. Lancet. 2017;389:2105–16.

    Article  Google Scholar 

  60. Sentilhes L, Merlot B, Madar H, Sztark F, Brun S, Deneux-Tharaux C. Postpartum haemorrhage: prevention and treatment. Expert Rev Hematol. 2016;9:1043–61.

    Article  CAS  Google Scholar 

  61. American College of Obstetricians and Gynecologists. ACOG committee opinion. Placenta accreta. Number 266, January 2002. Int J Gynaecol Obstet. 2002;77:77–8.

    Article  Google Scholar 

  62. NICE interventional procedure guidelines 144. Intraoperative blood cell salvage in obstetrics. Interventional procedures guidance Published: 23 November 2005 nice.org.uk/guidance/ipg144.

  63. Merien AE, van de Ven J, Mol BW, Houterman S, Oei SG. Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review. Obstet Gynecol. 2010;115:1021–31.

    Article  CAS  Google Scholar 

  64. Hilton G, Daniels K, Goldhaber-Fiebert SN, Lipman S, Carvalho B, Butwick A. Checklists and multidisciplinary team performance during simulated obstetric hemorrhage. Int J Obstet Anesth. 2016;25:9–16.

    Article  CAS  Google Scholar 

  65. Pascual JL, Holena DN, Vella MA, Palmieri J, Sicoutris C, Selvan B, Fox AD, Sarani B, Sims C, Williams NN, Schwab CW. Short simulation training improves objective skills in established advanced practitioners managing emergencies on the ward and surgical intensive care unit. J Trauma. 2011;71:330–7. discussion 337-8

    Article  Google Scholar 

  66. Chantry AA, Deneux-Tharaux C, Bonnet MP, Bouvier-Colle MH. Pregnancy-related ICU admissions in France: trends in rate and severity, 2006-2009. Crit Care Med. 2015;43:78–86.

    Article  Google Scholar 

  67. Clifford L, Jia Q, Subramanian A, Yadav H, Schroeder DR, Kor DJ. Risk factors and clinical outcomes associated with perioperative transfusion-associated circulatory overload. Anesthesiology. 2017;126:409–18.

    Article  Google Scholar 

  68. Clifford L, Jia Q, Subramanian A, Yadav H, Wilson GA, Murphy SP, Pathak J, Schroeder DR, Kor DJ. Characterizing the epidemiology of postoperative transfusion-related acute lung injury. Anesthesiology. 2015;122:12–20.

    Article  Google Scholar 

  69. Friedman T, Javidroozi M, Lobel G, Shander A. Complications of allogeneic blood product administration, with emphasis on transfusion-related acute lung injury and transfusion-associated circulatory overload. Adv Anesth. 2017;35:159–73.

    Article  Google Scholar 

  70. Kuhn JC, Falk RS, Langesaeter E. Haemodynamic changes during labour: continuous minimally invasive monitoring in 20 healthy parturients. Int J Obstet Anesth. 2017;31:74–83.

    Article  CAS  Google Scholar 

  71. Wanderer JP, Leffert LR, Mhyre JM, Kuklina EV, Callaghan WM, Bateman BT. Epidemiology of obstetric-related ICU admissions in Maryland: 1999-2008*. Crit Care Med. 2013;41:1844–52.

    Article  Google Scholar 

  72. Lubarsky SL, Barton JR, Friedman SA, Nasreddine S, Ramadan MK, Sibai BM. Late postpartum eclampsia revisited. Obstet Gynecol. 1994;83:502–5.

    Article  CAS  Google Scholar 

  73. Chames MC, Livingston JC, Ivester TS, Barton JR, Sibai BM. Late postpartum eclampsia: a preventable disease? Am J Obstet Gynecol. 2002;186:1174–7.

    Article  Google Scholar 

  74. Vigil-De Gracia P, Ortega-Paz L. Pre-eclampsia/eclampsia and hepatic rupture. Int J Gynaecol Obstet. 2012;118:186–9.

    Article  Google Scholar 

  75. Hildebrand AM, Liu K, Shariff SZ, Ray JG, Sontrop JM, Clark WF, Hladunewich MA, Garg AX. Characteristics and outcomes of AKI treated with dialysis during pregnancy and the postpartum period. J Am Soc Nephrol. 2015;26:3085–91.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Division of Anesthesia, Intensive Care and Pain Medicine, Tel-Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel

    Nadav Levy MD & Carolyn F. Weiniger MB ChB

  2. Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel

    Carolyn F. Weiniger MB ChB

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  1. Nadav Levy MD
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  2. Carolyn F. Weiniger MB ChB
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Editors and Affiliations

  1. Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Team Health Research Institute, Englewood, NJ, USA

    Aryeh Shander

  2. Department of Critical Care Medicine, Geisinger Health System, Danville, PA, USA

    Howard L. Corwin

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Levy, N., Weiniger, C.F. (2018). Hematologic Challenges in the Critically Ill: Obstetrics. In: Shander, A., Corwin, H. (eds) Hematologic Challenges in the Critically Ill. Springer, Cham. https://doi.org/10.1007/978-3-319-93572-0_11

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  • DOI: https://doi.org/10.1007/978-3-319-93572-0_11

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