Patients with postpartum hemorrhage admitted in intensive care unit: Patient condition, interventions, and outcome.

BACKGROUND: We conducted this study to analyze the data of patients admitted to intensive care unit (ICU) following postpartum hemorrhage (PPH) during one-year period, the interventions they received, and the outcome.
MATERIALS AND METHODS: Case records of patients admitted to ICU with PPH were analyzed. Data retrieved were as follows: Primary admission or referred case, duration between onset of PPH and arrival, condition at admission, resuscitative measures, procedures to manage PPH, presence of disseminated intravascular coagulation (DIC) and its management, duration of ICU stay, and the outcome.
RESULTS: Of 21 patients with PPH, 15 were admitted in the ICU. All were referred from other hospitals. Duration between onset of PPH and arrival was 6 (15) hours (mean [standard deviation]). All were conscious on arrival. In 10 patients, blood pressure was not recordable. Tachycardia was a common feature. One patient had bradycardia (54 bpm/BP not recordable). Resuscitative measures included oxygen supplementation and fluid resuscitation. Eight patients underwent uterine artery embolization, 2 patients underwent embolization followed by surgery, and 11 patients underwent surgical intervention only. Twelve patients had DIC on admission which was managed with blood component therapy. Duration of stay in ICU was 12.6 (5.4) days (mean [standard deviation]). Two patients expired following intractable DIC and multiorgan dysfunction syndrome. Though these 2 patients had severe shock on presentation, they did not have DIC at the time of presentation.
CONCLUSIONS: Despite early resuscitation and intensive care management, DIC is a major cause of mortality. Late onset DIC (onset after admission to ICU) was associated with poor outcome in this study.

Introduction

Postpartum hemorrhage (PPH) is one of the major causes of maternal mortality. It can occur immediately or several hours or days after delivery. Most cases are managed with conservative therapy using uterotonic drugs. In the case of persistent bleeding, refractory to conservative treatment vascular ligation or hysterectomy may be needed. Transcatheter embolization of uterine arteries is a relatively new treatment modality available for such cases. Anesthesiologist/intensivist is involved in the management of these cases during resuscitation following massive bleed, in the intensive care unit (ICU) following resuscitation, for anesthesia service during surgery or interventional radiology procedure to control bleeding. In this retrospective study, we analyzed the data of patients admitted to our ICU following PPH during one-year period, the interventions they received, and the outcome.

Materials and Methods

This retrospective analysis was conducted at Kasturba Hospital, Kasturba Medical College, after obtaining approval from Institutional Review Board. Case records of patients with PPH admitted to our 8-bed multidisciplinary ICU over a period of one year (December 2009-December 2010) were analyzed. Written informed consent for enrollment into the study was obtained from the patients. The variables recorded are given in [Table 1].

Table 1

Patient data retrieved from records

Results

During one-year period, anesthesiologist/intensivist were called for evaluation of 21 patients with PPH. Of these 21 patients, 15 were admitted to multidisciplinary ICU, while the other 6 patients were managed in the obstetric high-dependency unit. The mean (standard deviation) of age and weight of the admitted patients were 27 (4) years and 50 (4) kg, respectively. All the cases were referred from other hospitals or clinics to our tertiary care center. The duration between onset of PPH and start of resuscitative measures was 6 (15) (1-72) hours (data are mean (standard deviation) [range]).

Resuscitative measures (fluid resuscitation and oxygen supplementation) were started in all the patients before the intensivist/anesthesiologist arrived for evaluation. As a protocol, blood samples were drawn for hemoglobin, hematocrit, prothrombin time, activated partial thromboplastin time, platelet count, d-dimer, fibrinogen degradation products, and blood grouping and cross-matching.

All patients were conscious on arrival. In 10 patients, blood pressure was not recordable by noninvasive blood pressure measurement. Tachycardia was a common feature (100-154 beats/min). One patient had bradycardia (54 bpm/BP not recordable). Twelve patients had features suggestive of disseminated intravascular coagulation (DIC). Eight patients underwent uterine artery embolization, 2 patients underwent embolization followed by surgery, and 11 patients underwent surgical intervention only. Patients with persistent hypotension (in the ICU) despite fluid resuscitation to a central venous pressure (CVP) of 12 mmHg received dopamine infusion at a rate of 5 to 12 mcg/kg/min titrated to response. Four patients required mechanical ventilation with tracheal intubation; of them, two could get weaned in two days. Two patients required renal support therapy in the form of hemodialysis. These two patients expired following DIC resulting in uncontrolled bleeding, despite blood component transfusion and multiorgan dysfunction syndrome (MODS). Though these 2 patients had severe shock on presentation, they did not have DIC at the time of presentation [Table 2]. Delay in start of resuscitative measures adversely affected the outcome (Pearson correlation, P = 0.011). The total duration of stay in ICU was 12.6 (5.4) (7-23) days (data are mean (standard deviation) [range]).

Table 2

Details of patients with negative outcome

Discussion

Obstetric hemorrhage is a leading cause of maternal death and the most common contributor to serious obstetric morbidity. Maternal mortality audit data suggest that appropriate preparation and good emergency management leads to improved outcome.[1]

Data regarding patients with PPH who are admitted to ICU are scant in Indian literature. The treatment received by these patients and the outcomes are not clear. We conducted this retrospective audit to evaluate the interventions received by patients with PPH admitted in ICU and their outcomes.

All the patients were referred from either a primary healthcare center or a secondary referral center. There were no home deliveries. Despite conduct of delivery by trained personnel, the fluid resuscitation when PPH began was grossly inadequate. Majority of the patients were in shock on arrival in the hospital. Immediate resuscitative measures at our hospital were found to be satisfactory. Initial fluid resuscitation was directed by clinical end points like urine output, pulse rate/volume, and blood pressure. These measures had been initiated by the obstetricians even before the arrival of the intensivist.

When the uterotonic drugs failed to arrest the bleeding, tranexamic acid 500 mg IV was administered empirically to all the patients. Systemic antifibrinolytic agents are widely used in surgery to prevent clot breakdown in order to reduce surgical blood loss. Tranexamic acid is a potent antifibrinolytic agent that exerts its effect by blocking lysine-binding sites on plasminogen molecules and has the potential to enhance the effectiveness of the patient's own hemostatic mechanisms. Tranexamic acid significantly reduces uterine blood loss in women with menorrhagia. However, at present, there is little reliable evidence from randomized trials on the effectiveness of tranexamic acid in the treatment of PPH. The ongoing WOMAN trial will provide a reliable scientific basis for recommendations as to whether or not tranexamic acid should be used in the treatment of PPH.[2]

The decision to proceed with uterine artery embolization or surgical management was made by the obstetricians in consultation with interventional radiologists. Uterine artery embolization was the procedure of first choice, whenever possible and applicable, because it is generally well tolerated by patients, and possesses the advantages of shorter hospitalizations and potential fertility preservation.[3] The high success rate, low morbidity rate, and possibility of preserving reproductive function have made super-selective uterine artery embolization the technique of choice to control life-threatening, intractable PPH in hemodynamically stable patients, provided multidisciplinary medical teams are promptly available.[4] The utility of this technique has been evaluated and reported in the literature.[56]

In the ICU, monitoring comprised 5-electrode ECG, pulse oximetry, Non Invasive Blood Pressure (NIBP), temperature, urine output, central venous pressures, and invasive arterial pressures. Arterial blood gas analysis was done twice a day and then as required by the clinical situation. Besides general supportive care, DIC was managed with blood component therapy as dictated by results of coagulation of profile. Recombinant factor seven or other less conventional treatment modalities for DIC were not used.

The mortality rate in this series was 13.33%. This is comparable with the mortality rates reported in the literature.[7-9] MODS with intractable DIC was the cause of death in both the cases. Both the patients who had a negative outcome did not have DIC at the time of admission but developed it after admission to ICU. They received multiple transfusions of blood components due to ongoing DIC. Whether late onset DIC has a negative influence on the outcome cannot be determined as the number of patients in this series is small to definitely conclude this.

We found that there is still scope for improving the fluid resuscitative measures once PPH sets in. DIC and MODS are poor prognostic factors of outcome following PPH.