[Acute fibrinopenia in obstetrics]

A review of 10 cases of severe obstetrical haemorrhage is presented. The etiology is not always clear. The most significant biological sign is the early, acute and marked drop of fibrinogen levels, below 1 g in 20 p. cent of the cases and 0.5 g in 50 p. cent. An early and rapid treatment is essential and based on correcting the fibrinopenia; fibrinogen, in fractioned form, at a mean dose of 3 g, reduces the duration of the syndrome and minimize the risks of complications. In the acute phase, heparin therapy must be avoided because it might aggravate the haemorrhage.

Postpartum hemorrhage

Postpartum hemorrhage is usually unexpected, and blood loss can be massive. Excessive bleeding after delivery may result from uterine atony, disruption of the genital tract, placental abnormalities, coagulation disorders and miscellaneous obstetric complications. Prompt treatment is imperative. Treatment options include oxytocics, prostaglandins, uterine exploration, uterine packing and, occasionally, surgery.

Control of postpartum uterine atony by intramyometrial prostaglandin

Five patients with severe postpartum hemorrhage due to uterine atony and unresponsive to oxytocin, ergonovine, and massage were treated with intramyometrial injection of 250 micrograms of prostaglandin (15S)-15-methyl PGF2 alpha-Tham. Four patients received 2 injections (500 micrograms), and 1 patient required 1 injection (250 micrograms). Three (60%) of 5 patients responded successfully with an increase in uterine tone and cessation of uterine hemorrhage, thus obviating the need for hysterectomy. Two patients had no uterine response, possibly because of delayed use of the drug, excessive blood loss, and accompanying shock; they required hysterectomy. Intramyometrial injection of prostaglandin is an effective and safe method of managing severe postpartum hemorrhage unresponsive to oxytocin and ergonovine, but it must be used early during the management of atony to obtain maximum effect. This method should precede surgical management of uterine atony.

Trasylol in the management of abruptio placentae with consumption coagulopathy and uterine inertia

A study was conducted on 40 patients with abruptio placentae complicated by intrauterine death of the fetus, consumption coagulopathy and uterine inertia. All patients had severe hyperfibrinolysis (FDP > 300 microgram/ml). Following correction of shock, amniotomy was performed, intrauterine pressure catheters were placed, and oxytocin infusions were begun in all cases. The diagnosis of uterine inertia was made when the cervix failed to dilate following six hours of this treatment. After diagnosing uterine inertia, 18 patients (group B) did not. All but one patient in group A showed a marked improvement in the associated consumption coagulopathy and a rapid reawakening of uterine activity with progress to spontaneous vaginal delivery. Thirteen patients in group B did not show prepartum improvement in consumption coagulopathy or a resumption of uterine activity. These patients required cesarean section. There were two maternal deaths in group B; the overall complication rate in this group was greater than in group A.

Treatment of postpartum uterine atony with prostaglandin E2 vaginal suppositories

When severe postpartum hemorrhage secondary to uterine atony is unresponsive to medical management, including oxytocic drugs and/or ergonovine and its derivatives, surgical intervention becomes necessary. This case of postpartum uterine atony, with several features suggesting persistent myometrial dysfunction which did not respond to usual medical measures, responded to treatment with intravaginal prostaglandin E2 (PGE2) suppositories. Prostaglandin E2 vaginal suppositories may be useful in the treatment of persistent postpartum uterine atony.

The diagnosis and management of accidental haemorrhage with associated coagulopathy

An approach to the diagnosis and management of accidental haemorrhage with associated coagulation failure is discussed and outlined. It is stressed that special investigations play a minor role in planning management. The main aim should be to achieve rapid delivery, preferably via the vaginal route. About 50% of these cases are associated with uterine atony and inertia. This is probably due to raised local and circulating levels of fibrin/fibrinogen degradation products (FDP). In such cases uterine activity can be restored by the administration of large intravenous doses of Trasylol (Bayer). Life-endangering complications such as acute respiratory and renal failure should be prevented by prophylactic management and by treatment aimed at rapid delivery. The indications for Caesarean section are outlined. The need for careful assessment prior to discharge of these patients and for re-assessment throughout the puerperium is stressed.