Major obstetric hemorrhage

[Postpartum hemorrhage: an observational study of 21,726 deliveries in 28 months]

OBJECTIVE

To describe the management of severe postpartum hemorrhage.

MATERIAL AND METHODS

Prospective observational study from July 2005 to November 2007 in women who were admitted to the recovery unit of a tertiary referral hospital due to postpartum hemorrhage. We analyzed incidence, prevalence, morbidity, mortality, and associated risk factors.

RESULTS

The study included 21,726 deliveries (124 with severe bleeding). Postpartum hemorrhage was more common after an instrumental delivery (odds ratio [OR], 4.54) and after a cesarean delivery (OR, 2.86). The risk factors identified in the study population were multiple gestation pregnancy and fetal death. One patient died due to disseminated intravascular coagulation. The main causes of bleeding were uterine atony (45.2%) followed by vaginal tearing (26.6%). Treatment was provided using packed red blood cells in 96.8% of the patients, fibrinogen in 49.2%, prothrombin complex in 7.25% and activated factor VII in 3.2%. Selective arterial embolization was performed in 10.5% of the cases (success rate, 84.6%) and hysterectomy was required in 13.7%. The main complications were need for postoperative mechanical ventilation (11.3%), myocardial ischemia (4%), pulmonary edema (4.8%), acute renal failure (8.9%), ventricular fibrillation (0.8%), and death (0.8%).

CONCLUSIONS

The incidence of severe postpartum hemorrhage in patients treated at our hospital is low, as is the mortality rate. Use of fibrinogen is common and provides good results. Angiographic embolization is very effective, though the percentage of hysterectomies is still high. Multiple gestation pregnancy and fetal death are associated risk factors.

Failure of recombinant factor VIIa to correct the coagulopathy in a case of severe postpartum hemorrhage

BACKGROUND

Postpartum hemorrhage (PPH)remains an important cause of maternal morbidity and mortality. Several published reports suggest that recombinant factor VIIa (rFVIIa) is effective in controlling bleeding in PPH. This study reports a case of severe PPH complicated by disseminated intravascular coagulation(DIC), in which early rFVIIa (44 mg/kg) administration not only failed to control the bleeding in vivo but also, surprisingly, failed to correct the patient's international normalized ratio (INR) in vitro. It was hypothesized that the failure of rFVIIa to correct the INR indicated a deficiency in a downstream coagulation factor(s). To investigate this, coagulation factor levels were measured in blood samples that had been drawn periodically during resuscitation in the operating room.

STUDY DESIGN AND METHODS

Clinical and laboratory data were extracted from the medical record.Plasma samples that had been obtained during resuscitation were frozen, and activity levels of the following factors were subsequently measured: fibrinogen, FII, FV, FVII, F IX, and FX.

RESULTS

After rFVIIa administration, the patient's INR remained elevated at 1.9, and bleeding continued. It was determined that at the time rFVIIa was administered, the patient's fibrinogen level was very low(60 mg/dL). INR normalization and control of bleeding was achieved only after the patient's fibrinogen level was restored to normal. FII, F IX, and FX remained at hemostatic levels throughout resuscitation.

CONCLUSIONS

In this case of severe PPH complicated by DIC, fibrinogen appears to have been limiting at the time rFVIIa was administered. It is suggested that fibrinogen levels should be corrected during PPH resuscitation before rFVIIa use is considered.

Common errors and remedies in managing postpartum haemorrhage

Postpartum haemorrhage (PPH) is a major contributor to maternal morbidity and mortality. By only examining mortality, the full extent of the problem is not revealed and also it is important to evaluate the avoidable factors. This will identify the areas that need attention. The common errors include not treating anaemia in pregnancy, not practicing active management of the third stage of labour, delay in recognition, substandard care and lack of skills. The remedies include the correct medical treatment of PPH and the use of uterine tamponade. Cell savers can help to reduce the need for transfusion and transfusion associated complications. There are new treatment modalities such as embolisation that can be of value in certain settings.