Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage

Vacuum-induced tamponade for managing postpartum hemorrhage: a systematic review

OBJECTIVE

Postpartum hemorrhage is a leading cause of maternal mortality and morbidity around the globe. The novel low-suction vacuum hemorrhage device (VHD) provides an alternative treatment option for cases of postpartum hemorrhage when first-line uterotonic agents fail. This systematic review aims to review current data evaluating the overall efficacy and safety of VHDs in treating postpartum hemorrhage.

METHODS

We searched CINAHL Ultimate, Academic Search Premier, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE with Full Text, and PubMed and reference lists of retrieved studies for eligible studies that included outcomes of effectiveness, efficacy, or safety. Two independent reviewers used Covidence.org to screen Titles and Abstracts for 69 studies of which six were included in the analysis. Secondary outcomes measured across studies included time to bleeding control, total device deployment time, and adverse effects.

RESULTS

Six nonrandomized trials (N = 1018 participants) included studies conducted in Indonesia, the United States, Switzerland, and Canada. The VHDs were found to have 90% effectiveness in achieving bleeding control across the studies. For most patients, this was achieved in <5 min and required a total device deployment time of 3 h. Reported adverse events were not considered life-threatening, including endometritis in 11 patients and red blood cell transfusions in 38% of patients.

CONCLUSION

VHDs have the potential to be used as a rapidly effective means for mechanical intervention of postpartum hemorrhage. The efficacy and safety of VHDs must be further studied at the randomized controlled trial level to determine their clinical usage.

Healing the Broken Heart: A Cardiac Odyssey in the Face of Obstetric Crisis

Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality worldwide. The management of severe PPH remains challenging despite advances in obstetric care. Conventional methods of management with uterotonic agents, surgical techniques, and blood transfusions often fail to provide adequate hemostasis, more so in refractory cases. The intra-aortic balloon pump (IABP) has been recently described as a new therapeutic modality in refractory PPH and is commonly used in cardiology. This case report presents a rare case of severe uncontrollable PPH complicated by Takotsubo cardiomyopathy (TCM). She was managed with the conventional methods by adding a relatively new technique, the IABP. The case thus brings out the potential role of IABP in the management of severe PPH and also reinforces the multidisciplinary approach in obstetrical emergencies.

Conservative approaches to postpartum haemorrhage

Postpartum haemorrhage (PPH) and PPH-related deaths are disproportionately higher in low-income countries, with sub-Saharan Africa and Southern Asia accounting for approximately 85% of the global burden of PPH-related maternal deaths. Although PPH-related mortality is directly related to the amount and duration of bleeding, the high maternal death burden in resource-limited countries suggests that a great majority of these deaths would be avoidable with the appropriate resources and effective use of evidence-based interventions. Non-surgical management is often the first-line approach for PPH, but conservative surgical interventions may be required if bleeding persists or if the underlying cause is not responsive to the initial conservative measures. The appropriate interventions should be selected based on the individual's specific circumstances and clinical condition.

Postpartum Hemorrhage: Enhancing Outcomes for Mothers by Effective Management

Postpartum hemorrhage (PPH) remains a significant contributor to maternal morbidity and mortality worldwide. In India, PPH affects approximately 12% of women. The prevention and management of PPH are the significant challenges in obstetrics, with accurate assessment of blood loss and timely intervention being critical. Active Management of the Third Stage of Labor is a gold standard strategy for prevention. Recent advancements in PPH management include the use of recombinant activated factor VIIa, which has shown promise in decreasing the need for invasive procedures and second-line therapies. Additionally, surgical and radiological interventions have been effective in cases of refractory PPH. Overall, ongoing research and advancements in PPH management continue to enhance the quality of care and maternal outcomes experiencing this potentially life-threatening complication of childbirth. This editorial explores prevention and management of Atonic PPH with encompassing medical and surgical strategies, to enhance understanding and optimize clinical care for mothers at risk of this obstetric emergency.

Early treatment with Fibrinogen γ-chain peptide-coated, ADP-encapsulated Liposomes (H12-(ADP)-liposomes) ameliorates post-partum hemorrhage with coagulopathy caused by amniotic fluid embolism in rabbits

BACKGROUND

Amniotic fluid embolism is an unpredictable and sometimes lethal complication of childbirth. Fibrinogen γ-chain peptide-coated, ADP-encapsulated Liposomes (H12-(ADP)-liposomes), which were developed as a platelet substitute, may be useful to control postpartum hemorrhage with consumptive coagulopathy.

OBJECTIVE

This study aimed to establish a hemodynamically stable amniotic fluid embolism animal model and evaluate the efficacy of H12-ADP-liposome infusion in the initial management of postpartum hemorrhage complicated with amniotic fluid embolism-involved coagulopathy.

STUDY DESIGN

Pregnant New Zealand white rabbits (28th day of pregnancy or normal gestation period of 29-35 days) underwent cesarean delivery, followed by intravenous administration of amniotic fluid (a total of 3.0 mL administered in 4 doses over 9 minutes). Thereafter, uncontrolled postpartum hemorrhage was induced by transecting the right midartery and concomitant vein in the myometrium. After initial bleeding for 5 minutes, rabbits received isovolemic fluid resuscitation through the femoral vein with an equivalent volume of blood loss every 5 minutes for 60 minutes. The transfusion regimens included platelet-rich plasma, platelet-poor plasma, and a bolus administration of H12-ADP-liposomes followed by platelet-poor plasma transfusion (8 rabbits per group). Moreover, 60 minutes after initiation of bleeding, rabbits received surgical hemostasis by ligation of bleeding vessels, except in cases with spontaneous hemostasis.

RESULTS

The administration of amniotic fluid caused thrombocytopenia (56±3 × 103/μL) and prolonged both clotting time (before administration: 130.0±3.0 to 171.0±5.0 seconds) and prothrombin time (4.5±0.1 to 4.7±0.1 seconds). After the initial 5-minute bleeding in the rabbits, the mean arterial pressure fell to 43±2 mm Hg. Platelet-poor plasma transfusion alone further prolonged clotting time and prothrombin time at 60 minutes (192.0±10.0 and 5.2±0.1 seconds, respectively) with decreasing mean arterial pressure to <40 mm Hg. By contrast, the administration of H12-ADP-liposomes followed by platelet-poor plasma transfusion reduced the prolonged clotting time (153.0±5.0 seconds) and prothrombin time (4.9±0.1 seconds) similar to platelet-rich plasma transfusion (154.0±11.0 and 4.9±0.1 seconds, respectively) at 60 minutes. These rabbits maintained a mean arterial pressure of >45 mm Hg throughout the experiment. H12-ADP-liposome infusion and platelet-poor plasma transfusion and platelet-rich plasma transfusion yielded spontaneous hemostasis in 4 of 8 rabbits, whereas platelet-poor plasma transfusion did not stop bleeding in any of the rabbits. The total blood loss was 59±17 mL in the H12-ADP-liposomes and platelet-poor plasma group, which was half of that in the platelet-poor plasma group (124±10 mL).

CONCLUSION

H12-ADP-liposome infusion may be effective in the initial management of postpartum hemorrhage complicated with amniotic fluid embolism, resulting in mitigation of consumptive coagulopathy.