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Colucci G, Helsing K, Biasiutti FD, Raio L, Schmid P, Tsakiris DA, Eberle B, Surbek D, Lämmle B, Alberio L. Standardized Management Protocol in Severe Postpartum Hemorrhage: A Single-Center Study. Clin Appl Thromb Hemost 2018; 24:884-893. [PMID: 29669438 PMCID: PMC6714733 DOI: 10.1177/1076029618758956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Severe postpartum hemorrhage (sPPH) is an obstetric emergency that needs prompt and effective therapy to reduce the risk of complications. In this study, women who developed sPPH (study cohort, n = 27) were treated according to a standardized management protocol prescribing sequential administration of uterotonic drugs, crystalloids, tranexamic acid, labile blood products, low-dose fibrinogen, and recombinant activated factor VII (rFVIIa). This group was compared to patients treated with different strategies during 2 preceding periods: an in-house guideline regulating the administration of rFVIIa (historical cohort 1, n = 20) and no specific guideline (historical cohort 2, n = 27). The management protocol was used over 33 months. The study cohort had a lower estimated blood loss (P = .004) and required less red blood cell concentrates (P = .007), fresh frozen plasma units (P = .004), and platelet concentrates (P = .020) compared to historical cohort 1 and historical cohort 2, respectively. The necessity of emergency postpartum hysterectomy was lower in the study group (P = .012). In conclusion, in patients with sPPH treated with this standardized management protocol, we observed a decreased requirement of labile blood products and lower need to proceed to emergency postpartum hysterectomy.
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Affiliation(s)
- Giuseppe Colucci
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland.,2 Service of Hematology, Clinica Luganese Moncucco, Lugano, Switzerland
| | - Karin Helsing
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland
| | - Franziska Demarmels Biasiutti
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland
| | - Luigi Raio
- 3 Department of Obstetrics and Gynecology, University Hospital and University of Bern, Bern, Switzerland
| | - Pirmin Schmid
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland
| | | | - Balthasar Eberle
- 5 Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Daniel Surbek
- 3 Department of Obstetrics and Gynecology, University Hospital and University of Bern, Bern, Switzerland
| | - Bernhard Lämmle
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland.,6 Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
| | - Lorenzo Alberio
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland.,7 Service et laboratoire central d'hématologie, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
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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. [PMID: 24617726 DOI: 10.1111/trf.12550] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/13/2013] [Accepted: 11/14/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) remains one of the leading causes of maternal morbidity and mortality worldwide, although the lack of a precise definition precludes accurate data of the absolute prevalence of PPH. STUDY DESIGN AND METHODS An international expert panel in obstetrics, gynecology, hematology, transfusion, and anesthesiology undertook a comprehensive review of the literature. At a meeting in November 2011, the panel agreed on a definition of severe PPH that would identify those women who were at a high risk of adverse clinical outcomes. RESULTS The panel agreed on the following definition for severe persistent (ongoing) PPH: "Active bleeding >1000 mL within the 24 hours following birth that continues despite the use of initial measures including first-line uterotonic agents and uterine massage." A treatment algorithm for severe persistent PPH was subsequently developed. Initial evaluations include measurement of blood loss and clinical assessments of PPH severity. Coagulation screens should be performed as soon as persistent (ongoing) PPH is diagnosed, to guide subsequent therapy. If initial measures fail to stop bleeding and uterine atony persists, second- and third-line (if required) interventions should be instated. These include mechanical or surgical maneuvers, i.e., intrauterine balloon tamponade or hemostatic brace sutures with hysterectomy as the final surgical option for uncontrollable PPH. Pharmacologic options include hemostatic agents (tranexamic acid), with timely transfusion of blood and plasma products playing an important role in persistent and severe PPH. CONCLUSION Early, aggressive, and coordinated intervention by health care professionals is critical in minimizing blood loss to ensure optimal clinical outcomes in management of women with severe, persistent PPH.
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Affiliation(s)
- Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology, Royal Free Hospital, London, UK
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Magon N, Babu KM, Kapur K, Chopra S, Joneja GS. Recombinant activated factor VII in post partum haemorrhage. Niger Med J 2013; 54:289-94. [PMID: 24403703 PMCID: PMC3883225 DOI: 10.4103/0300-1652.122328] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Post-partum haemorrhage (PPH) is a life-threatening obstetric complication and the leading cause of maternal death. Any bleeding that results in or could result in haemodynamic instability, if untreated, must be considered as PPH. There is no controversy about the need for prevention and treatment of PPH. The keystone of management of PPH entails first, non-invasive and nonsurgical methods and then invasive and surgical methods. However, mortality remains high. Therefore, new advancements in the treatment are most crucial. One such advancement has been the use of recombinant activated factor VII (rFVIIa) in PPH. First used 12 years back in PPH, this universal haemostatic agent has been effectively used in controlling PPH. The best available indicator of rFVIIa efficacy is the arrest of haemorrhage, which is judged by visual evidence and haemodynamic stabilization. It also reduces costs of therapy and the use of blood components in massive PPH. In cases of intractable PPH with no other obvious indications for hysterectomy, administration of rFVIIa should be considered before surgery. We share our experience in a series of cases of PPH, successfully managed using rFVIIa.
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Affiliation(s)
- Navneet Magon
- Department of Obstetrics and Gynecology, Air Force Hospital, Jorhat, India
| | - K. M. Babu
- Department of Obstetrics and Gynecology, Command Hospital (AF) Bangaluru, India
| | - Krishan Kapur
- Department of Obstetrics and Gynecology, Army Hospital (R and R) Delhi, India
| | - Sanjiv Chopra
- Department of Obstetrics and Gynecology, Military Hospital, Meerut, Uttar Pradesh, India
| | - Gurdarshan Singh Joneja
- Department of Obstetrics and Gynecology, Sikkim Manipal Medical College, Gangtok, Sikkim, India
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Magon N, Babu KM. Recombinant Factor VIIa in Post-partum Hemorrhage: A New Weapon in Obstetrician's Armamentarium. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2012; 4:157-62. [PMID: 22536557 PMCID: PMC3334254 DOI: 10.4103/1947-2714.94938] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Post-partum hemorrhage (PPH) is a life-threatening obstetric complication and the leading cause of maternal death. The usual manner for its management includes, first, noninvasive and nonsurgical methods, and, then invasive and surgical methods. However, mortality and morbidity related to PPH still remains unacceptably high, contributing to hysterectomy in at least 50% of cases. Early, effective, and preferably noninvasive treatments that can reduce maternal mortality and morbidity due to this entity are therefore essential. One of the most spectacular advancements in the control of PPH has been the use of recombinant activated factor (rFVIIa), both as initial and a life- and uterus-saving therapy. rFVIIa also reduces costs of therapy and use of blood components in massive PPH. In cases of intractable bleeding with no other obvious indications for hysterectomy, administration of rFVIIa should be considered before surgery. A MEDLINE search was done to review relevant articles in English literature on use of rFVIIa in PPH. Data were constructed and issues were reviewed from there. Our experience in a series of three cases of PPH, two of atonic and one of traumatic, successfully managed using rFVIIa is also shared.
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Affiliation(s)
- Navneet Magon
- Department of Obstetrics and Gynecology, Air Force Hospital, Nathu Singh Road, Kanpur Cantt., India
| | - KM Babu
- Department of Obstetrics and Gynecology, Air Force Hospital, Nathu Singh Road, Kanpur Cantt., India
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Severe postpartum haemorrhage treated with recombinant activated Factor VII in 80 Czech patients: analysis of the UniSeven registry. Int J Obstet Anesth 2011; 20:367-8. [DOI: 10.1016/j.ijoa.2011.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 07/04/2011] [Accepted: 07/04/2011] [Indexed: 11/22/2022]
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8
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Lee AI, Kaufman RM. Transfusion Medicine and the Pregnant Patient. Hematol Oncol Clin North Am 2011; 25:393-413, ix. [DOI: 10.1016/j.hoc.2011.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Jan JY, Lin SY, Lin CH, Lee CN, Fan SZ, Han YY. Recombinant activated factor VII as a promising adjuvant therapy for postpartum hemorrhage in the practice of obstetric anesthesia: Experience from a university hospital in Taiwan. J Obstet Gynaecol Res 2011; 37:901-7. [DOI: 10.1111/j.1447-0756.2010.01422.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Management of post-partum haemorrhage (PPH) involves the treatment of uterine atony, evacuation of retained placenta or placental fragments, surgery due to uterine or birth canal trauma, balloon tamponade, effective volume replacement and transfusion therapy, and occasionally, selective arterial embolization. This article aims at introducing pregnancy- and haemorrhage-induced changes in coagulation and fibrinolysis and their relevant compensatory mechanisms, volume replacement therapy, optimal transfusion of blood products, and coagulation factor concentrates, and briefly cell salvage, management of uterine atony, surgical interventions, and selective arterial embolization. Special attention, respective management, and follow-up are required in women with bleeding disorders, such as von Willebrand disease, carriers of haemophilia A or B, and rare coagulation factor deficiencies. We also provide a proposal for practical instructions in the treatment of PPH.
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Affiliation(s)
- J Ahonen
- Departments of Anaesthesia and Intensive Care, Helsinki University Hospital, Finland.
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11
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Efficacité et tolérance du facteur VIIa recombinant dans l’hémorragie grave du post-partum : à propos d’un cas et revue de la littérature. ACTA ACUST UNITED AC 2010; 29:728-31. [DOI: 10.1016/j.annfar.2010.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Accepted: 05/04/2010] [Indexed: 11/21/2022]
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Hemorragia post-parto: embolización terapéutica. REVISTA MÉDICA CLÍNICA LAS CONDES 2010. [DOI: 10.1016/s0716-8640(10)70563-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Barillari G, Frigo MG, Casarotto M, Farnia A, Massè B, Wetzl R, Bianchin A, Rabi A, Malacarne P, Pasca S, Bigotto E. Use of recombinant activated factor VII in severe post-partum haemorrhage: data from the Italian Registry: a multicentric observational retrospective study. Thromb Res 2009; 124:e41-7. [PMID: 19783283 DOI: 10.1016/j.thromres.2009.08.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2008] [Revised: 08/10/2009] [Accepted: 08/18/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To report the Italian real experience in clinical practice about recombinant factor VII activated (rFVIIa) in Post-Partum Haemorrhage (PPH) treatment. METHODS An Italian retrospective survey of severe primary PPH cases treated with rFVIIa was performed. Anamnestic, clinical and haemostatic data about thirty-five patients with PPH, from 2005 to 2007, were collected. Coagulative parameters and transfusion requirements before and after rFVIIa treatment were compared. RESULTS After rFVIIa administration INR was significantly decreased, while fibrinogen levels were markedly increased. Median of packed red blood cells units, platelets units, fresh frozen plasma, crystalloids and colloids needed, before and after rFVIIa administration, were respectively 6 and 2 units (p<1.2exp-6), 1.5 and 0 units (p=0.001), 1250 and 0 mL (p<4.4exp-5), 3000 and 1250 mL (p<0,0042). Twenty-nine of 35 patients needed surgical intervention before rFVIIa administration, 9/35 after treatment. Hysterectomies have been performed respectively in 10/35 cases before and in 6/35 cases after rFVIIa infusion. No maternal deaths have been reported. No adverse events or thromboembolic complications were observed. CONCLUSIONS Our clinical and haemostatic data suggest that recombinant activated factor VII may be a safe and helpful adjunctive therapy in the PPH management.
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Affiliation(s)
- Giovanni Barillari
- Center for Hemorrhagic and Thrombotic Diseases, Department of Transfusion Medicine, General University Hospital of Udine, Italy.
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Disseminated intravascular coagulation in obstetric disorders and its acute haematological management. Blood Rev 2009; 23:167-76. [PMID: 19442424 DOI: 10.1016/j.blre.2009.04.002] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
As activation of the coagulation pathway is a physiological response to injury, the development of disseminated intravascular coagulation (DIC) is a warning signal to the clinician that the primary pathological disease state is decompensating. In pregnancy, DIC can occur in several settings, which include emergencies such as placental abruption and amniotic fluid embolism as well as complications such as pre-eclampsia. Whilst the acuteness of the event and the proportionality in the coagulant and fibrinolytic responses may vary between these different conditions, a common theme for pregnancy-associated DIC is the pivotal role played by the placenta. Removal of the placenta is the linchpin to treatment in most cases but appropriate blood product support is also key to management. This is necessary because DIC itself can have pathological consequences that translate clinically into a worse prognosis for affected patients. This article will describe how pregnancy-associated DIC can be diagnosed promptly and how treatment should be managed strategically. It also discusses the latest developments in our understanding of haemostatic mechanisms within the placenta and how these may have relevance to new diagnostic approaches as well as novel therapeutic modalities.
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Lewis NR, Brunker P, Lemire SJ, Kaufman RM. Failure of recombinant factor VIIa to correct the coagulopathy in a case of severe postpartum hemorrhage. Transfusion 2009; 49:689-95. [PMID: 19347977 DOI: 10.1111/j.1537-2995.2008.02029.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Nicole R Lewis
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Abstract
Postpartum hemorrhage (PPH) is an obstetric emergency that can occur following vaginal or cesarean delivery. Rapid diagnosis of PPH using laboratory and clinical parameters is an important first step in its management. Traditional blood components, including packed red blood cells, platelets, plasma, and cryoprecipitate, should be used in patients with significant bleeding. Recent studies underline the utility of transfusing these components in defined ratios to prevent dilutional coagulopathy. Disseminated intravascular coagulation (DIC) should be considered in severely bleeding obstetric patients and should be treated aggressively using blood components. Newer hemostatic agents, such as activated factor VII, will play significant roles in patients with bleeding that is refractory to standard therapy. Implementation of an obstetric bleeding protocol that integrates new knowledge in coagulation should aid physicians in improving outcomes for the mother and her fetus.
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Affiliation(s)
- Anand Padmanabhan
- The Section of Transfusion Medicine and Cell Therapy, Department of Pathology and Cell Biology, Columbia University Medical Center, College of Physicians and Surgeons of Columbia University, New York, NY, USA
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Nohira T, Osakabe Y, Suda S, Takahashi C, Tanaka A, Ikeda K, Ikeda T, Okabe K. Successful management by recombinant activated factor VII in a case of disseminated intravascular coagulopathy caused by obstetric hemorrhage. J Obstet Gynaecol Res 2009; 34:623-30. [PMID: 18840167 DOI: 10.1111/j.1447-0756.2008.00896.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Postpartum hemorrhage (PPH) is a life-threatening emergency in obstetrics. Although recombinant activated factor VII (rFVIIa) has become used for the treatment of some cases of massive hemorrhage, its applications in the field of obstetrics are still limited. We describe a case of successful treatment with rFVIIa for PPH due to placenta accreta. The patient was a 33-year-old woman with placental previa. Cesarean section (CS) was performed at gestational week 35. During CS, there was massive hemorrhage due to placenta accreta. After CS, disseminated intravascular coagulopathy and hypovolemic shock were diagnosed. The PPH was not controlled by transfusion therapy. On the fourth day after CS, rFVIIa (90 microg/kg x 2) was given because of the persistent PPH. Bleeding decreased and no further transfusion was required from 2 days after administration. rFVIIa was useful in the treatment of this case of obstetric hemorrhage.
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Affiliation(s)
- Tomoyoshi Nohira
- Department of Obstetrics and Gynecology, Hachioji Medical Center of Tokyo Medical University, Tokyo, Japan.
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Price LC, Slack A, Nelson-Piercy C. Aims of obstetric critical care management. Best Pract Res Clin Obstet Gynaecol 2008; 22:775-99. [PMID: 18693071 DOI: 10.1016/j.bpobgyn.2008.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aims of critical care management are broad. Critical illness in pregnancy is especially pertinent as the patient is usually young and previously fit, and management decisions must also consider the fetus. Assessment must consider the normal physiological changes of pregnancy, which may complicate diagnosis of disease and scoring levels of severity. Pregnant women may present with any medical or surgical problem, as well as specific pathologies unique to pregnancy that may be life threatening, including pre-eclampsia and hypertension, thromboembolic disease and massive obstetric haemorrhage. There are also increasing numbers of pregnancies in those with high-risk medical conditions such as cardiac disease. As numbers are small and clinical trials in pregnancy are not practical, management in most cases relies on general intensive care principles extrapolated from the non-pregnant population. This chapter will outline the aims of management in an organ-system-based approach, focusing on important general principles of critical care management with considerations for the pregnant and puerperal patient.
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Moore M, Morales J, Sabharwal T, Oteng-Ntim E, O’Sullivan G. Selective arterial embolisation: a first line measure for obstetric haemorrhage? Int J Obstet Anesth 2008; 17:70-3. [DOI: 10.1016/j.ijoa.2007.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2005] [Accepted: 01/16/2007] [Indexed: 10/22/2022]
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Van de Velde M. Recombinant factor VIIa should be used in massive obstetric haemorrhage. Int J Obstet Anesth 2007; 16:357-9. [PMID: 17702565 DOI: 10.1016/j.ijoa.2007.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Indexed: 11/18/2022]
Affiliation(s)
- M Van de Velde
- Department of Anaesthesiology, Katholieke Universiteit Leuven and University Hospitals Gasthuisberg, Leuven, Belgium
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21
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Plaat F. Recombinant factor VIIa should be used in massive obstetric haemorrhage. Int J Obstet Anesth 2007; 16:354-7. [PMID: 17698342 DOI: 10.1016/j.ijoa.2007.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Indexed: 11/17/2022]
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Burtelow M, Riley E, Druzin M, Fontaine M, Viele M, Goodnough LT. How we treat: management of life-threatening primary postpartum hemorrhage with a standardized massive transfusion protocol. Transfusion 2007; 47:1564-72. [PMID: 17725718 DOI: 10.1111/j.1537-2995.2007.01404.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Management of massive, life-threatening primary postpartum hemorrhage in the labor and delivery service is a challenge for the clinical team and hospital transfusion service. Because severe postpartum obstetrical hemorrhage is uncommon, its occurrence can result in emergent but variable and nonstandard requests for blood products. The implementation of a standardized massive transfusion protocol for the labor and delivery department at our institution after a maternal death caused by amniotic fluid embolism is described. This guideline was modeled on a existing protocol used by the trauma service mandating emergency release of 6 units of group O D- red cells (RBCs), 4 units of fresh frozen or liquid plasma, and 1 apheresis unit of platelets (PLTs). The 6:4:1 fixed ratio of uncrossmatched RBCs, plasma, and PLTs allows the transfusion service to quickly provide blood products during the acute phase of resuscitation and allows the clinical team to anticipate and prevent dilutional coagulopathy. The successful management of three cases of massive primary postpartum hemorrhage after the implementation of our new massive transfusion protocol in the maternal and fetal medicine service is described.
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Affiliation(s)
- Matthew Burtelow
- Department of Pathology, Stanford University Medical Center, Stanford, California, USA
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23
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Ahonen J, Jokela R, Korttila K. An open non-randomized study of recombinant activated factor VII in major postpartum haemorrhage. Acta Anaesthesiol Scand 2007; 51:929-36. [PMID: 17488316 DOI: 10.1111/j.1399-6576.2007.01323.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Empirical off-label use of recombinant activated factor VII (rFVIIa) has been reported to be effective in some cases of severe postpartum haemorrhage (PPH). Successful management of these patients has lead to more wide-spread use of rFVIIa in less severe cases without any evidence for the advantages of its administration. METHODS Until November 2006, we had administered rFVIIa to 38 parturients. Based on our initial experience with the first 12 patients, we prepared guidelines for the use of rFVIIa. During the existence of these guidelines, we made a retrospective comparison of the 26 women who received rFVIIa with another 22 women who were treated during the same time period without using rFVIIa. RESULTS The total amount of blood loss was significantly higher (11.3 +/- 4.5 vs. 8.0 +/- 3.1 l), and the coagulation screen revealed significantly longer partial thromboplastin time (APTT) and prothrombin time (PT) values and significantly lower fibrinogen values in patients receiving rFVIIa. The need for red blood cells, platelets and fibrinogen concentrate was significantly higher in these women. Although the response was considered good in two-thirds of the women, several patients received rFVIIa with a poor or no response as a result of arterial bleeding. CONCLUSION The decision to use rFVIIa resulted from a more profound haemorrhage. We did not gain any evidence to extend the use of rFVIIa into less severe cases of PPH. Furthermore, this policy would result in a profound increase in the overall costs of the treatment. Randomized placebo-controlled trials are urgently needed to optimize the use of rFVIIa in obstetric haemorrhage.
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Affiliation(s)
- J Ahonen
- Department of Anaesthesia and Intensive Care, Helsinki University Hospital, Helsinki, Finland.
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van Veen EJW, Monteban-Kooistra WE, Meertens JHJM, Ligtenberg JJM, Tulleken JE, Zijlstra JG. Recombinant human activated factor VII in postpartum hemorrhagic shock: the dark side. Intensive Care Med 2007; 34:211-2. [PMID: 17668176 PMCID: PMC3227034 DOI: 10.1007/s00134-007-0810-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2007] [Indexed: 11/29/2022]
Affiliation(s)
- E. J. W. van Veen
- Intensive and Respiratory Care, University Medical Centre Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, Netherlands
| | - W. E. Monteban-Kooistra
- Intensive and Respiratory Care, University Medical Centre Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, Netherlands
| | - J. H. J. M. Meertens
- Intensive and Respiratory Care, University Medical Centre Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, Netherlands
| | - J. J. M. Ligtenberg
- Intensive and Respiratory Care, University Medical Centre Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, Netherlands
| | - J. E. Tulleken
- Intensive and Respiratory Care, University Medical Centre Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, Netherlands
| | - J. G. Zijlstra
- Intensive and Respiratory Care, University Medical Centre Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, Netherlands
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Duffy MR. Guidelines for use of recombinant factor VIIa in life-threatening post-partum haemorrhage. Int J Obstet Anesth 2007; 16:299-300; author reply 300. [PMID: 17509865 DOI: 10.1016/j.ijoa.2007.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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