How is coagulopathy diagnosed in postpartum hemorrhage (PPH)?

Updated: Jun 27, 2018
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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Answer

Women experiencing PPH do not usually have a preexisting disorder of hemostasis; however, initial blood work includes a coagulation screen and platelet count. In previously healthy women, dilutional coagulopathy is not usually observed until approximately 80% of the original blood volume has been replaced. Regularly monitor hemostatic test results in all women who require a massive transfusion. If findings are abnormal in conjunction with ongoing bleeding or oozing from puncture sites, mucous surfaces, or wounds, additional blood products are required. Infuse fresh frozen plasma (FFP), beginning with 4 U and following with additional units to normalize the coagulation test findings. Many authorities recommend the addition of 1 U of FFP for every 5 U of PRBCs for patients who require continued transfusion.

Thrombocytopenia is likely after 1.5-2 times the blood volume has been replaced. Keep the platelet count more than 50 X 109/L by using platelet transfusion. Each unit of platelets increases the platelet count by approximately 10 X 109/L. (Platelets are usually given in packs of 5-6 U.) If bleeding is continuing and the platelet count is less than 50 X 109/L, administer 10-12 U initially. If surgical intervention is necessary, maintain the platelet count at more than 80-100 X 109/L. Platelet preparations contain some RBCs, and the administration of anti-D immunoglobulin (RhoGAM, WinRho) is recommended for Rh-negative women after the crisis has passed. [38]

If coagulation test results are abnormal from the onset of PPH, strongly consider an underlying cause (eg, abruptio placenta, HELLP syndrome, fatty liver of pregnancy, intrauterine fetal demise, amniotic fluid embolus, septicemia, preexisting disorder). Take specific steps to treat the underlying cause and the hemostatic abnormality.

DIC may also develop if shock has led to marked hypoperfusion of tissues, causing damage and release of tissue thromboplastins. In such cases, laboratory test results reveal that the D-dimer levels are elevated and fibrinogen levels are very low, with a prolonged thrombin time. The management of DIC is identical to that for a patient with dilutional coagulopathy. Restoration and maintenance of circulating volume along with blood product replacement is essential.

Cryoprecipitate may be useful along with FFP because of the markedly depressed fibrinogen levels. Cryoprecipitate provides a more concentrated form of fibrinogen and other clotting factors (VIII, XIII, von Willebrand factor) and is faster to prepare in the blood bank. It is commonly given in 6- to 12-U doses and may also be helpful immediately before any surgical intervention in patients with abnormal coagulation test results. The use of heparin and antifibrinolytic therapy is not recommended in women with DIC of obstetric origin.

Interest in and experience with recombinant activated factor VIIa (RFVIIa) in massive hemorrhage situations is growing. This experience has extended to severe postpartum hemorrhage and results have been encouraging. [39] RFVIIa has been used when conventional medical management has been unsuccessful and also when varying degrees of surgical management, up to and including hysterectomy have failed. Therapy is very expensive and some suggest that use in less severe cases may be potentially harmful. [40] RFVIIa may also be useful in cases of severe PPH complicated by DIC. [41] Further study is required before recombinant activated factor VII is put into widespread use.

Seek the advice of a hematologist in cases of massive transfusion or coagulopathy.


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