Advances in the Treatment of Postpartum Hemorrhage

Alison M El Ayadi; Nuriya Robinson; Stacie Geller; Suellen Miller

Disclosures

Expert Rev of Obstet Gynecol. 2013;8(6):525-537. 

In This Article

Transfusion Protocols for PPH

The WHO recommends that health facilities have a formal protocol in place for PPH management.[6] Recent resuscitation algorithms of PPH are modeled after trauma, and massive transfusion protocols demonstrate improved patient outcomes.[76] Such protocols focus on the creation of a multidisciplinary team for patient care, initiation of appropriate laboratory studies, restoration of fluid volume, correction of a coagulopathy with blood components and factors, appropriate responses to laboratory and hemodynamic assessments and correction of the primary cause of bleeding. Conventional resuscitation follows a stepwise approach starting with intravenous fluids, followed by red blood cells (RBCs) and clotting factors or platelets.[77] While this approach corrects hypovolemia, it worsens existing dilutional coagulopathy, enhances fibrinolysis and contributes to acidemia and hypothermia.[78,79] Recent advances from trauma medicine suggest that increasing the ratio of fresh frozen plasma (FFP) to RBCs from 1:3 and 1:4 to 1:1 or 1:2 improves survival.[80]

The fibrinogen decrease seen in severe PPH is of great concern and considered an early predictor of hemorrhage severity.[49,81] Treatment of hypofibrinogenemia involves cryoprecipitate transfusion to maintain fibrinogen levels (100–200 mg/dl).[49,81] While not approved for PPH treatment, fibrinogen concentrate is available in the US, Canada and Europe for other indications and may be an advantageous alternative. Fibrinogen concentrate is stable at room temperature and can be rapidly administered, unlike cryoprecipitate, which must be kept frozen and then thawed prior to administration. Fibrinogen concentrate also contains a greater concentration of fibrinogen and more reliably increases fibrinogen levels.[49] Widespread belief in benefits of early fibrinogen substitution for PPH spurred this off-label usage; the first RCT (FIB-PPH) is currently in progress.[82]

Rapid blood product selection may benefit from the use of a thromboelastograph, a point-of-care device that examines clot formation and dissolution in whole blood, and provides faster results than laboratory testing.[49,83] An observational study of thromboelastograph measurements found that clot amplitude and maximum clot firmness were strongly correlated with fibrinogen levels.[84] Availability of the thromboelastograph in the labor ward could be an important tool for managing PPH.

In obstetrical practice, as in other surgical specialties, patients may refuse transfusion of blood products. Worldwide, members of the Jehovah's Witness faith most commonly decline blood transfusions, even for life-saving purposes, posing unique challenges.[85] Advanced planning regarding alternative management options is critical for Jehovah's Witnesses and for patients with rare antibodies. This is especially true where cesarean section is anticipated.[72] Autologous blood donations can be alternatives to donated blood products, and provide a practical alternative for patients who prefer to avoid allogenic blood transfusions. Pre-operative donation has been successful for managing patients with placenta accreta or previa and appears to be well tolerated by women in the third trimester of pregnancy; however, it requires an operating blood bank for storage, and depends upon accurate prediction of an individual patient's risk of hemorrhage.[86,87] Intra-operative blood collection is accomplished via cell salvage systems; however, there are theoretical risks of contamination with amniotic fluid or fetal cells that can result in amniotic fluid embolism or isoimmunization (in an Rh negative patient), respectively.[88] While data to support these concerns is sparse, precautions such as washing and/or filtration of blood prior to re-administration can be implemented and Rh negative patients should receive Rhogam (Rho (D) immune globulin) following auto transfusion.[88] ACOG and NICE support intra-operative cell saver technology as a safe and feasible option during cesarean sections.[72,89]

rFVIIa is an effective, yet expensive, synthetic agent initially FDA-approved to control bleeding among patients with hemophilia and factor VII deficiency and is now used for trauma, surgical and severe PPH patients.[50,72] The effectiveness of rFVIIa is dependent upon adequate fibrinogen and platelets. Thus, where clinical response to rFVIIa is sub-optimal, evaluation and treatment with cryoprecipitate, fibrinogen concentrate or platelet transfusion should be initiated.[90] rFVIIa assists hemostasis in PPH patients with bleeding refractory to pharmacologic management and uterus sparing surgical techniques (e.g., uterine and hypogastric artery ligation).[90] rFVIIa use in the obstetrical population is controversial due to concern around increased thromboembolic events.[91] Multiple case reports synthesized in a review by Franchini et al. support the use of rFVIIa for severe bleeding following conventional treatment failure.[92] In these cases, rFVIIa was most often administered as a means to avert an emergency hysterectomy or prevent additional interventions where hysterectomy was already performed. No thromboembolic events were reported in the review. Recommended administration of rFVIIa is 90 μg/kg rFVIIa as IV bolus over 3–5 min, per RCOG and Franchini et al..[92,93] While RCTs are lacking, significant blood loss reductions have been noted in the available literature, suggesting that rFVIIa may have a place in severe PPH management.[94]

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