Coagulation management and transfusion in massive postpartum hemorrhage

Abstract

Purpose of ReviewExcessive bleeding during and following childbirth remains one of the leading causes of maternal mortality.Recent findingsCurrent guidelines differ in definitions and recommendations on managing transfusion and hemostasis in massive postpartum hemorrhage (PPH). Insights gained from trauma-induced coagulopathy are not directly transferable to the obstetric population due to gestational alterations and a differing pathophysiology.SummaryFactor deficiency is uncommon at the beginning of most etiologies of PPH but will eventually develop from consumption and depletion in the absence of bleeding control. The sensitivity of point-of-care tests for fibrinolysis is too low and may delay treatment, therefore tranexamic acid should be started early at diagnosis even without signs for hyperfibrinolysis. Transfusion management may be initiated empirically, but is best to be guided by laboratory and viscoelastic assay results as soon as possible. Hypofibrinogenemia is well detected by point-of-care tests, thus substitution may be tailored to individual needs, while reliable thresholds for fresh frozen plasma (FFP) and specific components are yet to be defined. In case of factor deficiency, prothrombin complex concentrate or lyophilized plasma allow for a more rapid restoration of coagulation than FFP. If bleeding and hemostasis are under control, a timely anticoagulation may be necessary.

Impact of Melatonin as a Premedication Agent in Caesarean Section on Blood Loss and Postoperative Pain Level

“…Furthermore, it has been found to possess significant anti-inflammatory properties [ 11 ] and has been utilized as a means to reduce blood loss during surgical procedures, particularly during cesarean delivery [ 3 ]. “Postpartum hemorrhage” (PPH) refers to excessive bleeding following childbirth, typically defined as blood loss of 1000 mL or more after a cesarean delivery [ 12 ]. It is a serious complication that can lead to maternal morbidity and mortality if not promptly and effectively managed.…”

Postpartum maternal tachycardia – diagnostic pitfalls!

“…Whilst there is no set threshold for initiating a transfusion, many hospitals will have a localised protocol to guide management. In a massive obstetric haemorrhage, a fixed ratio protocol of 1:1 packed red cells to fresh frozen plasma is recommended as empirical treatment to replace volume [9 ▪▪ ,10 ▪ ]. Further blood products are titrated to laboratory results, aiming to keep platelets >75 × 10 9 /l and fibrinogen >2 g/l with cryoprecipitate [10 ▪ ].…”

“…In a massive obstetric haemorrhage, a fixed ratio protocol of 1:1 packed red cells to fresh frozen plasma is recommended as empirical treatment to replace volume [9 ▪▪ ,10 ▪ ]. Further blood products are titrated to laboratory results, aiming to keep platelets >75 × 10 9 /l and fibrinogen >2 g/l with cryoprecipitate [10 ▪ ]. Viscoelastic haemostatic assays such as rotational thromboelastometry (ROTEM) or thromboelastography (TEG) can provide real-time graphical depiction of coagulation, to guide transfusion efforts.…”