Our experince with the use of recombinant activated factor VII in postpartum haemorrhage

Abstract

INTRODUCTION. Massive obstetric bleeding is the most common cause of maternal mortality and morbidity. The first step in treatment of these patients is establishing the adequate circulatory volume. The primary goal of therapy is to identify and remove the cause of bleeding, with appropriate symptomatic and substitution therapy. Human recombinant activated factor VII (rFVIIa) is officially registered for the treatment of patients suffering from haemophilia with inhibitors. Its use has also proved successful in other congenital and acquired coagulopathies and in patients with acute non-haemophilic bleeding. A special significance is given to the application of rFVIIa in cases of obstetric haemorrhage, in order to avoid postpartum hysterectomy and occurrence of complications of haemorrhagic shock in obstetrics. OBJECTIVE. The aim of this study is to show our experience and results of the use of rFVIIa in the treatment of patients with massive postpartum bleeding. METHOD. The retrospective study encompassed six patients with primary postpartum haemorrhage treated with rFVIIa at our institution in the period from 2005 to 2007. RESULTS. The treated patients were divided into two groups. In the first group, there were three patients who underwent hysterectomy and who received rFVIIa over 24 hours after delivery. The second group consisted of three patients who received rFVIIa in the first 24 hours after delivery, before we decided to perform hysterectomy. The application of rFVIIa led to successful cessation of bleeding in all patients. Relevant side effects were not registered. CONCLUSION. The administration of rFVIIa in obstetrics should be considered for each patient before decision to apply hysterectomy, and it should certainly be applied in patients who want to preserve the uterus and fertile capability. According to our experience, in cases of postpartum hemorrhagia rFVIIa is to be administered in intravenous bolus doses of at least 90 mcg/kg, at least 6 hours after the onset of bleeding. rFVIIa is not an alternative to adequate surgical haemostasis; therefore, it needs to be administered after its detailed revision.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

“…rFVIIa can be considered as second-line haemostatic therapy alongside intra-uterine tamponade, uterine compression sutures, pelvic vessel ligation and interventional radiology 925,926 . Case reports 927–931 and retrospective studies 926,932–936 support off-label use of rFVIIa for severe obstetric coagulopathic bleeding. Additional observational studies report increased risk of thrombosis 937,938 …”

History of caesarean hysterectomy

“…In recent decades, because of the substantial morbidity of the operation, caesarean hysterectomy has fallen from favor as an elective method of sterilisation 6 . Advances in blood transfusion and the use of blood products and medications to correct the coagulopathy, as well as advances in the conservative treatment for uterine atony, have greatly reduced the need for postpartum hysterectomy 7,8 . Although elective caesarean hysterectomy is still a controversial issue, there is no doubt that emergency hysterectomy in the event of intractable obstetric haemorrhage is life-saving.…”

“…Although elective caesarean hysterectomy is still a controversial issue, there is no doubt that emergency hysterectomy in the event of intractable obstetric haemorrhage is life-saving. At present, this procedure is generally restricted to the management of uncontrolled haemorrhage and infection, the rare cases of severe uterine trauma, or uterine and cervical pathology 3,6,7 . In recent years, the availability of potent uterotonics and broad-spectrum antibiotics, the development of embolisation techniques, and new methods of vessel ligation, have markedly reduced the need for cae-sarean hysterectomy, which, however, remains an important procedure in modern obstetric practice 6,8,9 .…”