Effect of cryoprecipitate transfusion therapy in patients with postpartum hemorrhage: a retrospective cohort study

Abstract

To evaluate the effect of cryoprecipitate (CRYO) transfusion in women referred for postpartum hemorrhage (PPH). This retrospective cohort study included patients with primary PPH referred to Gifu University Hospital between April 2013 and March 2020. We analyzed the effect of CRYO transfusion on fluid balance 24 h after the initial examination using a multivariable linear regression model adjusted for several confounding variables. To evaluate whether outcomes were modified by active bleeding, an interaction term of CRYO*active bleeding was incorporated into the multivariable model. We identified 157 women: 38 in the CRYO group (cases) and 119 in the control group. Fluid balance in the aforementioned period tended to decrease in the CRYO group compared with that in the control group (coefficient − 398.91; 95% CI − 1298.08 to + 500.26; p = 0.382). Active bleeding on contrast-enhanced computed tomography affected the relationship between CRYO transfusion and fluid balance (p = 0.016). Other outcomes, except for the overall transfusion requirement, were not significantly different; however, the interaction effect of active bleeding was significant (p = 0.016). CRYO transfusion may decrease the fluid balance in the first 24 h in PPH patients, especially in those without active bleeding.

Haemostatic support in postpartum haemorrhage

“…65 However, less fluids were administered in the cryoprecipitate group. 65 Overall, further studies are needed to assess not only the clinical efficacy but also the optimal dosing of early fibrinogen replacement therapy in PPH. 61 Other factor concentrates such as prothrombin complex concentrate (PCC, concentrate of human-derived vitamin K-dependent clotting factors II, VII, IX, X) or recombinant activated FVII (rFVIIa) concentrate have been occasionally used off-label in PPH treatment.…”

“… 65 However, less fluids were administered in the cryoprecipitate group. 65 Overall, further studies are needed to assess not only the clinical efficacy but also the optimal dosing of early fibrinogen replacement therapy in PPH. 61 …”

“…Preliminary clinical outcomes showed that cryoprecipitate administration at any time-point was accompanied by reductions in red blood cell (RBC) transfusions, surgery, and intensive care unit admission 64 . Another recent retrospective study suggested higher transfusion requirements in the cryoprecipitate treated group vs. control group 65 . However, less fluids were administered in the cryoprecipitate group 65 .…”

“…Another recent retrospective study suggested higher transfusion requirements in the cryoprecipitate treated group vs. control group 65 . However, less fluids were administered in the cryoprecipitate group 65 . Overall, further studies are needed to assess not only the clinical efficacy but also the optimal dosing of early fibrinogen replacement therapy in PPH 61 …”

高度救命救急センターに緊急転院搬送された10年間の産後出血症例の検討(Clinical characteristics of patients who were transferred to our tertiary care center for an emergency due to severe postpartum hemorrhage: a retrospective observational study)

“…また物理的圧迫やTAEなどに併用して行う早期輸血療法も非常に重要な治療戦略の一つであるが，主要凝固因子であるFib値を上昇させることで微小血管からの出血を止めることが主な目的となる。本邦では未だに約半数が有床診療所での分娩と，その比率が高く，輸血療法の開始が遅れることが指摘されている 22)。当院では超急性期に血漿Fib値が2g/L以上になるよう輸血療法を行うというガイドラインに従い，積極的に早期輸血療法を施行している 23)。なお，当院ではmassive transfusion protocol（MTP）を策定しておらず，投与タイミングや量は各救急医に委ねている。Fib投与法にはFFPおよびフィブリノゲン製剤，CRYOの3種類が存在し，CRYOはFFPを解凍して遠心分離した後に生じる濃縮沈殿物である。CRYOにはFibの他に，第VIII因子や第XIII因子，von Willebrand因子，フィブロネクチンなどの凝固タンパク質が含まれており，当院では2013年から投与開始している。自験例ではあるが，初療開始から24時間後の体液バランスが，有意差は認めなかったもののCRYOを投与された患者のほうが低下する傾向にあることがわかった。またサブ解析において，とくに活動性出血のない患者においては，CRYOを投与することで初療開始から24時間後の体液バランスを有意に減少させることが示唆された 24)。近年，輸液過多を防ぐことでうっ血性心不全や急性腎障害，人工呼吸管理期間の延長，死亡率の上昇などのリスクを減らせるとの報告が散見される 25), 26), 27)。それらも踏まえるとCRYO投与がとくにTAEの適応としない活動性出血のない症例で臨床的に有意義であると考えられ，今回の転帰にも影響を与えたことが示唆された。…”