Haemostatic management of obstetric haemorrhage

Abstract

SummaryThe haemostatic management of major obstetric haemorrhage remains challenging, and current published guidance relies heavily on experience from the non-pregnant population and expert opinion. In recent years, an interest in the implications of relative hypofibrinogenaemia, point-of-care monitoring of coagulation abnormalities, and the potential to give goal-directed therapy to correct coagulopathies, have created the possibility of significantly challenging and changing guidance. There is evidence that the haemostatic impairment in the pregnant population is different from trauma-induced bleeding, and the type and rate of onset of coagulopathies differ depending on the underlying cause. This review examines areas such as possible intervention points, describes evidence for overtransfusion of fresh frozen plasma in some situations and challenges conventional thinking on formulaic management. It also examines the rationale for other therapeutic options, including fibrinogen concentrate and tranexamic acid.

Cryoprecipitate transfusion: current perspectives

“…14 Observational data show that hypofibrinogenemia and hyperfibrinolysis are associated with adverse outcomes in traumatic hemorrhage 13 and there is increasing recognition of the critical role of fibrinogen in postpartum hemorrhage 11,15,16 and bleeding in cardiac surgery.…”

Platelet Count and Transfusion Requirements During Moderate or Severe Postpartum Haemorrhage

“…In the UK, postpartum haemorrhage causes 75% of severe obstetric morbidity [3] and is an important cause of direct maternal mortality [4]. Postpartum haemorrhage may be associated with the depletion of coagulation factors and platelets due to dilutional and consumptive coagulopathies [5][6][7]. Studies have described the consequences of reduced coagulation factors and their replacement with fresh frozen plasma (FFP), cryoprecipitate and fibrinogen concentrate [8][9][10][11][12] but there are limited data on the need for platelet transfusion.…”

“…There is a trend to adopt fixed-ratio platelet transfusion in postpartum haemorrhage [12,[17][18][19][20], a practice directly extrapolated from major trauma [21] despite the coagulopathies of trauma and obstetric bleeding being markedly different [5][6][7][22][23][24]. No studies have investigated whether this is an appropriate or safe strategy, and some groups describe good outcomes with low rates of platelet transfusion [25][26][27].…”

Efficacy and safety of blood transfusion in obstetric patients: systematic review of the literature

“…In addition, there is no consensus on patient profiles warranting blood transfusion, and what haemoglobin concentration is most effective and safe to decrease the likelihood of morbidity and mortality. As pregnancy is an aggravating situation to the clinical picture of patients and may trigger additional complications to them, the fetus and the newborn [3], we focus this study on this clinical situation. The purpose of our systematic review is to evaluate the efficacy and safety of www.…”