Haemostatic support in postpartum haemorrhage

Abstract

Postpartum haemorrhage (PPH) remains the leading cause of pregnancy-related deaths worldwide. Typically, bleeding is controlled by timely obstetric measures in parallel with resuscitation and treatment of coagulopathy. Early recognition of abnormal coagulation is crucial and haemostatic support should be considered simultaneously with other strategies as coagulopathies contribute to the progression to massive haemorrhage. However, there is lack of agreement on important topics in the current guidelines for management of PPH. A clinical definition of PPH is paramount to understand the situation to which the treatment recommendations relate; however, reaching a consensus has previously proven difficult. Traditional definitions are based on volume of blood loss, which is difficult to monitor, can be misleading and leads to treatment delay. A multidisciplinary approach to define PPH considering vital signs, clinical symptoms, coagulation and haemodynamic changes is needed. Moreover, standardised algorithms or massive haemorrhage protocols should be developed to reduce the risk of morbidity and mortality and improve overall clinical outcomes in PPH. If available, point-of-care testing should be used to guide goal-directed haemostatic treatment. Tranexamic acid should be administered as soon as abnormal bleeding is recognised. Fibrinogen concentrate rather than fresh frozen plasma should be administered to restore haemostasis where there is elevated risk of fibrinogen deficiency (e.g., in catastrophic bleeding or in cases of abruption or amniotic fluid embolism) as it is a more concentrated source of fibrinogen. Lastly, organisational considerations are equally as important as clinical interventions in the management of PPH and have the potential to improve patient outcomes.

A case of sudden multiple hematomas during cesarean section due to amniotic fluid embolism

“…Previous reports have characterized low fibrinogen levels as a cause of significant postpartum hemorrhage [ 7 ]. Moreover, fibrinogen concentrate has been reported to be more useful than FFP when fibrinogen levels are deficient [ 8 ]. Ideally, although we should have used fibrinogen concentrate in this case as well, we could not because it was not available at our hospital.…”

Haemostatic Support in Postpartum Haemorrhage: A Review of the Literature and Expert Opinion

“…1 They succinctly state the importance of the point-of-care assessment with VETs, TEG, and ROTEM, and the importance of fibrinogen. 1 The importance of the organizational aspects of PPH management, including the implementation of protocols, checklists, and simulation training is also emphasized, which I strongly concur as an obstetric anesthesiologist.…”

“…For obstetric hemorrhage this is often difficult because: (1) it is hard to determine the exact amount of blood loss, (2) the bleeding rate is rapid, and (3) disseminated intravascular coagulation can easily occur in the postpartum period. In this paper, Hoffer and colleagues present the causes, pathology, and definition of PPH, what is important about it, and what have been attempted to address the problem 1 . They succinctly state the importance of the point-of-care assessment with VETs, TEG, and ROTEM, and the importance of fibrinogen 1 .…”

“…In this paper, Hoffer and colleagues present the causes, pathology, and definition of PPH, what is important about it, and what have been attempted to address the problem 1 . They succinctly state the importance of the point-of-care assessment with VETs, TEG, and ROTEM, and the importance of fibrinogen 1 . The importance of the organizational aspects of PPH management, including the implementation of protocols, checklists, and simulation training is also emphasized, which I strongly concur as an obstetric anesthesiologist.…”

Hemostasis restoring in postpartum hemorrhage — algorithm 2023

“…Simultaneously, the team of anesthesiologists strives/struggles to maintain normal body temperature (normothermia) and to prevent acidosis [61]. It is of crucial importance to inhibit fibrinolysis by prompt intravenous administration of tranexamic acid (TXA) at a dose of 20 mg/kg body weight, usually 1 g [62][63][64]. The next step is fibrinogen substitution with fibrinogen concentrate at a dose of 2-4 g or with cryoprecipitate (2 U/10 kg b.w.)…”