Gynecology / Obstetrics

Abstract

Summary In this UK review, Catling states that “the case for avoiding allogeneic transfusion wherever possible has never been stronger.” As reasons the author sights shrinking blood supplies, increasing cost and ongoing safety concerns. Figures are presented showing that the price of red blood cells to hospitals in the UK has increased approximately 250% since 1998. A survey is referred to suggesting that many current donors would withdraw from donating blood if mandatory testing for vCJD was introduced, resulting in an estimated 50% reduction in the donor pool.

Summary To provide a basis for future study design Alfirevic and colleagues collected data from hospitals in 9 European countries on the use of recombinant activated factor VII (rFVIIa) between 2000 and 2004 in primary postpartum hemorrhage. By means of a registry questionnaire, data on rFVIIa use as “treatment” (defined as being administered after other standard treatment had failed) or “secondary prophylaxis” (defined as administered to support other interventions that were considered successful) after primary obstetric hemorrhage was collected and analyzed.

Summary Massive postpartum hemorrhage (mPPH) continues to be a considerable cause of morbidity and mortality and although new treatments are available, the estimated mortality rate is estimated as high as 34%. Recombinant factor VIIa (rFVIIa) has been proposed as a possible treatment for mPPH. McMorrow and colleagues describe their experience using this agent in a retrospective, case-matched study over a 3-y period. From 28 cases with mPPH (>5 units red cell concentrate in 24 h), 6 women had prolonged prothrombin times (PTs) and had been treated with rFVIIa.

Summary Hemorrhage is the second most common cause of direct maternal death. Conserving and using autologous blood is an option to avoid the risks associated with allogeneic blood transfusions. Because preoperative autologous donation does not provide enough blood for obstetric hemorrhages and because the need is rarely known before delivery, this procedure is currently not recommended in obstetric patients. Intraoperative cell salvage (IOCS) may be more effective in this patient population.

Summary Major primary postpartum hemorrhage (PPH) is among the top five causes of maternal morbidity and mortality worldwide. First-line treatment includes resuscitation and cessation of bleeding using uterotonics and treating the possible cause such as removing the placenta and suturing any tears. Further management includes uterine tamponade, brace sutures, artery ligation, embolization, or hysterectomy. Mousa and colleagues assessed risk factors and treatment of primary PPH in women who failed to respond to the traditional first-line therapies.

One possible treatment for postpartum hemorrhage (PPH) is the use of uterine balloon tamponade, a Sengstaken-Blakemore (o)esophageal catheter (SBOC), to determine which women will require surgery for the intractable bleeding. Reported success rates range from 60% to 100%, but the published retrospective studies are subject to inadequate reporting and selection and positive-outcome biases.

Summary Although the treatment of severe bleeding in childbirth is usually effective, in some cases obstetric hemorrhage carries devastating morbidity and mortality. With the availability of new hemostatic agents, another option for treatment now exists. Dhulkotia and colleagues report on a 26-y-old nulliparous patient with traumatic postpartum hemorrhage (PPH) who was successfully treated with a fibrin sealant. After an unremarkable pregnancy, she required a rotational forceps delivery because of the failure of the second stage of labor to progress. An episiotomy was also necessary.

Summary Placenta accreta is associated with considerable maternal morbidity and as the rates of cesarean delivery have increased so also have rates for associated placenta accreta. In this retrospective cohort study, Eller and colleagues determined which interventions for managing placenta accreta led to reduced maternal morbidity. All identified cases of placenta accreta reported from 1996 to 2008 were included. A scheduled delivery was one planned at least 1 d in advance and performed non-urgently.

Summary In this review article, Winograd discusses the risk factors, treatments, and emergency interventions for postpartum hemorrhage (PPH). Worldwide, PPH has a case-fatality rate of 1% among the 14 million cases that occur annually. Severe bleeding is the single most significant cause of maternal death and >50% of all deaths occur within 24 h of delivery; morbidity after PPH is also a major consideration. Primary PPH occurs within the first 24 h after delivery and secondary PPH between 24 h and 6-12 wk postpartum. However, no single, satisfactory definition of PPH has been developed.