Postpartum hemorrhage: Solutions to 2 intractable cases
A stepwise approach to bleeding caused by persistent uterine atony and placental abnormalities
IN THIS ARTICLE
Blood studies are also indicated
Send blood to the laboratory for measurement of prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen. If the hospital is not equipped to measure fibrinogen, perform a rapidclot observation test13 by filling a plain, red-top tube with blood and observing it for clotting. If a clot forms in 8 to 10 minutes and remains intact, the test is normal. When the fibrinogen level is less than 150 mg/dL, the blood will not clot or the clot will dissolve in 30 to 60 minutes.
This rapid test can guide the decision to infuse fresh frozen plasma. Each unit of fresh frozen plasma raises the fibrinogen level by 10 mg/dL. The goal is to keep the fibrinogen level above 100 mg/dL.
Platelet count often declines during hemorrhage
When blood loss is ongoing, try to keep the platelet count above 50×103/μL. Each unit of platelets will increase the platelet count by 5–10×103/μL. However, platelets are rapidly destroyed after transfusion, so continue to assess hemoglobin level, hematocrit, platelet count, and coagulation parameters. Also, check calcium and electrolyte levels, and correct levels after the transfusion of every 4 U of blood.
Cell-saver technology is an option for management of postpartum hemorrhage, once the surgical field has been cleared of amniotic fluid.14
Volume replacement can be accomplished with concurrent administration of crystalloid or other volume expanders, such as hetastarch (Hespan) or albumin. Monitor urine output to gauge the adequacy of volume replenishment.
Consider contacting a referral center about patient transfer or additional blood products if bleeding is ongoing or coagulation defects persist.
The authors report no financial relationships relevant to this article.
