Know Your Options for Peripartum Hemorrhage : A leading cause of maternal mortality, hemorrhage accounts for up to 18% of pregnancy-related deaths.

Based on the literature, the evidence is not sufficient at this time to support routine use of misoprostol for the prevention of PPH. “The drug has such a high safety profile that it may be more useful in a treatment role” said Dr. Mayer. He recommends using 800–1,000 mcg administered rectally.

Many PPH cases have a major component of acquired coagulopathy, making rFVIIa (Novoseven) a treatment option, indicated for hemophilia A or B, with inhibitors of factor VII or factor IX. The drug induces hemostasis independent of factor VII or IX. It complexes with tissue factor to promote the conversion of factor IX to factor IXa, factor X to factor Xa, and prothrombin to thrombin—the key parts of the coagulation cascade. The drug produces clots, making it theoretically contraindicated in patients with disseminated intravascular coagulopathy.

The literature on the use of rFVIIa for PPH has been encouraging so far. In a recent study, 12 patients with severe PPH (estimated blood loss of 5–25 L) were treated with the drug (Br. J. Anaesth. 2005;94:592–5). All had previously undergone surgery, and one-third had arterial ligation. Eleven patients had a positive response.

“They're feeling was to give the drug at 1.5 L blood volume loss—it buys time,” said Dr. Mayer.

However, the drug is very expensive. The cost equivalent of a single 90-mcg/kg dose is 50 units of packed red blood cells, 2 days in the ICU, or an embolization procedure. In patients for whom surgical options have been explored, for whom there are no vascular interventional radiology options, for whom significant blood products are required, and for whom results of the coagulation studies are elevated, “this is a very reasonable drug to give,” Dr. Mayer said.

Intraoperative autologous transfusion should be considered when there is major blood loss and an inadequate amount of packed red blood cells is available. Potential risks associated with obstetric use include amniotic fluid embolism and maternal exposure to fetal red cells. However, in 400 exposures to intraoperative autologous transfusion, there has been only one case of amniotic fluid embolism that was not confirmed pathologically. Heparin toxicity also has been associated with the technique.

At the University of North Carolina at Chapel Hill, the cell saver has been used for 12 obstetric patients. “It's a perfect solution for Jehovah's Witnesses with risk factors, such as a known placenta percreta,” said Dr. Mayer. Blood was autotransfused in only one case though. This patient received 1,200 mL of salvaged blood with no problems.

Selective arterial embolization is highly successful when it can be performed. There are very few complications—fever is the most common. The technique also can be used prophylactically using a balloon. Coagulopathy is not a contraindication, so it's a good option for these patients.