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postpartum hemorrhage

Etiology: - acquired coagulation factor inhibitors - coagulation factor VIII autoantibody - can appear in late pregnancy or early postpartum - thrombotic thrombocytopenic purpura can appear late in pregnancy or after delivery. - HELLP syndrome typically manifests before delivery, can appear after delivery - immune thrombocytopenic purpura - usually manifests by 3rd trimester - acute fatty liver of pregnancy - can manifest with thrombocytopenia; - almost always develops before delivery, but diagnosis may be delayed because of a failure to recognize Laboratory: - complete blood count (CBC) - peripheral smear - prothrombin time with INR & aPTT - mixing studies if aPTT prolonged - failure to correct with normal plasma 1:1 suggests coagulation factor inhibitor - most likely coagulation factor VIII autoantibody [1] - plasma fibrinogen, plasma D-dimer Management: - recominant factor VIIa for coagulation factor VIII autoantibody [1] - tranexamic acid (1 g as 10 mg/min intravenous infusion) reduces mortality [3] - effectiveness of tranexamic acid decreases 10% for every 15-minute delay & is negligible at 3 hours [4]

Related

postpartum

General

pregnancy-associated hemorrhage; obstetrical hemorrhage complications of the puerperium

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 16, American College of Physicians, Philadelphia 2012
  2. Gibson CJ, Berliner N, Miller AL et al A Bruising Loss. N Engl J Med 2016; 375:76-81. July 7, 201 PMID: 27406351 http://www.nejm.org/doi/full/10.1056/NEJMcps1500127
  3. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): An international, randomised, double-blind, placebo-controlled trial. Lancet 2017 Apr 26 PMID: 28456509 Free Article http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext
  4. Gayet-Ageron A, Prieto-Merino D et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: A meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet 2017 Nov 7; [e-pub]. PMID: 29126600 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32455-8/fulltext - Dries DJ. Tranexamic acid: Is it about time? Lancet 2017 Nov 7 PMID: 29126598 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32806-4/fulltext