SKENARIO 1

Ny. Tresta, usia 16 tahun, datang ke UGD RS Margono dengan rujukan dari praktek bidan

swasta dikarenakan penurunan kesadaran. Dikatakan oleh bidan tersebut bahwa Ny. T baru

saja melahirkan seorang bayi perempuan di klinik tersebut. Persalinan berlangsung lebih

lama dari waktu yang seharusnya. Plasenta lahir lengkap. Injeksi oxcytocin post partum telah

disuntikkan. Eksplorasi jalan lahir dilakukan, tidak ada robekan pada mulut rahim, terdapat

robekan pada vagina dan perineum, telah dijahit.

Namun perdarahan aktif terus berlangsung selama hampir 2 jam dari jalan lahir. Lama-

kelamaan pasien lemas dan pingsan. Pasien hanya melakukan pemeriksaan kehamilan 1 kali,

1 minggu sebelum melahirkan, dilakukan di bidan tsb, dikatakan pasien tidak pernah minum

suplemen zat besi maupun kalsium selama hamil.

A. Klarifikasi Istilah

1. Penurunan kesadaran

Penurunan tingkat kesadaran yang diukur baik secara kualitatif maupun kuantitatif

dengan glassgow coma scale, dimana hal ini berkorelasi dengan peningkatan

morbiditas dan mortalitas pasien (Kandel et al, 2000).

2. Persalinan berlangsung lebih lama

Persalinan yang ditandai dengan fase laten lebih dari 8 jam, kemudian persalinan

telah berlangsung 12 jam atau lebih tanpa kelahiran bayi, dan dilatasi cervix

terletak di sebelah kanan garis waspada pada partograf (Hanifa, 2002). Hal ini

dapat disebabkan oleh kelainan pada power, passage, dan passenger.

3. Pemeriksaan kehamilan

Pemeriksaan kehamilan (prenatal care atau antenatal care) merupakan

pemeriksaan medis rutin yang direkomendasikan untuk dilaksanakan ibu hamil.

Pemeriksaan ini bersifat preventif untuk mengetahui masalah kesehatan potensial

selama kehamilan secara dini dan melakukan penatalaksanaan yang adekuat

(Schmitt, 2009).

B. Batasan Masalah

1. Identitas : Ny. Tresta, 16 tahun G1P1A0

2. Status : Pasien rujukan bidan

3. KU : penurunan kesadaran

4. Kronologis :

a. partus lama (distosia)

b. plasenta lahir lengkap,

c. injeksi oxytocin postpartum (+),

d. robekan vagina dan perineum (+, telah dijahit),

e. terjadi perdarahan aktif dari jalan lahir selama 2 jam

5. Riwayat Kehamilan

a. Hanya melakukan pemeriksaan kehamilan 1x (1 minggu antepartum)

b. Tidak pernah meminum zat besi selama kehamilan

C. Analisis Masalah

1. Pemeriksaan Kehamilan (Ante Natal Care)

2. Faktor risiko perdarahan post partum

3. Hubungan nutrisi dan zat besi terhadap ibu hamil

4. Macam-macam kegawatdaruratan obstetrik

5. Langkah mengatasi kegawatdaruratan obstetrik

D. Pembahasan Masalah

Pemeriksaan Kehamilan (Ante Natal Care)

Pemeriksaan kehamilan dilakukan secara rutin dengan ketentuan sebagai berikut

(Schmitt, 2009):

a. Usia gestasi < 28 minggu dilaksanakan 1 kali setiap bulan

b. Usia gestasi 28 – 36 minggu dilaksanakan tiap 2-3 minggu

c. Usia gestasi > 36 minggu dilaksanakan tiap minggu

Pemeriksaan fisik yang dilakukan meliputi (Schmitt, 2009):

a. Pendataan riwayat medis ibu

b. Pemeriksaan tekanan darah

c. Pemeriksaan antropometri

d. Pemeriksaan pelvis

e. Pemantauan denyut jantung janin menggunakan Doppler

f. Tes urin dan darah

Pemeriksaan ultrasonografi juga dapat dilakukan, meliputi (Schmitt, 2009):

a. Diagnosis kehamilan

b. Pemeriksaan janin kembar

c. Menilai risiko yang mungkin terjadi seperti keguguran, kehamilan ektopik,

dan kehamilan mola

d. Pemeriksaan malformasi janin dan keutuhan bagian janin

e. Deteksi retardasi pertumbuhan intrauterine

f. Prediksi tanggal kelahiran

1. Faktor risiko perdarahan post partum

Beberapa faktor risiko yang memperbesar kemungkinan terjadi perdarahan

postpartum adalah (Janice et al, 2007) :

a. Partus lama

b. Multigravida

c. Episiotomy

d. Makrosomia

e. Riwayat postpartum hemoragik sebelumnya

f. Anemia pada saat kehamilan

Pencegahan perdarahan postpartum dapat dilaksanakan dengan mengetahui factor

risiko tersebut secara dini dan melakukan penatalaksanaan secara adekuat. Selain

itu, dapat pula dilakukan administrasi oksitosin maupun administrasi misoprostol.

Keduanya dapat menurunkan angka kejadian perdarahan postpartum sebanyak

40% (Janice et al, 2007).

2. Hubungan nutrisi dan zat besi terhadap ibu hamil

Kebutuhan nutrisi bagi ibu hamil adalah sebagai berikut (Schmitt, 2009)

a. Kalori : 2500 kalori

b. Asam folat : 400 mikrogram/hari

c. Ferrum : 30 mg pada TM 2 & TM 3

d. Kalsium : 1200 mg/hari

e. Zink : 20 mg/hari

3. Macam-macam kegawatdaruratan obstetric

Kegawatdaruratan obstetric yang dapat menyebabkan kecacatan dan kematian

sehingga harus dilakukan penatalaksanaan secara cepat tepat dan cermat, adalah

antara lain:

a. Abrupsio plasenta

Merupakan peristiwa lepasnya perlekatan plasenta dari uterus. Abrupsio

plasenta merupakan contributor signifikan peningkatan kematian ibu di

seluruh dunia (Usui et al, 2007).Usui, Rie; Matsubara, Shigeki; Ohkuchi, Akihide; Kuwata, Tomoyuki; Watanabe, Takashi; Izumi, Akio; Suzuki,

Mitsuaki (2007). "Fetal heart rate pattern reflecting the severity of placental abruption". Archives of Gynecology

and Obstetrics 277 (3): 249–53.doi:10.1007/s00404-007-0471-9. PMID 17896112.

b. Plasenta previa

Merupakan peristiwa implantasi plasenta pada posisi uterus segmen inferior

sehingga menyebabkan perdarahan antepartum (Arulkumaran, 2009).Arulkumaran, edited by Richard Warren, Sabaratnam (2009). Best practice in labour and delivery (1st ed., 3rd

printing. ed.). Cambridge: Cambridge University Press. pp. 142–146. ISBN 978-0-521-72068-7.

c. Perdarahan postpartum

Merupakan peristiwa perdarahan yang terjadi setelah persalinan yang dapat

menyebabkan kondisi syok hipovolemik. Perdarahan ini berjumlah >500 mL

(partus spontan) atau berjumlah >1000 mL (section caesaria). Perdarahan

postpartum adalah penyebab kematian perinatal tertinggi di seluruh dunia

(Anderson and Etches, 2007).Anderson JM, Etches D (March 2007). "Prevention and management of postpartum hemorrhage".American

Family Physician 75 (6): 875–82.PMID 17390600.

d. Emboli cairan amnion

Peristiwa dimana cairan amnion beserta sel fetal, rambut, dan debris lain yang

memasuki aliran darah ibu melalui plasenta, sehingga memicu reaksi alergi,

kolaps kardiorespirasi, dan koagulopati (Stafford and Sheffield, 2007).Stafford I, Sheffield J (2007). "Amniotic fluid embolism". Obstet. Gynecol. Clin. North Am. 34 (3): 545–53,

xii. doi:10.1016/j.ogc.2007.08.002.PMID 17921014.

e. Inversio uterus

Merupakan komplikasi fatal dari persalinan yang disebabkan kegagalan

pelepasan plasenta dari uterus, sehingga uterus tertarik keluar jalan lahir.

Langkah mengatasi kegawatdaruratan obstetric

Algoritma dalam mengatasi perdarahan postpartum menurut Janice et al (2007)

adalah sebagai berikut:

Penilaian awal meliputi:

a. Persiapan

b. Triase

c. Primary survey (ABCDE)

d. Resusitasi

e. Tambahan terhadap primary survey dan resusitasi

f. Secondary survey

g. Tambahan terhadap secondary survey

h. Pemantauan dan re-evaluasi berkesinarnbungan

i. Transfer ke pusat rujukan yang lebih baik

Manajemen perdarahan post partum dapat dibagi secara preventif dan

kuratif. Dokter dapat melakukan injeksi oksitosin IM di akhir stadium kedua

persalinan. Secara kuratif, dokter dapat mengulangi administrasi oksitosin,

melakukan pijat uterus untuk menstimulasi kontraksi, melakukan pengecekan

plasenta, kompresi bimanual, injeksi prostaglandin E2 intramyometrium,

operasi ligasi arteri (A. uterine, A. iliaca interna) maupun penjahitan metode

Lynch. Pilihan terakhir yang dapat dilakukan adalah histerektomi.

DAFTAR REFERENSI

Anderson JM, Etches D. 2007. Prevention and Management of Postpartum Hemorrhage Am

Fam Physician. 2007 Mar 15;75(6):875-882.

Hanifa W. 2002. Buku Panduan Praktis Pelayanan Kesehatan Maternal dan Neonatal. Jakarta:

Yayasan Bina Pustaka Sarwono Prawiroharjo.

JW Schmitt. 2009. Prenatal care fact sheet. U.S. Department of Health and Human Services

Kandel ER, Jessell, Thomas M.; Schwartz, James H. 2000. Principles of neural science. New

York: McGraw-Hill.

MANAGEMENT OF HEMORRHAGE■ Hypovolemic ShockShock from hemorrhage evolves through several stages. Early inthe course of massive bleeding, there are decreases in mean arterialpressure, stroke volume, cardiac output, central venous pressure,and pulmonary capillary wedge pressure. Increases in arteriovenousoxygen content difference reflect a relative increase in tissueoxygen extraction, although overall oxygen consumption falls.Blood flow to capillary beds in various organs is controlledby arterioles, which are resistance vessels that in turn are partiallycontrolled by the central nervous system. At least 70 percentof total blood volume is contained in venules, which arepassive resistance vessels controlled by humoral factors. Catecholaminerelease during hemorrhage causes a generalized increasein venular tone, resulting in an autotransfusion from this capacitancereservoir (Barber and colleagues, 1999). These changesare accompanied by compensatory increases in heart rate, systemicand pulmonary vascular resistance, and myocardial contractility.In addition, there is redistribution of cardiac outputand blood volume by selective, centrally mediated arteriolarconstriction. This results in diminished perfusion to the kidneys,splanchnic beds, skin, and uterus, but relative maintenanceof blood flow to the heart, brain, adrenal glands, and organsthat autoregulate their own flow.As the blood volume deficit exceeds 25 percent, compensatorymechanisms usually are inadequate to maintain cardiacoutput and blood pressure. At this point, additional small lossesof blood result in rapid clinical deterioration. Despite an initialincrease in total oxygen extraction by maternal tissue, maldistributionof blood flow results in local tissue hypoxia and metabolicacidosis, producing a vicious cycle of vasoconstriction, organ ischemia,and cellular death. Hemorrhage also activates lymphocytesand monocytes, which in turn cause endothelial cell activation.As with sepsis syndrome, these events lead to loss ofcapillary membrane integrity and additional loss of intravascularvolume. There is also increased platelet aggregation in hypovolemicshock, resulting in the release of a number of vasoactivemediators that cause small vessel occlusion and further impairmentof microcirculatory perfusion.Often overlooked is the importance of extracellular fluid andelectrolyte shifts in both the pathophysiology and successfultreatment of hypovolemic shock. This involves changes in thecellular transport of various ions, in which sodium and waterenter skeletal muscles and cellular potassium is lost to the extracellularfluid. Replacement of extracellular fluid is thus an importantcomponent of therapy in hypovolemic shock. Survivalis reduced in acute hemorrhagic shock when blood alone, comparedwith blood and lactated Ringer solution, is administered.■ Estimation of Blood LossVisual inspection is notoriously inaccurate, and clinical estimates

can average half the measured loss. Importantly, in obstetrics,part or all of the hemorrhage may be concealed. It is importantto realize that in a situation of acute hemorrhage, theimmediate hematocrit may not reflect actual blood loss. Afterthe loss of 1000 mL, the hematocrit typically falls only 3 volumepercent in the first hour. When resuscitation is given withrapid infusion of intravenous crystalloids, there is prompt equilibration.During an episode of acute significant hemorrhage,the initial hematocrit is always the highest. This istrue whether it is measured in the delivery room, operatingroom, or recovery room.Urine output is one of the most important “vital signs” to followin the woman with obstetrical hemorrhage. Renal blood flowis especially sensitive to changes in blood volume. Thus, in the absenceof diuretics, the rate of urine formation, when carefully measured,reflects the adequacy of renal perfusion and in turn, the perfusionof other vital organs. Urine flow of at least 30 mL, andpreferably 60 mL per hour, should be maintained. With potentiallyserious hemorrhage, an indwelling bladder catheter shouldbe inserted promptly to measure urine flow. Potent diureticssuch as furosemide invalidate the relationship between urineflow and renal perfusion. This need not be a problem in themanagement of the woman who is hemorrhaging, because diureticsshould be avoided in a hypovolemic patient. Another effectof furosemide is venodilation, which further reduces cardiacvenous return, thereby further compromising cardiac output.■ Resuscitation and Acute ManagementWhenever there is any suggestion of excessive blood loss afterdelivery, it is essential to immediately identify uterine atony, retainedplacental fragments, or genital tract lacerations. It is imperativethat at least one or two intravenous infusion systems oflarge caliber be established promptly to allow rapid administrationof crystalloid solutions and blood. An operating room, surgicalteam, and anesthesiologist should always be immediatelyavailable. Specific causes of postpartum hemorrhage are managedas discussed earlier in this chapter.Fluid ReplacementTreatment of serious hemorrhage demands prompt and adequaterefilling of the intravascular compartment. Crystalloid solutionstypically are used for initial volume resuscitation. Suchsolutions rapidly equilibrate into the extravascular space andonly 20 percent of crystalloid remains in the circulation of criticallyill patients after 1 hour (Shoemaker and Kram, 1991). Becauseof such equilibration, initial fluid infusion should involveabout three times as much crystalloid as the estimated blood loss.There is debate concerning fluid resuscitation of hypovolemicshock with colloid versus crystalloid solutions. Perel andRoberts (2007) performed a Cochrane review for resuscitation

of nonpregnant critically ill patients. They found equivalentbenefits but concluded that colloid solutions were more expensive.The Saline versus Albumin Fluid Evaluation (SAFE) trialof almost 7000 randomized nonpregnant patients reported similarresults (Finfer and co-workers, 2004). Because of this, weconcur with Bonnar (2000) that fluid resuscitation should bewith crystalloid and blood.Blood ReplacementConsiderable debate also surrounds the hematocrit level or hemoglobinconcentration that mandates blood transfusion. Accordingto deliberations of a Consensus Development Conference(1988), cardiac output does not substantively decreaseuntil the hemoglobin concentration falls to approximately 7g/dL or hematocrit of 20 volumes percent. Although the committeereported that otherwise healthy anesthetized animals survivedisovolemic anemia with hematocrit decreases to 5 volumespercent, they further cited that there was significantfunctional deterioration well before that point. It is difficult todefine a universal hematocrit or hemoglobin value below orabove which transfusion is either mandatory or contraindicated.That said, recommendations of the Consensus Conferenceshould be considered in clinical decision making. According tothese guidelines, red blood cells are not infused for moderateanemia in stable women.For the woman acutely bleeding, we recommend rapid bloodinfusion if the hematocrit is less than 25 volumes percent. This decisionis obviously dependent on whether there is imminent surgery,acute operative blood loss, acute hypoxia, vascular collapse, orother factors present. In Iraq, U.S. Military Combat Trauma Unitsaim for a hematocrit of 21 volumes percent (Barbieri, 2007).Hebert and associates (1999) reported results from theCanadian Critical Care Trials Group. A total of 838 critically illnonpregnant patients were randomly assigned to restrictive redcell transfusions to maintain hemoglobin concentration above 7g/dL or to liberal transfusions to maintain the hemoglobin 10to 12 g/dL. The 30-day mortality rate was similar—19 versus23 percent in the restrictive versus liberal groups, respectively.In patients who were not as ill—defined by Acute Physiologyand Chronic Health Evaluation (APACHE) scores of 20 orless—the 30-day mortality rate was significantly lower in the restrictivegroup—9 versus 26 percent. Morrison and colleagues(1991) reported no benefits of red cell transfusions given towomen who had suffered postpartum hemorrhage and whowere isovolemic but anemic with a hematocrit between 18 and 25volumes percent. Clearly, the level to which a woman is transfuseddepends not only on the present red cell mass, but also on the likelihoodof additional blood loss.Whole Blood and Blood ComponentsContents and effects of transfusion of various blood componentsare shown in Table 35-7. Compatible whole blood is ideal

for treatment of hypovolemia from catastrophic acute hemorrhage.It has a shelf life of 40 days, and 70 percent of the transfused redcells function for at least 24 hours following transfusion. Oneunit raises the hematocrit by 3 to 4 volume percent. Wholeblood replaces many coagulation factors, especially fibrinogen,and its plasma expands hypovolemia. Importantly, women withsevere hemorrhage are resuscitated with fewer blood donor exposuresthan with packed red cells and components. For example,after their review, Shaz and co-workers (2009) recommendedthat plasma, platelets, and red cells be given in a 1:1:1ratio for trauma patients undergoing massive transfusions.Drawbacks of such a scheme are exposure to many moredonors. In a randomized study of 33 nonpregnant patients undergoingliver transplantation, Laine and colleagues (2003)found that whole blood, compared with component therapy,was associated with fewer donor exposures yet provided equally

effective therapy for blood loss. Freshly donated whole bloodhas also been used for casualties with life-threatening massivehemorrhage at combat support hospitals in Iraq (Spinella andco-workers, 2008).Our experiences at Parkland Hospital also favor whole bloodfor massive hemorrhage. In a recent audit of more than 66,000women delivered at Parkland Hospital, Alexander andassociates (2009) reported significantly decreased incidences ofrenal failure, adult respiratory distress syndrome, pulmonaryedema, hypofibrinogenemia, admission to an intensive careunit, and maternal death when whole blood transfusions werecompared with packed red cell transfusions or combinations ofblood products.For women who are more stable and do not have massiveblood loss, packed red blood cell transfusions are suitable. Accordingto the National Institutes of Health (1993), componenttherapy provides better treatment because only the specificcomponent needed is given. Accordingly, the infusion of wholebanked blood is usually not necessary and is rarely available.Dilutional CoagulopathyWhen blood loss is massive, replacement with crystalloid solutionsand packed red blood cells usually results in a relative depletionof platelets and soluble clotting factors. This leads to adilutional coagulopathy that clinically is indistinguishable fromdisseminated intravascular coagulopathy (see p. 785). Such dilutionimpairs hemostasis and further contributes to blood loss.The most frequent coagulation defect found in women withblood loss and multiple transfusions is thrombocytopenia(Counts and colleagues, 1979). Stored whole blood is deficientin platelets and in factors V, VIII, and XI. Moreover, all solubleclotting factors are absent from packed red blood cells. Thus, severehemorrhage without factor replacement may also cause hypofibrinogenemia

and prolongation of the prothrombin andpartial thromboplastin times. In some women, frank consumptivecoagulopathy may accompany shock and confuse the distinctionbetween dilutional and consumptive coagulopathy.Fortunately, in most situations encountered in obstetrics, treatmentof both types of coagulopathy is the same.The impact of massive transfusion with resultant coagulopathyhas been studied recently by both civilian trauma groupsand military combat hospitals (Bochicchio, 2008; Borgman,2007; Gonzalez, 2007; Johansson, 2007, and all their co-workers).Patients undergoing massive transfusion—defined as 10 ormore units of blood—had much higher survival rates as the ratioof plasma:red cell units was closer to 1:1.4, that is, one unitof plasma for each unit of packed red cells. The highest mortalitygroup had a 1:8 ratio. Component replacement is rarely necessarywith acute replacement of 5 to 10 units of packed red bloodcells or less. When blood loss exceeds this amount, considerationshould be given to evaluation of platelet count, clotting studies,and plasma fibrinogen concentration.In the woman with obstetrical hemorrhage, the platelet countshould be maintained above 50,000/_L with the infusion ofplatelet concentrates. A fibrinogen level of less than 100 mg/dLor sufficiently prolonged prothrombin or partial thromboplastintimes in a woman with surgical bleeding is an indication forfresh-frozen plasma administration in doses of 10 to 15 mL/kg.Type and Screen versus CrossmatchIn any woman at significant risk for hemorrhage, typing andscreening or crossmatching is essential. The screening procedureinvolves mixing the maternal serum with standard reagent redcells that carry the antigens with which most of the commonclinically significant antibodies react. A crossmatch, on theother hand, involves the use of actual donor erythrocytes ratherthan standard red cells.Only 0.03 to 0.07 percent of patients who are determinednot to have antibodies in a type-and-screen procedure subsequentlyhave antibodies as determined by crossmatch (Boraland colleagues, 1979). Thus, administration of screened bloodrarely results in adverse clinical sequelae. Not performing acrossmatch also decreases blood bank costs. Moreover, bloodthat is crossmatched is held exclusively for that single potentialrecipient. With type-and-screening, blood is available for anypotential recipient and blood wastage is reduced. For all of thesereasons, type and screen is preferred in most obstetricalsituations.Packed Red Blood CellsCells packed from a unit of whole blood have a hematocrit of55 to 80 volumes percent, depending on the method used forpreparation and storage. A unit of packed red blood cells containsthe same volume of erythrocytes as whole blood and alsoraises the hematocrit by 3 to 4 volumes percent. Packed red

blood cell and crystalloid infusion are the mainstays of transfusiontherapy for most cases of obstetrical hemorrhage.PlateletsWhen needed, it is preferable to transfuse platelets obtained byapheresis from one donor. In this scheme, the equivalent ofplatelets from six individual donors is given as a one-unit onedonortransfusion. Such units generally cannot be stored morethan 5 days.If single-donor platelets are not available, random donorplatelet packs are used. These are prepared from individual unitsof whole blood by centrifugation, and then resuspended in 50 to70 mL of plasma. One unit of random donor platelets containsabout 5.5 _ 1010 platelets, and 6 to 10 such units are generallytransfused. Each unit transfused should raise the platelet countby 5000/_L (National Institutes of Health, 1993). The donorplasma must be compatible with recipient erythrocytes. Further,because some red blood cells are invariably transfused along withthe platelets, only platelets from D-negative donors should begiven to D-negative recipients. Even so, Lin and colleagues(2002) found that transfusion of ABO-nonidentical platelets innonpregnant patients undergoing cardiovascular surgery was notassociated with adverse effects. Platelet transfusion is consideredin a bleeding patient with a platelet count below 50,000/_L. Inthe nonsurgical patient, bleeding is rarely encountered if theplatelet count exceeds 5000 to 10,000/_L (Sachs, 1991).Fresh-Frozen PlasmaThis component is prepared by separating plasma from wholeblood and then freezing it. Approximately 30 minutes are requiredfor the frozen plasma to thaw. It is a source of all stable

and labile clotting factors, including fibrinogen. Thus, it is oftenused in the acute treatment of women with consumptive or dilutionalcoagulopathy as discussed previously. Fresh-frozen plasmais not appropriate for use as a volume expander in the absence ofspecific clotting factor deficiency. It should be considered in ableeding woman with a fibrinogen level below 100 mg/dL orwith abnormal prothrombin and partial thromboplastin times.CryoprecipitateThis component is prepared from fresh-frozen plasma. Cryoprecipitateis composed of factor VIII:C, factor VIII:von Willebrandfactor, 200 mg of fibrinogen, factor XIII, and fibronectin,all combined in less than 15 mL of the plasma from which itwas derived (American Association of Blood Banks, 1994). Cryoprecipitateis an ideal source of fibrinogen if levels are dangerouslylow and there is oozing from surgical incisions. There isno advantage to the use of cryoprecipitate for general clottingfactor replacement in the bleeding woman instead of freshfrozenplasma. The exception to this is in states of general factordeficiency where potential volume overload is a problem, and in

a few conditions involving deficiency of specific factors.Recombinant Activated Factor VIIThis synthetic vitamin K-dependent protein was approved bythe Food and Drug Administration (FDA) principally for treatmentof bleeding in individuals with hemophilia. Recombinantactivated factor VII—rFVIIa or NovoSeven—acts by binding toexposed tissue factor at the site of tissue and vascular injury.Thrombin so generated activates platelets and the coagulationcascade. Over the past 10 years, rFVIIa has been used successfullyto help control hemorrhage from surgery, trauma, andother causes (Mannucci and Levi, 2007). A number of reportsof successful treatment for obstetrical hemorrhage in womenwith hemophilia have accrued.Recombinant FVIIa has also been used to control severe obstetricalhemorrhage in women without hemophilia who havesevere hemorrhage from complications of pregnancy. In theirreview of 65 published cases, Franchini and associates (2007)reported that two thirds of women underwent cesarean delivery,and in a third of treated women, postpartum atony was thecause of bleeding. Overall, half of all 65 women also underwenthysterectomy. Alfirevic and co-workers (2007) described 113women with postpartum hemorrhage treated with rFVIIa andreported to the Northern European Registry. Over half haduterine atony, a third lacerations, and a fourth had placenta previaor abruption. Almost 35 percent underwent hysterectomyand 10 percent had uterine artery embolization. Bleeding wasdiminished or arrested in over 80 percent with no complicationsdue to rFVIIa. Lewis and co-workers (2009) caution thatrFVIIa administration will not be effective if plasma fibrinogenis depleted and levels are around 50 mg/dL or less.The specter of thrombosis with rFVIIa use is of concern(Mannucci and Levi, 2007). In a review of the FDA adverse eventreporting system by O’Connell and associates (2006), there were185 thrombotic events in 168 nonpregnant patients, and mostwere with off-label use of rFVIIa, mainly for hemorrhage. Theseevents may affect as many as 7 percent of treated patients, but appearso far to be uncommon in obstetrical patients.AutotransfusionThere are no convincing data that intraoperative blood salvageand autotransfusion is safe in obstetrical patients. A few smallstudies have uncovered no obvious problems (Rainaldi and colleagues,1998). In their contemporaneous review, Allam and associates(2008) document the lack of prospective trials, butfound no serious reported complications.Autologous TransfusionUnder some circumstances, autologous blood storage for transfusionmay be considered. In general, however, this has beendisappointing. For example, McVay and colleagues (1989) reportedobservations from 273 pregnant women in whom bloodwas drawn in the third trimester. Minimal requirements were a

hemoglobin concentration 11 g/dL or a hematocrit of 34 volumespercent. Unfortunately, almost three fourths of thesewomen donated only one unit, a volume of questionable value.In many cases, the need for transfusion cannot be predicted.Sherman and colleagues (1992) studied 27 women given two ormore transfusions in more than 16,000 deliveries. In only 40percent was an antepartum risk factor identified. Similar findingswere reported by Reyal and associates (2004). Andres andco-workers (1990) and Etchason and associates (1995) concludedthat autologous transfusions were not cost effective.

SURGICAL MANAGEMENT OF HEMORRHAGE■ Uterine Artery LigationUsed primarily for lacerations at the lateral part of the hysterotomyincision, this technique is shown in Figure 35-31.■ Uterine Compression SuturesSeveral modifications of the vertical brace suture described byB-Lynch and colleagues (1997) have been described for intractablepostpartum atony. These are discussed on page 777and shown in Figure 35-18.■ Internal Iliac Artery LigationLigation of the internal iliac arteries can reduce hemorrhage appreciably(Allahbadia, 1993; Joshi and colleagues, 2007). Theprocedure may be technically difficult, however, and is successfulin only approximately half of patients in whom it is attempted(American College of Obstetricians and Gynecologists,1998).