Treatment of a post partum bleeding complication with recombinant factor VIIa

Brueckner, S.; Sedemund Adib, B.; Malik, E.; Heringlake, M.; Schmucker, P.; Diedrich, K.; Siemens, H. J. achim G.

Introduction: A 31-year-old nulliparous woman with a triplet gestation and a beginning HELLP-syndrome (platelets 90/nl, GOT 58U/l) was delivered of healthy triplets by Cesarean section at 34 weeks gestation. Initially the post partum course was uneventful, platelets promptly rose to 150/nl and transaminases dropped. 8 hours post partum, the patient was transferred to the anesthesiologic ICU because of hyperkalemia (7.1 mmol/l). Course: Upon arrival in the ICU, the patient showed the signs of hemorrhagic shock and under the full picture of atonic uterine bleeding, the patient was promply hysterectomized. However, uncontrollable bleeding from drainages and oozing from all tissues during re-laparotomies (total of 8) persisted. 40 hours after hysterectomy, the patient had received a total of 54 PRBC's, 50 FFP's and 7 platelet concentrates. Therapy with rFVIIa was begun. Results: The lab work-up showed anemia, thrombocytopenia and persistent D-dimers, other coagulation parameters (factor activities) were within normal limits. Platelet concentrates prior to the administration of rFVIIa had not shown a sign increase in thrombocytes. However, after rFVIIa was given, a prompt increase in platelet count was observed. Bleeding from drainages was reduced, transfusion needs became significantly less and hematocrit and hemoglobin were stabilized. Outcome: Unfortunately, despite this threapy, the patient developed MOF and died on post partum day 9. Discussion/Conclusion: After hysterecetomy, diffuse bleeding persisted and mass transfusion became necessary. The patient did not have the typical signs of DIC except for increased D-dimers. All other factor concentrations were within normal limits. 2 days after hysterectomy, experimental therapy with rFVIIa was begun. However, it was obviously too late to save the patient's life, since other cascades leading to MOF had already been initiated. Possibly, an earlier and more frequent administration of recombinant factor VIIa could have saved the patient's life.