Best practice & research. Clinical obstetrics & gynaecology
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Best Pract Res Clin Obstet Gynaecol · Dec 2008
Recombinant factor VIIa and other pro-haemostatic therapies in primary postpartum haemorrhage.
Blood products are an essential component of the management of postpartum haemorrhage, although there is lack of evidence to guide optimal use. Prospective intervention studies, including randomized trials, are needed to clarify optimal timing and dosage. ⋯ It seems likely that antifibrinolytic agents will receive less attention in future. However, rFVIIa promises to be a powerful tool in managing massive obstetric haemorrhage, although many questions concerning its efficacy and safety in differing clinical scenarios remain unanswered.
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Best Pract Res Clin Obstet Gynaecol · Dec 2008
ReviewMisoprostol for the prevention and treatment of postpartum haemorrhage.
Postpartum haemorrhage (PPH) causes preventable maternal deaths, mainly in low-income countries. Misoprostol has powerful uterotonic effects and, because it is well absorbed orally and sublingually, has the potential to be used more widely than would be possible with injectable uterotonics alone. Misoprostol is clearly less effective than oxytocin. ⋯ Meta-analysis of direct and adjusted indirect comparisons between 600 and 400 microg showed very similar effectiveness. To date, there is very limited evidence for the effectiveness of misoprostol, the lowest effective dose and the magnitude of adverse effects, both direct and indirect. The need for further research is a matter of great urgency.
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The diagnosis of placenta accreta begins with clinical suspicion in patients at risk. Ultrasound and Doppler are first-choice diagnostic methods because of their accessibility and high sensitivity. Placental MRI is an accurate method of topographic stratification that makes it possible to define anatomy, to plan the surgical approach and to consider other therapeutic possibilities. ⋯ The main challenges include controlling the haemorrhage and dissection of the invaded tissues. Nowadays, there are two treatment options: caesarean hysterectomy or a conservative approach. With the latter, there is a choice between leaving the placenta in situ and waiting for its later resolution, and a one-step surgery that addresses the problems of invasion, vascular control and myometrial damage in a single surgical act.
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Best Pract Res Clin Obstet Gynaecol · Dec 2008
Anaesthetic issues related to postpartum haemorrhage (excluding antishock garments).
The obstetric anaesthetist is a key member of the multidisciplinary team required to manage postpartum haemorrhage, having been trained in resuscitation and being experienced in managing haemorrhage and in monitoring and caring for the critically ill patient. The diagnosis of shock, initial resuscitation controversies surrounding fluid replacement, cell salvage in obstetrics and monitoring are discussed.