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
  • plasma fibrinogen, plasma D-dimer

Management

• recominant factor VIIa for coagulation factor VIII autoantibody
• tranexamic acid (1 g as 10 mg/min intravenous infusion) reduces mortality
  • effectiveness of tranexamic acid decreases 10% for every 15-minute delay & is negligible at 3 hours

More general terms

• pregnancy-associated hemorrhage; obstetrical hemorrhage
• complications of the puerperium

Additional terms

• postpartum