The Use of Recombinant Activated Factor VII in the Management of Life-Threatening Post Partum Bleeding

Background: Recombinant activated factor VII (rFVIIa) is a novel hemostatic agent, originally developed for the treatment of hemorrhage in hemophiliacs with inhibitors, which has been successfully used recently in an increasing number of nonhemophilic bleeding conditions. We report on the use of this hemostatic agent in a case of severe postpartum bleeding, associated with disseminated intravascular coagulation, and unresponsive to standard treatment.

Case report: A healthy 39-year-old female presented with vaginal bleed and underwent emergency cesarean delivery of a full term baby. During the surgical procedure she was found to have an abruptio placentae, complicated with uncontrollable uterine bleeding that required a total hysterectomy. During the immediate post operative period the patient continued with profuse bleeding from the surgical wound. The diagnosis of clinical disseminated intravascular coagulopathy (DIC) was confirmed by the presence of thrombocytopenia, and a marked elevation of both prothrombin time (PT) and partial thromboplastin time (PTT) levels (both more than 100 seconds). During the first two postoperative days the patient required multiple transfusions of platelets, packed red blood cells (about 30 units), fresh frozen plasma, and cryoprecipitate. On the third postoperative day, she was taken to the operative room and a massive retroperitoneal clot was evacuated, although no specific bleeding site was found during the surgical exploration. After the procedure, and in addition to the usual hemostatic interventions, the patient was given three doses of rFVIIa (each dose consisted of 4.8 mg given intravenously over 2 minutes) over an eight-hour period. During the four subsequent days, the patient’s coagulopathy gradually improved, and eventually corrected. Although the clinical course was complicated with sepsis, renal failure, and respiratory failure, the patient was finally discharged home on stable condition twenty-six days after delivery. She is currently without any sequelae.

Conclusion: Severe post partum bleeding unresponsive to standard hemostatic therapy is associated with a high mortality. This case suggests a potential role of rFVIIa in the management of this complex medical condition.