Coagulopathy from Severe Postpartum Hemorrhage.

OBJECTIVE: The purpose of this study was to estimate the incidence and risk factors associated with coagulopathy from severe postpartum hemorrhage.

STUDY DESIGN: After approval by the Institutional Review Board at Duke University Medical Center, records with the ICD-9 code 666.12 for immediate postpartum hemorrhage were reviewed for the 5-year period from January 1, 2000, to December 31, 2004. Severe postpartum hemorrhage was defined as postpartum hemorrhage requiring transfusion. Coagulopathy from postpartum hemorrhage was defined as severe postpartum hemorrhage requiring factor replacement.

RESULTS: During this period there were 12,476 deliveries. 108 had severe postpartum hemorrhage. 30/108 became coagulopathic. They received a total of 108 units of fresh frozen plasma (FFP) and 12 units of cryoprecipitate (cryo). 28/30 also received 1 to 20 units of packed red blood cells and 5/30 received 1 to 3 units of platelets. All of the women who received cryo had also received FFP. The trigger for administration of factor replacement was clinical (oozing, continued bleeding) in 13/30 cases and a prolonged partial thromboplastin time (PTT) in 17/30 cases. Peak PTTs ranged from 27 to > 150 seconds. Lowest fibrinogen levels ranged from 27 to 580. In 2 cases, however, no fibrinogen levels were obtained. Hemorrhage was attributed to uterine atony in 11/30 cases, placenta accreta in 6/30, lacerations or incisions in 6/30, HELLP syndrome in 2/30, acute fatty liver of pregnancy in 1/30, amniotic fluid embolism in 1/30, fibroids, in 1/30, hemorrhage into an ovarian fibroma in 1/30, and chronic hepatitis B in 1/30. 22/30 cases were associated with cesarean delivery. In 12/30 cases hysterectomy was performed. Hospital length of stay ranged from 2 to 11 days with a mean of 5.4. 9/30 women spent from 1 to 3 days in the ICU. There were no deaths. 2 women had evidence of organ dysfunction from HELLP syndrome or acute fatty liver of pregnancy, but none developed organ dysfunction as a consequence of severe postpartum hemorrhage.

CONCLUSION: 2.4 per 1000 women developed coagulopathy as a result of severe postpartum hemorrhage. They received an average of 4 units of either FFP or cryo. 90% of the units were FFP and 10% were cryo. While 30% of the women required intensive care, all survived with no sequelae.