STRATEGIES FOR MANAGING COAGULOPATHY IN CASES OF SEVERE OBSTETRIC HEMORRHAGE: A COMPREHENSIVE REVIEW

ABSTRACT

Maternal mortality is largely driven by obstetric bleeding, which, in conjunction with hypertensive disorders, accounts for the majority of maternal deaths. Mortality rates have declined following the integration of systematic approaches such as "code red" protocols, increased access to institutional care, rapid transfusion strategies, and early alert mechanisms. Nevertheless, massive hemorrhage frequently leads to coagulopathy, requiring specialized management in an Intensive Care Unit. This narrative review provides an overview of the pharmacological agents used to manage complex coagulopathy in this clinical setting.

Keywords: pregnancy, labor, postpartum hemorrhage, coagulation disorders.

Introduction

Globally, obstetric bleeding and hypertensive disorders are responsible for over 50% of maternal deaths. Although major obstetric hemorrhage is a treatable condition, it remains a significant cause of maternal morbidity and early mortality. Modern clinical strategies—including rapid response teams, early transfusion protocols, and institutionalized delivery—have successfully reduced mortality rates. However, cases of massive hemorrhage still frequently require ICU admission and often lead to severe dilutional and hemorrhagic coagulopathy. The WHO continues to highlight this issue as a major global health concern [1, 2].

The COVID-19 pandemic has further complicated this landscape by creating a shortage of blood products. Given the decline in donor availability since 2020, there is an urgent need for evidence-based, rational blood management and the use of alternative pharmacological agents to control bleeding and prevent coagulopathy. This article reviews advanced drug therapies for managing obstetric hemorrhage, treating it as an acute coagulation disorder—akin to acquired hemophilia—driven by the rapid loss of fibrinogen and clotting factors [1, 2].

Materials and methods

This paper presents a descriptive review of the scientific literature covering the period from 2000 to 2023. The aim of the study was to conduct a comprehensive analysis of the pathophysiological mechanisms, therapeutic approaches, and clinical significance of postpartum hemorrhage (PPH). The search for sources was carried out in the electronic databases PubMed/MEDLINE, ScienceDirect, and LILACS using standardized MeSH terms: “postpartum hemorrhage,” “blood transfusion,” and “tranexamic acid.” The initial search identified 7,790 publications that potentially corresponded to the research topic. At the first stage of selection, two independent experts analyzed the titles and abstracts of the found materials. The inclusion criteria were based on clinical significance, methodological soundness, and relevance of the data. Special attention was paid to meta‑analyses, randomized controlled trials (RCTs), and systematic reviews published in peer‑reviewed journals included in quartile Q1.

Background

Globally, postpartum hemorrhage (PPH) remains a critical health crisis, claiming a woman’s life every four minutes. This translates to an annual toll exceeding 160,000 fatalities. Furthermore, obstetric hemorrhage is responsible for at least 20 million instances of severe maternal morbidity each year, with the burden falling disproportionately on low- and middle-income nations. Current clinical protocols for addressing PPH integrate pharmacological interventions, surgical procedures, and hematological stabilization [1, 2].

While various criteria exist to quantify blood loss for PPH classification, the most clinically relevant definition focuses on the volume of blood loss sufficient to induce physiological instability and threaten the patient's survival. PPH affects up to 18% of all deliveries worldwide, with mortality outcomes heavily influenced by the quality of local healthcare infrastructure and the timeliness of medical intervention [3].

Basic management of postpartum hemorrhage

Effective management of major obstetric bleeding encompasses hemorrhages occurring throughout all three trimesters of pregnancy, as well as the postpartum period. Standard care involves a combination of definitive surgical interventions—such as bimanual uterine massage, intrauterine tamponade (e.g., Bakri balloon), curettage for incomplete abortions, hemostatic suturing, laparotomy, or, in extreme cases, hysterectomy and pharmacological support. The latter includes the administration of uterotonic agents like oxytocin, misoprostol, and methylergometrine, alongside tranexamic acid, all of which are supported by robust clinical evidence [4, 5].

Simultaneously, clinicians must focus on correcting uterine atony through mechanical stimulation and tonics, while ensuring aggressive fluid resuscitation and hematological support. In Colombia, the implementation of the "Code Red" protocol—a structured, multidisciplinary approach—has significantly reduced mortality rates by streamlining the management of obstetric hemorrhage. Furthermore, the use of tranexamic acid is now considered a standard of care for all obstetric bleeding. Notably, the WOMAN trial confirmed that this intervention reduces mortality from obstetric hemorrhage by one-third, providing substantial benefits across various etiologies of PPH [7, 8].

Conclusion

Obstetric hemorrhage requires a comprehensive approach that includes medical and surgical management, uterotonics, cause identification and correction, tranexamic acid, fluid resuscitation, and transfusion of blood products. Fibrinogen concentrate and prothrombin concentrate are therapeutic options to be considered for transfusion.

In the scenarios of unavailable blood products and currently with the emergence of the pandemic, it is necessary to have alternatives to blood products given that there are scarce resources, and the current access to blood products is low, with the shortage of fresh frozen plasma and cryoprecipitates being more noticeable.

References:

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