Therapeutic Management of Postpartum Hemorrhage Associated with Patients with Coagulopathies - A Systematic Literature Review
Keywords: Hemostatic disorders, Therapeutic Management, postpartum hemorrhage.
Obstetric hemorrhage is the main direct cause of maternal morbidity and mortality, and it often happens during the puerperium. In this context, pregnancy complications or underlying disorders, when left untreated, can make the clinical picture worse. Following this line of reasoning, it has been noticed that patients with hemostatic deficiencies, such as lack of coagulation factors, as well as platelet and fibrinogen disorders, are more likely to be at risk, since they are among the causes of puerperal bleeding, due to the fact that the procoagulant substances level are not sufficient in this group of people, not being physiologically compatible as in a normal pregnancy. However, considering that Postpartum Hemorrhage, associated with coagulopathies, is potentially treatable, the clinical management contribution is essential to reduce such mortality rate. Thus, the present study aims to analyze the therapeutic approaches used in puerperal bleeding in patients with hemostatic disorders. For this purpose, a bibliographic and descriptive study was carried out, a systematic literature review type, in the MEDLINE, PUBMED and LILACS databases, based on articles published from 2015 to 2020, using health science descriptors (DeCS) to search: “postpartum hemorrhage, coagulopathies and treatment”. The guiding question was defined as: “What treatments are used in puerperal bleeding in coagulopathies cases?" The search was conducted through July, 2020 and 9 articles were selected based on the inclusion criteria. As results, it has been found that specific treatments and managements are used in order to contain and / or prevent puerperal bleeding in different coagulopathies types. In general, perfusion and oxygenation are maintained based on blood volume and hemoglobin levels. Furthermore, therapy is performed with blood components and hemostatic agents, in ways that, for Von Willebrand Disease, the treatment can vary according to the disease type, although, in general, it is based on factorial supplementation, using desmopressin and antifibrinolytics. For factors VIII and IX deficiency, the approach is similar, however, desmopressin use is only seen for FVIII deficiency. In case of FXI deficiency, factorial concentrates may or may not be associated with antifibrinolytics, also, fresh frozen plasma (FFP) has been reported to prevent bleeding. Regarding afibrinogenemia, dysfibrinogenemia and hypofibrinogenemia, the fibrinogen administration is effective, and, for the last one, cryoprecipitate and FFP. For platelet disorders, factor VIIIa, tranexamic acid, desmopressin and platelet concentrate (this one not being recommended to be used in case of Bernard-Soulier syndrome) are administered. In conclusion, therapies should be applied according to each coagulopathy specificity, in order to control postpartum hemorrhage, although there are procedures that may converge through the hemostatic disorders pathophysiology. Also, researches in this field are scarce, in this sense, this particular subject needs to be better exploited.
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