From the Editor

Activated factor VII proves to be a lifesaver in postpartum hemorrhage

OBG Manag. 2007 February;19(2):8-15

References

1. Dildy GA, Scott JR, Saffer CS, Belfort MA. An effective pressure pack for severe pelvic hemorrhage. Obstet Gynecol. 2006;108:1222-1226.

2. Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Breart G. Postpartum maternal mortality and cesarean delivery. Obstet Gynecol. 2006;108:541-548.

3. Kane G, Walden R, Eldad A, Martinowitz U. Treatment of traumatic bleeding with recombinant factor VIIa. Lancet. 1999;354:1879.-

4. Boffard KD, Riou B, Warren B, et al. Recombinant Factor VIIa as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials. J Trauma. 2005;59:8-18.

5. Bouwmeester FW, Jonkhoff AR, Verheijen RH, van Geijn HP. Successful treatment of life-threatening postpartum hemorrhage with recombinant activated factor VII. Obstet Gynecol. 2003;101:1174-1176.

6. Moscardo F, Perez F, de la Rubia J, et al. Successful treatment of severe intra-abdominal bleeding associated with disseminated intravascular coagulation using recombinant activated factor VII. Br J Haematol. 2001;114:174-176.

7. Hellman L, Wild C, Hojnacki B, Pollow K. Successful treatment of life-threatening bleeding after cesarean section with recombinant factor VII. Clin Appl Thromb Hemost. 2006;12:227-229.

8. Baudo F, Caimi TM, Mostarda G, de Cataldo F, Morra E. Critical bleeding in pregnancy: a novel therapeutic approach to bleeding. Minerva Anestesiol. 2006;72:389-393.

9. Branch DW, Rodgers GM. Recombinant activated factor VII: a new weapon in the fight against hemorrhage. Obstet Gynecol. 2003;101:1155-1156.

10. Danilos J, Goral A, Paluskiewicz P, Przesmycki K, Kotarski J. Successful treatment with recombinant factor VIIa for intractable bleeding at pelvic surgery. Obstet Gynecol. 2003;101:1172-1173.

11. Lim Y, Loo CC, Chia V, Fun W. Recombinant factor VIIa after amniotic fluid embolism and disseminated intravascular coagulopathy. Int J Gynaecol Obstet. 2004;87:178-179.

12. Tanchev S, Platikanov V, Karadimov D. Administration of recombinant factor VIIa for the management of massive bleeding due to uterine atonia in the post-placental period. Acta Obstet Gynecol Scand. 2005;4:402-403.

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14. Aledort LM. Comparative thrombotic event incidence after infusion of recombinant factor VIIa versus factor VIII inhibitor bypass activity. J Thromb Haemost. 2004;2:1700-1708.

15. Reynders FC, Senten L, Tjaima W, Jacquemyn Y. Postpartum hemorrhage: practical approach to a life-threatening complication. Clin Exp Obstet Gynecol. 2006;33:81-84.

In another series, 11 of 12 patients with massive postpartum hemorrhage responded to rF-VIIa treatment.¹³ This report, as well as others, indicates that, first, not all women respond to rF-VIIa treatment and, second, a multimodal approach, including surgery and interventional radiology, is critical to maximizing the success rate.

What about risks to women of child-bearing age?

Thromboembolic events. There is concern that treatment with rF-VIIa may be associated with intravascular clotting, leading to clinical syndromes of stroke and myocardial infarction. The FDA has issued a warning to clinicians of an increased risk of thromboembolic events with rF-VIIa—specifically, in elderly persons with intracerebral hemorrhage. In persons with atherosclerotic disease, damaged blood vessels may increase the amount of exposed TF; this raises the likelihood that rF-VIIa will bind to cells in the atherosclerotic plaque, triggering the coagulation cascade locally and causing a thrombotic event. It is estimated that the risk of these adverse outcomes is in the range of 25 events for every 100,000 infusions of rF-VIIa.¹⁴
Protection of age? In young women with massive postpartum hemorrhage, the risk of thrombosis in association with rF-VIIa is likely to be somewhat lower than it is in elderly patients who have preexisting atherosclerotic vascular disease.
Cost is a secondary concern. rF-VIIa is expensive—about $1,400/g—and so should be used judiciously.

Add rF-VIIa to your toolkit

In 2004, the Joint Commission on the Accreditation of Healthcare Organizations recommended that obstetric services practice their response to common obstetric emergencies such as postpartum hemorrhage. Many medical, surgical, and radiologic interventions are available to the ObGyn for postpartum hemorrhage (TABLE), and rF-VIIa is an important addition to our armamentarium. Use of this agent in obstetrics is likely to expand significantly; it’s to be hoped that, with a multimodal approach to obstetric hemorrhage,¹⁵ we can reduce the maternal death rate from this common problem.