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“Have you made best use of the Bakri balloon in PPH?”
Robert L. Barbieri, MD (Editorial, July 2011)
A nurse-midwife delivered a macrosomic fetus and identified multiple cervical, vaginal, and perineal tears. After spending approximately 30 minutes suturing a few of the vaginal lacerations, she realized that she needed an experienced obstetrician to complete the complex repair. She has consulted you.
You introduce yourself to the patient, obtain consent, and begin to assess the situation. You note that she has a tear of the anterior cervix at its intersection with the vagina; a few deep vaginal lacerations; and a fourth-degree tear. The uterus is well-contracted and the abdomen is not distended.
As you sit to begin the repair, you notice diffuse oozing of blood from all areas of vaginal and perineal trauma. You suture the cervical laceration and notice that, after tying the stitch, bleeding is continuing from the closed laceration.
Based on what you’re seeing, you become suspicious that the patient has a coagulopathy. What should you do?
Approximately 1 of every 300 deliveries is complicated by development of a clinically significant coagulopathy. Typically, these cases occur in conjunction with postpartum hemorrhage.
Because postpartum coagulopathy does not occur often, it’s difficult for an OB to gain extensive personal experience with this disorder. Yet recognizing postpartum coagulopathy early helps ensure a good outcome.
Diseases that can cause postpartum coagulopathy include:
- placental abruption
- preeclampsia
- amniotic fluid embolism
- acute fatty liver of pregnancy
- prolonged intrauterine retention of a fetal demise
- sepsis
- a previously undiagnosed coagulation disorder.
In addition postpartum hemorrhage of any cause—placenta previa, placenta accreta, postpartum uterine atony—can cause coagulopathy.1
Do you suspect postpartum coagulopathy? If so, you should review the above list of possible conditions and diseases for the likely cause, because treatment of any one of them must be tailored to the individual patient. If placenta accreta is present, for example, hysterectomy may be necessary to save the life of the mother.
In this Editorial, I review three approaches to identifying postpartum coagulopathy—any one or more of which might be necessary for a given patient:
- clinical diagnosis
- the whole blood clotting test
- clinical laboratory measurement of the coagulation profile.
Clinical observation and diagnosis—key to early, rapid recognition
An experienced clinician often has an inkling that a coagulopathy is present when she observes evidence of abnormal clotting:
- blood oozes excessively from many areas of minor trauma
- suturing lacerations fails to stanch bleeding
- blood is more “watery” and less deeply red than ordinarily encountered (the so-called Kool-Aid sign).
Direct observation of any of these findings might prompt an experienced clinician to immediately activate a postpartum coagulopathy protocol, as I describe below, without waiting for additional test results. Delay in treating the coagulopathy could result in an acceleration of a dire cycle of bleeding and a worsening coagulation defect, causing even more bleeding.
On the other hand, some clinicians prefer to wait for a laboratory test to confirm a coagulopathy before they activate a postpartum coagulopathy protocol.
Whole-blood clotting test
This is the so-called red-top–tube test—a simple test that can be performed at the patient’s bedside to identify a coagulopathy; it’s also known as the Lee and White test.2-4 Obtain a sample of venous blood in a red-top tube (a glass tube without additives); at the same time, send a specimen of venous blood to the lab for a stat coagulation profile. In people who have normal hematologic function, the median time for blood to clot in the red-top tube, at room temperature (65ºF to 90ºF), is approximately 6.5 minutes (range, 5 to 8 minutes).
When blood in the red-top tube takes longer than 10 minutes to clot, the patient has a coagulopathy. If the blood clots but the clot then lyses over the following hour, a disorder of fibrinolysis, a type of coagulopathy, is likely.
Coagulation laboratory panel
If you suspect a coagulopathy, have blood drawn for stat measurement of hemoglobin and hematocrit, platelet count, prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen.
Regrettably, it might take as long as 40 minutes from the time blood is drawn to receive the complete panel of results. Such a delay might necessitate your deciding on a course of action based on your clinical observation and diagnosis, rather than waiting for test results. To delay initiating the transfusion of clotting factors creates the risk of having the coagulopathy cause more bleeding, resulting in a worsening coagulopathy—a cycle that can spiral into a clinical disaster.
Activate the postpartum hemorrhage protocol!
Most obstetric services have developed a formal approach to managing postpartum hemorrhage. That protocol can also guide the treatment of a postpartum coagulopathy.