Hemostatic resuscitation: blood product replacement during cesarean delivery

Despite efforts to improve accurate prediction, early detection, and optimal medical and surgical treatments, obstetrical hemorrhage remains the leading cause of maternal mortality worldwide. The development and application of clinical bundles incorporating risk assessment tools focused on earlier detection and prompt intervention have demonstrated improved clinical outcomes. Many clinical bundles and obstetrical hemorrhage institutional protocols have incorporated different methods attempting to quantify intraoperative blood loss during cesarean. The addition of blood loss quantification, when incorporated into structured bundles, appears to improve outcomes. Although evidence specific to obstetrics is limited, the practice of hemostatic resuscitation and the use of massive transfusion protocols have been adapted from the trauma literature. Following identification of excessive hemorrhage, resuscitation with excessive crystalloid or colloid solutions should be avoided as it increases morbidity and mortality. Instead, hemostatic resuscitation including early administration of blood products should be instituted without delays. Early blood product and clotting factor administration, when indicated, with avoidance of hypothermia, excessive crystalloid or colloid solutions, hypocalcemia, and acidemia are key to achieve rapid hemostasis and avoid dilutional coagulopathy. At the same time, faster hemostasis results in decreased end-organ hypoperfusion/damage leading to inflammation-induced disseminated intravascular coagulation. Together with classical blood products (red blood cells, plasma, platelets, and cryoprecipitate), different adjuvants have been used to achieve faster hemostasis including tranexamic acid, fibrinogen concentrates, activated factor VII, and prothrombin complex concentrates. The efficacy of group O low titer whole blood is currently being studied in civilian trauma victims with hemorrhagic shock; its role in obstetrical hemorrhage is promising but will require validation in clinical trials. Point-of-care viscoelastic testing enables the identification of specific clotting anomalies, potentially reducing unnecessary transfusions through an individualized approach to transfusion. Viscoelastic testing may be used to guide transfusions after the acute phase of resuscitation when severe intraoperative active bleeding has been controlled. Persistence of nonsurgical bleeding following cesarean delivery may require the use of topical hemostatic agents or, in extreme cases, damage control surgery with abdominal packing and temporary abdominal closure followed by medical stabilization in the intensive care unit. Patients who receive large amounts of blood products should be followed closely for the development of abdominal compartment syndrome, a rare but potentially deadly complication. Abdominal compartment syndrome should be suspected in patients who received large-volume resuscitation with persistent hypotension and oliguria not responsive to further fluid administration together with ventilatory compromise secondary to decreased respiratory compliance. Diagnosis requires measurement of intravesical pressure. Immediate treatment includes surgical abdominal decompression.