title: Hemostatic resuscitation in postpartum hemorrhage - a supplement to surgery.
abstract: BACKGROUND
  Postpartum hemorrhage is a potentially life-threatening albeit preventable condition that persists as a leading cause of maternal death. Identification of safe and cost-effective hemostatic treatment options remains crucial as a supplement to surgery and uterotonic agents.
  
  
  OBJECTIVE
  This review summarizes the background, current evidence and recommendations with regard to the role of fibrinogen, tranexamic acid, prothrombin complex concentrate, desmopressin, and recombinant factor VIIa in the treatment of patients with postpartum hemorrhage. The benefits and evidence behind traditional standard laboratory tests and viscoelastic hemostatic assays, i.e. thromboelastography TEG(®) and thromboelastometry ROTEM(®) , are discussed. In addition we assess and elaborate on the current paradigm and evidence for transfusion of these patients.
  
  
  METHODS
  Publications between 1994 and 2014 were identified from PubMed, EMBASE, Cochrane Library databases, and ClinicalTrial.gov.
  
  
  RESULTS
  Viscoelastic hemostatic assays were found to provide a real-time continuum of coagulation and fibrinolysis when introduced as a supplement in transfusion management of postpartum hemorrhage. Fibrinogen should be considered when hypofibrinogenemia is identified. Early administration of 1-2 g tranexamic acid is recommended, followed by an additional dose in cases of ongoing bleeding. Uncontrolled hemorrhage requires early balanced transfusion.
  
  
  CONCLUSIONS
  Despite the lack of conclusive evidence for optimal hemostatic resuscitation in postpartum hemorrhage, the use of viscoelastic hemostatic assays, fibrinogen, tranexamic acid and balanced transfusion therapy may prove to be potentially pivotal in the treatment of postpartum hemorrhage.
authors: Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
authors: Kim
authors: K
authors: Ekelund
authors: Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
authors: Gabriele
authors: G
authors: Hanke
authors: Department of Anesthesia, Center of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.|Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
authors: Jakob
authors: J
authors: Stensballe
authors: Department of Anesthesiology, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark.
authors: Anne
authors: A
authors: Wikkelsøe
authors: Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
authors: Charlotte Krebs
authors: CK
authors: Albrechtsen
authors: Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
authors: Arash
authors: A
authors: Afshari
mesh_terms: D000933:Antifibrinolytic Agents / Q000627:therapeutic use; D001779:Blood Coagulation Factors / Q000627:therapeutic use; D001780:Blood Coagulation Tests; D001803:Blood Transfusion; D000077324:Crystalloid Solutions; D003894:Deamino Arginine Vasopressin / Q000627:therapeutic use; D015942:Factor VIIa / Q000627:therapeutic use; D005260:Female; D005340:Fibrinogen / Q000032:analysis; D006490:Hemostatics / Q000627:therapeutic use*; D006801:Humans; D007552:Isotonic Solutions / Q000627:therapeutic use; D006473:Postpartum Hemorrhage / Q000628:therapy*; D011247:Pregnancy; D011994:Recombinant Proteins / Q000627:therapeutic use; D013916:Thrombelastography; D014148:Tranexamic Acid / Q000627:therapeutic use
chemical_list: D000933:Antifibrinolytic Agents; D001779:Blood Coagulation Factors; D000077324:Crystalloid Solutions; D006490:Hemostatics; D007552:Isotonic Solutions; D011994:Recombinant Proteins; C025667:prothrombin complex concentrates; D014148:Tranexamic Acid; D005340:Fibrinogen; C103587:recombinant FVIIa; D015942:Factor VIIa; D003894:Deamino Arginine Vasopressin
keywords: Postpartum hemorrhage; fibrinogen; maternal morbidity; standard laboratory tests; tranexamic acid; transfusion strategy; viscoelastic hemostatic assays