Emerging treatments

Your Organisational Guidance

ebpracticenet urges you to prioritise the following organisational guidance:

Multidisciplinaire richtlijn Postpartumzorg in de eerste lijn (deel 1)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2022Guideline multidisciplinaire des soins postnatals dans la première ligne de soins (partie 1)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2022Multidisciplinaire richtlijn Postpartumzorg in de eerste lijn (deel 2)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2024Guideline multidisciplinaire des soins postnatals dans la première ligne de soins (partie 2)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2024

Recombinant coagulation factor VIIa

In refractory cases of PPH, medical interventions aimed at addressing coagulopathy may be considered. Among these options is recombinant activated factor VIIa (known as eptacog alfa in some countries).[36] It is approved in Europe for the treatment of severe PPH when uterotonics are insufficient to achieve haemostasis. However, it is not approved in the US for this indication, although it is sometimes used off-label.[146][147] While some studies have suggested a potential decrease in the overall need for blood product transfusion during acute haemorrhage with factor VIIa, a significant survival advantage has not been conclusively established.[141] The use of factor VIIa is limited by the heightened risk of thrombosis. Further research is needed to establish its safety profile and efficacy specifically for treating PPH. Nonetheless, in rare circumstances where immediate access to blood bank resources is constrained, it holds potential as an adjunct to massive transfusion protocols for prompt correction of coagulopathy, but must not delay, or be considered a substitute for, a life-saving procedure such as embolisation or surgery.[4] Careful consideration of risks and benefits is essential and a lower dose can help minimise the risk of thrombosis.[3][107][141][148][149]

Fibrinogen concentrates

Early activation of fibrinolysis during haemorrhage leads to a decline in serum fibrinogen levels, which serves as an early indicator of severe PPH. Replacing or augmenting fibrinogen levels is crucial for clot formation, and it has been established as an independent predictor of mortality in patients with major trauma.[150] Maintaining fibrinogen levels above 2 g/L (200 mg/dL) is typically recommended, and cryoprecipitate has traditionally been used for fibrinogen replacement. However, cryoprecipitate has limitations, including the need for thawing before use and the potential for viral transmission.[151] Fibrinogen concentrates undergo viral inactivation during the manufacturing process, resulting in an improved safety profile, and are available for immediate use at room temperature. Limited studies on the use of fibrinogen concentrates in PPH have shown a decreased need for blood product transfusion and subsequent volume overload without adverse effects.[152] Nonetheless, further research is necessary to explore the use of fibrinogen concentrates in managing PPH.

Prothrombin complex concentrates

Prothrombin complex concentrates consist of clotting factors II, VII, IX, and X, as well as proteins C and S, all of which are dependent on vitamin K. They are available in different preparations, with some including three of the factors and others all four.[141] Prothrombin complex concentrates are currently approved only for reversing warfarin-induced bleeding, but there are limited data on their off-label use for replenishing clotting factors in severe haemorrhage. Typically, the dose used is lower to minimise the risk of thrombosis.[153][154] This off-label use may be beneficial in the management of obstetric haemorrhage, particularly for patients with severe liver dysfunction or acquired factor deficiencies.[118] However, further research is necessary to establish the safety profile and determine the optimal dosing before prothrombin complex concentrates can be routinely used in the treatment of refractory PPH.[3][4][36]

Use of this content is subject to our disclaimer