Lewis Nicole R, Brunker Patricia, Lemire Susan J, Kaufman Richard M
Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
Transfusion. 2009 Apr;49(4):689-95. doi: 10.1111/j.1537-2995.2008.02029.x.
Postpartum hemorrhage (PPH)remains an important cause of maternal morbidity and mortality. Several published reports suggest that recombinant factor VIIa (rFVIIa) is effective in controlling bleeding in PPH. This study reports a case of severe PPH complicated by disseminated intravascular coagulation(DIC), in which early rFVIIa (44 mg/kg) administration not only failed to control the bleeding in vivo but also, surprisingly, failed to correct the patient's international normalized ratio (INR) in vitro. It was hypothesized that the failure of rFVIIa to correct the INR indicated a deficiency in a downstream coagulation factor(s). To investigate this, coagulation factor levels were measured in blood samples that had been drawn periodically during resuscitation in the operating room.
Clinical and laboratory data were extracted from the medical record.Plasma samples that had been obtained during resuscitation were frozen, and activity levels of the following factors were subsequently measured: fibrinogen, FII, FV, FVII, F IX, and FX.
After rFVIIa administration, the patient's INR remained elevated at 1.9, and bleeding continued. It was determined that at the time rFVIIa was administered, the patient's fibrinogen level was very low(60 mg/dL). INR normalization and control of bleeding was achieved only after the patient's fibrinogen level was restored to normal. FII, F IX, and FX remained at hemostatic levels throughout resuscitation.
In this case of severe PPH complicated by DIC, fibrinogen appears to have been limiting at the time rFVIIa was administered. It is suggested that fibrinogen levels should be corrected during PPH resuscitation before rFVIIa use is considered.
产后出血（PPH）仍然是孕产妇发病和死亡的重要原因。多项已发表的报告表明，重组凝血因子VIIa（rFVIIa）在控制PPH出血方面有效。本研究报告了一例严重PPH并发弥散性血管内凝血（DIC）的病例，其中早期给予rFVIIa（44 mg/kg）不仅未能在体内控制出血，而且令人惊讶的是，在体外也未能纠正患者的国际标准化比值（INR）。据推测，rFVIIa未能纠正INR表明下游凝血因子存在缺陷。为了对此进行研究，在手术室复苏期间定期采集的血样中检测了凝血因子水平。
从病历中提取临床和实验室数据。复苏期间获得的血浆样本被冷冻，随后检测以下因子的活性水平：纤维蛋白原、FII、FV、FVII、FIX和FX。
给予rFVIIa后，患者的INR仍高达1.9，出血仍在继续。确定在给予rFVIIa时，患者的纤维蛋白原水平非常低（60 mg/dL）。仅在患者的纤维蛋白原水平恢复正常后，INR才恢复正常且出血得到控制。在整个复苏过程中，FII、FIX和FX保持在止血水平。
在这例严重PPH并发DIC的病例中，在给予rFVIIa时，纤维蛋白原似乎是限制因素。建议在PPH复苏期间，在考虑使用rFVIIa之前先纠正纤维蛋白原水平。
