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Postpartum hemorrhage: use of hemostatic combat gauze
Case Reports
www. AJOG.org
Postpartum hemorrhage: use of hemostatic combat gauze Bernd C. Schmid, MD; Günther A. Rezniczek, PhD; Norbert Rolf, MD; Holger Maul, MD “
W
ar is the father of all and king of all” is a famous quote from Heraclitus of Ephesus; in regard to medicine, it is true that some advances have been made in the special circumstances, requirements, and limitations of the battlefields, such as the development of highly effective hemostatic agents for the rapid control of hemorrhage. This led to the development of chitosan-covered gauzes.1,2 Chitosan is a hydrophilic biopolymer that is obtained by deacetylation of chitin, which is a major component of crustacean shells such crab or shrimp.3 It has widespread applications and is highly biocompatible. The hemostatic mechanism of chitosan functions independently of the classic clotting cascade and appears to be due to electrostatic interactions between the cell membranes of erythrocytes and chitosan. It coagulates blood even in the presence of heparin, works under hypothermic conditions, exhibits antibacterial properties, and may reduce the risk of infections.4-6 Chitosan powder and chitosan-covered gauzes currently are being used as hemostatic agents by the United States and United Kingdom militaries. Here, we describe the successful application of a commercially available chitosan-covered gauze in a severe case of postpartum hemorrhage (PPH).
From the Departments of Obstetrics and Gynecology (Drs Schmid and Maul) and Anesthesiology (Dr Rolf), Marienkrankenhaus Hamburg, Germany; Department of Obstetrics and Gynecology, Ruhr-Universität Bochum (Marienhospital Herne), Herne, Germany (Dr Rezniczek). Received Aug. 11, 2011; revised Sept. 9, 2011; accepted Sept. 16, 2011. The authors report no conflict of interest. Reprints are not available from the authors. 0002-9378/free © 2012 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.09.018
e12
Cheap and simple interventions that are intended to minimize postpartum hemorrhage are of major public health concern. We report a case of postpartum hemorrhage in which conservative interventions had failed. The use of a chitosan-covered gauze that originally was developed for combat trauma allowed us to achieve hemostasis, and a seemingly inevitable hysterectomy was avoided. Key words: chitosan, postpartum hemorrhage, uterovaginal packing
Case report Our patient was a 32-year-old woman (gravida 2, para 0) who underwent an elective cesarean delivery at a gestational age of 37 weeks for complete placenta previa (type IV, completely covering the cervix). During the procedure, the placenta was delivered by manual removal without difficulty. There was no evidence of placenta accreta. Prophylactic oxytocin (3 units) was given to prevent uterine atony. Hemostasis was achieved, and the uterus was well contracted. However, 2 hours after the uneventfully completed initial surgery, heavy vaginal bleeding was observed that was controlled with additional oxytocin and sulprostone infusion (500 g/h) and manual compression. After another 2 hours, bleeding started again. Curettage revealed no retained placental tissue. The clinical picture was compatible with uterine atony; thus, relaparotomy was decided. B-Lynch sutures proved ineffective. Because control of the bleeding was not successful to this point, we chose to perform tight uterovaginal packing with a chitosan-covered gauze (Celox; Medtrade Products, Crewe, UK; Figure, A); hysterectomy was the only remaining alternative. Hemostasis was achieved, and the chitosan gauze was left in the uterus for 36 hours. Postoperatively, the patient made a good recovery. After removal of the chitosan gauze, no more bleeding occurred. Hematoxylin/eosin staining of coagulated blood revealed that the contact area between the red blood cells and chitosan granules was tight, which suggested a strong adherence of the red blood cells to the chitosan (Figure, B). In total, the patient had required 10 units of
American Journal of Obstetrics & Gynecology JANUARY 2012
packed red cells, 7 units of plasma, and 2 g fibrinogen.
Comment Obstetric hemorrhage is the world’s leading cause of maternal death (24% or an estimated 127,000 deaths). PPH, which often is caused by uterine atony, is the most common type.7 Therapy options comprise concentric uterine compression (such as massage or manual compression), compression sutures, pressure from an intrauterine tamponade with either a balloon catheter or uterine packing,8-11 and/or medication with uterotonic agents or intravenous hemostatic agents (such as tranexamic acid, an antifibrinolytic, and recombinant activated factor VIIa).7,12,13 Time-limiting blood loss and the possibility of disseminated intravascular coagulation are the reasons that the decision for a hysterectomy is ultimately inevitable in cases in which other interventions fail.14 It, therefore, would be of great advantage if the bleeding that is caused by the uterus atony could be stopped to allow more time for uterotonics to take action. We have shown here that the application of a chitosan-covered gauze directly at the site of bleeding acts as an effective local hemostatic. Although this is an atypical approach to the problem of PPH and further research is necessary to confirm the safety of using chitosan-impregnated gauze in PPH, the easy application and the low costs of chitosan-covered gauze may offer a promising new option in the armamentarium for the treatment of PPH in cases in which other conservative and surgical inf terventions fail.
Case Reports
www.AJOG.org REFERENCES
FIGURE
Chitosan granules
A, Chitosan granules bonded on to the surface of a stable gauze. The image was taken after the removal of the gauze from the uterus. The gauze that was used in this case report was 7.6 cm wide and 3 m long. B, Hematoxylin/eosin–stained section of chitosan granules with coagulated red blood cells and fibrin with missing fissuring (arrow) at the contact area. (Original magnification, ⫻100.)
1. Kozen BG, Kircher SJ, Henao J, Godinez FS, Johnson AS. An alternative hemostatic dressing: comparison of CELOX, HemCon, and QuikClot. Acad Emerg Med 2008;15:74-81. 2. Rao SB, Sharma CP. Use of chitosan as a biomaterial: studies on its safety and hemostatic potential. J Biomed Mater Res 1997; 34:21-8. 3. Muzzarelli RAA. Chitin. Oxford; New York: Pergamon Press, 1977. 4. Klokkevold PR, Fukayama H, Sung EC, Bertolami CN. The effect of chitosan (poly-N-acetyl glucosamine) on lingual hemostasis in heparinized rabbits. J Oral Maxillofac Surg 1999;57: 49-52. 5. Rao SB, Sharma CP. Use of chitosan as a biomaterial: studies on its safety and hemostatic potential. J Biomed Materials Res 1997; 34:21-8. 6. Tsai GJ, Su WH. Antibacterial activity of shrimp chitosan against Escherichia coli. J Food Prot 1999;62:239-43. 7. American College of Obstetricians and Gynecologists. Diagnosis and management of postpartum hemorrhage: ACOG technical bulletin no. 143. Int J Gynaecol Obstet 1991;36:159-63. 8. Anderson JF. Rupture of the uterus; treatment by gauze packing; recovery. Proc R Soc Med 1920;13:188-91. 9. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. BJOG 1997;104:372-5. 10. Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 2009;116:748-57. 11. Su LL, Chong YS, Samuel M. Oxytocin agonists for preventing postpartum haemorrhage. Cochrane Database Syst Rev 2007:CD005457. 12. Franchini M, Franchi M, Bergamini V, et al. The use of recombinant activated FVII in postpartum hemorrhage. Clin Obstet Gynecol 2010; 53:219-27. 13. Peitsidis P, Kadir RA. Antifibrinolytic therapy with tranexamic acid in pregnancy and postpartum. Expert Opin Pharmacother 2011;12: 503-16. 14. Hackethal A, Tcharchian G, Ionesi-Pasacica J, Muenstedt K, Tinneberg HR, Oehmke F. Uterine surgery in postpartum hemorrhage. Minerva Ginecol 2009;61:201-13.
Schmid. Use of CELOX in postpartum hemorrhage. Am J Obstet Gynecol 2012.
JANUARY 2012 American Journal of Obstetrics & Gynecology
e13
www. AJOG.org
Postpartum hemorrhage: use of hemostatic combat gauze Bernd C. Schmid, MD; Günther A. Rezniczek, PhD; Norbert Rolf, MD; Holger Maul, MD “
W
ar is the father of all and king of all” is a famous quote from Heraclitus of Ephesus; in regard to medicine, it is true that some advances have been made in the special circumstances, requirements, and limitations of the battlefields, such as the development of highly effective hemostatic agents for the rapid control of hemorrhage. This led to the development of chitosan-covered gauzes.1,2 Chitosan is a hydrophilic biopolymer that is obtained by deacetylation of chitin, which is a major component of crustacean shells such crab or shrimp.3 It has widespread applications and is highly biocompatible. The hemostatic mechanism of chitosan functions independently of the classic clotting cascade and appears to be due to electrostatic interactions between the cell membranes of erythrocytes and chitosan. It coagulates blood even in the presence of heparin, works under hypothermic conditions, exhibits antibacterial properties, and may reduce the risk of infections.4-6 Chitosan powder and chitosan-covered gauzes currently are being used as hemostatic agents by the United States and United Kingdom militaries. Here, we describe the successful application of a commercially available chitosan-covered gauze in a severe case of postpartum hemorrhage (PPH).
From the Departments of Obstetrics and Gynecology (Drs Schmid and Maul) and Anesthesiology (Dr Rolf), Marienkrankenhaus Hamburg, Germany; Department of Obstetrics and Gynecology, Ruhr-Universität Bochum (Marienhospital Herne), Herne, Germany (Dr Rezniczek). Received Aug. 11, 2011; revised Sept. 9, 2011; accepted Sept. 16, 2011. The authors report no conflict of interest. Reprints are not available from the authors. 0002-9378/free © 2012 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.09.018
e12
Cheap and simple interventions that are intended to minimize postpartum hemorrhage are of major public health concern. We report a case of postpartum hemorrhage in which conservative interventions had failed. The use of a chitosan-covered gauze that originally was developed for combat trauma allowed us to achieve hemostasis, and a seemingly inevitable hysterectomy was avoided. Key words: chitosan, postpartum hemorrhage, uterovaginal packing
Case report Our patient was a 32-year-old woman (gravida 2, para 0) who underwent an elective cesarean delivery at a gestational age of 37 weeks for complete placenta previa (type IV, completely covering the cervix). During the procedure, the placenta was delivered by manual removal without difficulty. There was no evidence of placenta accreta. Prophylactic oxytocin (3 units) was given to prevent uterine atony. Hemostasis was achieved, and the uterus was well contracted. However, 2 hours after the uneventfully completed initial surgery, heavy vaginal bleeding was observed that was controlled with additional oxytocin and sulprostone infusion (500 g/h) and manual compression. After another 2 hours, bleeding started again. Curettage revealed no retained placental tissue. The clinical picture was compatible with uterine atony; thus, relaparotomy was decided. B-Lynch sutures proved ineffective. Because control of the bleeding was not successful to this point, we chose to perform tight uterovaginal packing with a chitosan-covered gauze (Celox; Medtrade Products, Crewe, UK; Figure, A); hysterectomy was the only remaining alternative. Hemostasis was achieved, and the chitosan gauze was left in the uterus for 36 hours. Postoperatively, the patient made a good recovery. After removal of the chitosan gauze, no more bleeding occurred. Hematoxylin/eosin staining of coagulated blood revealed that the contact area between the red blood cells and chitosan granules was tight, which suggested a strong adherence of the red blood cells to the chitosan (Figure, B). In total, the patient had required 10 units of
American Journal of Obstetrics & Gynecology JANUARY 2012
packed red cells, 7 units of plasma, and 2 g fibrinogen.
Comment Obstetric hemorrhage is the world’s leading cause of maternal death (24% or an estimated 127,000 deaths). PPH, which often is caused by uterine atony, is the most common type.7 Therapy options comprise concentric uterine compression (such as massage or manual compression), compression sutures, pressure from an intrauterine tamponade with either a balloon catheter or uterine packing,8-11 and/or medication with uterotonic agents or intravenous hemostatic agents (such as tranexamic acid, an antifibrinolytic, and recombinant activated factor VIIa).7,12,13 Time-limiting blood loss and the possibility of disseminated intravascular coagulation are the reasons that the decision for a hysterectomy is ultimately inevitable in cases in which other interventions fail.14 It, therefore, would be of great advantage if the bleeding that is caused by the uterus atony could be stopped to allow more time for uterotonics to take action. We have shown here that the application of a chitosan-covered gauze directly at the site of bleeding acts as an effective local hemostatic. Although this is an atypical approach to the problem of PPH and further research is necessary to confirm the safety of using chitosan-impregnated gauze in PPH, the easy application and the low costs of chitosan-covered gauze may offer a promising new option in the armamentarium for the treatment of PPH in cases in which other conservative and surgical inf terventions fail.
Case Reports
www.AJOG.org REFERENCES
FIGURE
Chitosan granules
A, Chitosan granules bonded on to the surface of a stable gauze. The image was taken after the removal of the gauze from the uterus. The gauze that was used in this case report was 7.6 cm wide and 3 m long. B, Hematoxylin/eosin–stained section of chitosan granules with coagulated red blood cells and fibrin with missing fissuring (arrow) at the contact area. (Original magnification, ⫻100.)
1. Kozen BG, Kircher SJ, Henao J, Godinez FS, Johnson AS. An alternative hemostatic dressing: comparison of CELOX, HemCon, and QuikClot. Acad Emerg Med 2008;15:74-81. 2. Rao SB, Sharma CP. Use of chitosan as a biomaterial: studies on its safety and hemostatic potential. J Biomed Mater Res 1997; 34:21-8. 3. Muzzarelli RAA. Chitin. Oxford; New York: Pergamon Press, 1977. 4. Klokkevold PR, Fukayama H, Sung EC, Bertolami CN. The effect of chitosan (poly-N-acetyl glucosamine) on lingual hemostasis in heparinized rabbits. J Oral Maxillofac Surg 1999;57: 49-52. 5. Rao SB, Sharma CP. Use of chitosan as a biomaterial: studies on its safety and hemostatic potential. J Biomed Materials Res 1997; 34:21-8. 6. Tsai GJ, Su WH. Antibacterial activity of shrimp chitosan against Escherichia coli. J Food Prot 1999;62:239-43. 7. American College of Obstetricians and Gynecologists. Diagnosis and management of postpartum hemorrhage: ACOG technical bulletin no. 143. Int J Gynaecol Obstet 1991;36:159-63. 8. Anderson JF. Rupture of the uterus; treatment by gauze packing; recovery. Proc R Soc Med 1920;13:188-91. 9. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. BJOG 1997;104:372-5. 10. Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 2009;116:748-57. 11. Su LL, Chong YS, Samuel M. Oxytocin agonists for preventing postpartum haemorrhage. Cochrane Database Syst Rev 2007:CD005457. 12. Franchini M, Franchi M, Bergamini V, et al. The use of recombinant activated FVII in postpartum hemorrhage. Clin Obstet Gynecol 2010; 53:219-27. 13. Peitsidis P, Kadir RA. Antifibrinolytic therapy with tranexamic acid in pregnancy and postpartum. Expert Opin Pharmacother 2011;12: 503-16. 14. Hackethal A, Tcharchian G, Ionesi-Pasacica J, Muenstedt K, Tinneberg HR, Oehmke F. Uterine surgery in postpartum hemorrhage. Minerva Ginecol 2009;61:201-13.
Schmid. Use of CELOX in postpartum hemorrhage. Am J Obstet Gynecol 2012.
JANUARY 2012 American Journal of Obstetrics & Gynecology
e13