Factor VII and Postpartum Hemorrhage

Today, we had a presentation on OB hemorrhage management. It touched on the use of TXA, but it didn’t mention anything about recombinant factor VII in PPH. Although it has mixed results on the outcome with the use of factor VII, it seems that it still has its place in severe PPH based on the recent research data. So here we go and I hope you will find this useful in your OB practice.

First of all, I wanted to share with you the only RCT study on the use of recombinant factor VII that I can find entitled “Recombinant human FVIIa for reducing the need for invasive second-line therapies in severe refractory postpartum hemorrhage: a multicenter, randomized, open controlled trial.” It was published in 2015. They selected eighty-four women with severe PPH unresponsive to uterotonics and randomized half to receive one FVIIa infusion (n = 42) and half with standard care (no rhuFVIIa; n = 42). They evaluated the reduction of the need for specific second-line therapies, such as interventional hemostatic procedures, for blood loss and transfusions. In addition, deaths and thrombotic events were also assessed following rhuFVIIa infusion. They found that VIIa was associated with a reduction in second-line therapies compared with controls respectively 22/42 (52%) in VIIa group vs control 39/42 (93%). No death occurred in either group. Two venous thrombotic events occurred in the VIIa group with a non-severe pulmonary embolism. Overall it showed the benefits of reduction of second-line therapies in one in 3 patient approximately. The sample size is not that large and may not reflect the real occurrence, but in this RCT study, it appeared that one in 20 patients may develop non-fatal venous thrombotic event. For patients who are in fertility age and would like to have more children, use of factor VII may indeed have its place when patients are unresponsive to conventional therapy to prevent emergency hysterectomy.

In another retrospective study by Bouma LS,  76% of severe PPH patients had benefited the use of rFVIIa in preventing a hysterectomy (16 cases/21 cases total).

journal1factor7

This paper above is the only one I can find on pubmed that provides the guidelines for the use of factor VII in PPH. It recognizes there is no high quality randomized controlled trials published, expert opinions and guidelines were produced from the clinicians, such as obstetrics, anesthesia, hemotologists who have experience in using rFVII in New Zealand and Australian. As the flow chart shows below, if traditional therapy fails, rFVII should be considered before performing hysterectomy. The dosage of rFVII is listed as well for reference.

flowchartfactor7

I hope we would never have to be this situation, but the reality is that it may happen. Based on the research data, it suggested that it may be used as the last line of remedy to preserve fertility if necessary. Hopefully it provides you some useful information to deal with PPH.

Have a great evening and let me know if you have any questions or suggestions on topic you would like me to discuss. See you next week!

 

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