Topical Hemostatic Agents in Obstetric Hemorrhage: International Case Reports

Topical hemostatic agents are utilized as adjuncts to control intraoperative bleeding when standard surgical techniques (such as suturing, ligature, cautery, or pressure) are insufficient or impractical to implement1. Intraoperative scenarios where topical hemostatic agents may serve as adjuncts include bleeding near vital organs or nerves, at needle-holes, from raw surface areas, in friable or attenuated tissue, or in patients who are anticoagulated, have bleeding diatheses, or have platelet dysfunction. Physical agents and biologically active agents comprise the two main categories of topical hemostatic products. Physical agents promote hemostasis utilizing a passive substrate. Biologically active agents stimulate the coagulation cascade locally at the bleeding site1. Biologically active topical hemostatic agents have been marketed in the United States for over 10 years, paralleling the recent advances in biotechnology that resulted in rapid growth of available topical hemostatic agents2. Their use for intraoperative hemorrhage control has been described by various surgical specialties, including cardiovascular, otolaryngology, urology, and others2–6. Usage in gynecologic surgery has been reported, including laparoscopy, myomectomy, oncologic debulking and inguinal lymphadenectomy7–11. In 2007 Moriarty et al.12 (UK) presented a case report on the use topical hemostatic agents in massive postpartum hemorrhage (PPH) in a patient who underwent emergency cesarean delivery due to placental abruption. Approximately 3 hours after cesarean delivery, the patient underwent laparotomy and total abdominal hysterectomy for life-threatening hemorrhage resulting from uterine atony that was unresponsive to conservative measures. The patient developed disseminated intravascular coagulation, and, after hysterectomy, continued to bleed from vascular venous plexuses at the vaginal vault, as well as from suture holes. The topical hemostatic agent comprised of gelatin–thrombin matrix, FloSealTM (Baxter Healthcare Corporation, Fremont, California, USA), was applied to the bleeding areas. Thereafter, the authors described rapid achievement of hemostasis. Subsequently, in 2010, Law et al. (Hong Kong) reported a case of successful control of persistent PPH from the placental implantation site, using FloSeal13. Two hours after cesarean delivery for placenta previa, the patient underwent re-laparotomy for persistent vaginal bleeding, where heavy bleeding from the lower uterine segment was noted. The authors described ineffective suturing for controlling bleeding in the deep placental site, and, therefore, FloSeal was applied. Hemorrhage control was achieved with uterine preservation. In the same year, Fuglsang and Petersen (Denmark) published a series of 15 cases, delivered by cesarean for placenta previa, where excessive or intractable lower uterine segment hemorrhage was successfully controlled with direct local topical application of hemostatic collagen fleece coated with a mixture of human fibrinogen and thrombin (TachoSilTM, Nycomed, Denmark), at the time of cesarean section14. Subsequently, in 2011, Tinelli (Italy) reported a case where TachoSil application successfully controlled hemorrhage at the uterine incision site. After a scheduled repeat cesarean section, the patient was found in hemorrhagic shock on postoperative day 3. At re-laparotomy, hemoperitoneum was found, resulting from constant oozing from the uterine incision site and bladder vessels. After ineffective hemostatic suturing, TachoSil was applied with successful hemorrhage control15. Similarly, in 2011, Wohlmuth and Dela Merced (US) reported a case of placental implantation site hemorrhage, controlled at the time of cesarean delivery, with gelatin–thrombin matrix (FloSeal) in a patient with placenta previa16. In the case reports described, topical hemostatic agents were administered after unsuccessful utilization of traditional PPH treatments. These included uterotonic agents, vessel ligation, uterine compression sutures, packing or balloon tamponade, over-sewing placental bed bleeding sites, recombinant activated factor VII and consideration of uterine artery embolization17. The ineffectiveness of the traditional methods of hemorrhage control in the cases of placenta previa was attributed to bleeding from the noncontractile lower uterine segment, large surface areas