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Clinical Approach to Case of PPH
Published in Gowri Dorairajan, Management of Normal and High Risk Labour During Childbirth, 2022
Recombinant factor VIIa (rFVIIa): This can be used in life-threatening postpartum haemorrhage. However, there is limited evidence on its safety for use in obstetric haemorrhage. It has been found to increase the risk of arterial thrombosis and is usually indicated in inherited coagulopathy.
Primary Postpartum Haemorrhage
Published in Sanjeewa Padumadasa, Malik Goonewardene, Obstetric Emergencies, 2021
Sanjeewa Padumadasa, Malik Goonewardene
Life-threatening arterial and venous thromboembolic complications have been reported following the administration of recombinant factor VIIa. Therefore, routine use of recombinant factor VIIa is currently not recommended in the management of PPH, unless this is part of a trial.
Haematological problems
Published in Catherine Nelson-Piercy, Handbook of Obstetric Medicine, 2020
The coagulopathy is treated with the following: Fresh frozen plasma (FFP), which contains all the coagulation factors.Red cells (only needed to replace losses).Platelet concentrates (may be given to a bleeding patient if the platelet count is <80 × 109/L).Cryoprecipitate.Recombinant fibrinogen. Its use may be considered if there is haemorrhage and the fibrinogen concentration is <1 g/L.The use of recombinant factor VIIa is a powerful but expensive pro-haemostatic tool and is not recommended outside clinical trials.
Recent advances in surgery and its perioperative treatment in people with hemophilia
Published in Expert Review of Hematology, 2021
Concerning emicizumab, Seaman and Ragni reported a total hip arthroplasty (THA) that was planned to concur with the patient’s regularly arranged emicizumab maintenance dose of 1.5 mg/kg, which was given the morning of the surgical procedure [13]. The patient was given 180 μg/kg of recombinant factor VIIa (rFVIIa) immediately prior to the surgical procedure. Then, 90 μg/kg of rFVIIa was given every 3 h. The periodicity of administration was changed to every 6 h on postoperative day 4. Subsequently, dosing was decreased to every 8 h on postoperative day 8. On postoperative day 12, rFVIIa was given every 12 h until it was halted on postoperative day 14. This tapering set up was established, somewaht, based on the patient’s bleeding history and prior perioperative by-passing agents utilization. No supplementary rFVIIa was given. Because of the association with thrombotic microangiopathy (TMA), no activated prothrombin complex concentrate (APCC) was given. No laboratory checking for TMA was carried out. Emicizumab was kept going once a week as regularly planned. By contrast, the patient’s prior left knee arthrotomy, synovectomy, and excisional debridement of soft tissue to bone without emicizumab needed intensive therapy alternating rFVIIa and APCC, tapered during 8 weeks to keep hemostasis [13].
The clinical management of factor XI deficiency in pregnant women
Published in Expert Review of Hematology, 2020
Allison P. Wheeler, Celeste Hemingway, David Gailani
Recombinant factor VIIa has been used been successfully in FXI-deficient patients with FXI-neutralizing alloantibodies as prophylaxis during invasive procedures, including surgery on vulnerable tissues such as the urinary tract and oropharynx, and major surgeries where risk of bleeding is high such as abdominal aortic aneurysm repair [55,56,70,71]. The efficacy of factor VIIa in these patients makes sense considering the role of FXI depicted in Figure 1B. Here FXIa activates factor IX to supplement the factor IX activated by the factor VIIa/tissue factor complex. Administration of factor VIIa would enhance thrombin generation through factor VIIa/tissue factor, reducing or obviating the need for FXIa. Given the issues with FXI replacement, some practitioners now opt to use factor VIIa as front-line therapy for prophylaxis in FXI-deficient patients who do not have alloantibodies [72]. While the potential for factor VIIa-induced thrombosis is a concern in pregnant women, the doses of drug used in FXI-deficient patients are low, and would probably not enhance thrombotic risk appreciably [73].
An update on neurocritical care for intracerebral hemorrhage
Published in Expert Review of Neurotherapeutics, 2019
Ranier Reyes, Meera Viswanathan, Venkatesh Aiyagari
As mentioned previously, hematoma expansion has been well documented as an independent predictor of morbidity and mortality in intracerebral hemorrhage, and thus serves as a potential therapeutic target [41,42,52]. Recombinant factor VIIa (rFVIIa) is an approved option for excessive bleeding in hemophiliacs undergoing surgery or invasive procedures. In a small phase 2 study, rFVIIa was effective in reducing the size of intracerebral hemorrhages and improved functional outcomes when given within 4 h after symptom onset [53]. Based on these findings, the Factor Seven for Acute Hemorrhagic Stroke (FAST) trial was performed in which 841 ICH patients were randomized to receive a placebo or one of two doses of rFVIIa, 20 µg or 80 µg. Despite a benefit seen in the degree of volume expansion in favor of the higher dose intervention group, the study failed to show an advantage in its primary outcome of death or severe disability, defined as a modified Rankin scale (mRS) of 5–6 [54]. One explanation may be the increased frequency of adverse thromboembolic events in the treatment group, especially with the higher dose. Selecting a specific patient group at higher risk for hematoma expansion may potentially yield more favorable results [55,56]. With this in mind, rFVIIa has been tried in patients with a ‘spot sign’ who are at higher risk for hematoma expansion in the SPOTLIGHT and STOP-IT trials. However, a recently presented joint analysis of the two trials including 142 total patients did not show a difference in outcomes [57].