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.
“War 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.
Chitosan is a hydrophilic biopolymer that is obtained by deacetylation of chitin, which is a major component of crustacean shells such crab or shrimp. 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. 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).
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 μg/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 packed red cells, 7 units of plasma, and 2 g fibrinogen.
