Objective
To describe the use of gauze covered with chitosan, a potent hemostatic agent derived from chitin, in the treatment of postpartum hemorrhage (PPH).
Study Design
Patients suffering from postpartum hemorrhage were treated by uterine packing with chitosan-covered gauze, either through the hysterotomy in case of cesarean delivery or transvaginally, for up to 24 hours.
Results
Chitosan-covered gauze was used in 19 cases of postpartum hemorrhage due to uterine atony, placenta accreta/increta, or anticoagulation, including 5 severe cases where a hysterectomy seemed inevitable otherwise. In all but one case, the bleeding stopped and further interventions were avoided. Over comparable periods of time (18 months) and births (3822 vs 4077) before and after the introduction of the chitosan gauze in our clinic, the rate of peripartum hysterectomies was reduced by 75% (8 vs 2; odds ratio, 4.27; P = .044).
Conclusion
Chitosan-covered gauze is a viable option in the treatment of (severe) postpartum hemorrhage. It is easy to use and requires no special training. It can be used after both vaginal and cesarean deliveries, and there are no adverse side effects. Furthermore, it is very inexpensive compared with other treatment options, making it suitable for use also in low resource-countries, where the death toll due to postpartum hemorrhage is especially high.
Obstetric hemorrhage is the leading cause of maternal mortality, accounting for approximately 25% of the more than 500,000 pregnancy-related deaths worldwide in 2000. The most common type of obstetric hemorrhage is postpartum hemorrhage (PPH), which accounts for the majority of the 14 million cases of obstetric hemorrhage that occur each year and is mostly caused by uterine atony. Management of PPH resulting from uterine atony includes the administration of uterotonics, selective devascularization (either by angiographic embolization or suture ligation), the application of uterine compression sutures, and intrauterine packing. In cases of severe PPH, a hysterectomy remains the last option if conservative treatments fail. Recently, the rate of peripartum hysterectomy has increased considerably. Because it is associated with substantial maternal morbidity and results in the loss of fertility, avoiding peripartum hysterectomy improves patient safety and quality of care. Although the control of PPH by uterine packing is not new, the addition of a local hemostatic agent to the packing may improve the control of the bleeding and allows uterotonics more time to take action. The need for hemostasis on the battlefield, where hemorrhage remains the leading cause of mortality, led to the development of chitosan as a hemostatic substance. Chitosan, a hydrophilic biopolymer obtained through the deacetylation of chitin (a major component of crustacean shells such as from crab or shrimp) was found to exhibit excellent hemostatic properties. Electrostatic interaction between chitosan and the cell membranes of erythrocytes leads to coagulation of blood independent of the classical clotting cascade, and thus works under hypothermic conditions and even in the presence of heparin. This interaction is not exothermic and thus does not burn or alter the tissue surface in other ways. Furthermore, chitosan is fully biologically degradable and additionally exhibits antibacterial properties, likely reducing the risk of infection. In this study, we describe a case series of PPH successfully treated through the application of commercially available chitosan-covered gauze.
Materials and Methods
Between May 2011 and November 2012, 19 patients were treated with chitosan-covered gauze at the Marienkrankenhaus Hamburg. Patients delivering spontaneously or by cesarean and experiencing persistent bleeding despite uterotonic medication and/or curettage were candidates for treatment with chitosan-covered gauze (CELOX Gauze; Medtrade Products Ltd., Crewe, UK). CELOX is a CE marked class III medical device in the EU and is FDA approved for bleeding control. One complete gauze (3 meters long) was used for each patient with 1 exception where it was shortened to about half (case 7). All cases were managed by an experienced senior obstetrician, and the head of department was informed before the use of chitosan and/or the decision to perform a hysterectomy. In case of cesarean deliveries, the uterine cavity was packed with the gauze through the hysterotomy, with 1 end of the gauze passed through the cervix into the vagina for subsequent removal. In case of spontaneous deliveries, the gauze was inserted through the vagina and the uterus was compressed bimanually for several minutes. The gauze was usually removed after 24 hours by simply pulling the end left in the vagina. Treatment with sulprostone was continued during this time. Patient and treatment details are listed in Table 1 . All patients gave written consent for inclusion of their case data in this report.
| Case | Age | GA | G/P | Diagnosis | Delivery | Etiology of PPH | PPH interventions | Blood transfused | Removal of gauze | Complications |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 a | 32 | 36+2 | 2/0 | Placenta previa | Scheduled CD | Atony (2 h) | OX, SP, BC, C, BLS, CG | PRBC (10 u), FFP (7 u), fibrinogen (2 g) | 36 h | — |
| 2 | 41 | 40+1 | 3/2 | — | Spontaneous | Initially unknown; uterine rupture later diagnosed at laparotomy | OX, C, vCG+SP | PRBC (2 u), fibrinogen (2 g) | 24 h | Laparotomy and diagnosis of uterine rupture; decision to perform hysterectomy |
| 3 | 29 | 36+2 | 1/0 | Failed induction | Scheduled CD | Atony | OX, C, SP, BC, BLS, MP, TA, C, CG+BLS+SP | PRBC (24 u), FFP (21 u), fibrinogen (8 g) | 30 h | — |
| 4 | 42 | 38+6 | 2/1 | Placenta previa | Scheduled CD | Placenta percreta | OX, C, CG+BLS | — | 24 h | — |
| 5 | 35 | 39+5 | 2/1 | Malpresentation | Emergency CD | LMWH-induced (11 d) | OX, vCG | PRBC (11 u), FFP (8 u) | 24 h | — |
| 6 | 37 | 37+0 | 5/3 | Placenta previa | Scheduled CD | Atony | OX, C, SP, CG+BLS | — | 24 h | — |
| 7 | 39 | 40+1 | 4/1 | Vasa previa | Scheduled CD | Placenta increta | OX, C, SP, CG | PRBC (2 u) | 24 h | Residual gauze (removed 3 mon after CD) |
| 8 | 23 | 39+4 | 4/1 | — | induced labor | Placenta accreta | OX, C, SP, vCG+BC | PRBC (2 u), fibrinogen (2 g) | 24 h | — |
| 9 | 22 | 41+1 | 1/0 | — | Spontaneous | Atony (5 h) | OX, SP, C, vCG | PRBC (3 u) | 7 h | Fever (up to 39.8°C) |
| 10 | 38 | 23+0 | 4/2 | Membrane prolapse, placenta accreta | Spontaneous | Atony | OX, SP, vCG | PRBC (2 u) | 6 h | — |
| 11 | 24 | At term b | 2/1 | — | Spontaneous | Placental residuals (6 wk), bleeding as a consequence of curettage | OX, vCG | — | 16 h | — |
| 12 | 34 | 39+3 | 2/0 | — | Vacuum | Atony | OX, SP, C, CG+BLS | PRBC (14 u), FFP (8 u), fibrinogen (7 g), PCC (1000 IU), activated factor VII (1 mg) | 24 h | — |
| 13 | 21 | 38+0 | 2/0 | HIV-positive | Scheduled CD | Atony | OX, SP, BLS, CG | PRBC (4 u) | 14 h | — |
| 14 | 37 | 40+4 | 1/0 | Failure to progress | Emergency CD | Atony (15 min) | OX, SP, TA, BLS, CG+PS | PRBC (10 u), FFP (19 u), PC (1 u), fibrinogen (3 g) | 24 h | Lung edema; residual gauze (removed 6 weeks after CD) |
| 15 | 38 | 37+2 | 4/3 | Macrosomia | Spontaneous | Atony (15 min) | OX, SP, C, vCG+BC | — | 24 h | — |
| 16 | 42 | 38+2 | 2/0 | Maternal CF | Scheduled CD | Atony | OX, SP, BLS, PS, CG | — | 24 h | — |
| 17 | 32 | 41+3 | 1/0 | Malpresentation | Emergency CD | Atony | OX, SP, CG+BLS | — | 24 h | — |
| 18 | 32 | 38+2 | 3/2 | — | Spontaneous | Atony | OX, SP, C, vCG | PRBC (4 u), FFP (2 u), fibrinogen (2 g) | 24 h | — |
| 19 | 36 | 38+2 | 5/1 | — | Scheduled CD | Atony | C, OX, SP, BLS, CG | — | 24 h | — |
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