Severe postpartum hemorrhage (PPH) is defined as blood loss of more than 1000 ml. Since blood loss after delivery of the baby is difficult to measure accurately, major PPH may best be defined by a fall in hematocrit (Hct) or by the need for blood transfusion.1 Postpartum hemorrhage accounts for 28% of maternal deaths in developing countries, around 125,000 deaths each year, as there are 125,000,000 births annually in the developing world, the risk of maternal death from PPH is approximately one in 1000 deliveries.2-4 In the Kingdom of Saudi Arabia (KSA), PPH accounts for 20% of direct maternal deaths. Hemorrhage is the 4th leading cause of death in the United Kingdom. Eight deaths out of the 15 hemorrhage deaths were attributed directly to PPH alone and the risk of death from obstetric hemorrhage is 1:100,000 deliveries.5 The present report concerns 10 cases of major obstetric hemorrhage with disseminated intravascular coagulation (DIC), as evidenced by low platelet count prolongation of the coagulation screening tests, low fibrinogen level, and the presence of fibrin degradation product (FDP). The management in the face of a life-threatening obstetric hemorrhage with DIC, unfortunately, is not always evidence-based. When faced with such an emergency, obstetricians tend to give whatever is available at hand hoping to save the life of the mother. The aim of this retrospective study is to reflect on our experience on an optimal and cost-effective management protocol, which would prevent the occurrence and complications of DIC and minimize maternal mortality and morbidity.

Methods. Ten cases of severe obstetric hemorrhage that progressed to DIC were studied retrospectively over a 7 year period, October 1988 through to September 1995, in the Obstetric Unit, King Khalid University Teaching Hospital, Riyadh, KSA. Information was retrieved from the medical records regarding age and parity, detailed obstetric history illustrating the number of previous lower segment cesarian section (LSCS), placental localization, mode of delivery, blood loss, and clinical and laboratory evidence of disseminated intravascular coagulation (DIC). The available pre-hemorrhage, intra-hemorrhage, and post-replacement laboratory parameters were recorded. Replacement therapy in the form of crystalloid, colloid, blood and various blood components (platelets, fresh frozen plasma, and cryoprecipitate) was used. Conservative medical therapy includes various oxytoxic drugs, ranging from ergometrine, oxytocin and prostaglandin, administered via different routes. The antifibrinolytic agent tranexamic acid was used in some patients. Conservative surgical measures used in this study included uterine massage, suturing of placental bed, uterine packing, uterine and internal iliac artery ligation. Hysterectomy, total or subtotal was resorted to when conservative surgical attempts were not successful.

Results. Out of the 30,000 total deliveries during the 7 years study period, 735 patients developed postpartum hemorrhage of more than 500 ml blood loss giving an incidence of 2.5%. Severe postpartum hemorrhage of more than 1000 ml blood loss occurred in 84 patients giving an incidence of 0.5%. Ten cases of the severe PPH progressed to DIC giving an incidence of 0.03%. The age of the 10 patients ranged between 25 years - 40 years (mean = 36.1 years); nine patients were 35 years and above. Four patients were of high parity (6 and above), 4 were para 3, and 2 were para 2+0. Six patients had repeat LSCS for all their previous deliveries, and 3 patients had one previous cesarean section. The patient who did not have previous cesarean section had spontaneous vertex delivery at 30 weeks gestation, fo

Received 21st November 2001. Accepted for publication in final form 27th January 2002.