1. Introduction

The liver plays a key role in the hemostatic system, synthesizing most of the blood clotting factors. In decompensated liver diseases such as cirrhosis, pregnant women face high risks of bleeding due to the disruption of these functions. Coagulopathy arising from liver cirrhosis becomes a critical risk factor for massive obstetric hemorrhage (MOH). This article presents a clinical case demonstrating coagulopathy and growth factor deficiency in a pregnant woman with decompensated liver cirrhosis, and discusses methods for the prevention and treatment of MOH.

Coagulopathy and growth factor deficiency in pregnant women with decompensated liver diseases present a significant clinical challenge, as demonstrated in various studies. Maldonado et al. Reported a severe case of intrahepatic cholestasis of pregnancy leading to coagulopathy and emphasized the need for vigilant management to prevent maternal and fetal complications. Similarly, Chang detailed the pathogenesis of liver diseases in pregnancy, highlighting conditions like HELLP syndrome and acute fatty liver of pregnancy, which carry high risks of morbidity and mortality. Panther and Blum focused on liver dysfunction in pregnancy, categorizing them based on their association with preeclampsia and noting the critical need for prompt delivery in severe cases. Suresh et al. investigated predictors of fetal and maternal outcomes in hepatic dysfunction during pregnancy, underscoring the role of serum bilirubin and INR as significant predictors of adverse outcomes. [1]

These findings are complemented by Kumari et al., who conducted a retrospective study on liver disorders in pregnancy, demonstrating the high incidence of perinatal and maternal morbidity and mortality. Collectively, these studies underscore the complex interplay of hepatic and obstetric factors in managing pregnant women with liver disease, emphasizing early diagnosis, vigilant monitoring, and timely intervention to improve outcomes.

2. Materials and Methods

Massive obstetric hemorrhages represent one of the most serious and life-threatening complications faced by obstetricians and gynecologists worldwide. These hemorrhages can occur in various clinical situations related to pregnancy and childbirth, including bleeding associated with placenta previa or premature placental abruption, uterine ruptures, and birth canal injuries. MOH is characterized by a sudden onset and high rate of blood loss, which can lead to shock and multiple organ failure. This condition requires immediate medical intervention and often presents a complex clinical challenge, necessitating a multidisciplinary approach. [2]

The problem of MOH remains relevant not only in developing countries, where access to medical care may be limited, but also in developed countries, despite high standards of medical care. According to the World Health Organization (WHO), obstetric hemorrhages are one of the leading causes of death among pregnant women, especially in developing countries. In the Republic of Uzbekistan, despite active efforts to reduce maternal mortality rates, MOH continues to hold a significant place in the structure of maternal death causes. In recent years, there has been an increase in the number of cases of extragenital diseases, such as coagulopathies and systemic diseases, which also contribute to the increased risk of massive obstetric hemorrhages.

Coagulopathy arising from decompensated liver diseases, such as cirrhosis, poses a particular problem in pregnant women. The liver plays a key role in the synthesis of blood clotting factors, and its dysfunction leads to significantly increased blood clotting time and a higher risk of bleeding. Thrombocytopenia and reduced fibrinogen levels further exacerbate the situation, increasing the risk of massive hemorrhages during childbirth. [3]

Timely and effective prevention of massive obstetric hemorrhages in pregnant women with decompensated liver diseases is critically important for reducing maternal mortality and improving pregnancy outcomes. The use of prothrombin complex concentrates and tranexamic acid can significantly improve laboratory coagulation parameters, reduce blood loss volume, and decrease the frequency of coagulopathic complications. This makes the study of this problem particularly relevant and important for the development of new clinical guidelines and treatment protocols.

Thus, this study aims to improve the understanding of the effectiveness of various methods for the prevention and treatment of massive obstetric hemorrhages in pregnant women with decompensated liver diseases. This could significantly impact clinical practice and enhance the quality of medical care in obstetrics.

A 28-year-old patient, in her first pregnancy at 36 weeks, was hospitalized in the maternity hospital with decompensated liver cirrhosis. The diagnosis of liver cirrhosis was established 3 years ago in the context of chronic viral hepatitis B. During the pregnancy, the liver condition progressively worsened, with episodes of ascites, jaundice, and decreased albumin levels noted.

Examination Upon Admission

Upon admission, the following examinations were conducted:

Complete blood count: Hemoglobin 95 g/L, platelets 98,000/µL.

Coagulogram: Fibrinogen level 1.6 g/L, International Normalized Ratio (INR) 2.0.

Biochemical blood analysis: Albumin 27 g/L, total bilirubin 85 µmol/L.

Pathophysiology

In decompensated liver cirrhosis, the synthesis of clotting factors is disrupted, leading to increased blood clotting time and a higher risk of bleeding. Impaired synthesis of blood clotting factors, reduced fibrinogen levels, and thrombocytopenia result in a significant increase in blood clotting time. Coagulopathy in such patients is characterized by decreased levels of fibrinogen, platelets, and blood clotting factors, leading to increased bleeding tendency and a heightened risk of massive obstetric hemorrhages. [4]

Treatment and Prevention

The following measures were taken to prevent massive obstetric hemorrhage:

Prothrombin Complex Concentrates (PCC): The patient was administered two doses of PCC "Uman-Complex" 24-36 hours before the planned delivery. PCC includes clotting factors II, IX, and X, which help improve hemostasis.

Tranexamic Acid: Use of the antifibrinolytic drug to stabilize clots.

Medications and Dosage Regimen

The prothrombin complex concentrate (Uman-Complex) contains three major human clotting factors – II, IX, and X. It was used in two doses 24-36 hours before delivery to prevent massive hemorrhages. Tranexamic acid, with its antifibrinolytic action, was administered according to the standard regimen one day before the expected delivery.

Course of Delivery

The delivery was performed via cesarean section. During the surgery, the administration of PCC resulted in a significant reduction in blood loss volume (350 ml compared to the expected 700 ml in the decompensated state). Laboratory results after PCC administration showed an improvement in fibrinogen levels to 2.9 g/L and an increase in platelet aggregation to 88%. The fibrinogen level after treatment was 2.9 ± 0.5 g/L in the main group compared to 2.2 ± 0.4 g/L in the comparison group (p<0.05), indicating a significant improvement in blood coagulation.

3. Results and Discussion

The treatment results demonstrated the high effectiveness of using PCC in the prevention of MAH in pregnant women with decompensated liver cirrhosis. The administration of PCC 24-36 hours before delivery significantly improved laboratory coagulation parameters, reduced blood loss volume, and decreased the incidence of coagulopathic complications. The average blood loss in women in the main group was significantly lower compared to the comparison group. In the main group, the average blood loss was 350 ± 70 ml, while in the comparison group, this figure reached 520 ± 80 ml (p<0.01).

Comparative Analysis of the Effectiveness of PCC and Tranexamic Acid

The comparative analysis of the effectiveness of PCC and tranexamic acid in pregnant women at high risk of MAH showed that PCC is more effective in preventing the development of coagulopathy and ensuring reliable hemostasis. In the main group receiving PCC, there was a significant improvement in laboratory coagulation parameters and a reduction in the frequency of bleeding compared to the group receiving tranexamic acid. [5]

4. Conclusions

This case demonstrates that the use of prothrombin complex concentrates (PCC) is an effective method for the prevention and treatment of massive obstetric hemorrhages in pregnant women with decompensated liver diseases. The administration of PCC improves laboratory coagulation parameters, reduces the volume of blood loss, and decreases the frequency of coagulopathic complications. This confirms that PCC can be recommended for widespread use in clinical practice to improve pregnancy outcomes and reduce maternal mortality.

5. Recommendations for Clinical Practice

The implementation of PCC in the protocols for the prevention and treatment of massive obstetric hemorrhages in pregnant women at high risk can significantly improve pregnancy outcomes and reduce maternal mortality. The use of PCC, such as "Uman-Complex," should be considered a standard prophylactic agent in obstetric practice.

Calls for Further Research [6].

Additional clinical studies are needed to confirm the effectiveness and safety of PCC in pregnant women with other severe comorbidities, such as systemic lupus erythematosus and congenital coagulopathies. It is also important to assess the long-term outcomes for both mother and child when using PCC in obstetric practice.