To the Editors:

I would like to comment on your December 2014 article, Zero in on Postpartum Hemorrhage to Reduce Cuba’s Maternal Mortality. It refers to a problem that not only takes many lives in developing countries, but also surpasses puerperal sepsis as the number one cause of death there.

The author addresses its prevention from the perspective of obstetrics and prenatal care. However, what of the patients whose lives are more at risk if surgical procedures fail to control bleeding with no structural cause? That task falls to intensive care specialists.[¹1. Morales Wong M, Gómez Hernández M, Ramos Godinez A, Llanes Mendoza O, González Ortega, J. La Triada de la Muerte. Acidosis, hipotermia y coagulopatias en pacientes con traumas. Rev Médica Electrón [Internet]. 2007 Jan 29 [cited 2015 Feb 20]. Available from: http://revmedicaelectronica.sld.cu/index.php/rme/article/view/361. Spanish.
http://revmedicaelectronica.sld.cu/index... ]

In our experience with obstetric critical care, we have developed a hypothesis about puerperal hemorrhage coagulopathy, very frequent when the patient has had surgery more than twice and received blood transfusions and fluid replacement on several occasions. Besides the possible roles of hemodilution and polytransfusion, the patients are subject to hypothermia caused by multiple factors: prolonged labor, multiple surgeries and prolonged postoperative recovery in air-conditioned rooms, loss of body heat when the abdominal cavity is exposed during surgery, fluid replacement with solutions that have not been adequately warmed and multiple transfusions of cold blood.

In our ICUs, we receive hypothermic patients with temperatures as low as 31 °C. If we add hypoperfusion acidosis to that, only coagulopathy is needed to complete a lethal triad that, if not corrected quickly, is associated with high case fatality.

Our team has obtained good results by alerting anesthesiologists to how best to manage body temperature during surgery (using a rectal thermometer for constant monitoring), warming fluids and blood products, covering the patient properly, and even turning off air conditioning in the operating room. Coagulopathy problems associated with postpartum hemorrhage can generally be solved by controlling temperature and acidosis.[²2. Morillas-Ramirez F, Ortiz-Gómez JR, Palacio-Abizanda FJ, Fornet-Ruiz I, Pérez-Lucas R, Bermejo-Albares L. Actualización del protocolo de tratamiento de la hemorragia obstétrica [An update of the obstetrics hemorrhage treatment protocol]. Rev Esp Anestesiol Reanim. 2014 Apr;61(4):196–204. Spanish.]

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