A 35-year-old pregnant woman with dizygotic twins (through IVF) and GDM (A1) (gestational diabetes mellitus, treated with diet combined with exercise to control the blood glucose level without insulin) received an elective cesarean section at 38 + 1 weeks. She had no history of bleeding disorder and a normal preoperative hematologic profile, including a hemoglobin (Hb) of 105 g/L, hematocrit (Hct) of 33%, platelet (PLT) count of 145 $\times$ 10${}^9$/L, a fibrinogen concentration of 3.7 g/L (normal range 1.8–4.2 g/L), and a normal activated partial thromboplastic time (aPTT) and partial thromboplastin time (PT) of 29 and 11 s, respectively (aPTT normal range 21–37 s, PT normal range 9–12 s).

After successful hemostasis thorough cesarean section, two babies were delivered; a SORIN XTRA System (Sorin Group USA Inc.) with one suction device was used to aspirate the autologous red blood cells for reinfusion. All anesthesiologists who operated the system were trained and familiar with the use of the cell salvage machine in accordance with local established procedures and requirements. The estimated blood loss was approximately 700 mL during the surgery. The collected red blood cells were mixed with heparinized saline in the suction device and washed with 1000 mL of normal saline solution. After a washing and centrifugation cycle, 412 mL of autologous red blood cells (46% HCT) were reinfused by means of filtered blood administration. After surgery, the estimated blood loss was nearly 800 mL, and routine blood tests and coagulation profiles were evaluated. The Hb level was 101 g/L, the Hct was 31.4% and the PLT count was 110 $\times$ 10${}^9$/L. The normal PT, aPTT and fibrinogen concentration were 10 s, 32 s and 2.6 g/L, respectively, there was elevation of D-dimer (45.38 mg/L; normal range 1.3–4.2 mg/L) and fibrinogen degradation product (183.2 mg/L; FDP, normal range 0–13.98 mg/L).

Two hours after the operation, the condition of the patient was stable, but ten hours after the operation, a marked increase in vaginal bleeding was noted, and the estimated blood loss was up to 1060 mL. Blood tests showed a sharp decrease in the fibrinogen concentration of 1 g/L, and Hb was 86 g/L, Hct was 27%, and the PLT count was 110 $\times$ 10${}^9$/L; there were slightly elevated PT and normal aPTT values of 13 s and 34 s, respectively, and D-dimer was $>$80.00 mg/L and FDP was 332.8 mg/L. Then, to correct the coagulation function and anemia, 4 U of blood cell suspension, 400 mL of fresh frozen plasma and 4 U of cryoprecipitate were administered intravenously, and a Bakri intrauterine balloon tamponade was applied immediately.

Eleven hours after surgery, hemoglobinuria was detected, and 10 mg dexamethasone and 10 mg furosemide were intravenously injected. Thirteen hours after surgery, the total urine output was up to 700 mL. Coomb’s test was negative. Since there was no elevation in white blood cells and the temperature was normal before and after surgery, there was no evidence of infection. Normal coagulation tests performed over the next 24 hours showed a fibrinogen concentration of 4 g/L, an Hb of 78 g/L and a PLT count of 124 $\times$ 10${}^9$/L. Two days after the surgery, the Bakri intrauterine balloon was removed, and the patient was discharged 4 days after surgery.

A 30-year-old pregnant woman with suspected macrosomia had an elective cesarean section at 40 weeks. She had no history of bleeding disorder and a normal preoperative hematologic profile, including an Hb of 115 g/L, Hct of 36.1%, PLT count of 162 $\times$ 10${}^9$/L, and a PT, aPTT and fibrinogen concentration of 11 s, 27 s and 3.9 g/L, respectively.

After successful hemostasis thorough cesarean section, the patient delivered a son who weighed 3960 g via the SORIN XTRA System (Sorin Group USA Inc.), and anesthesiologists began to perform procedures as described above. The estimated blood loss was approximately 800 mL during the surgery. Red blood cells were collected and washed by following the same procedure used in case one. A total of 396 mL of autologous red blood cells (52% HCT) was reinfused. The hemodynamic status was stable with stable vital signs, and the urine output was approximately 100 mL.

Four hours after surgery, a marked increase in vaginal bleeding was noted, and the estimated blood loss was up to 1160 mL. A Bakri intrauterine balloon tamponade was applied immediately, and the hematologic profile also showed a sharp decrease in the fibrinogen concentration of 0.8 g/L; the Hb was 115 g/L, the Hct was 36.5%, the PLT count was 118 $\times$ 10${}^9$/L, and the abnormal PT and aPTT values were 14 s and 38 s, respectively. Then, 400 mL of fresh frozen plasma, 8 U of cryoprecipitate and 8 g of fibrinogen were infused immediately to improve coagulation function. After that, a small amount of constant blood loss still existed, and red blood cell suspension (2 U), fresh frozen plasma (200 mL), and cryoprecipitate (4 U) were infused to correct coagulation function and anemia. The hematologic profile showed an elevated fibrinogen concentration of 2.4 g/L, an Hb of 90 g/L, an Hct of 28.1%, a PLT count of 95 $\times$ 10${}^9$/L, and abnormal PT and aPTT values of 13 s and 32 s, respectively. Bilateral uterine artery embolization was carried out. Twelve hours after surgery, an abnormal PT of 18 s and an INR of 1.56 (normal range 0.85–1.15) were observed, and 900 U thrombin complex was administered intravenously to reverse the possible coagulation disorder.

Sixteen hours after surgery, the hematologic profile showed a fibrinogen concentration of 3.6 g/L, an Hb of 86 g/L, an Hct of 25.8%, a PLT count of 93 $\times$ 10${}^9$/L, and PT and aPTT values of 12 s and 40 s, respectively. On the first day after surgery, the coagulation tests became normal, with a hematologic profile showing a fibrinogen concentration of 4.1 g/L, an Hb of 83 g/L, an Hct of 25%, a PLT count of 101 $\times$ 10${}^9$/L, and normal PT and aPTT values of 11 and 27 s, respectively. Since there was no elevation of white blood cells and the temperature was normal before and after surgery, there was no evidence of infection. The Bakri intrauterine balloon was removed. This patient was discharged 9 days after surgery.

A 30-year-old pregnant woman was diagnosed with gestational thrombocytopenia during pregnancy. The lowest platelet count was 66 $\times$ 10${}^9$/L at 38 + 4 weeks throughout her pregnancy, and the platelet count was 77 $\times$ 10${}^9$/L when she was admitted at 38 + 6 weeks because of breech position. Other preoperative hematologic levels were within the normal range, including a fibrinogen concentration of 3.5 g/L, an Hb of 128 g/L, an Hct of 37.8%, and normal PT and aPTT values of 10 s and 30 s, respectively.

She underwent an emergency cesarean section on the day of admission, and the cesarean section was successful. The hemostasis was thorough, and a daughter was delivered that weighed 3420 g via the SORIN XTRA System (Sorin Group USA Inc.); the anesthesiologists started to perform procedures as described above. The estimated blood loss during the operation was 800 mL during the surgery. After a routine washing and centrifugation cycle, 203 mL of autologous red blood cells (60% HCT) were reinfused. The urine output was 100 mL at the end of the operation. Routine blood tests and coagulation profiles were performed during the operation. The fibrinogen concentration was 2.6 g/L, the Hb was 96 g/L, the Hct was 29.1%, and the PLT count was 58 $\times$ 10${}^9$/L. The hematologic file also showed elevated PT and normal aPTT values of 17 s and 33 s, respectively.

Fresh frozen plasma (400 mL) and 8 U cryoprecipitate were administered intravenously to improve coagulation function. Two hundred milligrams of hydrocortisone via intravenous drip was given after the operation for thrombocytopenia. During plasma transfusion, anaphylaxis emerged, so the intravenous drip of hydrocortisone was continued, and 1/3 subcutaneous injections of antiallergic epinephrine hydrochloride were used. Forty milligrams of methylprednisolone via intravenous drip was used for thrombocytopenia. During that time, the coagulation test showed sharp decreases in Fbg to 0.6 g/L, PT to 11 s, aPTT to 31 s, TT to 24 s, Hb to 123 g/L, the PLT count to 11 $\times$ 10${}^9$/L, and Hct to 36.2%. Single-donor apheresis of 2 U platelets, 6 g fibrinogen and tranexamic acid were used for treatment of thrombocytopenia and as a pro-coagulant. Then, 4 g fibrinogen and furosemide were used once again.

Eventually, hemostasis was achieved. At 7 hours after surgery, the urine output was 250 mL, and a coagulation test was performed. Other parameters were as follows: Fbg 4 g/L, PT 11 s, aPTT 32 s, TT 19 s, INR 0.97, Hb 103 g/L, PLT count 94 $\times$ 10${}^9$/L, and Hct 30.6%. Repeated blood tests during the 3-day hospital stay were normal, with an Hb of 96 g/L, a PLT count of 134 $\times$ 10${}^9$/L, and an Hct 30%; on postoperative day 7, the patient was discharged from the hospital. Since there was no increase in white blood cells and the temperature was normal before and after surgery, there was no evidence of infection. This patient was lost to follow-up, and we could not measure the PLT count later. Based on the elevated PLT count detected 4 days after delivery (134 $\times$ 10${}^9$/L), gestational thrombocytopenia was a possible diagnosis.