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Bernstein PS, Martin JN, Barton JR, Shields LE, Druzin ML, Scavone BM, Frost J, Morton CH, Ruhl C, Slager J, Tsigas EZ, Jaffer S, Menard MK. Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period. J Obstet Gynecol Neonatal Nurs 2017; 46:776-787. [PMID: 28709727 DOI: 10.1016/j.jogn.2017.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.
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ROSENBAUM THEA, MHYRE JILLM. The Anesthesiologist’s Role in the National Partnership for Maternal Safety’s Hemorrhage Bundle: A Review Article. Clin Obstet Gynecol 2017; 60:384-393. [DOI: 10.1097/grf.0000000000000278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Collis R, Guasch E. Managing major obstetric haemorrhage: Pharmacotherapy and transfusion. Best Pract Res Clin Anaesthesiol 2017. [DOI: 10.1016/j.bpa.2017.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Sentilhes L, Merlot B, Madar H, Sztark F, Brun S, Deneux-Tharaux C. Postpartum haemorrhage: prevention and treatment. Expert Rev Hematol 2016; 9:1043-1061. [PMID: 27701915 DOI: 10.1080/17474086.2016.1245135] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) is one of the leading causes of maternal death and severe maternal morbidity worldwide and strategies to prevent and treat PPH vary among international authorities. Areas covered: This review seeks to provide a global overview of PPH (incidence, causes, risk factors), prevention (active management of the third stage of labor and prohemostatic agents), treatment (first, second and third-line measures to control PPH), by also underlining recommendations elaborated by international authorities and using algorithms. Expert commentary: When available, oxytocin is considered the drug of first choice for both prevention and treatment of PPH, while peripartum hysterectomy remains the ultimate life-saving procedure if pharmacological and resuscitation measures fail. Nevertheless, the level of evidence for preventing and treating PPH is globally low. The emergency nature of PPH makes randomized controlled trials (RCT) logistically difficult. Population-based observational studies should be encouraged as they can usefully strengthen the evidence base, particularly for components of PPH treatment that are difficult or impossible to assess through RCT.
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Affiliation(s)
- Loïc Sentilhes
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Benjamin Merlot
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Hugo Madar
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - François Sztark
- b Department of Anesthesiology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Stéphanie Brun
- a Department of Obstetrics and Gynecology , Bordeaux University Hospital, University of Bordeaux , Bordeaux , France
| | - Catherine Deneux-Tharaux
- c INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Statistics Sorbonne Paris Cité , Paris Descartes University , Paris , France
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Policies for management of postpartum haemorrhage: the HERA cross-sectional study in France. Eur J Obstet Gynecol Reprod Biol 2016; 205:21-6. [DOI: 10.1016/j.ejogrb.2016.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/29/2016] [Accepted: 08/01/2016] [Indexed: 11/23/2022]
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Nadisauskiene RJ, Dobozinskas P, Kacerauskiene J, Kliucinskas M, Zhumagali I, Kokenova M, Bekeshov J, Dzabagijeva S, Sapargalijeva A, Glazebnaja I, Konyrbajeva G, Uteshova Z, Tasbulatova A. The impact of the implementation of the postpartum haemorrhage management guidelines at the first regional perinatal centre in Southern Kazakhstan. BMC Pregnancy Childbirth 2016; 16:238. [PMID: 27543151 PMCID: PMC4992266 DOI: 10.1186/s12884-016-1027-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 08/12/2016] [Indexed: 11/17/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) remains one of the most common causes of maternal morbidity and mortality. Therefore, clearly written PPH management guidelines should be used in clinical practice. The aim of this study was to evaluate the effectiveness of the implementation of PPH management guidelines at the First Regional Perinatal Centre of Southern Kazakhstan (FRPC). Methods Between 2012 and 2013 an interventional study was performed whereby the PPH management guidelines were implemented at the FRPC. All of the deliveries that were complicated by PPH 8 months before and 8 months after the intervention were analysed. Prevalence and severity of PPH, and the change in prevention, diagnostics and management of PPH was evaluated and statistical analysis using the SPSS 22.0 was performed. Results There were in total 5404 and 5956 deliveries in the pre- and post-intervention periods, respectively. The rates of PPH and severe PPH decreased from 1.17 to 1.02 % (p = 0.94) and from 0.24 to 0.22 % (p = 0.94), respectively. Blood loss on average increased from 1055 to 1170 ml in the post-intervention period. The pharmacological treatment of postpartum haemorrhage with uterotonics was administered most frequently during both periods. After the implementation of the guidelines, the number of transfused units of packed red blood cells decreased from 4.76 to 2.48 units/case. In addition, the amount of transfused fresh frozen plasma decreased by 20 %. The number of conservative interventions and conservative operations increased from 7.9 to 52.7 % and from 3.9 to 48.6 %, respectively. The number of hysterectomies decreased from 23.7 % in pre-intervention to 8.1 % in the post-intervention period. Conclusions The implementation of the PPH management guidelines had a positive effect on PPH prevention, diagnostics and management. It led to a more conservative aproach to the treatment of PPH. Therefore, clearly written PPH management guidelines, adapted for a particular hospital, should be developed and used in clinical practice.
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Affiliation(s)
- Ruta J Nadisauskiene
- Lithuanian University of Health Sciences, Eiveniu str. 2, 50167, Kaunas, Lithuania
| | - Paulius Dobozinskas
- Lithuanian University of Health Sciences, Eiveniu str. 2, 50167, Kaunas, Lithuania
| | | | | | - Ismailov Zhumagali
- Health Department of the Southern Kazakhstan Region, Zeltoksan str. 20 "A", Shymkent, 160012, South Kazakhstan Region, Republic of Kazakhstan
| | - Madina Kokenova
- First Regional Perinatal Centre in Southern Kazakhstan, G. Iliaeva str. 142A, Enbekshinskii raion, Shymkent, 160011, South Kazakhstan Region, Republic of Kazakhstan
| | - Jesengeldy Bekeshov
- First Regional Perinatal Centre in Southern Kazakhstan, G. Iliaeva str. 142A, Enbekshinskii raion, Shymkent, 160011, South Kazakhstan Region, Republic of Kazakhstan
| | - Saltanat Dzabagijeva
- Health Department of the Southern Kazakhstan Region, Zeltoksan str. 20 "A", Shymkent, 160012, South Kazakhstan Region, Republic of Kazakhstan
| | - Aigul Sapargalijeva
- Health Department of the Southern Kazakhstan Region, Zeltoksan str. 20 "A", Shymkent, 160012, South Kazakhstan Region, Republic of Kazakhstan
| | - Inna Glazebnaja
- Health Department of the Southern Kazakhstan Region, Zeltoksan str. 20 "A", Shymkent, 160012, South Kazakhstan Region, Republic of Kazakhstan
| | - Gulmyra Konyrbajeva
- First Regional Perinatal Centre in Southern Kazakhstan, G. Iliaeva str. 142A, Enbekshinskii raion, Shymkent, 160011, South Kazakhstan Region, Republic of Kazakhstan
| | - Zijas Uteshova
- First Regional Perinatal Centre in Southern Kazakhstan, G. Iliaeva str. 142A, Enbekshinskii raion, Shymkent, 160011, South Kazakhstan Region, Republic of Kazakhstan
| | - Aina Tasbulatova
- First Regional Perinatal Centre in Southern Kazakhstan, G. Iliaeva str. 142A, Enbekshinskii raion, Shymkent, 160011, South Kazakhstan Region, Republic of Kazakhstan
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Abstract
Postpartum Haemorrhage (PPH) is a major cause of maternal morbidity and mortality. Treatment of acquired coagulopathy observed in severe PPH is an important part of PPH management, but is mainly based on literature in trauma patients, and data thus should be interpreted with caution. This review describes recent advances in transfusion strategy and in the use of tranexamic acid and fibrinogen concentrates in women with PPH.
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Affiliation(s)
- Marie Pierre Bonnet
- Department of Anaesthesia and Intensive Care Medicine, Paris Descartes University, Paris, France
| | - Dan Benhamou
- Department of Anaesthesia and Intensive Care Medicine, Paris Sud University, Paris, France
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Traynor AJ, Aragon M, Ghosh D, Choi RS, Dingmann C, Vu Tran Z, Bucklin BA. Obstetric Anesthesia Workforce Survey. Anesth Analg 2016; 122:1939-46. [DOI: 10.1213/ane.0000000000001204] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Arora KS, Shields LE, Grobman WA, D'Alton ME, Lappen JR, Mercer BM. Triggers, bundles, protocols, and checklists--what every maternal care provider needs to know. Am J Obstet Gynecol 2016; 214:444-451. [PMID: 26478105 DOI: 10.1016/j.ajog.2015.10.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 09/13/2015] [Accepted: 10/08/2015] [Indexed: 12/29/2022]
Abstract
The rise in maternal morbidity and mortality has resulted in national and international attention at optimally organizing systems and teams for pregnancy care. Given that maternal morbidity and mortality can occur unpredictably in any obstetric setting, specialists in general obstetrics and gynecology along with other primary maternal care providers should be integrally involved in efforts to improve the safety of obstetric care delivery. Quality improvement initiatives remain vital to meeting this goal. The evidence-based utilization of triggers, bundles, protocols, and checklists can aid in timely diagnosis and treatment to prevent or limit the severity of morbidity as well as facilitate interdisciplinary, patient-centered care. The purpose of this document is to summarize the pertinent elements from this forum to assist primary maternal care providers in their utilization and implementation of these safety tools.
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Abstract
Postpartum hemorrhage remains the number one cause of maternal death globally despite the fact that it is largely a preventable and most often a treatable condition. While the global problem is appreciated, some may not realize that in the United States postpartum hemorrhage is a leading cause of mortality and unfortunately, the incidence is on the rise. In New York, obstetric hemorrhage is the second leading cause of maternal mortality in the state. National data suggests that hemorrhage is disproportionally overrepresented as a contributor to severe maternal morbidity and we suspect as we explore further this will be true in New York State as well. Given the persistent and significant contribution to maternal mortality, it may be useful to analyze the persistence of this largely preventable cause of death within the framework of the historic "Three Delays" model of maternal mortality. The ongoing national and statewide problem with postpartum hemorrhage will be reviewed in this context of delays in an effort to inform potential solutions.
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Affiliation(s)
- Dena Goffman
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, 1825 Eastchester Rd, Bronx, NY 10461.
| | - Lisa Nathan
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, 1825 Eastchester Rd, Bronx, NY 10461
| | - Cynthia Chazotte
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, 1825 Eastchester Rd, Bronx, NY 10461
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Stemming the Tide of Obstetric Morbidity: An Opportunity for the Anesthesiologist to Embrace the Role of Peridelivery Physician. Anesthesiology 2016; 123:986-9. [PMID: 26352382 DOI: 10.1097/aln.0000000000000847] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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65
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Postpartum Hemorrhage Preparedness Elements Vary Among Hospitals in New Jersey and Georgia. J Obstet Gynecol Neonatal Nurs 2016; 45:227-38. [PMID: 26852254 DOI: 10.1016/j.jogn.2015.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To identify the presence or absence of 38 postpartum hemorrhage preparedness elements in hospitals in New Jersey and Georgia as a component of the Postpartum Hemorrhage Project of the Association of Women's Health, Obstetric and Neonatal Nurses. DESIGN Quality improvement baseline assessment survey. SETTING Hospitals (N = 95) in New Jersey and Georgia. PARTICIPANTS Key informants were clinicians who were members of their hospitals' obstetric teams and were recognized as knowledgeable about their hospitals' postpartum hemorrhage policies. METHODS An electronic survey was sent by e-mail to each identified hospital's key informant. RESULTS The mean number of elements present was 23.1 (SD = 5.2; range = 12-34). Volume of births, students, magnet status, and other hospital characteristics did not predict preparedness. None of the hospitals had all of the 38 preparedness elements available. Less than 50% of the hospitals had massive hemorrhage protocols, performed risk assessments and drills, or measured blood loss. For every 10% increase in the total percentage of African American women who gave birth, there was a decrease of one preparedness element. CONCLUSION Objective measures of preparedness are needed, because perceptions of preparedness were inconsistent with the number of preparedness elements reported.
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Abstract
PURPOSE OF REVIEW Major obstetric hemorrhage is a leading cause of maternal morbidity and mortality. We will review transfusion strategies and the value of monitoring the maternal coagulation profile during severe obstetric hemorrhage. RECENT FINDINGS Epidemiologic studies indicate that rates of severe postpartum hemorrhage (PPH) in well resourced countries are increasing. Despite these increases, rates of transfusion in obstetrics are low (0.9-2.3%), and investigators have questioned whether a predelivery 'type and screen' is cost-effective for all obstetric patients. Instead, blood ordering protocols specific to obstetric patients can reduce unnecessary antibody testing. When severe PPH occurs, a massive transfusion protocol has attracted interest as a key therapeutic resource by ensuring sustained availability of blood products to the labor and delivery unit. During early postpartum bleeding, recent studies have shown that hypofibrinogenemia is an important predictor for the later development of severe PPH. Point-of-care technologies, such as thromboelastography and rotational thromboelastometry, can identify decreased fibrin clot quality during PPH, which correlate with low fibrinogen levels. SUMMARY A massive transfusion protocol provides a key resource in the management of severe PPH. However, future studies are needed to assess whether formula-driven vs. goal-directed transfusion therapy improves maternal outcomes in women with severe PPH.
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Collins P, Abdul-Kadir R, Thachil J. Management of coagulopathy associated with postpartum hemorrhage: guidance from the SSC of the ISTH. J Thromb Haemost 2016; 14:205-10. [PMID: 27028301 DOI: 10.1111/jth.13174] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 10/11/2015] [Indexed: 08/31/2023]
Affiliation(s)
- P Collins
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - R Abdul-Kadir
- The Royal Free Foundation Hospital, University College London, London, UK
| | - J Thachil
- Haemostasis and Thrombosis Unit, Manchester Royal Infirmary, Manchester, UK
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Green L, Knight M, Seeney F, Hopkinson C, Collins PW, Collis RE, Simpson NAB, Weeks A, Stanworth SJ. The haematological features and transfusion management of women who required massive transfusion for major obstetric haemorrhage in the UK: a population based study. Br J Haematol 2015; 172:616-24. [DOI: 10.1111/bjh.13864] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/12/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Laura Green
- Barts Health NHS Trust & NHS Blood and Transplant; London UK
| | - Marian Knight
- National Perinatal Epidemiology Unit; University of Oxford; Oxford UK
| | - Frances Seeney
- Statistics and Clinical Studies; NHS Blood and Transplant; Bristol UK
| | - Cathy Hopkinson
- Statistics and Clinical Studies; NHS Blood and Transplant; Bristol UK
| | | | - Rachel E. Collis
- Department of Anaesthetics; Cardiff and Vale University Health Board; Cardiff UK
| | | | - Andrew Weeks
- Department of Women's and Children's Health; University of Liverpool; Liverpool UK
| | - Simon J. Stanworth
- NHS Blood and Transplant; Oxford & Oxford University Hospitals NHS Trust; Oxford UK
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Hedriana HL, Wiesner S, Downs BG, Pelletreau B, Shields LE. Baseline assessment of a hospital-specific early warning trigger system for reducing maternal morbidity. Int J Gynaecol Obstet 2015; 132:337-41. [PMID: 26797195 DOI: 10.1016/j.ijgo.2015.07.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/15/2015] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine whether predefined maternal early warning triggers (MEWTs) can predict pregnancy morbidity. METHODS In a retrospective case-control study, obstetric patients admitted to the intensive care unit (ICU) between 2012 and 2013 at seven pilot US hospitals were compared with control patients who had a normal delivery outcome. Six MEWTs were assessed. RESULTS The case and control groups each contained 50 patients. Hemorrhage (15/50, 30%), sepsis (12/50, 24%), cardiac dysfunction (8/50, 16%), and pre-eclampsia (6/50, 12%) were the most common reasons for ICU admission. Significant associations were recorded between ICU admission and tachycardia (OR 5.0, 95% CI 2.1-11.7), mean arterial pressure less than 65 mm Hg (OR 4.5, 95% CI 1.9-10.8), temperature of at least 38°C (OR 44.1, 95% CI 13.0-839.1), and altered mental state (OR 44.1, 95% CI 13.1-839.0). Two or more triggers were persistent for 30 minutes or more in 36 (72%) ICU patients versus 2 (4%) controls (OR 61.7, 95% CI 13.2-288.0). Earlier medical intervention might have led to a lesser degree of maternal morbidity for 31 (62%) ICU patients with at least one MEWT. CONCLUSION Persistent MEWTs were present in most obstetric ICU cases. Retrospectively, MEWTs in this cohort seemed to separate normal obstetric patients from those for whom ICU admission was indicated; their use might reduce maternal morbidity.
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Affiliation(s)
- Herman L Hedriana
- Sacramento Maternal Fetal Medicine Medical Group, Sacramento, CA, USA.
| | - Suzanne Wiesner
- Dignity Health Patient Safety and Quality, San Francisco, CA, USA
| | - Brenda G Downs
- Dignity Health Clinical Performance Improvement, San Francisco, CA, USA
| | | | - Laurence E Shields
- Dignity Health Patient Safety and Quality, San Francisco, CA, USA; Marian Regional Medical Center, Obstetrics and Gynecology, Santa Maria, CA, USA
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Implementation of a multidisciplinary clinical pathway for the management of postpartum hemorrhage: a retrospective study. Int J Qual Health Care 2015; 27:459-65. [DOI: 10.1093/intqhc/mzv068] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2015] [Indexed: 11/15/2022] Open
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Stevens TA, Swaim LS, Clark SL. The Role of Obstetrics/Gynecology Hospitalists in Reducing Maternal Mortality. Obstet Gynecol Clin North Am 2015; 42:463-75. [PMID: 26333636 DOI: 10.1016/j.ogc.2015.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The United States experienced a 6.1% annual increase in the maternal death rate from 2000 to 2013. Maternal deaths from hemorrhage and complications of preeclampsia are significant contributors to the maternal death rate. Many of these deaths are preventable. By virtue of their continuous care of laboring patients, active involvement in hospital safety initiatives, and immediate availability, obstetric hospitalists are uniquely positioned to evaluate patients, initiate care, and coordinate a multidisciplinary effort. In cases of significant maternal hemorrhage, hypertensive crisis, and acute pulmonary edema, the availability of an obstetrics hospitalist may facilitate improved patient safety and fewer maternal deaths.
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Affiliation(s)
- Tobey A Stevens
- Department of Obstetrics & Gynecology, Baylor College of Medicine, 6651 Main Street, Suite1020, Houston, TX 77030, USA.
| | - Laurie S Swaim
- Division of Gynecologic and Obstetric Specialists, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite 1020, Houston, TX 77030, USA
| | - Steven L Clark
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 Main Street, Suite 1020, Houston, TX 77030, USA
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Butwick AJ, Carvalho B, Blumenfeld YJ, El-Sayed YY, Nelson LM, Bateman BT. Second-line uterotonics and the risk of hemorrhage-related morbidity. Am J Obstet Gynecol 2015; 212:642.e1-7. [PMID: 25582104 DOI: 10.1016/j.ajog.2015.01.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 11/10/2014] [Accepted: 01/06/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Uterine atony is a leading cause of postpartum hemorrhage. Although most cases of postpartum hemorrhage respond to first-line therapy with uterine massage and oxytocin administration, second-line uterotonics including methylergonovine and carboprost are integral for the management of refractory uterine atony. Despite their ubiquitous use, it is uncertain whether the risk of hemorrhage-related morbidity differs in women exposed to methylergonovine or carboprost at cesarean delivery. STUDY DESIGN We performed a secondary analysis using the Maternal-Fetal Medicine Units Network Cesarean Registry. We identified women who underwent cesarean delivery and received either methylergonovine or carboprost for refractory uterine atony. The primary outcome was hemorrhage-related morbidity defined as intraoperative or postoperative red blood cell transfusion or the need for additional surgical interventions including uterine artery ligation, hypogastric artery ligation, or peripartum hysterectomy for atony. We compared the risk of hemorrhage-related morbidity in those exposed to methylergonovine vs carboprost. Propensity-score matching was used to account for potential confounders. RESULTS The study cohort comprised 1335 women; 870 (65.2%) women received methylergonovine and 465 (34.8%) women received carboprost. After accounting for potential confounders, the risk of hemorrhage-related morbidity was higher in the carboprost group than the methylergonovine group (relative risk, 1.7; 95% confidence interval, 1.2-2.6). CONCLUSION In this propensity score-matched analysis, methylergonovine was associated with reduced risk of hemorrhage-related morbidity during cesarean delivery compared to carboprost. Based on these results, methylergonovine may be a more effective second-line uterotonic.
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Affiliation(s)
- Alexander J Butwick
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA.
| | - Brendan Carvalho
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA
| | - Yair J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Yasser Y El-Sayed
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Lorene M Nelson
- Department of Health Research Policy, Stanford University School of Medicine, Stanford, CA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol 2015; 212:272-80. [PMID: 25025944 DOI: 10.1016/j.ajog.2014.07.012] [Citation(s) in RCA: 143] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 06/17/2014] [Accepted: 07/03/2014] [Indexed: 11/22/2022]
Abstract
The purpose of this study was to assess the effectiveness of instituting a comprehensive protocol for the treatment of maternal hemorrhage within a large health care system. A comprehensive maternal hemorrhage protocol was initiated within a health care system with 29 different delivery units and with >60,000 annual births. Compliance with key elements of the protocol was assessed monthly by a dedicated perinatal safety nurse at each site and validated during site visits by system perinatal nurse specialist. Outcome variables were the total number of units of blood transfused and the number of puerperal hysterectomies. Three time points were assessed: (1) 2 months before implementation of the protocol, (2) a 2-month period that was measured at 5 months after implementation of the protocol, and (3) a 2-month period at 10 months after implementation. There were 32,059 deliveries during the 3 study periods. Relative to baseline, there was a significant reduction in blood product use per 1000 births (-25.9%; P < .01) and a nonsignificant reduction (-14.8%; P = .2) in the number of patients who required puerperal hysterectomy. Within a large health care system, the application of a standardized method to address maternal hemorrhage significantly reduced maternal morbidity, based on the need for maternal transfusion and peripartum hysterectomy. These data support implementation of standardized methods for postpartum care and treatment of maternal hemorrhage and support that this approach will reduce maternal morbidity.
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Einerson BD, Miller ES, Grobman WA. Does a postpartum hemorrhage patient safety program result in sustained changes in management and outcomes? Am J Obstet Gynecol 2015; 212:140-4.e1. [PMID: 25019484 DOI: 10.1016/j.ajog.2014.07.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 06/15/2014] [Accepted: 07/03/2014] [Indexed: 10/25/2022]
Abstract
We sought to determine whether the introduction of a postpartum hemorrhage (PPH) safety program was associated with changes in clinical practice and outcomes, and to examine whether these changes were sustained over time. In August 2008, a multidisciplinary PPH patient safety program was implemented at our single tertiary care hospital. We performed a cohort study of all women with PPH from August 2007 through December 2011. Changes in clinical practice and outcomes were compared before and after the intervention. Shewhart charts were used to examine sustainability of these changes over time. During the study period 52,819 women delivered, and 3105 (5.9%) experienced PPH. After the introduction of the program there was a significant increase in the use of uterotonic medications (P < .001), intrauterine balloon tamponade (P = .002), B-Lynch suture placement (P = .042), uterine artery embolization (P = .050), and cryoprecipitate use (P = .0222). Concomitantly, the number of days between admissions to the intensive care unit for PPH increased.
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Abstract
BACKGROUND Hemorrhage is a potentially preventable cause of adverse outcomes in surgical and obstetric patients. New understanding of the pathophysiology of hemorrhagic shock, including development of coagulopathy, has led to evolution of recommendations for treatment. However, no recent study has examined the legal outcomes of these claims. The authors reviewed closed anesthesia malpractice claims related to hemorrhage, seeking common factors to guide future management strategies. METHODS The authors analyzed 3,211 closed surgical or obstetric anesthesia malpractice claims from 1995 to 2011 in the Anesthesia Closed Claims Project. Claims where patient injury was attributed to hemorrhage were compared with all other surgical and obstetric claims. Risk factors for hemorrhage and coagulopathy, clinical factors, management, and communication issues were abstracted from claim narratives to identify recurrent patterns. RESULTS Hemorrhage occurred in 141 (4%) claims. Obstetrics accounted for 30% of hemorrhage claims compared with 13% of nonhemorrhage claims (P < 0.001); thoracic or lumbar spine surgery was similarly overrepresented (24 vs. 6%, P < 0.001). Mortality was higher in hemorrhage than nonhemorrhage claims (77 vs. 27%, P < 0.001), and anesthesia care was more often judged to be less than appropriate (55 vs. 38%, P < 0.001). Median payments were higher in hemorrhage versus nonhemorrhage claims ($607,750 vs. $276,000, P < 0.001). Risk factors for hemorrhage and coagulopathy were common, and initiation of transfusion therapy was commonly delayed. CONCLUSIONS Hemorrhage is a rare, but serious, cause of anesthesia malpractice claims. Understanding which patients are at risk can aid in patient referral decisions, design of institutional systems for responding to hemorrhage, and education of surgeons, obstetricians, and anesthesiologists.
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The future of obstetrics/gynecology in 2020: a clearer vision: finding true north and the forces of change. Am J Obstet Gynecol 2014; 211:617-22.e1. [PMID: 25173186 DOI: 10.1016/j.ajog.2014.08.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/30/2014] [Accepted: 08/19/2014] [Indexed: 01/17/2023]
Abstract
The pressure to transform health care has been building for many years, and many frameworks have been proposed for this transformation. The 'Triple Aim' concept of improving the health of the population, improving the experience of the patient, and controlling cost can be used as a guide post for the adoption of the necessary changes to thrive in a new construct of women's health care. Following these guiding principles should lead to improved clinical outcomes at affordable costs with high patient and provider satisfaction. The actual changes will come in the form of various 'transformational forces.' One of the driving forces will be conversion of the current payment structure from a fee-for-service model to value-based payments. In addition, the methods of care must be redesigned into a 'team-based' approach in which providers and patients use best practice protocols that are individualized to specific patient needs. Redesign will continue to drive consolidation of providers into larger groups to cover the cost of the needed infrastructure.
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Schlembach D, Mörtl MG, Girard T, Arzt W, Beinder E, Brezinka C, Chalubinski K, Fries D, Gogarten W, Hackelöer BJ, Helmer H, Henrich W, Hösli I, Husslein P, Kainer F, Lang U, Pfanner G, Rath W, Schleussner E, Steiner H, Surbek D, Zimmermann R. [Management of postpartum hemorrhage (PPH): algorithm of the interdisciplinary D-A-CH consensus group PPH (Germany - Austria - Switzerland)]. Anaesthesist 2014; 63:234-42. [PMID: 24584885 DOI: 10.1007/s00101-014-2291-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postpartum hemorrhage (PPH) is one of the main causes of maternal deaths even in industrialized countries. It represents an emergency situation which necessitates a rapid decision and in particular an exact diagnosis and root cause analysis in order to initiate the correct therapeutic measures in an interdisciplinary cooperation. In addition to established guidelines, the benefits of standardized therapy algorithms have been demonstrated. A therapy algorithm for the obstetric emergency of postpartum hemorrhage in the German language is not yet available. The establishment of an international (Germany, Austria and Switzerland D-A-CH) "treatment algorithm for postpartum hemorrhage" was an interdisciplinary project based on the guidelines of the corresponding specialist societies (anesthesia and intensive care medicine and obstetrics) in the three countries as well as comparable international algorithms for therapy of PPH.The obstetrics and anesthesiology personnel must possess sufficient expertise for emergency situations despite lower case numbers. The rarity of occurrence for individual patients and the life-threatening situation necessitate a structured approach according to predetermined treatment algorithms. This can then be carried out according to the established algorithm. Furthermore, this algorithm presents the opportunity to train for emergency situations in an interdisciplinary team.
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Affiliation(s)
- D Schlembach
- Abteilung für Geburtshilfe, Universitätsfrauenklinik, Universitätsklinikum Jena, Bachstr. 18, 07732, Jena, Deutschland,
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Massive blood transfusion during hospitalization for delivery in New York State, 1998-2007. Obstet Gynecol 2014; 122:1288-94. [PMID: 24201690 DOI: 10.1097/aog.0000000000000021] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To define the frequency, risk factors, and outcomes of massive transfusion in obstetrics. METHODS The State Inpatient Dataset for New York (1998-2007) was used to identify all delivery hospitalizations for hospitals that reported at least one delivery-related transfusion per year. Multivariable logistic regression analysis was performed to examine the relationship between maternal age, race, and relevant clinical variables and the risk of massive blood transfusion defined as 10 or more units of blood recorded. RESULTS Massive blood transfusion complicated 6 of every 10,000 deliveries with cases observed even in the smallest facilities. Risk factors with the strongest independent associations with massive blood transfusion included abnormal placentation (1.6/10,000 deliveries, adjusted odds ratio [OR] 18.5, 95% confidence interval [CI] 14.7-23.3), placental abruption (1.0/10,000, adjusted OR 14.6, 95% CI 11.2-19.0), severe preeclampsia (0.8/10,000, adjusted OR 10.4, 95% CI 7.7-14.2), and intrauterine fetal demise (0.7/10,000, adjusted OR 5.5, 95% CI 3.9-7.8). The most common etiologies of massive blood transfusion were abnormal placentation (26.6% of cases), uterine atony (21.2%), placental abruption (16.7%), and postpartum hemorrhage associated with coagulopathy (15.0%). A disproportionate number of women who received a massive blood transfusion experienced severe morbidity including renal failure, acute respiratory distress syndrome, sepsis, and in-hospital death. CONCLUSION Massive blood transfusion was infrequent, regardless of facility size. In the presence of known risk for receipt of massive blood transfusion, women should be informed of this possibility, should deliver in a well-resourced facility if possible, and should receive appropriate blood product preparation and venous access in advance of delivery. LEVEL OF EVIDENCE : II.
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Butwick A. Postpartum hemorrhage and low fibrinogen levels: the past, present and future. Int J Obstet Anesth 2013; 22:87-91. [DOI: 10.1016/j.ijoa.2013.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 01/14/2013] [Indexed: 10/27/2022]
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Miranda JE, Rojas-Suarez J, Paternina A, Mendoza R, Bello C, Tolosa JE. The effect of guideline variations on the implementation of active management of the third stage of labor. Int J Gynaecol Obstet 2013; 121:266-9. [DOI: 10.1016/j.ijgo.2012.12.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 12/19/2012] [Accepted: 02/15/2013] [Indexed: 11/30/2022]
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2012 Gerard W. Ostheimer Lecture – What’s new in obstetric anesthesia? Int J Obstet Anesth 2012; 21:348-56. [DOI: 10.1016/j.ijoa.2012.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 08/09/2012] [Indexed: 11/23/2022]
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Barger MK, Nannini A, DeJoy S, Wisner K, Markenson G. Maternal and newborn outcomes following uterine rupture among women without versus those with a prior cesarean. J Matern Fetal Neonatal Med 2012; 26:183-7. [PMID: 22954425 DOI: 10.3109/14767058.2012.725790] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare outcomes from uterine ruptures (UR) among women without versus with a prior cesarean. METHOD This case-control study matched on gestational age +/- 1 week and birth year +/- 2 years using a variable numbers of controls (maximum = 4) for each case. All URs in Massachusetts between 1990 and 1998 were identified using ICD-9 codes from linked hospital discharge and birth/fetal death certificate files and confirmed by medical record review. Complete hospitalization records were abstracted. Maternal outcomes were hysterectomy, transfusion, ICU admission, shock, assisted ventilation, and hospital length of stay. Infant outcomes were 5 min Apgar less than 3 or need for ventilation at birth, death, or poor prognosis at discharge. RESULTS The UR incidence in women without a prior cesarean was 7 per 100,000 births. Of the 49 women without a prior cesarean and a UR, 36 women met study criteria and were matched to 140 controls. Women without a prior cesarean had more severe maternal morbidity (50% vs. 16%) (adj OR 3.28, 95% CI: 1.70, 6.32) with 47% of cases requiring transfusion and 33% requiring ICU admission. Their hospital stays were nearly two days longer. Among their infants, 14% died or had a poor prognosis at discharge compared to 7% of control infants (OR = 2.42, 95% CI 0.94, 6.28). CONCLUSION Although UR in a woman without a prior cesarean is uncommon, providers should be prepared for more severe maternal morbidity which may be mitigated by prompt surgical intervention and heightened hemodynamic surveillance.
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Affiliation(s)
- Mary K Barger
- Department of Nursing, University of Massachusetts, Lowell, MA, USA.
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PURPOSE OF REVIEW This review summarizes recent developments in maternal mortality surveillance, and draws from recent confidential mortality reports to suggest ways the anesthesiologist can contribute to safer systems of care. RECENT FINDINGS Maternal mortality rates appear to be static in much of the developed world, but are increasing in the USA. While improvements in ascertainment explain some of these trends, deferred childbearing, increasing population rates of coexisting disease, multifetal pregnancy, and emerging infections also contribute. Risk is markedly elevated among certain racial and ethnic minorities, due to a confluence of factors that includes behavior, biology, environmental exposures, social circumstances, and the quality of clinical care. Approximately 30-40% of maternal deaths are potentially preventable, and recent maternal mortality reviews suggest specific strategies that may improve outcomes for women suffering from the most common causes of death: cardiovascular disease, hemorrhage, hypertensive disorders of pregnancy, venous thromboembolism, infection, and other medical conditions. SUMMARY A growing number of countries and organizations have established systems for comprehensive maternal death surveillance and confidential review to ensure that each death counts and that the lessons learned are widely disseminated to improve future maternal safety.
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