The Epidemiology of Postpartum Hemorrhage in a Large, Nationwide Sample of Deliveries

Tranexamic acid administered during cesarean delivery in high-risk patients: maternal pharmacokinetics, pharmacodynamics, and coagulation status

BACKGROUND

Tranexamic acid is frequently administered for postpartum hemorrhage. The World Health Organization recommends 1 g intravenous dosing, repeated once after 30 minutes for ongoing bleeding. Understanding the pharmacokinetics and pharmacodynamics of tranexamic acid in patients at high risk of postpartum hemorrhage may enable dosage tailoring for optimal antifibrinolysis with minimal adverse events, such as thrombosis or renal cortical necrosis.

OBJECTIVE

This study aimed to report tranexamic acid pharmacokinetics and pharmacodynamics after 1 g intravenous dosing during cesarean delivery in patients at risk of hemorrhage. The primary endpoint was tranexamic acid plasma concentration of >10 μg/mL, known to inhibit 80% of fibrinolysis. In addition, the correlation between patient demographics and rotational thromboelastometry coagulation changes were analyzed.

STUDY DESIGN

In this prospective study, 20 women aged 18 to 50 years, ≥23 weeks of gestation undergoing cesarean delivery with at least 1 major (placenta previa, suspected placenta accreta spectrum, or active bleeding) or 2 minor (≥2 previous cesarean deliveries, previous postpartum hemorrhage, chorioamnionitis, polyhydramnios, macrosomia, obesity, or suspected placental abruption) risk factors for postpartum hemorrhage were recruited. The exclusion criteria were allergy to tranexamic acid, inherited thrombophilia, previous or current thrombosis, seizure history, renal or liver dysfunction, anticoagulation, or category III fetal heart tracing. Tranexamic acid 1 g was administered after umbilical cord clamping. Blood samples were drawn at 3, 7, 15, and 30 minutes and then at 30-minute intervals up to 5 hours. Plasma concentrations were evaluated as mean (standard error). Serial rotational thromboelastometry was performed and correlated with tranexamic acid plasma concentrations.

RESULTS

The median age of participants was 37.5 years (interquartile range, 35.0-39.5), and the median body mass index was 28.6 kg/m2 (interquartile range, 24.9-35.0). The median blood loss (estimated or quantitative) was 1500 mL (interquartile range, 898.5-2076.0). Of note, 9 of 20 (45%) received a transfusion of packed red blood cells. The mean peak tranexamic acid plasma concentration at 3 minutes was 59.8±4.7 μg/mL. All patients had a plasma concentration >10 μg/mL for 1 hour after infusion. Plasma concentration was >10 μg/mL in more than half of the patients at 3 hours and fell <10 μg/mL in all patients at 5 hours. There was a moderate negative correlation between body mass index and the plasma concentration area under the curve (r=-0.49; 95% confidence interval, -0.77 to -0.07; P=.026). Rotational thromboelastometry EXTEM maximum clot firmness had a weak positive correlation with longitudinal plasma concentration (r=0.32; 95% confidence interval, 0.21-0.46; P<.001). EXTEM maximum clot lysis was 0% after infusion in 18 patients (90%), and no patient in the study demonstrated a maximum lysis of >15% at any interval from 3 minutes to 5 hours. There was no significant correlation between EXTEM clot lysis at 30 minutes and longitudinal tranexamic acid plasma concentrations (r=0.10; 95% confidence interval, -0.20 to 0.19; P=.252).

CONCLUSION

After standard 1 g intravenous dosing of tranexamic acid during cesarean delivery in patients at high risk of hemorrhage, a plasma concentration of ≥10 μg/mL was sustained for at least 60 minutes. Plasma tranexamic acid levels correlated inversely with body mass index. The concurrent use of rotational thromboelastometry may demonstrate tranexamic acid's impact on clot firmness but not a hyperfibrinolysis-derived trigger for therapy.

Risk factors and recurrence of cause-specific postpartum hemorrhage: A population-based study

OBJECTIVE

To explore risk profiles of the different types of postpartum hemorrhage (PPH >500ml or severe PPH >1500ml) and their recurrence risks in a subsequent delivery.

METHODS

With data from The Medical Birth Registry of Norway and Statistics Norway we performed a population-based cohort study including all singleton deliveries in Norway from 1967-2017. Multilevel logistic regression was used to calculate odds ratio (OR), with 95% confidence interval (CI), with different PPH types (PPH >500ml or PPH >1500ml (severe PPH) combined with retained placenta, uterine atony, obstetric trauma, dystocia, or undefined cause) as outcomes.

RESULT

We identified 277 746 PPH cases of a total of 3 003 025 births (9.3%) from 1967 to 2017. Retained placenta (and/or membranes) was most often registered as severe PPH (29.3%). Maternal, fetal, and obstetric characteristics showed different associations with the PPH types. Male sex of the neonate was associated with reduced risk of PPH. This effect was strongest on PPH due to retained placenta (adjusted OR, (aOR): 0.80, 95% CI 0.78-0.82), atony (aOR 0.92, 95% CI: 0.90-0.93) and PPH with undefined cause (aOR 0.96, 95% CI: 0.95-0.97). Previous cesarean section showed a strong association with PPH due to dystocia (aOR of 13.2, 95% CI: 12.5-13.9). Recurrence risks were highest for the same type: PPH associated with dystocia (aOR: 6.8, 95% CI: 6.3-7.4), retained placenta and/or membranes (aOR: 5.9, 95% CI: 5.5-6.4), atony (aOR: 4.0, 95% CI: 3.8-4.2), obstetric trauma (aOR: 3.9, 95% CI: 3.5-4.3) and PPH of undefined cause (aOR: 2.2, 95% CI: 2.1-2.3).

CONCLUSION

Maternal, fetal and obstetric characteristics had differential effects on types of PPH. Recurrence differed considerably between PPH types. Retained placenta was most frequently registered with severe PPH, and showed strongest effect of sex; delivery of a boy was associated with lower risk of PPH. Previous cesarean increased the risk of PPH due to dystocia.

Target areas to reduce the burden of maternal death due to obstetric hemorrhage in Ethiopia

BACKGROUND

Obstetric hemorrhage is defined as active bleeding of more than 500 ml in vaginal delivery or 1000ml following cesarean delivery. It is the leading cause of maternal death, which contributes to up to 50% of maternal deaths in Ethiopia. This study aims to assess the relationships between adverse maternal health exposure (personal and medical factors) and delay in health care (hesitancy in opting to seek care, lag in reaching a health facility, and wait in receiving health care at the facility) and adverse outcomes of obstetric hemorrhage among reviewed maternal deaths in Ethiopia.

METHODS

This study utilizes 4530 reported maternal death surveillance data obtained from Ethiopian maternal death surveillance and response (MDSR) system between 2013 to 2020. Latent class analysis was applied to identify underlying patterns of adverse maternal health exposures. Furthermore, the associations between latent classes and adverse outcomes of obstetric hemorrhage were analyzed using multilevel logistics regression model adjusted for clustering within reporting provinces.

RESULTS

Nearly 56% of the reviewed maternal deaths were due to the adverse outcome of obstetric hemorrhage, among which nearly 75% died during the postpartum period. The study identified six separate sub-groups of women based on their vulnerability to adverse maternal health conditions. The six subgroups identified by this study are 1) women who travelled for a long duration to reach a health care provider, 2) those who had no access to a health facility (HF) within a 5Km radius, 3) those who failed to decide to go to a health facility: 4) those with multiparity,5) those who were injured during delivery with history of coagulopathy, and 6) those who got injured during delivery and failed to decide to go to a health facility. Women in the class of grand multipara have demonstrated the highest risk of death due to the adverse outcomes of obstetric hemorrhage (β = 1.54, SE = 0.09, p<0.0001).

CONCLUSIONS

The study has attempted to identify women that are at a higher risk for the adverse outcomes of obstetric hemorrhage. Henceforth, targeted intervention should be taken on women of reproductive age group, and those identified as at a higher risk, to reduce the high rate of maternal death due to obstetric hemorrhage.

Determining the incidence of postpartum haemorrhage among Ontario women with and without inherited bleeding disorders: A population-based cohort study

INTRODUCTION

At a population level, there is a poor understanding of the incidence and pre-disposing risk factors of postpartum haemorrhage (PPH) among women with inherited bleeding disorders (IBD).

AIM

To determine the incidence of PPH, and identify maternal factors associated with risk of PPH among women with IBD.

METHODS

We conducted a retrospective cohort study using data housed within ICES (formerly known as the Institute for Clinical Evaluative Sciences). The cohort included women with an in-hospital, live or stillborn delivery, between January 2014 and December 2019. The primary outcome was PPH (identified by ICD-10 code O72). PPH incidence and risk factors were compared between women with and without IBD. Temporal trends were assessed using the Cochrane-Armitage test. Between group differences were assessed using standardised differences (std. difference).

RESULTS

Total 601,773 women were included; 2002 (.33%) had an IBD diagnosis. PPH incidence was 1.5 times higher (7.3 vs. 4.9 cases/100 deliveries, std. difference .1) among women with IBD compared to women without. Women with IBD were slightly older (31.7 vs. 30.7 years), had higher rates of hypertension, previous PPH, and induction of labour. Women with IBD were more frequently diagnosed with anaemia (4.8% vs. 1.8%; std difference .17) and had lower haemoglobin levels at admission for delivery compared to women without IBD.

CONCLUSIONS

This study contributes to the literature regarding obstetric bleeding among women with IBD, showing that anaemia at delivery may be an important risk factor for PPH. Given their predisposition to anaemia, clarifying this relationship will optimise management and outcomes.

Postpartum Hemorrhage Management and Blood Component Therapy

This article serves to highlight both the common nature and severity of postpartum hemorrhage (PPH). Identification of etiologies and management of each is reviewed. In addition, the evaluation and administration of proper blood component therapies and massive transfusion are also explained to help providers become comfortable with early administration and delivery of blood component therapies.

Trend Changes in the individual contribution of risk factors for postpartum hemorrhage over more than two decades

OBJECTIVE

Postpartum hemorrhage is an obstetric emergency with a rising incidence. The aim of this study was to identify trends in the specific contribution of various risk factors for postpartum hemorrhage by observing their odds ratios throughout different time periods.

STUDY DESIGN

In this population-based retrospective cohort study trends of change in odds ratios for known risk factors for postpartum hemorrhage occurring in three consecutive eight-year intervals between 1988 and 2014 were compared. Two multivariable logistic regression models were used in order to identify independent risk factors for postpartum hemorrhage in our population. Trends of various risk factors were compared along the time period of the study.

RESULTS

The incidence of postpartum hemorrhage increased from 0.5% to 1988 to 0.6%. Using logistic regression models, preeclampsia, vacuum extraction delivery, retained placenta, perineal or vaginal tears and delivery of a large for gestational age neonate were recognized as independent risk factors for postpartum hemorrhage. While the odds ratios for perineal or vaginal tears significantly increased, odds ratios for delivery of a large for gestational age neonate significantly decreased. Odds ratios for the other risk factors did not change significantly.

CONCLUSION

In our study, not only did the rates of statistically significant risk factors for postpartum hemorrhage change during the study period, the specific contribution of each risk factor changed as well. Having a better understanding of these trends might augment our ability to predict this grave obstetric complication and improve maternal outcomes in the future.

Hospital-level variation in rates of postpartum hemorrhage in California

BACKGROUND

To examine the extent of hospital-level variation in risk-adjusted rates of postpartum hemorrhage (PPH).

STUDY DESIGN AND METHODS

We performed a cross-sectional study examining live births in 257 California hospitals between 2011 and 2015 using linked birth certificate and maternal discharge data. PPH was measured using International Classification of Diseases Codes version 9. Mixed-effects logistic regression models were used to examine the presence and extent of hospital-level variation in PPH before and after adjustment for patient-level risk factors and select hospital characteristics (teaching status and annual delivery volume). Risk-adjusted rates of PPH were estimated for each hospital. The extent of hospital variation was evaluated using the median odds ratio (MOR) and intraclass correlation coefficient (ICC).

RESULTS

Our study cohort comprised 1,904,479 women who had a live birth delivery hospitalization at 247 hospitals. The median, lowest, and highest hospital-specific rates of PPH were 3.48%, 0.54%, and 12.0%, respectively. Similar rates were observed after adjustment for patient and hospital factors (3.44%, 0.60%, and 11.48%). After adjustment, the proportion of the total variation in PPH rates attributable to the hospital was low, with a MOR of 2.02 (95% confidence interval [CI]: 1.89-2.15) and ICC of 14.3% (95% CI: 11.9%-16.3%).

DISCUSSION

Wide variability exists in the rate of PPH across hospitals in California, not attributable to patient factors, hospital teaching status, and hospital annual delivery volume. Determining whether differences in hospital quality of care explain the unaccounted-for variation in hospital-level PPH rates should be a public health priority.

The association of preterm delivery with postpartum bleeding in otherwise uncomplicated pregnancies

Objective:

The primary aim was to investigate whether preterm delivery was an independent risk factor for blood or blood products transfusion in the intrapartum or postpartum period, considered as a proxy for severe obstetric bleeding.

Material and Methods:

Throughout a 9-month-period, 216 uncomplicated singleton deliveries were included in a cross-sectional study after exclusion of severe maternal and fetal morbidity, such as chorioamnionitis, and use of medications including tocolytics. Maternal and neonatal data were evaluated and compared across preterm (between 24 0/7-36 6/7 weeks’ gestation) and term (between 37 0/7-41 6/7 weeks’ gestation) deliveries. Primary and secondary outcomes were requirement for blood or blood products transfusion until discharge and change in hemoglobin value and hematocrit from baseline to postpartum hour 6, respectively. Logistic regression models were constructed to evaluate the effect of preterm delivery on the primary outcome.

Results:

There were 90 (41.7%) preterm deliveries with an overall cesarean section rate of 77.8%. Preterm delivery was not an independent risk factor for the primary outcome, when route of delivery, maternal body-mass index, antenatal steroid administration, and baseline (admission) platelet and leukocyte counts were controlled for [adjusted risk ratio, 2.46; 95% confidence interval (CI), 0.69-8.77; p=0.16]. Subgroup analysis, including cesarean deliveries, revealed a similar result (adjusted risk ratio, 1.65; 95% CI, 0.42-6.48; p=0.47). Secondary outcomes, including decrease in mean or percent values of hemoglobin and hematocrit measurements, were also similar across preterm and term groups, both after vaginal and cesarean delivery (for all comparisons, p>0.05).

Conclusion:

Preterm delivery is not independently associated with increased requirement for blood transfusions or decreased hemoglobin and hematocrit values following otherwise uncomplicated vaginal or cesarean delivery of singletons.

Anemia and Associated Factors Among Lactating Women in Sierra Leone: An Analysis of the Sierra Leone Demographic and Health Survey 2019

Background

Anemia is a condition in which hemoglobin (Hb) concentration and/or red blood cell (RBC) numbers are lower than normal and insufficient to meet an individual's physiological needs. The prevalence of anemia among women of reproductive age is high in Sub-Saharan Africa (SSA), including Sierra Leone. However, data on anemia among lactating women in Sierra Leone are scarce. Therefore, this study was conducted to estimate the prevalence of anemia and determine its associated factors among lactating women in Sierra Leone.

Methods

The 2019 Sierra Leone Demographic and Health Survey (SLDH) data were used of which 1543 lactating women aged 15 to 49 years old had hemoglobin measurements. Multistage stratified sampling was used to select study participants and data were collected using validated questionnaires. Multivariate binary logistic regression was used to determine factors associated with anemia among lactating women in Sierra Leone.

Results

The general prevalence of anemia among lactating women in Sierra Leone was 52.9% (95% CI = 50.9-55.8). Almost a quarter, 23.8% (95% CI = 22.1-26.3) of the lactating women had mild anemia, 27.4% (95% CI = 25.3-29.7) had moderate anemia and 1.7% (95% CI = 1.1-2.5) had severe anemia. The use of modern contraceptives (aOR = 1.64, 95% CI = 1.09-2.47), not being visited by a field worker in the past year (aOR = 1.51, 95% CI = 1.12-2.03) and being Muslim (aOR = 1.46, 95% CI = 1.11-1.91), were associated with higher odds of being anemic. Being given and having bought iron supplements during pregnancy (aOR = 0.46, 95% CI = 0.25-0.87) was associated with less odds of being anemic.

Conclusion

More than half of the lactating mothers in our study were anemic. The risk factors for anemia in our study included: use of modern contraceptives, not being visited by a field worker in the past year and being Muslim. Receiving iron supplements during pregnancy was protective against anemia. According to the results from this study, the recommendation for lactating women was to maintain routine interface with the healthcare system which includes being visited by a field worker who should prescribe and issue iron supplements to them. Lactating women especially Muslims should receive routine nutrition education by the health workers at the health facilities during antenatal care visits or postnatal care in regard to anemia and means of prevention and treatment. Community stakeholders should also work in collaboration to establish scalable methods to correctly identify pregnant women with risk factors, inform them about anemia with caution, and apply appropriate measures as trained or instructed.

Calcium chloride for the prevention of uterine atony during cesarean delivery: A pilot randomized controlled trial and pharmacokinetic study

STUDY OBJECTIVE

To assess the feasibility, patient tolerance, pharmacokinetics, and potential effectiveness of a randomized controlled trial protocol investigating intravenous calcium chloride for the prevention of uterine atony during cesarean delivery.

DESIGN

Double-blind, randomized controlled pilot trial with nested population pharmacokinetic analysis.

SETTING

This study was performed at Lucile Packard Children's Hospital, from August 2018 to September 2019.

PATIENTS

Forty patients with at least two risk factors for uterine atony at the time of cesarean delivery.

INTERVENTIONS

One gram of intravenous calcium chloride (n = 20 patients) or a saline placebo control (n = 20 patients), in addition to standard care with oxytocin, upon umbilical cord clamping.

MEASUREMENTS

The primary efficacy-related outcome was the presence of uterine atony defined as the use of a second-line uterotonic medication, surgical interventions for atony, or hemorrhage with blood loss >1000 mL. Blood loss, uterine tone numerical rating scores, serial venous blood calcium levels, hemodynamics, and potential side effects were also assessed.

MAIN RESULTS

The study protocol proved feasible. The incidence of atony was 20% in parturients who received calcium compared to 50% in the placebo group (relative risk 0.38, P = 0.07, 95% CI 0.15-1.07, NNT 3.3). Calcium recipients tolerated the drug infusion well, with no adverse events and an equal incidence of potential side effects in the calcium and placebo groups. Ionized calcium concentration rose significantly in all patients who received calcium infusion, from baseline 1.18 mmol/L to peak levels 1.50-1.60 mmol/L. One-compartment population pharmacokinetics established clearance of 0.93 (95% CI 0.63-1.52) L/min and volume of distribution 76 (95% CI 49-94) L.

CONCLUSIONS

In this pilot study, investigators found that intravenous calcium chloride was well-tolerated by the 20 patients assigned to receive the study drug and may be effective in prevention of uterine atony. A 1-g dose was sufficient to substantially increase calcium levels without any critically elevated lab values or concern for adverse side effects. These encouraging findings warrant further investigation of calcium as a novel agent to prevent uterine atony with an adequately powered clinical trial. Clinical trial registry NCT03867383 https://clinicaltrials.gov/ct2/show/NCT03867383.

Natural language processing of admission notes to predict severe maternal morbidity during the delivery encounter

BACKGROUND

Severe maternal morbidity and mortality remain public health priorities in the United States, given their high rates relative to other high-income countries and the notable racial and ethnic disparities that exist. In general, accurate risk stratification methods are needed to help patients, providers, hospitals, and health systems plan for and potentially avert adverse outcomes.

OBJECTIVE

Our objective was to understand if machine learning methods with natural language processing of history and physical notes could identify a group of patients at high risk of maternal morbidity on admission for delivery without relying on any additional patient information (eg, demographics and diagnosis codes).

STUDY DESIGN

This was a retrospective study of people admitted for delivery at 2 hospitals (hospitals A and B) in a single healthcare system between July 1, 2016, and June 30, 2020. The primary outcome was severe maternal morbidity, as defined by the Centers for Disease Control and Prevention; furthermore, we examined nontransfusion severe maternal morbidity. Clinician documents designated as history and physical notes were extracted from the electronic health record for processing and analysis. A bag-of-words approach was used for this natural language processing analysis (ie, each history or physical note was converted into a matrix of counts of individual words (or phrases) that occurred within the document). The least absolute shrinkage and selection operator models were used to generate prediction probabilities for severe maternal morbidity and nontransfusion severe maternal morbidity for each note. Model discrimination was assessed via the area under the receiver operating curve. Discrimination was compared between models using the DeLong test. Calibration plots were generated to assess model calibration. Moreover, the natural language processing models with history and physical note texts were compared with validated obstetrical comorbidity risk scores based on diagnosis codes.

RESULTS

There were 13,572 delivery encounters with history and physical notes from hospital A, split between training (A_train, n=10,250) and testing (A_test, n=3,322) datasets for model derivation and internal validation. There were 23,397 delivery encounters with history and physical notes from hospital B (B_valid) used for external validation. For the outcome of severe maternal morbidity, the natural language processing model had an area under the receiver operating curve of 0.67 (95% confidence interval, 0.63-0.72) and 0.72 (95% confidence interval, 0.70-0.74) in the A_test and B_valid datasets, respectively. For the outcome of nontransfusion severe maternal morbidity, the area under the receiver operating curve was 0.72 (95% confidence interval, 0.65-0.80) and 0.76 (95% confidence interval, 0.73-0.79) in the A_test and B_valid datasets, respectively. The calibration plots demonstrated the bag-of-words model's ability to distinguish a group of individuals at a substantially higher risk of severe maternal morbidity and nontransfusion severe maternal morbidity, notably those in the top deciles of predicted risk. Areas under the receiver operating curve in the natural language processing-based models were similar to those generated using a validated, retrospectively derived, diagnosis code-based comorbidity score.

CONCLUSION

In this practical application of machine learning, we demonstrated the capabilities of natural language processing for the prediction of severe maternal morbidity based on provider documentation inherently generated at the time of admission. This work should serve as a catalyst for providers, hospitals, and electronic health record systems to explore ways that artificial intelligence can be incorporated into clinical practice and evaluated rigorously for their ability to improve health.

How do I perform cell salvage during vaginal obstetric hemorrhage?

BACKGROUND

Obstetric hemorrhage is a leading cause of preventable maternal mortality. To combat this, obstetric organizations worldwide recommend consideration of autotransfusion during severe peripartum bleeding to minimize allogenic transfusion. Current guidelines for autotransfusion in obstetrics are limited to patients undergoing cesarean birth. At present, women experiencing vaginal obstetric hemorrhage are excluded from many obstetric autotransfusion protocols. However, emerging data suggest that autotransfusion of vaginally shed blood is both safe and feasible in the obstetric patient population.

METHODS AND MATERIALS

In this review, we will provide an overview of the current literature surrounding cell salvage of vaginally send blood and a detailed outline of our institution's blood collection protocol.

RESULTS

Recent data suggests autotransfusion of vaginally shed blood is both safe and effective.

DISCUSSION

Implementation of autotransfusion technology into the delivery room is a critical next step for the advancement of transfusion medicine in obstetrics. This review provides an overview of the data surrounding autotransfusion of vaginally shed blood during maternal hemorrhage and describes practical suggestions for how it can be effectively implemented into routine practice.

[Postpartum hemorrhage : Interdisciplinary consideration in the context of patient blood management]

Postpartum hemorrhage (PPH) nowadays still represents a severe complication of both a vaginal delivery and a cesarean section. In German-speaking areas a new definition of the term has recently become established and the nomenclature with respect to the severe form of PPH was dropped. The handling of misoprostol as a uterotonic during treatment of PPH is also new, which is available in Germany only as a medical direct import. For adequate diagnostics and targeted treatment interdisciplinary and standardized algorithms should be established and the specialist disciplines involved should be sensitized to this problem. In addition to an adequate hemostasis, a developing coagulopathy must be recognized at an early stage and treated with targeted coagulation management. Through implementation concepts, particularly the second pillar (minimization of blood loss) and the third pillar (rational use of blood transfusions) of patient blood management, various aspects for improvement of treatment of a PPH can be identified.

Disparities in obstetric hemorrhage outcomes

Both the maternal and fetal outcomes of pregnancy vary greatly according to a pregnant woman’s community and her condition. The most devastating outcome is the death of a mother. In 2017, there were ≈295,000 maternal deaths globally with dramatic differences in maternal mortality based on geographic region, country, and women’s underlying conditions. Worldwide, the leading cause of maternal death is hemorrhage, comprising 94% of maternal deaths, with most cases occurring in low‐ or middle‐income countries. Whether a hemorrhage originates from inside the uterus (80%‐90%), from lacerations or incisions (10%‐20%), or from an underlying coagulopathy (<1%), an acute acquired coagulopathy will evolve unless the hemorrhage is controlled. In low‐ or middle‐income countries, the full range of resources to control hemorrhage is not available, but besides the usual obstetric measures, blood availability, hemostatic medication, and hematologic expertise are necessary to save mothers’ lives. Hemostasis and thrombosis experts can address the disparities in obstetric hemorrhage outcomes not only as providers but as consultants, researchers, and advocates.

Trends in Venous Thromboembolism and Associated Risk Factors During Delivery Hospitalizations From 2000 to 2018

OBJECTIVE

To characterize trends in and risk factors for venous thromboembolism (VTE) during delivery hospitalizations in the United States.

METHODS

The 2000-2018 National Inpatient Sample was used for this repeated cross-sectional analysis. Venous thromboembolism (including deep vein thrombosis [DVT] and pulmonary embolism) during delivery hospitalizations for women aged 15 to 54 years was determined by year. Temporal trends in VTE were characterized using joinpoint regression with estimates presented as the average annual percent change. Temporal trends in common VTE risk factors were also analyzed. The proportion of vaginal and cesarean deliveries by year that had VTE risk factors was determined, and average annual percent changes with 95% CIs were calculated. The relationship between risk factors and the likelihood of VTE events was determined with adjusted and unadjusted logistic regression models.

RESULTS

Of 73,109,789 delivery hospitalizations, 48,546 VTE events occurred (6.6/10,000 deliveries), including 37,312 DVT diagnoses and 12,487 pulmonary embolism diagnoses. Rates increased significantly for vaginal (average annual percent change 2.5%, 95% CI 1.5-3.5%) but not for cesarean delivery hospitalizations (average annual percent change 0.3%, 95% CI -1.0 to 1.6%) over the study period. Pulmonary embolism increased for both vaginal delivery (average annual percent change 8.7%, 95% CI 6.0-11.5%) and cesarean delivery (average annual percent change 4.9%, 95% CI 3.6-6.2%). The proportion of cesarean deliveries with at least one VTE risk factor increased from 27.2% in 2000 to 43.6% in 2018 (average annual percent change 2.6%, 95% CI 2.2-3.1%) and for vaginal deliveries, from 17.7% to 31.4% (average annual percent change 3.4%, 95% CI 2.3-4.4%). The 5.9% of deliveries with at least two VTE risk factor diagnoses accounted for 25.4% of VTE diagnoses. Factors with the highest VTE risk included transfusion (adjusted odds ratio [aOR] 4.1, 95% CI 3.7-4.5), infection (aOR 5.8, 95% CI 5.3-6.3), history of VTE (aOR 7.2, 95% CI 6.2-8.4), and thrombophilias (aOR 9.6, 95% CI 8.5-11.0).

CONCLUSION

Both risk factors for VTE and rate of pulmonary embolism increased over the study period. Deep vein thrombosis increased during vaginal delivery hospitalizations but not during cesarean delivery hospitalizations.

Low-intensity ultrasound promotes uterine involution after cesarean section: the first multicenter, randomized, controlled clinical trial

OBJECTIVE

To evaluate the clinical efficacy and safety of low-intensity ultrasound (LIUS) in promoting uterine involution and relieving postpartum pain.

METHODS

The randomized controlled clinical trial in this study was conducted at five centers in three regions across China from June 2014 to December 2014. A total of 498 subjects were randomly divided into two groups. The LIUS group received ultrasound treatment, and the control group received sham ultrasound treatment. The fundal height and visual analogue scale (VAS) scores of the subjects following cesarean section were recorded separately before and after five treatments. The incidence of adverse events was recorded, while the records on lochia duration were obtained by telephone follow-up. The Full Analysis Set (FAS) comprised all subjects randomized who received at least one treatment. The Per-Protocol Set (PPS) comprised all patients who did not seriously violate the study protocol and had good compliance with complete report forms. Efficacy analyses were performed based on the FAS and PPS. All safety analyses were performed based on the safety set (SS), which included all patients who received at least one treatment.

RESULTS

In the analysis of PPS and FAS, the LIUS group performed better than the control group in reducing the fundal height, shortening the duration of lochia, and relieving postpartum pain, with a significant difference between the two groups (p < 0.0001). In the SS analysis, there were no treatment-related adverse events observed in either group.

CONCLUSIONS

The LIUS therapy is safe and effective, which contributes to uterine involution and the alleviation of postpartum pain.

A comprehensive digital phenotype for postpartum hemorrhage

OBJECTIVE

We aimed to establish a comprehensive digital phenotype for postpartum hemorrhage (PPH). Current guidelines rely primarily on estimates of blood loss, which can be inaccurate and biased and ignore complementary information readily available in electronic medical records (EMR). Inaccurate and incomplete phenotyping contributes to ongoing challenges in tracking PPH outcomes, developing more accurate risk assessments, and identifying novel interventions.

MATERIALS AND METHODS

We constructed a cohort of 71 944 deliveries from the Mount Sinai Health System. Estimates of postpartum blood loss, shifts in hematocrit, administration of uterotonics, surgical interventions, and diagnostic codes were combined to identify PPH, retrospectively. Clinical features were extracted from EMRs and mapped to common data models for maximum interoperability across hospitals. Blinded chart review was done by a physician on a subset of PPH and non-PPH patients and performance was compared to alternate PPH phenotypes. PPH was defined as clinical diagnosis of postpartum hemorrhage documented in the patient's chart upon chart review.

RESULTS

We identified 6639 PPH deliveries (9% prevalence) using our phenotype-more than 3 times as many as using blood loss alone (N = 1,747), supporting the need to incorporate other diagnostic and intervention data. Chart review revealed our phenotype had 89% accuracy and an F1-score of 0.92. Alternate phenotypes were less accurate, including a common blood loss-based definition (67%) and a previously published digital phenotype (74%).

CONCLUSION

We have developed a scalable, accurate, and valid digital phenotype that may be of significant use for tracking outcomes and ongoing clinical research to deliver better preventative interventions for PPH.

Association between anesthetic method and postpartum hemorrhage in Korea based on National Health Insurance Service data

Background

Postpartum hemorrhage (PPH) is a major cause of maternal mortality and the risk factors for PPH differ among studies. In this large-scale study, we investigated whether the anesthetic method used was associated with PPH after cesarean section.

Methods

We extracted data on cesarean sections performed between January 2008 and June 2013 from the National Health Insurance Service database. The anesthetic methods were categorized into general, spinal and epidural anesthesia. To compare the likelihood of PPH among deliveries using different anesthetic methods, crude and adjusted odds ratios (ORs) and 95% confidence intervals were calculated using logistic regression analysis.

Results

Data from 330,324 cesarean sections were analyzed, and 21,636 cases of PPH were identified. Univariate analysis showed that general and epidural anesthesia increased the risk of PPH compared to spinal anesthesia. The OR for PPH was highest for morbidly adherent placenta, followed by placenta previa, placental abruption, and hypertension. When other clinical covariates were controlled for, general and epidural anesthesia still remained significant risk factors for PPH compared to spinal anesthesia.

Conclusions

This study showed that general and epidural anesthesia elevated the risk of PPH compared to spinal anesthesia during cesarean section. Since we could not consider the potential bias of group differences in indications, more in-depth clinical trials are needed to validate our findings. Obstetric factors such as placental abnormalities had high odds ratios and thus are more important than the choice of anesthetic method, which should be based on the patient's clinical condition and institutional resources.

Cost-effectiveness analysis of carbetocin versus oxytocin for the prevention of postpartum hemorrhage following vaginal birth in the United Kingdom

AIMS

To assess the cost-effectiveness of carbetocin versus oxytocin for the prevention of postpartum hemorrhage (PPH) following vaginal birth from the perspective of the UK National Health Service (NHS).

MATERIALS AND METHODS

A decision tree model was designed to analyze the cost per PPH event avoided associated with utilizing carbetocin versus oxytocin for prophylactic treatment of PPH in women following vaginal birth from a UK perspective. It modelled the potential for women to require an additional uterotonic after prophylaxis, and to still experience a PPH event and receive associated treatment. Inpatient recovery and follow-up periods post-PPH were also included in the model. Costs associated with drug acquisition and administration, PPH management (i.e. additional staffing and possible operating theater and high dependency unit utilization), inpatient hospitalization, and follow-up visits were all considered. Adverse event management costs were not included. Resource utilization varied depending on the severity of the PPH event (as defined by the amount of blood lost). PPH events avoided were estimated. In an exploratory analysis, quality adjusted life years (QALYs) were estimated as well.

RESULTS

In the deterministic base case, costs were £55 lower and PPH events were 0.0342 lower per woman with carbetocin use compared to oxytocin use. Across the cohort of 100 women the reduction in PPH events led to the largest cost savings (£4,233 saved) out of all cost categories, with total cost savings of £5,495. Carbetocin utilization amongst the entire cohort led to 3.42 avoided PPH events compared to oxytocin utilization, comprised of 3.03 fewer mild/moderate PPH events and 0.39 fewer severe PPH events. Carbetocin utilization led to 0.0001 additional QALYs per woman.

CONCLUSION

Carbetocin utilization leads to lower prophylactic treatment costs and less PPH events versus oxytocin when utilized for the prevention of PPH following vaginal birth in the UK.

Utilization and Comparative Effectiveness of Uterine Artery Embolization vs. Hysterectomy for Severe Postpartum Hemorrhage: A National Inpatient Sample Study

PURPOSE

To assess if uterine artery embolization conferred a lower risk of mortality or prolonged hospital stay compared to hysterectomy in severe post-partum hemorrhage (PPH) and to analyze if geographical or clinical determinants affected which therapy was received.

MATERIALS AND METHODS

This National Inpatient Sample study from 2005-2017 included all patients with live-birth deliveries. Severe PPH was defined as those requiring transfusion, hysterectomy, or uterine artery embolization (UAE). Propensity score weighting adjusted demographic, maternal, and delivery risk factors were used to assess mortality and prolonged hospital stay.

RESULTS

Of 9.8 million identified live births, PPH occurred in 31.0 per 1,000. The most common intervention for PPH was transfusion (116.4 per 1,000 cases of PPH). Hysterectomy was used more frequently than UAE (20.4 vs 12.9 per 1,000). The following factors predicted hysterectomy would be used more commonly than UAE: previous cesarean delivery, breech fetal position, placenta previa, transient hypertension of pregnancy without pre-eclampsia, pre-existing hypertension without pre-eclampsia, pre-existing hypertension with pre-eclampsia, unspecified maternal hypertension, and gestational diabetes (all p<0.001). Delivery risk factors associated with greater utilization of hysterectomy over UAE included post-dates pregnancy, premature rupture of membranes, cervical laceration, forceps vaginal delivery, and shock (all p<0.001). There was no difference in mortality between hysterectomy and UAE. After balancing demographic, maternal, and delivery risk factors, the odds of prolonged hospital stay were 0.38 times lower with UAE than hysterectomy (p<0.001).

CONCLUSION

Despite similar mortality and shorter hospital stays, UAE is used far less than hysterectomy in the management of severe PPH.

Manual Removal versus Spontaneous Delivery of the Placenta at Cesarean Section: A Meta-Analysis of Randomized Controlled Trials

Purpose

Several randomized clinical trials (RCTs) investigated the effects of the manual placental removal on hemorrhage or other hemorrhage-related complications compared with the spontaneous placental removal during cesarean section (CS), while the results remained controversial and were inconsistent. The purpose of this meta-analysis was to quantify the pooled effects of the methods of placental removal on hemorrhage during CS.

Patients and Methods

A systematic literature search was conducted using PubMed, EMBASE, Web of Science, and Google Scholar. Heterogeneity was tested by I² statistics and Q-statistic. The random-effects model or fixed-effects model were used to calculate the pooled effect for the included studies according to heterogeneity. And the term of standardized mean difference (SMD) with 95% confidence intervals (CI) was pooled and estimated the effects across all studies.

Results

A total of nine RCTs were included in this meta-analysis. Compared with spontaneous group, manual placental removal increased the amount of hemorrhage (SMD = 0.53, 95% CI [0.12, 0.94]; Z = 2.54, P = 0.011) and increased the risk of endometritis (OR = 1.84, 95% CI [1.31, 2.58]; Z = 3.52, P < 0.0001). In contrast, there was no significant difference concerning the operating time (SMD = −0.30, 95% CI [−0.85, 0.24]; Z = 1.09, P = 0.276), the length of hospital stays (SMD = 0.11, 95% CI [−0.08, 0.30]; Z = 1.11, P = 0.265), and blood transfusion requirement (OR = 1.36, 95% CI [0.91, 2.04]; Z = 1.52, P = 0.129), respectively.

Conclusion

Comparing with spontaneous placental removal, manual placental removal appeared to be less positive effect during CS. Because of the limitations of this meta-analysis, more high-quality RCTs are needed to confirm our findings.

Current State and Future Direction of Postpartum Hemorrhage Risk Assessment

In the United States, postpartum hemorrhage is a leading preventable cause of maternal mortality and morbidity. To reduce morbidity from postpartum hemorrhage, risk assessment is an important starting point for informing decisions about risk management and hemorrhage prevention. Current perinatal care guidelines from the Joint Commission recommend that all patients undergo postpartum hemorrhage risk assessment at admission and after delivery. Three maternal health organizations-the California Maternal Quality Care Collaborative, AWHONN, and the American College of Obstetricians and Gynecologists' Safe Motherhood Initiative-have developed postpartum hemorrhage risk-assessment tools for clinical use. Based on the presence of risk factors, each organization categorizes patients as low-, medium-, or high-risk, and ties pretransfusion testing recommendations to these categorizations. However, the accuracy of these tools' risk categorizations has come under increasing scrutiny. Given their low positive predictive value, the value proposition of pretransfusion testing in all patients classified as medium- and high-risk is low. Further, 40% of all postpartum hemorrhage events occur in low-risk patients, emphasizing the need for early vigilance and treatment regardless of categorization. We recommend that maternal health organizations consider alternatives to category-based risk tools for evaluating postpartum hemorrhage risk before delivery.

A study of the healthcare resource use for the management of postpartum haemorrhage in France, Italy, the Netherlands, and the UK

OBJECTIVE

Postpartum haemorrhage (PPH) complicates approximately 5% of births worldwide and is a leading direct cause of maternal death. Rates of PPH are increasing in many developed countries, particularly PPH related to uterine atony. There is a lack of published up-to-date information about healthcare resource use associated with management of PPH following vaginal birth. The objective of this study was to describe healthcare resource use for the management of minor PPH (blood loss 500-1,000 ml) and major PPH (blood loss > 1,000 ml) compared to uncomplicated birth (no PPH) following hospital vaginal birth in France, Italy, the Netherlands, and the UK.

STUDY DESIGN

In-depth interviews with two midwives from each participating country were conducted to establish differences in resource use for the management of minor PPH, major PPH, and uncomplicated birth. A web-survey was then developed and one obstetrician per participating country reviewed the survey. In total, 100 midwives (25 per country) completed the survey. Results were discussed at a multi-professional consensus meeting of midwives and obstetricians/gynaecologists (n = 6).

RESULTS AND CONCLUSIONS

Midwives participating in the survey estimated that 80% of women receive Active Management of the Third Stage of Labour (AMTSL) and 93% of participants specified that uterotonics would routinely be used during AMTSL. Most participants (84%) reported that blood loss is routinely measured in their hospital, using a combination of methods. PPH is associated with increased healthcare resource use, including administration of additional uterotonics and use of additional medical interventions, such as urinary catheter, intravenous fluids, and possible requirement for surgery. The number of nurses, obstetricians/gynaecologists, and anaesthetists involved in the management of PPH increases with the occurrence and severity of PPH, as well as the proportion of healthcare personnel providing continuous care. Women may spend an additional 24 h in hospital following major PPH compared to uncomplicated birth. The results of this study highlight the burden of PPH management on healthcare resources. To reduce costs associated with PPH, prevention is the most effective strategy and can be enhanced with the use of an effective uterotonic as part of the active management of the third stage of labour.

Obstetrical Hemorrhage

Obstetric hemorrhage is a leading cause of morbidity and mortality. Prevention includes identifying patients with risk factors and actively managing the third stage of labor. The anesthesiologist should be ready to manage hemorrhage with general strategies as well as strategies tailored to the specific cause of hemorrhage. Both neuraxial anesthesia and general anesthesia are appropriate in different situations. Treatments proven to be effective include increasing the oxytocin infusion, administering tranexamic acid early, guiding transfusion with point-of-care tests, and using cell salvage. Utilization of protocols and checklists within systems that encourage effective communication between teams should be implemented.

Quality Assurance and Quality Improvement in the Labor and Delivery Setting

Quality assurance (QA) is the maintenance of a desired level of quality, whereas quality improvement (QI) is the continuous process of creating systems to make things better. Implementation science promotes the systematic uptake of best practices. Bundles are a structured list of best practices whereas toolkits provide the necessary details, rationale, and implementation materials, such as sample policies and protocols. Metrics that can guide care on the labor and delivery (L&D) floor may be related to team structure (obstetric, multidisciplinary, anesthetic), processes (patient monitoring, team effects), and outcomes (postpartum hemorrhage, venous thromboembolism). Multiple anesthetic quality metrics have been proposed, including the mode of anesthesia for cesarean delivery.

Study on the application of King's combined uterine suture for hemostasis during cesarean section

INTRODUCTION

Postpartum hemorrhage is a serious complication of childbirth and is still the leading cause of maternal death worldwide. Lower uterine segment hemorrhage during cesarean section is an important cause of postpartum hemorrhage. Our objective is to expore the efficacy and safety of King's combined uterine suture for hemostasis during cesarean section.

METHODS

We examined 48 cases: 16 cases of pernicious placenta previa (including one case of twins), 11 cases of central placenta previa (including one case of twins), 18 cases of uterine scarring (including two cases of twins), as well as one case of twin pregnancy, two cases of breech presentation, and one case of pulmonary hypertension. The "King's combined uterine suture" method for hemostasis was used in patients with lower uterine segment hemorrhage during cesarean section.

RESULTS

The results showed that all patients had successful hemostasis during surgery, and there were no cases of hysterectomy.

CONCLUSION

We have concluded that King's combined uterine suture is a fast and safe hemostasis method for cesarean section that can effectively reduce blood loss and restore the normal shape of the lower uterine segment. Furthermore, this suture method can reduce postpartum hemorrhage and hysterectomy rate, as well as improve maternal prognosis.

Impact of Deferred Cord Clamping on Mortality and Severe Neurologic Injury in Twins Born at <30 Weeks of Gestation

OBJECTIVE

To determine whether deferred cord clamping (DCC) compared with early cord clamping (ECC) was associated with reduction in death and/or severe neurologic injury among twins born at <30 weeks of gestation.

STUDY DESIGN

We performed a retrospective cohort study including all liveborn twins of <30 weeks admitted to a tertiary-level neonatal intensive care unit (NICU) in Canada between 2015 and 2018 using the Canadian Neonatal/Preterm Birth Network database. We compared DCC ≥30 seconds vs ECC <30 seconds. Our primary outcome was a composite of death and/or severe neurologic injury (severe intraventricular hemorrhage grade III/IV and/or periventricular leukomalacia). Secondary outcomes included neonatal morbidity and health care utilization outcomes. We calculated aORs and β coefficients for categorical and continuous variables, along with 95% CI. Models were fitted with generalized estimated equations accounting for twin correlation.

RESULTS

We included 1597 twins (DCC, 624 [39.1%]; ECC, 973 [60.9%]). Death/severe neurologic injury occurred in 17.8% (n = 111) of twins who received DCC and in 21.7% (n = 211) of those who received ECC. The rate of death/severe neurologic injury did not differ significantly between the DCC and ECC groups (aOR 1.07; 95% CI, 0.78-1.47). DCC was associated with reduced blood transfusions (adjusted β coefficient, -0.49; 95% CI, -0.86 to -0.12) and NICU length of stay (adjusted β coefficient, -4.17; 95% CI, -8.15 to -0.19).

CONCLUSIONS

The primary composite outcome of death and/or severe neurologic injury did not differ between twins born at <30 weeks of gestation who received DCC and those who received ECC, but DCC was associated with some benefits.

Understanding How Health Providers Identify Women with Postpartum Hemorrhage: A Qualitative Study

OBJECTIVE

 To identify how health providers recognize postpartum hemorrhage early and the difficulties involved in it.

METHODS

 An exploratory, descriptive study using a qualitative approach through a semi-structured interview technique. In total, 27 health professionals (nursing technicians, nurses, medical residents in Gynecology and Obstetrics, hired medical doctors, and medicine professors) working in a tertiary-level hospital of reference in women's health care in the State of São Paulo, Brazil, participated in the study through an invitation. After they accepted the invitation, they signed the free and informed consent form. All interviews were recorded and transcribed, and a thematic analysis was conducted. We found three analysis categories: a) perception of the severity: "there is something wrong with the women"; b) difficulties in the early diagnosis of postpartum hemorrhage; and c) the process to improve obstetrical care.

RESULTS

 Caregivers believe teamwork and communication should be improved. Besides the visual estimation of blood loss, the nursing team is attentive to behavioral symptoms like irritability, while the medical staff follow protocols and look for objective signs, such as altered vital signs.

CONCLUSION

 Besides the objective evaluations, the subjective perceptions of the providers are involved in the clinical judgement regarding the diagnosis of postpartum hemorrhage, and this should be included in a broader diagnosis strategy.

Early cryoprecipitate transfusion versus standard care in severe postpartum haemorrhage: a pilot cluster-randomised trial

There is a lack of evidence evaluating cryoprecipitate transfusion in severe postpartum haemorrhage. We performed a pilot cluster‐randomised controlled trial to evaluate the feasibility of a trial on early cryoprecipitate delivery in severe postpartum haemorrhage. Pregnant women (>24 weeks gestation), actively bleeding within 24 h of delivery and who required at least one unit of red blood cells were eligible. Women declining transfusion in advance or with inherited clotting deficiencies were not eligible. Four UK hospitals were randomly allocated to deliver either the intervention (administration of two pools of cryoprecipitate within 90 min of first red blood cell unit requested plus standard care), or the control group treatment (standard care, where cryoprecipitate is administered later or not at all). The primary outcome was the proportion of women who received early cryoprecipitate (intervention) vs. standard care (control). Secondary outcomes included consent rates, acceptability of the intervention, safety outcomes and preliminary clinical outcome data to inform a definitive trial. Between March 2019 and January 2020, 199 participants were recruited; 19 refused consent, leaving 180 for analysis (110 in the intervention and 70 in the control group). Adherence to assigned treatment was 32% (95%CI 23–41%) in the intervention group vs. 81% (95%CI 70–90%) in the control group. The proportion of women receiving cryoprecipitate at any time‐point was higher in the intervention (60%) vs. control (31%) groups; the former had fewer red blood cell transfusions at 24 h (mean difference −0.6 units, 95%CI −1.2 to 0); overall surgical procedures (odds ratio 0.6, 95%CI 0.3–1.1); and intensive care admissions (odds ratio 0.4, 95%CI 0.1–1.1). There was no increase in serious adverse or thrombotic events in the intervention group. Staff interviews showed that lack of awareness and uncertainty about study responsibilities contributed to lower adherence in the intervention group. We conclude that a full‐scale trial may be feasible, provided that protocol revisions are put in place to establish clear lines of communication for ordering early cryoprecipitate in order to improve adherence. Preliminary clinical outcomes associated with cryoprecipitate administration are encouraging and merit further investigation.

Comparison of vaginal birth outcomes in midwifery-led versus physician-led setting: A propensity score-matched analysis

BACKGROUND

Experts in many countries are recommending a scaling up midwifery-led care as a model to improve maternal and newborn outcomes, reduce rates of unnecessary interventions, realise cost savings, and facilitate normal spontaneous vaginal birth.

OBJECTIVE

The aim of this study was to compare midwifery-led and obstetrician-gynaecologist-led care-related vaginal birth outcomes.

PARTICIPANTS

Pregnant women in Kaunas city maternity care facilities.

METHODS

A propensity score-matched case-control study of midwifery-led versus physician-led low-risk birth outcomes. Patient characteristics and outcomes were compared between the groups. Continuous variables are presented as mean ± standard deviation and analysed using the Mann-Whitney U test. Categorical and binary variables are presented as frequency (percentage), and differences were analysed using the chi-square test. Analyses were conducted separately for the unmatched (before propensity score matched [PSM]) and matched (after PSM) groups.

RESULTS

After adjusting groups for propensity score, postpartum haemorrhage differences between physician-led and midwifery-led labours were significantly different (169.5 and 152.6 mL; p = 0.026), same for hospital stay duration (3.3 and 3.1 days, p = 0.042). Also, in matched population, significant differences were seen for episiotomy rates (chi2 = 4.8; p = 0.029), newborn Apgar 5 min score (9.58 and 9.76; p = 0.002), and pain relief (chi2 = 14.9; p = 0.002). Significant differences were seen in unmatched but not confirmed in matched population for obstetrical procedures used during labour, breastfeeding, birth induction, newborn Apgar 1 min scores, and successful vaginal birth as an overall spontaneous vaginal birth success measure.

CONCLUSION

The midwifery-led care model showed significant differences from the physician-led care model in episiotomy rates, hospital stay duration and postpartum haemorrhage, and newborn Apgar 5 min scores. Midwifery-led care is as safe as physician-led care and does not influence the rate of successful spontaneous vaginal births.

Obstetric venous thromboembolism prophylaxis, risk factors and outcomes

PURPOSE OF REVIEW

Risk factors for obstetric venous thromboembolism (VTE), a leading cause of maternal mortality in the United States, are increasing on a population basis. This review provides the obstetrician with an update of current issues related to obstetric VTE risk, prophylaxis, outcomes, anaesthesia considerations and future research opportunities.

RECENT FINDINGS

Obstetric VTE affects approximately 1 per 1000 pregnancies and accounts consistently for 9-10% of maternal deaths in the United States. In industrialized countries, risk factors for VTE, including overweight/obesity, caesarean delivery and obstetrical complications such postpartum haemorrhage and infection continue to increase. VTE prophylaxis is central to reducing maternal mortality. However, recommendations for prophylaxis from leadership societies vary widely. In the UK, maternal mortality risk from VTE has decreased significantly in the setting of broader heparin prophylaxis. In the United States where mechanical VTE prophylaxis is used more commonly, mortality risk has remained constant.

SUMMARY

Obstetric VTE is a leading cause of maternal mortality in the United States. The incidence of risk factors for obstetric VTE continues to increase. Currently, recommendations for obstetric VTE prophylaxis vary substantially. Opportunities for research in this area exist to optimize prophylaxis and improve maternal outcomes.

Postpartum haemorrhage trends in Sweden using the Robson ten group classification system: a population-based cohort study

OBJECTIVE

To examine postpartum haemorrhage (PPH) trends in Sweden using the Robson classification system.

DESIGN

Population-based cohort study.

SETTING

Sweden.

POPULATION

Deliveries in 2000-2016, classified as Robson groups 1-5 (singleton pregnancies in vertex presentation, from gestational weeks 37+0; n = 1 590 178).

METHODS

We examined temporal trends in PPH between 2000 and 2016 overall, and within each Robson group, and performed logistic regression to examine the influence of changes in risk factors (maternal, comorbidity, obstetric practice and infant factors) over time.

MAIN OUTCOME MEASURES

Postpartum haemorrhage, defined as an estimated blood loss of >1000 ml.

RESULTS

The overall PPH rate increased from 5.4 to 7.3%, corresponding to a 37% (OR 1.37, 95% CI 1.32-1.42) increase over time. Rates varied between Robson groups, ranging from 4.5% in group 3 to 14.3% in group 4b. Increasing trends in PPH were found in all Robson groups except for groups 2b and 4b (prelabour caesarean deliveries). In the unstratified analysis, adjusting for maternal, comorbidity and obstetric practice factors slightly attenuated the risk of PPH in the later period (2013-2016), compared with the reference period (2000-2004; crude OR 1.26, 95% CI 1.24-1.29, adjusted OR 1.22, 95% CI 1.20-1.25). Within individual Robson groups, changes in risk factors did not explain increasing rates of PPH.

CONCLUSIONS

Postpartum haemorrhage rates varied between Robson groups. Changes in risk factors could not explain the 37% increase in PPH for women in Robson groups 1-5 in Sweden, 2000-2016.

TWEETABLE ABSTRACT

Changes in risk factors could not explain the increasing trend of PPH in Sweden, and rates of PPH varied widely between Robson groups.

Development of an Obstetric Hemorrhage Response Intervention: The Postpartum Hemorrhage Cart and Medication Kit

BACKGROUND

Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity in the United States, and timely treatment is imperative. Delay in treatment of PPH can lead to significant blood loss and increased morbidity and mortality. Supplies and medications essential for treating PPH are typically not located in close proximity to the hemorrhaging patient, leading to inefficiency and delay in timely response to hemorrhage.

METHODS

An in situ hemorrhage simulation was created dictating the collection of a prespecified list of supplies commonly used in response to PPH on labor and delivery (L&D). Baseline data were collected, then Lean Six Sigma tools were used to construct a process map, including recording times and cumulative distance traveled for collection of each item. The simulation was repeated after development, creation, and deployment of each intervention. For the first intervention, a PPH cart was created containing the supplies most used in response to PPH. Second, a PPH medication kit was created consisting of a refrigerated box containing all medications typically administered during a PPH.

RESULTS

The average time to collect a prespecified list of supplies and medications in response to a PPH scenario was 11 minutes 5 seconds (standard deviation [SD] = 3 minutes 33 seconds), with an average cumulative distance traveled of 4,092 feet. Following Intervention 1, the time decreased to 4 minutes 0 seconds, with 918 feet traveled (only one trial performed). Intervention 2 further reduced the average time and cumulative distance to 2 minutes 14 seconds (SD = 16 seconds) and 462 feet, respectively. This represents a 79.8% reduction in time and an 88.7% reduction in distance from baseline to postintervention.

CONCLUSION

A PPH cart and medication kit can significantly reduce the amount of time and distance traveled to obtain materials necessary to treat hemorrhage, thus optimizing a team's ability to efficiently treat PPH.

Expert review: prevention of obstetrical venous thromboembolism

Venous thromboembolism represents a persistent proportionate cause of maternal mortality in the United States accounting for 9% to 10% of maternal deaths. Given that overall maternal mortality rose >40% since the late 1990s, it is likely that absolute venous thromboembolism mortality risk increased as well. This persistent risk may be secondary to increases in broad population-based risk factors for venous thromboembolism such as obesity and cesarean delivery. Widespread adoption of perioperative cesarean mechanical thromboprophylaxis is associated with reduced risk for venous thromboembolism events but has not been sufficient to reduce mortality. Experts agree that improved clinical care is required to reduce risk as it is unlikely that trends in venous thromboembolism risk factors will reverse course anytime soon. Experts further agree that improving prophylaxis and prevention may provide the largest benefit. However, how to best improve prophylaxis is highly controversial with both experts and guidelines in disagreement. In the United Kingdom, mortality risk decreased substantially following the 2004 recommendations for broader heparin prophylaxis without evidence of increased mortality risk from hemorrhage. A key clinical question in the United States is whether heparin prophylaxis should be expanded to patients hospitalized for cesarean delivery or an antepartum indication. Some experts, including us, support expanded heparin prophylaxis. Evidence supporting heparin prophylaxis includes (1) demonstration of safety and efficacy in the United Kingdom, (2) that mechanical prophylaxis-the primary alternative to heparin-has major limitations outside the immediate perioperative setting, and (3) that hospitalized cesarean and antepartum patients are at high relative risk of events. Experts against broader heparin prophylaxis cite concerns related to safety, efficacy, and cost. This expert review focused on whether heparin prophylaxis should be routinely used during antepartum hospitalizations and after cesarean delivery. First, we review the differences in major society guidelines. Second, we review arguments for and against broader heparin prophylaxis. Third, we discuss what future research may be most likely to further inform best practices. Fourth, we review practical clinical considerations with heparin prophylaxis, including access to neuraxial anesthesia. Given the best available data, we concluded that expanding heparin prophylaxis represents a modest intervention with the potential to meaningfully reduce venous thromboembolism mortality.

Hemorrhage Risk Assessment on Admission: Utility for Prediction of Maternal Morbidity

OBJECTIVE

Hemorrhage is a major cause of maternal morbidity and mortality prompting creation of innovative risk assessment tools to identify patients at highest risk. We aimed to investigate the association of hemorrhage risk assessment with maternal morbidity and to evaluate maternal outcomes after implementation of the risk assessment across hospital sites.

STUDY DESIGN

We conducted a retrospective cohort analysis of a multicenter database including women admitted to labor and delivery from January 2015 to June 2018. The Association of Women's Health, Obstetric and Neonatal Nurses risk assessment tool was used to categorize patients as low, medium, or high risk for hemorrhage. Multivariate logistic regression was used to describe the association between hemorrhage risk score and markers of maternal morbidity and evaluate maternal outcomes before and after standardized implementations of the risk assessment tool.

RESULTS

In this study, 14,861 women were categorized as low risk (26%), 26,080 (46%) moderate risk, and 15,730 (28%) high risk (N = 56,671 births). For women with high-risk scores, the relative risk (RR) ratio compared with low-risk women was 4.9 (RR: 95% confidence interval [CI]: 3.2-7.4) for blood transfusion and 5.2 (RR: 95% CI: 4.6-5.9) for estimated blood loss (EBL) ≥ 1,000 mL. For the second objective, 110,633 women were available for pre- and postimplementation analyses (39,027 and 71,606, respectively). A 20% reduction in rates of blood transfusion (0.5-0.4%, p = 0.02) and EBL ≥ 1,000 mL (6.3-5.9%, p = 0.014) was observed between pre- and postimplementations of the admission hemorrhage risk assessment tool.

CONCLUSION

Women who were deemed high risk for hemorrhage using a hemorrhage risk assessment tool had five times higher risk for blood transfusion and EBL ≥ 1,000 mL compared with low-risk women. Given the low incidence of the outcomes explored, the hemorrhage risk assessment works moderately well to identify patients at risk for peripartum morbidity.

KEY POINTS

· This study aimed to understand the utility of the AWOHNN hemorrhage risk assessment tool for predicting hemorrhage-related morbidity and to evaluate maternal outcomes before and after tool implementations.. · A high score using a hemorrhage risk assessment tool on admission is associated with five times higher risk for blood transfusion and/or estimated blood loss ≥ 1,000 mL, compared with a low score.. · Use of a hemorrhage risk assessment tool works moderately well to identify patients at highest risk for hemorrhage-related morbidity..

Validation of Postpartum Hemorrhage Admission Risk Factor Stratification in a Large Obstetrics Population

OBJECTIVE

This study aimed to evaluate the performance of the California Maternal Quality Care Collaborative (CMQCC) admission risk criteria for stratifying postpartum hemorrhage risk in a large obstetrics population.

STUDY DESIGN

Using detailed electronic health record data, we classified 261,964 delivery hospitalizations from Kaiser Permanente Northern California hospitals between 2010 and 2017 into high-, medium-, and low-risk groups based on CMQCC criteria. We used logistic regression to assess associations between CMQCC risk groups and postpartum hemorrhage using two different postpartum hemorrhage definitions, standard postpartum hemorrhage (blood loss ≥1,000 mL) and severe postpartum hemorrhage (based on transfusion, laboratory, and blood loss data). Among the low-risk group, we also evaluated associations between additional present-on-admission factors and severe postpartum hemorrhage.

RESULTS

Using the standard definition, postpartum hemorrhage occurred in approximately 5% of hospitalizations (n = 13,479), with a rate of 3.2, 10.5, and 10.2% in the low-, medium-, and high-risk groups. Severe postpartum hemorrhage occurred in 824 hospitalizations (0.3%), with a rate of 0.2, 0.5, and 1.3% in the low-, medium-, and high-risk groups. For either definition, the odds of postpartum hemorrhage were significantly higher in medium- and high-risk groups compared with the low-risk group. Over 40% of postpartum hemorrhages occurred in hospitalizations that were classified as low risk. Among the low-risk group, risk factors including hypertension and diabetes were associated with higher odds of severe postpartum hemorrhage.

CONCLUSION

We found that the CMQCC admission risk assessment criteria stratified women by increasing rates of severe postpartum hemorrhage in our sample, which enables early preparation for many postpartum hemorrhages. However, the CMQCC risk factors missed a substantial proportion of postpartum hemorrhages. Efforts to improve postpartum hemorrhage risk assessment using present-on-admission risk factors should consider inclusion of other nonobstetrical factors.

Prehospital assessment and management of postpartum haemorrhage- healthcare personnel's experiences and perspectives

BACKGROUND

Postpartum hemorrhage (PPH) is a serious obstetric emergency, and one of the top five causes of maternal mortality globally. The most common causes of PPH include uterine atony, placental disorders, birth trauma and coagulation defects. Timely diagnosis and early management are critical to reduce morbidity, the need for blood transfusion or even mortality. External, manual aortic compression (AC) has been suggested as an intervention that reduce PPH and extend time for control of bleeding or resuscitation. This procedure is not commonly utilized by healthcare personnel. The incidence of home-births is increasing, and competence in PPH assessment and management is essential in prehospital personnel. The objective was to explore prehospital personnel's competence in PPH and AC, utilizing different tools.

METHODS

The study was conducted in a county in South-eastern Norway, including five ambulance stations. All prehospital personnel (n = 250) were invited to participate in a questionnaire study. The questionnaire included the PPH self-efficacy (PPHSE) and PPH collective efficacy (PPHCE) tools, as well as tool developed utilizing the Delphi technique. Descriptive statistics were used to analyze the quantitative data, while quantitative content analysis was used to analyse free-text responses.

RESULTS

A total of 87 prehospital personnel responded to the questionnaire, 57.5% male, mean age 37.9 years. In total, 80.4% were ambulance workers and/or paramedics, and 96.6 and 97.7% respectively reported to need more education or training in PPH. Moreover, 82.8% reported having managed patient(s) with PPH, but only 2.9% had performed AC. Prehospital personnels' responses varied extensively regarding knowledge about what PPH is, how to estimate and handle PPH, and how to perform AC. Mean self-efficacy varied from 3.3 to 5.6, while collective efficacy varied from 1.9 to 3.8.

CONCLUSIONS

This study indicates that prehospital personnel lack knowledge about PPH and AC, due to various responses to the developed questionnaire. Even though AC is an acknowledged intervention in PPH, few participants reported that this was utilized. Our findings emphasize the need for education and training in PPH and PPH handling generally, and in AC specifically.

Refractory uterine atony: still a problem after all these years

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality, and uterine atony is the leading cause of postpartum hemorrhage. Risk factors for uterine atony include induced or augmented labor, preeclampsia, chorio-amnionitis, obesity, multiple gestation, polyhydramnios, and prolonged second stage of labor. Although a risk assessment is recommended for all parturients, many women with uterine atony do not have risk factors, making uterine atony difficult to predict. Oxytocin is the first-line drug for prevention and treatment of uterine atony. It is a routine component of the active management of the third stage of labor. An oxytocin bolus dose as low as 1 IU is sufficient to produce satisfactory uterine tone in almost all women undergoing elective cesarean delivery. However, a higher bolus dose (3 IU) or infusion rate is recommended for women undergoing intrapartum cesarean delivery. Carbetocin, available in many countries, is a synthetic oxytocin analog with a longer duration than oxytocin that allows bolus administration without an infusion. Second line uterotonic agents include ergot alkaloids (ergometrine and methylergonovine) and the prostaglandins, carboprost and misoprostol. These drugs work by a different mechanism to oxytocin and should be administered early for uterine atony refractory to oxytocin. Rigorous studies are lacking, but methylergonovine and carboprost are likely superior to misoprostol. Currently, the choice of second-line agent should be based on their adverse effect profile and patient comorbidities. Surgical and radiologic management of uterine atony includes uterine tamponade using balloon catheters and compression sutures, and percutaneous transcatheter arterial embolization.

Association of Gestational Age with Postpartum Hemorrhage: An International Cohort Study

BACKGROUND

Risk factors for postpartum hemorrhage, such as chorioamnionitis and multiple gestation, have been identified in previous epidemiologic studies. However, existing data describing the association between gestational age at delivery and postpartum hemorrhage are conflicting. The aim of this study was to assess the association between gestational age at delivery and postpartum hemorrhage.

METHODS

The authors conducted a population-based retrospective cohort study of women who underwent live birth delivery in Sweden between 2014 and 2017 and in California between 2011 and 2015. The primary exposure was gestational age at delivery. The primary outcome was postpartum hemorrhage, classified using International Classification of Diseases, Ninth Revision-Clinical Modification codes for California births and a blood loss greater than 1,000 ml for Swedish births. The authors accounted for demographic and obstetric factors as potential confounders in the analyses.

RESULTS

The incidences of postpartum hemorrhage in Sweden (23,323/328,729; 7.1%) and in California (66,583/2,079,637; 3.2%) were not comparable. In Sweden and California, the incidence of postpartum hemorrhage was highest for deliveries between 41 and 42 weeks' gestation (7,186/75,539 [9.5%] and 8,921/160,267 [5.6%], respectively). Compared to deliveries between 37 and 38 weeks, deliveries between 41 and 42 weeks had the highest adjusted odds of postpartum hemorrhage (1.62 [95% CI, 1.56 to 1.69] in Sweden and 2.04 [95% CI, 1.98 to 2.09] in California). In both cohorts, the authors observed a nonlinear (J-shaped) association between gestational age and postpartum hemorrhage risk, with 39 weeks as the nadir. In the sensitivity analyses, similar findings were observed among cesarean deliveries only, when postpartum hemorrhage was classified only by International Classification of Diseases, Tenth Revision-Clinical Modification codes, and after excluding women with abnormal placentation disorders.

CONCLUSIONS

The postpartum hemorrhage incidence in Sweden and California was not comparable. When assessing a woman's risk for postpartum hemorrhage, clinicians should be aware of the heightened odds in women who deliver between 41 and 42 weeks' gestation.

EDITOR’S PERSPECTIVE

The golden hour for postpartum hemorrhage: Results from a prospective cohort study

OBJECTIVE

To evaluate the predictive capacity of vital signs for the diagnosis of postpartum hemorrhage (PPH).

METHODS

A prospective cohort study performed at the University of Campinas, Brazil, between February 2015 and March 2016 with women who delivered vaginally. Vital signs and postpartum bleeding were collected over 24 h. Exploratory data analysis was performed plus receiver operating characteristic curve analysis where the areas under the curve was used to determine the best cutoff points for sensitivity, specificity, likelihood ratio, and diagnostic odds ratio.

RESULTS

For the 270 women recruited, mean blood loss after 120 min was 427.49 ± 335.57 ml, while 84 (31.1%) and 22 (8.1%) women had blood loss ≥500 and ≥1000 ml, respectively. Heart rate cutoff point of 105 bpm measured between 21-40 min after birth identified blood loss ≥1000 ml with 90% specificity. A shock index (SI) of 0.965 at 41-60 min after birth identified blood loss ≥500 and ≥1000 ml within 2 h with approximately 95% specificity.

CONCLUSION

Shock index and heart rate measured after birth showed high specificity with low sensitivity to identify PPH. In clinical practice, "The rule of 1s" should receive special attention: SI ≥1, or heart rate >100 bpm, or estimated blood loss ≥1 L.

Restrictive versus liberal fluid resuscitation strategy, influence on blood loss and hemostatic parameters in mild obstetric hemorrhage: An open-label randomized controlled trial. (REFILL study)

Background

Evidence for optimal hemostatic resuscitation in postpartum hemorrhage (PPH) is lacking. Liberal fluid administration may result in acidosis, hypothermia and coagulopathy.

Objective

We hypothesize that in early PPH a restrictive fluid administration results in less progression to moderate PPH.

Study design

In four Dutch hospitals we recruited women of 18 years and over, and more than 24 weeks pregnant. Exclusion criteria were: anticoagulant therapy, known coagulation disorders, pre-eclampsia, antenatal diagnosis of abnormally adhesive placenta, and a contraindication for liberal fluid therapy. We blindly randomized participants at 500 mL and ongoing blood loss in the third stage of labor between restrictive fluid administration (clear fluids 0.75–1.0 times the volume of blood lost) and liberal fluid administration (clear fluids 1.5–2.0 times the volume of blood lost). The primary outcome was progression to more than 1000 mL blood loss. Analyses were according to the intention-to-treat principle.

Results

From August 2014 till September 2019, 5190 women were informed of whom 1622 agreed to participate. A total of 252 women were randomized of which 130 were assigned to the restrictive group and 122 to the liberal group. In the restrictive management group 51 of the 130 patients (39.2%) progressed to more than 1000 mL blood loss versus 61 of the 119 patients (51.3%) in the liberal management group (difference, -12.0% [95%-CI -24.3% to 0.3%], p = 0.057). There was no difference in the need for blood transfusion, coagulation parameters, or in adverse events between the groups.

Conclusions

Although a restrictive fluid resuscitation in women with mild PPH could not been proven to be superior, it does not increase the need for blood transfusion, alter coagulation parameters, or cause a rise in adverse events. It can be considered as an alternative treatment option to liberal fluid resuscitation.

Trial registration

NTR3789.

Tranexamic acid: current use in obstetrics, major orthopedic, and trauma surgery

PURPOSE

In this Continuing Professional Development module, we review the practical pharmacology of tranexamic acid and its clinical use in trauma, obstetrics, and major orthopedic surgery.

PRINCIPAL FINDINGS

Tranexamic acid is a synthetic drug that inhibits fibrinolysis. Multiple clinical trials in various clinical settings have shown that it can reduce blood loss, transfusion rates, and bleeding-associated mortality. In trauma and obstetrical bleeding, early tranexamic acid administration (< three hours) may have greater clinical benefits. Overall, tranexamic acid use appears safe with no significant increase of thromboembolic or seizure events. Nevertheless, current evidence has limitations related to wide heterogeneity in dose, route, and timing of drug administration, as well as generalizability of the large-scale trial findings to higher income nations.

CONCLUSIONS

Tranexamic acid is an efficacious and safe pharmacological-based blood conservation technique in the management of clinically significant hemorrhage. All anesthesiologists should have a good understanding of the pharmacotherapeutic properties and perioperative role of tranexamic acid therapy both inside and outside of the operating room. The use of tranexamic acid is likely to continue to rise with endorsement by various clinical guidelines and healthcare organizations. Further quantitative research is needed to evaluate optimal dosing and drug efficacy in these clinical scenarios.