Lactate and fibrinogen as good predictors of massive transfusion in postpartum hemorrhage

The value of fibrinogen combined with D-dimer and neonatal weight in predicting postpartum hemorrhage in vaginal delivery

OBJECTIVES

The purpose of this study was to explore whether fibrinogen (Fib) can be used as a predictor of postpartum hemorrhage (PPH) in parturients with vaginal delivery, and the value of combining Fib with other indexes to predict postpartum hemorrhage in vaginal delivery.

METHODS

A total of 207 parturients who delivered via vagina were divided into PPH group (n=102) and non-PPH group (n=105). The PPH group was further divided into mild PPH group and severe PPH group. The differences of Fib, platelet (PLT), mean platelet volume (MPV), platelet distribution width (PDW), D-dimer (D-D), hemoglobin (HGB) and neonatal weight (Nw) between the two groups were compared to explore the significance of these indexes in predicting PPH.

RESULTS

Fib, PLT and PDW in PPH group were significantly lower than those in non-PPH group, while D-D and Nw in PPH group were significantly higher than those in non-PPH group. In the binary logistic regression model, we found that Fib, D-D and Nw were independently related to PPH. The risk of PPH increased by 9.87 times for every 1 g/L decrease in Fib. The cut-off value of Fib is 4.395 (sensitivity 0.705, specificity 0.922). The AUC value of PPH predicted by Fib combined with D-D and Nw was significantly higher than that of PPH predicted by Fib (p<0.05, 95 % CI 0.00313-0.0587).

CONCLUSIONS

Fib, D-D and Nw have good predictive value for PPH of vaginal delivery, among which Fib is the best. The combination of three indexes of Fib, D-D and Nw can predict PPH more systematically and comprehensively, and provide a basis for clinical prevention and treatment of PPH.

Association between Initial Fibrinogen Levels and the Need for Massive Transfusion in Emergency Department Patients with Primary Postpartum Hemorrhage: A Retrospective Study from a Single Center in Korea

BACKGROUND

This study aimed to evaluate the association between initial fibrinogen levels and massive transfusion (MT) in emergency department (ED) patients with primary postpartum hemorrhage (PPH).

METHODS

This retrospective study was conducted in the ED of a university-affiliated, tertiary referral center from January 2004 to August 2023. Patients were divided into two groups: the MT group, which included those who received a transfusion of 10 or more units of packed red blood cells within the first 24 h, and the Non-MT group.

RESULTS

Out of the 364 patients included in the study, 97 (26.6%) required MT. Fibrinogen, shock index, and lactate were independently associated with MT (odds ratio [OR] 0.987; 95% confidence interval [CI] 0.983-0.991; p < 0.001, OR 7.277; 95% CI 1.856-28.535; p = 0.004, and OR 1.261; 95% CI 1.021-1.557; p = 0.031, respectively). The area under the receiver operating characteristic curve for fibrinogen, shock index, and lactate in predicting MT was 0.871 (95% CI 0.832-0.904; p < 0.001), 0.821 (95% CI 0.778-0.859; p < 0.001), and 0.784 (95% CI 0.738-0.825; p < 0.001), respectively. When the cutoff value of fibrinogen was 400 mg/dL, both the sensitivity and negative predictive values for predicting MT were 100.0%. When the cutoff value of fibrinogen was 100 mg/dL, the specificity and positive predictive values were 91.8% and 70.7%, respectively.

CONCLUSION

The initial fibrinogen levels were independently associated with the need for MT in ED patients with primary PPH.

Risk-factor model for postpartum hemorrhage after cesarean delivery: a retrospective study based on 3498 patients

This study aimed to investigate the risk factors of patients with postpartum hemorrhage (PPH) after cesarean delivery (CD) and to develop a risk-factor model for PPH after CD. Patients were selected from seven affiliated medical institutions of Chongqing Medical University from January 1st, 2015, to January 1st, 2020. Continuous and categorical variables were obtained from the hospital's electronic medical record systems. Independent risk factors were identified by univariate analysis, least absolute shrinkage and selection operator and logistic regression. Furthermore, logistic, extreme gradient boosting, random forest, classification and regression trees, as well as an artificial neural network, were used to build the risk-factor model. A total of 701 PPH cases after CD and 2797 cases of CD without PPH met the inclusion criteria. Univariate analysis screened 28 differential indices. Multi-variable analysis screened 10 risk factors, including placenta previa, gestational age, prothrombin time, thrombin time, fibrinogen, anemia before delivery, placenta accreta, uterine atony, placental abruption and pregnancy with uterine fibroids. Areas under the curve by random forest for the training and test sets were 0.957 and 0.893, respectively. The F1 scores in the random forest training and test sets were 0.708. In conclusion, the risk factors for PPH after CD were identified, and a relatively stable risk-factor model was built.

Epidemiology and definition of PPH worldwide

Postpartum/peripartum hemorrhage (PPH) is an obstetric emergency complicating 1-10% of all deliveries and is a leading cause of maternal mortality and morbidity worldwide. However, the incidence of PPH differs widely according to the definition and criteria used, the way of measuring postpartum blood loss, and the population being studied with the highest numbers in developing countries. Despite all the significant progress in healthcare, the incidence of PPH is rising due to an incomplete implementation of guidelines, resulting in treatment delays and suboptimal care. A consensus clinical definition of PPH is needed to enable awareness, early recognition, and initiation of appropriate intensive treatment. Unfortunately, the most used definition of PPH based on blood loss ≥500 ml after delivery suffers from inaccuracies in blood loss quantification and is not clinically relevant in most cases, as the amount of blood loss does not fully reflect the severity of bleeding.

Plasental invazyon anomalisi olan hastalarda anestezi yönetimi: Tek merkez deneyimi

Aim: Postpartum hemorrhage is a life-threatening obstetric emergent clinical situation accompanied by blood loss of more than 500 ml after vaginal delivery and more than 1000 ml after cesarean section. This situation, frequently encountered in placental adhesion anomalies, is essential in terms of follow-up, treatment, and multidisciplinary management. We aimed to retrospectively evaluate the perioperative anesthesia management, transfusion requirement, and postoperative intensive care unit requirement of patients diagnosed with placental invasion anomaly who had an intraoperative hemorrhage Methods: In our single-center study, a total of 58 female patients diagnosed with of placental invasion anomaly with a cesarean section between 2017-2020 were examined. Patients under 18 years of age and missing data were excluded from the study. Demographic data of patients (age, American Society of Anesthesiologists score (ASA)), diagnosis, duration of operation, perioperative laboratory findings, anesthesia type, perioperative hemodynamics (highest heart rate, lowest mean arterial pressure, shock index), amount of bleeding, blood products, and fluids used, surgical interventions (B-Lynch, Bacri balloon application, uterine artery ligation, hysterectomy), intraoperative vasopressor/inotrope use, ICU stay, laboratory results in the first 24 hours postoperatively, and total hospital stay were recorded. Results: In the preoperative evaluation, 27 (46.5%) patients were diagnosed with placenta accreta, and placenta previa was diagnosed in 19 (32.7%) patients. Perioperatively mean of 3.08 ± 1.7 units of Red blood cell was used. In patients with postoperative intensive care unit hospitalization, the highest intraoperative lactate value was 3.5±1.8 mmol/L, shock index was 1.3±0.3 (0.6-1.8). In patients given intraoperative fibrinogen concentrate, the intraoperative shock index was 1.5±0.2 (0.9-1.8), the amount of intraoperative bleeding was 2575±302.2 ml, and the fibrinogen levels measured in the first 24 hours after surgery were 294.7±79.7 mg/dl. Conclusions: Anesthesia management of patients diagnosed with abnormal placental invasion is important because of significant hemorrhage. Due to unstable hemodynamics, preoperative blood product preparation with a multidisciplinary approach and a postoperative intensive care unit plan should be made for these patients.

JTH in Clinic - Obstetric bleeding: VWD and other inherited bleeding disorders

Individuals with inherited bleeding disorders (IBDs) have higher bleeding risk during pregnancy, childbirth, and the postpartum period. Clinical management requires recognition of the IBD as high risk for postpartum hemorrhage and a personalized multidisciplinary approach that includes the patient in decision making. When the fetus is known or at risk to inherit a bleeding disorder, fetal and neonatal bleeding risk also need to be considered. In pregnant IBD patients, it is common for providers to need to make decisions in the absence of high level of certainty evidence. We here present the case of a pregnant von Willebrand disease patient that reached multiple decision points where there is currently clinical ambiguity due to a lack of high level of certainty evidence. For each stage of her care, from diagnosis to the postpartum period, we discuss current literature and describe our approach. This is followed by a brief overview of considerations in other IBDs and pregnancy.

Predictive accuracy of the shock index for severe postpartum hemorrhage in high-income countries: A systematic review and meta-analysis

AIM

The shock index has been suggested as a screening tool for predicting postpartum hemorrhage (PPH); however, there is little comprehensive evidence regarding its predictive accuracy. This systematic review and meta-analysis aim to investigate the predictive accuracy of the shock index for severe PPH in high-income countries.

METHODS

A comprehensive search was conducted on MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science (from inception to June 2021). Studies assessing the predictive performance of the shock index for PPH in high-income countries were included. Two or more reviewers independently extracted the data and assessed the risk of bias and applicability concerns using the modified Quality Assessment of Diagnostic Accuracy Studies 2 tool. PPH requiring higher-level care, such as blood transfusions, were considered as primary analyses. We described the hierarchical summary receiver-operating characteristic curve for data synthesis.

RESULTS

Nine studies were included after the eligibility assessment. All studies were considered to either have a high risk of bias or high applicability concerns. The sensitivity of the four studies that defined severe PPH as PPH requiring blood transfusion ranged from 0.51 to 0.80, whereas their specificity ranged from 0.33 to 0.92.

CONCLUSIONS

This review shows that the predictive performance of the shock index for severe PPH is inconsistent. Therefore, the evidence for using the shock index alone as a screening tool for PPH in high-income countries is insufficient.

STUDY REGISTRATION

This review was prospectively registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000044230).

Hemorragia postparto: intervenciones y tratamiento del profesional de enfermería para prevenir shock hipovolémico

Introducción: En Colombia la hemorragia postparto es la segunda causa de mortalidad en mujeres gestantes de 24 a 34 años con 6,9 casos por cada 1000 nacidos vivos. Después del parto se prevé que el 8.2% de las mujeres latinoamericanas presentarán hemorragia postparto. Objetivo: Describir el cuidado de enfermería a mujeres que presentan hemorragia postparto para disminuir el riesgo de shock hipovolémico, a través de una revisión integrativa de la literatura. Metodología: Revisión integrativa de la literatura siguiendo la propuesta por Sasso, de Campos y Galvão, se realizó una búsqueda en ClinicalKey, LILACS, CINAHL, Epistemonikos, Cochrane Library, PubMed, Scielo y Google Scholar; se incluyeron artículos publicados en los últimos cinco años, en español, inglés y portugués, se clasificaron por nivel de evidencia y grado de recomendación. Esta investigación es de bajo riesgo por ser de tipo documental. Resultados: Se recopilaron 41 artículos definitivos. La información se organizó en: cuadro clínico, cuidados de enfermería y dificultades en la atención gineco-obstétrica. Discusión: El profesional de enfermería debe identificar barreras en la atención evaluando la capacidad resolutiva de las instituciones y analizando los casos de muerte materna. Se recomienda el uso de misoprostol con oxitocina o únicamente de carbetocina y la combinación de ergometrina con oxitocina según el volumen de sangrado. Conclusión: Es pertinente realizar un examen físico para reconocer signos de inestabilidad hemodinámica, y de shock hipovolémico. Además, los diagnósticos e intervenciones de enfermería se enfocan en brindar cuidados de calidad, para evitar complicaciones como la muerte.

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.

Predicting the need for blood transfusion requirement in postpartum hemorrhage

OBJECTIVE

We aimed to assess the role of lactate and hemoglobin levels as predictors for the need for blood transfusion in post-partum hemorrhage (PPH).

METHODS

A retrospective cohort study of women with PPH in a single university-affiliated tertiary medical center between August 2018 and June 2020. PPH was defined as an estimated excessive blood loss (of more than 500 ml following vaginal delivery and 1000 ml following a cesarean delivery) requiring at least one uterotonic drug and fluid resuscitation. Women were stratified by the need of requiring blood transfusion due to hemorrhage. The criteria for blood transfusion were: (1) clinically severe uncontrollable ongoing hemorrhage; (2) symptomatic anemia (maternal tachycardia >110 beats per minute, dizziness, syncope or presyncope) in the presence of Hb 7-8 g/dL^; or (3) postpartum Hb level < 7 g/dL regardless of maternal symptoms or signs of anemia. Demographic, labor characteristics as well as laboratory data were collected. For all women the Shock Index (SI: heart rate divided by systolic blood pressure) was calculated. Women without available data on immediate (more than 15 min from the bleeding initiation) hemoglobin (Hb) level and lactate concentrations were excluded.

RESULTS

Overall, out of 22,241 deliveries during the study, 94 women were included, of them 26 (23.4%) required blood transfusion. The antepartum Hb level was lower in the transfused group (11.7 ± vs 12.4 ± 1.0 re/dL, p = .01). No significant differences were found in demographic and labor characteristics. In multivariate logistic regression analysis, a lower immediate postpartum Hb and a higher SI higher were associated with blood transfusion requirement (adjusted odds ratio (aOR) 3.45 [CI] 1.82-7.69, p < .001] and aOR 1.25 [CI 1.03-1.55, p = .03], respectively). The combination of SI, immediate postpartum Hb and lactate concentration provided the best integration, with an area under the curve of 0.86, sensitivity 92.65%, specificity 61.54%, positive and negative predictive values of 86.3% and 76.2%, respectively.

CONCLUSION

The combination of SI, immediate postpartum Hb and lactate levels is a good predictor for the need of blood requirement in PPH.