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Celikkan C, Ibanoglu MC, Engin-Ustun Y. Use of Shock Index, Modified Shock Index, and Age-Adjusted Shock Index for Detection of Postpartum Hemorrhage. Z Geburtshilfe Neonatol 2024; 228:370-376. [PMID: 38838714 DOI: 10.1055/a-2322-1861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE The aim of this study is to evaluate the role of shock index (SI), modified shock index (MSI), and delta shock index (ΔSI) in predicting postpartum hemorrhage (PPH) and adverse maternal outcomes. MATERIAL AND METHODS In this cross-sectional cohort study, a study group consisting of 416 pregnant women who delivered at our hospital and had postpartum hemorrhage was compared with 467 control patients with normal follow-up. SI (pulse/systolic blood pressure), MSI (pulse/mean arterial pressure), ΔSI (input SI - 2nd- or 6th-hour SI) values were calculated. RESULTS A total of 883 postpartum women were included in the study. The study group had higher peripartum, 2nd-hour, and 6th-hour SI values (p=0.011, p=0.001, p<0.001, respectively). Peripartum MSI values (p=0.004), 2nd-hour MSI values (p<0.001), and 6th-hour MSI values (p<0.001) were significantly lower in the control group than in the PPH group. When the groups were evaluated, the cut-off value of the 2nd-hour SI parameter was>0.8909 (sensitivity 30%, specificity 84%), and the 6th-hour SI parameter was>0.8909 (sensitivity 40%, specificity 80%) for predicting postpartum hemorrhage requiring blood transfusion and surgical intervention. The cut-off value of the 2nd-hour MSI parameter was>1.2 (sensitivity 34%, specificity 82%), and the cut-off value of the 6th-hour MSI parameter was>1.2652 (sensitivity 32%, specificity 90%). CONCLUSION The 2nd- and 6th-hour SI and 2nd- and 6th-hour MSI values were significantly higher in patients with postpartum hemorrhage. Values greater than 0.89 for SI and 1.2 for MSI were considered significant for predicting postpartum hemorrhage with maternal impairment.
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Affiliation(s)
- Cagla Celikkan
- Obstetrics and Gynecology, Ankara Etlik Zübeyde Hanım Kadın Hastalıkları Eğitim ve Araştırma Hastanesi, Ankara, Turkey
| | - Mujde Can Ibanoglu
- Obstetrics and Gynecology, Etlik İhtisas Eğitim ve Araştırma Hastanesi, Ankara, Turkey
- Obstetrics and Gynecology, Ankara Şehir Hastanesi Üniversiteler Mahallesi, Ankara, Turkey
| | - Yaprak Engin-Ustun
- Obstetrics and Gynecology, Ankara Etlik Zübeyde Hanım Kadın Hastalıkları Eğitim ve Araştırma Hastanesi, Ankara, Turkey
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Miranda J, Miller S, Alfieri N, Lalonde A, Ivan-Ortiz E, Hanson C, Steinholt M, Palshetkar N, Suharjono H, Gebhardt S, Dossou JP, Pascali-Bonaro D, Jacobsson B, Okong P. Global health systems strengthening: FIGO's strategic view on reducing maternal and newborn mortality worldwide. Int J Gynaecol Obstet 2024; 165:849-859. [PMID: 38651311 DOI: 10.1002/ijgo.15553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE To demonstrate that successful health systems strengthening (HSS) projects have addressed disparities and inequities in maternal and perinatal care in low-income countries. METHODS A comprehensive literature review covered the period between 1980 and 2022, focusing on successful HSS interventions within health systems' seven core components that improved maternal and perinatal care. RESULTS The findings highlight the importance of integrating quality interventions into robust health systems, as this has been shown to reduce maternal and newborn mortality. However, several challenges, including service delivery gaps, poor data use, and funding deficits, continue to hinder the delivery of quality care. To improve maternal and newborn health outcomes, a comprehensive HSS strategy is essential, which should include infrastructure enhancement, workforce skill development, access to essential medicines, and active community engagement. CONCLUSION Effective health systems, leadership, and community engagement are crucial for a comprehensive HSS approach to catalyze progress toward universal health coverage and global improvements in maternal and newborn health.
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Affiliation(s)
- Jezid Miranda
- Department of Obstetrics and Gynecology, Grupo de Investigación en Cuidado Intensivo y Obstetricia (GRICIO), Universidad de Cartagena, Cartagena de Indias, Colombia
- Centro Hospitalario Serena del Mar y Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Suellen Miller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Nikita Alfieri
- Department of Obstetrics and Gynecology, San Paolo Hospital Medical School, University of Milano, Milano, Italy
| | - Andre Lalonde
- FIGO International Childbirth Initiative and Working Group, Ottawa, Ontario, Canada
| | - Edgar Ivan-Ortiz
- Department of Obstetrics and Gynecology, Universidad del Valle, Cali, Colombia
| | - Claudia Hanson
- Public Health Sciences - Global Health - Health Systems and Policy, Karolinska Institute, Stockholm, Sweden
| | - Margit Steinholt
- Helgeland Hospital Trust, Sandnessjøen, Norway
- Norwegian University of Science and Technology, Trondheim, Norway
| | - Nandita Palshetkar
- Department of Reproductive Medicine, Patil Medical College, Mumbai, India
| | - Harris Suharjono
- Department of Obstetrics and Gynaecology, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Stefan Gebhardt
- Department of Obstetrics and Gynaecology, Stellenbosch University, Stellenbosch, South Africa
| | - Jean-Paul Dossou
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Debra Pascali-Bonaro
- International Childbirth Consultant, Trainer, and Speaker, River Vale, New Jersey, USA
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Genetics and Bioinformatics, Domain of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
| | - Pius Okong
- Department of Obstetrics and Gynecology, St Francis Hospital Nsambya, Kampala City, Uganda
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Candidori S, Osouli K, Graziosi S, Zanini AA, Costantino ML, De Gaetano F. A novel low-cost uterine balloon tamponade kit to tackle maternal mortality in low-resource settings. Sci Rep 2024; 14:10004. [PMID: 38693193 PMCID: PMC11063067 DOI: 10.1038/s41598-024-60064-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/18/2024] [Indexed: 05/03/2024] Open
Abstract
The 3.1 target of the Sustainable Development Goals of the United Nations aims to reduce the global maternal mortality ratio to less than 70 maternal deaths per 100,000 live births by 2030. The last updates on this target show a significant stagnation in the data, thus reducing the chance of meeting it. What makes this negative result even more serious is that these maternal deaths could be avoided through prevention and the wider use of pharmacological strategies and devices to stop postpartum haemorrhage (PPH). PPH is the leading obstetric cause of maternal mortality in low- and middle-income countries (LMICs). Despite low-cost devices based on the uterine balloon tamponade (UBT) technique are already available, they are not safe enough to guarantee the complete stop of the bleeding. When effective, they are too expensive, especially for LMICs. To address this issue, this study presents the design, mechanical characterisation and technology assessment performed to validate a novel low-cost UBT kit, particularly a novel component, i.e., the connector, which guarantees the kit's effectiveness and represents the main novelty. Results proved the device's effectiveness in stopping PPH in a simulated scenario. Moreover, economic and manufacturing evaluations demonstrated its potential to be adopted in LMICs.
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Affiliation(s)
- Sara Candidori
- Department of Mechanical Engineering, Politecnico Di Milano, Via La Masa 1, 20156, Milan, Italy
| | - Kasra Osouli
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico Di Milano, Piazza Leonardo da Vinci 31, 20133, Milan, Italy
| | - Serena Graziosi
- Department of Mechanical Engineering, Politecnico Di Milano, Via La Masa 1, 20156, Milan, Italy.
| | | | - Maria Laura Costantino
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico Di Milano, Piazza Leonardo da Vinci 31, 20133, Milan, Italy
| | - Francesco De Gaetano
- Department of Chemistry, Materials and Chemical Engineering "G. Natta", Politecnico Di Milano, Piazza Leonardo da Vinci 31, 20133, Milan, Italy
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Yu H, Diao J, Fei J, Wang X, Li D, Yin Z. Conservative management or cesarean hysterectomy for placenta accreta spectrum in middle-income countries: A systematic review and meta-analysis. Int J Gynaecol Obstet 2024. [PMID: 38650462 DOI: 10.1002/ijgo.15558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/04/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Cesarean hysterectomy is a dominant and effective approach during delivery in patients with placenta accreta spectrum (PAS). However, as hysterectomy results in a loss of fertility, conservative management is an alternative approach. However, management selection may be affected by a country's overall economic level. Thus the preferred treatment for PAS generates controversy in middle-income countries. OBJECTIVES We aimed to compare conservative management and cesarean hysterectomy for managing PAS in middle-income countries. SEARCH STRATEGY China National Knowledge Infrastructure, Wanfang Med Online Databases, Cochrane Library, Ovid MEDLINE, PubMed, Web of Science, EMBASE, clinicaltrials.gov, and Scopus were searched from inception through to October 1, 2022. SELECTION CRITERIA We included studies that evaluated at least one complication comparing conservative management and hysterectomy. All cases were diagnosed with PAS prenatally and intraoperatively. DATA COLLECTION AND ANALYSIS The primary outcomes were blood loss, adjacent organ damage, and the incidence of hysterectomy. Descriptive analyses were conducted for studies that did not meet the meta-analysis criteria. A fixed-effects model was used for studies without heterogeneity and a random-effects model was used for studies with statistical heterogeneity. MAIN RESULTS In all, 11 observational studies were included, with 975 and 625 patients who underwent conservative management and cesarean hysterectomy, respectively. Conservative management was significantly associated with decreased blood loss and lower risks of adjacent organ injury and hysterectomy. Conservative management significantly reduced blood transfusions, hospitalization duration, operative time, intensive care unit admission rates, and infections. There were no significant differences in the risks of coagulopathy, thromboembolism, or reoperation. CONCLUSION Given short-term complications and future fertility preferences for patients, conservative management appears to effectively manage PAS in middle-income countries. Owing to low levels of evidence, high heterogeneity and insufficient long-term follow-up data, further detailed studies are warranted.
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Affiliation(s)
- Huihui Yu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jingyi Diao
- Department of Medical Administration, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jiajia Fei
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xingxing Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Dan Li
- Department of Scientific Research, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zongzhi Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- NHC Key Laboratory of the Study on abnormal gametes and the reproductive tract, Anhui Medical University, Hefei, China
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Sonnie M, Kella F, Stern A, Mannino CA, Adelman S, Fuller L, Forbush L, Mann J, van de Water B, Falahee B, Sayeed S, Ewing H, Kerry V. A Sierra Leone 2021 Midwifery Clinical Training Needs Assessment: A Call to Action to Augment Clinical Precepting. Ann Glob Health 2023; 89:10. [PMID: 36819968 PMCID: PMC9936905 DOI: 10.5334/aogh.3970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/16/2022] [Indexed: 02/17/2023] Open
Abstract
Objective Sierra Leone has one of the highest maternal mortality and infant mortality rates globally. We share findings from a Midwifery Clinical Training Needs Assessment, conducted in 2021 as a collaboration between the Government of Sierra Leone and Seed Global Health. The assessment identified existing needs and gaps in midwifery clinical training at health facilities in Sierra Leone from various stakeholders' perspectives. Methods The descriptive needs assessment utilized mixed methods, including surveys, focus group discussions (FGDs), interviews, and reviews of maternal medical records. Results The following showed needs and gaps in labor and delivery management; record keeping; triage processes; clinical education for students, recent graduates, and preceptors; and lack of infrastructure and resources. Conclusion The knowledge gained from this needs assessment can further the development of midwifery clinical training programs in Sierra Leone and other low-income countries facing similar challenges. We discuss the implication of our findings.
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Clarke-Deelder E, Opondo K, Oguttu M, Burke T, Cohen JL, McConnell M. Immediate postpartum care in low- and middle-income countries: A gap in healthcare quality research and practice. Am J Obstet Gynecol MFM 2023; 5:100764. [PMID: 36216312 DOI: 10.1016/j.ajogmf.2022.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/16/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
Abstract
The immediate postpartum period carries significant risks for complications such as postpartum hemorrhage and sepsis. Postpartum monitoring, including taking vital signs and monitoring blood loss, is important for the early identification and management of complications, but many women in low- and middle-income countries receive minimal attention in the period following childbirth to facility discharge. The World Health Organization recently released new guidelines on postnatal care, which include recommendations for immediate postpartum monitoring. In light of the new guidelines, this presented an opportune moment to address the gaps in postpartum monitoring in low- and middle-income countries. In this commentary, we bring attention to the importance of immediate postpartum monitoring. We identified opportunities for strengthening this often overlooked aspect of maternity care through improvements in quality measurement and data availability, research into barriers against high-quality care, and innovations in service delivery design.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell); Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland (Dr Clarke-Deelder).
| | - Kennedy Opondo
- Kisumu Medical and Education Trust, Kisumu, Kenya (Mr Opondo and Dr Oguttu); Vayu Global Health Foundation, Boston, MA (Mr Opondo and Dr Burke)
| | - Monica Oguttu
- Kisumu Medical and Education Trust, Kisumu, Kenya (Mr Opondo and Dr Oguttu)
| | - Thomas Burke
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell); Vayu Global Health Foundation, Boston, MA (Mr Opondo and Dr Burke); Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (Dr Burke); Harvard Medical School, Boston, MA (Dr Burke)
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell)
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell)
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Duval Jensen J, Ledderer L, Beedholm K. How digital health documentation transforms professional practices in primary healthcare in Denmark: A WPR document analysis. Nurs Inq 2023; 30:e12499. [PMID: 35538598 PMCID: PMC10078429 DOI: 10.1111/nin.12499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/21/2022] [Accepted: 04/24/2022] [Indexed: 01/25/2023]
Abstract
Historically, recordkeeping has been an essential task for health professionals. Today, this mandatory task increasingly takes place as digital documentation. This study critically examines problem constructions in practical documents on digital documentation strategies in Danish municipal healthcare and how these problem constructions imply particular solutions. A document analysis based on the approach presented in Bacchi's "What's the problem represented to be?" was applied. Forty practical documents in the form of guidelines, strategies, and quality control documents were included. The analysis uncovered three problem representations: lack of coherence between health services in a complex healthcare system, lack of assessable data for management and political prioritization, and inefficiency in the healthcare system. The proposed solution is a digitalized and standardized practice that transforms recordkeeping in the municipalities. However, municipal healthcare is at risk of being fragmented due to digital documentation's focus on the organizational management of health with task-oriented practices supplied by an anonymous health professional. We find that digital documentation functions as an organizational micromanagement approach that assigns the health professional a subject position as an employee acting according to the organization's framework rather than the profession's normative framework.
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Affiliation(s)
| | - Loni Ledderer
- Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - Kirsten Beedholm
- Department of Public Health, Aarhus University, Aarhus C, Denmark
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Gilliot S, Ducloy-Bouthors AS, Loingeville F, Hennart B, Allorge D, Lebuffe G, Odou P. Pharmacokinetics of Curative Tranexamic Acid in Parturients Undergoing Cesarean Delivery. Pharmaceutics 2022; 14:pharmaceutics14030578. [PMID: 35335955 PMCID: PMC8952437 DOI: 10.3390/pharmaceutics14030578] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/27/2022] [Accepted: 03/02/2022] [Indexed: 02/04/2023] Open
Abstract
The aim of this study was to evaluate the population pharmacokinetics of tranexamic acid (TXA) administered intravenously at a single dose of 0.5 or 1 g in parturients undergoing active hemorrhagic cesarean delivery and to evaluate the influence of patient variables on TXA pharmacokinetics. Subjects from three recruiting centers were included in this PK sub-study if randomized in the experimental group (i.v TXA 0.5 g or 1 g over one minute) of the TRACES study. Blood samples and two urinary samples were collected within 6 h after TXA injection. Parametric non-linear mixed-effect modeling (Monolix v2020R1) was computed. The final covariate model building used 315 blood and 117 urinary concentrations from seventy-nine patients. A two-compartment model with a double first-order elimination from the central compartment best described the data. The population estimates of clearance (CL), central volume of distribution (V1), and half-life for a typical 70 kg patient with an estimated renal clearance of 150 mL/min (Cockroft–Gault) were 0.14 L/h, 9.25 L, and 1.8 h. A correlation between estimated creatinine clearance and CL, body weight before pregnancy, and V1 was found and partly explained the PK variability. The final model was internally validated using a 500-run bootstrap. The first population pharmacokinetic model of TXA in active hemorrhagic caesarean section was successfully developed and internally validated.
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Affiliation(s)
- Sixtine Gilliot
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Institut de Pharmacie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
- Correspondence:
| | - Anne-Sophie Ducloy-Bouthors
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Pôle Anesthésie-Réanimation, Hôpital Huriez, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
| | - Florence Loingeville
- ULR2694—METRICS—Evaluation des Technologies de Santé et des Pratiques Médicales, Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France;
| | - Benjamin Hennart
- Unité Fonctionnelle de Toxicologie, Pôle Biologie Pathologie Génétique, Centre Biologie Pathologie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (B.H.); (D.A.)
| | - Delphine Allorge
- Unité Fonctionnelle de Toxicologie, Pôle Biologie Pathologie Génétique, Centre Biologie Pathologie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (B.H.); (D.A.)
- ULR 4483-IMPECS-IMPact de l’Environnement Chimique sur la Santé, Faculté de Médecine-Pôle Recherche, Université de Lille, 1 Place de Verdun, F-59045 Lille, France
| | - Gilles Lebuffe
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Pôle Anesthésie-Réanimation, Hôpital Huriez, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
| | - Pascal Odou
- ULR-7365-Groupe de Recherche sur les Formes Injectables et les Technologies Associées (GRITA), Université de Lille, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France; (A.-S.D.-B.); (G.L.); (P.O.)
- Institut de Pharmacie, Centre Hospitalier Universitaire de Lille, F-59000 Lille, France
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Intraoperative Cell Salvage for Women at High Risk of Postpartum Hemorrhage During Cesarean Section: a Systematic Review and Meta-analysis. Reprod Sci 2022; 29:3161-3176. [PMID: 35023053 DOI: 10.1007/s43032-021-00824-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
Postpartum hemorrhage (PPH) can lead to substantial blood loss that compromises maternal hemodynamic stability and consequently cause severe maternal complications such as organ dysfunction or death. Intraoperative cell salvage (IOCS), an effective method of blood conservation used in other surgical specialties, can be an alternative intervention for managing PPH. Thus, our aim was to evaluate the efficacy and safety of IOCS for women at high risk of PPH undergoing cesarean sections. We conducted a systematic search of electronic databases from inception to February 25, 2021 for randomized controlled studies and observational studies published in English or Mandarin about IOCS use in cesarean sections. Primary outcomes of interest were changes in postoperative hematologic parameters and any adverse events reported among patients that had IOCS and controls that had an allogeneic blood transfusion. The certainty of the evidence of the outcomes was evaluated using the GRADE approach. A total of 24 studies with 5872 patients were included in the meta-analysis. Eleven randomized controlled trials (RCTs), and 13 observational studies were analyzed. Postoperative hemoglobin levels were higher among patients with IOCS SMD 0.39 (95% CI; 0.20, 0.60; P < 0.001, high certainty). Allogeneic blood transfusion increased adverse events RR = 1.81(95% CI; 1.24, 2.62; P = 0.002, low certainty). IOCS shortened hospital stay SMD - 0.59 (95% CI: - 0.98, - 0.19; P = 0.004, low certainty) and shortened prothrombin time SMD - 0.67 (95% CI; - 1.31, - 0.04), P = 0.037, low certainty). The lower incidence of transfusion-related adverse events and shorter hospital stay among other findings demonstrate that IOCS use in obstetrics is an effective and safe alternative for the management of PPH; however, high-quality randomized control studies are required to confirm this evidence.
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