Mild thrombocytopenia and the risk for postpartum hemorrhage in twin pregnancies

Is Grand Multiparity an Independent Risk Factor for Blood Transfusion?

The relation between grand multiparity and poor pregnancy outcome, especially postpartum hemorrhage and blood transfusion, has displayed inconsistent findings. Some studies have identified an increased maternal and neonatal morbidity, but the more recent literature is less clear about the risks. The objective of the study is to determine the association of grand multiparity with postpartum blood transfusion. We conducted a retrospective cohort study in a single tertiary university-affiliated medical center between 2011 and 2019. All women were categorized into one of three groups based on the number of previous deliveries: (a) nulliparous (no previous delivery), (b) multiparous (1-4 previous deliveries), and (c) grand multiparous (≥ 5 previous deliveries). We compared the demographic, clinical, and pregnancy outcomes of the study groups. The primary outcome was the need for red blood cell transfusion during the index admission. During the study period, there were 87,343 deliveries in our center. Among the study population, 36,777 (42.1%) were nulliparous, 49,072 (56.1%) were multipara, and 1494 (1.7%) were grand multiparous. Overall, 1602 women (1.8%) were treated with RBC transfusion. Cesarean delivery, macrosomia, preterm delivery, multiple gestations, antenatal anemia, thrombocytopenia, intrauterine fetal death (IUFD), and prolonged second or third stage of labor were more prevalent among women who were treated with RBC transfusion. After controlling for potential confounders, including maternal age, preterm delivery, IUFD, mode of delivery, and antenatal thrombocytopenia, grand multiparity was found to be an independent protective factor for RBC transfusion (RR = 0.2 (0.007-0.56). After controlling for cofounders, grand multiparity alone is not associated with postpartum blood transfusion.

Risk factors for postpartum hemorrhage in twin pregnancies with cesarean section

The rates of twin pregnancies and cesarean section have increased in recent years, and both of them are at high risks of postpartum hemorrhage (PPH). However, few studies have concentrated on the risks of PPH in twin pregnancies and cesarean deliveries. In this study, we aimed to identify the risk factors for PPH among twin-pregnant women with cesarean section. This was a retrospective observational study including 1,649 women with twin pregnancies delivered by cesarean section from 2016 to 2022 in the Second Affiliated Hospital of Wenzhou Medical University, China. The eligible women were divided into PPH group (n = 116) and non-PPH group (n = 1,533) according to the blood loss after delivery within 24 h. The baseline maternal and perinatal characteristics were compared between the two groups. Logistic regression analysis was conducted to identify the potential risk factors for PPH. We found nulliparity, assisted reproductive technology (ART) usage, preeclampsia or HELLP syndrome, placenta previa, placenta accreta and general anesthesia were more common in PPH group than non-PPH group (P < 0.05). Women in PPH group had higher maternal body mass index at delivery and higher combined birthweight of the twins than non-PPH group, but had lower parity (P < 0.05). Seven independent risk factors for PPH were identified after logistic regression analysis: ART usage (OR 2.354 95% CI 1.357-4.083, P = 0.002), preeclampsia or HELLP syndrome (OR 2.605, 95% CI 1.471-4.616, P = 0.001), placenta previa (OR 7.325, 95% CI 3.651-14.697, P < 0.001), placenta accreta (OR 6.296, 95% CI 1.316-30.12, P = 0.021), thrombocytopenia (OR 1.636, 95% CI 1.056-2.535, P = 0.027), general anesthesia (OR 2.394, 95% CI 1.223-4.686, P = 0.011), and combined birthweight (OR 1.00032, 95% CI 1.00005-1.00059, P = 0.020). Collectively, in women with twin pregnancies delivered by cesarean section, the use of ART, preeclampsia or HELLP syndrome, placenta previa, placenta accreta, thrombocytopenia, general anesthesia and the combined birthweight were identified as independent risk factors for PPH. More attention should be paid to women with these risk factors.

Hemostatic biomarkers associated with postpartum hemorrhage: a systematic review and meta-analysis

Postpartum hemorrhage (PPH) is a leading cause of maternal morbi-mortality. Although obstetric risk factors are well described, the impact of predelivery hematologic and hemostatic biomarkers remains incompletely understood. In this systematic review, we aimed to summarize the available literature on the association between predelivery hemostatic biomarkers and PPH/severe PPH. Searching MEDLINE, EMBASE, and CENTRAL databases from inception to October 2022, we included observational studies on unselected pregnant women without bleeding disorder reporting on PPH and on predelivery hemostatic biomarkers. Two review authors independently performed title, abstract and full-text screening, upon which quantitative syntheses of studies reporting on the same hemostatic biomarker were conducted, calculating the mean difference (MD) between women with PPH/severe PPH and controls. A search on 18 October 2022 yielded 81 articles fitting our inclusion criteria. The heterogeneity between studies was considerable. With regard to PPH, the estimated average MD in the investigated biomarkers (platelets, fibrinogen, hemoglobin, Ddimer, activated partial thromboplastin time, and prothrombin time) were not statistically significant. Women who developed severe PPH had lower predelivery platelets than controls (MD = -26.0 109/L; 95% confidence interval, -35.8 to -16.1), whereas differences in predelivery fibrinogen concentration (MD = -0.31 g/L; 95% confidence interval, -0.75 to 0.13) and levels of factor XIII or hemoglobin were not statistically significant in women with and without severe PPH. Predelivery platelet counts were, on average, lower in women with severe PPH compared with controls, suggesting the potential usefulness of this biomarker for predicting severe PPH. This trial was registered at the International Prospective Register of Systematic Reviews as CRD42022368075.