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Bruce BR, Shepherd HL, Khan SA, Haunton CR, Leask J, De Vries BS. Association between intravenous fluids during labor and primary postpartum hemorrhage: A retrospective cohort study. Acta Obstet Gynecol Scand 2024; 103:1541-1549. [PMID: 38856239 PMCID: PMC11266724 DOI: 10.1111/aogs.14896] [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: 02/16/2024] [Revised: 04/19/2024] [Accepted: 05/29/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION There is a major research gap relating to the impact of intravenous (IV) fluids administration during labor on maternal and neonatal outcomes. It is biologically plausible that a relationship between volume of IV fluids and primary postpartum hemorrhage (PPH) exists. The primary objective of this study was to evaluate whether the administration of high-volume IV fluids during labor (≥ 2500 mL) increases the risk of primary PPH and other adverse outcomes for women with a term, singleton pregnancy, in comparison to low-volume IV fluids during labor (<2500 mL). MATERIAL AND METHODS A retrospective cohort study was conducted at a tertiary referral hospital in Sydney, Australia between 1st September 2021 and 31st October 2022. Inclusion criteria were: women with a live singleton fetus in a cephalic presentation; planning a vaginal birth; and admitted for labor and birth care between 37 and 42 week gestation. The study factor was IV fluids during labor and the primary outcome was primary PPH ≥500 mL. Secondary outcomes included cesarean section and major perineal injury. Pregnancy, birth, and postnatal data were obtained from the hospital's electronic clinical database, electronic medical records, and paper fluid order documentation. Multivariable logistic regression and multiple imputation were used to explore the relationship between volume of IV fluids in labor and PPH. RESULTS A total of 1023 participants were included of which 339 had a primary PPH (33.1%). There was no association between high-volume IV fluids and PPH after adjusting for demographic and clinical factors (adjusted odds ratio [ORadj]1.02 95% confidence interval [95%CI] 0.72, 1.44). However, there was a positive association between high-volume IV fluids and cesarean section (ORadj 1.99; 95%CI 1.4, 2.8). CONCLUSIONS The findings of this research are important to further knowledge relating to the administration of IV fluids during labor. The findings emphasize the importance of accurately documenting IV fluids administration and identifies research priorities to enable us to better understand the broader implications of IV fluids administration on pregnancy and perinatal outcomes.
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Affiliation(s)
- Belinda R. Bruce
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Sydney Institute for Women, Children and their FamiliesRPA Women and Babies, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Heather L. Shepherd
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Saleem Ahmed Khan
- RPA Women and Babies, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Charlotte R. Haunton
- RPA Women and Babies, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Julie Leask
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Bradley S. De Vries
- Sydney Institute for Women, Children and their FamiliesRPA Women and Babies, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
- Central Clinical School, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
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Ragusa A, Ficarola F, Ferrari A, Spirito N, Ardovino M, Giraldi D, Stuzziero E, Rinaldo D, Procaccianti R, Larciprete G, De Luca C, D'Avino S, Principi G, Angioli R, Svelato A. Tranexamic acid versus oxytocin prophylaxis in reducing post-partum blood loss, in low-risk pregnant women: TRANOXY STUDY, a phase III randomized clinical trial. EClinicalMedicine 2024; 73:102665. [PMID: 38873634 PMCID: PMC11169955 DOI: 10.1016/j.eclinm.2024.102665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 06/15/2024] Open
Abstract
Background To assess the equivalence of tranexamic acid (TRAN) versus synthetic oxytocin (OXY) in reducing post-partum blood loss, in full-term patients (37-42 weeks), at low risk of post-partum hemorrhage, with vaginal childbirth. Methods Phase III, randomized (1:1), open-label, longitudinal, multi-center, prospective clinical trial (Prot. n 63209, ClinicalTrials.gov Identifier: NCT02775773). From January 7, 2020, to June 30, 2023, a total of 256 women were enrolled at two general urban community hospitals in Italy, serving a multi-ethnic patient population with National Health Insurance. The primary outcome was to explore a potential equivalence between the two treatments (OXY and TRAN) in preventing total blood loss. Therefore, we randomized 231 women into two groups: Group A (OXY), 127 women who were administered 10UI intramuscularly within 5 min from childbirth; Group B (TRAN), 104 women to whom 1-g slow intravenous infusion was administered within 5 min from childbirth. Findings At the time of delivery, mean blood loss for OXY group versus TRAN group was 269.12 mL versus 263.88 mL, respectively, with equivalence between the two groups. Similarly, there was equivalence in total blood loss between the OXY and the TRAN group (397.66 mL versus 405.64 mL, respectively. No statistical differences between Hb levels at admission and discharge in the two groups were reported. No difference was found in terms of additional uterotonic and surgical therapies between the two groups of patients. Neither group showed thrombotic complications at check-up performed after 7 days or after a questionnaire regarding adverse effects, subjected after 40 days. Interpretation The study shows the equivalence of tranexamic acid versus synthetic oxytocin in post-partum blood loss prophylaxis in term patients at low risk of PPH with vaginal childbirth. The safety profiles of OXY and TRAN were similar. Funding None.
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Affiliation(s)
- Antonio Ragusa
- Department of Obstetrics and Gynecology, Maggiore Hospital Carlo Alberto Pizzardi Bologna, Italy
| | - Fernando Ficarola
- Unit of Gynecology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Unit of Gynecology, Department of Surgical and Medical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Amerigo Ferrari
- Institute of Management, MeS (Management and Health) Laboratory, Sant’Anna School of Advanced Studies, Pisa, Italy
| | - Nicoletta Spirito
- Department of Obstetrics and Gynecology, Ospedale Apuane, Massa Carrara, Italy
| | - Mario Ardovino
- Department of Obstetrics and Gynecology, Ospedale S.G. Moscati, Avellino, Italy
| | - Domenico Giraldi
- Department of Obstetrics and Gynecology, Ospedale S.G. Moscati, Avellino, Italy
| | - Elisario Stuzziero
- Department of Obstetrics and Gynecology, Ospedale S.G. Moscati, Avellino, Italy
| | - Denise Rinaldo
- Department of Obstetrics and Gynecology, ASST Bergamo Est, Bolognini Hospital, Seriate, Italy
| | - Roberto Procaccianti
- Department of Gynecology and Obstetrics, Fondazione Istituto San Raffaele G Giglio, Cefalù, Italy
| | - Giovanni Larciprete
- Department of Obstetrics and Gynecology, Fatebenefratelli Gemelli Hospital, Isola Tiberina, Roma, Italy
| | - Caterina De Luca
- Department of Obstetrics and Gynecology, Fatebenefratelli Gemelli Hospital, Isola Tiberina, Roma, Italy
| | - Sara D'Avino
- Department of Obstetrics and Gynecology, Fatebenefratelli Gemelli Hospital, Isola Tiberina, Roma, Italy
| | - Giulia Principi
- Department of Obstetrics and Gynecology, University of Messina, Messina, Italy
| | - Roberto Angioli
- Unit of Gynecology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Alessandro Svelato
- Department of Obstetrics and Gynecology, Fatebenefratelli Gemelli Hospital, Isola Tiberina, Roma, Italy
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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. [PMID: 38838714 DOI: 10.1055/a-2322-1861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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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Patel M. Postpartum Hemorrhage: Enhancing Outcomes for Mothers by Effective Management. J Obstet Gynaecol India 2024; 74:191-195. [PMID: 38974747 PMCID: PMC11224172 DOI: 10.1007/s13224-024-02022-3] [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: 05/31/2024] [Accepted: 06/13/2024] [Indexed: 07/09/2024] Open
Abstract
Postpartum hemorrhage (PPH) remains a significant contributor to maternal morbidity and mortality worldwide. In India, PPH affects approximately 12% of women. The prevention and management of PPH are the significant challenges in obstetrics, with accurate assessment of blood loss and timely intervention being critical. Active Management of the Third Stage of Labor is a gold standard strategy for prevention. Recent advancements in PPH management include the use of recombinant activated factor VIIa, which has shown promise in decreasing the need for invasive procedures and second-line therapies. Additionally, surgical and radiological interventions have been effective in cases of refractory PPH. Overall, ongoing research and advancements in PPH management continue to enhance the quality of care and maternal outcomes experiencing this potentially life-threatening complication of childbirth. This editorial explores prevention and management of Atonic PPH with encompassing medical and surgical strategies, to enhance understanding and optimize clinical care for mothers at risk of this obstetric emergency.
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Affiliation(s)
- Madhuri Patel
- Clinical Associate, Nowrosjee Wadia Maternity Hosp, Mumbai, India
- Mahatma Gandhi Memorial Hospital, Parel, Mumbai, India
- Grant Medical College and Sir J.J. Group of Hospitals, Mumbai, India
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Nivatpumin P, Nithi-Uthai J, Lertbunnaphong T, Sukcharoen N, Soponsiripakdee T, Yonphan P. Perioperative outcomes and causes of postpartum hemorrhage in patients undergoing cesarean delivery in Thailand: A comprehensive retrospective study. PLoS One 2024; 19:e0300620. [PMID: 38626161 PMCID: PMC11020384 DOI: 10.1371/journal.pone.0300620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 03/03/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND This study aimed to identify the characteristics, causes, perioperative anesthetic, and obstetric outcomes of patients experiencing postpartum hemorrhage (PPH) after cesarean delivery. METHODS We retrospectively analyzed patients who underwent cesarean delivery at the largest university hospital in Bangkok, Thailand, during a 5-year period (January 1, 2016-December 31, 2020). PPH was defined as an estimated blood loss (EBL) of ≥ 1000 ml within 24 hours postpartum. RESULTS Of 17 187 cesarean deliveries during the study period, 649 patients were included for analysis. The mean EBL was 1774.3 ± 1564.4 ml (range: 1000-26 000 ml). Among the patients, 166 (25.6%) experienced massive PPH (blood loss > 2000 ml). Intraoperative blood transfusions were necessary for 264 patients (40.7%), while 504 individuals (77.7%) needed intraoperative vasopressors. The analysis revealed uterine atony as the leading cause of PPH in 62.7% (n = 407) of the patients, with abnormal placentation following at 29.3% (n = 190). Abnormal placentation was associated with a significantly higher mean EBL of 2345.0 ± 2303.9 ml compared to uterine atony, which had a mean EBL of 1504.0 ± 820.7 ml (P < 0.001). Abnormal placentation also significantly increased the likelihood of blood transfusions and hysterectomies (P < 0.001 for both) and led to more intensive care unit admissions (P = 0.032). The risk of EBL exceeding 2000 ml was markedly higher in patients with abnormal placentation (odds ratio [OR] 5.12, 95% confidence interval [CI] 3.45-7.57, P < 0.001) and in cases involving trauma to the internal organs (OR 2.33, 95% CI 1.16-4.71, P = 0.018) than in patients with uterine atony. The study documented three instances of perioperative cardiac arrest, one of which was fatal. CONCLUSIONS These findings highlight the importance of comprehensive perioperative management strategies, including the ready availability of adequate blood and blood products, particularly in scenarios predisposed to significant hemorrhage. TRIAL REGISTRATION Clinical trial registration: Clinicaltrial.gov registration number NCT04833556 (April 6, 2021).
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Affiliation(s)
- Patchareya Nivatpumin
- Faculty of Medicine Siriraj Hospital, Department of Anesthesiology, Mahidol University, Bangkok, Thailand
| | - Jitsupa Nithi-Uthai
- Faculty of Medicine Siriraj Hospital, Department of Anesthesiology, Mahidol University, Bangkok, Thailand
| | - Tripop Lertbunnaphong
- Faculty of Medicine Siriraj Hospital, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Nattapon Sukcharoen
- Faculty of Medicine Siriraj Hospital, Department of Anesthesiology, Mahidol University, Bangkok, Thailand
| | - Thanyarat Soponsiripakdee
- Faculty of Medicine Siriraj Hospital, Department of Anesthesiology, Mahidol University, Bangkok, Thailand
| | - Pawana Yonphan
- Faculty of Medicine Siriraj Hospital, Department of Anesthesiology, Mahidol University, Bangkok, Thailand
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Siefen AC, Kurte MS, Kron F. Economic effects of treating postpartum hemorrhage with vacuum-induced hemorrhage control devices - A budget impact analysis of the Jada® System in the German obstetrics setting. Eur J Obstet Gynecol Reprod Biol 2024; 294:222-230. [PMID: 38301501 DOI: 10.1016/j.ejogrb.2024.01.024] [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: 12/20/2023] [Accepted: 01/17/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE This study aimed to assess the budget impact of vacuum-induced hemorrhage control (VHC) devices for treating postpartum hemorrhage (PPH) from the perspective of the German statutory health insurance (SHI). STUDY DESIGN Evidence shows that treating PPH with VHC instead of uterine balloon tamponade (UBT) can reduce resource consumption (e.g., reduced number of blood transfusions and length of stay). A budget impact model combining aggregated German real-world reimbursement data of PPH cases with the assumption of resource reduction due to VHC usage was developed. Diagnosis-related groups (DRG) of PPH cases and their frequencies were collected using a publicly available database. A "downgrading mechanism" was performed, leading to a less resource-intensive DRG, i.e., resulting in a lower flat fee to be paid by SHI. Four subgroups were differentiated based on coded diagnoses and procedures: 1) PPH (O72.-) as main diagnosis, 2) PPH as secondary diagnosis, 3) UBT procedure coded, and 4) UBT or standard tamponade coded. Weighted averages of cost savings per case were calculated. RESULTS Data from 7,129 (subgroup 1), 49,523 (subgroup 2), 1,668 (subgroup 3), and 3,406 (subgroup 4) cases were retrieved. After applying the downgrading mechanism, cost savings (weighted average) resulted in 184.09 €, 210.50 €, 921.33 €, and 633.74 € for subgroups 1-4, respectively, CONCLUSION: This is the first German budget impact analysis of VHC for the treatment of PPH. Results showed the highest cost-saving potential for cases currently treated with UBT. Demonstrating not only clinical but also financial consequences of innovative treatments is crucial for the adoption into clinical practice.
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Affiliation(s)
| | - Melina S Kurte
- VITIS Healthcare Group, Cologne, Germany; Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Florian Kron
- VITIS Healthcare Group, Cologne, Germany; Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology (CIO ABCD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; FOM University of Applied Sciences, Essen, Germany.
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Alkhfaji H, Kahloul M, Askar TRM, Alhamaidah MF, Ali Hussein H. Impact of Melatonin as a Premedication Agent in Caesarean Section on Blood Loss and Postoperative Pain Level. Anesthesiol Res Pract 2023; 2023:8102111. [PMID: 38116042 PMCID: PMC10730253 DOI: 10.1155/2023/8102111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/09/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Background Postpartum hemorrhage (PPH) is a serious postdelivery condition with a high incidence of morbidity and mortality for women who undergo childbirth with or without a caesarean section. Melatonin has been suggested to increase the contractility of myometrium and reduce the pain score postoperatively, therefore it is believed that the use of melatonin before surgery may decrease blood loss, reduce pain score, and decrease the need for postoperative opioids. Objectives The main objectives of this study are focused on the investigation of melatonin as a premedication agent to reduce blood loss and decrease pain score postoperatively in patients undergoing cesarean section under spinal anesthesia. Methods 80 patients were scheduled for spinal anesthesia-based cesarean sections and randomly assigned to two groups, melatonin group (M) 40 patients and placebo group (P) 40 patients to receive either 10 mg of sublingual melatonin or a placebo of 90 minutes preoperatively. Hemoglobin levels were been measured preoperative and 12 hrs. Postoperatively, blood loss volume was calculated by measuring both the weight of used materials before and after the surgery and the volume sucked in the suction bottle after placental delivery. Postoperative visual pain score and analgesic requirements were used to evaluate pain levels. Results Analyzed collected data showed a significant decrease in blood loss in the melatonin group in comparison with the placebo group as measured by the hemoglobin level. On the other hand, there is a significant decrease in pain score and analgesia requirement with the melatonin group compared to the placebo group. Conclusion Melatonin is a promising premedication drug that has a significant impact on postpartum hemorrhage by reducing blood loss and pain levels of mothers who have undergone C-sections.
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Affiliation(s)
- Hussein Alkhfaji
- Department of Anesthesia, College of Health and Medical Technology, Al-Ayen University, Nasiriyah, Iraq
- Department of Anesthesia and Intensive Care, Faculty of Medicine Ibn El Jazzar, University of Sousse, Sousse, Tunisia
| | - Mohamed Kahloul
- Department of Anesthesia and Intensive Care, Sahloul Teaching Hospital, University of Sousse, Faculty of Medicine of Sousse, Sousse, Tunisia
| | | | - Majid Fakhir Alhamaidah
- Department of Anesthesia, College of Health and Medical Technology, Al-Ayen University, Nasiriyah, Iraq
| | - Hussein Ali Hussein
- Department of Anesthesia, College of Health and Medical Technology, Al-Ayen University, Nasiriyah, Iraq
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Glenzer MM, Correia M, Nhantumbo V, Barnes RF, Luis E, Boaventura I, Manguele N, Silva P, von Drygalski A. Postpartum hemorrhage in Sub-Saharan Africa-a prospective study in metropolitan Mozambique. J Thromb Haemost 2023; 21:3463-3476. [PMID: 37709148 DOI: 10.1016/j.jtha.2023.09.002] [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: 03/22/2023] [Revised: 08/12/2023] [Accepted: 09/01/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Estimates indicate approximately ≈500 to 1000 maternal deaths per 100,000 live births in Sub-Saharan Africa (SSA) (vs ≈5-20 in developed countries). Postpartum hemorrhage (PPH) seems a major contributor to maternal mortality (MM), but there are no comprehensive data for the region. OBJECTIVES Analyze MM, PPH, and associated risk factors. METHODS We collected prospective data on MM, PPH, and associated risk factors in metropolitan Mozambique. We recorded consecutive deliveries at the Maputo Central Hospital between February 2019 and January 2021. Data included age, HIV status, parity, delivery mode, notes, vital signs, laboratory values, and fetal parameters. PPH was determined by charted diagnosis, blood loss of >500 mL, transfusion, and/or notes indicating significant bleeding. RESULTS Of 8799 deliveries, ≈40% occurred in women residing outside Maputo City ("nonlocal"), with similar demographic characteristics between local and nonlocal women. However, compared with local women, nonlocal women had worse outcomes, including higher rates of MM (1.52% vs 0.78%; P =.0012) and PPH (16.51% vs 12.39%; P <.0001), whereby PPH was strongly associated with MM (adjusted odds ratio = 5.56; P <.0001). Almost all women with uterine atony (≈1%) experienced PPH. For women receiving laboratory tests on admission (drawn only if in distress; local, n = 561; nonlocal, n = 514), both cohorts revealed similar distributions of hemoglobin levels and platelet counts. Prepartum anemia (≈57%) and thrombocytopenia (≈21%) were prominent risk factors for PPH; risk increased with increasing severity and was additive in the presence of both. CONCLUSIONS PPH is a serious problem in Maputo province, a metropolitan area of SSA, portending high MM. Identification of correctable risk factors, including anemia, should catalyze the development of region-specific prevention protocols.
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Affiliation(s)
- Michael M Glenzer
- Department of Medicine, University of California San Diego, San Diego, California, USA.
| | - Momade Correia
- Department of Gynecology/Obstetrics, Universidade Eduardo Mondlane, Hospital, Central Maputo, Maputo, Mozambique
| | - Virgilio Nhantumbo
- Department of Hematology, Universidade Eduardo Mondlane, Hospital, Central Maputo, Maputo, Mozambique
| | - Richard Fw Barnes
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Elvira Luis
- Department of Gynecology/Obstetrics, Universidade Eduardo Mondlane, Hospital, Central Maputo, Maputo, Mozambique
| | - Ines Boaventura
- Department of Gynecology/Obstetrics, Universidade Eduardo Mondlane, Hospital, Central Maputo, Maputo, Mozambique
| | - Nelia Manguele
- Department of Hematology, Universidade Eduardo Mondlane, Hospital, Central Maputo, Maputo, Mozambique
| | - Patricia Silva
- Department of Hematology, Universidade Eduardo Mondlane, Hospital, Central Maputo, Maputo, Mozambique
| | - Annette von Drygalski
- Department of Medicine, University of California San Diego, San Diego, California, USA
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Huhn EA, Göbl CS, Fischer T, Todesco Bernasconi M, Kreft M, Kunze M, Vogt DR, Dölzlmüller E, Jaksch-Bogensperger H, Heldstab S, Eppel W, Husslein P, Ochsenbein Kölble N, Richter A, Bäz E, Winzeler B, Hoesli I. Sensitivity, specificity, and diagnostic accuracy of WHO 2013 criteria for diagnosis of gestational diabetes mellitus in low risk early pregnancies: international, prospective, multicentre cohort study. BMJ MEDICINE 2023; 2:e000330. [PMID: 37720695 PMCID: PMC10503330 DOI: 10.1136/bmjmed-2022-000330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 07/17/2023] [Indexed: 09/19/2023]
Abstract
Objective To evaluate the predictability of gestational diabetes mellitus wth a 75 g oral glucose tolerance test (OGTT) in early pregnancy, based on the 2013 criteria of the World Health Organization, and to test newly proposed cut-off values. Design International, prospective, multicentre cohort study. Setting Six university or cantonal departments in Austria, Germany, and Switzerland, from 1 May 2016 to 31 January 2019. Participants Low risk cohort of 829 participants aged 18-45 years with singleton pregnancies attending first trimester screening and consenting to have an early 75 g OGTT at 12-15 weeks of gestation. Participants and healthcare providers were blinded to the results. Main outcome measures Fasting, one hour, and two hour plasma glucose concentrations after an early 75 g OGTT (12-15 weeks of gestation) and a late 75 g OGTT (24-28 weeks of gestation). Results Of 636 participants, 74 (12%) developed gestational diabetes mellitus, according to World Health Organization 2013 criteria, at 24-28 weeks of gestation. Applying WHO 2013 criteria to the early OGTT with at least one abnormal value gave a low sensitivity of 0.35 (95% confidence interval 0.24 to 0.47), high specificity of 0.96 (0.95 to 0.98), positive predictive value of 0.57 (0.41 to 0.71), negative predictive value of 0.92 (0.89 to 0.94), positive likelihood ratio of 10.46 (6.21 to 17.63), negative likelihood ratio of 0.65 (0.55 to 0.78), and diagnostic odds ratio of 15.98 (8.38 to 30.47). Lowering the postload glucose values (75 g OGTT cut-off values of 5.1, 8.9, and 7.8 mmol/L) improved the detection rate (53%, 95% confidence interval 41% to 64%) and negative predictive value (0.94, 0.91 to 0.95), but decreased the specificity (0.91, 0.88 to 0.93) and positive predictive value (0.42, 0.32 to 0.53) at a false positive rate of 9% (positive likelihood ratio 5.59, 4.0 to 7.81; negative likelihood ratio 0.64, 0.52 to 0.77; and diagnostic odds ratio 10.07, 6.26 to 18.31). Conclusions The results of this prospective low risk cohort study indicated that the 75 g OGTT as a screening tool in early pregnancy is not sensitive enough when applying WHO 2013 criteria. Postload glucose values were higher in early pregnancy complicated by diabetes in pregnancy. Lowering the postload cut-off values identified a high risk group for later development of gestational diabetes mellitus or those who might benefit from earlier treatment. Results from randomised controlled trials showing a beneficial effect of early intervention are unclear. Trial registration ClinicalTrials.gov NCT02035059.
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Affiliation(s)
- Evelyn A Huhn
- Department of Feto-Maternal Medicine and Obstetrics, University Hospital Basel, Basel, Switzerland
- Department of Prenatal Diangosis and Obstetrics, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christian S Göbl
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | - Thorsten Fischer
- Department of Obstetrics and Gynaecology, Salzburger Landeskrankenhaus, Paracelsus Medical University, Salzburg, Austria
| | | | - Martina Kreft
- Department of Obstetrics and Gynaecology, University Hospital Zurich, Zurich, Switzerland
| | - Mirjam Kunze
- Department of Obstetrics and Gynaecology, University Hospital Freiburg, Freiburg, Germany
| | - Deborah R Vogt
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Eva Dölzlmüller
- Department of Obstetrics and Gynaecology, Salzburger Landeskrankenhaus, Paracelsus Medical University, Salzburg, Austria
| | - Heidi Jaksch-Bogensperger
- Department of Obstetrics and Gynaecology, Salzburger Landeskrankenhaus, Paracelsus Medical University, Salzburg, Austria
| | - Sandra Heldstab
- Department of Obstetrics and Gynaecology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Wolfgang Eppel
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | - Peter Husslein
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | | | - Anne Richter
- Department of Obstetrics and Gynaecology, University Hospital Zurich, Zurich, Switzerland
| | - Elke Bäz
- Department of Obstetrics and Gynaecology, University Hospital Freiburg, Freiburg, Germany
| | - Bettina Winzeler
- Department of Endocrinology and Diabetology, University Hospital Basel, Basel, Switzerland
| | - Irene Hoesli
- Department of Obstetrics and Gynaecology, University Hospital Basel, Basel, Switzerland
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10
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Fiol AG, Yoo J, Yanez D, Fardelmann KL, Salimi N, Alian M, Mancini P, Alian A. Baseline rotational thromboelastometry (ROTEM) values in a healthy, diverse obstetric population and parameter changes by pregnancy-induced comorbidities. Proc AMIA Symp 2023; 36:562-571. [PMID: 37614857 PMCID: PMC10443986 DOI: 10.1080/08998280.2023.2217534] [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: 03/26/2023] [Accepted: 05/21/2023] [Indexed: 08/25/2023] Open
Abstract
Background Point-of-care testing provides a representation of the patient's coagulability status during effective postpartum hemorrhage management. Baseline values of rotational thromboelastometry (ROTEM) have not yet been reported in a heterogeneous obstetric population. This study aimed to establish a baseline for a diverse population representative of the United States. The secondary aim was to evaluate the association of these hematologic parameters with comorbidities, race, and socioeconomic factors. Methods The study was a retrospective review of collected ROTEM values of women undergoing vaginal or cesarean delivery with a history of or at risk for postpartum hemorrhage. Patients were divided into healthy and comorbid groups. Exclusion criteria for both groups included active or recent bleeding, receipt of blood products or clot-enhancing factors, and liver disease. Mean values of ROTEM by race and comorbidities were included. Median values were reported for intrinsic pathway thromboelastometry (INTEM), extrinsic pathway thromboelastometry (EXTEM), and fibrin polymerization thromboelastometry (FIBTEM) amplitude at 10 minutes (A10) and 20 minutes (A20), coagulation time, clot formation time, and maximum clot firmness. Results A total of 681 records were reviewed; 485 met inclusion criteria, and 267 met healthy criteria. The mean (standard deviation) demographics for maternal age (years), body mass index (kg/m2), and gestational age (weeks) were 32.2 (5.7), 34 (7.3), and 35.4 (5), respectively. The median INTEM, EXTEM, and FIBTEM A10 were 63, 65, and 23 mm. The mean for INTEM, EXTEM, and FIBTEM A10 was increased for those who were Black or obese, whereas a decreased FIBTEM and EXTEM A10 was noted in those who were Asian or those who had the hemolysis, elevated liver enzymes, low platelet syndrome. Conclusions Our heterogeneous population presents ROTEM values within the interquartile range of those previously reported in European studies. Black race, obesity, and preeclampsia were associated with hypercoagulable profiles.
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Affiliation(s)
| | - Jin Yoo
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - David Yanez
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nayema Salimi
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Marah Alian
- University of New England College of Osteopathic Medicine, Biddeford, Maine, USA
| | - Peter Mancini
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Aymen Alian
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
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11
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Glonnegger H, Glenzer MM, Lancaster L, Barnes RF, von Drygalski A. Prepartum Anemia and Risk of Postpartum Hemorrhage: A Meta-Analysis and Brief Review. Clin Appl Thromb Hemost 2023; 29:10760296231214536. [PMID: 37968861 PMCID: PMC10655792 DOI: 10.1177/10760296231214536] [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: 11/17/2023] Open
Abstract
Postpartum hemorrhage (PPH) is responsible for 30% to 50% of maternal deaths. There is conflicting evidence if prepartum anemia facilitates PPH. A comprehensive analysis of studies describing their relation is missing. An extensive database search was conducted applying the terms "anemia" OR "hemoglobin" AND "postpartum hemorrhage." We used a random-effects meta-analysis model to estimate an overall odds ratio (OR) for PPH and prepartum anemia, separating studies that were conformant and non-conformant with the World Health Organization (WHO) definitions for anemia. The search yielded 2519 studies, and 46 were appropriate for analysis. The meta-analyses of WHO-conformant (n = 22) and non-conformant (n = 24) studies showed that the risk of PPH was increased when anemia was present. The ORs were 1.45 (CL: 1.23-1.71) for WHO-conformant studies, 2.88 (CL: 1.38-6.02) for studies applying lower thresholds for anemia, and 3.28 (CL: 2.08-5.19) for undefined anemia thresholds. PPH risk appeared to increase with lower anemia thresholds. Prepartum anemia is associated with an increased risk of PPH, an observation that is important regarding improved anemia correction strategies such as iron supplementation.
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Affiliation(s)
- Hannah Glonnegger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center-University of Freiburg, Freiburg, Germany
| | - Michael M. Glenzer
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, CA, USA
| | - Lian Lancaster
- Department of Emergency Medicine, The George Washington University Washington DC, Washington DC, USA
| | - Richard F.W. Barnes
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, CA, USA
| | - Annette von Drygalski
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, CA, USA
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