Spécificités obstétricales et anesthésiques de la prise en charge d’une hémorragie du post-partum (HPP) associée à la césarienne

Cephalad-caudad vs transverse blunt expansion of low transverse hysterotomy during caesarean section and risk of severe postpartum haemorrhage: A prospective comparative study

BACKGROUND

The global prevalence of caesarean section as a delivery method is increasing worldwide. However, there is notable divergence among countries in their national guidelines regarding the optimal technique for blunt expansion hysterotomy of the low transverse uterine incision during caesarean section (cephalad-caudad or transverse).

AIM

To compare the risk of severe postpartum haemorrhage (PPH) between cephalad-caudad and transverse blunt expansion hysterotomy during caesarean section.

METHODS

This prospective comparative observational study was conducted in a university maternity hospital. All women who gave birth to one infant by caesarean section after 30 weeks of gestation between November 2020 and November 2021 were included in this study. The exclusion criteria were a coagulation disorder, the presence of placenta previa, multiple pregnancies, or enlargement of the hysterotomy with scissors. The choice between cephalad-caudad or transverse blunt expansion of the low transverse hysterotomy was left to the surgeon's discretion. The primary outcome measure was severe PPH, defined as estimated blood loss ≥ 1000 ml. Univariate and multivariate analyses were employed to assess the risk of severe PPH associated with the two methods of enlarging the low transverse hysterotomy.

RESULTS

The study included 850 women, of whom 404 underwent transverse blunt expansion and 446 underwent cephalad-caudad blunt expansion. The overall incidence of severe PPH was 13.3 %. Univariate analysis revealed no significant difference in the frequency of severe PPH between the cephalad-caudad and transverse blunt expansion groups (13.9 % vs 12.6 %; p = 0.61). However, the use of additional surgical sutures (mainly additional haemostatic stitches) was less common with cephalad-caudad blunt expansion (26.7 % vs 36.9 %; p < 0.05). Multivariate analysis showed no significant difference in risk between the two techniques (odds ratio 1.17, 95 % confidence interval 0.77-1.78).

CONCLUSION

No significant difference in the risk of severe PPH was found between cephalad-caudad and transverse blunt expansion of the low transverse hysterotomy during caesarean section.

Investigation of The Effects of Oxytocin Administration Timing on Postpartum Hemorrhage during Cesarean Section

Background and Objectives: To determine and compare the effects of the timing of oxytocin administration (routinely used for intraoperative uterotonic purposes in cesarean section (CS) deliveries in our clinic) on the severity of postpartum hemorrhage following CS. Materials and Methods: All study participants (n = 216) had previous cesarean deliveries, were 38-40 weeks pregnant, and had CS planned under elective conditions. The cases were randomly divided into two groups: one group (n = 108) receiving oxytocin administration before the removal of the placenta (AOBRP) and another group (n = 108) receiving oxytocin administration after the removal of the placenta (AOARP). In all cases, the placenta was removed using the manual traction method. The standard dose of oxytocin is administered as an intravenous (IV) push of 3 international units (IU); simultaneously, 10 IU of oxytocin is added to 1000 cc isotonic fluid and given as an IV infusion at a rate of 250 cc/h. All methods and procedures applied to both groups were identical, except for the timing of administration of the standard oxytocin dose. Age, body mass index (BMI), parity, gestational week, preoperative hemoglobin (HB) and hematocrit (HTC), postoperative 6th and 24th hour HB-HTC, intraoperative hemorrhage, additional uterotonic need during cesarean section, postoperative hemorrhage (number of pads), need for blood transfusion during or after cesarean section, cesarean section time, and postpartum newborn baby weight were evaluated. Results: Age (year), BMI (kg/m²), parity, gestational week, surgical time, and newborn weight (g) did not differ between the groups (p > 0.05). The AOBRP group had significantly higher postoperative 6th hour HB and HTC and postoperative 24th hour HB and HTC values (p < 0.05). The intraoperative hemorrhage level was higher in the AOARP group (p = 0.000). Conclusions: The administration of oxytocin before placenta removal did not change the volume of bleeding in the postoperative period but significantly reduced the volume of bleeding in the intraoperative period. Therefore, in the postoperative period, the HB and HTC values of the AOBRP group were higher than those of the AOARP group.

Route of oxytocin administration for preventing blood loss at caesarean section: a systematic review with meta-analysis

OBJECTIVES

Assess the effects of different routes of prophylactic oxytocin administration for preventing blood loss at caesarean section (CS).

DESIGN

Systematic review and meta-analysis.

METHODS

Medline, EMBASE, CINAHL, Cochrane Library, BVS, SciELO and Global Index Medicus were searched through 24 May 2020 for randomised controlled trials (RCTs) comparing different routes of prophylactic oxytocin administration during CS. Study selection, data extraction and quality assessment were conducted by two investigators independently. We pooled results in fixed effects meta-analyses and calculated average risk ratio (RR), mean difference (MD) and 95% CI. We used GRADE to assess the overall quality of evidence for each outcome.

RESULTS

Three trials (180 women) were included in the review. All studies compared intramyometrial (IMY) versus intravenous oxytocin in women having prelabour CS. IMY compared with intravenous oxytocin administration may result in little or no difference in the incidence of postpartum haemorrhage (RR 0.14, 95% CI 0.01 to 2.70; N=100 participants; 1 RCT), hypotension (RR 1.00, 95% CI 0.29 to 3.45; N=40; 1 RCT), headache (RR 3.00, 95% CI 0.13 to 69.52; N=40; 1 RCT) or facial flushing (RR 0.50, 95% CI 0.05 to 5.08; N=40; 1 RCT); IMY oxytocin may reduce nausea/vomiting (RR 0.13, 95% CI 0.02 to 0.69; N=140; 2 RCTs). We are very uncertain about the effect IMY versus intravenous oxytocin on the need for additional uterotonics (RR 0.82; 95% CI 0.25 to 2.69; N=140; 2 RCTs). IMY oxytocin may reduce blood loss slightly (MD -57.40 mL, 95% CI -101.71 to -13.09; N=40; 1 RCT).

CONCLUSIONS

There is limited, low to very low certainty evidence on the effects of IMY versus intravenous oxytocin at CS for preventing blood loss. The evidence is insufficient to support choosing one route over another. More trials, including studies that assess intramuscular oxytocin administration, are needed on this relevant question.

PROSPERO REGISTRATION NUMBER

CRD42020186797.

Timing of oxytocin administration to prevent post-partum hemorrhage in women delivered by cesarean section: A systematic review and metanalysis

Background

There is no consensus on the best timing for prophylactic oxytocin administration during cesarean section (CS) to prevent post-partum hemorrhage (PPH).

Objectives

Assess the effects of administrating prophylactic oxytocin at different times during CS.

Methods

We searched nine databases to identify relevant randomized controlled trials (RCT). We pooled results and calculated average risk ratios (RR), mean differences (MD), and 95% confidence intervals (CI). We used GRADE to assess the overall evidence certainty.

Results

We screened 13,389 references and included four trials. We found no statistically significant differences between oxytocin given before versus after fetal delivery on PPH (RR 0.60, 95%CI 0.15–2.47; 1 RCT, N = 300) or nausea/vomiting (RR 1.21, 95%CI 0.69–2.13; 1 RCT, N = 300). There was a significant reduction in the need for additional uterotonics when oxytocin was given immediately before uterine incision versus after fetal delivery (RR 0.37, 95%CI 0.18–0.73; I² = 0%; 2 RCTs; N = 301). Oxytocin given before fetal delivery significantly reduced intra-operative blood loss (MD -146.77mL, 95%CI -168.10 to -125.43; I² = 0%; 3 RCTs, N = 601) but did not change the incidence of blood transfusion (RR 0.50, 95%CI 0.13–1.95; I² = 0%; 2 RCTs, N = 301) or hysterectomy (RR 3.00; 95%CI 0.12–72.77; I² = 0%; 2 RCTs, N = 301). One trial (N = 100) compared prophylactic oxytocin before versus after placental separation and found no significant differences on PPH, additional uterotonics, or nausea/vomiting.

Conclusions

In women having pre-labor CS, there is limited evidence indicating no significant differences between prophylactic oxytocin given before versus after fetal delivery on PPH, nausea/vomiting, blood transfusion, or hysterectomy. Earlier oxytocin administration may reduce the volume of blood loss and need for additional uterotonics. There is very limited evidence suggesting no significant differences between prophylactic oxytocin given before versus after placental separation on PPH, need for additional uterotonic, or nausea/vomiting. The overall certainty of the evidence was mostly low or very low due to imprecision. Protocol: CRD42020186797.

Risk factors of relaparotomy for intra-abdominal hemorrhage after cesarean delivery

OBJECTIVE

the main objective was to identify risk factors of relaparotomy for intra-abdominal hemorrhage (IAH) after cesarean delivery. The secondary objectives were to identify clinical warning signs associated with IAH: heart rate>120/min, systolic blood pressure<90 mmHg, scar bleeding, unconsciousness or abdominal pain with visual analog pain scale > 7 or use of category 3 analgesic medications, in the post-anesthesia care unit and in the post-partum unit.

STUDY DESIGN

a case-control study (1:2 ratio), in two academic tertiary perinatal centers during 2008-2017. Postpartum laparotomies performed for another indication were excluded. The cases were women who underwent relaparotomy for IAH. A control group comprised women who had an uncomplicated cesarean delivery before and after each case.

RESULTS

19,007 women had a cesarean delivery during the study period and among them 52 relaparotomies (0.27 %) for IAH were performed. 48 cases were compared to 96 controls. In multivariate analysis, the existence of a preeclampsia (aOR = 2.8, 95 % IC 1.1-7.4), urgent cesarean (aOR = 3.2, 95 % IC 1.1-9.6), surgical difficulties during initial cesarean (aOR = 9.0, 95 % IC 2.8-23.8), and estimated blood loss > 500 mL during initial cesarean (aOR = 7.4, 95 % IC 2.4-22.5) were independently associated with IAH. Tachycardia > 120/min was the most discriminating factor associated with the occurrence of relaparotomy for IAH (84 %). In the absence of tachycardia, hypotension < 90 mmHg was the second most discriminant factor for IAH (73 %).

CONCLUSION

preeclampsia, urgent cesarean, surgical difficulties and blood loss > 500 mL during initial cesarean were independently associated with an increased risk of relaparotomy for IAH. Tachycardia and/or hypotension were discriminant-warning signs for severe IAH.

[Anesthetic management of severe or worsening postpartum hemorrhage]

INTRODUCTION

Risk factors of maternal morbidity and mortality during postpartum hemorrhage (PPH) include non-optimal anesthetic management. As the anesthetic management of the initial phase is addressed elsewhere, the current chapter is dedicated to the management of severe PPH.

METHODS

A literature search was performed using PubMed and Medline databases, and the Cochrane Library, for articles published from 2003 up to and including 2013. Several keywords related to anesthetic and critical care practice, and obstetrical management were used, in various combinations. Guidelines from several societies and organisations were also read.

RESULTS

When PPH worsens, one should ask for additional team personnel (professional consensus). Patients should be monitored for heart rate, blood pressure, skin and mucosal pallor, bleeding at skin puncture sites, diuresis and the volume of genital bleeding (grade B). Because of the possible rapid worsening of coagulapathy, patients should undergo regular evaluation of coagulation status (professional consensus). Prevention and management of hypothermia should be considered (professional consensus), by warming intravenous fluids and blood products, and by active body warming (grade C). Antibiotics should be given, if not already administered at the initial phase (professional consensus). Vascular fluids must be given (grade B), the choice being left at the physician discretion. Blood products transfusion should be decided based on the clinical severity of PPH (professional consensus). Priority is given to red blood cells (RBC) transfusion, with the aim to maintain Hb concentration>8g/dL. The first round of products could include 3 units of RBC (professional consensus), and the following round 3 units of RBC, and 3 units of fresh frozen plasma (FFP). The FFP:RBC ratio should be kept between 1:2 and 1:1 (professional consensus). Depending on the etiology of PPH, the early administration of FFP is left at the discretion of the physician (professional consensus). Platelet count should be maintained at>50 G/L (professional consensus). During massive PPH, fibrinogen concentration should be maintained at>2g/L (professional consensus). Fibrinogen can be given without prior fibrinogen measurement in case of massive bleeding (professional consensus). General anesthesia should be considered in case of hemodynamic instability, even when an epidural catheter is in place (professional consensus).

CONCLUSION

The anesthetic management aims to restore and maintain optimal respiratory state and circulation, to treat coagulation disorders, and to allow invasive obstetrical and radiologic procedures. Clinical and instrumental monitoring are needed to evaluate the severity of PPH, to guide the choice of therapeutic options, and to assess treatments efficacy.