Transfusion Management of Obstetric Hemorrhage

An in vitro study of coagulation evaluation in obstetric hemorrhage for pregnancy-induced hypertension with coagulation and platelet function analyzer

This study aimed to establish in vitro hemodilution and resupplementation assays for obstetric hemorrhage in pregnancy-induced hypertension (PIH) and to monitor the coagulation function dynamically using a coagulation and platelet function analyzer. Forty-seven singleton pregnant women were divided into normal (n = 24) and PIH (n = 23) groups. Peripheral blood samples were used to construct the assays, and the activated clotting time (ACT), clotting rate (CR), and platelet function index (PF) were measured. The results showed that the baseline ACT was higher in the PIH group (p < 0.01). Hemodilution assays showed decreased ACT and increased CR and PF, with ACT changes significantly lower in the PIH group (p < 0.05). CR changed most in both groups at lower dilution ratios (35% to 50%), while ACT changed most at a higher dilution ratio (75%). In the resupplementation assay, ACT exhibited the most significant response. The analyzer effectively detected differences between pregnant women with and without PIH. Thus, we need to pay more attention to the changes of ACT in the actual clinical application to assess the coagulation status of parturients.

Detection of Postpartum Hemorrhage Using Compensatory Reserve Index in Patients Undergoing Cesarean Delivery

BACKGROUND

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. Early recognition and management are imperative for improved outcomes. The compensatory reserve index (CRI) is a novel physiological parameter that trends changes in intravascular volume, by continuously comparing extracted photoplethysmogram waveforms to a reference model that was derived from a human model of acute blood loss. This study sought to determine whether the CRI pattern was differential between those who do and do not experience PPH during cesarean delivery and compare these results to the American Society of Anesthesiologists (ASA) standards for noninvasive monitoring.

METHODS

Parturients undergoing cesarean delivery were enrolled between February 2020 and May 2021. A noninvasive CRI monitor was applied to collect continuous CRI values throughout the intraoperative and immediate postpartum periods. Patients were stratified based on blood loss into PPH versus non-PPH groups. PPH was defined as a quantitative blood loss >1000 mL. Function-on-scalar (FoS) regression was used to compare trends in CRI between groups (PPH versus non-PPH) during the 10 to 60-minute window after delivery. Two subanalyses excluding patients who received general anesthesia and preeclamptics were performed.

RESULTS

Fifty-one patients were enrolled in the study. Thirteen (25.5%) patients experienced PPH. Pregnant patients who experienced PPH had, on average, lower postdelivery CRI values (-0.13; 95% CI, -0.13 to -0.12; P < .001) than those who did not experience PPH. This persisted even when adjusting for preeclampsia and administration of uterotonics. The average mean arterial pressure (MAP) measurements were not statistically significant (-1.67; 95% CI, -3.57 to 0.22; P = .09). Similar trends were seen when excluding patients who underwent general anesthesia. When excluding preeclamptics, CRI values remained lower in those who hemorrhaged (-0.18; 95% CI, -0.19 to -0.17; P < .001).

CONCLUSIONS

CRI detects changes in central volume status not distinguished by MAP. It has the potential to serve as a continuous, informative metric, notifying providers of acute changes in central volume status due to PPH during cesarean delivery.

Leveraging Clinical Ladder Nurses to Support an Education Program on Intraoperative Cell Salvage for Obstetric Patients

Postpartum hemorrhage continues to be a leading cause of maternal morbidity and mortality in the United States. With the use of appropriate screening tools and treatment modalities, most of these deaths are preventable. Various interventions are used to prevent and treat postpartum hemorrhage, though intraoperative cell salvage historically has been contraindicated in the obstetric setting. This article explores the implementation of intraoperative cell salvage in the obstetric setting at two campuses of a health care system with the assistance of nurses participating in a professional nurses advancement program (ie, a clinical ladder). The initiative comprised a literature review, interdisciplinary collaboration, and education planning and execution. The educational approach focused on adult learners and included both self-directed and instructor-led elements. Including clinical nurses in clinical education is beneficial because they are highly motivated to share evidence-based practice with their peers to elevate patient safety and quality measures, making them ideal education partners.

Guideline No. 431: Postpartum Hemorrhage and Hemorrhagic Shock

OBJECTIVE

This guideline aims to provide evidence for prevention, recognition, and treatment of postpartum hemorrhage including severe hemorrhage leading to hemorrhagic shock.

TARGET POPULATION

All pregnant patients.

BENEFITS, HARMS, AND COSTS

Appropriate recognition and treatment of postpartum hemorrhage can prevent serious morbidity while reducing costs to the health care system by minimizing more costly interventions and length of hospital stays.

EVIDENCE

Medical literature, PubMed, ClinicalTrials.gov, the Cochrane Database, and grey literature were searched for articles, published between 2012 and 2021, on postpartum hemorrhage, uterotonics, obstetrical hemorrhage, and massive hemorrhage protocols.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All members of the health care team who care for labouring or postpartum women, including, but not restricted to, nurses, midwives, family physicians, obstetricians, and anesthesiologists.

RECOMMENDATIONS

Bilateral ligation of the anterior trunk of the internal iliac artery in uterine atony secondary to uterine inversion: case report

Postpartum hemorrhage is one of the leading causes of maternal mortality worldwide. Uterine atony is the main cause, representing up to 90% of cases, and is a risk factor for uterine inversion. Morbidity and mortality occur in 41% of uterine inversion cases, including massive obstetric hemorrhage. Massive obstetric hemorrhage is a medical emergency that puts life and reproductive function at risk, and therefore, its treatment must be timely and immediate. If there is no favorable response with the initial measures, surgical intervention proceeds. When choosing the surgical procedure, priority should be given to the technique with the easiest access and which is the least invasive, the safest, and in which the surgeon has more experience. We present a case report with our technique of bilateral ligation of the anterior trunk of the hypogastric artery, after a uterine compression suture failed, with excellent results and preserved fertility in an adolescent patient. We describe the technique and the result. The response time of the uterus with normal tone was 5 minutes, and postligation bleeding was only 50 mL after the patient had bled 1200 mL without complications; thus, it is an adequate and cost-effective technique. The bilateral ligation of the anterior trunk of the hypogastric artery technique in the case of postpartum hemorrhage is an effective, safe, and fertility-preserving surgical procedure that constitutes an alternative to emergency obstetrical hysterectomy when other, less invasive methods have failed.

Latest advances in postpartum hemorrhage management

Hemorrhage is the leading cause of maternal mortality worldwide. A maternal health priority is improving how healthcare providers prevent and manage postpartum hemorrhage (PPH). Because anesthesiologists can help facilitate how hospitals develop approaches for PPH prevention and anticipatory planning, we review the potential utility of PPH risk-assessment tools, bundles, and protocols. Anesthesiologists rely on clinical and diagnostic information for initiating and evaluating medical management. Therefore, we review modalities for measuring blood loss after delivery, which includes visual, volumetric, gravimetric, and colorimetric approaches. Point-of-care technologies for assessing changes in central hemodynamics (ultrasonography) and coagulation profiles (rotational thromboelastometry and thromboelastography) are also discussed. Anesthesiologists play a critical role in the medical and transfusion management of PPH. Therefore, we review blood ordering and massive transfusion protocols, fixed-ratio vs. goal-directed transfusion approaches, coagulation changes during PPH, and the potential clinical utility of the pharmacological adjuncts, tranexamic acid, and fibrinogen concentrate.

Effect of intraoperative cell rescue on bleeding related indexes after cesarean section

BACKGROUND

Obstetric hemorrhage is the leading cause of maternal mortality globally, especially in China. The key to a successful rescue is immediate and rapid blood transfusion. Autotransfusion has become an integral part of clinical blood transfusion, with intraoperative cell salvage (IOCS) being the most widely used.

AIM

To investigate the application of IOCS in cesarean section.

METHODS

A total of 87 patients who underwent cesarean section and blood transfusion in our hospital from March 2015 to June 2020 were included in this prospective controlled study. They were divided into the observation (43 cases) and control (44 cases) groups using the random number table method. The patients in both groups underwent lower-segment cesarean section. The patients in the control group were treated with traditional allogeneic blood transfusion, whereas those in the observation group were treated with IOCS. Hemorheology [Red blood cell count, platelet volume, and fibrinogen (FIB)] and coagulation function (partial prothrombin time, prothrombin time (PT), platelet count, and activated coagula-tion time) were measured before and 24 h after transfusion. In the two groups, adverse reactions, such as choking and dyspnea, within 2 h after cesarean section were observed.

RESULTS

Before and after transfusion, no significant differences in hemorheology and coagulation function indices between the two groups were observed (P > 0.05). About 24 h after transfusion, the erythrocyte count, platelet ratio, and FIB value significantly decreased in the two groups (P < 0.05); the PLT value significantly decreased in the two groups; the activated partial thromboplastin time, PT, and activated clotting time significantly increased in the two groups (P < 0.05); and no statistical differences were observed in hemorheology and coagulation function indices between the two groups (P > 0.05). Furthermore, there was no significant difference in the incidence of adverse reactions between the two groups (P > 0.05).

CONCLUSION

In patients undergoing cesarean section, intraoperative cell salvage has a minimum effect on hemorheology and coagulation function and does not increase the risk of amniotic fluid embolism.

Efficacy of sonorheometry point of the care device in determining low fibrinogen levels in pregnant blood: an invitro dilution and reconstitution study

Quantra® Hemostasis Analyzer is a Point of the care device that uses ultrasound technology to assess clot formation. In this study, we establish how Quantra® system performs compared to conventional coagulation tests at low levels of fibrinogen in the blood obtained from pregnant women. 24 mL blood was obtained from each healthy parturient. Blood was analyzed for Quantra® variables (Q): Clot time (CT), Clot stiffness (CS), platelet contribution to CS (PCS), fibrinogen contribution to CS (FCS), and conventional coagulation (CL) tests: PT, aPTT, INR, Factor VIII and fibrinogen. 6 ml blood were centrifuged to obtain pregnant plasma. 30 mL of saline was added to 10 mL of blood to simulate crystalloid resuscitation (DB) and was evaluated for Q and CL. Fractions of pregnant plasma, or nonpregnant plasma (Blood Bank) was added to DB to obtain 15% and 30% clotting factor enriched samples. 4 ml of DB was added to 4 ml of original blood (1:1) to obtain the final sample (resus). Each of the samples were analyzed for Q and CL parameters. Regression analysis and Receiving Characteristics Curves were used to study the relationship between Quantra variables and CL tests. There were remarkably high linear correlations between Fibrinogen and CS (R = 0.93, P < 0.001), fibrinogen and FCS (R = 0.77, P < 0.001). An FCS value 2.45 (sensitivity of 79.2 and specificity of 97.3%), and CS value 10.85 hPa (sensitivity of 83% and specificity of 100%) predicted fibrinogen of 200 mg/dL. This study demonstrates a good correlation between Quantra® CS, FCS and serum fibrinogen.Clinical Trial Number: NCT04301193.

A retrospective study of maternal near miss in the Critical Maternal Care Center in Suqian City, Jiangsu Province, China: A single-center study

BACKGROUND AND AIMS

Through a retrospective study of maternal near miss (MNM) cases treated by the Suqian Critical Maternal Care Center in Suqian City, Jiangsu Province, we summarized the most common diseases that caused MNM, treatment measures, and short-term prognosis in this region. The purpose of the research is to improve the clinical evidence of maternal health care in the region.

METHODS

The study is a retrospective descriptive study. Among the pregnant women admitted to the Critical Maternal Care Center from 1 January 2015, to 31 December 2019, the pregnant women with severe pregnancy complications or comorbidities were identified as the research subjects. The study subjects were divided into an MNM group and a control group according to the MNM criteria recommended by the WHO.A retrospective analysis of the study subject data, including causes and clinical manifestations of MNM, treatment measures, and short-term prognosis, was conducted.

RESULTS

The total number of deliveries was 27 619. There were 145 women in the control group and 65 women in the MNM group. The number of MNM cases accounted for 2.4% (65/27619) of the total number of deliveries. Placenta previa, postpartum hemorrhage, and hypertension accounted for 72.3% (47/65) of the causes of MNM cases observed. In the MNM group, the most common clinical manifestation was bleeding (80.0%, 52/65). Sixty-three patients underwent massive blood transfusion (96.9%, 63/65), and 36 underwent hysterectomy (55.4%,36/65). The prevalence of interventional procedures and unplanned secondary operations in the MNM group was higher than that in the control group.

CONCLUSIONS

The top three causes of MNM were placenta previa, postpartum hemorrhage, and hypertension in pregnancy in Suqian area. Sufficient blood sources, convenient and fast blood transfusion procedures, and the use of large amounts of blood transfusion technology have an important impact on the success of treatment. Hysterectomy is still the main method of MNM treatment.

Resuscitative efficacy of hemoglobin vesicles for severe postpartum hemorrhage in pregnant rabbits

We aimed to investigate the resuscitative efficacy of hemoglobin vesicles (HbVs) as a red blood cell (RBC) substitute for the initial treatment of severe postpartum hemorrhage (PPH). Twenty-five pregnant rabbits underwent cesarean section; uncontrolled hemorrhage was induced by transecting the right uterine artery to establish a severe PPH model. During the first 30 min, all rabbits were administered 6% hydroxyethyl starch (HES) of an equivalent volume to the hemorrhage every 5 min. Thereafter, they received any of the following three isovolemic fluids for resuscitation every 5 min: RBCs with platelet-poor plasma (RBC/PPP) (n = 8), 6% HES (n = 7), or HbVs with 25% human serum albumin (n = 10). After surgical hemostasis at 60 min, survival was monitored until 12 h. No rabbits receiving only HES infusion survived beyond 6 h, whereas all rabbits receiving RBC/PPP transfusion survived. The rabbits receiving HbV infusion showed significantly higher mean arterial pressure and hemoglobin levels than the HES-receiving rabbits, and 8 of 10 rabbits survived for 6 h. The HbV group showed significantly higher survival than the HES group but worse survival than the RBC/PPP group. In conclusion, HbV infusion for severe PPH effectively prevents lethal hemorrhagic shock in a pregnant rabbit model.

[Local application of recombinant activated factor VII for massive surgical bleeding]

The authors report resection of anaplastic convexital meningioma in a middle-aged woman complicated by expected massive blood loss. The most intense bleeding occurred at the final stage of resection and it was impossible to stop it with traditional approaches. The surgeon pressed a standard tachocomb plate moistened with a diluted solution of recombinant activated factor VII (coagil, Russia) to the most bleeding area for 5 minutes. Subsequently, surgeon replaced finger pressure with a permanent napkin. Hemostatic effect of recombinant activated factor VII following its systemic administration is well known and convincingly proven in many surgical areas including neurosurgery. However, we do not know any descriptions of its local application in neurosurgical patients.

Prevention of postpartum hemorrhage

Postpartum hemorrhage is a leading cause of severe maternal morbidity and mortality worldwide and the United States. While the rates of maternal mortality attributable to hemorrhage are declining, severe maternal morbidity continues to be a growing problem. Efforts in recent years to more appropriately identify patients at risk, define significant hemorrhage, quantify blood loss, and standardize approaches to care in pregnancy and postpartum have led to an increasing preventability of PPH. We aim to review the most current recommendation for the prevention and effective management of obstetric hemorrhage.

Perioperative patient blood management during parallel transverse uterine incision cesarean section in patient with pernicious placenta previa: A retrospective cohort analysis

Pernicious placenta previa (PPP) is the main cause of severe obstetric postpartum hemorrhage and hysterectomy and often requires donor blood transfusion. Prophylactic internal iliac artery (IIA) balloon occlusion (BO) combined with cell salvage is increasingly being deployed in parallel transverse uterine incision (PTUI) cesarean section (CS). The aim of this study was to explore the differences in blood management in PTUI CS with or without prophylactic IIA BO and to evaluate the safety and efficacy of cell salvage to reduce the need for donor blood transfusion during PTUI CS.This retrospective study included all women who were diagnosed with PPP and PA and underwent PTUI CS from October 1, 2016, to October 31, 2018. Sixty-four patients were included: 34 underwent prophylactic IIA BO (IIA group), whereas 30 were treated without prophylactic IIA BO (control group). The primary outcome was a composite measure of perioperative blood management outcomes, including the estimated blood loss (EBL), donor blood transfusion, salvaged blood returned, fresh frozen plasma (FFP), pre- and postoperative serum hemoglobin and hematocrit. In addition, the baseline conditions of mother and neonates were compared.EBL was significantly higher in the IIA group compared to the control group (2883.5 mL in the IIA group vs 1868.7 mL in the control group, P = .001). Overall, the donor blood transfusion rate was 23.5% (8/34), averaging 4.2 U, in the IIA group versus 30% (9/30), averaging 3.4 U, in the control group, which were not significantly different. The FFP transfusion rate was 47%, averaging 765.6 mL, in the IIA group versus 20%, averaging 816.7 mL, in the control group. In the IIA group, 97.1% used cell savage and had salvaged blood returned, averaging 954.9 mL. In the control group, 90% had salvaged blood returned, averaging 617.9 mL. No cases of amniotic fluid embolism were observed with leukocyte depletion filters.Prophylactic IIA BO during PTUI CS in women with PPP and PA does not lead to a statistically significant reduction in EBL. Cell salvage was associated with a reduction in the rate of donor blood transfusion during PTUI CS.

Haematological features, transfusion management and outcomes of massive obstetric haemorrhage: findings from the Australian and New Zealand Massive Transfusion Registry

Massive obstetric haemorrhage (MOH) is a leading cause of maternal morbidity and mortality world-wide. Using the Australian and New Zealand Massive Transfusion Registry, we performed a bi-national cohort study of MOH defined as bleeding at ≥20 weeks' gestation or postpartum requiring ≥5 red blood cells (RBC) units within 4 h. Between 2008 and 2015, we identified 249 cases of MOH cases from 19 sites. Predominant causes of MOH were uterine atony (22%), placenta praevia (20%) and obstetric trauma (19%). Intensive care unit admission and/or hysterectomy occurred in 44% and 29% of cases, respectively. There were three deaths. Hypofibrinogenaemia (<2 g/l) occurred in 52% of cases in the first 24 h after massive transfusion commenced; of these cases, 74% received cryoprecipitate. Median values of other haemostatic tests were within accepted limits. Plasma, platelets or cryoprecipitate were transfused in 88%, 66% and 57% of cases, respectively. By multivariate regression, transfusion of ≥6 RBC units before the first cryoprecipitate (odds ratio [OR] 3·5, 95% CI: 1·7-7·2), placenta praevia (OR 7·2, 95% CI: 2·0-26·4) and emergency caesarean section (OR 4·9, 95% CI: 2·0-11·7) were independently associated with increased risk of hysterectomy. These findings confirm MOH as a major cause of maternal morbidity and mortality and indicate areas for practice improvement.

Use of nitroglycerin for parallel transverse uterine cesarean section in patients with pernicious placenta previa and placenta accrete and predicted difficult airway: A case report and review of literature

RATIONALE

The incidence of obstetric hemorrhage due to pernicious placenta previa (PPP) and placenta accreta is currently increasing in China. Parallel transverse uterine incision (PTUI) cesarean section (CS) is a novel technique designed to avoid transecting the placenta and control postpartum hemorrhage during CS in these patients in our hospital. A key point of anesthesia management related to PTUI CS involves keeping the uterus relaxed. General anesthesia (GA) has often been performed, and inhaled volatile anesthetics have traditionally been recommended for this purpose; however, GA may be contraindicated in patients with difficult airways.

PATIENT CONCERNS

The patient was predicted to have a difficult airway, and GA may have resulted in potentially life-threatening complications. An alternative and safer method of achieving uterine relaxation during PTUI CS was thus required.

DIAGNOSES

The patient was diagnosed with PPP, and a predicted difficult airway was suspected preoperatively.

INTERVENTIONS

PTUI CS was planned to control postpartum hemorrhage and preserve fertility during CS. Uterine relaxation during PTUI CS was achieved with intravenous nitroglycerin under combined spinal-epidural anesthesia.

OUTCOME

Intravenous nitroglycerin and combined spinal-epidural anesthesia achieved uterine relaxation during the time from delivery of the neonate to making the second transverse incision in the lower segment of the uterus during PTUI CS. Both the parturient and neonate were well and were discharged 4 days later.

LESSIONS

Intravenous nitroglycerin and combined spinal-epidural anesthesia may offer an alternative to GA for achieving uterine relaxation in patients with PPP and a predicted difficult airway undergoing PTUI CS to control postpartum hemorrhage.

Peripartum Anesthesia Considerations for Placenta Accreta

Placenta accreta spectrum is becoming more common and is the most frequent indication for peripartum hysterectomy. Management of cesarean delivery in the setting of a morbidly adherent placenta has potential for massive hemorrhage, coagulopathies, and other morbidities. Anesthetic management of placenta accreta spectrum presents many challenges including optimizing surgical conditions, providing a safe and satisfying maternal delivery experience, preparing for massive hemorrhage and transfusion, preventing coagulopathies, and optimizing postoperative pain control. Balancing these challenging goals requires meticulous preparation with a thorough preoperative evaluation of the parturient and a well-coordinated multidisciplinary approach in order to optimize outcomes for the mother and fetus.

Successful resuscitation of a patient with pernicious placenta previa and placenta accreta who had massive life-threatening bleeding during cesarean section: A case report

RATIONALE

Pernicious placenta accrete (PPP) is an obstetrical complication associated with severe life-threatening hemorrhage, which is one of the leading causes of maternal mortality worldwide. Caesarean hysterectomy is the effective method to control intraoperative bleeding for this unscheduled high-risk patient. But a challenge for clinicians in this case is to determine the optimal timing of hysterectomy, because it will directly determine maternal outcome.

PATIENT CONCERNS

We here report a case diagnosed with PPP who suffered from a severe life-threatening hemorrhage during cesarean section but was successfully resuscitated and subsequently discharged from hospital after a smooth recovery.

DIAGNOSES

Although binding the lower uterine segment with a tourniquet markedly reduced bleeding in the surgical field after delivery, massive concealed vaginal life-threatening bleeding occurred immediately, and the amount of vaginal blood loss within 10 minutes was as much as 3000 mL.

INTERVENTIONS

An experienced multidisciplinary team was immediately established, and an unscheduled caesarean hysterectomy was performed immediately, and cell salvage was used.

OUTCOME

The patient was successfully resuscitated and both the parturient and neonate were well and discharged.

LESSON

If binding the lower uterine segment with a tourniquet markedly reduces bleeding in the surgical field after cesarean delivery in high-risk patients with PPP, and persistence of hypotension after active resuscitation of the circulation is detected, anesthesiologist should be vigilant enough to detect the possibility of concealed vaginal life-threatening bleeding. If this is confirmed, it should be quickly identified whether bleeding can be quickly controlled within a short period of time. If not, the preferred strategy is that the earlier the unscheduled hysterectomy, the better the outcome. A well-established multidisciplinary team and autologous blood recovery and transfusion techniques are also important in ensuring successful resuscitation of patients.

International assessment of massive transfusion protocol contents and indications for activation

BACKGROUND

Massive transfusion protocols (MTPs) provide blood products rapidly and in fixed amounts. MTPs are commonly used in trauma but may also be used in other clinical settings, although evidence to support fixed-ratio resuscitation in nontraumatic hemorrhage is lacking. The goals of this study were to describe the types and contents of available MTPs and the clinical indications for MTP activation.

METHODS

A survey was distributed to 353 transfusion medicine specialists to assess the types and contents of available MTPs. Survey participants were invited to provide the clinical indications for consecutive adult and pediatric MTP activations for at least 6 months during 2015 to 2017.

RESULTS

There were 125 completed surveys (35% response rate) including three from children's specialty hospitals. Most hospitals that treated adult patients (90/122, 74%) utilized only one MTP for all adult bleeding emergencies, while one hospital had no MTP. Of the 31 hospitals that provided more than one adult MTP, 20 provided MTPs specific for obstetric bleeding cases. Of these, 50% (10/20) included at least one pool of cryoprecipitate or fibrinogen concentrate in the first MTP round, compared with 14% (13/90) of the hospitals with one MTP (p = 0.0012). Fifty-seven hospitals provided the clinical indication for 4176 adult and 155 pediatric MTP activations. Although trauma was the single most common indication, the majority of adult (58%) and pediatric (65%) activations were for nontrauma indications.

CONCLUSIONS

The majority of hospitals use a single MTP to manage massive hemorrhage. The majority of MTP activations were for nontrauma indications.