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Ahmadzia HK, Wiener AA, Felfeli M, Berger JS, Macri CJ, Gimovsky AC, Luban NL, Amdur RL. Predicting risk of peripartum blood transfusion during vaginal and cesarean delivery: A risk prediction model. J Neonatal Perinatal Med 2023; 16:375-385. [PMID: 37718867 DOI: 10.3233/npm-230079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
OBJECTIVE The objective of this study is to develop a model that will help predict the risk of blood transfusion using information available prior to delivery. STUDY DESIGN The study is a secondary analysis of the Consortium on Safe Labor registry. Women who had a delivery from 2002 to 2008 were included. Pre-delivery variables that had significant associations with transfusion were included in a multivariable logistic regression model predicting transfusion. The prediction model was internally validated using randomly selected samples from the same population of women. RESULTS Of 156,572 deliveries, 5,463 deliveries (3.5%) required transfusion. Women who had deliveries requiring transfusion were more likely to have a number of comorbidities such as preeclampsia (6.3% versus 4.1%, OR 1.21, 95% CI 1.08-1.36), placenta previa (1.8% versus 0.4%, OR 4.11, 95% CI 3.25-5.21) and anemia (10.6% versus 5.4%, OR 1.30, 95% CI 1.21-1.41). Transfusion was least likely to occur in university teaching hospitals compared to community hospitals. The c statistic was 0.71 (95% CI 0.70-0.72) in the derivation sample. The most salient predictors of transfusion included type of hospital, placenta previa, multiple gestations, diabetes mellitus, anemia, asthma, previous births, preeclampsia, type of insurance, age, gestational age, and vertex presentation. The model was well-calibrated and showed strong internal validation. CONCLUSION The model identified independent risk factors that can help predict the risk of transfusion prior to delivery. If externally validated in another dataset, this model can assist health care professionals counsel patients and prepare facilities/resources to reduce maternal morbidity.
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Affiliation(s)
- H K Ahmadzia
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, George Washington University, Washington, DC, USA
| | - A A Wiener
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, George Washington University, Washington, DC, USA
| | - M Felfeli
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, George Washington University, Washington, DC, USA
| | - J S Berger
- Department of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC, USA
| | - C J Macri
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, George Washington University, Washington, DC, USA
| | - A C Gimovsky
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, George Washington University, Washington, DC, USA
| | - N L Luban
- Department of Pediatrics George Washington University, Division of Pediatric Hematology, Children's National Hospital, Washington, DC, USA
| | - R L Amdur
- Department of Surgery, George Washington University, Washington, DC, USA
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Nowadly CD, Fisher AD, Borgman MA, Mdaki KS, Hill RL, Nicholson SE, Bynum JA, Schauer SG. The Use of Whole Blood Transfusion During Non-Traumatic Resuscitation. Mil Med 2021; 187:e821-e825. [PMID: 33856481 DOI: 10.1093/milmed/usab128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/19/2021] [Accepted: 03/26/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Evidence from military populations showed that resuscitation using whole blood (WB), as opposed to component therapies, may provide additional survival benefits to traumatically injured patients. However, there is a paucity of data available for the use of WB in uninjured patients requiring transfusion. We sought to describe the use of WB in non-trauma patients at Brooke Army Medical Center (BAMC). MATERIALS AND METHODS Between January and December 2019, the BAMC ClinComp electronic medical record system was reviewed for all patients admitted to the hospital who received at least one unit of WB during this time period. Patients were sorted based on their primary admission diagnosis. Patients with a primary trauma-based admission were excluded. RESULTS One hundred patients were identified who received at least one unit of WB with a primary non-trauma admission diagnosis. Patients, on average, received 1,064 mL (750-2,458 mL) of WB but received higher volumes of component therapy. Obstetric/gynecologic (OBGYN) indications represented the largest percentage of non-trauma patients who received WB (23%), followed by hematologic/oncologic indications (16%). CONCLUSION In this retrospective study, WB was most commonly used for OBGYN-associated bleeding. As WB becomes more widespread across the USA for use in traumatically injured patients, it is likely that WB will be more commonly used for non-trauma patients. More outcome data are required to safely expand the indications for WB use beyond trauma.
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Affiliation(s)
- Craig D Nowadly
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
| | - Andrew D Fisher
- Medical Command, Texas Army National Guard, Austin, TX 78703, USA.,Department of Surgery, UNM School of Medicine, Albuquerque, NM 87131, USA
| | - Matthew A Borgman
- Department of pediatric, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA.,Uniformed Services Univeristy of the Health Sciences, Bethesda, Maryland 20814, USA
| | - Kennedy S Mdaki
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
| | - Ronnie L Hill
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
| | - Susannah E Nicholson
- Department of Surgery, University of Texas Health Science Center, San Antonio, TX 78229, USA
| | - James A Bynum
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
| | - Steven G Schauer
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX 78234, USA.,Uniformed Services Univeristy of the Health Sciences, Bethesda, Maryland 20814, USA
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Ouh YT, Lee KM, Ahn KH, Hong SC, Oh MJ, Kim HJ, Han SW, Cho GJ. Predicting peripartum blood transfusion: focusing on pre-pregnancy characteristics. BMC Pregnancy Childbirth 2019; 19:477. [PMID: 31805880 PMCID: PMC6896253 DOI: 10.1186/s12884-019-2646-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/27/2019] [Indexed: 01/09/2023] Open
Abstract
Background Obstetric hemorrhage is one of the most common causes of obstetrical morbidity and mortality, and transfusion is the most important management for hemorrhage. The aim of our study was to investigate the pre-pregnancy and pregnancy risk factors for peripartum transfusion. Methods Women who delivered a baby from 2010 to 2014 in Korea and participated in the Korean National Health Screening Program for Infants and Children were included. To analyze pre-pregnant risk factors for peripartum transfusion, an additional analysis was done for women who underwent a National Health Screening Examination within 1 year before pregnancy, including maternal waist circumference, body mass index, blood pressure, laboratory tests and history of smoking. Multivariable logistic regression analysis was used to estimate the risk factors for peripartum transfusion. Results Of the total 1,980,126 women who met the inclusion criteria, 36,868 (1.86%) were transfused at peripartum. In a multivariable regression model, the pregnancy risk factors for peripartum transfusion included maternal age above 35 years [odds ratio (OR): 1.41; 95% confidence interval (CI): 1.32–1.50], preterm birth (OR: 2.39; 95% CI: 2.15–2.65), and maternal hypertension (OR: 2.49; 95% CI: 2.24–2.77). Pre-pregnancy risk factors including fasting glucose level of more than 126 mg/dL (OR: 1.11; 95% CI: 1.02–1.20), current-smoker status (OR: 1.20; 95% CI: 1.06–1.37), and waist-circumference less than 80 cm (OR: 1.18; 95% CI: 1.06–1.30) were independently associated with peripartum blood transfusion. Conclusions Several pre-pregnancy and pregnancy risk factors were associated with peripartum blood transfusion. Some identified factors are modifiable before conception, and our study validated peripartum blood transfusion as a form of triage.
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Affiliation(s)
- Yung-Taek Ouh
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Kyu-Min Lee
- School of Industrial Management Engineering, Korea University, 145 Anam-Ro, Seongbuk-Gu, Seoul, 02841, Republic of Korea
| | - Ki Hoon Ahn
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Soon-Cheol Hong
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Min-Jeong Oh
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Hai-Joong Kim
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
| | - Sung Won Han
- School of Industrial Management Engineering, Korea University, 145 Anam-Ro, Seongbuk-Gu, Seoul, 02841, Republic of Korea.
| | - Geum Joon Cho
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea.
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Karacaer F, Biricik E, Ilgınel M, Tunay D, Sucu M, Ünlügenç H. Retrospective Analysis of Eighty-Nine Caesarean Section Cases with Abnormal Placental Invasion. Turk J Anaesthesiol Reanim 2019; 47:112-119. [PMID: 31080952 DOI: 10.5152/tjar.2018.31799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 07/12/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Abnormal placental invasion (API) is defined as an abnormal adherence of the placenta to the underlying uterine wall. Undiagnosed API may result in catastrophic maternal haemorrhage during delivery. In the present retrospective analysis, anaesthetic and surgical records were evaluated in patients with API who had undergone caesarean delivery (CD). Methods Clinical records of 89 patients with API who had undergone CD were retrospectively reviewed in our clinic between April 2010 and February 2017. Results Amongst the patients, 87 (97.8%) had a history of previous CD and 68 (76.4%) had placenta previa. In regression analysis, weak positive correlation was found between an increase in packed red blood cell (PRBC) (r=0.420, p=0.001) and fresh frozen plasma (FFP) (r=0.476, p=0.022) transfusions and time of hospital stay. PRBC and FFP consumptions were significantly greater in intensive care unit (ICU) patients than in non-ICU patients (p<0.001). ICU requirement were significantly greater in patients who had more than average crystalloid (p=0.004) and colloid (p<0.001) infusions. Elective CD was performed in 81 (91%) patients and emergency CD in 8 (9%). PRBC transfusions were 7±4.3 U in patients undergoing emergency CD and 3.85±3 U in patients undergoing elective CD (p=0.034). The number of patients requiring care in ICU was 4 (50%), who underwent emergency CD and 12 (14%) who underwent elective CD, (p=0.032). Conclusion It is crucial that the anaesthesiologist should be familiar with the risk factors and diagnosis of API because of the potential risk of massive haemorrhage. Multidisciplinary approach with surgery and blood bank decreases the amount of bleeding, blood transfusion requirement, ICU and hospital stay in patients with API.
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Affiliation(s)
- Feride Karacaer
- Department of Anaesthesiology and Reanimation, Çukurova University School of Medicine, Adana, Turkey
| | - Ebru Biricik
- Department of Anaesthesiology and Reanimation, Çukurova University School of Medicine, Adana, Turkey
| | - Murat Ilgınel
- Department of Anaesthesiology and Reanimation, Çukurova University School of Medicine, Adana, Turkey
| | - Demet Tunay
- Department of Anaesthesiology and Reanimation, Çukurova University School of Medicine, Adana, Turkey
| | - Mete Sucu
- Department of Gynecology and Obstetrics, Çukurova University School of Medicine, Adana, Turkey
| | - Hakkı Ünlügenç
- Department of Anaesthesiology and Reanimation, Çukurova University School of Medicine, Adana, Turkey
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Ahmadzia HK, Phillips JM, James AH, Rice MM, Amdur RL. Predicting peripartum blood transfusion in women undergoing cesarean delivery: A risk prediction model. PLoS One 2018; 13:e0208417. [PMID: 30551126 PMCID: PMC6294610 DOI: 10.1371/journal.pone.0208417] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 11/18/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE There has been an appreciable rise in postpartum hemorrhage requiring blood transfusions in the United States. Our objective is to better define patients at greatest risk for peripartum transfusion at the time of cesarean in order to identify cases for early intervention and monitoring. METHODS Our study is a secondary analysis of a retrospective cohort study. Cases of intraoperative and immediate postpartum blood transfusion among women undergoing cesarean delivery were identified. Multivariable logistic regression models were used to identify antepartum and intrapartum risk factors that were independently associated with blood transfusion. A risk calculator was then developed to predict the need for transfusion. RESULTS Of 56,967 women, 1488 (2.6%) required any blood transfusion. The strongest risk factors for peripartum blood transfusion included anemia (odds ratio [OR] 3.7, 95% CI 3.3-4.3), abruption on presentation (OR 3.3, CI 2.6-4.1), general anesthesia (OR 5.2, CI 4.4-6.1) and abnormal placentation (OR 92.0, CI 57.4-147.6). An antepartum (model 1) and combined antepartum plus intrapartum risk model (model 2) were developed (model 1 AUC = 0.77, model 2 AUC = 0.83) and internally validated. CONCLUSIONS Among women who required cesarean delivery, we were able to identify risk factors which predispose women to peripartum blood transfusion and developed a prediction model with good discrimination.
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Affiliation(s)
- Homa K. Ahmadzia
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, George Washington University, Washington, DC, United States of America
| | - Jaclyn M. Phillips
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, George Washington University, Washington, DC, United States of America
| | - Andra H. James
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine and Department of Medicine, Division of Hematology, Duke University, Durham, NC, United States of America
| | - Madeline M. Rice
- Department of Epidemiology and Biostatistics and the Biostatistics Center, George Washington University, Washington, DC, United States of America
| | - Richard L. Amdur
- Department of Surgery, George Washington University, Washington, DC, United States of America
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Kennedy BB, McMurtry Baird S. Collaborative Strategies for Management of Obstetric Hemorrhage. Crit Care Nurs Clin North Am 2017; 29:315-330. [PMID: 28778291 DOI: 10.1016/j.cnc.2017.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Obstetric hemorrhage is a significant cause of perinatal morbidity and mortality that requires prompt recognition and collaborative intervention to prevent poor outcomes. Medical and surgical management goals include controlling bleeding, supporting tissue oxygenation and perfusion, and monitoring for coagulopathies and complications.
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Affiliation(s)
- Betsy Babb Kennedy
- Vanderbilt University School of Nursing, 204 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240, USA.
| | - Suzanne McMurtry Baird
- Clinical Concepts in Obstetrics, Inc, Nashville, TN, USA; Labor and Delivery, Vanderbilt University Medical Center, Vanderbilt University School of Nursing, Nashville, TN, USA
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7
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Dillard AC. Obstetric Hemorrhage in the Rural Emergency Department: Rapid Response. J Emerg Nurs 2017; 43:15-20. [PMID: 28131345 DOI: 10.1016/j.jen.2016.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 09/20/2016] [Accepted: 10/01/2016] [Indexed: 10/20/2022]
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Using in situ simulation to evaluate operational readiness of a children's hospital-based obstetrics unit. Simul Healthc 2015; 9:102-11. [PMID: 24401917 DOI: 10.1097/sih.0000000000000005] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Relocating obstetric (OB) services to a children's hospital imposes demands on facility operations, which must be met to ensure quality care and a satisfactory patient experience. We used in situ simulations to prospectively and iteratively evaluate operational readiness of a children's hospital-based OB unit before it opened for patient care. METHODS This project took place at a 314-bed, university-affiliated children's hospital. We developed 3 full-scale simulation scenarios depicting a concurrent maternal and neonatal emergency. One scenario began with a standardized patient experiencing admission; the mannequin portrayed a mother during delivery. We ran all 3 scenarios on 2 dates scheduled several weeks apart. We ran 2 of the scenarios on a third day to verify the reliability of key processes. During the simulations, content experts completed equipment checklists, and participants identified latent safety hazards. Each simulation involved a unique combination of scheduled participants who were supplemented by providers from responding ancillary services. RESULTS The simulations involved 133 scheduled participants representing OB, neonatology, and anesthesiology. We exposed and addressed operational deficiencies involving equipment availability, staffing, interprofessional communication, and systems issues such as transfusion protocol failures and electronic order entry challenges. Process changes between simulation days 1 to 3 decreased the elapsed time between transfusion protocol activation and blood arrival to the operating room and labor/delivery/recovery/postpartum setting. CONCLUSIONS In situ simulations identified multiple operational deficiencies on the OB unit, allowing us to take corrective action before its opening. This project may guide other children's hospitals regarding care processes likely to require significant focus and possible modification to accommodate an OB service.
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Wikkelsø AJ, Hjortøe S, Gerds TA, Møller AM, Langhoff-Roos J. Prediction of postpartum blood transfusion--risk factors and recurrence. J Matern Fetal Neonatal Med 2014; 27:1661-7. [PMID: 24313457 DOI: 10.3109/14767058.2013.872095] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim was to find clinically useful risk factors for postpartum transfusion and to assess the joint predictive value in a population of women with a first and second delivery. METHODS All Danish women with a first and second delivery from January 2001 to September 2009 who gave birth in a hospital that reported transfusion of red blood cells to a national database: A total of 96 545 women were included. RESULTS Retained placental tissue explained more than all other risk factors in vaginal deliveries. Retained placental tissue at first delivery was associated with postpartum transfusion at a second vaginal delivery, and may also be used as an early predictor in parallel with a history of either placental abruption, postpartum transfusion or caesarean delivery. The positive predictive values of having more than one risk factor was low (2.2%-2.7%). CONCLUSIONS Prediction of postpartum transfusion is difficult. Retained placental tissue is the strongest predictor of postpartum blood transfusion in vaginal deliveries. Retained placental tissue is usually diagnosed for the first time when the bleeding starts, which limits the clinical value of prediction. We need tools for an early diagnosis of retained placenta to intervene early before transfusion is needed.
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Affiliation(s)
- Anne J Wikkelsø
- Department of Anaesthesia and Intensive Care Medicine, University of Copenhagen, Herlev Hospital , Herlev , Denmark
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Ayadi AME, Robinson N, Geller S, Miller S. Advances in the treatment of postpartum hemorrhage. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.2013.847622] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ehrenthal DB, Chichester ML, Cole OS, Jiang X. Maternal Risk Factors for Peripartum Transfusion. J Womens Health (Larchmt) 2012; 21:792-7. [DOI: 10.1089/jwh.2011.3248] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Deborah B. Ehrenthal
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Deleware
- Department of Internal Medicine, Christiana Care Health System, Newark, Deleware
| | - Melanie L. Chichester
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Deleware
| | | | - Xiaozhang Jiang
- Christiana Care Center for Outcomes Research, Christiana Care Health System, Newark, Delaware
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Matsunaga S, Seki H, Ono Y, Matsumura H, Murayama Y, Takai Y, Saito M, Takeda S, Maeda H. A retrospective analysis of transfusion management for obstetric hemorrhage in a Japanese obstetric center. ISRN OBSTETRICS AND GYNECOLOGY 2012; 2012:854064. [PMID: 22462007 PMCID: PMC3302117 DOI: 10.5402/2012/854064] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 10/24/2011] [Indexed: 11/23/2022]
Abstract
Background. Since cryoprecipitate, fibrinogen concentrate, or recombinant activated factor VII is not approved by public medical insurance in Japan, we retrospectively assessed blood product usage in patients with obstetric hemorrhage at our tertiary obstetric center. Material and Methods. 220 patients with obstetric hemorrhagic disorders who underwent blood product transfusion in our institution during a 5-year period were reviewed for the types and volumes of blood products transfused. Results. There was a significant positive correlation (P< 0.001) between the volume of RCC (red blood cell concentrate) transfused and that of FFP (fresh frozen plasma), irrespective of underlying obstetric disorders. The median of FFP to RCC ratio in each patient was 1.3-1.4, when 6 or more units of RCC were transfused. Conclusions. In transfusion for massive obstetric hemorrhage in terms of appropriate supplementation of coagulation factors, the transfusion of RCC : FFP = 1 : 1.3-1.4 may be desirable.
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Affiliation(s)
- Shigetaka Matsunaga
- Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
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Erhabor O, Adias TC. From whole blood to component therapy: the economic, supply/demand need for implementation of component therapy in sub-Saharan Africa. Transfus Clin Biol 2011; 18:516-26. [PMID: 22037104 DOI: 10.1016/j.tracli.2011.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 06/26/2011] [Indexed: 11/28/2022]
Abstract
Blood may be transfused as whole blood or as one of its components. Because patients seldom require all of the components of whole blood, it makes sense to transfuse only that portion needed by the patient for a specific condition or disease. This treatment, known as "blood component therapy", allows several patients to benefit from one unit of donated whole blood. Blood components include red blood cells, plasma, platelets, and cryoprecipitate. A considerable literature has accumulated over the past decade indicating that leukocytes present in allogeneic cellular blood components, intended for transfusion, are associated with adverse effects to the recipient. These include the development of febrile transfusion reactions, graft-versus-host disease, alloimmunization to leukocyte antigens, and the immunomodulatory effects that might influence the prognosis of patients with a malignancy. Moreover, it has become evident that such leukocytes may be the vector of infectious agents such as cytomegalovirus (CMV), Human T-Lymphotrophic Virus 1/11 (HTLV-I/II), and Epstein Barr (EBV) as well as other viruses. Effective stewardship of blood ensuring that several patients potentially benefit from components derived from one unit of donated whole blood is important for economic, supply/demand reasons and to protect the national inventory at times of national blood shortage. Blood safety in developing countries can be improved by more appropriate use of blood components rather than whole blood transfusion and the provision of alternatives such as oral and intravenous iron, erythropoietin, saline and colloids. This will facilitate the optimal use of the limited blood supply. Political will and open-mindedness to innovative ways to improve supply, appropriateness, optimal use and safety of blood from all types of donors are essential to promote more evidence-based approaches to blood transfusion practice in sub-Saharan Africa.
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Affiliation(s)
- O Erhabor
- Department of Blood Sciences, Royal Bolton Hospital NHS Trust UK, 4, Minerva Road, BL4 0JR Bolton, United Kingdom.
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Gayat E, Resche-Rigon M, Morel O, Rossignol M, Mantz J, Nicolas-Robin A, Nathan-Denizot N, Lefrant JY, Mercier FJ, Samain E, Fargeaudou Y, Barranger E, Laisné MJ, Bréchat PH, Luton D, Ouanounou I, Plaza PA, Broche C, Payen D, Mebazaa A. Predictive factors of advanced interventional procedures in a multicentre severe postpartum haemorrhage study. Intensive Care Med 2011; 37:1816-25. [PMID: 21805157 DOI: 10.1007/s00134-011-2315-0] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 05/05/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE Severe postpartum haemorrhage (SPPH) is the leading cause of peripartum hysterectomy and maternal death. There are no easily measurable parameters that indicate the failure of medical therapy and the need for an advanced interventional procedure (AIP) to stop genital tract bleeding. The aim of the study was to define factors predictive of the need for an AIP in the management of emergent PPH. METHODS The study included two phases: (1) an initial retrospective study of 257 consecutive patients with SPPH, allowing the determination of independent predictors of AIP, which were subsequently grouped in a predictive score, followed by (2) a multicentre study of 239 patients admitted during 2007, designed to validate the score. The main outcome measure was the need for an AIP, defined as uterine artery embolization, intraabdominal packing, arterial ligation or hysterectomy. RESULTS Abnormalities of placental implantation, prothrombin time <50% (or an International Normalized Ratio >1.64), fibrinogen <2 g/l, troponin detectable, and heart rate >115 bpm were independently predictive of the need for an AIP. The SPPH score included each of the five predictive factors with a value of 0 or 1. The greater the SPPH score, the greater the percentage of patients needing an AIP (11% for SPPH 0, to 75% for SPPH ≥2). The AUC of the ROC curve of the SPPH score was 0.80. CONCLUSIONS We identified five independent predictors of the need for an AIP in patients with SPPH and persistent bleeding. Using these predictors in a single score could be a reliable screening tool in patients at risk of persistent genital tract bleeding and needing an AIP.
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Affiliation(s)
- Etienne Gayat
- Department of Anesthesiology and Critical Care Medicine, Mobile Care Unit, Lariboisière University Hospital, AP-HP, EA322, Paris Cedex 10, France
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Abstract
Hemorrhage remains a leading cause of pregnancy-related morbidity and mortality. A rapid collaborative approach to management of the woman experiencing excessive blood loss is required to optimize outcomes. Successful treatment of the hemorrhaging pregnant woman is dependent on early recognition of bleeding and clinical manifestations of shock, treatment of the underlying cause of the hemorrhage, and simultaneous restoration of adequate circulating volume as well as blood component therapy. Early communication with providers, identified triggers for changes in patient condition, and drills/simulations with the multidisciplinary healthcare team are critical strategies for improving response and outcomes.
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Affiliation(s)
- Donna Ruth
- Department of Nursing Education and Professional Development, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA.
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Stotler B, Padmanabhan A, Devine P, Wright J, Spitalnik SL, Schwartz J. Transfusion requirements in obstetric patients with placenta accreta. Transfusion 2011; 51:2627-33. [DOI: 10.1111/j.1537-2995.2011.03205.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Butwick AJ, Hilton G, Riley ET, Carvalho B. Non-invasive measurement of hemoglobin during cesarean hysterectomy: a case series. Int J Obstet Anesth 2011; 20:240-5. [PMID: 21640577 DOI: 10.1016/j.ijoa.2011.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Revised: 02/13/2011] [Accepted: 03/29/2011] [Indexed: 11/26/2022]
Abstract
Obstetric patients diagnosed with abnormal placentation (placenta accreta, increta or percreta) are at increased risk of major postpartum hemorrhage and cesarean hysterectomy. Obstetric anesthesiologists are primarily involved in intraoperative transfusion management in these cases. Hemoglobin assessment is invaluable for assisting transfusion decision-making during the acute period of obstetric hemorrhage. However, laboratory and point-of-care tests of hemoglobin concentration are time-dependent and intermittent, and do not provide a real-time assessment of change during the acute phase of blood loss. A new non-invasive hemoglobin monitor has been introduced recently, which provides real-time measurement of hemoglobin values (SpHb) using multi-wavelength pulse co-oximetry. We present a review of five patients with suspected abnormal placentation who received SpHb monitoring during cesarean hysterectomy at our institution. We discuss the potential clinical utility of non-invasive hemoglobin monitoring for pregnant patients at high risk of obstetric hemorrhage, and the potential role of SpHb in guiding transfusion therapy.
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Affiliation(s)
- A J Butwick
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Evaluation of compliance and outcomes of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in Pakistan. BMC Pregnancy Childbirth 2011; 11:28. [PMID: 21489279 PMCID: PMC3087691 DOI: 10.1186/1471-2393-11-28] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 04/13/2011] [Indexed: 11/10/2022] Open
Abstract
Background Massive postpartum hemorrhage is a life threatening obstetric emergency. In order to prevent the complications associated with this condition, an organized and step-wise management protocol should be immediately initiated. Methods An evidence based management protocol for massive postpartum hemorrhage was implemented at Aga Khan University Hospital, Karachi, Pakistan after an audit in 2005. We sought to evaluate the compliance and outcomes associated with this management protocol 3 years after its implementation. A review of all deliveries with massive primary postpartum hemorrhage (blood loss ≥ 1500 ml) between January, 2008 to December, 2008 was carried out. Information regarding mortality, mode of delivery, possible cause of postpartum hemorrhage and medical or surgical intervention was collected. The estimation of blood loss was made via subjective and objective assessment. Results During 2008, massive postpartum hemorrhage occurred in 0.64% cases (26/4,052). No deaths were reported. The mean blood loss was 2431 ± 1817 ml (range: 1500 - 9000 ml). Emergency cesarean section was the most common mode of delivery (13/26; 50%) while uterine atony was the most common cause of massive postpartum hemorrhage (14/26; 54%). B-lynch suture (24%) and balloon tamponade (60%) were used more commonly as compared to our previously reported experience. Cesarean hysterectomy was performed in 3 cases (12%) for control of massive postpartum hemorrhage. More than 80% compliance was observed in 8 out of 10 steps of the management protocol. Initiation of blood transfusion at 1500 ml blood loss (89%) and overall documentation of management (92%) were favorably observed in most cases. Conclusion This report details our experience with the practical implementation of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in a developing country. With the exception of arterial embolization, relatively newer, simpler and potentially safer techniques are now being employed for the management of massive postpartum hemorrhage at our institution. Particular attention should be paid to the documentation of the management steps while ensuring a stricter adherence to the formulated protocols and guidelines in order to further ameliorate patient outcomes in emergency obstetrical practice. More audits like the one we performed are important to recognize and rectify any deficiencies in obstetrical practice in developing countries. Dissemination of the same is pivotal to enable an open discourse on the improvement of existing obstetrical strategies.
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de Lloyd L, Bovington R, Kaye A, Collis R, Rayment R, Sanders J, Rees A, Collins P. Standard haemostatic tests following major obstetric haemorrhage. Int J Obstet Anesth 2011; 20:135-41. [DOI: 10.1016/j.ijoa.2010.12.002] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 10/15/2010] [Accepted: 12/14/2010] [Indexed: 11/25/2022]
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Postpartum Hemorrhage: Evidence-based Medical Interventions for Prevention and Treatment. Clin Obstet Gynecol 2010; 53:165-81. [DOI: 10.1097/grf.0b013e3181ce0965] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Maternal haemorrhage is the leading cause of preventable maternal death worldwide and encompasses antepartum, intrapartum, and postpartum bleeding. This review highlights factors that predispose to severe bleeding, its management, and the most recent treatment and guidelines. Advances in obstetric care have provided physicians with the diagnostic tools to detect, anticipate, and prevent severe life-threatening maternal haemorrhage in most patients who have had prenatal care. In an optimal setting, patients at high risk for haemorrhage are referred to tertiary care centres where multidisciplinary teams are prepared to care for and deal with known potential complications. However, even with the best prenatal care, unexpected haemorrhage occurs. The first step in management is stabilization of haemodynamic status, which involves securing large bore i.v. access, invasive monitoring, and aggressive fluid management and transfusion therapy. Care for the patient with maternal bleeding should follow an algorithm that goes through a rapid and successive sequence of medical and surgical approaches to stem bleeding and decrease morbidity and mortality. With the addition of potent uterotonic agents and the advent of minimally invasive interventional radiological techniques such as angiographic embolization and arterial ligation, definitive yet conservative management is now possible in an attempt to avoid hysterectomy in patients with severe peripartum bleeding. If these interventions are inadequate to control the bleeding, the decision to proceed to hysterectomy must be made expeditiously. Recombinant factor VIIa is a relatively new treatment that could prove useful for severe coagulopathy and intractable bleeding.
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Affiliation(s)
- M Walfish
- SUNY Downstate Medical Center, 450 Clarkson Ave., Box 6, Brooklyn, NY 11203, USA.
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