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Riascos N, Loaiza-Osorio S, Monroy A, Barona JS, Carvajal J, Echavarria MP, Nasner D, Escobar MF. Effect of the postpartum hemorrhage intervention package implementation in a fourth-level hospital in Latin America. Int J Gynaecol Obstet 2023; 163:291-301. [PMID: 37269178 DOI: 10.1002/ijgo.14886] [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: 01/17/2023] [Revised: 04/12/2023] [Accepted: 05/09/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of the implementation of intervention packages for postpartum hemorrhage (PPH) management in pregnant women hospitalized in a High Obstetric Complexity Unit in a Latin American country. METHODS Retrospective cohort study including pregnant women with PPH attended between January 2011 to December 2019. Three periods of time were defined according to management strategies We performed univariate and multivariate robust Poisson regression logistic models for each of the outcomes derived from each period. RESULTS We included 602 patients. There was a reduction in period 3 of the incidence of massive PPH (16% versus 12% P < 0.001, relative risk [RR] 0.61, 95% confidence interval [CI] 0.44-0.85; P = 0.003), major surgery (24%, 13%, 11%, P = 0.002, RR 0.54, 95% CI 0.33-0.883; P = 0.014), and admission to the intensive care unit (ICU) (14%, 7%, 6.1%, P = 0.0, RR 0.40, 95% CI 0.17-0.96 P = 0.00). CONCLUSION The implementation of PPH intervention packages in a hospital in a middle-income country from Latin America, led to a significant decrease in the incidence of massive bleeding, the rate of major surgery, and the ICU stay of pregnant women affected by this condition.
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Affiliation(s)
- Natalia Riascos
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Sara Loaiza-Osorio
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - Angelica Monroy
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Juan Sebastián Barona
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Javier Carvajal
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
| | | | - Daniela Nasner
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - María Fernanda Escobar
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Department of Telemedicine, Fundación Valle del Lili, Cali, Colombia
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Liu LY, Nathan L, Sheen JJ, Goffman D. Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage. Int J Womens Health 2023; 15:905-926. [PMID: 37283995 PMCID: PMC10241213 DOI: 10.2147/ijwh.s366675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/03/2023] [Indexed: 06/08/2023] Open
Abstract
Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.
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Affiliation(s)
- Lilly Y Liu
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Lisa Nathan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jean-Ju Sheen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Dena Goffman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
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Postpartum Hemorrhage Trends and Outcomes in the United States, 2000-2019. Obstet Gynecol 2023; 141:152-161. [PMID: 36701615 DOI: 10.1097/aog.0000000000004972] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/19/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To analyze temporal trends in and risk factors for postpartum hemorrhage and to analyze the association of risk factors with postpartum hemorrhage-related interventions such as blood transfusion and peripartum hysterectomy. METHODS This repeated cross-sectional study analyzed delivery hospitalizations from 2000 to 2019 in the National (Nationwide) Inpatient Sample. Trends analyses were conducted using joinpoint regression to estimate the average annual percent change (AAPC) with 95% CIs. Unadjusted and adjusted survey-weighted logistic regression models were performed to evaluate the relationship between postpartum hemorrhage risk factors and likelihood of 1) postpartum hemorrhage, 2) postpartum hemorrhage that requires blood transfusion, and 3) peripartum hysterectomy in the setting of postpartum hemorrhage, with unadjusted odds ratios and adjusted odds ratios with 95% CIs as measures of association. RESULTS Of an estimated 76.7 million delivery hospitalizations, 2.3 million (3.0%) were complicated by postpartum hemorrhage. From 2000 to 2019, the rate of postpartum hemorrhage increased from 2.7% to 4.3% (AAPC 2.6%, 94% CI 1.7-3.5%). Over the study period, the proportion of deliveries to individuals with at least one postpartum hemorrhage risk factor increased from 18.6% to 26.9% (AAPC 1.9%, 95% CI 1.7-2.0%). Among deliveries complicated by postpartum hemorrhage, blood transfusions increased from 5.4% to 16.7% from 2000 to 2011 and then decreased from 16.7% to 12.6% from 2011 to 2019. Peripartum hysterectomy among hospitalized individuals with postpartum hemorrhage increased from 1.4% to 2.4% from 2000 to 2009, did not change significantly from 2009 to 2016, and then decreased significantly from 2.1% to 0.9% from 2016 to 2019 (AAPC -27.0%, 95% CI -35.2% to -17.6%). Risk factors associated with postpartum hemorrhage and transfusion and hysterectomy in the setting of postpartum hemorrhage included prior cesarean delivery with previa or placenta accreta, placenta previa without prior cesarean delivery, and antepartum hemorrhage or placental abruption. CONCLUSION Postpartum hemorrhage and related risk factors increased over a 20-year period. Despite the increased postpartum hemorrhage rates, blood transfusions, and hysterectomy rates decreased in recent years.
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Jackson A, Haynes L. A Blueprint for Medium-Fidelity Postpartum Hemorrhage Simulations. Nurs Womens Health 2020; 24:351-369. [PMID: 32916105 DOI: 10.1016/j.nwh.2020.07.008] [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: 10/11/2019] [Revised: 07/29/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
Many pregnancy-related deaths remain preventable, particularly those associated with postpartum hemorrhage (PPH). The use of bundles for care of women during the perinatal period has been shown to improve maternal and neonatal outcomes. Drills or simulation-based learning are an integral part of a broader implementation of postpartum hemorrhage bundles. In addition, The Joint Commission has cited drills as one of the required performance elements of accreditation. It is therefore incumbent upon perinatal clinical teams to conduct PPH simulations as a readiness tool. This article is intended to help nurses and other clinicians enhance the realism of low- and medium-fidelity PPH simulations.
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Lumbreras-Marquez MI, Campos-Zamora M, Ramirez-De Avila AL, Soto-Galindo JC, Olivas-Chavez JC, Tecayehuatl-Delgado G, Hernandez-Rayon YI, Ramirez-Calvo JA, Farber MK. Training for the surgical management of postpartum hemorrhage: a multicenter survey of resident physicians. J Matern Fetal Neonatal Med 2019; 34:3503-3509. [PMID: 31744352 DOI: 10.1080/14767058.2019.1685974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: To actively address maternal morbidity and mortality in Mexico, proficiency among obstetrics and gynecology (OBGYN) residents in the surgical management of postpartum hemorrhage (PPH) is a priority. However, the capacity of programs to provide this training is unknown.Objective: The self-reported knowledge, education, and proficiency of common surgical techniques for the management of PPH among OBGYN residents in Mexico was evaluated. Educational resources, perceived barriers to acquiring skills, and clinical decision-making were explored.Materials and methods: In July of 2018, an anonymous electronic survey was sent to 86 residents at four hospitals throughout Mexico. Surgical techniques queried included uterine tamponade (UT), uterine compression sutures (UCS), uterine devascularization (UD), hypogastric artery ligation (HAL), and gravid hysterectomy (HT). Participants also answered case-based questions about a patient with PPH.Results: The survey response rate was 59.3% (51/86). Seventy-nine percent of residents reported understanding the rationale and techniques for the surgical intervention of PPH. However, 43.9% reported limited ability to perform these procedures with autonomy. Eighty-six percent of residents reported exposure to these techniques while performing a rescue procedure during PPH and 49% reported learning these procedures while performing prophylactic techniques in patients without PPH. Only 25.5% had been exposed to simulation training. Lack of a training module for these skills in their curriculum was noted by 74.5%. The majority of the participants chose UCS, UD, HAL, and HT as the first, second, third, and fourth rescue procedures to perform for PPH, respectively.Conclusion: Most residents reported theoretical knowledge of surgical interventions for PPH, but their self-rated ability to independently perform such skills and a curriculum focused on PPH management was suboptimal.
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Affiliation(s)
- Mario Isaac Lumbreras-Marquez
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Melissa Campos-Zamora
- Master of Medical Science in Medical Education, Harvard Medical School, Boston, MA, USA
| | - Ana Laura Ramirez-De Avila
- Department of Obstetrics and Gynecology, Hospital Central "Dr. Ignacio Morones Prieto", San Luis Potosí, Mexico
| | | | | | | | - Yessica Ivonne Hernandez-Rayon
- Department of Obstetrics and Gynecology, Hospital Materno Infantil de Durango, Durango, Mexico.,Deparment of Maternal and Fetal Medicine, Instituto Nacional de Perinatologia, Mexico City, Mexico
| | | | - Michaela Kristina Farber
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Bundles for Maternal Safety: Promises and Challenges of Bundle Implementation: The Case of Obstetric Hemorrhage. Clin Obstet Gynecol 2019; 62:539-549. [DOI: 10.1097/grf.0000000000000470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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