Postpartum hemorrhage: Anesthesia management

Racial and Ethnic Patient Care Disparities in Anesthesiology: History, Current State, and a Way Forward

Disparities in patient care and outcomes are well-documented in medicine but have received comparatively less attention in anesthesiology. Those disparities linked to racial and ethnic identity are pervasive, with compelling evidence in operative anesthesiology, obstetric anesthesiology, pain medicine, and critical care. This narrative review presents an overview of disparities in perioperative patient care that is grounded in historical context followed by potential solutions for mitigating disparities and inequities.

Incidence and predictors of severe postpartum hemorrhage after cesarean delivery in South Central Ethiopia: a retrospective cohort study

Severe postpartum hemorrhage is an obstetric emergency that needs immediate intervention and is a leading cause of maternal death. Despite its significant health burden, little is known, about its magnitude and risk factors, especially after cesarean delivery in Ethiopia. This study aimed to evaluate the incidence and predictors of severe postpartum hemorrhage following cesarean section. This study was conducted on 728 women who underwent cesarean section. We retrospectively collected data from the medical records, including baseline characteristics, obstetrics, and perioperative data. Potential predictors were investigated using multivariate logistic regression analyses, adjusted odd ratios, and a 95% confidence interval to see associations. A p-value < 0.05 is considered statistically significant. The incidence of severe postpartum hemorrhage was 26 (3.6%). The independently associated factors were previous CS scar ≥ 2 (AOR 4.08: 95% CI 1.20-13.86), antepartum hemorrhage (AOR 2.89: 95% CI 1.01-8.16), severe preeclampsia (AOR 4.52: 95% CI 1.24-16.46), maternal age ≥ 35 years (AOR 2.77: 95% CI 1.02-7.52), general anesthesia (AOR 4.05: 95% CI 1.37-11.95) and classic incision (AOR 6.01: 95% CI 1.51-23.98). One in 25 women who gave birth during cesarean section experienced severe postpartum hemorrhage. Considering appropriate uterotonic agents and less invasive hemostatic interventions for high-risk mothers would help to decrease its overall rate and related morbidity.

Spontaneous subcapsular hepatic hematoma in pregnant patients

Spontaneous subcapsular hepatic hematoma (SSHH) with or without previous history of preeclampsia and/or HELLP syndrome represents a very rare pathological condition in pregnancy and postpartum, (1/45,000-1/225,000 pregnancies). Its importance for the anesthesiologist lays in its association with high morbidity and mortality for the mother (60-86%, 39%) and newborn (42%). After a high clinical suspicion, the certainty clinical diagnosis is settled by different imaging techniques. However, in most cases the diagnosis of SSHH is a casual intraoperative finding associated to a maternal or foetal compromise. Nowadays the obstetric and anaesthetic management of a SSHH is not standardized and depends on its integrity, hemodynamic stability and the gestational period when diagnosed. The possibility of an acute critic haemorrhage with necessity of massive transfusion, makes advisable to provide updated protocols for the treatment of obstetric hemorrhage, adapting them to the clinical peculiarities of these patients. After the acute phase, close attention should be kept on thromboembolic complications.

Main operating room deliveries for patients with high-risk cardiovascular disease

BACKGROUND

High-risk cardiovascular disease (CVD) prevalence in pregnant patients is increasing. Management of this complex population is not well studied, and little guidance is available regarding labour and delivery planning for optimal outcomes.

OBJECTIVE

We aimed to describe the process for and outcomes of our centre's experience with the main operating room (OR) caesarean deliveries for patients with high-risk CVD, including procedural and postpartum considerations.

STUDY DESIGN

We performed a retrospective evaluation of pregnant patients with high-risk CVD who delivered in the main OR at a large academic centre between January 2010 and March 2021. Patients were classified by CVD type: adult congenital heart disease, cardiac arrest, connective tissue disease with aortopathy, ischaemic cardiomyopathy, non-ischaemic cardiomyopathy or valve disease. We examined demographic, anaesthetic and procedure-related variables and in-hospital maternal and fetal outcomes. Multidisciplinary delivery planning was evaluated before and after formalising a cardio-obstetrics programme.

RESULTS

Of 25 deliveries, connective tissue disease (n=9, 36%) was the most common CVD type, followed by non-ischaemic cardiomyopathy (n=5, 20%). Scheduled deliveries that went as initially planned occurred for six patients (24%). Fourteen (56%) were unscheduled and urgent or emergent. Patients in modified WHO Class IV frequently underwent unscheduled, urgent deliveries (64%). Most deliveries were safely achieved with neuraxial regional anaesthesia (80%) and haemodynamic monitoring via arterial lines (88%). Postdelivery intensive care unit stays were common (n=18, 72%), but none required mechanical circulatory support. There were no in-hospital maternal or perinatal deaths; 60-day readmission rate was 16%. Some delivery planning was achieved for most patients (n=21, 84%); more planning was evident after establishing a cardio-obstetrics programme. Outcomes did not differ significantly by CVD group or delivery era.

CONCLUSIONS

Our experience suggests that short-term outcomes of pregnant patients with high-risk CVD undergoing main OR delivery are favourable. Multidisciplinary planning may support the success of these complex cases.

Patient Blood Management programs for post-partum hemorrhage

Patient blood management (PBM) strategies aim to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss to improve patient outcomes. Because postpartum hemorrhage (PPH) is a leading cause of maternal mortality and blood product utilization, PBM principles can be applied in its therapeutic approach. First, pre-operative identification of risk factors for PPH and identification of peri-delivery anemia should be conducted. Iron supplementation should be used to optimize hemoglobin concentration before delivery; it can also be used to treat anemia in the postpartum period after severe PPH. Both acute normovolemic hemodilution and intraoperative cell salvage can be effective techniques to reduce allogeneic blood transfusion during or after surgical procedures. Furthermore, these strategies appear to be safe when used in the pregnant population.

Early and systematic administration of fibrinogen concentrate in postpartum haemorrhage following vaginal delivery: the FIDEL randomised controlled trial

OBJECTIVE

To assess the benefits and safety of early human fibrinogen concentrate in postpartum haemorrhage (PPH) management.

DESIGN

Multicentre, double-blind, randomised placebo-controlled trial.

SETTING

30 French hospitals.

POPULATION

Patients with persistent PPH after vaginal delivery requiring a switch from oxytocin to prostaglandins.

METHODS

Within 30 minutes after introduction of prostaglandins, patients received either 3 g fibrinogen concentrate or placebo.

MAIN OUTCOME MEASURES

Failure as composite primary efficacy endpoint: at least 4 g/dl of haemoglobin decrease and/or transfusion of at least two units of packed red blood cells within 48 hours following investigational medicinal product administration. Secondary endpoints: PPH evolution, need for haemostatic procedures and maternal morbidity-mortality within 6 ± 2 weeks after delivery.

RESULTS

437 patients were included: 224 received FC and 213 placebo. At inclusion, blood loss (877 ± 346 ml) and plasma fibrinogen (4.1 ± 0.9 g/l) were similar in both groups (mean ± SD). Failure rates were 40.0% and 42.4% in the fibrinogen and placebo groups, respectively (odds ratio [OR] = 0.99) after adjustment for centre and baseline plasma fibrinogen; (95% CI 0.66-1.47; P = 0.96). No significant differences in secondary efficacy outcomes were observed. The mean plasma FG was unchanged in the Fibrinogen group and decreased by 0.56 g/l in the placebo group. No thromboembolic or other relevant adverse effects were reported in the Fibrinogen group versus two in the placebo group.

CONCLUSIONS

As previous placebo-controlled studies findings, early and systematic administration of 3 g fibrinogen concentrate did not reduce blood loss, transfusion needs or postpartum anaemia, but did prevent plasma fibrinogen decrease without any subsequent thromboembolic events.

TWEETABLE ABSTRACT

Early systematic blind 3 g fibrinogen infusion in PPH did not reduce anaemia or transfusion rate, reduced hypofibrinogenaemia and was safe.

Anesthetic considerations for repeat cesarean section

PURPOSE OF REVIEW

The prevalence of cesarean delivery is increasing worldwide despite the advance of Trial of Labor After Cesarean section. In many countries, a history of previous cesarean section is an almost absolute indication for a repeat cesarean section. The purpose of this review was to examine if the perioperative anesthetic management of patients with repeat cesarean section is different from the anesthetic management of patients with primary cesarean section.

RECENT FINDINGS

This review discusses important topics, such as early diagnosis of cases with a potentially high risk for complications; the need for assessment of patients diagnosed with abnormal placentation; the importance of a multidisciplinary approach that includes interaction of the anesthesiologist, gynaecologist, and invasive radiologist; emphasizing the need for reinforcement of new methods of invasive procedures; management of massive bleeding, use of new technologies, and development of an institutional protocol for management of patients with abnormal placentation.

SUMMARY

According to this review, we show that the management of patients with repeat cesarean section without abnormal placentation is almost the same as the management of patients for primary cesarean section. Timely diagnosis of patient with abnormal placentation and multidisciplinary approach is crucial for prevention of morbidity or even mortality.