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Zhang P, Jia Y, Song H, Fan Y, Lv Y, Geng H, Zhao Y, Cui H, Chen X. Novel biomarkers for prediction of atonic postpartum hemorrhage among 'low-risk' women in labor. Front Immunol 2024; 15:1416990. [PMID: 39055706 PMCID: PMC11269088 DOI: 10.3389/fimmu.2024.1416990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 06/26/2024] [Indexed: 07/27/2024] Open
Abstract
Background Postpartum hemorrhage (PPH) is the primary cause of maternal mortality globally, with uterine atony being the predominant contributing factor. However, accurate prediction of PPH in the general population remains challenging due to a lack of reliable biomarkers. Methods Using retrospective cohort data, we quantified 48 cytokines in plasma samples from 40 women diagnosed with PPH caused by uterine atony. We also analyzed previously reported hemogram and coagulation parameters related to inflammatory response. The least absolute shrinkage and selection operator (LASSO) and logistic regression were applied to develop predictive models. Established models were further evaluated and temporally validated in a prospective cohort. Results Fourteen factors showed significant differences between the two groups, among which IL2Rα, IL9, MIP1β, TNFβ, CTACK, prenatal Hb, Lymph%, PLR, and LnSII were selected by LASSO to construct predictive model A. Further, by logistic regression, model B was constructed using prenatal Hb, PLR, IL2Rα, and IL9. The area under the curve (AUC) values of model A in the training set, internal validation set, and temporal validation set were 0.846 (0.757-0.934), 0.846 (0.749-0.930), and 0.875 (0.789-0.961), respectively. And the corresponding AUC values for model B were 0.805 (0.709-0.901), 0.805 (0.701-0.894), and 0.901 (0.824-0.979). Decision curve analysis results showed that both nomograms had a high net benefit for predicting atonic PPH. Conclusion We identified novel biomarkers and developed predictive models for atonic PPH in women undergoing "low-risk" vaginal delivery, providing immunological insights for further exploration of the mechanism underlying atonic PPH.
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Affiliation(s)
- Pei Zhang
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
| | - Yanju Jia
- School of Medicine, Nankai University, Tianjin, China
- Department of Obstetrics, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
| | - Hui Song
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
- Department of Obstetrics, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
| | - Yifan Fan
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
- Department of Obstetrics, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
| | - Yan Lv
- Department of Obstetrics, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
| | - Hao Geng
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
- Department of Obstetrics, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
| | - Ying Zhao
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
- Department of Obstetrics, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
| | - Hongyan Cui
- School of Medicine, Nankai University, Tianjin, China
- Department of Obstetrics, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
| | - Xu Chen
- School of Medicine, Nankai University, Tianjin, China
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
- Department of Obstetrics, Tianjin Central Hospital of Gynecology Obstetrics, Tianjin, China
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de Moreuil C, Mehic D, Nopp S, Kraemmer D, Gebhart J, Schramm T, Couturaud F, Ay C, Pabinger I. Hemostatic biomarkers associated with postpartum hemorrhage: a systematic review and meta-analysis. Blood Adv 2023; 7:5954-5967. [PMID: 37307172 PMCID: PMC10562765 DOI: 10.1182/bloodadvances.2023010143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/09/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023] Open
Abstract
Postpartum hemorrhage (PPH) is a leading cause of maternal morbi-mortality. Although obstetric risk factors are well described, the impact of predelivery hematologic and hemostatic biomarkers remains incompletely understood. In this systematic review, we aimed to summarize the available literature on the association between predelivery hemostatic biomarkers and PPH/severe PPH. Searching MEDLINE, EMBASE, and CENTRAL databases from inception to October 2022, we included observational studies on unselected pregnant women without bleeding disorder reporting on PPH and on predelivery hemostatic biomarkers. Two review authors independently performed title, abstract and full-text screening, upon which quantitative syntheses of studies reporting on the same hemostatic biomarker were conducted, calculating the mean difference (MD) between women with PPH/severe PPH and controls. A search on 18 October 2022 yielded 81 articles fitting our inclusion criteria. The heterogeneity between studies was considerable. With regard to PPH, the estimated average MD in the investigated biomarkers (platelets, fibrinogen, hemoglobin, Ddimer, activated partial thromboplastin time, and prothrombin time) were not statistically significant. Women who developed severe PPH had lower predelivery platelets than controls (MD = -26.0 109/L; 95% confidence interval, -35.8 to -16.1), whereas differences in predelivery fibrinogen concentration (MD = -0.31 g/L; 95% confidence interval, -0.75 to 0.13) and levels of factor XIII or hemoglobin were not statistically significant in women with and without severe PPH. Predelivery platelet counts were, on average, lower in women with severe PPH compared with controls, suggesting the potential usefulness of this biomarker for predicting severe PPH. This trial was registered at the International Prospective Register of Systematic Reviews as CRD42022368075.
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Affiliation(s)
- Claire de Moreuil
- UMR 1304, Groupe d'Etude de la Thrombose de Bretagne Occidentale, Université de Bretagne Occidentale, Brest, France
- Internal Medicine, Vascular Medicine and Pneumology Department, Brest University Hospital, Brest, France
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Dino Mehic
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Stephan Nopp
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Daniel Kraemmer
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Theresa Schramm
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Francis Couturaud
- UMR 1304, Groupe d'Etude de la Thrombose de Bretagne Occidentale, Université de Bretagne Occidentale, Brest, France
- Internal Medicine, Vascular Medicine and Pneumology Department, Brest University Hospital, Brest, France
| | - Cihan Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
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Abstract
Postpartum haemorrhage (PPH) remains the leading cause of pregnancy-related deaths worldwide. Typically, bleeding is controlled by timely obstetric measures in parallel with resuscitation and treatment of coagulopathy. Early recognition of abnormal coagulation is crucial and haemostatic support should be considered simultaneously with other strategies as coagulopathies contribute to the progression to massive haemorrhage. However, there is lack of agreement on important topics in the current guidelines for management of PPH. A clinical definition of PPH is paramount to understand the situation to which the treatment recommendations relate; however, reaching a consensus has previously proven difficult. Traditional definitions are based on volume of blood loss, which is difficult to monitor, can be misleading and leads to treatment delay. A multidisciplinary approach to define PPH considering vital signs, clinical symptoms, coagulation and haemodynamic changes is needed. Moreover, standardised algorithms or massive haemorrhage protocols should be developed to reduce the risk of morbidity and mortality and improve overall clinical outcomes in PPH. If available, point-of-care testing should be used to guide goal-directed haemostatic treatment. Tranexamic acid should be administered as soon as abnormal bleeding is recognised. Fibrinogen concentrate rather than fresh frozen plasma should be administered to restore haemostasis where there is elevated risk of fibrinogen deficiency (e.g., in catastrophic bleeding or in cases of abruption or amniotic fluid embolism) as it is a more concentrated source of fibrinogen. Lastly, organisational considerations are equally as important as clinical interventions in the management of PPH and have the potential to improve patient outcomes.
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Winebrenner H, Gelfand H, Roman-Banegas L, Angelo T, Jabaut JM. A Case Report of the Anesthetic Management of a Parturient With Congenital Hypofibrinogenemia and Complete Placenta Previa. A A Pract 2021; 15:e01426. [PMID: 33760775 DOI: 10.1213/xaa.0000000000001426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A multidisciplinary approach among the obstetric, hematological, pharmaceutical, nursing, and anesthetic team proved essential for the successful peripartum management of a gravida 3, para 2 female with a new diagnosis of congenital hypofibrinogenemia complicated by a complete placenta previa. The patient presented to labor and delivery triage with vaginal bleeding. This case report describes the management of this parturient and presents a review of the literature available for the anesthetic management of parturients with congenital hypofibrinogenemia.
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Affiliation(s)
- Hans Winebrenner
- From the Department of Anesthesiology, Walter Reed National Military Medical Center (Walter Reed NMMC), Bethesda, Maryland
| | - Harold Gelfand
- From the Department of Anesthesiology, Walter Reed National Military Medical Center (Walter Reed NMMC), Bethesda, Maryland
| | - Luciano Roman-Banegas
- From the Department of Anesthesiology, Walter Reed National Military Medical Center (Walter Reed NMMC), Bethesda, Maryland
| | - Tiffany Angelo
- Department of Anesthesiology, Stony Brook Medicine, Stony Brook, New York
| | - Joshua M Jabaut
- From the Department of Anesthesiology, Walter Reed National Military Medical Center (Walter Reed NMMC), Bethesda, Maryland
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