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Schlembach D, Helmer H, Henrich W, von Heymann C, Kainer F, Korte W, Kühnert M, Lier H, Maul H, Rath W, Steppat S, Surbek D, Wacker J. Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry No. 015/063, March 2016). Geburtshilfe Frauenheilkd 2018; 78:382-399. [PMID: 29720744 PMCID: PMC5925693 DOI: 10.1055/a-0582-0122] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 02/08/2018] [Accepted: 02/26/2018] [Indexed: 12/12/2022] Open
Abstract
Purpose
This is an official interdisciplinary guideline, published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG), the Austrian Society of Gynaecology and Obstetrics (OEGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG). The guideline was developed for use in German-speaking countries and is backed by the German Society of Anaesthesiology and Intensive Medicine (DGAI), the Society of Thrombosis and Haemostasis Research (GTH) and the German Association of Midwives. The aim is to provide a consensus-based overview of the diagnosis and management of peripartum bleeding obtained from an evaluation of the relevant literature.
Methods
This S2k guideline was developed from the structured consensus of representative members of the various professional associations and professions commissioned by the Guideline Commission of the DGGG.
Recommendations
The guideline encompasses recommendations on definitions, risk stratification, prevention and management.
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Affiliation(s)
| | - Hanns Helmer
- Universitätsklinik für Frauenheilkunde, Klinische Abteilung für Geburtshilfe und feto-maternale Medizin, Medizinische Universität Wien, Wien, Austria
| | - Wolfgang Henrich
- Klinik für Geburtsmedizin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian von Heymann
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Franz Kainer
- Geburtshilfe und Pränatalmedizin, Klinik Hallerwiese, Nürnberg, Germany
| | | | - Maritta Kühnert
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Gießen-Marburg, Marburg, Germany
| | - Heiko Lier
- Klinik für Anästhesie und operative Intensivmedizin, Universitätsklinik Köln, Köln, Germany
| | - Holger Maul
- Geburtshilfe & Pränatalmedizin, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Werner Rath
- Gynäkologie und Geburtshilfe, Universitätsklinikum RWTH Aachen, Aachen, Germany
| | | | - Daniel Surbek
- Universitätsklinik für Frauenheilkunde, Geburtshilfe und feto-maternale Medizin, Bern, Switzerland
| | - Jürgen Wacker
- Klinik für Gynäkologie und Geburtshilfe, Fürst-Stirum-Klinik Bruchsal, Bruchsal, Germany
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Abstract
Obstetric hemorrhage remains the leading cause of maternal death and severe morbidity worldwide. Although uterine atony is the most common cause of peripartum bleeding, abnormal placentation, coagulation disorders, and genital tract trauma contribute to adverse maternal outcomes. Given the inability to reliably predict patients at high risk for obstetric hemorrhage, all parturients should be considered susceptible, and extreme vigilance must be exercised in the assessment of blood loss and hemodynamic stability during the peripartum period. Obstetric-specific hemorrhage protocols, facilitating the integration and timely escalation of pharmacologic, radiological, surgical, and transfusion interventions, are critical to the successful management of peripartum bleeding.
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Affiliation(s)
- Emily J Baird
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mailcode UH2, Portland, OR 97239, USA.
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Management of the Jehovah's Witness in Obstetrics and Gynecology: A Comprehensive Medical, Ethical, and Legal Approach. Obstet Gynecol Surv 2017; 71:488-500. [PMID: 27526872 DOI: 10.1097/ogx.0000000000000343] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Obstetricians and gynecologists frequently deal with hemorrhage so they should be familiar with management of patients who refuse blood transfusion. Although there are some reports in the literature about management of Jehovah's Witness patients in obstetrics and gynecology, most of them are case reports, and a comprehensive review about these patients including ethicolegal perspective is lacking. OBJECTIVE This review outlines the medical, ethical, and legal implications of management of Jehovah's Witness patients in obstetrical and gynecological settings. EVIDENCE ACQUISITION A search of published literature using PubMed, Ovid Medline, EMBASE, and Cochrane databases was conducted about physiology of oxygen delivery and response to tissue hypoxia, mortality rates at certain hemoglobin levels, medical management options for anemic patients who refuse blood transfusion, and ethical/legal considerations in Jehovah's Witness patients. RESULTS Early diagnosis of anemia and immediate initiation of therapy are essential in patients who refuse blood transfusion. Medical management options include iron supplementation and erythropoietin. There are also some promising therapies that are in development such as antihepcidin antibodies and hemoglobin-based oxygen carriers. Options to decrease blood loss include antifibrinolytics, desmopressin, recombinant factor VII, and factor concentrates. When surgery is the only option, every effort should be made to pursue minimally invasive approaches. CONCLUSION AND RELEVANCE All obstetricians and gynecologists should be familiar with alternatives and "less invasive" options for patients who refuse blood transfusions.
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Oh KJ, Hong JS, Youm J, Cho SH, Jung EY. Can coagulopathy in post-partum hemorrhage predict maternal morbidity? J Obstet Gynaecol Res 2016; 42:1509-1518. [DOI: 10.1111/jog.13098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 06/11/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Kyung Joon Oh
- Department of Obstetrics and Gynecology; Seoul National University Bundang Hospital; Gyeonggi Korea
| | - Joon-Seok Hong
- Department of Obstetrics and Gynecology; Seoul National University Bundang Hospital; Gyeonggi Korea
| | - Jina Youm
- Department of Obstetrics and Gynecology; Seoul National University College of Medicine; Seoul Korea
| | - Soo-hyun Cho
- Department of Obstetrics and Gynecology; Seoul National University Bundang Hospital; Gyeonggi Korea
| | - Eun Young Jung
- Department of Obstetrics and Gynecology; Seoul National University Bundang Hospital; Gyeonggi Korea
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Massive obstetric hemorrhage: Current approach to management. Med Intensiva 2016; 40:298-310. [PMID: 27184441 DOI: 10.1016/j.medin.2016.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 02/11/2016] [Accepted: 02/18/2016] [Indexed: 01/25/2023]
Abstract
Massive obstetric hemorrhage is a major cause of maternal mortality and morbidity worldwide. It is defined (among others) as the loss of>2,500ml of blood, and is associated to a need for admission to critical care and/or hysterectomy. The relative hemodilution and high cardiac output found in normal pregnancy allows substantial bleeding before a drop in hemoglobin and/or hematocrit can be identified. Some comorbidities associated with pregnancy can contribute to the occurrence of catastrophic bleeding with consumption coagulopathy, which makes the situation even worse. Optimization, preparation, rational use of resources and protocolization of actions are often useful to improve outcomes in patients with postpartum hemorrhage. Using massive obstetric hemorrhage protocols is useful for facilitating rapid transfusion if needed, and can also be cost-effective. If hypofibrinogenemia during the bleeding episode is identified, early fibrinogen administration can be very useful. Other coagulation factors in addition to fibrinogen may be necessary during postpartum hemorrhage replacement measures in order to effectively correct coagulopathy. A hysterectomy is recommended if the medical and surgical measures prove ineffective.
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Predelivery maternal fibrinogen as a predictor of blood loss after vaginal delivery. Arch Gynecol Obstet 2016; 294:745-51. [DOI: 10.1007/s00404-016-4031-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 01/27/2016] [Indexed: 11/25/2022]
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Sentilhes L, Lasocki S, Ducloy-Bouthors A, Deruelle P, Dreyfus M, Perrotin F, Goffinet F, Deneux-Tharaux C. Tranexamic acid for the prevention and treatment of postpartum haemorrhage. Br J Anaesth 2015; 114:576-87. [DOI: 10.1093/bja/aeu448] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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New approaches to obstetric hemorrhage: the postpartum hemorrhage consensus algorithm. Curr Opin Anaesthesiol 2014; 27:267-74. [PMID: 24739248 DOI: 10.1097/aco.0000000000000081] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Postpartum hemorrhage is increasingly frequent and a major contributor to maternal morbidity and mortality. Although individual steps, such as coagulation or surgical management, have been reviewed, there is little information on treatment algorithms. RECENT FINDINGS A treatment algorithm for postpartum hemorrhage was developed by the experts from three different specialties and from three countries. The algorithm describes symptoms, diagnosis, general measurements, medication, and organizational aspects. SUMMARY The algorithm is thought to serve as a template for local adaptation. It will hopefully improve the management of postpartum hemorrhage.
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Abstract
Cryoprecipitate, originally developed as a therapy for patients with antihaemophilic factor deficiency, or haemophilia A, has been in use for almost 50 yr. However, cryoprecipitate is no longer administered according to its original purpose, and is now most commonly used to replenish fibrinogen levels in patients with acquired coagulopathy, such as in clinical settings with haemorrhage including cardiac surgery, trauma, liver transplantation (LT), or obstetric haemorrhage. Cryoprecipitate is a pooled product that does not undergo pathogen inactivation, and its administration has been associated with a number of adverse events, particularly transmission of blood-borne pathogens and transfusion-related acute lung injury. As a result of these safety concerns, along with emerging availability of alternative fibrinogen preparations, cryoprecipitate has been withdrawn from use in a number of European countries. Compared with the plasma from which it is prepared, cryoprecipitate contains a high concentration of coagulation factor VIII, coagulation factor XIII, and fibrinogen. Cryoprecipitate is usually licensed by regulatory authorities for the treatment of hypofibrinogenaemia, and recommended for supplementation when plasma fibrinogen levels decrease below 1 g litre(-1); however, this threshold is empiric and is not based on solid clinical evidence. Consequently, there is uncertainty over the appropriate dosing and optimal administration of cryoprecipitate, with some guidelines from professional societies to guide clinical practice. Randomized, controlled trials are needed to determine the clinical efficacy of cryoprecipitate, compared with the efficacy of alternative preparations. These trials will allow the development of evidence-based guidelines in order to inform physicians and guide clinical practice.
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Affiliation(s)
- B Nascimento
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - L T Goodnough
- Departments of Pathology and Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - J H Levy
- Departments of Anesthesiology and Surgery, Duke University School of Medicine, 2301 Erwin Road, 5691H HAFS, Box 3094, Durham, NC 27710, USA
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Manoj EM, Ranasinghe G, Ragunathan MK. Successful use of N-acetyl cysteine and activated recombinant factor VII in fulminant hepatic failure and massive bleeding secondary to dengue hemorrhagic fever. J Emerg Trauma Shock 2014; 7:313-5. [PMID: 25400395 PMCID: PMC4231270 DOI: 10.4103/0974-2700.142771] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 11/23/2013] [Indexed: 12/29/2022] Open
Abstract
Consensus on management of complicated cases of dengue infection is evolving. Dengue hemorrhagic fever (DHF) occasionally progress to fulminant liver failure with high fatality rate. Inadvertent use of blood products to control massive bleeding in dengue shock syndrome may worsen fluid overload and subsequently the multi-organ dysfunction. We report a case of 37-years-old Sri Lankan man who developed fulminant liver failure and massive bleeding associated with DHF, subsequently recovered completely with supportive measures including administration of N-acetyl cysteine and activated recombinant factor VII. In conclusion, prevention of ischemic injury to liver and adoption of early aggressive supportive measures in complicated cases of dengue hemorrhagic fever is crucial for a favorable outcome. Indications for rFVIIa to arrest uncontrolled internal bleeding and use of NAC in non-acetaminophen-induced acute liver failure in complicated DHF are a platform for discussion.
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Affiliation(s)
| | - Gayan Ranasinghe
- Medical Department (Ward 42), National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - M K Ragunathan
- Medical Department (Ward 42), National Hospital of Sri Lanka, Colombo, Sri Lanka
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LUNDE J, STENSBALLE J, WIKKELSØ A, JOHANSEN M, AFSHARI A. Fibrinogen concentrate for bleeding--a systematic review. Acta Anaesthesiol Scand 2014; 58:1061-74. [PMID: 25059813 DOI: 10.1111/aas.12370] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2014] [Indexed: 12/19/2022]
Abstract
Fibrinogen concentrate as part of treatment protocols increasingly draws attention. Fibrinogen substitution in cases of hypofibrinogenaemia has the potential to reduce bleeding, transfusion requirement and subsequently reduce morbidity and mortality. A systematic search for randomised controlled trials (RCTs) and non-randomised studies investigating fibrinogen concentrate in bleeding patients was conducted up to November 2013. We included 30 studies of 3480 identified (7 RCTs and 23 non-randomised). Seven RCTs included a total of 268 patients (165 adults and 103 paediatric), and all were determined to be of high risk of bias and none reported a significant effect on mortality. Two RCTs found a significant reduction in bleeding and five RCTs found a significant reduction in transfusion requirements. The 23 non-randomised studies included a total of 2825 patients, but only 11 of 23 studies included a control group. Three out of 11 found a reduction in transfusion requirements while mortality was reduced in two and bleeding in one. In the available RCTs, which all have substantial shortcomings, we found a significant reduction in bleeding and transfusions requirements. However, data on mortality were lacking. Weak evidence from RCTs supports the use of fibrinogen concentrate in bleeding patients, primarily in elective cardiac surgery, but a general use of fibrinogen across all settings is only supported by non-randomised studies with serious methodological shortcomings. It seems pre-mature to conclude whether fibrinogen concentrate has a routine role in the management of bleeding and coagulopathic patients. More RCTs are urgently warranted.
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Affiliation(s)
- J. LUNDE
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. STENSBALLE
- Section for Transfusion Medicine; Capital Region Blood Bank; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesia; Centre of Head and Orthopedics; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. WIKKELSØ
- Department of Anaesthesia and Intensive Care Medicine; Herlev Hospital; University of Copenhagen; Copenhagen Denmark
| | - M. JOHANSEN
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesiology; Department of Neuroanaesthesia and Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. AFSHARI
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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HEESEN M, BÖHMER J, KLÖHR S, ROSSAINT R, VAN DE VELDE M, DUDENHAUSEN JW, STRAUBE S. Prophylactic tranexamic acid in parturients at low risk for post-partum haemorrhage: systematic review and meta-analysis. Acta Anaesthesiol Scand 2014; 58:1075-85. [PMID: 25069636 DOI: 10.1111/aas.12341] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2014] [Indexed: 11/26/2022]
Abstract
Tranexamic acid is effective in reducing blood loss during various types of surgery and after trauma. No compelling evidence has yet been presented for post-partum haemorrhage. A systematic literature search of relevant databases was performed to identify trials that assessed blood loss and transfusion incidence after tranexamic acid administration for post-partum haemorrhage. The random effects model was used for meta-analysis. Risk ratios (RRs) and weighted mean differences (WMDs) were calculated with 95% confidence intervals (CIs). Seven trials with a low risk of bias comparing tranexamic acid vs. placebo with a total of 1760 parturients were included in our systematic review and meta-analysis. Blood loss was significantly lower after tranexamic acid use (WMD -140.29 ml, 95% CI -189.64 to -90.93 ml; P<0.00001). Tranexamic acid reduced the risk for blood transfusions (RR 0.34, 95% CI 0.20-0.60, P=0.0001). The incidence of transfusions in the placebo group varied between 1.4% and 33%. When omitting the two trials with the highest incidence of transfusions, the RR was no longer significant. Additional uterotonics were necessary in the placebo groups; gastrointestinal adverse events were more common after tranexamic acid use. Only four cases of thrombosis were found, two each in the tranexamic acid and control groups. Tranexamic acid effectively reduced post-partum blood loss; the effect on the incidence of blood transfusions requires further studies. Only few trials observed adverse events including thromboembolic complications and seizures.
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Affiliation(s)
- M. HEESEN
- Department of Anaesthesia; Klinikum Bamberg; Bamberg Germany
| | - J. BÖHMER
- Department of Anaesthesia; Klinikum Bamberg; Bamberg Germany
| | - S. KLÖHR
- Department of Anaesthesia; Klinikum Bamberg; Bamberg Germany
| | - R. ROSSAINT
- Department of Anaesthesia; University Hospital Aachen; Aachen Germany
| | - M. VAN DE VELDE
- Department of Anaesthesia; Universitair Zieckenhuis Leuven; Leuven Belgium
| | - J. W. DUDENHAUSEN
- Weill Cornell Medical College; Sidra Medical and Research Center; Charite University Medicine Berlin; Doha Qatar
| | - S. STRAUBE
- Department of Occupational, Social and Environmental Medicine; University Medical Center Göttingen; Göttingen Germany
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Blood transfusion practice in obstetric and gynecology: impact of educational programs to create awareness for judicious use of blood components. Indian J Hematol Blood Transfus 2014; 30:175-9. [PMID: 25114403 DOI: 10.1007/s12288-013-0229-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 01/08/2013] [Indexed: 10/27/2022] Open
Abstract
The study presents the data analysis (1) To find out the trend of blood component use during the period 2003-2010 and to determine impact of component awareness programs on reduction in whole blood (WB) and single unit transfusions. (2) To determine Hb trigger. The details about blood units issued were entered in the integrated blood bank management software as well as in Microsoft Excel. The data of 4,838 cases of pregnancy anemia; 2,244 receiving blood for obstetric (Ob) hemorrhage including 270 cases of disseminated intravascular coagulation; 1,413 women having Gynecological (Gy) bleeding; 911 Ob, 2,032 Gy and 740 surgeries for Gy malignancy were analyzed. During the years 2003-2010 there was gradual increase in component utilization for pregnancy anemia, Ob/Gy surgeries and Ob/Gy bleeding and significant reduction in WB transfusions due to component awareness programs. But single unit transfusions showed comparatively lower trend of reduction. The mean Hb was 6.4 g/dL for pregnancy anemia, 8.1 g/dL for surgeries and 7.3 g/dL for Ob/Gy bleeding.
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Dyer RA, Vorster AD, Arcache MJ, Vasco M. New trends in the management of postpartum haemorrhage. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2014.10844564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- RA Dyer
- Department of Anaesthesia, University of Cape Town and Groote Schuur Hospital, Cape Town
| | - AD Vorster
- Department of Anaesthesia, University of Cape Town and Groote Schuur Hospital, Cape Town
| | - MJ Arcache
- Department of Anaesthesia, University of Cape Town and Groote Schuur Hospital, Cape Town
| | - M Vasco
- Unisanitas and Clinica Reina Sofia, Bogota, Colombia
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[Declarative survey about postpartum haemorrhage management by anaesthesiologists in Pays de la Loire area (France): what's the adherence to clinical practice guidelines?]. ACTA ACUST UNITED AC 2014; 33:310-7. [PMID: 24836116 DOI: 10.1016/j.annfar.2014.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 03/14/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the management of postpartum hemorrhage (PPH) by anaesthesiologists in Pays de la Loire area. METHODS A declarative survey was conducted from November 2011 to January 2012 with an online questionnaire to assess prevention and PPH specific care and to clarify the PPH transfusion practices and interest of new therapies. Nine indicators of adherence to clinical practice guidelines were selected to distinguish two groups: one group "adhering to the RCP" and another "not adhering to the RCP". RESULTS Response rate 53%. One hundred and one responses were analyzed. Use of a collection bag graded blood receipt pockets 93%, start time of PPH noted: 76%, leaf specific monitoring: 67%, management of the third part of the work: 78%. The evacuation of the placenta is performed within 30minutes in 75% of cases. The transfusion strategy happens early (92% before the biological assessment results) and "aggressive" (ratio RCB/FFP is 1/1 for 72%). The use of tranexamic acid is not systematic (53%). Seventy-nine percent of respondents adhere to the RCP. Practitioners in maternity level 1 (with few deliveries) don't follow these RCP as much. CONCLUSION Some inappropriate practices remain in structures not used to support them. The use of new therapies remain controversial. The priority at this time is the implementation and enforcement of the current RCP, not their modifications.
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Morillas-Ramírez F, Ortiz-Gómez JR, Palacio-Abizanda FJ, Fornet-Ruiz I, Pérez-Lucas R, Bermejo-Albares L. [An update of the obstetrics hemorrhage treatment protocol]. ACTA ACUST UNITED AC 2014; 61:196-204. [PMID: 24560060 DOI: 10.1016/j.redar.2013.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 11/17/2013] [Accepted: 11/28/2013] [Indexed: 10/25/2022]
Abstract
Obstetric hemorrhage is still a major cause of maternal and fetal morbimortality in developed countries. This is an underestimated problem, which usually appears unpredictably. A high proportion of the morbidity of obstetric hemorrhage is considered to be preventable if adequately managed. The major international clinical guidelines recommend producing consensus management protocols, adapted to local characteristics and keep them updated in the light of experience and new scientific publications. We present a protocol updated, according to the latest recommendations, and our own experience, in order to be used as a basis for those anesthesiologists who wish to use and adapt it locally to their daily work. This last aspect is very important to be effective, and is a task to be performed at each center, according to the availability of resources, personnel and architectural features.
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Affiliation(s)
| | - J R Ortiz-Gómez
- Servicio de Anestesiología, Hospital Virgen del Camino, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
| | | | - I Fornet-Ruiz
- Servicio de Anestesiología, Hospital Puerta de Hierro, Majadahonda, Madrid, España
| | - R Pérez-Lucas
- Servicio de Ginecología, Hospital Gregorio Marañón, Madrid, España
| | - L Bermejo-Albares
- Servicio de Anestesiología, Hospital Gregorio Marañón, Madrid, España
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Legrand M, Rossignol M, Muller F, Payen D. [Amniotic fluid embolism: an update]. ACTA ACUST UNITED AC 2013; 32:189-97. [PMID: 23422343 DOI: 10.1016/j.annfar.2013.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 01/08/2013] [Indexed: 12/14/2022]
Abstract
Amniotic fluid embolism (AFE) results from the passage of fœtal and amniotic fragments into the maternal circulation, occurring mostly within minutes before or after delivery. Although maternal and fœtal mortality of AFE remains high (about 40%), AFE should no longer be considered as having an ineluctable fatal course. Diagnosis is often made upon clinical presentation but histological confirmation is difficult owing favorable outcome and because an autopsy has not been performed. Identification of squamous cells in the maternal circulation could not confirm the diagnosis because of their possible maternal origin. High plasma level of insulin-like growth factor-binding protein-1 (IGFBP-1) has recently been identified as a biomarker of amniotic fluid passage into the maternal circulation and might therefore be used to confirm the diagnosis when lung tissue histology is not available. Treatment of AFE remains supportive with a special focus on correction of the coagulopathy and search for acute core pulmonale. In this later case, physicians should consider initiating an extracorporeal life support when facing a patient with refractory shock. Finally, caution is needed with the use of recombinant factor VIIa in this context.
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Affiliation(s)
- M Legrand
- Département d'anesthésie-réanimation-Smur, EA-3509, université Paris 7, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75475 Paris, France.
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Dyer RA. Obstetric anaesthesia: Is there anything new under the sun? SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2013. [DOI: 10.1080/22201173.2013.10872887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- RA Dyer
- Department of Anaesthesia, University of Cape Town
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Kikuchi M, Itakura A, Miki A, Nishibayashi M, Ikebuchi K, Ishihara O. Fibrinogen concentrate substitution therapy for obstetric hemorrhage complicated by coagulopathy. J Obstet Gynaecol Res 2012; 39:770-6. [PMID: 23278972 DOI: 10.1111/j.1447-0756.2012.02058.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 09/17/2012] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to assess the efficacy and safety of fibrinogen concentrate therapy for women with obstetric hemorrhage complicated by dilutional or consumptive coagulopathy by retrospectively reviewing the medical records of relevant patients from a single tertiary center. MATERIAL AND METHODS Eighteen cases of coagulopathy (8 dilutional, 10 consumptive) administered fibrinogen concentrate at our center over the past 5 years for treating hypofibrinogenemia were identified. Hemoglobin levels, platelet counts, fibrinogen levels, prothrombin time, activated partial thromboplastin time, and D-dimer levels were examined before and after fibrinogen substitution. Units of red blood cells, fresh frozen plasma, and pooled platelet concentrates transfused; blood loss volume; patient outcomes; and adverse events were obtained from medical and laboratory records. RESULTS The overall response to fibrinogen concentrate was considered good in 12 cases, moderate in four, and poor in two. The response rate was good or moderate in 88% (7/8) of dilutional coagulopathy cases and 89% (9/10) of consumptive coagulopathy cases. Fibrinogen levels significantly increased after fibrinogen substitution therapy (approximately 40 mg/L per g fibrinogen concentrate) in both groups. Although prothrombin time and activated partial thromboplastin time improved after substitution, hemoglobin levels, platelet counts, and D-dimer levels remained unchanged. No serious adverse event was causally associated with fibrinogen substitution therapy. CONCLUSION Fibrinogen concentrate substitution therapy for obstetric hemorrhage increases fibrinogen levels and appears to be effective in managing dilutional or consumptive coagulopathy.
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Affiliation(s)
- Mariko Kikuchi
- Department of Obstetrics and Gynecology, Saitama Medical University, Saitama, Japan
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Su LL, Chong YS. Massive obstetric haemorrhage with disseminated intravascular coagulopathy. Best Pract Res Clin Obstet Gynaecol 2012; 26:77-90. [DOI: 10.1016/j.bpobgyn.2011.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 10/19/2011] [Indexed: 10/15/2022]
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Lancé MD, Ninivaggi M, Schols SEM, Feijge MAH, Oehrl SK, Kuiper GJAJM, Nikiforou M, Marcus MAE, Hamulyak K, van Pampus ECM, ten Cate H, Heemskerk JWM. Perioperative dilutional coagulopathy treated with fresh frozen plasma and fibrinogen concentrate: a prospective randomized intervention trial. Vox Sang 2011; 103:25-34. [PMID: 22211833 DOI: 10.1111/j.1423-0410.2011.01575.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Treatment of dilutional coagulopathy by transfusing fresh frozen plasma (FFP) remains sub-optimal. We hypothesized that partial replacement of transfused FFP by fibrinogen concentrate results in improved coagulant activity and haemostasis. This was tested in a controlled clinical intervention trial with patients experiencing massive bleeding during major surgery. METHODS Patients undergoing major elective surgery were treated according to current protocols. When transfusion with FFP was required, patients were randomized as follows: group A received 4 units FFP and group B received 2 units FFP plus 2 g fibrinogen concentrate. Blood samples were taken before and after the intervention. Analysts were blinded to the treatment type. RESULTS Group A (B) consisted of 21 (22) patients, in 16 (17) of whom bleeding stopped after intervention. Plasma fibrinogen increased significantly more in group B (0·57 g/l) than in group A (0·05 g/l). However, levels of prothrombin and factors VIII, IX and X increased more in group A than in group B. Rotational thromboelastometry (ROTEM) of whole blood and plasma revealed improved fibrin clot formation in group B but not in group A. Thrombin generation [calibrated automated thrombogram (CAT)] in plasma increased more in group A. Principal parameters determining whole-blood thromboelastometry were the fibrinogen level and platelet count. In vitro addition of fibrinogen and prothrombin complex concentrate to pre-intervention samples restored both ROTEM and CAT parameters. CONCLUSIONS Partial replacement of transfused FFP by fibrinogen increases fibrin clot formation at the expense of less improved thrombin generation. Coagulation factors other than fibrinogen alone are required for full restoration of haemostasis.
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Affiliation(s)
- M D Lancé
- Department of Anesthesiology, CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
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Saule I, Hawkins N. Transfusion practice in major obstetric haemorrhage: lessons from trauma. Int J Obstet Anesth 2011; 21:79-83. [PMID: 22119633 DOI: 10.1016/j.ijoa.2011.09.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 08/08/2011] [Accepted: 09/19/2011] [Indexed: 11/29/2022]
Abstract
The management of massive haemorrhage with blood products is changing as evidence arrives from civilian and military trauma. Rapid early replacement of coagulation factors and platelets is now becoming central to improving outcome, usually given in higher ratios with respect to red cell units than previously recommended and using empiric transfusion based on clinical rather than laboratory parameters. The management of three cases of major obstetric haemorrhage based on these principles is presented. Packed red blood cells, fresh frozen plasma, platelets and cryoprecipitate were transfused in the ratios 5:2:2:1, 4.5:1:1:1 and 4.5:2:1:1. Each patient had acceptable full blood count and coagulation results after surgery and all made an uneventful recovery. These outcomes support the opinion that major obstetric haemorrhage can be managed in a similar fashion to blood loss in trauma. Recommendations from the Association of Anaesthetists of Great Britain and Ireland, and the UK National Patient Safety Agency should be considered during major obstetric haemorrhage.
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Affiliation(s)
- I Saule
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK.
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Monitoring transfusion requirements in major obstetric haemorrhage: out with the old and in with the new? Int J Obstet Anesth 2011; 20:275-8. [DOI: 10.1016/j.ijoa.2011.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 06/29/2011] [Indexed: 10/16/2022]
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Chavez-Tapia NC, Alfaro-Lara R, Tellez-Avila F, Barrientos-Gutiérrez T, González-Chon O, Mendez-Sanchez N, Uribe M. Prophylactic activated recombinant factor VII in liver resection and liver transplantation: systematic review and meta-analysis. PLoS One 2011; 6:e22581. [PMID: 21818342 PMCID: PMC3144913 DOI: 10.1371/journal.pone.0022581] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 06/24/2011] [Indexed: 01/10/2023] Open
Abstract
Background and Aim Intraoperative blood loss is a frequent complication of hepatic resection and orthotopic liver transplantation. Recombinant activated coagulation factor VII (rFVIIa) is a coagulation protein that induces hemostasis by directly activating factor X. There is no clear information about the prophylactic value of rFVIIa in hepatobiliary surgery, specifically in liver resection and orthotopic liver transplantation. The aim of this study was to assess the effect of rFVIIa prophylaxis to prevent mortality and bleeding resulting from hepatobiliary surgery. Methods Relevant randomized trials were identified by searching The Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index. Randomized clinical trials comparing different rFVIIa prophylactic schemas against placebo or no intervention to prevent bleeding in hepatobiliary surgery were included. Adults undergoing liver resection, partial hepatectomy, or orthotopic liver transplantation were included. Dichotomous data were analyzed calculating odds ratios (ORs) and 95% confidence intervals (CIs). Continuous data were analyzed calculating mean differences (MD) and 95% CIs. Results Four randomized controlled trials were included. There were no significant differences between rFVIIa and placebo for mortality (OR 0.96; 95% CI 0.35–2.62), red blood cell units (MD 0.32; 95% CI −0.08–0.72) or adverse events (OR 1.55; 95% CI 0.97–2.49). Conclusions The available information is limited, precluding the ability to draw conclusions regarding bleeding prophylaxis in hepatobiliary surgery using rFVIIa. Although an apparent lack of effect was observed in all outcomes studied, further research is needed.
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Current world literature. Curr Opin Anaesthesiol 2011; 24:224-33. [PMID: 21386670 DOI: 10.1097/aco.0b013e32834585d6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Aya AG, Mercier FJ. [The role of rFVIIa in treatment of severe postpartum haemorrhage: to evaluate the risk/benefit ratio]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2010; 29:673-5. [PMID: 20832236 DOI: 10.1016/j.annfar.2010.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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