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Card LM, Klinkowski AV, Salzer E, Nemec Ii EC, Rose SJ. Vacuum-induced tamponade for managing postpartum hemorrhage: a systematic review. J Matern Fetal Neonatal Med 2024; 37:2349957. [PMID: 38735867 DOI: 10.1080/14767058.2024.2349957] [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: 12/28/2023] [Accepted: 04/26/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE Postpartum hemorrhage is a leading cause of maternal mortality and morbidity around the globe. The novel low-suction vacuum hemorrhage device (VHD) provides an alternative treatment option for cases of postpartum hemorrhage when first-line uterotonic agents fail. This systematic review aims to review current data evaluating the overall efficacy and safety of VHDs in treating postpartum hemorrhage. METHODS We searched CINAHL Ultimate, Academic Search Premier, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE with Full Text, and PubMed and reference lists of retrieved studies for eligible studies that included outcomes of effectiveness, efficacy, or safety. Two independent reviewers used Covidence.org to screen Titles and Abstracts for 69 studies of which six were included in the analysis. Secondary outcomes measured across studies included time to bleeding control, total device deployment time, and adverse effects. RESULTS Six nonrandomized trials (N = 1018 participants) included studies conducted in Indonesia, the United States, Switzerland, and Canada. The VHDs were found to have 90% effectiveness in achieving bleeding control across the studies. For most patients, this was achieved in <5 min and required a total device deployment time of 3 h. Reported adverse events were not considered life-threatening, including endometritis in 11 patients and red blood cell transfusions in 38% of patients. CONCLUSION VHDs have the potential to be used as a rapidly effective means for mechanical intervention of postpartum hemorrhage. The efficacy and safety of VHDs must be further studied at the randomized controlled trial level to determine their clinical usage.
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Affiliation(s)
- Laura M Card
- Master of Physician Assistant Studies, Sacred Heart University, Fairfield, Connecticut, USA
| | - Alexandra V Klinkowski
- Master of Physician Assistant Studies, Sacred Heart University, Fairfield, Connecticut, USA
| | - Elijah Salzer
- College of Health Professions, PACE University, New York, New York, USA
| | - Eric C Nemec Ii
- Master of Physician Assistant Studies, Sacred Heart University, Fairfield, Connecticut, USA
| | - Suzanne J Rose
- Master of Physician Assistant Studies, Sacred Heart University, Fairfield, Connecticut, USA
- Department of Research and Discovery, Stamford Health, Stamford, Connecticut, USA
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2
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Futterman ID, Conroy EM, Chudnoff S, Alagkiozidis I, Minkoff H. Complex obstetrical surgery: building a team and defining roles. Am J Obstet Gynecol MFM 2024; 6:101421. [PMID: 38969176 DOI: 10.1016/j.ajogmf.2024.101421] [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: 04/18/2024] [Revised: 05/23/2024] [Accepted: 06/26/2024] [Indexed: 07/07/2024]
Abstract
As the number of placenta accreta spectrum cases continues to rise, the gap in surgical skills in labor and delivery units becomes more apparent. Recent scholarly work has highlighted the diminishing advanced surgical skills among obstetrician-gynecologists, particularly among new graduates. Therefore, it has become a practice in many institutions to refer complex cesarean deliveries and obstetrical hysterectomies to subspecialists, specifically gynecologic oncologists. Hence, in this commentary, we propose a process through which key personnel within departments of obstetrics and gynecology are identified and their appropriate level of involvement in cases of complex obstetrical surgery is delineated. In doing so, we describe the surgical skills expected from each provider level so that the cesarean delivery complexity level can be matched with specific surgical expertise. Through this process, an obstetrician-led complex obstetrical surgery team is formed. Ultimately, the goal of this process is 2-fold; first, to return cases with higher levels of surgical complexity back to obstetricians and, second, to reduce the surgical back-up burden from gynecology subspecialists such as gynecologic oncologists.
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Affiliation(s)
- Itamar D Futterman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Futterman and Minkoff); Division of Complex Obstetrical Surgery, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Futterman and Conroy).
| | - Erin M Conroy
- Division of Complex Obstetrical Surgery, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Futterman and Conroy); Hospitalist Division, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Conroy)
| | - Scott Chudnoff
- Division of Minimally Invasive Gynecology, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Chudnoff)
| | - Ioannis Alagkiozidis
- Division of Gynecology Oncology, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Alagkiozidis)
| | - Howard Minkoff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Futterman and Minkoff); Department of Obstetrics and Gynecology and School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, NY (Minkoff)
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3
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Makwe CC, Okunade KS. Conservative approaches to postpartum haemorrhage. Best Pract Res Clin Obstet Gynaecol 2024; 95:102516. [PMID: 38902107 DOI: 10.1016/j.bpobgyn.2024.102516] [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: 02/06/2024] [Revised: 03/21/2024] [Accepted: 06/12/2024] [Indexed: 06/22/2024]
Abstract
Postpartum haemorrhage (PPH) and PPH-related deaths are disproportionately higher in low-income countries, with sub-Saharan Africa and Southern Asia accounting for approximately 85% of the global burden of PPH-related maternal deaths. Although PPH-related mortality is directly related to the amount and duration of bleeding, the high maternal death burden in resource-limited countries suggests that a great majority of these deaths would be avoidable with the appropriate resources and effective use of evidence-based interventions. Non-surgical management is often the first-line approach for PPH, but conservative surgical interventions may be required if bleeding persists or if the underlying cause is not responsive to the initial conservative measures. The appropriate interventions should be selected based on the individual's specific circumstances and clinical condition.
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Affiliation(s)
- Christian Chigozie Makwe
- Department of Obstetrics & Gynaecology, College of Medicine University of Lagos, Nigeria; Department of Obstetrics & Gynaecology, Lagos University Teaching Hospital, Nigeria.
| | - Kehinde Sharafadeen Okunade
- Department of Obstetrics & Gynaecology, College of Medicine University of Lagos, Nigeria; Department of Obstetrics & Gynaecology, Lagos University Teaching Hospital, Nigeria
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4
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Sadiku OD, Aina SA, Odoemene CC, Ogunmoyin TE, Adedara VO, Olasimbo O, Ashir FA, Adili SC, Kuteyi AO, Fakayode OO, Faletti DO, Nogales Bernal MB. Approaches to the Prevention and Treatment of Postpartum Hemorrhage: A Systematic Review of Past Advances, Recent Developments, and Best Practices. Cureus 2024; 16:e65096. [PMID: 39171024 PMCID: PMC11337975 DOI: 10.7759/cureus.65096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/23/2024] Open
Abstract
Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality worldwide, with uterine atony being the most significant contributing factor. Other risk factors for PPH include increased maternal age, coagulation abnormalities, retained placenta, and prolonged third-stage labor. Despite the potential for prevention through early detection and management, PPH can still occur even in the absence of known risk factors. For this reason, adequate preparation and comprehensive management strategies must be implemented. This study, which comprises research from 2006 to 2023, reviews and analyzes various prevention and management techniques for PPH, including surgical and nonsurgical approaches. Key findings indicate that the presence of well-trained critical control teams is essential for the effective management of PPH. In addition, early detection techniques have significantly reduced mortality outcomes associated with PPH, highlighting their importance in patient care.
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Affiliation(s)
- Oluwatosin D Sadiku
- Obstetrics and Gynecology, St. George's University School of Medicine, St. George's, GRD
| | - Susan A Aina
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | | | - Temiloluwa E Ogunmoyin
- Medicine, Family Medicine, and Obstetrics, St. George's University School of Medicine, St. George's, GRD
| | - Victor O Adedara
- Internal Medicine and Neurology, St. George's University School of Medicine, St. George's, GRD
| | - Omolara Olasimbo
- Internal Medicine, Temple University Hospital, Philadelphia, USA
| | - Faridah A Ashir
- Internal Medicine, St. George's University School of Medicine, St. George's, GRD
| | | | - Azeez O Kuteyi
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | - Opeyemi O Fakayode
- Medicine and Surgery, St. George's University School of Medicine, St. George's, GRD
| | - Donald O Faletti
- Medicine, St. George's University School of Medicine, St. George's, GRD
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5
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Overton E, D'Alton M, Goffman D. Intrauterine devices in the management of postpartum hemorrhage. Am J Obstet Gynecol 2024; 230:S1076-S1088. [PMID: 37690862 DOI: 10.1016/j.ajog.2023.08.015] [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: 05/31/2023] [Revised: 07/28/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023]
Abstract
Obstetrical hemorrhage is a relatively frequent obstetrical complication and a common cause of maternal morbidity and mortality worldwide. The majority of maternal deaths attributable to hemorrhage are preventable, thus, developing rapid and effective means of treating postpartum hemorrhage is of critical public health importance. Intrauterine devices are one option for managing refractory hemorrhage, with rapid expansion of available devices in recent years. Intrauterine packing was historically used for this purpose, with historical cohorts documenting high rates of success. Modern packing materials, including chitosan-covered gauze, have recently been explored with success rates comparable to uterine balloon tamponade in small trials. There are a variety of balloon tamponade devices, both commercial and improvised, available for use. Efficacy of 85.9% was cited in a recent meta-analysis in resolution of hemorrhage with the use of uterine balloon devices, with greatest success in the setting of atony. However, recent randomized trials have demonstrated potential harm associated with improvised balloon tamponade use In low resource settings and the World Health Organization recommends use be restricted to settings where monitoring is available and care escalation is possible. Recently, intrauterine vacuum devices have been introduced, which offer a new mechanism for achieving hemorrhage control by mechanically restoring uterine tone via vacuum suction. The Jada device, which is is FDA-cleared and commercially available in the US, found successful bleeding control in 94% of cases in an initial single-arm trial, with recent post marketing registry study described treatment success following hemorrhage in 95.8% of vaginal and 88.2% of cesarean births. Successful use of improvised vacuum devices has been described in several studies, including suction tube uterine tamponade via Levin tubing, and use of a modified Bakri balloon. Further research is needed with head-to-head comparisons of efficacy of devices and assessment of cost within the context of both device pricing and overall healthcare resource utilization.
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Affiliation(s)
- Eve Overton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY.
| | - Mary D'Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY
| | - Dena Goffman
- Department of Obstetrics and Gynecology, Columbia University, New York, NY
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6
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Siefen AC, Kurte MS, Kron F. Economic effects of treating postpartum hemorrhage with vacuum-induced hemorrhage control devices - A budget impact analysis of the Jada® System in the German obstetrics setting. Eur J Obstet Gynecol Reprod Biol 2024; 294:222-230. [PMID: 38301501 DOI: 10.1016/j.ejogrb.2024.01.024] [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: 12/20/2023] [Accepted: 01/17/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE This study aimed to assess the budget impact of vacuum-induced hemorrhage control (VHC) devices for treating postpartum hemorrhage (PPH) from the perspective of the German statutory health insurance (SHI). STUDY DESIGN Evidence shows that treating PPH with VHC instead of uterine balloon tamponade (UBT) can reduce resource consumption (e.g., reduced number of blood transfusions and length of stay). A budget impact model combining aggregated German real-world reimbursement data of PPH cases with the assumption of resource reduction due to VHC usage was developed. Diagnosis-related groups (DRG) of PPH cases and their frequencies were collected using a publicly available database. A "downgrading mechanism" was performed, leading to a less resource-intensive DRG, i.e., resulting in a lower flat fee to be paid by SHI. Four subgroups were differentiated based on coded diagnoses and procedures: 1) PPH (O72.-) as main diagnosis, 2) PPH as secondary diagnosis, 3) UBT procedure coded, and 4) UBT or standard tamponade coded. Weighted averages of cost savings per case were calculated. RESULTS Data from 7,129 (subgroup 1), 49,523 (subgroup 2), 1,668 (subgroup 3), and 3,406 (subgroup 4) cases were retrieved. After applying the downgrading mechanism, cost savings (weighted average) resulted in 184.09 €, 210.50 €, 921.33 €, and 633.74 € for subgroups 1-4, respectively, CONCLUSION: This is the first German budget impact analysis of VHC for the treatment of PPH. Results showed the highest cost-saving potential for cases currently treated with UBT. Demonstrating not only clinical but also financial consequences of innovative treatments is crucial for the adoption into clinical practice.
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Affiliation(s)
| | - Melina S Kurte
- VITIS Healthcare Group, Cologne, Germany; Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Florian Kron
- VITIS Healthcare Group, Cologne, Germany; Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology (CIO ABCD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; FOM University of Applied Sciences, Essen, Germany.
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7
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Jackson TL, Tuuli MG. Intrauterine Postpartum Hemorrhage-Control Devices. Obstet Gynecol 2023; 142:1000-1005. [PMID: 37797338 DOI: 10.1097/aog.0000000000005403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/29/2023] [Indexed: 10/07/2023]
Abstract
Postpartum hemorrhage , defined as a cumulative blood loss of 1,000 mL or more or blood loss associated with signs or symptoms of hypovolemia regardless of the route of delivery, is the leading cause of preventable maternal death worldwide. The United States has one of the highest maternal mortality rates among developed countries, with about 14% of all maternal deaths associated with postpartum hemorrhage. Although postpartum hemorrhage has multiple causes, the most common is uterine atony-when the uterus fails to adequately contract after childbirth-accounting for 80% of all postpartum hemorrhages. When postpartum hemorrhage occurs despite preventive measures, therapeutic measures are used. Intrauterine hemorrhage-control devices are often the second-line therapy when medical management is unsuccessful. Despite its widespread use in current obstetric practice, the mechanism of intrauterine balloon tamponade, such as the Bakri balloon, is counterintuitive to the physiologic uterine contraction that occurs after delivery to control bleeding, and data on its effectiveness are mixed. Vacuum-induced hemorrhage control, such as with the Jada System, cleared by the U.S. Food and Drug Administration in 2020, is a novel modality for control of postpartum bleeding. It mimics postpartum physiology by applying low-level intrauterine negative pressure to facilitate uterine compressive forces, thereby constricting blood vessels to achieve hemostasis. Preliminary data from four studies are promising but are limited by a lack of control groups, selection bias, or modest sample sizes. The results of ongoing and planned randomized controlled trials will clarify the role of the Jada System for reducing morbidity from postpartum hemorrhage.
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Affiliation(s)
- Tracy L Jackson
- Department of Obstetrics and Gynecology, Warren Alpert Medical School at Brown University, and Women and Infants Hospital of Rhode Island, Providence, Rhode Island
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8
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Goffman D, Rood KM, Bianco A, Biggio JR, Dietz P, Drake K, Heilman E, Hopkins M, De Four Jones M, Katz T, Martin C, Prasad M, Smid MC, Wine KD, Ryan R, Yong C, Carney PI, Simhan HN. Real-World Utilization of an Intrauterine, Vacuum-Induced, Hemorrhage-Control Device. Obstet Gynecol 2023; 142:1006-1016. [PMID: 37713322 DOI: 10.1097/aog.0000000000005366] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/20/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE To assess the real-world effectiveness and safety of a U.S. Food and Drug Administration (FDA)-cleared intrauterine vacuum-induced-hemorrhage control device for postpartum hemorrhage (PPH) management. METHODS Sixteen centers in the United States participated in this observational, postmarket registry medical record review (October 2020 through March 2022). The primary effectiveness outcome was treatment success , defined as bleeding control after insertion with no treatment escalation or bleeding recurrence. Additional outcomes included blood loss, time to device insertion, indwelling time, bleeding recurrence, and time to bleeding control. Treatment success and severe maternal morbidity measures (transfusion of 4 or more units of red blood cell, intensive care unit admission, and hysterectomy) were evaluated by blood loss before insertion. To assess safety, serious adverse events (SAEs) and adverse device effects were collected. All outcomes were summarized by mode of delivery; treatment success was summarized by bleeding cause (all causes, any atony, isolated atony, nonatony). RESULTS In total, 800 individuals (530 vaginal births, 270 cesarean births) were treated with the device; 94.3% had uterine atony (alone or in combination with other causes). Median total blood loss at device insertion was 1,050 mL in vaginal births and 1,600 mL in cesarean births. Across all bleeding causes, the treatment success rate was 92.5% for vaginal births and was 83.7% for cesarean births (95.8% [n=307] and 88.2% [n=220], respectively, in isolated atony). Median indwelling time was 3.1 hours and 4.6 hours, respectively. In vaginal births, 14 SAEs were reported among 13 individuals (2.5%). In cesarean births, 22 SAEs were reported among 21 individuals (7.8%). Three (0.4%) SAEs were deemed possibly related to the device or procedure. No uterine perforations or deaths were reported. CONCLUSION For both vaginal and cesarean births in real-world settings, rapid and effective bleeding control was achieved with an FDA-cleared intrauterine vacuum-induced hemorrhage-control device. The safety profile was consistent with that observed in the registrational trial (NCT02883673), and SAEs or adverse device effects were of the nature and severity expected in the setting of PPH. This device is an important new tool for managing a life-threatening condition, and timely utilization may help to improve obstetric hemorrhage outcomes. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT04995887.
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Affiliation(s)
- Dena Goffman
- New York-Presbyterian/Columbia University Irving Medical Center and the Icahn School of Medicine at Mount Sinai, New York, and the Long Island Jewish Medical Center, New Hyde Park, New York; The Ohio State University-Wexner Medical Center and OhioHealth, Columbus, and the Women's Health Institute, Cleveland Clinic, and Case Western Reserve University, University Hospitals Cleveland, Cleveland, Ohio; Ochsner Health, New Orleans, Louisiana; the West Virginia University School of Medicine and Charleston Area Medical Center, Charleston, West Virginia; The Mother Baby Center at Abbott Northwestern Hospital, Minneapolis, Minnesota; ChristianaCare Health System, Newark, Delaware; Loma Linda University Children's Hospital, Loma Linda, and Alydia Health Inc, Menlo Park, California; the University of Utah Health, Salt Lake City, Utah; Organon & Co., Jersey City, New Jersey; and the University of Pittsburgh Medical Center-Magee Women's Hospital, Pittsburgh, Pennsylvania
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9
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Nasrullah A, Herrera M, Garbinski A, DuMont T, Alhajhusain A. Medical Emergencies in the Pregnant Patient. Crit Care Nurs Q 2023; 46:403-416. [PMID: 37684736 DOI: 10.1097/cnq.0000000000000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
This review article provides a comprehensive overview of common medical emergencies that can occur in pregnant patients. We summarize the key diagnostic and management steps for each emergency to assist health care professionals in identifying and treating these potentially life-threatening conditions. The medical emergencies discussed in this article include postpartum hemorrhage; hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome; acute fatty liver of pregnancy; amniotic fluid embolism; pulmonary embolism; acute respiratory distress syndrome; and shock. Each condition is described in detail, with a focus on the clinical presentation, diagnostic workup, and treatment options. The information presented in this review article is based on current best practices and guidelines from leading medical organizations. We hope this article will serve as a valuable resource for health care professionals who care for pregnant patients and help improve outcomes for these patients in emergency situations.
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Affiliation(s)
- Adeel Nasrullah
- Division of Pulmonology and Critical Care, Allegheny Health Network, Pittsburgh, Pennsylvania
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10
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Bonetta-Misteli F, Collins T, Pavek T, Carlgren M, Bashe D, Frolova A, Shmuylovich L, O’Brien CM. Development and evaluation of a wearable peripheral vascular compensation sensor in a swine model of hemorrhage. BIOMEDICAL OPTICS EXPRESS 2023; 14:5338-5357. [PMID: 37854551 PMCID: PMC10581812 DOI: 10.1364/boe.494720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 10/20/2023]
Abstract
Postpartum hemorrhage (PPH) is the leading and most preventable cause of maternal mortality, particularly in low-resource settings. PPH is currently diagnosed through visual estimation of blood loss or monitoring of vital signs. Visual assessment routinely underestimates blood loss beyond the point of pharmaceutical intervention. Quantitative monitoring of hemorrhage-induced compensatory processes, such as the constriction of peripheral vessels, may provide an early alert for PPH. To this end, we developed a low-cost, wearable optical device that continuously monitors peripheral perfusion via laser speckle flow index (LSFI) to detect hemorrhage-induced peripheral vasoconstriction. The measured LSFI signal produced a linear response in phantom models and a strong correlation coefficient with blood loss averaged across subjects (>0.9) in a large animal model, with superior performance to vital sign metrics.
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Affiliation(s)
| | - Toi Collins
- Division of Comparative Medicine, Washington University in St. Louis; St. Louis, USA
| | - Todd Pavek
- Division of Comparative Medicine, Washington University in St. Louis; St. Louis, USA
| | - Madison Carlgren
- Department of Biomedical Engineering, Washington University in St. Louis; St. Louis, USA
- Department of Obstetrics & Gynecology, Washington University in St. Louis; St. Louis, USA
| | - Derek Bashe
- Department of Biomedical Engineering, Washington University in St. Louis; St. Louis, USA
- Department of Radiology, Washington University in St. Louis; St. Louis, USA
| | - Antonina Frolova
- Department of Obstetrics & Gynecology, Washington University in St. Louis; St. Louis, USA
| | - Leonid Shmuylovich
- Department of Radiology, Washington University in St. Louis; St. Louis, USA
- Department of Dermatology, Washington University in St. Louis; St. Louis, USA
| | - Christine M. O’Brien
- Department of Biomedical Engineering, Washington University in St. Louis; St. Louis, USA
- Department of Obstetrics & Gynecology, Washington University in St. Louis; St. Louis, USA
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11
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Gabbai D, Many A, Lerner-Geva L, Attali E. Risk factors for blood component therapy in parturients-Case-control study. Int J Gynaecol Obstet 2023; 162:906-912. [PMID: 37002925 DOI: 10.1002/ijgo.14747] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/22/2023] [Accepted: 03/27/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE Postpartum hemorrhage is a major cause of maternal morbidity and mortality, so early identification of patients at risk is crucial. In this study, we aim to assess the risk factors for major transfusion in parturients. METHODS A case-control study was conducted between 2011 and 2019. The cases included women who were treated with postpartum major transfusion compared with two control groups, one of which was treated with 1-2 packed red blood cells and one of which was not treated with packed red blood cells. Cases were matched with controls based on two variables: multiple pregnancies and previous history of three or more cesarean sections. A multivariable conditional logistic regression model was used to determine the role of the independent risk factors. RESULTS Of the 187 424 deliveries included in the present study, 246 (0.3%) women were treated with major transfusions. After applying a multivariate analysis, maternal age (odds ratio [OR] 1.07, 95% confidence interval [CI] 0.996-1.16), antenatal anemia with hemoglobin less than 10 g/dL (OR 12.58, 95% CI 2.86-55.25), retained placenta (OR 5.5, 95% CI 2.15-13.78), and cesarean delivery (OR 10.12, 95% CI 0.93-1.95) remained independent risk factors for major transfusions. DISCUSSION Retained placenta and antenatal anemia (hemoglobin < 10 g/dL) are independent risk factors for major transfusion. Of these, anemia was found to be the most significant.
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Affiliation(s)
- Daniel Gabbai
- Division of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- School of Public Heath, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Many
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Obstetrics and Gynecology, Maayanei Hayeshuah Medical Center, Bnei Brak, Israel
| | - Liat Lerner-Geva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- School of Public Heath, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Women and Children's Health Research Unit, Gertner Institute, Tel-Hashomer, Israel
| | - Emmanuel Attali
- Division of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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12
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Abstract
Postpartum hemorrhage is a common and potentially life-threatening obstetric complication, with successful management relying heavily on early identification of hemorrhage and prompt intervention. This article will review the management of postpartum hemorrhage, including initial steps, exam-specific interventions, medical therapy, minimally invasive, and surgical interventions.
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Affiliation(s)
- Sara E Post
- Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, Ohio
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13
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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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Gulersen M, Gerber RP, Rochelson B, Nimaroff M, Jones MDF. Vacuum-induced hemorrhage control versus uterine balloon tamponade for postpartum hemorrhage. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:267-272. [PMID: 36924993 DOI: 10.1016/j.jogc.2023.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVE To compare maternal outcomes of uterine balloon tamponade (UBT) versus an intrauterine vacuum-induced hemorrhage-control device (VHD) for the management of primary postpartum hemorrhage (PPH). METHODS Retrospective cohort of all patients with PPH due to uterine atony treated with an intrauterine device within a university health system from January 2019 to June 2021. The primary outcome of massive transfusion, defined as PPH requiring transfusion of ≥ 4 units of packed red blood cells (PRBC), was compared between 2 groups: UBT (n = 78) versus VHD (n = 36). Statistical analysis included use of Chi-squared and Wilcoxon rank sum tests with statistical significance set at P < 0.05. RESULTS Baseline characteristics were similar between the 2 groups. The proportion of patients who received ≥ 4 units of PRBC was significantly lower in the VHD group compared to the UBT group (2.8% vs. 20.5%, P = <0.01). The proportion of patients who were transfused ≥ 2 units of PRBC and median estimated blood loss (EBL) were also both significantly lower in the VHD group compared to the UBT group (36.1% vs. 57.7%, P = <0.01, and 1 500 mL vs. 1 875 mL, P = 0.02, respectively). Rates of other secondary outcomes were similar between the 2 groups. CONCLUSION Our data suggest that the use of intrauterine VHD in the management of PPH is associated with a lower number of massive transfusions and EBL compared to UBT. Randomized controlled trials are needed before drawing definitive conclusions on which device is more effective in this setting.
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Affiliation(s)
- Moti Gulersen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Division of Maternal- Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA.
| | - Rachel P Gerber
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Burton Rochelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Michael Nimaroff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Monique D F Jones
- Department of Obstetrics and Gynecology, Long Island Jewish Medical Center - Zucker School of Medicine at Hofstra/Northwell, Queens, NY
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15
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Bonetta-Misteli F, Collins T, Pavek T, Carlgren M, Frolova A, Shmuylovich L, O'Brien CM. Development and evaluation of a wearable peripheral vascular compensation sensor in a swine model of hemorrhage. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.20.529156. [PMID: 36865173 PMCID: PMC9979989 DOI: 10.1101/2023.02.20.529156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Postpartum hemorrhage (PPH) is both the leading and most preventable cause of maternal mortality. PPH is currently diagnosed through visual estimation of blood loss or vital sign analysis of shock index (ratio of heart rate to systolic blood pressure). Visual assessment underestimates blood loss, particularly in the setting of internal bleeding, and compensatory mechanisms stabilize hemodynamics until hemorrhage is massive, beyond the point of pharmaceutical intervention. Quantitative monitoring of hemorrhage-induced compensatory processes, such as the constriction of peripheral vessels to shunt blood to the central organs, may provide an early alert for PPH. To this end, we developed a low-cost, wearable optical device that continuously monitors peripheral perfusion via laser speckle flow index (LSFI) to detect hemorrhage-induced peripheral vasoconstriction. The device was first tested using flow phantoms across a range of physiologically relevant flow rates and demonstrated a linear response. Subsequent testing occurred in swine hemorrhage studies (n=6) by placing the device on the posterior side of the swine's front hock and withdrawing blood from the femoral vein at a constant rate. Resuscitation with intravenous crystalloids followed the induced hemorrhage. The mean LSFI vs. percent estimated blood volume loss had an average correlation coefficient of -0.95 during the hemorrhage phase and 0.79 during resuscitation, both of which were superior to the performance of the shock index. With continued development, this noninvasive, low-cost, and reusable device has global potential to provide an early alert of PPH when low-cost and accessible management strategies are most effective, helping to reduce maternal morbidity and mortality from this largely preventable problem.
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Phillips JM, Eppes C, Rodriguez M, Sakamoto S. Traditional uterine tamponade and vacuum-induced uterine tamponade devices in obstetrical hemorrhage management. Am J Obstet Gynecol MFM 2023; 5:100739. [PMID: 36058519 DOI: 10.1016/j.ajogmf.2022.100739] [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: 04/30/2022] [Revised: 08/11/2022] [Accepted: 08/30/2022] [Indexed: 11/19/2022]
Abstract
Obstetrical hemorrhage is the leading cause of maternal morbidity and mortality worldwide, and the rates of severe hemorrhage are increasing. There is a crucial need to expand treatment options for hemorrhage to address this global crisis. Over the last decade, the evolution of hemorrhage control devices has contributed to advancements in obstetrical hemorrhage management. The number of existing hemorrhage control devices and techniques has increased markedly in recent years, and new devices are in development. The current evidence for established and investigational hemorrhage control devices has been summarized in this review. Of note, 2 main categories of devices exist: traditional uterine tamponade and vacuum-induced uterine tamponade. Although traditional intrauterine balloon tamponade devices are currently used widely in postpartum hemorrhage management, novel hemorrhage control devices and techniques have been developed. These include the minisponge tamponade device, the Jada System, a modified Bakri balloon technique, and a suction tube uterine tamponade technique. Reassuring safety data and preliminary efficacy data from pilot studies of these novel techniques support the powerful role intrauterine devices can play in obstetrical hemorrhage management. This review aimed to improve awareness of device options so that continued efforts can be made to integrate new technology into hemorrhage management protocols. Well-designed studies inclusive of new hemorrhage control devices are essential to understanding where new technology fits into preexisting obstetrical hemorrhage algorithms. In addition, access to new tamponade technology remains limited on a global scale. Programs aimed at both increasing access to devices and expanding educational initiatives are essential to make new technology a standard component for hemorrhage management.
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Affiliation(s)
- Jaclyn M Phillips
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh Medical Center Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA (Drs Phillips and Sakamoto).
| | - Catherine Eppes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Eppes)
| | - Maria Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR (Dr Rodriguez)
| | - Sara Sakamoto
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh Medical Center Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA (Drs Phillips and Sakamoto)
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Püchel J, Sitter M, Kranke P, Pecks U. Procedural techniques to control postpartum hemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:371-382. [PMID: 36513432 DOI: 10.1016/j.bpa.2022.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
Postpartum hemorrhage can occur unexpectedly and with high dynamics. The mother's life often depends on quick action and good communication within an interdisciplinary team. Knowledge of each other's therapeutic options plays a major role. Treatment procedures include obstetric, surgical, and radiologic techniques. In addition to availability and experience with the techniques, two important aspects must be considered in the selection process: the type of delivery and the cause of the hemorrhage. In particular, the distinction between pregnancies with or without disturbed placentation from the placenta accreta spectrum is crucial. From these two points of view, we discuss here different uterus-preserving and uterus-removing techniques. We describe in detail the advantages and disadvantages of each procedure. Because most therapeutic options are based on small case series and uncontrolled studies, local circumstances and physician experience are critical in setting internal standards.
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Affiliation(s)
- Jodok Püchel
- Department of Gynaecology and Obstetrics, University Hospital of Cologne, Germany.
| | - Magdalena Sitter
- Department of Anaesthesia, Critical Care Medicine, Emergency Medicine and Pain Medicine, University Hospital of Wuerzburg, Germany.
| | - Peter Kranke
- Department of Anaesthesia, Critical Care Medicine, Emergency Medicine and Pain Medicine, University Hospital of Wuerzburg, Germany.
| | - Ulrich Pecks
- Department of Gynaecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
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18
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Effect of Mirena Intrauterine Device on Endometrial Thickness, Quality of Life Score, and Curative Effect in Patients with Perimenopausal Abnormal Uterine Bleeding. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5648918. [PMID: 36238482 PMCID: PMC9553334 DOI: 10.1155/2022/5648918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 08/25/2022] [Accepted: 09/19/2022] [Indexed: 11/18/2022]
Abstract
Objective To study the effect of Mirena intrauterine device (IUD) on endometrial thickness, life quality score, and curative effect in patients with perimenopausal abnormal uterine bleeding. Methods Eighty patients with perimenopausal abnormal uterine bleeding cured from January 2020 to December 2021 were enrolled as the object of study. According to random number table, the patients were classified into the study (n = 40) and control (n = 40) groups. The control cases were cured with medroxyprogesterone. The study cases were cured with Mirena IUD. The effective rate of clinical therapies was evaluated after 3 months of treatment. The endometrial thickness, menstrual volume score, and life quality score (WHOQOL-BREF) was measured after 1 month, 2 months, and 3 months of treatment. Results The effective rate of patients with Mirena IUD for 3 months was higher compared to the control group (P < 0.05). The endometrial thickness and menstrual volume scores of study cohort after 1 month, 2 months, and 3 months following treatment were remarkably lower than those before treatment (P < 0.05) and were considerably lower than those of control cohort (P < 0.05). The hemoglobin level of the studied cases after 1 month, 2 months, and 3 months after therapy was remarkably upregulated (P < 0.05) and was greatly higher compared to the controlled cases (P < 0.05). After 3-month treatment, the WHOQOL-BREF score of the study group was higher compared to the control group (P < 0.05). Conclusion The Mirena IUD is far more effective in the treatment of perimenopausal abnormal uterine bleeding and is helpful in reducing the thickness of the endometrium. Patients' menstrual flow can be controlled, and anemia can be corrected; thus, patients improve their quality of life and health status and can be considered for further promotion.
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19
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Obstetric Disorders and Critical Illness. Clin Chest Med 2022; 43:471-488. [PMID: 36116815 DOI: 10.1016/j.ccm.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this article, we discuss some of the more common obstetric-related conditions that can lead to critical illness and require management in an ICU. These include the hypertensive disorders of pregnancy, postpartum hemorrhage, hemolysis, elevated liver enzymes, and low platelet syndrome, acute fatty liver of pregnancy, amniotic fluid embolism, and peripartum cardiomyopathy. We also discuss pulmonary embolism and Covid-19. Despite not being specific to obstetric patients, pulmonary embolism is a common, life-threatening diagnosis in pregnancy with particular risks and management aspects. Covid-19 does not seem to occur with higher frequency in pregnant women, but it leads to higher rates of ICU admissions and mechanical ventilation in pregnant women than in their nonpregnant peers. Its prevalence during our current global pandemic makes it important to discuss in this article. We provide a basis for critical care physicians to be engaged in informed conversations and management in a multidisciplinary manner with other relevant providers in the care of critically ill pregnant and postpartum women.
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20
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Abstract
This article serves to highlight both the common nature and severity of postpartum hemorrhage (PPH). Identification of etiologies and management of each is reviewed. In addition, the evaluation and administration of proper blood component therapies and massive transfusion are also explained to help providers become comfortable with early administration and delivery of blood component therapies.
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21
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Postpartum Hemorrhage: Emergency Management for Uncontrolled Vaginal Bleeding. Adv Emerg Nurs J 2022; 44:213-219. [PMID: 35900241 DOI: 10.1097/tme.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postpartum hemorrhage (PPH) represents total cumulative blood loss in excess of 1,000 ml or blood loss accompanied by signs and/or symptoms of hypovolemia within 24 hr following birth (The American College of Obstetricians and Gynecologists [ACOG], 2017). As a large number of PPHs occur in low-risk women (ACOG, 2019), the emergency nurse practitioner must be prepared to identify and manage this uncommon but life-threatening condition. The etiology, pharmacological management strategies, and other interventions are reviewed in an algorithmic approach. This organized approach not only supports maternal survival during PPH but is also applicable to postprocedural bleeding of obstetric and gynecological etiologies.
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22
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Helmer P, Schlesinger T, Hottenrott S, Papsdorf M, Wöckel A, Sitter M, Skazel T, Wurmb T, Türkmeneli I, Härtel C, Hofer S, Alkatout I, Messroghli L, Girard T, Meybohm P, Kranke P. [Postpartum hemorrhage : Interdisciplinary consideration in the context of patient blood management]. Anaesthesist 2022; 71:181-189. [PMID: 35244736 DOI: 10.1007/s00101-022-01098-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 12/20/2022]
Abstract
Postpartum hemorrhage (PPH) nowadays still represents a severe complication of both a vaginal delivery and a cesarean section. In German-speaking areas a new definition of the term has recently become established and the nomenclature with respect to the severe form of PPH was dropped. The handling of misoprostol as a uterotonic during treatment of PPH is also new, which is available in Germany only as a medical direct import. For adequate diagnostics and targeted treatment interdisciplinary and standardized algorithms should be established and the specialist disciplines involved should be sensitized to this problem. In addition to an adequate hemostasis, a developing coagulopathy must be recognized at an early stage and treated with targeted coagulation management. Through implementation concepts, particularly the second pillar (minimization of blood loss) and the third pillar (rational use of blood transfusions) of patient blood management, various aspects for improvement of treatment of a PPH can be identified.
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Affiliation(s)
- Philipp Helmer
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Tobias Schlesinger
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Sebastian Hottenrott
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Michael Papsdorf
- Frauenklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Achim Wöckel
- Frauenklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Magdalena Sitter
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Tobias Skazel
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Thomas Wurmb
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Ismail Türkmeneli
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Christoph Härtel
- Kinderklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Stefan Hofer
- Klinik für Anästhesie, Intensiv‑, Notfallmedizin und Schmerztherapie, Westpfalz-Klinikum, Kaiserslautern, Deutschland
| | - Ibrahim Alkatout
- Klinik für Gynäkologie und Geburtshilfe (Frauenheilkunde), Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Leila Messroghli
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
| | - Thierry Girard
- Anästhesiologie, Universitätsspital Basel, Basel, Schweiz
| | - Patrick Meybohm
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Peter Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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Abstract
Obstetric hemorrhage is a leading cause of morbidity and mortality. Prevention includes identifying patients with risk factors and actively managing the third stage of labor. The anesthesiologist should be ready to manage hemorrhage with general strategies as well as strategies tailored to the specific cause of hemorrhage. Both neuraxial anesthesia and general anesthesia are appropriate in different situations. Treatments proven to be effective include increasing the oxytocin infusion, administering tranexamic acid early, guiding transfusion with point-of-care tests, and using cell salvage. Utilization of protocols and checklists within systems that encourage effective communication between teams should be implemented.
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Affiliation(s)
- Sarah Kroh
- Obstetric Anesthesiology, UPMC Magee Women's Hospital, University of Pittsburgh Medical School, 300 Halket Street, Pittsburgh, PA 15213, USA.
| | - Jonathan H Waters
- Anesthesiology & Perioperative Medicine, UPMC Magee-Womens Hospital, Patient Blood Management Program, 300 Halket Street, Pittsburgh, PA 15213, USA
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Cebekhulu SN, Abdul H, Batting J, Chauke L, Dlakavu F, Fawcus S, Govender L, Majeke B, Mbongozi X, Singata-Madliki M, Middleton K, Mlandu P, Naidoo P, Ndaba S, Soma-Pillay P, Spence T, Ntambua SC, Hofmeyr J. "Suction Tube Uterine Tamponade" for treatment of refractory postpartum hemorrhage: Internal feasibility and acceptability pilot of a randomized clinical trial. Int J Gynaecol Obstet 2021; 158:79-85. [PMID: 34605016 DOI: 10.1002/ijgo.13963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/09/2021] [Accepted: 09/30/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess feasibility and acceptability of a novel, low-cost "Suction Tube Uterine Tamponade" (STUT) treatment for refractory postpartum hemorrhage (PPH). METHODS We allocated patients with refractory PPH by randomly ordered envelopes to STUT or routine uterine balloon tamponade (UBT, Ellavi free-flow system) in 10 hospitals in South Africa. In the STUT group, a 24FG Levin stomach tube was inserted into the uterine cavity and vacuum created with a vacuum pump or manual vacuum aspiration syringe. RESULTS For this internal pilot study, 12 participants were allocated to STUT and 12 to UBT. Insertion failed in one of each group and was recorded as difficult in 3/10 STUT and 4/9 UBT insertions respectively (five missing data). There were two laparotomies and one intensive care unit admission in the UBT group. Pain during STUT insertion was graded as none/mild in 9/10 and severe in 1/10. The experience of the STUT procedure was graded as fine in 4/11 and "uncomfortable but acceptable" in 7/11. CONCLUSION STUT is feasible and acceptable, justifying continuation of our trial. These data will also inform a large World Health Organization trial to test effectiveness of uterine tamponade methods. The numbers are too small to support any clinical recommendation.
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Affiliation(s)
- Sylvia N Cebekhulu
- Department of Obstetrics and Gynaecology, Department of Health, Bloemfontein, Bongani Regional Hospital, University of the Free State, Hartbeespoort, South Africa
| | - Hazmath Abdul
- Department of Obstetrics & Gynaecology, Queen Nandi Regional Hospital, Empangeni, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Joanne Batting
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand, Walter Sisulu, and Fort Hare, East London, South Africa
| | - Lawrence Chauke
- Department Obstetrics and Gynaecology Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Witwatersrand, South Africa
| | - Fuziwe Dlakavu
- Department of Obstetrics and Gynaecology, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Sue Fawcus
- Department Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Logie Govender
- Department of Obstetrics & Gynaecology, Queen Nandi Regional Hospital, Empangeni, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Busiwe Majeke
- Department of Obstetrics and Gynaecology at Cecilia Makiwane Hospital, Walter Sisulu University, East London, South Africa
| | - Xolani Mbongozi
- Department of Obstetrics and Gynaecology, Nelson Mandela Academic Hospital, Walter Sisulu University, Mthatha, South Africa
| | - Mandisa Singata-Madliki
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand, Walter Sisulu, and Fort Hare, East London, South Africa
| | - Katrin Middleton
- Department of Obstetrics and Gynaecology, Frere Hospital and Walter Sisulu University, East London, South Africa
| | - Philiswa Mlandu
- Department of Obstetrics and Gynaecology, Chris Hani Baragwaneth Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Poovangela Naidoo
- Department of Obstetrics and Gynaecology, Chris Hani Baragwaneth Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Sanele Ndaba
- Department of Obstetrics and Gynaecology Kalafong Hospital, University of Pretoria, Pretoria, South Africa
| | - Priya Soma-Pillay
- UP/SAMRC Research Centre for Maternal, Fetal, Newborn and Child Healthcare Strategies, Department of Obstetrics and Gynaecology Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Trevi Spence
- Department of Obstetrics and Gynaecology, New Somerset Hospital, Cape Town, South Africa
| | - Symphorien C Ntambua
- Department of Health, Department of Obstetrics and Gynaecology, Bongani Regional Hospital, Free State, Hartbeespoort, South Africa
| | - Justus Hofmeyr
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand, Walter Sisulu, and Fort Hare, East London, South Africa.,University of Botswana, Botswana, South Africa
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25
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D'Alton M, Rood K, Simhan H, Goffman D. Profile of the Jada® System: the vacuum-induced hemorrhage control device for treating abnormal postpartum uterine bleeding and postpartum hemorrhage. Expert Rev Med Devices 2021; 18:849-853. [PMID: 34355991 DOI: 10.1080/17434440.2021.1962288] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Abnormal postpartum uterine bleeding occurs commonly after birth and can quickly become an obstetric emergency. With postpartum hemorrhage representing the leading cause of maternal mortality, accounting for 25% of maternal deaths due to obstetric complications, there is a critical need for effective and easy to use treatment options. AREAS COVERED This profile describes the Jada System, a novel intrauterine vacuum-induced hemorrhage control device that provides a rapid and effective treatment option for abnormal postpartum uterine bleeding and postpartum hemorrhage. In addition to explaining the mechanism of action of vacuum-induced hemorrhage control and reviewing the device's safety and effectiveness, this profile elucidates how the Jada System compares to currently available medications and devices for treatment of this obstetric emergency. EXPERT OPINION New therapies to address this life-threatening condition are needed to reduce the risk of maternal mortality and severe maternal morbidity. Data demonstrate that the Jada System provides rapid, effective control of abnormal postpartum uterine bleeding and postpartum hemorrhage, while offering reported ease of use and short treatment duration. These results suggest that use of the Jada System in treatment algorithms may improve outcomes.
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Affiliation(s)
- Mary D'Alton
- Department of Obstetrics and Gynecology, New York Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Kara Rood
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, USA
| | - Hyagriv Simhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
| | - Dena Goffman
- Department of Obstetrics and Gynecology, New York Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
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Haslinger C, Weber K, Zimmermann R. Vacuum-Induced Tamponade for Treatment of Postpartum Hemorrhage. Obstet Gynecol 2021; 138:361-365. [PMID: 34352848 PMCID: PMC8366764 DOI: 10.1097/aog.0000000000004510] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022]
Abstract
Vacuum-induced tamponade appears to be an easy-to-use, promising method for the treatment of postpartum hemorrhage, particularly in women with uterine atony. BACKGROUND: Postpartum hemorrhage is a main cause of maternal mortality worldwide, with rising incidence, thus demanding new treatment approaches. Intrauterine balloon systems with application of intrauterine vacuum are a promising new method. METHOD: All women treated with vacuum-induced tamponade using a modified balloon system were included in this single-center study. Aiming to reduce uterine size for control of postpartum hemorrhage, the intrauterine balloon was filled to 50–100 mL and connected to a vacuum device. Success rate of vacuum-induced tamponade, defined as no need for additional interventional treatment, was analyzed by etiology of postpartum hemorrhage and time period of use. EXPERIENCE: Vacuum-induced tamponade was applied in 66 women. Success rate was 86% in women with uterine atony (n=44) and 73% in women with postpartum hemorrhage due to placental pathology (n=22). Success rate improved over the study period, culminating in a success rate of 100% in women with postpartum hemorrhage due to uterine atony in the second half of the observation period (n=22). CONCLUSION: This observational study supports our pathophysiologic understanding of uterine atony: to treat an atonic uterus, uterine volume must be reduced, leading to coiling of the uterine spiral arteries and, hence, reduced blood loss.
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Affiliation(s)
- Christian Haslinger
- Department of Obstetrics, University Hospital Zurich, and the University of Zurich, Zurich, Switzerland
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In Reply. Obstet Gynecol 2021; 137:1127-1128. [PMID: 34011878 DOI: 10.1097/aog.0000000000004419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Balki M, Wong CA. Refractory uterine atony: still a problem after all these years. Int J Obstet Anesth 2021; 48:103207. [PMID: 34391025 DOI: 10.1016/j.ijoa.2021.103207] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/27/2021] [Accepted: 07/12/2021] [Indexed: 02/04/2023]
Abstract
Postpartum hemorrhage is a leading cause of maternal morbidity and mortality, and uterine atony is the leading cause of postpartum hemorrhage. Risk factors for uterine atony include induced or augmented labor, preeclampsia, chorio-amnionitis, obesity, multiple gestation, polyhydramnios, and prolonged second stage of labor. Although a risk assessment is recommended for all parturients, many women with uterine atony do not have risk factors, making uterine atony difficult to predict. Oxytocin is the first-line drug for prevention and treatment of uterine atony. It is a routine component of the active management of the third stage of labor. An oxytocin bolus dose as low as 1 IU is sufficient to produce satisfactory uterine tone in almost all women undergoing elective cesarean delivery. However, a higher bolus dose (3 IU) or infusion rate is recommended for women undergoing intrapartum cesarean delivery. Carbetocin, available in many countries, is a synthetic oxytocin analog with a longer duration than oxytocin that allows bolus administration without an infusion. Second line uterotonic agents include ergot alkaloids (ergometrine and methylergonovine) and the prostaglandins, carboprost and misoprostol. These drugs work by a different mechanism to oxytocin and should be administered early for uterine atony refractory to oxytocin. Rigorous studies are lacking, but methylergonovine and carboprost are likely superior to misoprostol. Currently, the choice of second-line agent should be based on their adverse effect profile and patient comorbidities. Surgical and radiologic management of uterine atony includes uterine tamponade using balloon catheters and compression sutures, and percutaneous transcatheter arterial embolization.
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Affiliation(s)
- M Balki
- Department of Anesthesiology and Pain Medicine, Department of Obstetrics and Gynecology, University of Toronto, The Lunefeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - C A Wong
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, United States.
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Intrauterine Vacuum-Induced Hemorrhage-Control Device for Rapid Treatment of Postpartum Hemorrhage. Obstet Gynecol 2021; 137:1127. [PMID: 34011877 DOI: 10.1097/aog.0000000000004418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Goals for Collaborative Management of Obstetric Hemorrhage. Obstet Gynecol Clin North Am 2021; 48:151-171. [PMID: 33573784 DOI: 10.1016/j.ogc.2020.11.001] [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: 11/21/2022]
Abstract
Hemorrhage remains a leading cause of preventable maternal morbidity and mortality worldwide and in the United States. Postpartum hemorrhage is the number one cause of severe morbidity during hospitalization for birth, despite hospital, state, and national initiatives. In addition, studies show that more than 90% of maternal deaths related to obstetric hemorrhage are preventable. This article reviews relevant physiologic changes of pregnancy that may have an impact on hemorrhage management and describes collaborative approaches for management of hemorrhage in this unique population.
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Matsubara S. Creating a good research question, with hemostasis of uterine bleeding as an example. J Obstet Gynaecol Res 2021; 47:1924. [PMID: 33650285 DOI: 10.1111/jog.14739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 02/21/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Shigeki Matsubara
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, Japan.,Department of Obstetrics and Gynecology, Koga Red Cross Hospital, Koga, Ibaraki, Japan
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New Approaches to the Age-Old Problem of Uterine Atony. Obstet Gynecol 2020; 136:874-875. [PMID: 33095541 DOI: 10.1097/aog.0000000000004156] [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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