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Bruce BR, Shepherd HL, Khan SA, Haunton CR, Leask J, De Vries BS. Association between intravenous fluids during labor and primary postpartum hemorrhage: A retrospective cohort study. Acta Obstet Gynecol Scand 2024; 103:1541-1549. [PMID: 38856239 PMCID: PMC11266724 DOI: 10.1111/aogs.14896] [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: 02/16/2024] [Revised: 04/19/2024] [Accepted: 05/29/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION There is a major research gap relating to the impact of intravenous (IV) fluids administration during labor on maternal and neonatal outcomes. It is biologically plausible that a relationship between volume of IV fluids and primary postpartum hemorrhage (PPH) exists. The primary objective of this study was to evaluate whether the administration of high-volume IV fluids during labor (≥ 2500 mL) increases the risk of primary PPH and other adverse outcomes for women with a term, singleton pregnancy, in comparison to low-volume IV fluids during labor (<2500 mL). MATERIAL AND METHODS A retrospective cohort study was conducted at a tertiary referral hospital in Sydney, Australia between 1st September 2021 and 31st October 2022. Inclusion criteria were: women with a live singleton fetus in a cephalic presentation; planning a vaginal birth; and admitted for labor and birth care between 37 and 42 week gestation. The study factor was IV fluids during labor and the primary outcome was primary PPH ≥500 mL. Secondary outcomes included cesarean section and major perineal injury. Pregnancy, birth, and postnatal data were obtained from the hospital's electronic clinical database, electronic medical records, and paper fluid order documentation. Multivariable logistic regression and multiple imputation were used to explore the relationship between volume of IV fluids in labor and PPH. RESULTS A total of 1023 participants were included of which 339 had a primary PPH (33.1%). There was no association between high-volume IV fluids and PPH after adjusting for demographic and clinical factors (adjusted odds ratio [ORadj]1.02 95% confidence interval [95%CI] 0.72, 1.44). However, there was a positive association between high-volume IV fluids and cesarean section (ORadj 1.99; 95%CI 1.4, 2.8). CONCLUSIONS The findings of this research are important to further knowledge relating to the administration of IV fluids during labor. The findings emphasize the importance of accurately documenting IV fluids administration and identifies research priorities to enable us to better understand the broader implications of IV fluids administration on pregnancy and perinatal outcomes.
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Affiliation(s)
- Belinda R. Bruce
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Sydney Institute for Women, Children and their FamiliesRPA Women and Babies, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Heather L. Shepherd
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Saleem Ahmed Khan
- RPA Women and Babies, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Charlotte R. Haunton
- RPA Women and Babies, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Julie Leask
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- School of Public Health, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
| | - Bradley S. De Vries
- Sydney Institute for Women, Children and their FamiliesRPA Women and Babies, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
- Central Clinical School, Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
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Iolascon A, Andolfo I, Russo R, Sanchez M, Busti F, Swinkels D, Aguilar Martinez P, Bou-Fakhredin R, Muckenthaler MU, Unal S, Porto G, Ganz T, Kattamis A, De Franceschi L, Cappellini MD, Munro MG, Taher A. Recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia. Hemasphere 2024; 8:e108. [PMID: 39011129 PMCID: PMC11247274 DOI: 10.1002/hem3.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/16/2024] [Accepted: 05/27/2024] [Indexed: 07/17/2024] Open
Abstract
Iron is an essential nutrient and a constituent of ferroproteins and enzymes crucial for human life. Generally, nonmenstruating individuals preserve iron very efficiently, losing less than 0.1% of their body iron content each day, an amount that is replaced through dietary iron absorption. Most of the iron is in the hemoglobin (Hb) of red blood cells (RBCs); thus, blood loss is the most common cause of acute iron depletion and anemia worldwide, and reduced hemoglobin synthesis and anemia are the most common consequences of low plasma iron concentrations. The term iron deficiency (ID) refers to the reduction of total body iron stores due to impaired nutrition, reduced absorption secondary to gastrointestinal conditions, increased blood loss, and increased needs as in pregnancy. Iron deficiency anemia (IDA) is defined as low Hb or hematocrit associated with microcytic and hypochromic erythrocytes and low RBC count due to iron deficiency. IDA most commonly affects women of reproductive age, the developing fetus, children, patients with chronic and inflammatory diseases, and the elderly. IDA is the most frequent hematological disorder in children, with an incidence in industrialized countries of 20.1% between 0 and 4 years of age and 5.9% between 5 and 14 years (39% and 48.1% in developing countries). The diagnosis, management, and treatment of patients with ID and IDA change depending on age and gender and during pregnancy. We herein summarize what is known about the diagnosis, treatment, and prevention of ID and IDA and formulate a specific set of recommendations on this topic.
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Affiliation(s)
- Achille Iolascon
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche Università degli Studi di Napoli Federico II Napoli Italy
- CEINGE Biotecnologie Avanzate Franco Salvatore Napoli Italy
| | - Immacolata Andolfo
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche Università degli Studi di Napoli Federico II Napoli Italy
- CEINGE Biotecnologie Avanzate Franco Salvatore Napoli Italy
| | - Roberta Russo
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche Università degli Studi di Napoli Federico II Napoli Italy
- CEINGE Biotecnologie Avanzate Franco Salvatore Napoli Italy
| | - Mayka Sanchez
- Department of Basic Sciences, Iron metabolism: Regulation and Diseases Universitat Internacional de Catalunya (UIC) Barcelona Spain
| | - Fabiana Busti
- Department of Medicine, Section of Internal Medicine and Azienda Ospedaliera Universitaria Integrata of Verona, EuroBloodNEt Referral Center for Iron Disorders, Policlinico G.B. Rossi University of Verona Verona Italy
| | - Dorine Swinkels
- Department of Laboratory Medicine, Translational Metabolic Laboratory (TML 830) Radboud University Medical Center Nijmegen The Netherlands
| | - Patricia Aguilar Martinez
- Department of Hematological Biology, Reference Center on Rare Red Cell Disorders Montpellier University Hospital Montpellier France
| | - Rayan Bou-Fakhredin
- Department of Clinical Sciences and Community Health University of Milan Milan Italy
| | - Martina U Muckenthaler
- Molecular Medicine Partnership Unit European Molecular Biology Laboratory Heidelberg Germany
- Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), University of Heidelberg Heidelberg Germany
- German Centre for Cardiovascular Research, Partner Site Heidelberg Germany
| | - Sule Unal
- Department of Pediatric Hematology Hacettepe University Ankara Turkey
| | - Graça Porto
- HematologyServiço de Imuno-hemoterapia, CHUdSA-Centro Hospitalar Universitário de Santo António Porto Portugal
| | - Tomas Ganz
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles California USA
| | - Antonis Kattamis
- Division of Pediatric Hematology-Oncology, First Department of Pediatrics, National & Kapodistrian University of Athens "Aghia Sophia" Children's Hospital Athens Greece
| | - Lucia De Franceschi
- Department of Medicine University of Verona & AOUI Verona, Policlinico GB Rossi Verona Italy
| | - Maria Domenica Cappellini
- Department of Clinical Sciences and Community University of Milan, Cà Granda Foundation IRCCS Maggiore Policlinico Hospital Milan Italy
| | - Malcolm G Munro
- Department of Obstetrics and Gynecology David Geffen School of Medicine Los Angeles California USA
| | - Ali Taher
- Division of Hematology-Oncology, Department of Internal Medicine American University of Beirut Medical Center Beirut Lebanon
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3
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Elkington M, Kurinczuk JJ, Pasupathy D, Plachcinski R, Rogers J, Williams C, Rowe R. Postpartum haemorrhage occurring in UK midwifery units: A national population-based case-control study to investigate incidence, risk factors and outcomes. PLoS One 2023; 18:e0291795. [PMID: 37796876 PMCID: PMC10553245 DOI: 10.1371/journal.pone.0291795] [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: 07/18/2022] [Accepted: 09/02/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVES To estimate the incidence of, and investigate risk factors for, postpartum haemorrhage (PPH) requiring transfer to obstetric care following birth in midwifery units (MU) in the UK; to describe outcomes for women who experience PPH requiring transfer to obstetric care. METHODS We conducted a national population-based case-control study in all MUs in the UK using the UK Midwifery Study System (UKMidSS). Between September 2019 and February 2020, 1501 women with PPH requiring transfer to obstetric care following birth in an MU, and 1475 control women were identified. We used multivariable logistic regression, generating adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to investigate risk factors for PPH requiring transfer to obstetric care. RESULTS The incidence of PPH requiring transfer to obstetric care following birth in an MU was 3.7% (95% CI 3.6%-3.9%). Factors independently associated with PPH requiring transfer to obstetric care were smoking during pregnancy (aOR = 0.73; 95% CI 0.56-0.94), nulliparity (aOR = 1.96; 95% CI 1.66-2.30), previous PPH (aOR = 2.67; 95% CI 1.67-4.25), complications in a previous pregnancy other than PPH (aOR = 2.40; 95% CI 1.25-4.60), gestational age ≥41 weeks (aOR = 1.36; 95% CI 1.10-1.69), instrumental birth (aOR = 2.69; 95% CI 1.53-4.72), third stage of labour ≥60 minutes (aOR = 5.56; 95% CI 3.93-7.88), perineal trauma (aOR = 4.67; 95% CI 3.16-6.90), and birthweight 3500-3999g (aOR = 1.71; 95% CI 1.42-2.07) or ≥4000g (aOR = 2.31; 95% CI 1.78-3.00). One in ten (10.6%) cases received a blood transfusion and one in five (21.0%) were admitted to higher level care. CONCLUSIONS The risk factors identified in this study align with those identified in previous research and with current guidelines for women planning birth in an MU in the UK. Maternal outcomes after PPH were broadly reassuring and indicative of appropriate management. NHS organisations should ensure that robust guidelines are in place to support management of PPH in MUs.
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Affiliation(s)
- Madeline Elkington
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jennifer J. Kurinczuk
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Dharmintra Pasupathy
- Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Rachel Plachcinski
- Independent Parent, Patient and Public Involvement Consultant, Dewsbury, United Kingdom
| | - Jane Rogers
- Consultant Midwife, Formerly at University Hospitals Southampton, Southampton, United Kingdom
| | - Catherine Williams
- Independent Parent, Patient and Public Involvement Consultant, Henley on Thames, United Kingdom
| | - Rachel Rowe
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Riascos N, Loaiza-Osorio S, Monroy A, Barona JS, Carvajal J, Echavarria MP, Nasner D, Escobar MF. Effect of the postpartum hemorrhage intervention package implementation in a fourth-level hospital in Latin America. Int J Gynaecol Obstet 2023; 163:291-301. [PMID: 37269178 DOI: 10.1002/ijgo.14886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/12/2023] [Accepted: 05/09/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of the implementation of intervention packages for postpartum hemorrhage (PPH) management in pregnant women hospitalized in a High Obstetric Complexity Unit in a Latin American country. METHODS Retrospective cohort study including pregnant women with PPH attended between January 2011 to December 2019. Three periods of time were defined according to management strategies We performed univariate and multivariate robust Poisson regression logistic models for each of the outcomes derived from each period. RESULTS We included 602 patients. There was a reduction in period 3 of the incidence of massive PPH (16% versus 12% P < 0.001, relative risk [RR] 0.61, 95% confidence interval [CI] 0.44-0.85; P = 0.003), major surgery (24%, 13%, 11%, P = 0.002, RR 0.54, 95% CI 0.33-0.883; P = 0.014), and admission to the intensive care unit (ICU) (14%, 7%, 6.1%, P = 0.0, RR 0.40, 95% CI 0.17-0.96 P = 0.00). CONCLUSION The implementation of PPH intervention packages in a hospital in a middle-income country from Latin America, led to a significant decrease in the incidence of massive bleeding, the rate of major surgery, and the ICU stay of pregnant women affected by this condition.
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Affiliation(s)
- Natalia Riascos
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Sara Loaiza-Osorio
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
| | - Angelica Monroy
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Juan Sebastián Barona
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Javier Carvajal
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
| | | | - Daniela Nasner
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - María Fernanda Escobar
- Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Department of Telemedicine, Fundación Valle del Lili, Cali, Colombia
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5
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Patek K, Friedman P. Postpartum Hemorrhage-Epidemiology, Risk Factors, and Causes. Clin Obstet Gynecol 2023; 66:344-356. [PMID: 37130373 DOI: 10.1097/grf.0000000000000782] [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: 05/04/2023]
Abstract
The incidence of postpartum hemorrhage (PPH) is increasing worldwide and in the United States. Coinciding, is the increased rate of severe maternal morbidity with blood transfusion in the United States over the past 2 decades. Consequences of PPH can be life-threatening and carry significant cost burden to the health care system. This review will discuss the current trends, distribution, and risk factors for PPH. Causes of PPH will be explored in detail.
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Affiliation(s)
- Kara Patek
- Corewell Health William Beaumont University Hospital, Royal Oak, Michigan
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6
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Zewdu D, Tantu T. Incidence and predictors of severe postpartum hemorrhage after cesarean delivery in South Central Ethiopia: a retrospective cohort study. Sci Rep 2023; 13:3635. [PMID: 36869166 PMCID: PMC9984450 DOI: 10.1038/s41598-023-30839-x] [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: 10/14/2022] [Accepted: 03/02/2023] [Indexed: 03/05/2023] Open
Abstract
Severe postpartum hemorrhage is an obstetric emergency that needs immediate intervention and is a leading cause of maternal death. Despite its significant health burden, little is known, about its magnitude and risk factors, especially after cesarean delivery in Ethiopia. This study aimed to evaluate the incidence and predictors of severe postpartum hemorrhage following cesarean section. This study was conducted on 728 women who underwent cesarean section. We retrospectively collected data from the medical records, including baseline characteristics, obstetrics, and perioperative data. Potential predictors were investigated using multivariate logistic regression analyses, adjusted odd ratios, and a 95% confidence interval to see associations. A p-value < 0.05 is considered statistically significant. The incidence of severe postpartum hemorrhage was 26 (3.6%). The independently associated factors were previous CS scar ≥ 2 (AOR 4.08: 95% CI 1.20-13.86), antepartum hemorrhage (AOR 2.89: 95% CI 1.01-8.16), severe preeclampsia (AOR 4.52: 95% CI 1.24-16.46), maternal age ≥ 35 years (AOR 2.77: 95% CI 1.02-7.52), general anesthesia (AOR 4.05: 95% CI 1.37-11.95) and classic incision (AOR 6.01: 95% CI 1.51-23.98). One in 25 women who gave birth during cesarean section experienced severe postpartum hemorrhage. Considering appropriate uterotonic agents and less invasive hemostatic interventions for high-risk mothers would help to decrease its overall rate and related morbidity.
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Affiliation(s)
- Dereje Zewdu
- Department of Anesthesia, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia.
| | - Temesgen Tantu
- Department of Obstetrics and Gynecology, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia
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7
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Faysal H, Araji T, Ahmadzia HK. Recognizing who is at risk for postpartum hemorrhage: targeting anemic women and scoring systems for clinical use. Am J Obstet Gynecol MFM 2023; 5:100745. [PMID: 36075528 DOI: 10.1016/j.ajogmf.2022.100745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/29/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
Iron deficiency anemia during pregnancy is a common concern, affecting 38% of women worldwide and up to 50% in developing countries. It is defined differently throughout all 3 trimesters. It has several detrimental effects on pregnancy outcomes for both the mother and the fetus, such as increasing the risk for postpartum depression, preterm delivery, cesarean delivery, preeclampsia, and low birthweight. Management of iron deficiency anemia is done classically via oral iron supplementation. However, recent evidence has shown that intravenous iron is a good alternative to oral iron if patients are unable to tolerate it, not responding, or present with a new diagnosis very late in pregnancy. Management of iron deficiency anemia was demonstrated to be protective against postpartum hemorrhage. Other ways to prevent postpartum hemorrhage include improving prediction tools that can identify those at risk. Several risk assessment kits have been developed to estimate the risk for postpartum hemorrhage among patients and have been proven useful in the prediction of patients at high risk for postpartum hemorrhage despite limitations among low-risk groups. More comprehensive tools are also being explored by determining clinically relevant factors through nomograms, with some proving their efficacy after implementation. Machine learning is also being used to develop more complete tools by including risk factors previously not accounted for. These newer tools, however, still require external validation before being adopted despite promising results under testing conditions.
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Affiliation(s)
- Hani Faysal
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Tarek Araji
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Homa K Ahmadzia
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC.
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8
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Bláha J, Bartošová T. Epidemiology and definition of PPH worldwide. Best Pract Res Clin Anaesthesiol 2022; 36:325-339. [PMID: 36513428 DOI: 10.1016/j.bpa.2022.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/17/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022]
Abstract
Postpartum/peripartum hemorrhage (PPH) is an obstetric emergency complicating 1-10% of all deliveries and is a leading cause of maternal mortality and morbidity worldwide. However, the incidence of PPH differs widely according to the definition and criteria used, the way of measuring postpartum blood loss, and the population being studied with the highest numbers in developing countries. Despite all the significant progress in healthcare, the incidence of PPH is rising due to an incomplete implementation of guidelines, resulting in treatment delays and suboptimal care. A consensus clinical definition of PPH is needed to enable awareness, early recognition, and initiation of appropriate intensive treatment. Unfortunately, the most used definition of PPH based on blood loss ≥500 ml after delivery suffers from inaccuracies in blood loss quantification and is not clinically relevant in most cases, as the amount of blood loss does not fully reflect the severity of bleeding.
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Affiliation(s)
- Jan Bláha
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
| | - Tereza Bartošová
- Department of Anaesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
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Ramtohul VB, Cronjé L, Chellan CL, Tomlinson JM, Hendricks N, Rodseth R. A prospective, multicentre, observational, cross-sectional study of the prevalence of blood transfusion associated with caesarean section in KwaZulu-Natal, South Africa. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2022. [DOI: 10.36303/sajaa.2022.28.6.2844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- VB Ramtohul
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
| | - L Cronjé
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
- Perioperative Research Group, Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal,
South Africa
| | - CL Chellan
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
| | - JM Tomlinson
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
| | - N Hendricks
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal,
South Africa
| | - R Rodseth
- Perioperative Research Group, Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal,
South Africa
- Consistency of Care Division, Netcare,
South Africa
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10
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Morelli A, Rogers J, Sanders J, Kurinczuk JJ, Rowe R. Outcomes for women admitted for labour care to alongside midwifery units in the UK following a postpartum haemorrhage in a previous pregnancy: A national population-based cohort and nested case-control study using the UK Midwifery Study System (UKMidSS). Women Birth 2022; 36:e361-e368. [PMID: 36376224 DOI: 10.1016/j.wombi.2022.11.002] [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: 07/22/2022] [Revised: 10/26/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Women who have experienced a postpartum haemorrhage (PPH) 'requiring treatment or transfusion' are typically advised to plan birth in obstetric-led settings in subsequent pregnancies. Many UK alongside midwifery units (AMU) admit women for labour care following a previous PPH. We aimed to describe outcomes in women admitted for labour care to AMUs following a previous PPH, compare outcomes with other multiparous women admitted to the same AMUs, and explore risk factors for recurrence. METHODS A national cohort and nested case-control study using the UK Midwifery Study System (UKMidSS), between August 2018 and April 2019. Multivariable Poisson regression and logistic regression were performed to compare outcomes and investigate risk factors for recurrence. FINDINGS Women who experienced a previous PPH were significantly more likely than comparison women to: have a PPH requiring transfer to obstetric care (4·2% vs. 2·4%, aRR=1·65, 95% CI 1·14-2·38), be transferred to obstetric care for any reason (17·8% vs 11·9%; aRR=1·41; 95% CI 1·09-1·83), and have any PPH≥ 500 ml (22·7% vs 11·1%, aRR=1·86, 95% CI 1·49-2·32). Among women with a previous PPH, previous blood loss > 1500 ml; uterotonics for previous PPH; Caesarean associated with previous PPH; gestation at admission and higher birthweight were independent risk factors for PPH. CONCLUSION Women considering birth in an AMU after a previous PPH should be advised that they are at increased risk of experiencing a subsequent PPH requiring transfer to obstetric care, compared with other multiparous women who have not had a PPH. The absolute risk of a subsequent PPH in this group is low and comparable to the overall risk of having a PPH among women having a spontaneous vaginal birth in England.
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Affiliation(s)
- Alessandra Morelli
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, United Kingdom.
| | - Jane Rogers
- University Hospitals Southampton, Coxford Road, Southampton SO16 5YA, United Kingdom
| | - Julia Sanders
- School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University Room 1.7, Ty Dewi Sant, Heath Park, Cardiff CF14 4XN, United Kingdom
| | - Jennifer J Kurinczuk
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, United Kingdom
| | - Rachel Rowe
- NIHR Policy Research Unit in Maternal and Neonatal Health and Care, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, United Kingdom. https://twitter.com/@RachelRowe3
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11
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Tolossa T, Fetensa G, Zewde EA, Besho M, Jidha TD. Magnitude of postpartum hemorrhage and associated factors among women who gave birth in Ethiopia: a systematic review and meta-analysis. Reprod Health 2022; 19:194. [PMID: 36131345 PMCID: PMC9490897 DOI: 10.1186/s12978-022-01498-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background Postpartum hemorrhage (PPH) is the leading cause of maternal mortality and morbidity worldwide, particularly in resource-limited countries such as Ethiopia. Findings from a few studies were inconsistent and inconclusive. Therefore, this study aimed to estimates the pooled magnitude of PPH and factors associated with PPH among women who gave birth in Ethiopia. Methods Electronic databases such as Medline, Pub Med, Cochrane library, the Web of Science, and Google Scholar were used to search for articles. The search period for articles was conducted from 15th August 2021 to 15th November 2021. Data were extracted using a standardized data extraction checklist and the analyses were conducted using Stata version 14. The Cochrane Q test statistic and I2 statistics were used to assessing heterogeneity. To estimate the pooled magnitude of postpartum hemorrhage, a random-effects model was fitted. Association between PPH and independent variables was reported in odds ratio (OR) with 95% confidence interval (CI). Visual assessment of publication bias was assessed using a funnel plot and Egger’s test was used to check the significant presence of publication bias. Results A total of 876 studies were identified from several databases and nine studies fulfilled eligibility criteria and were included in the meta-analysis. The pooled magnitude of PPH in Ethiopia was 11.14% (95% CI 7.21, 15.07). The current meta-analysis revealed that lack of antenatal care follow-up (ANC) (OR = 6.52, 95% CI 2.87, 14.81), being multipara (OR = 1.88, 95% CI 1.25, 2.85), and having the previous history of PPH (OR = 7.59, 95% CI 1.88, 30.55) were found to be significantly associated with PPH. Conclusion In Ethiopia the magnitude of PPH was high, and lack of ANC up follow-up, being multipara, and having a previous history of PPH were risk factors for postpartum hemorrhage. Thus, improving antenatal care follow-up is needed to decrease the magnitude of postpartum hemorrhage. Postpartum hemorrhage (PPH) is the leading cause of maternal mortality and morbidity worldwide, particularly in resource-limited countries such as Ethiopia. Findings from a few studies were inconsistent and inconclusive. Therefore, this study aimed to estimate the pooled magnitude of PPH and factors associated with PPH among women who gave birth in Ethiopia. Electronic databases such as Medline, Pub Med, Cochrane library, the Web of Science, and Google Scholar were used to search for articles. Data were extracted using a standardized data extraction checklist and the analyses were conducted using Stata version 14. The Cochrane Q test statistic and I2 statistics were used to assessing heterogeneity. To estimate the pooled magnitude of postpartum hemorrhage, a random-effects model was fitted. Association between PPH and independent variables was reported in odds ratio (OR) with 95% confidence interval (CI). The pooled magnitude of PPH in Ethiopia was 11.14% (95% CI 7.21, 15.07). The current meta-analysis revealed that lack of antenatal care follow-up (ANC) (OR = 6.52, 95% CI 2.87, 14.81), being multipara (OR = 1.88, 95% CI 1.25, 2.85), and having the previous history of PPH (OR = 7.59, 95% CI 1.88, 30.55) were found to be significantly associated with PPH. In Ethiopia the magnitude of PPH was high, and lack of ANC follow-up, being multipara, and having the previous history of PPH were risk factors for postpartum hemorrhage. Thus, improving antenatal care follow-up is needed to decrease the magnitude of postpartum hemorrhage.
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Affiliation(s)
- Tadesse Tolossa
- Department of Public Health, Institutes of Health Sciences, Wollega University, P.O.BOX: 395, Nekemte, Ethiopia.
| | - Getahun Fetensa
- Department of Nursing, School of Nursing and Midwifery, Wollega University, Nekemte, Ethiopia.,Department of Health Behavior and society, Faculty of public Health, Jimma medical center, Jimma University, Jimma, Ethiopia
| | - Edgeit Abebe Zewde
- Department of Biomedical Science, College of Health Sciences, Debretabor University, Debretabor, Ethiopia
| | - Merga Besho
- Department of Midwifery, School of Nursing and Midwifery, Wollega University, Nekemte, Ethiopia
| | - Tafese Dejene Jidha
- College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
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12
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Okunlola O, Raza S, Osasan S, Sethia S, Batool T, Bambhroliya Z, Sandrugu J, Lowe M, Hamid P. Race/Ethnicity as a Risk Factor in the Development of Postpartum Hemorrhage: A Thorough Systematic Review of Disparity in the Relationship Between Pregnancy and the Rate of Postpartum Hemorrhage. Cureus 2022; 14:e26460. [PMID: 35923676 PMCID: PMC9339374 DOI: 10.7759/cureus.26460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/29/2022] [Indexed: 11/21/2022] Open
Abstract
Postpartum hemorrhage (PPH) is a major cause of maternal death and morbidity worldwide. Throughout the years, there have not been many studies looking into the association of race and ethnicity with the occurrence of PPH. The goal of this study was to assess race and ethnicity as risk factors in the development of PPH in pregnant women. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) standards, we conducted the analysis and conducted a literature search using Google Scholar and PubMed. After applying our inclusion and exclusion criteria, the search technique yielded a total of eight articles. The analysis included seven observational studies and one randomized controlled trial. The incidence of PPH was chosen as the major outcome measure. An evaluation of eight studies revealed that although Hispanics, Asians, Native Hawaiians, and other Pacific Islanders (NHOPI) have a higher chance of developing PPH caused by uterine atony, Caucasians had a greater rate of transfusion than the other groups. In addition, compared to Caucasians, African Americans or African descendants had a lower risk of atonic PPH but increased odds of atonic PPH requiring interventions. On the other hand, compared to non-native groups, Native Americans had increased odds of uterine atony. The results showed that, in contrast to other races/ethnicities, Caucasians had the lowest risk of PPH. Additionally, it was shown that African Americans or those descended from Africans had a higher chance of PPH but a lower risk of atonic PPH.
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13
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Green LJ, Aye CYL, Mohamed-Ahmed R, Sagoo B, Mant L, Frise CJ. Haematinic deficiency in pregnancy: another HELLP mimic. Obstet Med 2022. [DOI: 10.1177/1753495x221101802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Haematinic deficiency is not uncommon in pregnancy. Folate deficiency is more common than B12 deficiency because of the increased uptake of folate in pregnancy, and the fact that B12 stores take much longer to deplete. Described here are five cases of anaemia in pregnancy secondary to severe haematinic deficiency with subsequent management and pregnancy outcomes. In the majority of cases, the women were proteinuric, but systemically well and normotensive. Thrombotic thrombocytopenic purpura and HELLP were both considered, but the identification of very abnormal folate levels of less than 3 μg/L in all and low B12 deficiency in the majority made haematinic deficiency the most likely diagnosis. They all received high dose folic acid, parenteral vitamin B12 and oral iron and made good haematological recoveries. Adequate antenatal correction of vitamin deficiency like this avoids bone marrow suppression and helps minimise poor obstetric outcomes associated with pre-existing anaemia including post-partum haemorrhage.
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Affiliation(s)
- Lauren J Green
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Christina YL Aye
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | | | - Balvinder Sagoo
- Frimley Health NHS Foundation Trust, Wexham Park Hospital, Slough, UK
| | - Lucy Mant
- Frimley Health NHS Foundation Trust, Wexham Park Hospital, Slough, UK
| | - Charlotte J Frise
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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14
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Voillequin S, Rozenberg P, Ravaud P, Rousseau A. Promptness of oxytocin administration for first-line treatment of postpartum hemorrhage: a national vignette-based study among midwives. BMC Pregnancy Childbirth 2022; 22:353. [PMID: 35461215 PMCID: PMC9034651 DOI: 10.1186/s12884-022-04648-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide. Midwives play a key role in the initial management of PPH. Uterotonic agents are widely used in its prevention and treatment, with oxytocin the first-line agent. Nonetheless, a standardized guideline for optimal dose and rate of administration has not been clearly defined. The aim of this study was to investigate French midwives’ practices regarding first-line oxytocin treatment and the factors influencing its delayed administration. Methods This multicenter study was based on clinical vignettes of PPH management collected using an anonymous online questionnaire. A random sample of midwives from 145 maternity units in France from 15 randomly selected perinatal networks were invited to participate by email. The Previously validated case vignettes described two different scenarios of severe PPH. Vignette 1 described a typical immediate, severe PPH, and vignette 2 a less typical case of severe but gradual PPH They were constructed in three successive steps and included multiple-choice questions proposing several types of clinical practice options at each stage. For each vignette separately, we analyzed the lack of prompt oxytocin administration and the factors contributing to them, that is, characteristics of the midwives and organizational features of maternity units. Bivariate analysis and multivariable logistic regression analysis were applied. Results In all, 450 midwives from 87 maternity units provided complete responses. Lack of promptness was observed in 21.6% of responses (N = 97) in Vignette 1 and in 13.8% (N = 62) in Vignette 2 (p < .05). After multivariate analysis, the risk of delay was lower among with midwives working in university maternity hospitals (ORa 0.47, 95% 0.21, 0.97) and in units with 1500 to 2500 births per year (ORa 0.49, 95% CI 0.26, 0.90) for Vignette 1. We also noticed that delay increased with the midwives’ years of experience (per 10-year period) (ORa 1.30, 95% CI 1.01, 1.69). Conclusions This study using clinical vignettes showed delays in oxytocin administration for first-line treatment of PPH. Because delay in treatment is a major cause of preventable maternal morbidity in PPH, these findings suggest that continuing training of midwives should be considered, especially in small maternity units. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04648-5.
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Affiliation(s)
- S Voillequin
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France. .,INSERM UMR1018 "Clinical Epidemiology Team", Research Center on Epidemiology and Population Health (CESP), UVSQ, Paris Saclay University, Villejuif, France. .,Midwifery Department, Strasbourg University, Strasbourg, France.
| | - P Rozenberg
- INSERM UMR1018 "Clinical Epidemiology Team", Research Center on Epidemiology and Population Health (CESP), UVSQ, Paris Saclay University, Villejuif, France.,Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
| | - Ph Ravaud
- INSERM UMR1153, Centre of Research Epidemiology and Statistics (CRESS), Université de Paris, Paris, France.,Center for Clinical Epidemiology, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Hôtel Dieu, Paris, France
| | - A Rousseau
- INSERM UMR1018 "Clinical Epidemiology Team", Research Center on Epidemiology and Population Health (CESP), UVSQ, Paris Saclay University, Villejuif, France.,Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
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15
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Lim HI, DeSancho MT. Management and outcomes of mild hemophiliacs and hemophilia carriers during pregnancy and peripartum period: a hemophilia treatment center experience in the United States. J Matern Fetal Neonatal Med 2022; 35:9759-9764. [PMID: 35414333 DOI: 10.1080/14767058.2022.2051699] [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: 10/18/2022]
Abstract
BACKGROUND Pregnancy, peripartum management, and outcomes of mild hemophiliacs and hemophilia carriers in the United States are not well established. AIM To describe the management and outcomes of mild hemophiliacs and hemophilia carriers during assisted conception, pregnancy, peripartum and post-partum period at our hemophilia treatment center (HTC). METHODS Retrospective review of electronic medical records of pregnant women with mild hemophilia A or B (Factor VIII [FVIII] or Factor IX [FIX] level <0.4 IU/mL) and hemophilia A and B carriers followed at our HTC from January 2008 to October 2020. Demographics, the reason for diagnosis, FVIII and FIX levels at baseline and third trimester, bleeding phenotype and genotype were obtained. Method of conception, factor replacement, iron supplementation, mode of delivery, type of anesthesia, peripartum complications, and offspring outcomes was recorded. RESULTS There was a total of 18 pregnancies in 12 women (2 with mild hemophilia A, 2 mild hemophilia B, 6 hemophilia A carriers, and 2 hemophilia B carriers). Eleven pregnancies (61%) were conceived naturally and 7 (39%) via in-vitro fertilization (IVF). Eight (44.4%) and 10 (55.6%) pregnancies were vaginal and C-section deliveries, respectively. Neuraxial anesthesia was administered in 17 (94.4%) deliveries without complications. Four pregnancies (22.2%) had bleeding complications, 2 of which were post-partum hemorrhages not requiring transfusion. CONCLUSION In our case series of pregnant hemophilia carriers and mild hemophiliacs, successful outcomes were achieved with a carefully detailed multidisciplinary-driven approach.
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Affiliation(s)
- Hana I Lim
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA
| | - Maria T DeSancho
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA
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16
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Bell S, Collis R, Collins P. Comparison of haematological indices and transfusion management in severe and massive postpartum haemorrhage: analysis of a two-year national prospective observational study. Int J Obstet Anesth 2022; 50:103547. [DOI: 10.1016/j.ijoa.2022.103547] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 03/02/2022] [Accepted: 03/24/2022] [Indexed: 11/25/2022]
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17
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Machine learning-based prediction of postpartum hemorrhage after vaginal delivery: combining bleeding high risk factors and uterine contraction curve. Arch Gynecol Obstet 2022; 306:1015-1025. [PMID: 35171347 DOI: 10.1007/s00404-021-06377-0] [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] [Received: 10/11/2021] [Accepted: 12/22/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE This work used a machine learning model to improve the accuracy of predicting postpartum hemorrhage in vaginal delivery. METHODS Among the 25,098 deliveries in the obstetrics department of the First Hospital of Jinan University recorded from 2016 to 2020, 10,520 were vaginal deliveries with complete study data. Further review selected 850 cases of postpartum hemorrhage (amount of bleeding > 500 mL) and 54 cases of severe postpartum hemorrhage (amount of bleeding > 1000 mL). Indicators of clinical risk factors for postpartum hemorrhage were retrieved from electronic medical records. Features of the uterine contraction curve were extracted 2 h prior to vaginal delivery and modeled using a 49-variable machine learning with 90% of study cases used in the training set and 10% of study cases used in the test set. Accuracy was compared among the assessment table, classical statistical models, and machine learning models used to predict postpartum hemorrhage to assess their clinical use. The assessment table contained 16 high-risk factor scores to predict postpartum hemorrhage. The classical statistical model used was Logistic Regression (LR). The machine learning models were Random Forest (RF), K Nearest Neighbor (KNN), and the one integrated with Lightgbm (LGB) and LR. The effect of model prediction was evaluated by area under the receiver operating characteristic curve (AUC), namely, C-static, calibration curve Brier score, decision curve, F-measure, sensitivity (SE), and specificity (SP). RESULTS 1: Among the tested tools, the machine learning model LGB + LR has the best performance in predicting postpartum hemorrhage. Its Brier, AUC, and F-measure scores are better than those of other models in each group, and its SE and SP reach 0.694 and 0.800, respectively. The predictive performance of the classical statistical model LR is AUC: 0.729, 95%CI [0.702-0.756]). 2: Verification on the testing set reveals that the features of uterine contraction contribute to the improved accuracy of the model prediction. 3: LGB + LR model suggested that among the 49 indicators for predicting severe postpartum hemorrhage, the importance of the first 10 characteristics in descending order is as follows: hematocrit (%), shock index, frequency of contractions (min-1), white blood cell count, gestational hypertension, neonatal weight (kg), time of second labor (min), mean area of contractions (mmHg s), total amniotic fluid (mL), and body mass index (BMI). The prediction effect is close to that of the model after training with all 49 features. The predictive effect was close to that of the model after training using all 49 features. 4: Contraction frequency and intensity Mean_Area (representing effective contractions) have a high predictive value for severe postpartum hemorrhage. 5: Blood loss amount within 2 h has a high warning effect on postpartum hemorrhage, and the increase in AUC to 0.95 indicates that postpartum bleeding mostly occurs within 2 h after delivery. CONCLUSION Machine learning models incorporated with uterine contraction features can further improve the accuracy of postpartum hemorrhage prediction in vaginal delivery and provide a reference for clinicians to intervene early and reduce adverse pregnancy outcomes.
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18
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Bazirete O, Nzayirambaho M, Umubyeyi A, Karangwa I, Evans M. Risk factors for postpartum haemorrhage in the Northern Province of Rwanda: A case control study. PLoS One 2022; 17:e0263731. [PMID: 35167600 PMCID: PMC8846539 DOI: 10.1371/journal.pone.0263731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 01/26/2022] [Indexed: 12/04/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) remains a major global burden contributing to high maternal mortality and morbidity rates. Assessment of PPH risk factors should be undertaken during antenatal, intrapartum and postpartum periods for timely prevention of maternal morbidity and mortality associated with PPH. The aim of this study is to investigate and model risk factors for primary PPH in Rwanda. Methods We conducted an observational case-control study of 430 (108 cases: 322 controls) pregnant women with gestational age of 32 weeks and above who gave birth in five selected health facilities of Rwanda between January and June 2020. By visual estimation of blood loss, cases of Primary PPH were women who changed the blood-soaked vaginal pads 2 times or more within the first hour after birth, or women requiring a blood transfusion for excessive bleeding after birth. Controls were randomly selected from all deliveries without primary PPH from the same source population. Poisson regression, a generalized linear model with a log link and a Poisson distribution was used to estimate the risk ratio of factors associated with PPH. Results The overall prevalence of primary PPH was 25.2%. Our findings for the following risk factors were: antepartum haemorrhage (RR 3.36, 95% CI 1.80–6.26, P<0.001); multiple pregnancy (RR 1.83; 95% CI 1.11–3.01, P = 0.02) and haemoglobin level <11 gr/dL (RR 1.51, 95% CI 1.00–2.30, P = 0.05). During the intrapartum and immediate postpartum period, the main causes of primary PPH were: uterine atony (RR 6.70, 95% CI 4.78–9.38, P<0.001), retained tissues (RR 4.32, 95% CI 2.87–6.51, P<0.001); and lacerations of genital organs after birth (RR 2.14, 95% CI 1.49–3.09, P<0.001). Coagulopathy was not prevalent in primary PPH. Conclusion Based on our findings, uterine atony remains the foremost cause of primary PPH. As well as other established risk factors for PPH, antepartum haemorrhage and intra uterine fetal death should be included as risk factors in the development and validation of prediction models for PPH. Large scale studies are needed to investigate further potential PPH risk factors.
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Affiliation(s)
- Oliva Bazirete
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- * E-mail:
| | | | - Aline Umubyeyi
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
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19
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Feferkorn I, Badeghiesh A, Baghlaf H, Dahan MH. The relation between cigarette smoking with delivery outcomes. An evaluation of a database of more than nine million deliveries. J Perinat Med 2022; 50:56-62. [PMID: 34331422 DOI: 10.1515/jpm-2021-0053] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/25/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Smoking in pregnancy is associated with an increased risk of preterm birth (PTB), intrauterine growth restriction, placental abruption and perinatal death. The association between smoking and other delivery outcomes, such as chorioamnionitis, mode of delivery or postpartum hemorrhage (PPH), however, is insufficient as only few studies addressed these issues. The aim of the study was to evaluate the association between prenatal smoking and delivery outcomes in a large database, while controlling for confounding effects. METHODS A retrospective population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS). A dataset of all deliveries between 2004 and 2014 (inclusively) was created. Our control group included all pregnant women who did not smoke during pregnancy, which was compared to pregnant women who smoked. A multivariate logistic analysis was conducted, adjusting for any statistically significant confounding effects. RESULTS Our study identified 9,096,788 births between 2004 and 2014. Of which, 443,590 (4.8%) had a documented diagnosis of smoking. A significantly higher risk was found for PTB (odds ratio 1.39, CI 1.35-1.43), preterm premature rupture of membranes (odds ratio 1.52, CI 1.43-1.62) and small for gestational age (SGA) neonates (odds ratio 2.27, CI 2.19-2.35). The risks of preeclampsia (odds ratio 0.82, CI 0.78-0.85), chorioamnionitis (odds ratio 0.88, CI 0.83-0.4), PPH (odds ratio 0.94 CI 0.9-0.98) and operative vaginal delivery (odds ratio 0.9, CI 0.87-0.94) were lower among smokers. CONCLUSIONS This large database confirms the findings of previous smaller studies, according to which smoking decreases the risk of preeclampsia while increasing the risk of PTB and SGA neonates. The current study also revealed a decreased risk for PPH as well as for chorioamnionitis among pregnant smokers.
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Affiliation(s)
- Ido Feferkorn
- Division of Reproductive Endocrinology and Infertility, McGill University Health Care Center, Montreal, QC, Canada
| | - Ahmad Badeghiesh
- Division of Reproductive Endocrinology and Infertility, McGill University Health Care Center, Montreal, QC, Canada
| | - Haitham Baghlaf
- Maternal-Fetal Medicine Division, Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Michael H Dahan
- Division of Reproductive Endocrinology and Infertility, McGill University Health Care Center, Montreal, QC, Canada
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20
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Linde LE, Ebbing C, Moster D, Kessler J, Baghestan E, Gissler M, Rasmussen S. Recurrence of postpartum hemorrhage, maternal and paternal contribution, and the effect of offspring birthweight and sex: a population-based cohort study. Arch Gynecol Obstet 2022; 306:1807-1814. [PMID: 34999924 PMCID: PMC9519656 DOI: 10.1007/s00404-021-06374-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 12/20/2021] [Indexed: 12/17/2022]
Abstract
Purpose This study examines individual aggregation of postpartum hemorrhage (PPH), paternal contribution and how offspring birthweight and sex influence recurrence of PPH. Further, we wanted to estimate the proportion of PPH cases attributable to a history of PPH or current birthweight. Methods We studied all singleton births in Norway from 1967 to 2017 using data from Norwegian medical and administrational registries. Subsequent births in the parents were linked. Multilevel logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (CI) for PPH defined as blood loss > 500 ml, blood loss > 1500 ml, or the need for blood transfusion in parous women. Main exposures were previous PPH, high birthweight, and fetal sex. We calculated adjusted population attributable fractions for previous PPH and current high birthweight. Results Mothers with a history of PPH had three- and sixfold higher risks of PPH in their second and third deliveries, respectively (adjusted OR 2.9; 95% CI 2.9–3.0 and 6.0; 5.5–6.6). Severe PPH (> 1500 ml) had the highest risk of recurrence. The paternal contribution to recurrence of PPH in deliveries with two different mothers was weak, but significant. If the neonate was male, the risk of PPH was reduced. A history of PPH or birthweight ≥ 4000 g each accounted for 15% of the total number of PPH cases. Conclusion A history of PPH and current birthweight exerted strong effects at both the individual and population levels. Recurrence risk was highest for severe PPH. Occurrence and recurrence were lower in male fetuses, and the paternal influence was weak. Supplementary Information The online version contains supplementary material available at 10.1007/s00404-021-06374-3.
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Affiliation(s)
| | - Cathrine Ebbing
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
| | - Dag Moster
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Jörg Kessler
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
| | - Elham Baghestan
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
| | - Mika Gissler
- Department of Information Services, Finnish Institute for Health and Welfare, Helsinki, Finland.,Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Svein Rasmussen
- Department of Clinical Science, University of Bergen, Bergen, Norway
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21
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Amarasinghe GS, Agampodi TC, Mendis V, Malawanage K, Kappagoda C, Agampodi SB. Prevalence and aetiologies of anaemia among first trimester pregnant women in Sri Lanka; the need for revisiting the current control strategies. BMC Pregnancy Childbirth 2022; 22:16. [PMID: 34986796 PMCID: PMC8734253 DOI: 10.1186/s12884-021-04341-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/09/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Sustainable development goals, which focus strongly on equity, aim to end all forms of malnutrition by 2030. However, a significant cause of intergenerational transfer of malnutrition, anaemia in pregnancy, is still a challenge. It is especially so in the low- and middle-income settings where possible context-specific aetiologies leading to anaemia have been poorly explored. This study explores the prevalence of etiological factors significantly contributing to anaemia in pregnancy in Sri Lanka, a lower-middle-income country with a high prevalence of malnutrition albeit robust public health infrastructure. METHODS All first-trimester pregnant women registered in the public maternal care programme in the Anuradhapura district from July to September 2019 were invited to participate in Rajarata Pregnancy Cohort (RaPCo). After a full blood count analysis, high-performance liquid chromatography, peripheral blood film examination, serum B12 and folate levels were performed in anaemic participants, guided by an algorithm based on the red cell indices in the full blood count. In addition, serum ferritin was tested in a random subsample of 213 participants. Anaemic women in this subsample underwent B12 and folate testing. RESULTS Among 3127 participants, 14.4% (95%CI 13.2-15.7, n = 451) were anaemic. Haemoglobin ranged between 7.4 to 19.6 g/dl. 331(10.6%) had mild anaemia. Haemoglobin ≥13 g/dl was observed in 39(12.7%). Microcytic, normochromic-normocytic, hypochromic-normocytic and macrocytic anaemia was observed in 243(54%), 114(25.3%), 80(17.8%) and two (0.4%) of full blood counts in anaemic women, respectively. Microcytic anaemia with a red cell count ≥5 * 106 /μl demonstrated a 100% positive predictive value for minor haemoglobinopathies. Minor hemoglobinopathies were present in at least 23.3%(n = 105) of anaemic pregnant women. Prevalence of iron deficiency, B12 deficiency and Southeast Asian ovalocytosis among the anaemic was 41.9% (95%CI 26.4-59.2), 23.8% (95%CI 10.6-45.1) and 0.9% (95%CI 0.3-2.3%), respectively. Folate deficiency was not observed. CONCLUSION Even though iron deficiency remains the primary cause, minor hemoglobinopathies, B 12 deficiency and other aetiologies substantially contribute to anaemia in pregnancy in this study population. Public health interventions, including screening for minor hemoglobinopathies and multiple micronutrient supplementation in pregnancy, should be considered in the national programme for areas where these problems have been identified.
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Affiliation(s)
- Gayani Shashikala Amarasinghe
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka.
| | - Thilini Chanchala Agampodi
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Vasana Mendis
- Department of Pathology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Krishanthi Malawanage
- Regional Director of Health Services Office - Anuradhapura, Ministry of Health, Anuradhapura, Sri Lanka
| | - Chamila Kappagoda
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Suneth Buddhika Agampodi
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
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22
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Graugaard HL, Maimburg RD. Is the increase in postpartum hemorrhage after vaginal birth because of altered clinical practice?: A register-based cohort study. Birth 2021; 48:338-346. [PMID: 33694193 DOI: 10.1111/birt.12543] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 02/01/2021] [Accepted: 02/12/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND To identify risk factors for severe postpartum hemorrhage (PPH) ≥1000 ml in women giving birth vaginally. METHOD A register-based cohort study including women with singleton pregnancies giving birth vaginally at term to a live-born child at Aarhus University Hospital, Denmark, from January 1, 2004, to December 31, 2012. Logistic multivariable regression was used to analyze data. RESULTS In 31 837 births, 1832 women (5.7%) experienced severe PPH. Maternal age, smoking during pregnancy, and prepregnancy body mass index did not increase the risk of severe PPH. However, nulliparous and multiparous women with a previous cesarean birth had an increased risk of severe PPH. Antepartum and intrapartum risk factors for severe PPH included gestational age >40 weeks, induction of labor, augmentation of labor, irregular fetal position, instrumental birth, and birthweight >4000 g. In particular, the combination of induction and augmentation of labor doubled the risk of severe PPH. Among genital tract tears, vaginal tears >3 cm were associated with the highest risk of severe PPH. CONCLUSIONS Maternal characteristics did not increase the risk of severe PPH, except for nulliparous and multiparous women with a previous cesarean birth. Obstetric interventions such as induction of labor, augmentation of labor, and a birthweight higher than 4000 g increased the risk of severe PPH. Larger vaginal tears presented the highest risk of severe PPH. Clinical practice with rigorous indications for obstetric interventions and timely identification and management of genital tract tears may reduce risk of severe PPH.
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Affiliation(s)
- Hanne Lønstrup Graugaard
- Department of Midwifery, University College South Denmark, Esbjerg, Denmark.,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Rikke Damkjaer Maimburg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,School of Nursing and Midwifery, Western Sydney University, Greater Western Sydney, NSW, Australia
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23
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Schol PBB, de Lange NM, Woiski MD, Langenveld J, Smits LJM, Wassen MM, Henskens YM, Scheepers HCJ. Restrictive versus liberal fluid resuscitation strategy, influence on blood loss and hemostatic parameters in mild obstetric hemorrhage: An open-label randomized controlled trial. (REFILL study). PLoS One 2021; 16:e0253765. [PMID: 34170943 PMCID: PMC8232446 DOI: 10.1371/journal.pone.0253765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 06/13/2021] [Indexed: 11/19/2022] Open
Abstract
Background Evidence for optimal hemostatic resuscitation in postpartum hemorrhage (PPH) is lacking. Liberal fluid administration may result in acidosis, hypothermia and coagulopathy. Objective We hypothesize that in early PPH a restrictive fluid administration results in less progression to moderate PPH. Study design In four Dutch hospitals we recruited women of 18 years and over, and more than 24 weeks pregnant. Exclusion criteria were: anticoagulant therapy, known coagulation disorders, pre-eclampsia, antenatal diagnosis of abnormally adhesive placenta, and a contraindication for liberal fluid therapy. We blindly randomized participants at 500 mL and ongoing blood loss in the third stage of labor between restrictive fluid administration (clear fluids 0.75–1.0 times the volume of blood lost) and liberal fluid administration (clear fluids 1.5–2.0 times the volume of blood lost). The primary outcome was progression to more than 1000 mL blood loss. Analyses were according to the intention-to-treat principle. Results From August 2014 till September 2019, 5190 women were informed of whom 1622 agreed to participate. A total of 252 women were randomized of which 130 were assigned to the restrictive group and 122 to the liberal group. In the restrictive management group 51 of the 130 patients (39.2%) progressed to more than 1000 mL blood loss versus 61 of the 119 patients (51.3%) in the liberal management group (difference, -12.0% [95%-CI -24.3% to 0.3%], p = 0.057). There was no difference in the need for blood transfusion, coagulation parameters, or in adverse events between the groups. Conclusions Although a restrictive fluid resuscitation in women with mild PPH could not been proven to be superior, it does not increase the need for blood transfusion, alter coagulation parameters, or cause a rise in adverse events. It can be considered as an alternative treatment option to liberal fluid resuscitation. Trial registration NTR3789.
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Affiliation(s)
- Pim B. B. Schol
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Obstetrics and Gynecology, Zuyderland, Sittard-Geleen, The Netherlands
- * E-mail:
| | - Natascha M. de Lange
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Obstetrics and Gynecology, Zuyderland, Sittard-Geleen, The Netherlands
| | - Mallory D. Woiski
- Department of Obstetrics and Gynecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Josje Langenveld
- Department of Obstetrics and Gynecology, Zuyderland, Sittard-Geleen, The Netherlands
| | - Luc J. M. Smits
- Department of Epidemiology, Caphri School for Public Health and Primary Care, Maastricht, The Netherlands
| | - Martine M. Wassen
- Department of Obstetrics and Gynecology, Zuyderland, Sittard-Geleen, The Netherlands
| | - Yvonne M. Henskens
- Central Diagnostics Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hubertina C. J. Scheepers
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- GROW: School for Oncology and Developmental Biology and Department of Obstetrics and Gynecology, Maastricht University Medical Centre, Maastricht, The Netherlands
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24
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Benson CS, Shah A, Frise MC, Frise CJ. Iron deficiency anaemia in pregnancy: A contemporary review. Obstet Med 2021; 14:67-76. [PMID: 34394714 PMCID: PMC8358243 DOI: 10.1177/1753495x20932426] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/13/2020] [Indexed: 01/01/2023] Open
Abstract
Iron deficiency anaemia is a global health problem, which particularly affects pregnant women. Iron deficiency anaemia during pregnancy is associated with increased maternal and perinatal morbidity and mortality. Maternal iron deficiency may also be associated with neurocognitive deficits in infants. Iron requirements increase during pregnancy and are influenced by hepcidin, the master regulator of iron homeostasis. The enduring global burden of maternal anaemia suggests that currently employed iron supplementation strategies are suboptimal. Recent developments in our understanding of systemic and placental iron homeostasis may improve therapeutic effectiveness by altering the dose and frequency of oral iron. Intravenous iron appears to be a safe treatment to correct maternal anaemia rapidly but research on patient-centred outcomes and cost-effectiveness is needed. Future trials should be adequately powered to assess outcomes relevant to pregnant women.
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Affiliation(s)
- Charlotte S Benson
- Department of Obstetrics, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Akshay Shah
- Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - Matthew C Frise
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
- Intensive Care Unit, Royal Berkshire Hospital, NHS Foundation Trust, Reading, UK
| | - Charlotte J Frise
- Fetal Maternal Medicine Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
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25
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Lindquist AC, Hastie RM, Hiscock RJ, Pritchard NL, Walker SP, Tong S. Risk of major labour-related complications for pregnancies progressing to 42 weeks or beyond. BMC Med 2021; 19:126. [PMID: 34030675 PMCID: PMC8145839 DOI: 10.1186/s12916-021-01988-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/19/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Post-term gestation beyond 41+6 completed weeks of gestation is known to be associated with a sharp increase in the risk of stillbirth and perinatal mortality. However, the risk of common adverse outcomes related to labour, such as shoulder dystocia and post-partum haemorrhage for those delivering at this advanced gestation, remains poorly characterised. The objective of this study was to examine the risk of adverse, labour-related outcomes for women progressing to 42 weeks gestation or beyond, compared with those giving birth at 39 completed weeks. METHODS We performed a state-wide cohort study using routinely collected perinatal data in Australia. Comparing the two gestation cohorts, we examined the adjusted relative risk of clinically significant labour-related adverse outcomes, including macrosomia (≥ 4500 at birth), post-partum haemorrhage (≥1000 ml), shoulder dystocia, 3rd or 4th degree perineal tear and unplanned caesarean section. Parity, maternal age and mode of birth were adjusted for using logistic regression. RESULTS The study cohort included 91,314 women who birthed at 39 completed weeks and 4317 at ≥42 completed weeks. Compared to 39 weeks gestation, those giving birth ≥42 weeks gestation had an adjusted relative risk (aRR) of 1.85 (95% CI 1.55-2.20) for post-partum haemorrhage following vaginal birth, 2.29 (95% CI 1.89-2.78) following instrumental birth and 1.44 (95% CI 1.17-1.78) following emergency caesarean section; 1.43 (95% CI 1.16-1.77) for shoulder dystocia (for non-macrosomic babies); and 1.22 (95% CI 1.03-1.45) for 3rd or 4th degree perineal tear (all women). The adjusted relative risk of giving birth to a macrosomic baby was 10.19 (95% CI 8.26-12.57) among nulliparous women and 4.71 (95% CI 3.90-5.68) among multiparous women. The risk of unplanned caesarean section was 1.96 (95% CI 1.86-2.06) following any labour and 1.47 (95% CI 1.38-1.56) following induction of labour. CONCLUSIONS Giving birth at ≥42 weeks gestation may be an under-recognised risk factor for several important, labour-related adverse outcomes. Clinicians should be aware that labour at this advanced gestation incurs a higher risk of adverse outcomes. In addition to known perinatal risks, the risk of obstetric complications should be considered in the counselling of women labouring at post-term gestation.
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Affiliation(s)
- Anthea C Lindquist
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia. .,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia.
| | - Roxanne M Hastie
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia
| | - Richard J Hiscock
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia
| | - Natasha L Pritchard
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, 163 Studley Rd., Heidelberg, Victoria, 3084, Australia
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26
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Parry-Smith W, Šumilo D, Subramanian A, Gokhale K, Okoth K, Gallos I, Coomarasamy A, Nirantharakumar K. Postpartum haemorrhage and risk of long-term hypertension and cardiovascular disease: an English population-based longitudinal study using linked primary and secondary care databases. BMJ Open 2021; 11:e041566. [PMID: 33952535 PMCID: PMC8103369 DOI: 10.1136/bmjopen-2020-041566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To investigate the long-term risk of developing hypertension and cardiovascular disease (CVD) among those women who suffered a postpartum haemorrhage (PPH) compared with those women who did not. DESIGN Population-based longitudinal open cohort study. SETTING English primary care (The Health Improvement Network (THIN)) and secondary care (Hospital Episode Statistics (HES)) databases. POPULATION Women exposed to PPH during the study period matched for age and date of delivery, and unexposed. METHODS We conducted an open cohort study using linked primary care THIN and HES Databases, from 1 January 1997 to 31 January 2018. A total of 42 327 women were included: 14 109 of them exposed to PPH during the study period and 28 218 matched for age and date of delivery, and unexposed to PPH. HRs for cardiovascular outcomes among women who had and did not have PPH were estimated after controlling for covariates using multivariate Cox regression models. OUTCOME MEASURES Risk of hypertensive disease, ischaemic heart disease, heart failure, stroke or transient ischaemic attack. RESULTS During a median follow-up of over 4 years, there was no significant difference in the risk of hypertensive disease after adjustment for covariates (adjusted HR (aHR): 1.03 (95% CI: 0.87 to 1.22); p=0.71). We also did not observe a statistically significant difference in the risk of composite CVD (ischaemic heart disease, heart failure, stroke or transient ischaemic attack) between the exposed and the unexposed cohort (aHR: 0.86 (95% CI: 0.52 to 1.43; p=0.57). CONCLUSION Over a median follow-up of 4 years, we did not observe an association between PPH and hypertension or CVD.
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Affiliation(s)
- William Parry-Smith
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, Telford, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Dana Šumilo
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Krishna Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kelvin Okoth
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis Gallos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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27
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Ratsch A, Bogossian F, Steadman K. Central Australian Aboriginal women's pregnancy, labour and birth outcomes following maternal smokeless tobacco (pituri) use, cigarette use or no-tobacco use: a prospective cohort study. BMC Public Health 2021; 21:814. [PMID: 33910555 PMCID: PMC8082654 DOI: 10.1186/s12889-021-10872-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/15/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Outcomes related to maternal smoked tobacco (cigarette) use have been substantially examined over the past 50 years with resultant public health education targeted towards the reduction of use during pregnancy. However, worldwide the effects of maternal smokeless tobacco use have been less well explored and in Australia, there has been no examination of maternal outcomes in relation to the use of Australian Nicotiana spp. (tobacco plant) as a smokeless tobacco, colloquially known as pituri. The aim of this study is to describe the maternal outcomes of a group of central Australian Aboriginal women in relation to their self-reported tobacco use. METHODS Eligible participants were > 18 years of age, with a singleton pregnancy, > 28 weeks gestation, and who planned to birth at the Alice Springs Hospital (the major regional hospital for central Australia, in the Northern Territory, Australia). The sample consisted of 73 conveniently recruited women categorized by tobacco-use status as no-tobacco users (n = 31), pituri chewers (n = 19), and smokers (n = 23). RESULTS There were differences in the groups in relation to teenage pregnancies; 35% of no-tobacco users, compared with 5% of pituri users, and 13% of smokers were < 20 years of age. The chewers had a higher rate (48%) of combined pre-existing and pregnancy-related elevated glucose concentrations compared with smokers (22%) and no-tobacco users (16%).The pituri chewers had the lowest rate (14%) of clinically significant post-partum hemorrhage (> 1000 ml) compared with 22% of smokers and 36% of the no-tobacco users. CONCLUSIONS This is the first research to examine pituri use in pregnancy and the findings indicate possible associations with a range of adverse maternal outcomes. The use of smokeless tobacco needs to be considered in maternal healthcare assessment to inform antenatal, intrapartum and postpartum care planning. IMPLICATIONS FOR PUBLIC HEALTH Female smokeless tobacco use is a global phenomenon and is particularly prevalent in low and middle income countries and in Indigenous populations. The findings contribute to the developing knowledge around maternal smokeless tobacco use and maternal outcomes. Maternal screening for a broader range of tobacco and nicotine products is required. NOTE TO READERS In this research, the central Australian Aboriginal women chose the term 'Aboriginal' to refer to themselves, and 'Indigenous' to refer to the broader First Peoples. That choice has been maintained in the reporting of the research findings.
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Affiliation(s)
- Angela Ratsch
- Wide Bay Hospital and Health Services, Hervey Bay, Queensland 4655 Australia
| | - Fiona Bogossian
- Professor of Practice Education in Health at the University of the Sunshine Coast (USC) and USC Academic Lead at the Sunshine Coast Health Institute (SCHI), Birtinya, Queensland 4575 Australia
| | - Kathryn Steadman
- Associate Professor School of Pharmacy, The University of Queensland, Brisbane, Queensland 4102 Australia
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28
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Bell SF, Collis RE, Bailey C, James K, John M, Kelly K, Kitchen T, Scarr C, Macgillivray E, Collins PW. The incidence, aetiology, and coagulation management of massive postpartum haemorrhage: a two-year national prospective cohort study. Int J Obstet Anesth 2021; 47:102983. [PMID: 33994274 DOI: 10.1016/j.ijoa.2021.102983] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 02/23/2021] [Accepted: 03/14/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Between 2017 and 2018 a national quality improvement initiative was introduced incorporating point-of-care viscoelastic haemostatic assays (VHA) to guide blood product transfusion. Laboratory coagulation profiles, use and results of VHA, and administration of blood products were investigated. METHODS A two-year prospective cohort study of maternal outcomes of women experiencing massive postpartum haemorrhage (PPH) >1000 mL in Wales. In this study, cases of massive PPH (≥2500 mL and/or ≥5 units red blood cell (RBC) transfusion) were identified. RESULTS Massive PPH occurred in 349 of 60 914 maternities (rate 5.7 per 1000). There were no deaths from PPH. Intensive care unit admission and/or hysterectomy occurred in 34/311 (10.9%) and 16/347 (4.6%), respectively. The leading cause of massive PPH was genital tract trauma (107/349, 30.6%). Two hundred and seventy-nine (80.6%) required RBC transfusion and 79/345 (22.9%) received at least one blood coagulation product. Results of VHA were recorded in 245/349 (70.2%), with 44/98 (44.9%) women tested in the first six months vs 63/77 (81.8%) in the final six months. Hypofibrinogenaemia (Clauss fibrinogen <2 g/L or FIBTEM A5 <12 mm) was observed in 56/328 (17.1%) of women, thrombocytopaenia (count <75 × 109/L) in 17/334 (5.1%) and either PT or aPTT >1.5×reference range in 10/293 (3.4%). CONCLUSION In Wales, the use of VHA in cases of massive PPH increased over time, enabling clinicians to adopt a targeted, patient-specific approach to blood product administration, with only 22.9% of women receiving blood coagulation products and 17.1% having a documented clotting abnormality.
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Affiliation(s)
- S F Bell
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK.
| | - R E Collis
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - C Bailey
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - K James
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - M John
- Department of Emergency Medicine, Aneurin Bevan University Health Board, Newport, UK
| | - K Kelly
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - T Kitchen
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - C Scarr
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | - P W Collins
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
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29
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Benson CS, Shah A, Stanworth SJ, Frise CJ, Spiby H, Lax SJ, Murray J, Klein AA. The effect of iron deficiency and anaemia on women's health. Anaesthesia 2021; 76 Suppl 4:84-95. [PMID: 33682105 DOI: 10.1111/anae.15405] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 12/14/2022]
Abstract
Iron deficiency and anaemia are global health problems and major causes of morbidity in women. Current definitions of anaemia in women are historic and have been challenged by recent data from observational studies. Menstrual loss, abnormal uterine bleeding and pregnancy put women at risk of developing iron deficiency which can result in severe fatigue, reduced exercise capacity and poor work performance. Iron deficiency and anaemia during pregnancy are associated with adverse maternal and fetal outcomes, including neurocognitive deficits in children born to iron-deficient mothers. Both iron deficiency and anaemia are common in women undergoing surgery but their association with poor outcomes remains uncertain. The enduring burden of iron deficiency and anaemia in women suggests that current strategies for recognition, prevention and treatment are limited in their utility. Improvements in our understanding of iron homeostasis and the development of new iron preparations, which are better absorbed with fewer side-effects, may improve therapeutic effectiveness of oral iron. Intravenous iron is efficacious for correcting anaemia rapidly but high-quality data on patient-centred outcomes and cost-effectiveness are currently lacking. Many recommendations for the treatment of iron deficiency and anaemia in national guidelines are not supported by high-quality evidence. There is a need for robust epidemiological data and well-designed clinical trials. The latter will require collaborative working between researchers and patients to design studies in ways that incorporate patients' perspectives on the research process and target outcomes that matter to them.
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Affiliation(s)
| | - A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK.,Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S J Stanworth
- NIHR Oxford Biomedical Research Centre, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NHS Blood and Transplant, Oxford, UK.,Fetal Maternal Medicine Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C J Frise
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK.,School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - S J Lax
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - J Murray
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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30
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van der Nelson H, O'Brien S, Burnard S, Mayer M, Alvarez M, Knowlden J, Winter C, Dailami N, Marques E, Burden C, Siassakos D, Draycott T. Intramuscular oxytocin versus Syntometrine ® versus carbetocin for prevention of primary postpartum haemorrhage after vaginal birth: a randomised double-blinded clinical trial of effectiveness, side effects and quality of life. BJOG 2021; 128:1236-1246. [PMID: 33300296 DOI: 10.1111/1471-0528.16622] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare intramuscular oxytocin, Syntometrine® and carbetocin for prevention of postpartum haemorrhage after vaginal birth. DESIGN Randomised double-blinded clinical trial. SETTING Six hospitals in England. POPULATION A total of 5929 normotensive women having a singleton vaginal birth. METHODS Randomisation when birth was imminent. MAIN OUTCOME MEASURES Primary: use of additional uterotonic agents. Secondary: weighed blood loss, transfusion, manual removal of placenta, adverse effects, quality of life. RESULTS Participants receiving additional uterotonics: 368 (19.5%) oxytocin, 298 (15.6%) Syntometrine and 364 (19.1%) carbetocin. When pairwise comparisons were made: women receiving carbetocin were significantly more likely to receive additional uterotonics than those receiving Syntometrine (odds ratio [OR] 1.28, 95% CI 1.08-1.51, P = 0.004); the difference between carbetocin and oxytocin was non-significant (P = 0.78); Participants receiving Syntometrine were significantly less likely to receive additional uterotonics than those receiving oxytocin (OR 0.75, 95% CI 0.65-0.91, P = 0.002). Non-inferiority between carbetocin and Syntometrine was not shown. Use of Syntometrine reduced non-drug PPH treatments compared with oxytocin (OR 0.64, 95% CI 0.42-0.97) but not carbetocin (P = 0.64). Rates of PPH and blood transfusion were not different. Syntometrine was associated with an increase in maternal adverse effects and reduced ability of the mother to bond with her baby. CONCLUSIONS Non-inferiority of carbetocin to Syntometrine was not shown. Carbetocin is not significantly different to oxytocin for use of additional uterotonics. Use of Syntometrine reduced use of additional uterotonics and need for non-drug PPH treatments compared with oxytocin. Increased maternal adverse effects are a disadvantage of Syntometrine. TWEETABLE ABSTRACT IM carbetocin does not reduce additional uterotonic use compared with IM Syntometrine or oxytocin.
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Affiliation(s)
- H van der Nelson
- North Bristol NHS Trust, Bristol, UK.,University of Bristol, Bristol, UK
| | - S O'Brien
- North Bristol NHS Trust, Bristol, UK.,University of Bristol, Bristol, UK
| | - S Burnard
- Royal United Hospitals NHS Trust, Bath, UK
| | - M Mayer
- North Bristol NHS Trust, Bristol, UK
| | - M Alvarez
- North Bristol NHS Trust, Bristol, UK
| | | | - C Winter
- North Bristol NHS Trust, Bristol, UK
| | - N Dailami
- University of the West of England, Bristol, UK
| | - E Marques
- North Bristol NHS Trust, Bristol, UK
| | - C Burden
- North Bristol NHS Trust, Bristol, UK.,University of Bristol, Bristol, UK
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Briley AL, Silverio SA, Singh C, Sandall J, Bewley S. "It's like a bus, going downhill, without a driver": A qualitative study of how postpartum haemorrhage is experienced by women, their birth partners, and healthcare professionals. Women Birth 2020; 34:e599-e607. [PMID: 33358131 DOI: 10.1016/j.wombi.2020.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 12/03/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
PROBLEM Postpartum haemorrhage [PPH] remains a major cause of maternal morbidity and mortality. Whilst low-resource settings bear the greatest burden of deaths, women live with associated morbidities in all healthcare settings. Limited data exists regarding the experience for women, their partners, or healthcare professionals [HCPs], affected by PPH. AIM To qualitatively investigate the experience of PPH, for women (n=9), birth partners (n=4), and HCPs (n=9) in an inner-city tertiary referral centre. To provide multi-faceted insight into PPH and improve understanding and future care practices. METHODS Participants were interviewed about their experiences within two weeks of a PPH. Data were analysed using thematic analysis. FINDINGS Four distinct, but related, themes were identified: 'Knowledge specific to PPH'; 'Effective and appropriate responses to PPH'; 'Communication of risk factors'; and 'Quantifying blood loss'; which collected around a central organising concept of 'Explaining the indescribable'. DISCUSSION PPH was viewed as a 'crisis-style emergency', generating respectful fear in HCPs, whilst women and partners had little-to-no prior knowledge. Specific PPH knowledge dictated HCPs' response and risk communication. PPH risks were typically linked to quantification of blood loss, assessment of which varied with acknowledged questionable accuracy. Women's and partners' confidence in HCPs' ability to deal with PPH was unquestionable. Non-verbal communication was highlighted, with HCP body language betraying professional confidence. CONCLUSION Information about blood loss during childbirth must be imparted in a sensitive, timely manner. Whilst training for HCPs results in effective PPH management, consideration should be given to their non-verbal cues and the impact of dealing with this stressful, 'everyday emergency'.
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Affiliation(s)
- Annette L Briley
- Caring Futures Institute, College of Nursing & Health Sciences, Flinders University, Adelaide, Australia; Department of Women & Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom.
| | - Sergio A Silverio
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom; Elizabeth Garrett Anderson Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, United Kingdom. https://twitter.com/Silverio_SA_?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor
| | - Claire Singh
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom; Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Jane Sandall
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom; Centre for Midwifery, Child and Family Health, School of Nursing and Midwifery, University of Technology, Sydney, Australia. https://twitter.com/SandallJane?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor
| | - Susan Bewley
- Department of Women & Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom. https://twitter.com/susan_bewley?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor
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Rand T, Patel R, Magerle W, Uberoi R. CIRSE standards of practice on gynaecological and obstetric haemorrhage. CVIR Endovasc 2020; 3:85. [PMID: 33245432 PMCID: PMC7695782 DOI: 10.1186/s42155-020-00174-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 10/27/2020] [Indexed: 12/14/2022] Open
Abstract
This CIRSE Standards of Practice document provides best practices for obstetric haemorrhage embolisation (OHE) in the management of postpartum haemorrhage (PPH). The document is aimed at interventional radiologists involved in treating postpartum haemorrhage, and has been developed by a writing group established by the CIRSE Standards of Practice Committee. CIRSE Standards of Practice documents are not clinical practice guidelines and do not intend to impose a standard of care, rather provide reasonable approaches to and best practices for specific interventional radiology treatments and techniques.
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Affiliation(s)
- Thomas Rand
- Institute for Interventional and Diagnostic Radiology, Klinik Floridsdorf, Brünnerstr.68, 1210, Vienna, Austria. .,Scientific research in diagnostics and interventional radiology, Karl Landsteiner Society, St. Pölten, Austria.
| | - Rafiuddin Patel
- John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | - Raman Uberoi
- John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
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33
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Xu C, Zhong W, Fu Q, Yi L, Deng Y, Cheng Z, Lin X, Cai M, Zhong S, Wang M, Tao H, Xiong H, Jiang X, Chen Y. Differential effects of different delivery methods on progression to severe postpartum hemorrhage between Chinese nulliparous and multiparous women: a retrospective cohort study. BMC Pregnancy Childbirth 2020; 20:660. [PMID: 33129300 PMCID: PMC7603680 DOI: 10.1186/s12884-020-03351-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 10/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delivery methods are associated with postpartum hemorrhage (PPH) both in nulliparous and multiparous women. However, few studies have examined the difference in this association between nulliparous and multiparous women. This study aimed to explore the difference of maternal and neonatal characteristics and delivery methods between Chinese nulliparous and multiparous women, and then examine the differential effects of different delivery methods on PPH between these two-type women. METHODS Totally 151,333 medical records of women who gave birth between April 2013 to May 2016 were obtained from the electronic health records (EHR) in a northern province, China. The severity of PPH was estimated and classified into blood loss at the level of < 900 ml, 900-1500 ml, 1500-2100 ml, and > 2100 ml. Neonatal and maternal characteristics related to PPH were derived from the same database. Multiple ordinal logistic regression was used to estimate associations. RESULTS Medical comorbidities, placenta previa and accreta were higher in the nulliparous group and the episiotomy rate was higher in the multiparous group. Compared with spontaneous vaginal delivery (SVD), the adjusted odds (aOR) for progression to severe PPH due to the forceps-assisted delivery was much higher in multiparous women (aOR: 9.32; 95% CI: 3.66-23.71) than in nulliparous women (aOR: 1.70; 95% CI: 0.91-3.18). The (aOR) for progression to severe PPH due to cesarean section (CS) compared to SVD was twice as high in the multiparous women (aOR: 4.32; 95% CI: 3.03-6.14) as in the nulliparous women (aOR: 2.04; 95% CI: 1.40-2.97). However, the (aOR) for progression to severe PPH due to episiotomy compared to SVD between multiparous (aOR: 1.24; 95% CI: 0.96-1.62) and nulliparous women (aOR: 1.55; 95% CI: 0.92-2.60) was not significantly different. The (aOR) for progression to severe PPH due to vacuum-assisted delivery compared to SVD in multiparous women (aOR: 2.41; 95% CI: 0.36-16.29) was not significantly different from the nulliparous women (aOR: 1.05; 95% CI: 0.40-2.73). CONCLUSIONS Forceps-assisted delivery and CS methods were found to increase the risk of severity of the PPH. The adverse effects were even greater for multiparous women. Episiotomy and the vacuum-assisted delivery, and SVD were similar to the risk of progression to severe PPH in either nulliparous or multiparous women. Our findings have implications for the obstetric decision on the choice of delivery methods, maternal and neonatal health care, and obstetric quality control.
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Affiliation(s)
- Chang Xu
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Wanting Zhong
- Department of medical administration, Zhuhai People's Hospital (Zhuhai hospital affiliated with Jinan University), Zhuhai, 519000, China
| | - Qiang Fu
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, 63013, USA
| | - Li Yi
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Yuqing Deng
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Zhaohui Cheng
- Department of Health Statistics and Research Development, Chongqing Health Information Center, Chongqing, 401120, China
| | - Xiaojun Lin
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, 610041, China
| | - Miao Cai
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, 63013, USA
| | - Shilin Zhong
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Manli Wang
- China Center for Special Economic Zone Research, Shenzhen University, Shenzhen, 518060, Guangdong, China.
| | - Hongbing Tao
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430016, China
| | - Haoling Xiong
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430016, China
| | - Xin Jiang
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
| | - Yun Chen
- Peking University Shenzhen Hospital, Shenzhen, 518036, China
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Cheloufi M, Picard J, Hoffmann P, Bosson JL, Allenet B, Berveiller P, Albaladejo P. How to agree on what is fundamental to optimal teamwork performance in a situation of postpartum hemorrhage? A multidisciplinary Delphi French study to develop the Obstetric Team Performance Assessment Scale (OTPA Scale). Eur J Obstet Gynecol Reprod Biol 2020; 256:6-16. [PMID: 33161212 DOI: 10.1016/j.ejogrb.2020.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The objective of this study was to develop a new interdisciplinary teamwork scale, the Obstetric Team Performance Assessment (OTPA), for the management of the post-partum hemorrhage, through consensus agreement of obstetric caregivers. The goal is to provide a reliable tool for teaching and evaluating teams in high-fidelity simulation. METHODS This prospective study is based on an expert consensus, using a Delphi method. The authors developed the "OTPA» specifically related to the management of post-partum hemorrhage, using existing recommendations. For the Delphi survey, the scale was distributed to a selected group of experts. After each round of Delphi, authors quantitatively analyzed each element of the scale, based on the percentages of agreement received, and reviewed each comment. This blind examination then led to the modification of the scale. The rounds were continued until 80-100 % agreement with a median overall response score equal to or greater than 8 was obtained for at least 60 % of items. Repeated 3 times, the process led to consensus and to a final version of the OTPA scale. RESULTS From February to October 2018, 16 of the 33 invited experts participated in four Delphi cycles. Of the 37 items selected in the first round, only 19 (51.3 %) had an agreement of 80-100% with a median overall response score equal to or greater than 8 in the second round, and a third round was conducted. During this third round, 24 of the 37 items were validated (64.9 %) and 82 of the 88 sub-items obtained 80 %-100 % agreement (93.2 %). The fourth round consisted of proposing a weighting of the different items. CONCLUSION Using a structured Delphi method, we provided a new interdisciplinary teamwork scale (OTPA), for the management of the post-partum hemorrhage. Thus, this scale will be able to be used during high-fidelity scenarii to assess performances of various teams facing a scenari of PPH. Moreover, this scale, focusing some crucial aspects of interdisciplinary teamwork will be useful for teaching purpose.
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Affiliation(s)
- Meryam Cheloufi
- Department of Obstetrics and Gynecology, Armand Trousseau Children's Hospital, AP-HP, Paris, France.
| | - Julien Picard
- Department of Anesthesia and Critical Care, Simulation Center, Grenoble Alps University Hospital, Grenoble, France; TheMAS, TIMC, UMR-CNRS 5525, Clinical Investigation Center, Grenoble Alps University Hospital, Grenoble, France
| | - Pascale Hoffmann
- Department of Obstetrics and Gynecology, Armand Trousseau Children's Hospital, AP-HP, Paris, France
| | - Jean-Luc Bosson
- TheMAS, TIMC, UMR-CNRS 5525, Clinical Investigation Center, Grenoble Alps University Hospital, Grenoble, France
| | - Benoit Allenet
- TheMAS, TIMC, UMR-CNRS 5525, Clinical Investigation Center, Grenoble Alps University Hospital, Grenoble, France
| | - Paul Berveiller
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
| | - Pierre Albaladejo
- Department of Anesthesia and Critical Care, Simulation Center, Grenoble Alps University Hospital, Grenoble, France; TheMAS, TIMC, UMR-CNRS 5525, Clinical Investigation Center, Grenoble Alps University Hospital, Grenoble, France
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Ladfors LV, Muraca GM, Butwick A, Edgren G, Stephansson O. Accuracy of postpartum hemorrhage coding in the Swedish Pregnancy Register. Acta Obstet Gynecol Scand 2020; 100:322-330. [PMID: 32956490 PMCID: PMC7891624 DOI: 10.1111/aogs.13994] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/31/2020] [Accepted: 09/10/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) is recognized as a leading cause of obstetric morbidity and mortality. Population-wide studies have used International Classification of Diseases (ICD) diagnostic codes to track and report the prevalence of PPH. Although the 10th revision (ICD-10) was introduced in Sweden in 1997, the accuracy of ICD-10 codes for PPH is not known. Thus, the aim was to determine the accuracy of diagnostic coding for PPH in the Swedish Pregnancy Register. MATERIAL AND METHODS We performed a retrospective cohort study of 609 807 deliveries in Sweden between 2014 and 2019. Information on ICD-10 codes for PPH and estimated blood loss were extracted from the Swedish Pregnancy Register. Using an estimated blood loss >1000 mL as the reference standard, we evaluated the diagnostic accuracy of ICD-10 codes for PPH by estimating sensitivity, specificity, positive predictive value and negative predictive value with exact binomial 95% confidence intervals (CIs). In our secondary analysis, we assessed the ICD-10 coding accuracy for severe PPH, defined as an estimated blood loss >1000 mL and transfusion of at least 1 unit of red blood cells registered in the Scandinavian Donations and Transfusion database. RESULTS Of the 609 807 deliveries, 43 312 (7.1%) had an ICD-10 code for PPH and 45 071 (7.4%) had an estimated blood loss >1000 mL. The ICD codes had a sensitivity of 88.5% (95% CI 88.2-88.7), specificity of 99.4% (95% CI 99.4-99.4), positive predictive value of 92.0% (95% CI 91.8-92.3) and negative predictive value of 99.1% (95% CI 99.1-99.1). In our secondary analysis, on deliveries with severe PPH, the sensitivity for an ICD code was 91.3% (95% CI 90.7-91.9), whereas specificity was 83.5% (95% CI 82.3-84.6). CONCLUSIONS Our findings indicate that ICD-10 codes for PPH in Sweden have moderately high sensitivity and excellent specificity. These results suggest that PPH diagnostic codes in medical records and linked pregnancy and birth registers can be used for research, quality improvement and reporting PPH prevalence in Sweden.
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Affiliation(s)
- Linnea V Ladfors
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
| | - Giulia M Muraca
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and gynecology, University of British Columbia, Children's and Women's Hospital and Health Centre of British Columbia, Vancouver, Canada
| | - Alexander Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Gustaf Edgren
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of Medicine - Solna, Karolinska Institutet, Stockholm, Sweden
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36
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Postpartum bleeding in women with inherited bleeding disorders: a matched cohort study. Blood Coagul Fibrinolysis 2020; 31:452-458. [DOI: 10.1097/mbc.0000000000000945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ogawa L, Shimoda GT, Wei CY, Püschel VADA. Prevention and management of primary postpartum hemorrhage among puerperae in a teaching hospital in São Paulo, Brazil: a best practice implementation project. ACTA ACUST UNITED AC 2020; 17:414-428. [PMID: 30870332 DOI: 10.11124/jbisrir-2017-003830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The aim of this project was to develop and implement strategies to promote standardization and formal documentation of increased bleeding within the first 24 h after birth, in compliance with best practice. INTRODUCTION Official data from Brazil shows a maternal mortality rate of around 52 to 75 deaths per 100,000 live births, 8% of which are caused by hemorrhage. Early diagnosis is promoted through standardization and formal documentation of the first signs of hemorrhage. METHODS The current implementation project used the Joanna Briggs Institute Practical Application of Clinical Evidence System, a baseline audit was conducted on a sample size of 108 patients and 67 nursing staff. Based on the results of the baseline audit, strategies to address non-compliance were developed and implemented. A follow-up audit was conducted on a sample size of 110 patients and 68 nursing staff, using the same audit criteria. RESULTS The baseline audit showed poor compliance with evidence-based best practice in every criterion. The implemented protocol for postpartum hemorrhage was well received by the nursing staff, promoting early diagnosis of increased bleeding within 24 h after birth and providing support for further medical treatment. There were significant improvements in every best practice criterion in the follow-up audit. CONCLUSION The current implementation project managed to improve the nursing staff professional practice, reducing the absence of records while promoting greater awareness of the first signs of primary postpartum hemorrhage.
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Affiliation(s)
- Luciana Ogawa
- University Hospital, University of São Paulo, São Paulo, Brazil
| | - Gilcéria Tochika Shimoda
- University Hospital, University of São Paulo, São Paulo, Brazil.,The Brazilian Centre for Evidence-informed Healthcare: a Joanna Briggs Institute Centre of Excellence, São Paulo, Brazil
| | - Chang Yi Wei
- University Hospital, University of São Paulo, São Paulo, Brazil
| | - Vilanice Alves de Araújo Püschel
- The Brazilian Centre for Evidence-informed Healthcare: a Joanna Briggs Institute Centre of Excellence, São Paulo, Brazil.,School of Nursing, University of São Paulo, São Paulo, Brazil
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Bell SF, Watkins A, John M, Macgillivray E, Kitchen TL, James D, Scarr C, Bailey CM, Kelly KP, James K, Stevens JL, Edey T, Collis RE, Collins PW. Incidence of postpartum haemorrhage defined by quantitative blood loss measurement: a national cohort. BMC Pregnancy Childbirth 2020; 20:271. [PMID: 32375687 PMCID: PMC7201938 DOI: 10.1186/s12884-020-02971-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Visual estimation of blood loss following delivery often under-reports actual bleed volume. To improve accuracy, quantitative blood loss measurement was introduced for all births in the 12 hospitals providing maternity care in Wales. This intervention was incorporated into a quality improvement programme (Obstetric Bleeding Strategy for Wales, OBS Cymru). We report the incidence of postpartum haemorrhage in Wales over a 1-year period using quantitative measurement. METHODS This prospective, consecutive cohort included all 31,341 women giving birth in Wales in 2017. Standardised training was cascaded to maternity staff in all 12 hospitals in Wales. The training comprised mock-scenarios, a video and team drills. Uptake of quantitative blood loss measurement was audited at each centre. Data on postpartum haemorrhage of > 1000 mL were collected and analysed according to mode of delivery. Data on blood loss for all maternities was from the NHS Wales Informatics Service. RESULTS Biannual audit data demonstrated an increase in quantitative measurement from 52.1 to 87.8% (P < 0.001). The incidence (95% confidence intervals, CI) of postpartum haemorrhage of > 1000 mL, > 1500 mL and > 2000 mL was 8.6% (8.3 to 8.9), 3.3% (3.1 to 3.5) and 1.3% (1.2 to 1.4), respectively compared to 5%, 2% and 0.8% in the year before OBS Cymru. The incidence (95% CI) of bleeds of > 1000 mL was similar across the 12 hospitals despite widely varied size, staffing levels and case mix, median (25th to 75th centile) 8.6% (7.8-9.6). The incidence of PPH varied with mode of delivery and was mean (95% CI) 4.9% (4.6-5.2) for unassisted vaginal deliveries, 18.4 (17.1-19.8) for instrumental vaginal deliveries, 8.5 (7.7-9.4) for elective caesarean section and 19.8 (18.6-21.0) for non-elective caesarean sections. CONCLUSIONS Quantitative measurement of blood loss is feasible in all hospitals providing maternity care and is associated with detection of higher rates of postpartum haemorrhage. These results have implications for the definition of abnormal blood loss after childbirth and for management and research of postpartum haemorrhage.
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Affiliation(s)
- Sarah F Bell
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Adam Watkins
- 1000 Lives Improvement, Public Health Wales, Tyndall Street, Cardiff, UK
| | - Miriam John
- Department of Emergency Medicine, Aneurin Bevan University Health Board, Newport, UK
| | | | - Thomas L Kitchen
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Donna James
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Cerys Scarr
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Christopher M Bailey
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Ysbyty Gwynedd, Bangor, UK
| | - Kevin P Kelly
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Kathryn James
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Jenna L Stevens
- Department of Anaesthetics, Aneurin Bevan University Health Board, Newport, UK
| | - Tracey Edey
- Department of Obstetrics and Gynaecology, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Rachel E Collis
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Peter W Collins
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK. .,Departmentt of Haematology, University Hospital of Wales Heath Park, Cardiff, UK.
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Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, Suarez-Rebling D, Eckardt M, Theron G, Burke TF. Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis. Am J Obstet Gynecol 2020; 222:293.e1-293.e52. [PMID: 31917139 DOI: 10.1016/j.ajog.2019.11.1287] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/12/2019] [Accepted: 11/18/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the efficacy, effectiveness, and safety of uterine balloon tamponade for treating postpartum hemorrhage. STUDY DESIGN We searched electronic databases (from their inception to August 2019) and bibliographies. We included randomized controlled trials, nonrandomized studies, and case series that reported on the efficacy, effectiveness, and/or safety of uterine balloon tamponade in women with postpartum hemorrhage. The primary outcome was the success rate of uterine balloon tamponade for treating postpartum hemorrhage (number of uterine balloon tamponade success cases/total number of women treated with uterine balloon tamponade). For meta-analyses, we calculated pooled success rate for all studies, and relative risk with 95% confidence intervals for studies that included a comparative arm. RESULTS Ninety-one studies, including 4729 women, met inclusion criteria (6 randomized trials, 1 cluster randomized trial, 15 nonrandomized studies, and 69 case series). The overall pooled uterine balloon tamponade success rate was 85.9% (95% confidence interval, 83.9-87.9%). The highest success rates corresponded to uterine atony (87.1%) and placenta previa (86.8%), and the lowest to placenta accreta spectrum (66.7%) and retained products of conception (76.8%). The uterine balloon tamponade success rate was lower in cesarean deliveries (81.7%) than in vaginal deliveries (87.0%). A meta-analysis of 2 randomized trials that compared uterine balloon tamponade vs no uterine balloon tamponade in postpartum hemorrhage due to uterine atony after vaginal delivery showed no significant differences between the study groups in the risk of surgical interventions or maternal death (relative risk, 0.59; 95% confidence interval, 0.02-16.69). A meta-analysis of 2 nonrandomized before-and-after studies showed that introduction of uterine balloon tamponade in protocols for managing severe postpartum hemorrhage significantly decreased the use of arterial embolization (relative risk, 0.29; 95% confidence interval, 0.14-0.63). A nonrandomized cluster study reported that use of invasive procedures was significantly lower in the perinatal network that routinely used uterine balloon tamponade than that which did not use uterine balloon tamponade (3.0/1000 vs 5.1/1000; P < .01). A cluster randomized trial reported that the frequency of postpartum hemorrhage-related invasive procedures and/or maternal death was significantly higher after uterine balloon tamponade introduction than before uterine balloon tamponade introduction (11.6/10,000 vs 6.7/10,000; P = .04). Overall, the frequency of complications attributed to uterine balloon tamponade use was low (≤6.5%). CONCLUSION Uterine balloon tamponade has a high success rate for treating severe postpartum hemorrhage and appears to be safe. The evidence on uterine balloon tamponade efficacy and effectiveness from randomized and nonrandomized studies is conflicting, with experimental studies suggesting no beneficial effect, in contrast with observational studies. Further research is needed to determine the most effective programmatic and healthcare delivery strategies on uterine balloon tamponade introduction and use.
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Affiliation(s)
- Sebastian Suarez
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Internal Medicine, Boston Medical Center, Boston, Massachusetts.
| | - Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan
| | - Anderson Borovac-Pinheiro
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas (SP), Brazil
| | - Daniela Suarez-Rebling
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Melody Eckardt
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Gerhard Theron
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Thomas F Burke
- Division of Global Health Innovation, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Bell SF, Kitchen T, John M, Scarr C, Kelly K, Bailey C, James K, Watkins A, Macgillivray E, Edey T, Greaves K, Volikas I, Tozer J, Sengupta N, Francis C, Collis R, Collins P. Designing and implementing an all Wales postpartum haemorrhage quality improvement project: OBS Cymru (the Obstetric Bleeding Strategy for Wales). BMJ Open Qual 2020; 9:e000854. [PMID: 32273281 PMCID: PMC7326295 DOI: 10.1136/bmjoq-2019-000854] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/06/2020] [Accepted: 03/20/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) contributes to substantial maternal morbidity. Research into PPH has led to improvements in care which have been incorporated into the Obstetric Bleeding Strategy for Wales. INTERVENTION A national quality improvement team supported local teams in implementing multiple interventions including risk assessment, objective measurement of blood loss, multiprofessional assessment (at the bedside at 1000 mL blood loss) and point-of-care (POC) testing of coagulation to guide blood product resuscitation during PPH. The project was rolled out to all 12 obstetric units in 2017. The interventions were reinforced by an All Wales Guideline, PPH proforma and standardised training. A national database, biannual audits, and patient and staff surveys reported process and outcome measures. RESULTS Process measures: during 2017, there was an increase in the percentage of maternities with documented risk assessment (0%-76%), objective measurement of blood loss (52%-88%) and POC testing for coagulation for PPH ≥1500 mL (38%-59%). Maternity staff survey indicated that 94% were aware of the project and 87% stated that it had changed their unit's management of PPH. Interim outcome measures: the incidence (95% CI) of PPH ≥2500 mL per 1000 maternities in 2017 was 6.03 (5.23-6.95). The annual number of women receiving any red blood cell transfusion, level 3 intensive care admission and hysterectomy for PPH was 19.7 (18.2 to 21.3), 0.702 (0.464 to 1.06) and 0.255 (0.129 to 0.504) per 1000 maternities, respectively. CONCLUSIONS A high level of project awareness across Welsh maternity units has been achieved. Measurement of blood loss was reported to be the most important early change in practice, while PPH documentation and POC testing continue to be embedded. Combining qualitative and quantitative measures to inform implementation has improved project delivery and allowed teams to adapt to local contexts.
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Affiliation(s)
- Sarah Frances Bell
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | - Thomas Kitchen
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | - Miriam John
- Emergency Medicine, Aneurin Bevan University Health Board, Newport, UK
| | - Cerys Scarr
- Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Kevin Kelly
- Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - Christopher Bailey
- Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - Kathryn James
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | | | | | - Tracey Edey
- Midwifery, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | | | - Ingrid Volikas
- Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - James Tozer
- Anaesthesia and Critical Care, Aneurin Bevan University Health Board, Newport, UK
| | - Niladril Sengupta
- Obstetrics and Gynaecology, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - Claire Francis
- Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Rachel Collis
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | - Peter Collins
- Haematology, University Hospital of Wales, Cardiff, UK
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Stachetti T, Spodenkiewicz M, Winer A, Boukerrou M, Jesson J, Gérardin P. Factors associated with severe postpartum haemorrhage: systematic review using Bradford Hill’s causality framework. JOURNAL OF GLOBAL HEALTH REPORTS 2019. [DOI: 10.29392/joghr.3.e2019085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Davey MA, Flood M, Pollock W, Cullinane F, McDonald S. Risk factors for severe postpartum haemorrhage: A population-based retrospective cohort study. Aust N Z J Obstet Gynaecol 2019; 60:522-532. [PMID: 31758550 DOI: 10.1111/ajo.13099] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/21/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Severe postpartum haemorrhage (PPH) is a serious clinical problem that is increasing in incidence. AIM To identify risk factors for severe PPH. MATERIALS AND METHODS Population-based retrospective cohort study of all women who gave birth in Victoria in 2009-2013 using the validated Victorian Perinatal Data Collection. Three multivariable logistic regression models estimated the adjusted risk of severe PPH. Adjusted odds ratios (aOR) and their 95% confidence intervals are reported. The primary outcome was severe PPH (estimated blood loss of ≥1500 mL). RESULTS Severe PPH occurred in 1.4% of all births (n = 5122). Maternal characteristics significantly associated with severe PPH included: multiple pregnancy; older maternal age; overweight/obesity; first births. Other risk factors included placental complications, macrosomia, instrumental vaginal birth, third and fourth degree perineal lacerations, in-labour caesarean section, birth at a gestation other than 37-41 weeks, duration of labour 12 to <24 h, and use of oxytocin infusions in labour. Planned pre-labour caesarean section was associated with reduced odds of severe PPH. Severe PPH also occurred in 0.7% (n = 104) of women with none of the identified risk factors. CONCLUSIONS Numerous risk factors for severe PPH are identified but some cases are not modifiable or predictable. Limiting use of oxytocin infusions in labour to cases with clear indications, and strategies to prevent severe perineal lacerations would prevent some severe PPHs. Close surveillance of all women in the hours immediately following birth is crucial to detect and manage excessive blood loss and reduce severe PPH and associated morbidity.
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Affiliation(s)
- Mary-Ann Davey
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Margaret Flood
- Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Wendy Pollock
- Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia
| | - Fiona Cullinane
- Maternity Services, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Susan McDonald
- Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia
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Pavord S, Daru J, Prasannan N, Robinson S, Stanworth S, Girling J. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol 2019; 188:819-830. [PMID: 31578718 DOI: 10.1111/bjh.16221] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/26/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Sue Pavord
- Department of Haematology Oxford University Hospitals Oxford UK
| | - Jan Daru
- Women's Health Research Unit Centre for Primary Care and Public Health WHO Collaborating Centre Blizard Institute London UK
| | - Nita Prasannan
- Department of Obstetrics and Gynaecology Guys and St Thomas' NHS Foundation Trust London UK
| | - Susan Robinson
- Haematology Department Guys and St Thomas' NHS Foundation Trust London UK
| | - Simon Stanworth
- NHSBT/Department of Haematology John Radcliffe Hospital Oxford UK
| | - Joanna Girling
- Department of Obstetrics and Gynaecology West Middlesex University Hospital and Chelsea & Westminster Hospital London UK
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Morfaw F, Fundoh M, Pisoh C, Ayaba B, Mbuagbaw L, Anderson LN, Thabane L. Misoprostol as an adjunct to oxytocin can reduce postpartum-haemorrhage: a propensity score-matched retrospective chart review in Bamenda-Cameroon, 2015-2016. BMC Pregnancy Childbirth 2019; 19:257. [PMID: 31331275 PMCID: PMC6647290 DOI: 10.1186/s12884-019-2407-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 07/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is some evidence that suggests misoprostol may supplement the action of oxytocin in preventing post-partum haemorrhage (PPH). The primary objective of this study was to determine the effect of the administration of 600 μg misoprostol in addition to oxytocin versus oxytocin alone, on the risk of PPH among pregnant women after delivery. The secondary objectives were to determine the effects of the above combination on maternal death and blood transfusion among pregnant women after delivery; and to determine the incidence of PPH, its case fatality, and the maternal mortality ratio in our hospital. METHODS Design and setting: Retrospective chart review of 1736 women delivering at the Regional Hospital Bamenda Cameroon, between 2015 and 2016. This was a pre versus post study following a policy change in the prevention of PPH. Exposure groups: One group received oxytocin-misoprostol (January-April 2016: period after policy change), and the second group received oxytocin-only (January-April 2015: period before policy change) after delivery. OUTCOMES The primary outcome was PPH, and the secondary outcomes were maternal death and blood transfusion. STATISTICAL ANALYSIS A 1:1 matching with replacement was done with the propensity score (PS). The groups were compared using PS matching with conditional logistic regression on the matched pairs as the main analysis. A sensitivity analysis was done using other PS adjustment methods and multiple regression. RESULTS Of the 1736 women included in this study, 1238 were matched and compared. Women who received oxytocin-misoprostol were less likely to have PPH as compared to those receiving oxytocin-only (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.08, 0.59, p = 0.003). This reduced odds of PPH was upheld in the different sensitivity analyses. There were no significant differences in the odds of maternal death and the use of blood transfusions between the two groups: OR 3.91, 95% CI [0.44, 35.08], p = 0.22, and OR 0.89, 95% CI [0.14-5.63], p = 0.91, respectively. Sensitivity analyses showed similar results. The incidence of PPH was 2.9% (before adding misoprostol the incidence was 4.4% and after adding misoprostol it was 1.5%), the case fatality rate of PPH was 1.96%, and the overall maternal mortality ratio in the hospital was 293 maternal deaths/100000 life births. CONCLUSION Our evidence suggests that using 600 μg misoprostol as an add-on to oxytocin in the prevention of post-partum haemorrhage significantly reduces the odds of PPH without affecting other maternal outcomes.
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Affiliation(s)
- Frederick Morfaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
- Department of Obstetrics and Gynaecology, Faculty of Medicines and Biomedical Sciences University of Yaounde 1, Yaoundé, Cameroon
- Department of Clinical Sciences, Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon
| | - Mercy Fundoh
- Department of Clinical Sciences, Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon
| | - Christopher Pisoh
- Department of Clinical Sciences, Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon
| | - Bi Ayaba
- Regional Hospital Bamenda, Bamenda, Cameroon
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
- Biostatistics Unit, St Joseph Healthcare—Hamilton, Hamilton, ON Canada
- Centre for Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Laura N. Anderson
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON Canada
- Biostatistics Unit, St Joseph Healthcare—Hamilton, Hamilton, ON Canada
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Developing and evaluating an online learning tool to improve midwives’ accuracy of visual estimation of blood loss during waterbirth: An experimental study. Midwifery 2019; 68:65-73. [DOI: 10.1016/j.midw.2018.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 09/14/2018] [Accepted: 10/16/2018] [Indexed: 11/21/2022]
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Newsam R. Operating department practitioners and midwives: The undervalued obstetric care collaboration. ACTA ACUST UNITED AC 2018. [DOI: 10.12968/bjom.2018.26.11.714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Rebecca Newsam
- Operating department practitioner, Liverpool Heart and Chest Hospital NHS Foundation Trust
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Validation of the accuracy of postpartum haemorrhage data in the ObstetriX database: A retrospective cohort study. Int J Med Inform 2018; 120:42-49. [PMID: 30409345 DOI: 10.1016/j.ijmedinf.2018.09.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 09/21/2018] [Accepted: 09/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Data related to postpartum haemorrhage (PPH) are important clinical parameters which can be applied to all places of birth, and their recording can be missed by busy clinicians providing critical care to women. We compared the accuracy of electronic ObstetriX records to the paper-based medical records of the women who sustained PPH. METHODS In this retrospective cohort study over a period of one month, 363 electronic records were compared to the paper-based medical records. The volume of blood loss for each patient and interventions for PPH were compared across birth unit, operating theatre and postpartum ward. The kappa statistic for agreement between the two types of recording methods was calculated. RESULTS There was substantial agreement between the ObstetriX records and medical records for the volume of blood loss at birth (kappa = 0.74), but poor agreement between records for the cumulative total volume of blood loss (kappa = 0.18). More women who experienced PPH and delivered in the operating theatre had errors in their ObstetriX records compared to women who had PPH with births in the birth unit (50% vs 16%; n = 73, P = 0.005). Interventions for PPH were found to be poorly recorded in ObstetriX, with 84% (n = 64/76) of women who experienced PPH having none of the interventions they received recorded. CONCLUSIONS The ObstetriX database was not a generally reliable source of data relating to PPH. However, some data were recorded reliably, in particular, the volume of blood loss at birth.
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Bouchè C, Wiesenfeld U, Ronfani L, Simeone R, Bogatti P, Skerk K, Ricci G. Meconium-stained amniotic fluid: a risk factor for postpartum hemorrhage. Ther Clin Risk Manag 2018; 14:1671-1675. [PMID: 30254448 PMCID: PMC6140737 DOI: 10.2147/tcrm.s150049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background/aim Clinical data with respect to the impact of meconium on the risk of maternal hemorrhage are scarce. Therefore, in this study, we aimed to determine whether meconium-stained amniotic fluid (MSAF) represents a risk factor for postpartum hemorrhage (PPH) after vaginal delivery in a large unselected population. Patients and methods A retrospective cohort study evaluated 78,542 consecutive women who had a vaginal delivery between 24th and 44th weeks of gestation. The women who had undergone cesarean section were excluded to avoid possible bias. Postpartum blood loss was measured with graduated blood sack. Postpartum blood loss between 1,000 and 2,000 mL and >2,000 mL were classified as moderate and severe PPH, respectively. Results A total of 74,144 patients were available for analysis. According to the color of amniotic fluid (AF), two groups of patients were identified: MSAF (n=10,997) and clear AF (n=63,147). The rates of severe and massive PPH were found to be significantly higher in the MSAF group than that of clear AF group (OR=1.3, 95% CI: 1.2-1.5, p<0.001 and OR=2.5, 95% CI: 1.5-4.2, p<0.001). Operative vaginal delivery rate was found to be higher in the MSAF group than that of clear AF group, but the difference was only borderline significant (OR=1.5, 95% CI: 1.0-2.2, p=0.05). There were no significant differences between the MSAF and the clear AF groups with respect to episiotomies, second- or third-degree perineal tears, vaginal-perineal thrombus, cervical lacerations, vaginal births after cesarean section, twin deliveries, and placental retention rates. Conclusion To the best of our knowledge, this is the first clinical study that has investigated the role of MSAF as a risk factor for PPH after vaginal delivery in an unselected population. Our results suggest that MSAF is significantly associated with higher risk of moderate and severe PPH than clear AF.
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Affiliation(s)
- Carlo Bouchè
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy,
| | - Uri Wiesenfeld
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy,
| | - Luca Ronfani
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy,
| | - Roberto Simeone
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy,
| | - Paolo Bogatti
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy,
| | - Kristina Skerk
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy,
| | - Giuseppe Ricci
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy, .,Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy,
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Evaluating Adherence to Guideline-Based Quality Indicators for Postpartum Hemorrhage Care in the Netherlands Using Video Analysis. Obstet Gynecol 2018; 132:656-667. [DOI: 10.1097/aog.0000000000002781] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Effect of Cesarean Section on the Severity of Postpartum Hemorrhage in Chinese Women: The Shanxi Study. Curr Med Sci 2018; 38:618-625. [PMID: 30128870 DOI: 10.1007/s11596-018-1922-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 05/30/2018] [Indexed: 12/12/2022]
Abstract
Postpartum hemorrhage (PPH) is one of the most adverse obstetric outcomes. Our aim is to detect the risks of multilevel PPH in different cesarean section (CS) groups [including nulliparous CS with indications, nulliparous CS without indications, repeat cesarean (RC), vaginal birth after cesarean (VBAC), cesarean after vaginal birth (CAVB)]. We conducted a retrospective cohort study, and the data on 127 145 women collected from January 2014 to May 2016 and from 35 tertiary hospitals in Shanxi province, China, were reviewed. Based on the measuring results of PPH, an ordered logistic regression model was used to analyze the adjusted PPH risks for each of the CS groups, and comparisons were drawn between them. Finally, a total of 99 066 nulliparous (77.92%) and 28 079 multiparous (22.08%) women were observed. The number of CS cases was 61 117, and the rate for CS was 48.07%. A total of 10 029 women did not show indications for CS and accounted for 16.41% of the CS parturient, whereas 9103 women underwent a repeated cesarean, with a CS frequency of 14.89%. The number of VBAC cases was 989, whose rate was 9.88% in prior CS women. The number (proportions) of PPH was 3658 (2.88%) in LI (PPH volume: ≥900 and <1500 mL), 520 (0.41%) in 12 (PPH volume: >1500 and <2100 mL), and 201 (0.16%) in L3 (PPH volume: ≥2100 mL). The Ln (n=l, 2,3, etc.) represented the increasing order of PPH severity. In the adjusted results, compared with spontaneous vaginal delivery (SVD) as the reference group, in the adjusted result for nulliparous, there was a decreased PPH risk in CS with indications (OR: 2.32; CI: 2.04-2.62), which was lower than that of CS without indications (OR: 2.50; CI: 2.01-2.96). The highest PPH risk in all subgroups (i.e. nulliparous and multiparous groups) was observed in the RC (OR: 3.61; CI: 3.16-4.17), which was nearly twice higher than that of the VBAC (OR: 1.82; CI: 1.33-2.52). CAVB (OR: 1.03; CI: 0.65-1.62) showed no significant difference with the reference group. Thus, we deemed that CS should be avoided in nulliparous pregnancies unless indicated, to prevent or reduce the rates for the use of RC or VBAC which are high risks of severe PPH to the parturient women.
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