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Cravassac L, Hamadmad R, Crequit S, Redel D, Yakhou L, Verton C, Haddad B, Lecarpentier E. Clinical and biological factors associated with red blood cell transfusion during severe postpartum haemorrhage - A single-center retrospective cohort study. J Gynecol Obstet Hum Reprod 2024; 53:102774. [PMID: 38521407 DOI: 10.1016/j.jogoh.2024.102774] [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: 11/21/2023] [Revised: 03/11/2024] [Accepted: 03/20/2024] [Indexed: 03/25/2024]
Abstract
INTRODUCTION Red blood cell (RBC) transfusions are of utmost importance in the management of severe post-partum haemorrhage. Although the recommendations for blood transfusion protocols are regularly issued, there are significant differences in management depending on the context and the medical teams involved. OBJECTIVE To determine during the first 24 h, the clinical and biological factors associated with the decision for RBC transfusion during severe PPH (≥1000 mL) for vaginal and caesarean deliveries. STUDY DESIGN Monocentric retrospective study conducted in a tertiary care university maternity unit (CHI-Creteil) including all parturients from November 23th 2018 to 31th December 2020 with severe PPH (≥1000 mL). RESULTS Over the study period, we reported 7103 deliveries, out of which 682 were complicated by PPH (9.6 %) with 200 cases of PPH ≥1000 mL (2.8 %). In our study, 40 % of patients (80/200) required a RBC transfusion". After multivariate analysis, severe PPH caused by placental abruption, uterine rupture or placental implantation disorders (aOR = 3.48 IC95 [1.27-9.52], p < 0.001), estimated blood loss ≥1500 mL (aOR = 9.60 IC95 [3.69-24.95], p < 0. 001), invasive measures such as uterine balloon tamponade, arterial ligation and uterine packing (aOR = 4.15 IC95 [1.80-9.61], p < 0.001), pre-labor hemoglobin <10 g/dL (aOR =4.88 IC95 [1.57-15.15], p < 0.001) or abnormal biological results in the acute phase (including hemoglobin <7.0 g/dL and/or fibrinogen <2 g/L and/or platelets <100 G/L) (aOR =356 IC95 [1,05-12,10], p < 0.001) were significantly and independently associated with the decision to initiate RBC transfusions. CONCLUSIONS In a monocentric retrospective study including 200 consecutive cases of severe PPH (≥1000 mL) we identified groups of clinical and biological factors directly accessible to clinicians, significantly and independently associated with RBC transfusion in the first 24 h of management.
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Affiliation(s)
- Lauren Cravassac
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France
| | - Rayan Hamadmad
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France
| | - Simon Crequit
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France
| | - Diane Redel
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France
| | - Leila Yakhou
- Service d'Anesthésie Réanimation, Centre Hospitalier Intercommunal de Créteil, France
| | - Caroline Verton
- Service d'Anesthésie Réanimation, Centre Hospitalier Intercommunal de Créteil, France
| | - Bassam Haddad
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France; Faculté de santé, Université Paris-Est Créteil, France
| | - Edouard Lecarpentier
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France; Faculté de santé, Université Paris-Est Créteil, France; Équipe Biologie du Trophoblaste et Pathologies Vasculaires Placentaires, INSERM, CNRS, UPC, Institut Cochin, France.
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Al Khatib A, Sagot P, Cottenet J, Aroun M, Quantin C, Desplanches T. Author reply. BJOG 2024. [PMID: 38800977 DOI: 10.1111/1471-0528.17867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/29/2024] [Indexed: 05/29/2024]
Affiliation(s)
- A Al Khatib
- Pôle de Gynécologie-Obstétrique et Biologie de la Reproduction, Dijon University Hospital, Dijon, France
| | - P Sagot
- Pôle de Gynécologie-Obstétrique et Biologie de la Reproduction, Dijon University Hospital, Dijon, France
| | - J Cottenet
- Service de Biostatistiques et d'Information Médicale (DIM), CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - M Aroun
- Pôle de Gynécologie-Obstétrique et Biologie de la Reproduction, Dijon University Hospital, Dijon, France
| | - C Quantin
- Service de Biostatistiques et d'Information Médicale (DIM), CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- Université Paris-Saclay, UVSQ, Inserm, CESP, Villejuif, France
| | - T Desplanches
- Pôle de Gynécologie-Obstétrique et Biologie de la Reproduction, Dijon University Hospital, Dijon, France
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland
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de Vries PLM, Deneux-Tharaux C, Baud D, Chen KK, Donati S, Goffinet F, Knight M, D'Souzah R, Sueters M, van den Akker T. Postpartum haemorrhage in high-resource settings: Variations in clinical management and future research directions based on a comparative study of national guidelines. BJOG 2023; 130:1639-1652. [PMID: 37259184 DOI: 10.1111/1471-0528.17551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 04/15/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH. DESIGN Comparative study. SETTING High-resource countries. POPULATION Women with PPH. METHODS Systematic comparison of guidance on PPH from eight high-income countries. MAIN OUTCOME MEASURES Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour. CONCLUSIONS Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines. RESULTS Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.
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Affiliation(s)
- Pauline L M de Vries
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Port-Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Catherine Deneux-Tharaux
- Université Paris Cité, Inserm, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), CRESS, Paris, France
| | - David Baud
- Department of Gynaecology and Obstetrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Kenneth K Chen
- Departments of Medicine & ObGyn, Brown University, Providence, Rhode Island, USA
| | - Serena Donati
- National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanità-Italian National Institute of Health, Rome, Italy
| | - Francois Goffinet
- Port-Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rohan D'Souzah
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Departments of Obstetrics & Gynaecology and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Obstetrics and Gynaecology, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marieke Sueters
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Sugimura M, Ohtani Y, Tamai S, Kishimoto U, Ito N. Ferric derisomaltose for the treatment of iron deficiency anemia with postpartum hemorrhage: Results of a single-arm, open-label, phase 3 study in Japan. J Obstet Gynaecol Res 2023; 49:946-955. [PMID: 36653310 DOI: 10.1111/jog.15546] [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: 05/26/2022] [Accepted: 12/28/2022] [Indexed: 01/20/2023]
Abstract
AIM Single-arm, open-label, phase 3 study to evaluate the efficacy and safety of ferric derisomaltose (FDI) for iron deficiency anemia (IDA) in Japanese women with postpartum hemorrhage (PPH). METHODS Postpartum women aged 20-39 years with serum ferritin <25.0 ng/ml, hemoglobin (Hb) <10.0 g/dl, and blood loss ≥500 ml within 24 h post-delivery were eligible to receive high-dose intravenous FDI. The primary endpoint was the maximum change in Hb concentration by Week 8. Key secondary endpoints included change in iron parameters and percentage of patients with a total Edinburgh Postnatal Depression Score (EPDS) ≥9. Safety assessments included treatment-emergent adverse events (TEAEs) and iron concentrations in maternal milk. RESULTS All (n = 21 [100.0%]) patients received the predetermined total iron dose by Day 8. Hb concentrations increased rapidly and significantly (p < 0.001) following FDI. Serum ferritin levels also increased rapidly and were maintained near or above the upper limit of normal reference value (250 ng/ml). Following FDI, two (9.5%) patients had a total EPDS score of ≥9. TEAEs occurred in 23 of 42 (54.8%) patients and neonates overall, including 18 of 21 (85.7%) patients and 5 of 21 (23.8%) neonates. TEAEs were mild in all adult patients and four neonates, and moderate in one neonate. Iron concentrations in maternal milk remained within normal reference values. Appropriate patient selection and patient-adjusted dosage selection facilitated safe and effective administration of high-dose (≥1000 mg) FDI. CONCLUSIONS Rapid and sustained improvements in Hb and iron stores occurred following FDI for IDA with PPH, with no new safety signals identified. CLINICAL TRIAL IDENTIFIER JapicCTI-194888.
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Affiliation(s)
- Motoi Sugimura
- Department of Obstetrics, Gynecology and Family Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yasuyoshi Ohtani
- Research and Development Administration Department, Nippon Shinyaku Co. Ltd., Kyoto, Japan
| | - Soichiro Tamai
- Clinical Development Division, Data Science Department, Nippon Shinyaku Co. Ltd., Kyoto, Japan
| | - Umi Kishimoto
- Clinical Development Division, Clinical Development Department, Nippon Shinyaku Co. Ltd., Kyoto, Japan
| | - Naoki Ito
- Department of Pediatrics, Teikyo University School of Medicine, Tokyo, Japan
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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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Chantry AA, Berrut S, Donati S, Gissler M, Goldacre R, Knight M, Maraschini A, Monteath K, Morris A, Teixeira C, Wood R, Zeitlin J, Deneux-Tharaux C. Monitoring severe acute maternal morbidity across Europe: A feasibility study. Paediatr Perinat Epidemiol 2020; 34:416-426. [PMID: 31502306 DOI: 10.1111/ppe.12557] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/23/2019] [Accepted: 03/25/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Monitoring severe acute maternal morbidity (SAMM) appears essential for optimising care and informing health care policies, especially given changes in obstetric practices and mother profiles. International comparisons can identify areas where improvement is needed, but the comparability of indicators must be evaluated. OBJECTIVE To assess the feasibility of monitoring SAMM using common definitions from hospital discharge databases across Europe. METHODS We used hospital discharge data in eight countries (2 826 868 deliveries) to identify women with SAMM among all hospitalisations of women of reproductive age admitted for antenatal or delivery care. Five SAMM indicators were investigated: eclampsia, septicaemia, hysterectomy, hysterectomy associated with a diagnosis of obstetric haemorrhage, and red blood cell (RBC) transfusion associated with a diagnosis of obstetric haemorrhage. Between-country variation was described, by the ratio of the highest to lowest rates, while external validation was assessed by comparing with population-based studies on maternal morbidity. RESULTS Ratios for hysterectomy and red blood cell (RBC) transfusion in the context of obstetric haemorrhage were 1:2.1 and 1:3.5, respectively. High values of hysterectomy and low values of transfusion were both consistent with high maternal mortality from haemorrhage (France, Italy, Portugal). Ratios across countries were relatively low for eclampsia (1:3.4) but very high for septicaemia (1:22.5). Compared to population-based morbidity estimates, eclampsia was over-reported in hospital databases whereas the two indicators of severe haemorrhage had good external validity. CONCLUSIONS In association with diagnosis codes indicating obstetric haemorrhage, hysterectomy and RBC transfusion appear to be good candidates for surveillance of maternal morbidity in Europe.
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Affiliation(s)
- Anne A Chantry
- INSERM UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,Midwifery School of Baudelocque, Assistance Publique-Hôpitaux de Paris, DHU Risks in Pregnancy, Paris-Descartes University, Paris, France
| | | | - Serena Donati
- Maternal and Child Health Unit, National Centre for Disease Prevention and Health Promotion - Italian National Institute of Health, Rome, Italy
| | - Mika Gissler
- Information Services Department, THL National Institute for Health and Welfare, Helsinki, Finland.,Division of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden
| | - Raphael Goldacre
- Unit of Health-Care Epidemiology, Big Data Institute, Nuffield Department of Population Health, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alice Maraschini
- Maternal and Child Health Unit, National Centre for Disease Prevention and Health Promotion - Italian National Institute of Health, Rome, Italy
| | - Kirsten Monteath
- Information Services Division, NHS National Services Scotland, Edinburgh, UK.,Department of Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Anna Morris
- Information Services Department, NHS Wales Informatics Service, Cardiff, UK
| | - Cristina Teixeira
- EPI Unit Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
| | - Rachael Wood
- Information Services Division, NHS National Services Scotland, Edinburgh, UK.,Department of Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Jennifer Zeitlin
- INSERM UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Catherine Deneux-Tharaux
- INSERM UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), DHU Risks in Pregnancy, Paris Descartes University, Paris, France
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Deleu F, Deneux-Tharaux C, Chiesa-Dubruille C, Seco A, Bonnet M. A population-based analysis of French transfusion practices for women experiencing severe postpartum hemorrhage. Int J Obstet Anesth 2020; 42:11-19. [DOI: 10.1016/j.ijoa.2019.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 06/28/2019] [Accepted: 07/15/2019] [Indexed: 01/01/2023]
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Abstract
A critical tool in the successful management of patients with abnormal placentation is an established massive transfusion protocol designed to rapidly deliver blood products in obstetrical and surgical hemorrhage. Spurred by trauma research and an understanding of consumptive coagulopathy, the past 2 decades have seen a shift in volume resuscitation from an empiric, crystalloid-based method to balanced, targeted transfusion therapy. The present article reviews patient blood management in abnormal placentation, beginning with optimizing the patient's status in the antenatal period to the laboratory assessment and transfusion strategy for blood products at the time of hemorrhage.
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Enright S, Varadkar S, Demaio A, Flynn C, Ni Áinle F, Hehir MP. Antecedents of red cell transfusion in a large contemporary obstetric cohort. J Perinat Med 2019; 47:195-199. [PMID: 30285948 DOI: 10.1515/jpm-2018-0227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/07/2018] [Indexed: 11/15/2022]
Abstract
Background Hemorrhage is a critical contributor to maternal morbidity but estimation of blood loss at delivery is frequently inaccurate. Due to this inaccuracy we sought to examine blood transfusion as a surrogate marker for morbidity in a large non-population based consecutive cohort. Methods A retrospective analysis of prospectively gathered data was carried out at two university institutions serving a heterogeneous urban obstetric population from January to December 2016. Data were analyzed to determine whether individual characteristics were associated with perinatal transfusion. Hematological indices and requirement for other blood products were also characterized. Results A total of 16,581 deliveries were recorded during the study and 1.7% (289/16,581) of the cohort required red cell transfusion. Those who received transfusion were more likely to be nulliparous, and to deliver <37 weeks' or >42 weeks' gestation. They were also more likely to have a macrosomic infant (birthweight >4 kg) and to have had a multiple pregnancy. Characteristics not associated with risk of transfusion included obesity [18% (52/289) vs. 15% (2445/16,292); P=0.18], and maternal age ≥35 years [28% (82/289) vs. 33% (5537/16,292); P=0.05]. Additional blood products were necessary in a small number of patients who received red cells. Conclusion The rate of transfusion in a contemporary Irish cohort has risen compared with previous data. Several variables associated with transfusion are consistent with older studies but importantly; maternal obesity and advanced maternal age are not associated with transfusion. These data may encourage the investment of resources in a population previously considered low-risk and, following future studies, to improve strategies aimed at limiting blood transfusion.
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Affiliation(s)
| | - Sonia Varadkar
- Coombe Women and Infants University Hospital, Cork St., Merchants Quay, Dublin 8, Ireland
| | - Alison Demaio
- Coombe Women and Infants University Hospital, Cork St., Merchants Quay, Dublin 8, Ireland
| | - Catherine Flynn
- Coombe Women and Infants University Hospital, Cork St., Merchants Quay, Dublin 8, Ireland
| | | | - Mark P Hehir
- Rotunda Hospital, Parnell Square, Dublin 1, Ireland
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Patterson JA, Nippita TA, Randall D, Irving DO, Ford JB, Bowen JR, Cochrane S, Irving DO, Isbister JP, Morris JM, Mayson E, Nicholl MC, Peek MJ, Roberts CL, Thomson A. Outcomes associated with transfusion in low‐risk women with obstetric haemorrhage. Vox Sang 2018; 113:678-685. [DOI: 10.1111/vox.12707] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 07/23/2018] [Accepted: 08/06/2018] [Indexed: 01/28/2023]
Affiliation(s)
- Jillian A. Patterson
- Clinical and Population Perinatal Health Research Kolling Institute Northern Sydney Local Health District St Leonards NSW Australia
- The University of Sydney Northern Clinical School St Leonards NSW Australia
| | - Tanya A. Nippita
- Clinical and Population Perinatal Health Research Kolling Institute Northern Sydney Local Health District St Leonards NSW Australia
- The University of Sydney Northern Clinical School St Leonards NSW Australia
- Department of Obstetrics and Gynaecology Royal North Shore Hospital Northern Sydney Local Health District St Leonards NSW Australia
| | - Deborah Randall
- Clinical and Population Perinatal Health Research Kolling Institute Northern Sydney Local Health District St Leonards NSW Australia
- The University of Sydney Northern Clinical School St Leonards NSW Australia
| | - David O. Irving
- Research and Development Australian Red Cross Blood Service Sydney NSW Australia
| | - Jane B. Ford
- Clinical and Population Perinatal Health Research Kolling Institute Northern Sydney Local Health District St Leonards NSW Australia
- The University of Sydney Northern Clinical School St Leonards NSW Australia
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Yazer MH, Dunbar NM, Cohn C, Dillon J, Eldib H, Jackson B, Kaufman R, Murphy MF, O'Brien K, Raval JS, Seheult J, Staves J, Waters JH. Blood product transfusion and wastage rates in obstetric hemorrhage. Transfusion 2018. [DOI: 10.1111/trf.14571] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mark H. Yazer
- Department of Pathology; Pittsburgh Pennsylvania
- The Institute for Transfusion Medicine; Pittsburgh Pennsylvania
| | - Nancy M. Dunbar
- Department of Pathology and Laboratory Medicine; Dartmouth-Hitchcock Medical Center; Lebanon New Hampshire
| | - Claudia Cohn
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Jessica Dillon
- Department of Pathology and Laboratory Medicine; Dartmouth-Hitchcock Medical Center; Lebanon New Hampshire
| | - Howida Eldib
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Bryon Jackson
- Department of Pathology and Laboratory Medicine; Emory University School of Medicine; Atlanta Georgia
| | - Richard Kaufman
- Brigham and Women's Hospital Adult Transfusion Service; Boston Massachusetts
| | - Michael F. Murphy
- NHS Blood & Transplant, Oxford University Hospitals, and University of Oxford; Oxford UK
| | - Kerry O'Brien
- Department of Pathology; Beth Israel Deaconess Medical Center; Boston Massachusetts
| | - Jay S. Raval
- Department of Pathology and Laboratory Medicine; University of North Carolina, Chapel Hill, North Carolina; the McGowan Institute for Regenerative Medicine; Pittsburgh Pennsylvania
| | | | | | - Jonathan H. Waters
- Departments of Anesthesiology and Bioengineering; University of Pittsburgh; Pittsburgh Pennsylvania
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Woiski MD, van Vugt HC, Dijkman A, Grol RP, Marcus A, Middeldorp JM, Mol BW, Mols F, Oudijk MA, Porath M, Scheepers HJ, Hermens RP. From Postpartum Haemorrhage Guideline to Local Protocol: A Study of Protocol Quality. Matern Child Health J 2017; 20:2160-8. [PMID: 27395381 PMCID: PMC5025494 DOI: 10.1007/s10995-016-2050-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Postpartum hemorrhage (PPH) has a continuously rising incidence worldwide, suggesting suboptimal care. An important step in optimizing care is the translation of evidence-based guidelines into comprehensive hospital protocols. However, knowledge about the quality of these protocols is lacking. The objective of this study was to evaluate the quality of PPH-protocols on structure and content in the Netherlands. Methods We performed an observational multicenter study. Eighteen PPH-protocols from 3 University Hospitals (UH), 8 Teaching Hospitals (TH) and 7 Non-Teaching hospitals (NTH) throughout the Netherlands were acquired. The structure of the PPH-protocols was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE-II) Instrument. The content was appraised using previously developed quality indicators, based on international guidelines and Advance-Trauma-Life-Support (ATLS)-based course instructions. Results The quality of the protocols for postpartum hemorrhage for both structure and content varied widely between different hospitals, but all of them showed room for improvement. The protocols scored mainly below average on the different items of the AGREE-II instrument (8 of the 10 items scored <4 on a 1–7 scale). Regarding the content, adoption of guideline recommendations in protocols was 46 %. In addition, a timely indication of ‘when to perform’ a recommendation was lacking in three-fourths of the items. Conclusion This study shows that the quality of the PPH-protocols for both structure and content in the Netherlands is suboptimal. This makes adherence to the guideline and ATLS-based course instructions difficult.
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Affiliation(s)
- Mallory D Woiski
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, Geert Grootplein 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Helena C van Vugt
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, Geert Grootplein 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Anneke Dijkman
- Department of Obstetrics and Gynaecology, Reinier de Graaf Hospital, P.O. Box 5011, 2600 GA, Delft, The Netherlands
| | - Richard P Grol
- Institute for Quality of Healthcare (IQ Healthcare), Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Abraham Marcus
- Department of Anesthesiology, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Johanna M Middeldorp
- Department of Obstetrics, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Academic Medical Centre (AMC), P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Femke Mols
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, Geert Grootplein 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Martina Porath
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, P.O. Box 90052, 5600 PD, Veldhoven, The Netherlands
| | - Hubertina J Scheepers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Rosella P Hermens
- Institute for Quality of Healthcare (IQ Healthcare), Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Vendittelli F, Barasinski C, Pereira B, Lémery D. Incidence of immediate postpartum hemorrhages in French maternity units: a prospective observational study (HERA study). BMC Pregnancy Childbirth 2016; 16:242. [PMID: 27552986 PMCID: PMC4995746 DOI: 10.1186/s12884-016-1008-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 08/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most estimates of postpartum hemorrhage (PPH) are calculated from studies that use administrative or medical birth databases, and only a few from prospective observational studies. Our principal objective was to estimate the incidence of PPH according to their severity (mild or severe) in vaginal deliveries (>500 mL, ≥1000 mL) and cesareans (>1000 mL and ≥1500 mL). The secondary objectives were to describe the incidence of PPH according to maternity unit characteristics, causes, and types of PPH management. METHODS This prospective observational study took place in French maternity wards. Women who gave birth at a term ≥ 22 weeks were eligible for the study. 182 maternity units participated in a study with prospective data collection from 1 February, 2011, to 31 July, 2011. The main outcome measure was PPH incidence. RESULTS PPH incidence after vaginal delivery was 3.36 % [95 % CI: 3.25-3.47 %] and after cesareans 2.83 % [95 % CI: 2.63-3.04 %]. The incidence of severe PPH after vaginal delivery was 1.11 % [95 % CI: 1.05-1.18 %] and after cesareans 1.00 % [95 % CI: 0.88-1.13 %]. This incidence rate varied according to maternity unit characteristics. The principal cause of PPH for both modes of delivery was uterine atony (57.7 % for vaginal births and 66.3 % for cesareans). Vascular embolization was more frequent among women with cesareans (10.0 vs. 2.9 %), who also required transfusions more often (44.4 vs 12.7 %). CONCLUSIONS The incidence of PPH was lower than the rate expected from the literature. Effective treatment of uterine atony and optimizing the identification of blood loss remain important priorities.
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Affiliation(s)
- Françoise Vendittelli
- Pôle Femme et Enfant, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, 63003, France. .,Université d'Auvergne, EA 4681, PEPRADE (Périnatalité, grossesse, Environnement, PRAtiques médicales et DEveloppement), Clermont Université, Clermont-Ferrand, France. .,AUDIPOG (Association des Utilisateurs de Dossiers Informatisés en Pédiatrie, Obstétrique et Gynécologie), Faculté de médecine RTH Laennec, Lyon, France.
| | - Chloé Barasinski
- Pôle Femme et Enfant, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, 63003, France.,Université d'Auvergne, EA 4681, PEPRADE (Périnatalité, grossesse, Environnement, PRAtiques médicales et DEveloppement), Clermont Université, Clermont-Ferrand, France
| | - Bruno Pereira
- Direction de la Recherche clinique, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, 63003, France
| | - Didier Lémery
- Pôle Femme et Enfant, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, 63003, France.,Université d'Auvergne, EA 4681, PEPRADE (Périnatalité, grossesse, Environnement, PRAtiques médicales et DEveloppement), Clermont Université, Clermont-Ferrand, France.,AUDIPOG (Association des Utilisateurs de Dossiers Informatisés en Pédiatrie, Obstétrique et Gynécologie), Faculté de médecine RTH Laennec, Lyon, France
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Jones RM, de Lloyd L, Kealaher EJ, Lilley GJ, Precious E, Burckett st Laurent D, Hamlyn V, Collis RE, Collins PW. Platelet count and transfusion requirements during moderate or severe postpartum haemorrhage. Anaesthesia 2016; 71:648-56. [DOI: 10.1111/anae.13448] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2016] [Indexed: 11/30/2022]
Affiliation(s)
- R. M. Jones
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - L. de Lloyd
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - E. J. Kealaher
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - G. J. Lilley
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - E. Precious
- Institute of Infection and Immunity; School of Medicine; Cardiff University; Cardiff UK
| | - D. Burckett st Laurent
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - V. Hamlyn
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - R. E. Collis
- Department of Anaesthetics and Pain Control; 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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Nash CM, Allen VM. The Use of Parenteral Iron Therapy for the Treatment of Postpartum Anemia. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:439-442. [DOI: 10.1016/s1701-2163(15)30259-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Wikkelsø A, Edwards H, Afshari A, Stensballe J, Langhoff-Roos J, Albrechtsen C, Ekelund K, Hanke G, Secher E, Sharif H, Pedersen L, Troelstrup A, Lauenborg J, Mitchell A, Fuhrmann L, Svare J, Madsen M, Bødker B, Møller A, Wikkelsø A, Edwards H, Afshari A, Stensballe J, Langhoff-Roos J, Møller AM, Albrechtsen C, Ekelund K, Hanke G, Sharif HF, Secher EL, Christensen M, Ramsing BU, Jensen-Gadegaard P, Engskov A, Wulff C, Berntsen M, Andersen KJ, Classen V, Opstrup P, Lundstrøm LH, Flindt MS, Lunde J, Pedersen LM, Troelstrup A, Lauenborg J, Lassen B, Andersson M, Winther-Olsen M, Hougaard S, Andersen C, Petersen M, Mitchell A, Fuhrmann L, Svare J, Nielsen CV, Lefort Sønderskov M, Winkel R, Johansen M, Søgaard M, Madsen MG, Bødker B, Okkels C, Berthelsen R, Elisabeth Linnet K, Stendall L, Darfeld I, Madsen M, Pedersen L. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial †. Br J Anaesth 2015; 114:623-33. [DOI: 10.1093/bja/aeu444] [Citation(s) in RCA: 162] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Ekelund K, Hanke G, Stensballe J, Wikkelsøe A, Albrechtsen CK, Afshari A. Hemostatic resuscitation in postpartum hemorrhage - a supplement to surgery. Acta Obstet Gynecol Scand 2015; 94:680-692. [PMID: 25660118 DOI: 10.1111/aogs.12607] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 10/14/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Postpartum hemorrhage is a potentially life-threatening albeit preventable condition that persists as a leading cause of maternal death. Identification of safe and cost-effective hemostatic treatment options remains crucial as a supplement to surgery and uterotonic agents. OBJECTIVE This review summarizes the background, current evidence and recommendations with regard to the role of fibrinogen, tranexamic acid, prothrombin complex concentrate, desmopressin, and recombinant factor VIIa in the treatment of patients with postpartum hemorrhage. The benefits and evidence behind traditional standard laboratory tests and viscoelastic hemostatic assays, i.e. thromboelastography TEG(®) and thromboelastometry ROTEM(®) , are discussed. In addition we assess and elaborate on the current paradigm and evidence for transfusion of these patients. DATA SOURCES Publications between 1994 and 2014 were identified from PubMed, EMBASE, Cochrane Library databases, and ClinicalTrial.gov. RESULTS Viscoelastic hemostatic assays were found to provide a real-time continuum of coagulation and fibrinolysis when introduced as a supplement in transfusion management of postpartum hemorrhage. Fibrinogen should be considered when hypofibrinogenemia is identified. Early administration of 1-2 g tranexamic acid is recommended, followed by an additional dose in cases of ongoing bleeding. Uncontrolled hemorrhage requires early balanced transfusion. CONCLUSION Despite the lack of conclusive evidence for optimal hemostatic resuscitation in postpartum hemorrhage, the use of viscoelastic hemostatic assays, fibrinogen, tranexamic acid and balanced transfusion therapy may prove to be potentially pivotal in the treatment of postpartum hemorrhage.
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Affiliation(s)
- Kim Ekelund
- Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Gabriele Hanke
- Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Stensballe
- Department of Anesthesia, Center of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anne Wikkelsøe
- Department of Anesthesiology, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
| | - Charlotte Krebs Albrechtsen
- Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Arash Afshari
- Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Aya AG, Ducloy-Bouthors AS, Rugeri L, Gris JC. [Anesthetic management of severe or worsening postpartum hemorrhage]. ACTA ACUST UNITED AC 2014; 43:1030-62. [PMID: 25447392 DOI: 10.1016/j.jgyn.2014.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Risk factors of maternal morbidity and mortality during postpartum hemorrhage (PPH) include non-optimal anesthetic management. As the anesthetic management of the initial phase is addressed elsewhere, the current chapter is dedicated to the management of severe PPH. METHODS A literature search was performed using PubMed and Medline databases, and the Cochrane Library, for articles published from 2003 up to and including 2013. Several keywords related to anesthetic and critical care practice, and obstetrical management were used, in various combinations. Guidelines from several societies and organisations were also read. RESULTS When PPH worsens, one should ask for additional team personnel (professional consensus). Patients should be monitored for heart rate, blood pressure, skin and mucosal pallor, bleeding at skin puncture sites, diuresis and the volume of genital bleeding (grade B). Because of the possible rapid worsening of coagulapathy, patients should undergo regular evaluation of coagulation status (professional consensus). Prevention and management of hypothermia should be considered (professional consensus), by warming intravenous fluids and blood products, and by active body warming (grade C). Antibiotics should be given, if not already administered at the initial phase (professional consensus). Vascular fluids must be given (grade B), the choice being left at the physician discretion. Blood products transfusion should be decided based on the clinical severity of PPH (professional consensus). Priority is given to red blood cells (RBC) transfusion, with the aim to maintain Hb concentration>8g/dL. The first round of products could include 3 units of RBC (professional consensus), and the following round 3 units of RBC, and 3 units of fresh frozen plasma (FFP). The FFP:RBC ratio should be kept between 1:2 and 1:1 (professional consensus). Depending on the etiology of PPH, the early administration of FFP is left at the discretion of the physician (professional consensus). Platelet count should be maintained at>50 G/L (professional consensus). During massive PPH, fibrinogen concentration should be maintained at>2g/L (professional consensus). Fibrinogen can be given without prior fibrinogen measurement in case of massive bleeding (professional consensus). General anesthesia should be considered in case of hemodynamic instability, even when an epidural catheter is in place (professional consensus). CONCLUSION The anesthetic management aims to restore and maintain optimal respiratory state and circulation, to treat coagulation disorders, and to allow invasive obstetrical and radiologic procedures. Clinical and instrumental monitoring are needed to evaluate the severity of PPH, to guide the choice of therapeutic options, and to assess treatments efficacy.
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Affiliation(s)
- A G Aya
- Département anesthésie-douleur, groupe hospitalo-universitaire Caremeau, place du Pr.-Debré, 30029 Nîmes cedex 09, France; EA2992, faculté de médecine Montpellier-Nîmes, 186, chemin du Carreau-de-Lanes, 30029 Nîmes cedex 2, France.
| | - A-S Ducloy-Bouthors
- Pôle d'anesthésie-réanimation, CHU Lille, 2, avenue Oscar-Lambret, 59037 Lille, France
| | - L Rugeri
- Unité d'hémostase clinique, hôpital Édouard-Herriot, pavillon E 5, place d'Arsonval, 69003 Lyon, France
| | - J-C Gris
- Laboratoire et consultations d'hématologie, groupe hospitalo-universitaire Caremeau, place du Pr.-Debré, 30029 Nîmes cedex 09, France; EA2992, faculté de médecine Montpellier-Nîmes, 186, chemin du Carreau-de-Lanes, 30029 Nîmes cedex 2, France
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Straface G, Bassi E, De Santis M, Scambia G, Zanardo V. Tranfusion risk: is "two-step" vaginal delivery a risk for postpartum hemorrhage? J Matern Fetal Neonatal Med 2014; 28:2172-5. [PMID: 25354292 DOI: 10.3109/14767058.2014.980232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE In the active management strategy of third stage of labor, the optimal timing for clamping the umbilical cord after birth has been a subject of controversy. We want to evaluate if "two-step" delivery is a risk factor for postpartum hemorrhage (PPH), defined as need of transfusion, comparing to operative delivery, elective caesarean delivery and emergency caesarean delivery. METHODS This is a retrospective cohort study conducted in division of Perinatal Medicine, Policlinico Abano Terme. We evaluated the need of transfusion in all cases of PPH verified in all single deliveries between January 2011 and December 2012. The main outcome measure was blood loss and red blood cell transfusion. RESULTS We found 17 cases of PPH (0.88%). The distribution of PPH in relation to mode of delivery was 0.71%, 2.46% and 1.98% respectively for two-step vaginal delivery (RR = 0.81 (0.56-1.22)), emergency cesarean section (RR = 2.88 (1.27-7.77)) and operative vaginal delivery (RR = 2.88 (0.59-5.66)). In labor induction there is a stronger relative risk association between PPH and as emergency cesarean delivery (p < 0.05) as operative vaginal delivery (p < 0.05). CONCLUSION "Two-step" delivery approach did not increase the risk of PPH with respect to operative delivery, elective caesarean section and emergency caesarean section.
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Affiliation(s)
- Gianluca Straface
- a Division of Perinatal Medicine , Policlinico Abano Terme , Abano Terme , Italy and
| | - Emma Bassi
- a Division of Perinatal Medicine , Policlinico Abano Terme , Abano Terme , Italy and
| | - Marco De Santis
- b Department of Obstetrics and Gynaecology , Catholic University of Sacred Heart , Rome , Italy
| | - Giovanni Scambia
- b Department of Obstetrics and Gynaecology , Catholic University of Sacred Heart , Rome , Italy
| | - Vincenzo Zanardo
- a Division of Perinatal Medicine , Policlinico Abano Terme , Abano Terme , Italy and
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Fibrin-based clot formation as an early and rapid biomarker for progression of postpartum hemorrhage: a prospective study. Blood 2014; 124:1727-36. [DOI: 10.1182/blood-2014-04-567891] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Key Points
Fibtem is an early and rapidly available biomarker for predicting progression of moderate to severe postpartum hemorrhage. Fibtem was predictive of need for blood transfusion and invasive procedures, bleeds >2500 mL, duration of bleed, and time in high dependency.
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Steele HB, Goetzl L. The practical utility of routine postpartum hemoglobin assessment. Am J Obstet Gynecol 2014; 210:576.e1-6. [PMID: 24583198 DOI: 10.1016/j.ajog.2014.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 01/28/2014] [Accepted: 02/22/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate a policy of routine versus selective postpartum complete blood count (CBC). STUDY DESIGN Historic case control design with matched subjects from 1 year periods bracketing the policy change (n = 800). Our primary outcome was postpartum transfusion rate. Univariable and multivariable analyses were performed. Total hospital costs were estimated. RESULTS Eliminating routine postpartum CBC testing was associated with decreased transfusion rates (5.5% vs 1.8%, P = .007) despite similar transfusion risks. CBC utilization decreased from 59% to 22.2% (P < .0001). No adverse bleeding outcomes occurred. Multivariable modeling suggested that the occurrence of postpartum hemorrhage was the best clinical predictors of transfusion n risk. Tachycardia, oliguria, and symptoms were also effective at identifying transfusion candidates. Elimination of routine CBC was independently associated with a reduced risk of transfusion (odds ratio, 0.30; 95% confidence interval, 0.12-0.72). Annual cost savings were estimated at $58,000. CONCLUSION Targeted CBC testing results in fewer transfusions, lower costs and improved quality of patient care.
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Froessler B, Collingwood J, Hodyl NA, Dekker G. Intravenous ferric carboxymaltose for anaemia in pregnancy. BMC Pregnancy Childbirth 2014; 14:115. [PMID: 24667031 PMCID: PMC3986933 DOI: 10.1186/1471-2393-14-115] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 03/06/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Iron deficiency is a common nutritional deficiency amongst women of childbearing age. Peri-partum iron deficiency anaemia (IDA) is associated with significant maternal, fetal and infant morbidity. Current options for treatment are limited: these include oral iron supplementation, which can be ineffective and poorly tolerated, and red blood cell transfusions, which carry an inherent risk and should be avoided. Ferric carboxymaltose is a new treatment option that may be better tolerated.The study was designed to assess the safety and efficacy of iron deficiency anaemia (IDA) correction with intravenous ferric carboxymaltose in pregnant women with mild, moderate and severe anaemia in the second and third trimester. METHODS Prospective observational study; 65 anaemic pregnant women received ferric carboxymaltose up to 15 mg/kg between 24 and 40 weeks of pregnancy (median 35 weeks gestational age, SD 3.6). Treatment effectiveness was assessed by repeat haemoglobin (Hb) measurements and patient report of well-being in the postpartum period. Safety was assessed by analysis of adverse drug reactions and fetal heart rate monitoring during the infusion. RESULTS Intravenous ferric carboxymaltose infusion significantly increased Hb values (p < 0.01) above baseline levels in all women. Increased Hb values were observed at 3 and 6 weeks post infusion and up to 8 weeks post-infusion. Ferritin values increased significantly after the infusion. Only 4 women had repeat ferritin values post-partum which remained above baseline levels. Fetal heart rate monitoring did not indicate a drug related negative impact on the fetus. Of the 29 (44.6%) women interviewed, 19 (65.5%) women reported an improvement in their well-being and 9 (31%) felt no different after the infusion. None of the women felt worse. No serious adverse effects were found and minor side effects occurred in 13 (20%) patients. CONCLUSIONS Our prospective data is consistent with existing observational reports of the safe and effective use of ferric carboxymaltose in the treatment of iron deficiency anaemia in pregnancy.
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Affiliation(s)
- Bernd Froessler
- Department of Anaesthesia, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale 5112, South Australia, Australia.
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Clausen C, Lönn L, Langhoff-Roos J. Management of placenta percreta: a review of published cases. Acta Obstet Gynecol Scand 2013; 93:138-43. [PMID: 24266548 DOI: 10.1111/aogs.12295] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 10/23/2013] [Indexed: 11/30/2022]
Abstract
Publications on abnormally invasive placenta in general report what can be considered a mixture of the conditions true accreta, increta and percreta varieties. The aim of this review was to identify all published cases of the most severe condition, placenta percreta in order to describe complications associated with the three commonly used surgical strategies: local resection, hysterectomy or leaving the placenta in situ, and to describe the outcome, with respect to blood loss and transfusion requirements, with the different endovascular interventions that may be used as adjuncts in the management of the conditions. A PubMed search was performed in April 2013 and the final review included 119 published placenta percreta cases. Conservative management, where the placenta is left in situ for resorption, seems to be associated with severe long-term complications of hemorrhage and infections, including a 58% risk that a hysterectomy will eventually be needed up till nine months after the delivery. Local resection seems to be associated with fewer complications within 24 h postoperatively compared with hysterectomy or leaving the placenta in situ. A selection bias in the direction of less severe cases for the local resection technique might in part explain the lower complication rates with that approach. Future prospective data collection activities should include intended as well as actual management, and long-term follow-up of all cases is of vital importance.
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Affiliation(s)
- Caroline Clausen
- Department of Cardiovascular Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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