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Nii M, Oda T, Morikawa M, Nakabayashi Y, Adachi T, Kobayashi T, Itakura A. Changes in use and outcomes after fibrinogen concentrate insurance coverage for critical obstetrical hemorrhage: a nationwide questionnaire survey in Japan. Sci Rep 2024; 14:6711. [PMID: 38509152 PMCID: PMC10954662 DOI: 10.1038/s41598-024-57244-2] [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: 09/12/2023] [Accepted: 03/15/2024] [Indexed: 03/22/2024] Open
Abstract
Fibrinogen concentrate (FC) for acquired hypofibrinogenemia associated with critical obstetrical hemorrhage (COH) was covered by public medical insurance in September 2021 in Japan. We aimed to investigate changes in the policy of FC use and its effect on COH after insurance coverage. A primary survey covering September 2020 to August 2021 and a secondary survey covering September 2021 to August 2022 were conducted at 428 higher-level medical facilities. We investigated the policy of FC use in transfusion strategy and the maternal outcomes in COH. Among the hospitals that responded to both surveys, the number of facilities that use FC increased from 51.5 (101/196) to 78.6% (154/196) (P < 0.0001). The number of COH cases treated using FC increased from 14.3 to 24.3% (P < 0.0001) and that transfused with ≥ 10 units of red blood cells (RBCs) decreased from 36.8 to 29.8% (P = 0.001). The incidence of pulmonary edema reduced by 3.7-2.0% (P = 0.021), and transfusion-induced allergy by 1.9-0.7% (P = 0.008). No changes were observed in the incidence of thromboembolism, arterial embolization, or hysterectomy. The increased use of FC after insurance coverage led to changes in the transfusion strategy, which may be associated with decreases in transfusions of RBCs, pulmonary edema, and transfusion-induced allergies.
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Affiliation(s)
- Masafumi Nii
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Japan.
- The Japan Society of Obstetrical, Gynecological and Neonatal Hematology (JSOGNH), Kitakyushu, Japan.
| | - Tomoaki Oda
- The Japan Society of Obstetrical, Gynecological and Neonatal Hematology (JSOGNH), Kitakyushu, Japan
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Mamoru Morikawa
- The Japan Society of Obstetrical, Gynecological and Neonatal Hematology (JSOGNH), Kitakyushu, Japan
- Department of Obstetrics and Gynecology, Kansai Medical University, Osaka, Japan
| | - Yasushi Nakabayashi
- The Japan Society of Obstetrical, Gynecological and Neonatal Hematology (JSOGNH), Kitakyushu, Japan
- Department of Obstetrics and Gynecology, Nakabayashi Hospital, Tokyo, Japan
| | - Tomoko Adachi
- The Japan Society of Obstetrical, Gynecological and Neonatal Hematology (JSOGNH), Kitakyushu, Japan
- Department of Obstetrics and Gynecology, Aiiku Hospital, Tokyo, Japan
| | - Takao Kobayashi
- The Japan Society of Obstetrical, Gynecological and Neonatal Hematology (JSOGNH), Kitakyushu, Japan
- Department of Obstetrics and Gynecology, Hamamatsu Medical Center, Hamamatsu, Japan
| | - Atsuo Itakura
- The Japan Society of Obstetrical, Gynecological and Neonatal Hematology (JSOGNH), Kitakyushu, Japan
- Department of Obstetrics and Gynecology, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Nakajima K, Fujii T, Iriyama T, Ichinose M, Toshimitsu M, Sayama S, Seyama T, Kumasawa K, Ikeda T, Osuga Y. Efficacy of prompt administration of cryoprecipitate in severe postpartum hemorrhage of preeclampsia patients. J Obstet Gynaecol Res 2023; 49:2811-2816. [PMID: 37723942 DOI: 10.1111/jog.15792] [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: 06/30/2023] [Accepted: 09/01/2023] [Indexed: 09/20/2023]
Abstract
AIM Cryoprecipitate (CRYO) is a concentrated preparation of coagulation factors formulated from fresh frozen plasma (FFP), which can replenish coagulation factors rapidly. Preeclampsia (PE) is frequently associated with postpartum hemorrhage (PPH), and the rapid replenishment of coagulation factors is vital in the management. We conducted a retrospective cohort study to determine the efficacy of administering CRYO irrespective of fibrinogen levels in patients with PE who experienced severe PPH. METHODS Patients with PPH accompanied by PE and those who required red blood cell (RBC) transfusion were included. Cases were divided into two groups: those treated with CRYO (N = 16) and those not treated with CRYO (N = 10). The total transfusion volume, blood loss before and after transfusion initiation, duration of hospitalization, presence of pulmonary edema, and performance of either interventional radiology or hysterectomy were compared. RESULTS The median fibrinogen levels before transfusion were 2.24 and 2.34 g/L in the CRYO group and the not using group, respectively. Although blood loss before transfusion was comparable between the two groups, blood loss after transfusion was significantly less in the CRYO group (median: 520 vs. 2352 mL, p = 0.015), as well as the total blood loss (median: 2285 vs. 3825 mL, p = 0.005) and total transfusion volume (median: RBC 6 vs. 16 U, p = 0.01, FFP 10 vs. 20 U, p = 0.017). CONCLUSION Prompt replenishment of coagulation factors using CRYO to patients with PE who experience severe PPH could decrease further bleeding.
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Affiliation(s)
- Keisuke Nakajima
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Fujii
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takayuki Iriyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mari Ichinose
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatake Toshimitsu
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Seisuke Sayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takahiro Seyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keiichi Kumasawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiyuki Ikeda
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Umeda S, Abe T, Obata S, Aoki S, Takeuchi I. Effectiveness of call system implementation for postpartum hemorrhage in a tertiary emergency medical center: a retrospective cohort study. BMC Pregnancy Childbirth 2023; 23:787. [PMID: 37951860 PMCID: PMC10638699 DOI: 10.1186/s12884-023-06095-2] [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: 09/29/2022] [Accepted: 10/30/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Postpartum hemorrhage is the leading cause of maternal death and severe maternal morbidity worldwide. Previous studies have reported the importance of multidisciplinary treatment approaches for postpartum hemorrhage; however, only a few studies have shown a clear improvement in maternal outcomes. Therefore, this study aimed to investigate the efficacy of a call system for postpartum hemorrhage in a tertiary emergency facility for rapid multidisciplinary treatment and its effect on maternal outcomes. METHODS This single-center retrospective cohort study included patients transferred to our hospital due to postpartum hemorrhage between April 1, 2013, and March 31, 2019. The primary outcome was mortality, and the secondary outcomes were morbidity (duration of hospital stay, duration of intensive care unit stay, admission to the intensive care unit, respirator use, duration of ventilator support, acute kidney injury, transfusion-associated circulatory overload/transfusion-related acute lung injury, hysterectomy, composite adverse events, blood transfusion initiation time, blood transfusion volume, and treatment for postpartum hemorrhage). An in-hospital call system implementation commenced on April 1, 2016. The study outcomes were compared 3 years before and after implementing the call system. RESULTS The blood transfusion initiation time and duration of hospital stay were significantly shortened after implementing the call system for postpartum hemorrhage. No maternal deaths were observed after implementing the system. CONCLUSIONS Implementing call systems specialized for postpartum hemorrhage in tertiary emergency facilities may improve maternal outcomes.
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Affiliation(s)
- Sayo Umeda
- Perinatal Center for Maternity and Neonates, Yokohama City University Medical Center, Yokohama, Japan.
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, Japan.
| | - Takeru Abe
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Soichiro Obata
- Perinatal Center for Maternity and Neonates, Yokohama City University Medical Center, Yokohama, Japan
| | - Shigeru Aoki
- Perinatal Center for Maternity and Neonates, Yokohama City University Medical Center, Yokohama, Japan
| | - Ichiro Takeuchi
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, Japan
- Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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Ishida Y, Homma Y, Murakoshi T, Toba Y. Clinical experience of the use of fibrinogen concentrate for massive postpartum hemorrhage: a retrospective case series study. J Anesth 2023; 37:820-822. [PMID: 37620626 PMCID: PMC10543518 DOI: 10.1007/s00540-023-03247-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Affiliation(s)
- Yoshiaki Ishida
- Department of Anesthesiology, Seirei Hamamatsu General Hospital, Naka Ku, 2-12-12 Sumiyoshi, Hamamatsu, Shizuoka, 430-8558, Japan.
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Sumida-Ku, Tokyo, Japan.
| | - Yoichiro Homma
- Department of General Internal Medicine, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Takeshi Murakoshi
- Department of Obstetrics and Gynecology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Yoshie Toba
- Department of Anesthesiology, Seirei Hamamatsu General Hospital, Naka Ku, 2-12-12 Sumiyoshi, Hamamatsu, Shizuoka, 430-8558, Japan
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Lord MG, Calderon JA, Ahmadzia HK, Pacheco LD. Emerging technology for early detection and management of postpartum hemorrhage to prevent morbidity. Am J Obstet Gynecol MFM 2023; 5:100742. [PMID: 36075527 DOI: 10.1016/j.ajogmf.2022.100742] [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: 04/29/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
Despite advances in hemorrhage detection and management, postpartum hemorrhage remains the single leading cause of maternal death worldwide. Within the United States, hemorrhage is the leading cause of maternal death on the day of delivery and within the first week after delivery. Blood transfusion after hemorrhage represents a large proportion of severe maternal morbidity during and after delivery. Blood loss during delivery has historically been assessed visually by inspecting soiled pads, linens, and laparotomy sponges. These methods underestimate the volume of blood loss by as much as 40%, becoming increasingly inaccurate as blood loss increases. Young, healthy obstetrical patients compensate for blood loss via peripheral vasoconstriction, maintaining heart rate and blood pressure in a normal range until over 1 L of blood has been lost. A significant decrease in blood pressure along with marked tachycardia (>120 bpm) may not be seen until 30% to 40% of blood volume has been lost, or 2.0 to 2.6 L in a healthy term pregnant patient, after which the patient may rapidly decompensate. In resource-poor settings especially, the narrow window between the emergence of significant vital sign abnormalities and clinical decompensation may prove catastrophic. Once hemorrhage is detected, decisions regarding blood product transfusion are routinely made on the basis of inaccurate estimates of blood loss, placing patients at risk of underresuscitation (increasing the risk of hemorrhagic shock and end-organ damage) or overresuscitation (increasing the risk of transfusion reaction, fluid overload, and alloimmunization). We will review novel technologies that have emerged to assist both in the early and accurate detection of postpartum hemorrhage and in decisions regarding blood product transfusion.
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Affiliation(s)
- Megan G Lord
- Division of Maternal-Fetal Medicine, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI (Dr Lord).
| | - Joaquin A Calderon
- Division of Maternal-Fetal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (Drs Calderon and Ahmadzia)
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (Drs Calderon and Ahmadzia)
| | - Luis D Pacheco
- Divisions of Maternal-Fetal Medicine and Surgical Critical Care, University of Texas Medical Branch, Galveston, TX (Dr Pacheco)
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Ducloy-Bouthors AS, Mercier FJ, Grouin JM, Bayoumeu F, Corouge J, Le Gouez A, Rackelboom T, Broisin F, Vial F, Luzi A, Capronnier O, Huissoud C, Mignon A. Early and systematic administration of fibrinogen concentrate in postpartum haemorrhage following vaginal delivery: the FIDEL randomised controlled trial. BJOG 2021; 128:1814-1823. [PMID: 33713384 DOI: 10.1111/1471-0528.16699] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/30/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the benefits and safety of early human fibrinogen concentrate in postpartum haemorrhage (PPH) management. DESIGN Multicentre, double-blind, randomised placebo-controlled trial. SETTING 30 French hospitals. POPULATION Patients with persistent PPH after vaginal delivery requiring a switch from oxytocin to prostaglandins. METHODS Within 30 minutes after introduction of prostaglandins, patients received either 3 g fibrinogen concentrate or placebo. MAIN OUTCOME MEASURES Failure as composite primary efficacy endpoint: at least 4 g/dl of haemoglobin decrease and/or transfusion of at least two units of packed red blood cells within 48 hours following investigational medicinal product administration. Secondary endpoints: PPH evolution, need for haemostatic procedures and maternal morbidity-mortality within 6 ± 2 weeks after delivery. RESULTS 437 patients were included: 224 received FC and 213 placebo. At inclusion, blood loss (877 ± 346 ml) and plasma fibrinogen (4.1 ± 0.9 g/l) were similar in both groups (mean ± SD). Failure rates were 40.0% and 42.4% in the fibrinogen and placebo groups, respectively (odds ratio [OR] = 0.99) after adjustment for centre and baseline plasma fibrinogen; (95% CI 0.66-1.47; P = 0.96). No significant differences in secondary efficacy outcomes were observed. The mean plasma FG was unchanged in the Fibrinogen group and decreased by 0.56 g/l in the placebo group. No thromboembolic or other relevant adverse effects were reported in the Fibrinogen group versus two in the placebo group. CONCLUSIONS As previous placebo-controlled studies findings, early and systematic administration of 3 g fibrinogen concentrate did not reduce blood loss, transfusion needs or postpartum anaemia, but did prevent plasma fibrinogen decrease without any subsequent thromboembolic events. TWEETABLE ABSTRACT Early systematic blind 3 g fibrinogen infusion in PPH did not reduce anaemia or transfusion rate, reduced hypofibrinogenaemia and was safe.
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Affiliation(s)
- A S Ducloy-Bouthors
- Pole anesthésie réanimation, maternité Jeanne de Flandre, CHRU Lille, Lille, France.,ULR 7365 Université Lille, Lille, France
| | - F J Mercier
- Hôpital Antoine Béclère, Assistance Publique Hôpitaux de Paris, Clamart, France
| | - J M Grouin
- Inserm U1219, Population Health, Bordeaux, France
| | - F Bayoumeu
- Hôpital Paule de Viguier, CHU Toulouse, Toulouse, France
| | - J Corouge
- Pole anesthésie réanimation, maternité Jeanne de Flandre, CHRU Lille, Lille, France
| | - A Le Gouez
- Hôpital Antoine Béclère, Assistance Publique Hôpitaux de Paris, Clamart, France
| | - T Rackelboom
- Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - F Broisin
- Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - F Vial
- Maternité Adolphe Pinard, CHU de Nancy, Nancy, France
| | - A Luzi
- CHU Sud, St Pierre-de-la-Réunion, France
| | | | - C Huissoud
- Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,INSERM U846, Stem Cell and Brain Research Institute, Bron, France
| | - A Mignon
- Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
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Management of disseminated intravascular coagulation associated with placental abruption and measures to improve outcomes. Obstet Gynecol Sci 2019; 62:299-306. [PMID: 31538072 PMCID: PMC6737058 DOI: 10.5468/ogs.2019.62.5.299] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/26/2019] [Accepted: 04/17/2019] [Indexed: 11/08/2022] Open
Abstract
Placental abruption is a condition that should be carefully considered in perinatal management because it is associated with serious events in both the mother and neonate, such as intrauterine fetal death, cerebral palsy, obstetric critical bleeding, and uncontrollable bleeding. The concomitant presence of disseminated intravascular coagulation (DIC) more easily causes critical bleeding that may necessitate hysterectomy or multi-organ failure resulting in maternal death. Therefore, early management should be provided to prevent progression to serious conditions by performing both hemostatic procedures and DIC treatment. To take measures to improve the outcomes in both the mother and neonate, health guidance for pregnant women, early diagnosis, early treatment, development of the emergency care system, and provision of a system for transport to higher-level medical institutions should be implemented.
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Abstract
Background Postpartum hemorrhage (PPH) is related to several factors but is frequently associated with coagulopathy with maternal mortality. Fibrinogen is a very important agent for bleeding. When its concentration is decreased, severe surgical blood loss may occur. Here, we investigate the association of postpartum bleeding characteristics with evolution of PPH in patients who were taking fibrinogen concentrate (FC). Material/Methods PPH patients’ demographic parameters, outcome variables, and laboratory findings before and at ICU were recorded between January 2015 and July 2017. The duration of ICU stay and plasmapheresis, renal replacement therapy, maternal-fetal deaths, RBC, FFP, and PC replacement were calculated. Results Group I: Fibrinogen levels were ≤150 mg/dl (n: 31), Group II: Fibrinogen levels were >151 mg/dl (n: 18). In the peroperative period, there was no difference between the 2 groups in terms of RBC, FFP, or PC transfussion. In intraoperative and ICU admission period, patients in Group I had higher INR, APTT, and PT values than in the other group. FC replacement according to fibrinogen level was given, ranging from to 1 to 6 gr in Group I and 1–2 gr in Group II intraoperatively and at ICU 2–8 gr FC was given in both groups. In the intraoperative and ICU admission period, blood transfusion requirements of patients after fibrinogen replacement were evaluated and there was no statistically significant difference between groups. There were no differrences between groups in duration of intensive care unit stay, hospital stay, and mechanical ventilation. Conclusions Adequate FC therapy prevents unnecessary RBC, FFP, and PC replacement and prevents complications and volume overload.
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Affiliation(s)
- Ayca Sultan Sahin
- Department of Anesthesiology and Reanimation, SBU Kanuni Sultan Suleyman Education and Training Hospital, Istanbul, Turkey
| | - Sureyya Ozkan
- Department of Anesthesiology and Reanimation, SBU Kanuni Sultan Suleyman Education and Training Hospital, Istanbul, Turkey
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9
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Matsunaga S, Takai Y, Seki H. Fibrinogen for the management of critical obstetric hemorrhage. J Obstet Gynaecol Res 2018; 45:13-21. [PMID: 30155944 PMCID: PMC6585962 DOI: 10.1111/jog.13788] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/28/2018] [Indexed: 01/01/2023]
Abstract
AIM In cases of critical obstetric hemorrhage leading to extreme hypofibrinogenemia, fibrinogen is the marker that indicates the critical severity, and early fibrinogen supplementation centering on hemostatic resuscitation is a vital treatment to stabilize a catastrophic condition. In this review, we investigated the effect of fibrinogen level on hemostasis and what we can do to treat hypofibrinogenemia efficiently and improve patients' outcome. METHODS We reviewed numerous articles related to hypofibrinogenemia in critical obstetric hemorrhage. Especially, we performed a systematic review on target value of fibrinogen for hemostasis and effectiveness of fibrinogen concentrate. We also reviewed the articles about the methods for early normalization of fibrinogen level such as tranexamic acid, massive transfusion protocol, and point-of-care testing. RESULTS The target value of fibrinogen calculated by needs for massive transfusion was 200 mg/dL or 10 mm of A5FIBTEM . Although fibrinogen concentrate worked poorly on fibrinogen levels within the normal range, it improved the blood fibrinogen levels rapidly when it was administered to critical obstetric hemorrhage patients with serious hypofibrinogenemia. Hence, the volume of FFP transfused could be reduced along with a reduction in the frequency of pulmonary edema due to volume overload. CONCLUSION The patient group for which fibrinogen concentrate works most effectively is cases with severe hypofibrinogenemia. Further research is required in the light of evidence. The essence of the transfusion algorithm in critical obstetric hemorrhage is to approach the target value for obtaining hemostasis, ensure an accurate and prompt grasp of the severity using point-of-care testing, introduce a massive transfusion protocol and use tranexamic acid.
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Affiliation(s)
- Shigetaka Matsunaga
- Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Yasushi Takai
- Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Hiroyuki Seki
- Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
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10
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Seto S, Itakura A, Okagaki R, Suzuki M, Ishihara O. An algorithm for the management of coagulopathy from postpartum hemorrhage, using fibrinogen concentrate as first-line therapy. Int J Obstet Anesth 2017; 32:11-16. [DOI: 10.1016/j.ijoa.2017.03.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/28/2017] [Accepted: 03/10/2017] [Indexed: 11/29/2022]
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11
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The Clinical Efficacy of Fibrinogen Concentrate in Massive Obstetric Haemorrhage with Hypofibrinogenaemia. Sci Rep 2017; 7:46749. [PMID: 28436465 PMCID: PMC5402272 DOI: 10.1038/srep46749] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/24/2017] [Indexed: 12/28/2022] Open
Abstract
Massive obstetric haemorrhage remains a major cause of maternal death attributable to hypofibrinogenaemia. Transfusion of large volumes of fresh frozen plasma (FFP) is required to normalise fibrinogen levels. We compared the efficacy of FFP (F group) with that of FFP plus fibrinogen concentrate (F + F group) in massive obstetric haemorrhage. In this retrospective study, we compared the medical charts (2004–2016) of 137 patients with <150 mg/dl fibrinogen treated with F + F (n = 47; after August 2009) or F (n = 56; before August 2009). Although fibrinogen concentrate was only administered in severe cases, the FFP/red blood cell concentrate (RCC) ratio was significantly lower in the F + F group than in the F group. A sub-group analysis of cases requiring ≥18 RCC units showed that the F + F group received significantly less FFP than the F group (40.2 ± 19.6 versus 53.4 ± 18.5 units; P = 0.047) and showed significantly less pulmonary oedema (24.0% vs 57.1%; P < 0.05) in the absence of any significant differences in pre-transfusion coagulation, estimated blood loss, or RCC transfusion volume. Administration of fibrinogen concentrate increased the rate of fibrinogen supplementation five-fold and reduced FFP dosage, the FFP/RCC ratio, and the incidence of pulmonary oedema.
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12
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Abstract
Obstetric hemorrhage remains the leading cause of maternal death and severe morbidity worldwide. Although uterine atony is the most common cause of peripartum bleeding, abnormal placentation, coagulation disorders, and genital tract trauma contribute to adverse maternal outcomes. Given the inability to reliably predict patients at high risk for obstetric hemorrhage, all parturients should be considered susceptible, and extreme vigilance must be exercised in the assessment of blood loss and hemodynamic stability during the peripartum period. Obstetric-specific hemorrhage protocols, facilitating the integration and timely escalation of pharmacologic, radiological, surgical, and transfusion interventions, are critical to the successful management of peripartum bleeding.
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Affiliation(s)
- Emily J Baird
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mailcode UH2, Portland, OR 97239, USA.
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13
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Ducloy-Bouthors AS, Mignon A, Huissoud C, Grouin JM, Mercier FJ. Fibrinogen concentrate as a treatment for postpartum haemorrhage-induced coagulopathy: A study protocol for a randomised multicentre controlled trial. The fibrinogen in haemorrhage of DELivery (FIDEL) trial. Anaesth Crit Care Pain Med 2016; 35:293-8. [DOI: 10.1016/j.accpm.2015.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 10/18/2015] [Accepted: 10/30/2015] [Indexed: 10/22/2022]
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Abstract
Postpartum Haemorrhage (PPH) is a major cause of maternal morbidity and mortality. Treatment of acquired coagulopathy observed in severe PPH is an important part of PPH management, but is mainly based on literature in trauma patients, and data thus should be interpreted with caution. This review describes recent advances in transfusion strategy and in the use of tranexamic acid and fibrinogen concentrates in women with PPH.
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Affiliation(s)
- Marie Pierre Bonnet
- Department of Anaesthesia and Intensive Care Medicine, Paris Descartes University, Paris, France
| | - Dan Benhamou
- Department of Anaesthesia and Intensive Care Medicine, Paris Sud University, Paris, France
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15
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Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GDV. An update on the use of massive transfusion protocols in obstetrics. Am J Obstet Gynecol 2016; 214:340-4. [PMID: 26348379 DOI: 10.1016/j.ajog.2015.08.068] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/14/2015] [Accepted: 08/31/2015] [Indexed: 12/16/2022]
Abstract
Obstetrical hemorrhage remains a leading cause of maternal mortality worldwide. New concepts involving the pathophysiology of hemorrhage have been described and include early activation of both the protein C and fibrinolytic pathways. New strategies in hemorrhage treatment include the use of hemostatic resuscitation, although the optimal ratio to administer the various blood products is still unknown. Massive transfusion protocols involve the early utilization of blood products and limit the traditional approach of early massive crystalloid-based resuscitation. The evidence behind hemostatic resuscitation has changed in the last few years, and debate is ongoing regarding optimal transfusion strategies. The use of tranexamic acid, fibrinogen concentrates, and prothrombin complex concentrates has emerged as new potential alternative treatment strategies with improved safety profiles.
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Affiliation(s)
- Luis D Pacheco
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, TX; Department of Anesthesiology, The University of Texas Medical Branch at Galveston, Galveston, TX.
| | - George R Saade
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Maged M Costantine
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, TX
| | - Steven L Clark
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Gary D V Hankins
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, TX
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Makino S, Takeda S, Kobayashi T, Murakami M, Kubo T, Hata T, Masuzaki H. National survey of fibrinogen concentrate usage for post-partum hemorrhage in Japan: Investigated by the Perinatology Committee, Japan Society of Obstetrics and Gynecology. J Obstet Gynaecol Res 2015; 41:1155-60. [DOI: 10.1111/jog.12708] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 02/02/2015] [Accepted: 02/04/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Shintaro Makino
- Perinatology Committee; Japan Society of Obstetrics & Gynecology
- Department of Obstetrics and Gynecology; Juntendo University Faculty of Medicine; Tokyo
| | - Satoru Takeda
- Perinatology Committee; Japan Society of Obstetrics & Gynecology
- Department of Obstetrics and Gynecology; Juntendo University Faculty of Medicine; Tokyo
| | - Takao Kobayashi
- Perinatology Committee; Japan Society of Obstetrics & Gynecology
- Department of Obstetrics and Gynecology; Hamamatsu Medical Center; Shizuoka
| | - Maki Murakami
- Perinatology Committee; Japan Society of Obstetrics & Gynecology
- Department of Obstetrics and Gynecology; Aiwa Hospital; Saitama
| | - Takahiko Kubo
- Perinatology Committee; Japan Society of Obstetrics & Gynecology
- Division of Obstetrics, Center of Maternal-Fetal, Neonatal and Reproductive Medicine; National Center for Child Health and Development; Tokyo
| | - Toshiyuki Hata
- Perinatology Committee; Japan Society of Obstetrics & Gynecology
- Department of Perinatology and Gynecology; Kagawa University Graduate School of Medicine; Kagawa
| | - Hideaki Masuzaki
- Perinatology Committee; Japan Society of Obstetrics & Gynecology
- Department of Obstetrics and Gynecology; Nagasaki University Faculty of Medicine; Nagasaki Japan
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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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Ickx B, Samama C. Fibrinogen concentrates for post-partum haemorrhage? Do not miss the most relevant population! Br J Anaesth 2015; 114:548-50. [DOI: 10.1093/bja/aev033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Cryoprecipitate, originally developed as a therapy for patients with antihaemophilic factor deficiency, or haemophilia A, has been in use for almost 50 yr. However, cryoprecipitate is no longer administered according to its original purpose, and is now most commonly used to replenish fibrinogen levels in patients with acquired coagulopathy, such as in clinical settings with haemorrhage including cardiac surgery, trauma, liver transplantation (LT), or obstetric haemorrhage. Cryoprecipitate is a pooled product that does not undergo pathogen inactivation, and its administration has been associated with a number of adverse events, particularly transmission of blood-borne pathogens and transfusion-related acute lung injury. As a result of these safety concerns, along with emerging availability of alternative fibrinogen preparations, cryoprecipitate has been withdrawn from use in a number of European countries. Compared with the plasma from which it is prepared, cryoprecipitate contains a high concentration of coagulation factor VIII, coagulation factor XIII, and fibrinogen. Cryoprecipitate is usually licensed by regulatory authorities for the treatment of hypofibrinogenaemia, and recommended for supplementation when plasma fibrinogen levels decrease below 1 g litre(-1); however, this threshold is empiric and is not based on solid clinical evidence. Consequently, there is uncertainty over the appropriate dosing and optimal administration of cryoprecipitate, with some guidelines from professional societies to guide clinical practice. Randomized, controlled trials are needed to determine the clinical efficacy of cryoprecipitate, compared with the efficacy of alternative preparations. These trials will allow the development of evidence-based guidelines in order to inform physicians and guide clinical practice.
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Affiliation(s)
- B Nascimento
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - L T Goodnough
- Departments of Pathology and Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - J H Levy
- Departments of Anesthesiology and Surgery, Duke University School of Medicine, 2301 Erwin Road, 5691H HAFS, Box 3094, Durham, NC 27710, USA
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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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Ducloy-Bouthors AS, Susen S, Wong CA, Butwick A, Vallet B, Lockhart E. Medical Advances in the Treatment of Postpartum Hemorrhage. Anesth Analg 2014; 119:1140-7. [DOI: 10.1213/ane.0000000000000450] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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LUNDE J, STENSBALLE J, WIKKELSØ A, JOHANSEN M, AFSHARI A. Fibrinogen concentrate for bleeding--a systematic review. Acta Anaesthesiol Scand 2014; 58:1061-74. [PMID: 25059813 DOI: 10.1111/aas.12370] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2014] [Indexed: 12/19/2022]
Abstract
Fibrinogen concentrate as part of treatment protocols increasingly draws attention. Fibrinogen substitution in cases of hypofibrinogenaemia has the potential to reduce bleeding, transfusion requirement and subsequently reduce morbidity and mortality. A systematic search for randomised controlled trials (RCTs) and non-randomised studies investigating fibrinogen concentrate in bleeding patients was conducted up to November 2013. We included 30 studies of 3480 identified (7 RCTs and 23 non-randomised). Seven RCTs included a total of 268 patients (165 adults and 103 paediatric), and all were determined to be of high risk of bias and none reported a significant effect on mortality. Two RCTs found a significant reduction in bleeding and five RCTs found a significant reduction in transfusion requirements. The 23 non-randomised studies included a total of 2825 patients, but only 11 of 23 studies included a control group. Three out of 11 found a reduction in transfusion requirements while mortality was reduced in two and bleeding in one. In the available RCTs, which all have substantial shortcomings, we found a significant reduction in bleeding and transfusions requirements. However, data on mortality were lacking. Weak evidence from RCTs supports the use of fibrinogen concentrate in bleeding patients, primarily in elective cardiac surgery, but a general use of fibrinogen across all settings is only supported by non-randomised studies with serious methodological shortcomings. It seems pre-mature to conclude whether fibrinogen concentrate has a routine role in the management of bleeding and coagulopathic patients. More RCTs are urgently warranted.
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Affiliation(s)
- J. LUNDE
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. STENSBALLE
- Section for Transfusion Medicine; Capital Region Blood Bank; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesia; Centre of Head and Orthopedics; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. WIKKELSØ
- Department of Anaesthesia and Intensive Care Medicine; Herlev Hospital; University of Copenhagen; Copenhagen Denmark
| | - M. JOHANSEN
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesiology; Department of Neuroanaesthesia and Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. AFSHARI
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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Era S, Matsunaga S, Matsumura H, Murayama Y, Takai Y, Seki H. Usefulness of shock indicators for determining the need for blood transfusion after massive obstetric hemorrhage. J Obstet Gynaecol Res 2014; 41:39-43. [DOI: 10.1111/jog.12480] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 04/18/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Sumiko Era
- Center for Maternal, Fetal and Neonatal Medicine; Saitama Medical Center; Saitama Medical University; Kawagoe Japan
| | - Shigetaka Matsunaga
- Center for Maternal, Fetal and Neonatal Medicine; Saitama Medical Center; Saitama Medical University; Kawagoe Japan
| | - Hideyoshi Matsumura
- Center for Maternal, Fetal and Neonatal Medicine; Saitama Medical Center; Saitama Medical University; Kawagoe Japan
| | - Yoshihiko Murayama
- Center for Maternal, Fetal and Neonatal Medicine; Saitama Medical Center; Saitama Medical University; Kawagoe Japan
| | - Yasushi Takai
- Center for Maternal, Fetal and Neonatal Medicine; Saitama Medical Center; Saitama Medical University; Kawagoe Japan
| | - Hiroyuki Seki
- Center for Maternal, Fetal and Neonatal Medicine; Saitama Medical Center; Saitama Medical University; Kawagoe Japan
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Kobayashi T. Obstetrical disseminated intravascular coagulation score. J Obstet Gynaecol Res 2014; 40:1500-6. [DOI: 10.1111/jog.12426] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 02/10/2014] [Indexed: 11/28/2022]
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Butwick A. Postpartum hemorrhage and low fibrinogen levels: the past, present and future. Int J Obstet Anesth 2013; 22:87-91. [DOI: 10.1016/j.ijoa.2013.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 01/14/2013] [Indexed: 10/27/2022]
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