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Akaishi T, Tarasawa K, Hamada H, Iwama N, Tomita H, Akaishi M, Fushimi K, Fujimori K, Yaegashi N, Saito M. Prenatal hypertension as the risk of eclampsia, HELLP syndrome, and critical obstetric hemorrhage. Hypertens Res 2024; 47:455-466. [PMID: 37993593 PMCID: PMC10838768 DOI: 10.1038/s41440-023-01511-8] [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: 07/29/2023] [Revised: 09/28/2023] [Accepted: 10/20/2023] [Indexed: 11/24/2023]
Abstract
Critical bleeding is a common cause of maternal mortality in obstetric patients. However, the non-obstetric factors underlying critical obstetric bleeding remain uncertain. Therefore, this study aimed to clarify the impact of chronic hypertension on obstetric hemorrhage by evaluating a nationwide administrative database in Japan. Women who gave birth between 2018 and 2022 were enrolled. The primary outcome was critical hemorrhage requiring massive red blood cell (RBC) transfusion during childbirth. In total, 354, 299 eligible women were selected from the database. The maternal mortality rate was >1.0% among those who received a massive RBC transfusion (≥4000 cc), and this amount was used as the cutoff of the outcome. Critical hemorrhage was less frequent with elective Caesarean section (CS) compared with vaginal childbirth or emergent CS (odds ratio [OR], 0.38; 95% confidence interval, 0.30-0.47). Multiple logistic regression analysis adjusting for these obstetric risks revealed that a higher maternal age (adjusted OR [aOR] per 1 year, 1.07 [1.05-1.09]); oral medications with prednisolone (aOR, 2.5 [1.4-4.4]), anti-coagulants (aOR, 10 [5.4-19]), and anti-platelets (aOR, 2.9 [1.3-6.4]); and a prenatal history of hypertension (aOR, 2.5 [1.5-4.4]) and hypoproteinemia (aOR, 5.8 [1.7-20]) are the risks underlying critical obstetric hemorrhage. Prenatal history of hypertension was significantly associated with obstetric disseminated intravascular coagulation (OR, 1.9 [1.5-2.4]); Hemolysis, Elevated Liver enzymes, and Low platelet count (HELLP) syndrome (OR, 3.3 [2.7-4.2]); and eclampsia (OR, 6.1 [4.6-8.1]). In conclusion, a maternal prenatal history of hypertension is associated with the development of HELLP syndrome, eclampsia, and resultant critical hemorrhage. The incidence of HELLP syndrome and eclampsia increased more than fivefold in the presence of prenatal hypertension. However, the likelihood of subsequently developing DIC or experiencing critical bleeding did not change by the presence of prenatal hypertension.
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Affiliation(s)
- Tetsuya Akaishi
- Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan.
| | - Kunio Tarasawa
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hirotaka Hamada
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyuki Iwama
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hasumi Tomita
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miho Akaishi
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Tokyo, Japan
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Masatoshi Saito
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Guan CS, Boyer TM, Darwin KC, Henshaw C, Michos ED, Lawson S, Vaught AJ. Racial disparities in care escalation for postpartum hemorrhage requiring transfusion. Am J Obstet Gynecol MFM 2023; 5:100938. [PMID: 36948294 PMCID: PMC10481353 DOI: 10.1016/j.ajogmf.2023.100938] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Postpartum hemorrhage is a leading cause of maternal morbidity and mortality in the United States and disproportionately affects pregnant persons of color. OBJECTIVE This study aimed to identify the demographic and obstetrical characteristics of those who received different levels of antihemorrhagic intervention in the setting of severe postpartum hemorrhage requiring blood transfusion. STUDY DESIGN This was a retrospective cohort study of patients with documented postpartum hemorrhage (estimated blood loss of ≥1000 mL) and blood product transfusion. Moreover, 3 levels of antihemorrhagic intervention were defined as follows: level 1, administration of uterotonics only; level 2, performance of a procedure (ie, B-Lynch suture, O'Leary stitch, Bakri balloon, dilation and curettage, laceration repair, or embolization); and level 3, hysterectomy. Maternal demographics, obstetrical characteristics, and comorbidities were extracted from electronic health records. Ordinal logistic regression was used to estimate the odds of higher intervention levels adjusting for maternal demographic and obstetrical characteristics. RESULTS Of note, 365 patients were included in this study, with a racial or ethnic composition of 30% White, 42% Black, 18% Hispanic, and 10% other. Moreover, 233 patients (64%) received level 1 intervention, 98 patients (27%) received level 2 intervention, and 34 patients (9%) received level 3 intervention. Patients receiving higher levels of intervention were more likely to have greater estimated blood loss (P<.001), have more transfusions (P<.001), and be of advanced maternal age (P=.004). Black and Hispanic patients were less likely to have received higher levels of intervention than White patients (P=.034). After adjusting for estimated blood loss, advanced maternal age, placenta accreta spectrum, and fibroids, Black patients remained significantly less likely to receive higher levels of intervention (adjusted odds ratio, 0.55; 95% confidence interval, 0.30-0.98). This difference persisted at an estimated blood loss of ≥3000 mL, with Black and Hispanic patients being significantly less likely to receive higher levels of intervention than White patients (odds ratio, 0.31 [95% confidence interval, 0.10-0.92] and 0.10 [95% confidence interval, 0.01-0.53], respectively). CONCLUSION Among patients experiencing postpartum hemorrhage and receiving transfusion, Black patients are less likely to receive higher levels of antihemorrhagic intervention. This disparity is concerning in this high-risk population and requires further attention and investigation.
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Affiliation(s)
- Carolyn S Guan
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD (Mses Guan and Boyer and Drs Darwin, Henshaw, Lawson, and Vaught)
| | - Theresa M Boyer
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD (Mses Guan and Boyer and Drs Darwin, Henshaw, Lawson, and Vaught)
| | - Kristin C Darwin
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD (Mses Guan and Boyer and Drs Darwin, Henshaw, Lawson, and Vaught)
| | - Chelsea Henshaw
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD (Mses Guan and Boyer and Drs Darwin, Henshaw, Lawson, and Vaught)
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr Michos)
| | - Shari Lawson
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD (Mses Guan and Boyer and Drs Darwin, Henshaw, Lawson, and Vaught)
| | - Arthur J Vaught
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD (Mses Guan and Boyer and Drs Darwin, Henshaw, Lawson, and Vaught).
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Ogoyama M, Takahashi H, Baba Y, Yamamoto H, Horie K, Nagayama S, Suzuki H, Usui R, Ohkuchi A, Matsubara S, Fujiwara H. Bleeding-related outcomes of low-risk total placenta previa are equivalent to those of partial/marginal placenta previa. Taiwan J Obstet Gynecol 2022; 61:447-452. [PMID: 35595436 DOI: 10.1016/j.tjog.2022.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To clarify whether "low-risk total PP" patients bleed more than partial/marginal PP patients. MATERIALS AND METHODS The retrospective cohort study was performed involving patients with PP between April 2006 and December 2018. The placental position was determined by ultrasound. From medical charts, the backgrounds as well as obstetric and neonatal outcomes of PP patients were retrieved. RESULTS This study included 349 patients with PP, which was classified into three types according to the distance between the placenta and internal ostium: total (n = 174), partial (n = 52), and marginal (n = 123) PP. In total PP patients, three factors (prior CS, anterior placenta, and placental lacunae on ultrasound) significantly increased blood loss at CS, the need for hysterectomy, homologous transfusion (≥10 U), and ICU admission. No significant difference was observed in bleeding-related poor outcomes (rate of blood loss ≥2000 mL, amount of homologous transfusion, need for hysterectomy, and ICU admission) between total PP patients without all three factors: "low-risk total PP patients" and partial/marginal PP patients (19.8 vs. 17.1%; p = 0.604, 3.7 vs. 1.1%; p = 0.330, 1.2 vs. 1.1%; p = 1.000, and 1.2 vs. 1.1%; p = 1.000, respectively). CONCLUSION Prior CS, anterior placenta, and placental lacunae on ultrasound were risk factors for a bleeding-related poor outcome in total PP patients. Total PP patients without these three factors showed the same bleeding-related poor outcome as partial/marginal PP patients.
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Affiliation(s)
- Manabu Ogoyama
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan.
| | - Yosuke Baba
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan
| | - Hiromichi Yamamoto
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan
| | - Kenji Horie
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan
| | - Shiho Nagayama
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan
| | - Hirotada Suzuki
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan
| | - Rie Usui
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan
| | - Akihide Ohkuchi
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan
| | - Shigeki Matsubara
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan
| | - Hiroyuki Fujiwara
- Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1, Shimotsuke, Tochigi 329-0498, Japan
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Retrospective Evaluation of Anesthetic Management in Cesarean Sections of Pregnant Women with Placental Anomaly. Anesthesiol Res Pract 2020; 2020:1358258. [PMID: 32411215 PMCID: PMC7210521 DOI: 10.1155/2020/1358258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/09/2020] [Indexed: 11/17/2022] Open
Abstract
Background In this study, patients who underwent cesarean section and had placenta previa and placenta accreta were examined and compared in terms of haemorrhagic indicators and perioperative anesthetic management. Methods A retrospective study was conducted in a university hospital in Kahramanmaras, Turkey. It included 95 pregnant women who had placental anomaly and underwent cesarean section between December 15, 2014, and February 15, 2016. Results The pregnant women were divided into two groups: Group P (previa) (n = 67) and Group A (accreta) (n = 28). The types of anesthesia administered were general anesthesia (GA), which was administered to 50 patients (74.6%) in Group P and 27 patients (96.4%) in Group A, and spinal anesthesia (SA), which was administered to 17 patients (25.4%) in Group P and one patient (3.6%) in Group A.. The mean blood loss was 685.82 ± 262.82 in Group P and 1582.14 ± 790.71 in Group A, and the given amount of crystalloid was higher in Group A with an average of 1628.57 ± 728.19 ml. The use of erythrocyte and fresh frozen plasma solution was higher in Group A than Group P. Eleven patients were intubated and taken to the Intensive Care Unit (ICU) in Group A. Postoperative mechanical ventilation duration was significantly higher in Group A (75.14 ± 43.84 h) (p < 0.001). ICU stay was longer in Group A with 2.80 ± 1.13 days. (p < 0.001). Conclusion The intraoperative management and the availability of postoperative ICU conditions are important in placental anomalies cases. The communication between operation team with regard to the development of a standard protocol for these cases will be of great benefit in reducing morbidity and mortality.
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Beckmann N, Sutton JM, Hoehn RS, Jernigan PL, Friend LA, Johanningman TA, Schuster RM, Lentsch AB, Caldwell CC, Pritts TA. IFNγ and TNFα mediate CCL22/MDC production in alveolar macrophages after hemorrhage and resuscitation. Am J Physiol Lung Cell Mol Physiol 2020; 318:L864-L872. [PMID: 32101016 DOI: 10.1152/ajplung.00455.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Acute lung injury is a major complication of hemorrhagic shock and the required resuscitation with large volumes of crystalloid fluids and blood products. We previously identified a role of macrophage-derived chemokine (CCL22/MDC) pulmonary inflammation following hemorrhage and resuscitation. However, further details regarding the induction of CCL22/MDC and its precise role in pulmonary inflammation after trauma remain unknown. In the current study we used in vitro experiments with a murine alveolar macrophage cell line, as well as an in vivo mouse model of hemorrhage and resuscitation, to identify key regulators in CCL22/MDC production. We show that trauma induces expression of IFNγ, which leads to production of CCL22/MDC through a signaling mechanism involving p38 MAPK, NF-κB, JAK, and STAT-1. IFNγ also activates TNFα production by alveolar macrophages, potentiating CCL22/MDC production via an autocrine mechanism. Neutralization of IFNγ or TNFα with specific antibodies reduced histological signs of pulmonary injury after hemorrhage and reduced inflammatory cell infiltration into the lungs.
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Affiliation(s)
- Nadine Beckmann
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jeffrey M Sutton
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Richard S Hoehn
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Peter L Jernigan
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Lou Ann Friend
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Taylor A Johanningman
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Rebecca M Schuster
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Alex B Lentsch
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Charles C Caldwell
- Division of Research, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Division of Research, Shriners Hospital for Children, Cincinnati, Ohio
| | - Timothy A Pritts
- Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Zea-Prado F, Hernández-Pacheco J, Ortiz-Ramírez M, Gutiérrez-Marín A, Estrada-Gutierrez G, Escobar M, Seligson-Rios A, Espino-Y-Sosa S. Initial management of primary postpartum hemorrhage: a survey. J Matern Fetal Neonatal Med 2019; 34:2841-2847. [PMID: 31570073 DOI: 10.1080/14767058.2019.1671342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The objective of this study is to evaluate the actions taken by obstetricians when faced with postpartum hemorrhage (PPH). MATERIALS AND METHODS A standardized open-ended survey was applied to 235 physicians at five hospitals and at an obstetrics and gynecology conference, inquiring about which actions are recommended in the initial stages of PPH. We calculated the frequency and confidence intervals of the actions mentioned and correlated the number of actions with the number of clinicians mentioning them using Spearman's rho test. RESULTS Asking for help was mentioned by 45% of the respondents and 38% asked for vital signs. Only one-fifth of those surveyed asked for blood count, coagulation testing, arterial blood gas, or urinary catheter. Very few mentioned hypothermia prevention, oxygen administration, or blood transfusion. A total of 80% of those interviewed only mentioned 3 of the 16 recommended actions. CONCLUSION Postpartum hemorrhage training should include instructions on initial steps in order to improve treatment comprehension and outcomes.
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Affiliation(s)
| | | | | | | | | | - Maria Escobar
- Instituto Nacional de Perinatologia, Mexico City, Mexico
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7
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Gillissen A, van den Akker T, Caram-Deelder C, Henriquez DDCA, Bloemenkamp KWM, van Roosmalen JJM, Eikenboom J, van der Bom JG. Association between fluid management and dilutional coagulopathy in severe postpartum haemorrhage: a nationwide retrospective cohort study. BMC Pregnancy Childbirth 2018; 18:398. [PMID: 30305108 PMCID: PMC6180574 DOI: 10.1186/s12884-018-2021-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/24/2018] [Indexed: 01/05/2023] Open
Abstract
Background The view that 2 l of crystalloid and 1.5 l of colloid can be infused while awaiting compatible blood for patients with major postpartum haemorrhage is based on expert opinion documents. We describe real-world changes in levels of coagulation parameters after the administration of different volumes of clear fluids to women suffering from major postpartum haemorrhage. Methods We performed a nationwide retrospective cohort study in the Netherlands among 1038 women experiencing severe postpartum haemorrhage who had received at least four units of red cells or fresh frozen plasma or platelets in addition to red cells. The volume of clear fluids administered before the time of blood sampling was classified into three fluid administration strategies, based on the RCOG guideline: < 2 L, 2–3.5 L and > 3.5 L. Outcomes included haemoglobin, haematocrit, platelet count, fibrinogen, aPTT and PT levels. Results Haemoglobin, haematocrit, platelet count, fibrinogen and aPTT were associated with volumes of clear fluids, which was most pronounced early during the course of postpartum haemorrhage. During the earliest phases of postpartum haemorrhage median haemoglobin level was 10.1 g/dl (IQR 8.5–11.6) among the women who received < 2 L clear fluids and 8.1 g/dl (IQR 7.1–8.4) among women who received > 3.5 L of clear fluids; similarly median platelet counts were 181 × 109/litre (IQR 131–239) and 89 × 109/litre (IQR 84–135), aPTT 29 s (IQR 27–33) and 38 s (IQR 35–55) and fibrinogen 3.9 g/L (IQR 2.5–5.2) and 1.6 g/L (IQR 1.3–2.1). Conclusions In this large cohort of women with severe postpartum haemorrhage, administration of larger volumes of clear fluids was associated with more severe deterioration of coagulation parameters corresponding to dilution. Our findings provide thus far the best available evidence to support expert opinion-based guidelines recommending restrictive fluid resuscitation in women experiencing postpartum haemorrhage. Trial registration Netherlands Trial Register (NTR4079), registration date July 17, 2013. Electronic supplementary material The online version of this article (10.1186/s12884-018-2021-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ada Gillissen
- Center for Clinical Transfusion Research, Sanquin Research, Plesmanlaan 1a - 5th floor, 2333, BZ, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands.,Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands.,National Perinatal Epidemiology Unit, University of Oxford, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - Camila Caram-Deelder
- Center for Clinical Transfusion Research, Sanquin Research, Plesmanlaan 1a - 5th floor, 2333, BZ, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Dacia D C A Henriquez
- Center for Clinical Transfusion Research, Sanquin Research, Plesmanlaan 1a - 5th floor, 2333, BZ, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands.,Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Kitty W M Bloemenkamp
- Department of Obstetrics, Birth Centre Wilhelmina's Children Hospital, University Medical Center Utrecht, Lundlaan 6, 3584, EA, Utrecht, The Netherlands
| | - Jos J M van Roosmalen
- Department of Obstetrics, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands.,Athena Institute, VU University Amsterdam, De Boelelaan 1105, 1081, HV, Amsterdam, The Netherlands
| | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Johanna G van der Bom
- Center for Clinical Transfusion Research, Sanquin Research, Plesmanlaan 1a - 5th floor, 2333, BZ, Leiden, The Netherlands. .,Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands.
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Kennedy BB, McMurtry Baird S. Collaborative Strategies for Management of Obstetric Hemorrhage. Crit Care Nurs Clin North Am 2017; 29:315-330. [PMID: 28778291 DOI: 10.1016/j.cnc.2017.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Obstetric hemorrhage is a significant cause of perinatal morbidity and mortality that requires prompt recognition and collaborative intervention to prevent poor outcomes. Medical and surgical management goals include controlling bleeding, supporting tissue oxygenation and perfusion, and monitoring for coagulopathies and complications.
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Affiliation(s)
- Betsy Babb Kennedy
- Vanderbilt University School of Nursing, 204 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240, USA.
| | - Suzanne McMurtry Baird
- Clinical Concepts in Obstetrics, Inc, Nashville, TN, USA; Labor and Delivery, Vanderbilt University Medical Center, Vanderbilt University School of Nursing, Nashville, TN, USA
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Hoehn RS, Jernigan PL, Chang AL, Edwards MJ, Caldwell CC, Gulbins E, Pritts TA. Acid Sphingomyelinase Inhibition Prevents Hemolysis During Erythrocyte Storage. Cell Physiol Biochem 2016; 39:331-40. [PMID: 27352097 PMCID: PMC5731776 DOI: 10.1159/000445627] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 12/29/2022] Open
Abstract
Background/Aims During storage, units of human red blood cells (pRBCs) experience membrane destabilization and hemolysis which may cause harm to transfusion recipients. This study investigates whether inhibition of acid sphingomyelinase could stabilize erythrocyte membranes and prevent hemolysis during storage. Methods Human and murine pRBCs were stored under standard blood banking conditions with and without the addition of amitriptyline, a known acid sphingomyelinase inhibitor. Hemoglobin was measured with an electronic hematology analyzer and flow cytometry was used to measure erythrocyte size, complexity, phosphatidylserine externalization, and band 3 protein expression. Results Cell-free hemoglobin, a marker of hemolysis, increased during pRBC storage. Amitriptyline treatment decreased hemolysis in a dose-dependent manner. Standard pRBC storage led to loss of erythrocyte size and membrane complexity, increased phosphatidylserine externalization, and decreased band 3 protein integrity as determined by flow cytometry. Each of these changes was reduced by treatment with amitriptyline. Transfusion of amitriptyline-treated pRBCs resulted in decreased circulating free hemoglobin. Conclusion Erythrocyte storage is associated with changes in cell size, complexity, membrane molecular composition, and increased hemolysis. Acid sphingomyelinase inhibition reduced these changes in a dose-dependent manner. Our data suggest a novel mechanism to attenuate the harmful effects after transfusion of aged blood products.
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Affiliation(s)
- Richard S Hoehn
- Department of Surgery and Institute for Military Medicine, University of Cincinnati, Cincinnati, USA
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Cleland S, Corredor C, Ye JJ, Srinivas C, McCluskey SA. Massive haemorrhage in liver transplantation: Consequences, prediction and management. World J Transplant 2016; 6:291-305. [PMID: 27358774 PMCID: PMC4919733 DOI: 10.5500/wjt.v6.i2.291] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 03/16/2016] [Accepted: 04/11/2016] [Indexed: 02/05/2023] Open
Abstract
From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity (need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both pro- and anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shown improvements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.
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11
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Hoehn RS, Jernigan PL, Chang AL, Edwards MJ, Pritts TA. Molecular mechanisms of erythrocyte aging. Biol Chem 2016; 396:621-31. [PMID: 25803075 DOI: 10.1515/hsz-2014-0292] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 03/10/2015] [Indexed: 01/08/2023]
Abstract
Anemia and hemorrhagic shock are leading causes of morbidity and mortality worldwide, and transfusion of human blood products is the ideal treatment for these conditions. As human erythrocytes age during storage in blood banks they undergo many biochemical and structural changes, termed the red blood cell 'storage lesion'. Specifically, ATP and pH levels decrease as metabolic end products, oxidative stress, cytokines, and cell-free hemoglobin increase. Also, membrane proteins and lipids undergo conformational and organizational changes that result in membrane loss, viscoelastic changes and microparticle formation. As a result, transfusion of aged blood is associated with a host of adverse consequences such as decreased tissue perfusion, increased risk of infection, and increased mortality. This review summarizes current research detailing the known parts of the erythrocyte storage lesion and their physiologic consequences.
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Phillippi JC, Buxton M, Overstreet M. Interprofessional simulation of a retained placenta and postpartum hemorrhage. Nurse Educ Pract 2015; 15:333-8. [PMID: 25707310 DOI: 10.1016/j.nepr.2015.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 01/29/2015] [Accepted: 02/05/2015] [Indexed: 11/26/2022]
Abstract
To improve quality and safety in healthcare, national and international organizations have called for students to receive dedicated training in interprofessional communication and collaboration. We developed a simulation for nurse-midwifery and nurse-anesthesia students, using the Core Competencies for Interprofessional Collaborative Practice framework. The simulation, involving a postpartum women with a retained placenta and acute blood loss, allowed students to collaboratively manage a high-risk situation. We present the details of the simulation and evaluation to assist educators.
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Affiliation(s)
- Julia C Phillippi
- Vanderbilt University School of Nursing, 517 Godchaux Hall, 461 21st Ave South, Nashville, TN 37240, USA.
| | - Margaret Buxton
- Vanderbilt University School of Nursing, 345 Frist Hall, Nashville, TN 37240, USA.
| | - Maria Overstreet
- Middle Tennessee School of Anesthesia, 315 Hospital Drive, Madison, TN 37116, USA.
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