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Madar H, Sentilhes L, Deneux-Tharaux C. Importance of the time sequence between measurement of the predictor and the predicted outcome. Int J Obstet Anesth 2024; 58:103991. [PMID: 38580609 DOI: 10.1016/j.ijoa.2024.103991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 12/27/2023] [Accepted: 03/13/2024] [Indexed: 04/07/2024]
Affiliation(s)
- Hugo Madar
- Université Paris Cité, Women's Health IHM, U1153, Centre of Research In Epidemiology and Statistics, Obstetrical, Perinatal and Pediatric Epidemiology EPOPé Research Team, INSERM, INRAE, Paris, France; Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France.
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Catherine Deneux-Tharaux
- Université Paris Cité, Women's Health IHM, U1153, Centre of Research In Epidemiology and Statistics, Obstetrical, Perinatal and Pediatric Epidemiology EPOPé Research Team, INSERM, INRAE, Paris, France
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Köroğlu N, Tayyar A, Soydar A, Albayrak N, Aydın T, Çetin BA. Pre-delivery fibrinogen level is a predictor for severity of placental abruption. Eur J Obstet Gynecol Reprod Biol X 2023; 20:100264. [PMID: 38058588 PMCID: PMC10696460 DOI: 10.1016/j.eurox.2023.100264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/05/2023] [Accepted: 11/24/2023] [Indexed: 12/08/2023] Open
Abstract
Objective To determine pre-delivery fibrinogen levels in predicting adverse maternal or neonatal outcomes in patients with placental abruption. Materials and method We conducted a retrospective study of all women admitted for placental abruption between January 2012 and May 2018. Postpartum hemorrhage (PPH), disseminated intravascular coagulation (DIC), massive blood transfusion and hospitalization in intensive care unit parameters were evaluated for maternal outcomes. For the neonatal outcomes, the 5th minute APGAR score, umbilical artery pH and stillbirth were evaluated. Results The mean predelivery fibrinogen levels were 221.3 ± 111.6 mg/dL. In multivariate logistic regression analysis, fibrinogen level was determined as an independent indicator for PPH, red cell concentrate (RCC) and fresh frozen plasma (FFP) transfusion. When fibrinogen levels decreased below 130 mg/dL, the risk of PPH increased and when fibrinogen levels decreased below 100 mg/dL, the risk of overt DİC and also the risk of red cell concentrate and fresh frozen plasma transfusion increased. In terms of the fetal results, there may be adverse neonatal outcomes when fibrinogen levels are below 250 mg/dL. Conclusion Predelivery fibrinogen levels are good indicators for predicting adverse maternal outcomes in placental abruption cases. In addition, fibrinogen levels might be a guide for management of placental abruption cases.
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Affiliation(s)
- Nadiye Köroğlu
- Acıbadem Mehmet Ali Aydınlar University, Faculty of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Ahmet Tayyar
- Acıbadem Mehmet Ali Aydınlar University, Faculty of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Ali Soydar
- Akhisar Mustafa Kirazoğlu State Hospital, Department of Obstetrics and Gynecology, Manisa, Turkey
| | - Nazli Albayrak
- Acıbadem Mehmet Ali Aydınlar University, Faculty of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Turgut Aydın
- Acıbadem Mehmet Ali Aydınlar University, Faculty of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Berna Aslan Çetin
- Başakşehir Çam ve Sakura City Hospital, Department of Obstetrics and Gynecology, İstanbul, Turkey
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Madar H, Deneux-Tharaux C, Froeliger A, Bouchghoul H, Sentilhes L. [H. Madar, C. Deneux-Tharaux, A. Froeliger, H. Bouchghoul, L. Sentilhes in reply to the article R Cahierc et al. entitled « Evolution of the obstetrical Shock Index in post-partum haemorrhage according to the use of sulprostone». Gynecol Obstet Fertil 2023; 51(10): Doi: 10.1016/j.gofs.2023.08.001]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:545-546. [PMID: 37703918 DOI: 10.1016/j.gofs.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/10/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Hugo Madar
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France; Université Paris Cité, épidémiologie obstétricale périnatale et pédiatrique (EPOPé), Centre de recherche épidémiologie et statistiques U1153, Inserm, INRAE, Paris, France.
| | - Catherine Deneux-Tharaux
- Université Paris Cité, épidémiologie obstétricale périnatale et pédiatrique (EPOPé), Centre de recherche épidémiologie et statistiques U1153, Inserm, INRAE, Paris, France
| | - Alizée Froeliger
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Hanane Bouchghoul
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Loïc Sentilhes
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France
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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: 66] [Impact Index Per Article: 66.0] [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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5
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Coleman JR, Fabbri S, Anderson M, Moore EE, Cohen MJ, Hadley J, Ghasabyan A, Chandler J, Kelher M, Freeman K, Miller ZD, Silliman CC. Beyond uterine atony: characterizing postpartum hemorrhage coagulopathy. Am J Obstet Gynecol MFM 2023; 5:100822. [PMID: 36464240 DOI: 10.1016/j.ajogmf.2022.100822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/16/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Postpartum hemorrhage is a leading cause of morbidity and mortality worldwide, yet the associated early coagulopathy is not well defined. OBJECTIVE We hypothesized that women who develop postpartum hemorrhage have a distinct derangement of thrombin generation and coagulation factors compared with postpartum women without postpartum hemorrhage. STUDY DESIGN This prospective study of pregnant patients with postpartum hemorrhage was completed at a single urban hospital. Blood was drawn on postpartum hemorrhage diagnosis and 2 and 4 hours later. Assays of patients with postpartum hemorrhage included thrombelastography, whole blood thrombin generation, coagulation factor activity, tissue factor levels and activity, and tissue factor pathway inhibitor levels, which were compared with that of patients without postpartum hemorrhage. RESULTS A total of 81 patients were included in this study. Of those patients, 66 had postpartum hemorrhage, and 15 served as controls. Compared with patients without PPH, patients with postpartum hemorrhage had lower fibrinogen levels (469.0 mg/dL vs 411.0 mg/dL; P=.02), increased tissue plasminogen activator resistance (fibrinolysis 30 minutes after maximal clot strength: 8.7% vs 4.2%; P=.02), decreased peak thrombin concentration (150.2 nM vs 40.7 nM; P=.01), and decreased maximal rate of thrombin generation (60.1 nM/minute vs 2.8 nM/minute; P=.02). Furthermore, compared with patients without postpartum hemorrhage, patients with postpartum hemorrhage had decreased tissue factor levels (444.3 pg/mL vs 267.1 pg/mL; P=.02) and increased tissue factor pathway inhibitor levels (0.6 U/mL vs 0.8 U/mL; P=.04), with decreased tissue factor pathway inhibitor ratios (624 vs 299; P=.01). CONCLUSION PPH is not only an issue of uterine tone and mechanical bleeding but also a distinct coagulopathy that is characterized by decreased fibrinogen level, clot breakdown resistance, and markedly low thrombin generation. This pathology seemed to be driven by low tissue factor and high tissue factor pathway inhibitor levels.
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Affiliation(s)
- Julia R Coleman
- Department of Surgery, University of Colorado Denver, Aurora, CO (Drs Coleman, Cohen, and Hadley)
| | - Stefka Fabbri
- Department of Obstetrics and Gynecology, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO (Dr Fabbri and Mr Anderson).
| | - Murphy Anderson
- Department of Obstetrics and Gynecology, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO (Dr Fabbri and Mr Anderson)
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO (Dr Moore, Mr Ghasabyan, and XX Chandler)
| | - Mitchell J Cohen
- Department of Surgery, University of Colorado Denver, Aurora, CO (Drs Coleman, Cohen, and Hadley)
| | - Jamie Hadley
- Department of Surgery, University of Colorado Denver, Aurora, CO (Drs Coleman, Cohen, and Hadley)
| | - Arsen Ghasabyan
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO (Dr Moore, Mr Ghasabyan, and XX Chandler)
| | - James Chandler
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO (Dr Moore, Mr Ghasabyan, and XX Chandler)
| | | | - Kalev Freeman
- Department of Surgery, University of Vermont, Burlington, VT (Dr Freeman and XX Miller)
| | - Zachary D Miller
- Department of Surgery, University of Vermont, Burlington, VT (Dr Freeman and XX Miller)
| | - Christopher C Silliman
- Vitalant Research Institute, Denver CO (Ms Kelher and Dr Silliman); Department of Pediatrics, School of Medicine, University of Colorado Denver, Aurora, CO (Dr Silliman)
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Shock Index for Early Detection of Low Plasma Fibrinogen in Trauma: A Prospective Observational Cohort Pilot Study. J Clin Med 2023; 12:jcm12041707. [PMID: 36836242 PMCID: PMC9966073 DOI: 10.3390/jcm12041707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
Shock index (a ratio between heart rate and systolic blood pressure) predicts transfusion requirements and the need for haemostatic resuscitation in severe trauma patients. In the present study, we aimed to determine whether prehospital and on-admission shock index values can be used to predict low plasma fibrinogen in trauma patients. Between January 2016 and February 2017, trauma patients admitted from the helicopter emergency medical service into two large trauma centres in the Czech Republic were prospectively assessed for demographic, laboratory and trauma-associated variables and shock index at scene, during transport and at admission to the emergency department. Hypofibrinogenemia defined as fibrinogen plasma level of 1.5 g·L-l was deemed as a cut-off for further analysis. Three hundred and twenty-two patients were screened for eligibility. Of these, 264 (83%) were included for further analysis. The hypofibrinogenemia was predicted by the worst prehospital shock index with the area under the receiver operating characteristics curve (AUROC) of 0.79 (95% CI 0.64-0.91) and by the admission shock index with AUROC of 0.79 (95% CI 0.66-0.91). For predicting hypofibrinogenemia, the prehospital shock index ≥ 1 has 0.5 sensitivity (95% CI 0.19-0.81), 0.88 specificity (95% CI 0.83-0.92) and a negative predictive value of 0.98 (0.96-0.99). The shock index may help to identify trauma patients at risk of hypofibrinogenemia early in the prehospital course.
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Nakamura E, Matsunaga S, Kikuchi A, Takai Y. Comparative retrospective study on the validity of point-of-care testing device for massive obstetrical hemorrhage: dry hematology vs thromboelastography. Am J Obstet Gynecol MFM 2023; 5:100778. [PMID: 36273811 DOI: 10.1016/j.ajogmf.2022.100778] [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: 08/20/2022] [Revised: 10/08/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Early recognition of hypofibrinogenemia and prompt initiation of transfusion therapy in patients with massive obstetrical hemorrhage can improve prognosis. There are reports on the usefulness of point-of-care testing, which provides quicker test results compared with fibrinogen measurements using the conventional Clauss method. OBJECTIVE This study aimed to compare and investigate the diagnostic accuracy of dry hematology and thromboelastography in point-of-care testing for the diagnosis of hypofibrinogenemia. STUDY DESIGN A single-center, retrospective study of 126 massive obstetrical hemorrhage cases with point-of-care testing before treatment was initiated. The correlation of fibrinogen values with the Clauss method and the diagnostic accuracy for hypofibrinogenemia were compared between dry hematology and thromboelastography. RESULTS Fibrinogen value in dry hematology showed a strong positive correlation with values measured by the Clauss method, and the diagnostic accuracy for hypofibrinogenemia was high, but there were many residuals above 100 mg/dL, and the distribution of these residuals was not uniform. Although thromboelastography cannot be used to directly measure fibrinogen values, maximum amplitude citrated functional fibrinogen, amplitude-10 citrated rapid thromboelastography, and amplitude-10 citrated functional fibrinogen showed a strong positive correlation with fibrinogen values using the Clauss method, and no significant difference in correlation or diagnostic accuracy was observed relative to dry hematology. CONCLUSION Dry hematology and thromboelastography were equally accurate in diagnosing hypofibrinogenemia, with results correlating well with fibrinogen values measured by the Clauss method.
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Affiliation(s)
- Eishin Nakamura
- Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Saitama, Japan (Dr Nakamura and Dr Kikuchi).
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, Saitama, Japan (Dr Matsunaga and Dr Takai)
| | - Akihiko Kikuchi
- Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, Saitama, Japan (Dr Nakamura and Dr Kikuchi)
| | - Yasushi Takai
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, Saitama, Japan (Dr Matsunaga and Dr Takai)
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LncRNA SNHG7 Knockdown Aggravates Hepatic Ischemia–Reperfusion Injury and Promotes Apoptosis in Hemorrhagic Shock Pregnant Rats by Modulating miR-34a-5p/YWHAG Axis. Mol Biotechnol 2022; 65:983-996. [DOI: 10.1007/s12033-022-00613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/14/2022] [Indexed: 11/26/2022]
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Sano Y, Kasai M, Shinoda S, Miyagi E, Aoki S. The indicators for early blood transfusion in patients with placental abruption with intrauterine fetal death: a retrospective review. BMC Pregnancy Childbirth 2022; 22:847. [PMID: 36397012 PMCID: PMC9670574 DOI: 10.1186/s12884-022-05187-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 11/07/2022] [Indexed: 11/18/2022] Open
Abstract
Abstract
Background
Placental abruption (PA) with intrauterine fetal death (IUFD) is associated with a high risk of postpartum hemorrhage (PPH) resulting from severe disseminated intravascular coagulation (DIC). Therefore, blood products that are sufficient for coagulation factor replacement must be prepared, and delivery should occur at referral medical institutions that are equipped with sufficient blood products and emergency transfusion protocols. We retrospectively reviewed the records of patients with PA and IUFD (PA-IUFD) to identify possible factors that may indicate the need for early blood transfusion and investigated whether the Japanese scoring system for PPH can be applied in such cases.
Methods
We used a database of 16,058 pregnant patients who delivered at Yokohama City University Medical Center between January 2000 and February 2016. Thirty-three patients were diagnosed with PA-IUFD before delivery and categorized into two groups–blood transfusion and non-transfusion–to compare the maternal characteristics and pregnancy outcomes.
Results
In patients with PA-IUFD, the transfusion group exhibited significantly more blood loss; lower fibrinogen levels and platelet counts; higher levels of fibrin degradation products (FDP), D-dimer, and prothrombin time; and a tendency for tachycardia on admission, compared to the non-transfusion group. Many patients in the transfusion group had normal fibrinogen levels on admission but later displayed markedly decreased fibrinogen levels. The Japan Society of Obstetrics and Gynecology (JSOG) DIC score was significantly higher in the transfusion than in the non-transfusion group.
Conclusions
In PA-IUFD, the fibrinogen level, platelet count, D-dimer, FDP, heart rate, and JSOG DIC score on admission may indicate the need for blood transfusion. However, even with normal fibrinogen levels on admission, continuous monitoring is indispensable for identifying progressive fibrinogen reductions in patients with PA-IUFD.
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10
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Makino Y, Miyake K, Okada A, Ikeda Y, Okada Y. Predictive accuracy of the shock index for severe postpartum hemorrhage in high-income countries: A systematic review and meta-analysis. J Obstet Gynaecol Res 2022; 48:2027-2037. [PMID: 35661488 DOI: 10.1111/jog.15292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/29/2022] [Accepted: 05/05/2022] [Indexed: 02/01/2023]
Abstract
AIM The shock index has been suggested as a screening tool for predicting postpartum hemorrhage (PPH); however, there is little comprehensive evidence regarding its predictive accuracy. This systematic review and meta-analysis aim to investigate the predictive accuracy of the shock index for severe PPH in high-income countries. METHODS A comprehensive search was conducted on MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science (from inception to June 2021). Studies assessing the predictive performance of the shock index for PPH in high-income countries were included. Two or more reviewers independently extracted the data and assessed the risk of bias and applicability concerns using the modified Quality Assessment of Diagnostic Accuracy Studies 2 tool. PPH requiring higher-level care, such as blood transfusions, were considered as primary analyses. We described the hierarchical summary receiver-operating characteristic curve for data synthesis. RESULTS Nine studies were included after the eligibility assessment. All studies were considered to either have a high risk of bias or high applicability concerns. The sensitivity of the four studies that defined severe PPH as PPH requiring blood transfusion ranged from 0.51 to 0.80, whereas their specificity ranged from 0.33 to 0.92. CONCLUSIONS This review shows that the predictive performance of the shock index for severe PPH is inconsistent. Therefore, the evidence for using the shock index alone as a screening tool for PPH in high-income countries is insufficient. STUDY REGISTRATION This review was prospectively registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000044230).
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Affiliation(s)
- Yuto Makino
- Department of Preventive Services, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kentaro Miyake
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Asami Okada
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - Yumie Ikeda
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Yohei Okada
- Department of Preventive Services, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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11
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Pacagnella RC, Borovac-Pinheiro A, Silveira C, Siani Morais S, Argenton JLP, Souza JP, Weeks AD, Cecatti JG. The golden hour for postpartum hemorrhage: Results from a prospective cohort study. Int J Gynaecol Obstet 2021; 156:450-458. [PMID: 34254311 DOI: 10.1002/ijgo.13823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the predictive capacity of vital signs for the diagnosis of postpartum hemorrhage (PPH). METHODS A prospective cohort study performed at the University of Campinas, Brazil, between February 2015 and March 2016 with women who delivered vaginally. Vital signs and postpartum bleeding were collected over 24 h. Exploratory data analysis was performed plus receiver operating characteristic curve analysis where the areas under the curve was used to determine the best cutoff points for sensitivity, specificity, likelihood ratio, and diagnostic odds ratio. RESULTS For the 270 women recruited, mean blood loss after 120 min was 427.49 ± 335.57 ml, while 84 (31.1%) and 22 (8.1%) women had blood loss ≥500 and ≥1000 ml, respectively. Heart rate cutoff point of 105 bpm measured between 21-40 min after birth identified blood loss ≥1000 ml with 90% specificity. A shock index (SI) of 0.965 at 41-60 min after birth identified blood loss ≥500 and ≥1000 ml within 2 h with approximately 95% specificity. CONCLUSION Shock index and heart rate measured after birth showed high specificity with low sensitivity to identify PPH. In clinical practice, "The rule of 1s" should receive special attention: SI ≥1, or heart rate >100 bpm, or estimated blood loss ≥1 L.
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Affiliation(s)
- Rodolfo C Pacagnella
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Anderson Borovac-Pinheiro
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Carla Silveira
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Sirlei Siani Morais
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | - Joao Paulo Souza
- Department of Social Medicine, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, Brazil
| | - Andrew D Weeks
- Sanyu Research Unit, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - José G Cecatti
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
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12
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Attali E, Many A, Kern G, Reicher L, Kahana A, Shemer A, Kagan G, Gamzu R, Yogev Y, Zakar L. Predicting the need for blood transfusion requirement in postpartum hemorrhage. J Matern Fetal Neonatal Med 2021; 35:7911-7916. [PMID: 34107848 DOI: 10.1080/14767058.2021.1937992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We aimed to assess the role of lactate and hemoglobin levels as predictors for the need for blood transfusion in post-partum hemorrhage (PPH). METHODS A retrospective cohort study of women with PPH in a single university-affiliated tertiary medical center between August 2018 and June 2020. PPH was defined as an estimated excessive blood loss (of more than 500 ml following vaginal delivery and 1000 ml following a cesarean delivery) requiring at least one uterotonic drug and fluid resuscitation. Women were stratified by the need of requiring blood transfusion due to hemorrhage. The criteria for blood transfusion were: (1) clinically severe uncontrollable ongoing hemorrhage; (2) symptomatic anemia (maternal tachycardia >110 beats per minute, dizziness, syncope or presyncope) in the presence of Hb 7-8 g/dL; or (3) postpartum Hb level < 7 g/dL regardless of maternal symptoms or signs of anemia. Demographic, labor characteristics as well as laboratory data were collected. For all women the Shock Index (SI: heart rate divided by systolic blood pressure) was calculated. Women without available data on immediate (more than 15 min from the bleeding initiation) hemoglobin (Hb) level and lactate concentrations were excluded. RESULTS Overall, out of 22,241 deliveries during the study, 94 women were included, of them 26 (23.4%) required blood transfusion. The antepartum Hb level was lower in the transfused group (11.7 ± vs 12.4 ± 1.0 re/dL, p = .01). No significant differences were found in demographic and labor characteristics. In multivariate logistic regression analysis, a lower immediate postpartum Hb and a higher SI higher were associated with blood transfusion requirement (adjusted odds ratio (aOR) 3.45 [CI] 1.82-7.69, p < .001] and aOR 1.25 [CI 1.03-1.55, p = .03], respectively). The combination of SI, immediate postpartum Hb and lactate concentration provided the best integration, with an area under the curve of 0.86, sensitivity 92.65%, specificity 61.54%, positive and negative predictive values of 86.3% and 76.2%, respectively. CONCLUSION The combination of SI, immediate postpartum Hb and lactate levels is a good predictor for the need of blood requirement in PPH.
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Affiliation(s)
- Emmanuel Attali
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Many
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy Kern
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lee Reicher
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adiel Kahana
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Shemer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Georgy Kagan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Anesthesiology, Pain and Critical Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ronni Gamzu
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yariv Yogev
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat Zakar
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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13
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Fibrinogen may aid in the early differentiation between amniotic fluid embolism and postpartum haemorrhage: a retrospective chart review. Sci Rep 2021; 11:8379. [PMID: 33863968 PMCID: PMC8052446 DOI: 10.1038/s41598-021-87685-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 03/31/2021] [Indexed: 12/13/2022] Open
Abstract
This study aimed to determine whether blood loss and fibrinogen can differentiate amniotic fluid embolism (AFE) from postpartum haemorrhage (PPH). This retrospective case–control study included nine patients with clinical AFE (“AFE group”) and 78 patients with PPH managed at our tertiary care perinatal centre between January 2014 and March 2016. Patients meeting the Japanese diagnostic criteria for AFE were stratified into cardiopulmonary collapse-type AFE and disseminated intravascular coagulation (DIC)-type AFE groups. The relationship between blood loss and fibrinogen at onset was examined to compare DIC severity. Vital signs at onset were not significantly different. The AFE group had significantly less blood loss at onset (1506 mL vs 1843 mL, P = 0.0163), significantly more blood loss 2 h post-onset (3304 mL vs 1996 mL, P < 0.0001) and more severe coagulopathy and fibrinolysis. The blood loss/fibrinogen (B/F) ratio at onset was significantly higher in the DIC-type AFE group (23.15 ± 8.07 vs 6.28 ± 3.35 mL dL/mg, P < 0.0001). AFE was complicated by catastrophic DIC irrespective of blood loss at onset. Fibrinogen exhibited the strongest correlation among test findings at onset. The B/F ratio may help differentiate PPH from DIC-type AFE and diagnose clinical AFE, facilitating optimal replacement of coagulation factors during the early stages.
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14
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Drew T, Carvalho JCA, Subramanian C, Yoon EW, Downey K, Thorneloe B, Balki M. The association of shock index and haemoglobin variation with postpartum haemorrhage after vaginal delivery: a prospective cohort pilot study. Int J Obstet Anesth 2020; 45:67-73. [PMID: 33298343 DOI: 10.1016/j.ijoa.2020.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 10/03/2020] [Accepted: 10/24/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Shock index and continuous non-invasive haemoglobin monitoring (SpHb) have both been proposed for the timely recognition of postpartum haemorrhage (PPH). We sought to determine, in parallel, the association of each of shock index and SpHb with blood loss after vaginal delivery. METHODS Sixty-six women were recruited to this prospective observational study. Shock index and SpHb were recorded postpartum for 120 min. The association between each of shock index and SpHb with quantitative blood loss (QBL) at 30, 60 and 120 min postpartum was determined using linear mixed models. Area-under-the-receiver-operator-characteristic (AUROC) curves were constructed to evaluate the diagnostic ability of shock index and SpHb to detect PPH (defined as QBL ≥1000 mL). RESULTS Shock index trend was associated with QBL over the first 30 min (r=0.37, P=0.002), but not over 60 or 120 min. There was an association of SpHb trend with QBL over the first 30 min (P=0.06), but not over 60 min (r=-0.32, P=0.009) or 120 min (r=-0.26, P=0.03). Maximum shock index within 60 min correlated with QBL (r=0.54, P <0.001) and was a predictor of PPH (P=0.0012, AUROC 0.796). Maximum change in SpHb within 60 min negatively correlated with QBL (r=-0.4, P <0.001) and was a predictor of PPH (P=0.048, AUROC 0.761). CONCLUSIONS The trend of shock index and its peak values are associated with blood loss after vaginal delivery and are early indicators of PPH. Negative trend of SpHb is a late sign of PPH and has a weaker association with blood loss than shock index.
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Affiliation(s)
- T Drew
- Department of Anaesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada.
| | - J C A Carvalho
- Department of Anaesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada; Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - C Subramanian
- Department of Anaesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - E W Yoon
- Maternal and Infant Care Research Center, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - K Downey
- Department of Anaesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - B Thorneloe
- Department of Anaesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - M Balki
- Department of Anaesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Canada; Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada; Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
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15
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Yilmaz EPT, Celik Y, Topdagi YE, Guzel AI, Al RA. New approach to the risk variables for administration of fibrinogen in patients with postpartum hemorrhage by using cluster analysis. Int J Gynaecol Obstet 2020; 152:256-261. [PMID: 32967036 DOI: 10.1002/ijgo.13386] [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: 02/16/2020] [Revised: 06/26/2020] [Accepted: 09/17/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To analyze all the variables in women who received fibrinogen for postpartum hemorrhage (PPH) using hierarchical cluster analysis, to provide greater insight into the risk variables involved in these women. METHODS This retrospective study of women with at least 500 mL of bleeding at birth or during the postpartum period and treated with fibrinogen was conducted at the Department of Obstetrics and Gynecology, Atatürk University School of Medicine from January 2013 to January 2018. Data on the women were obtained from medical records and various risk variables were recorded and analyzed using hierarchical cluster analysis. RESULTS A total of 114 women with PPH were included in the study. Based on a dendrogram, three main clusters of similar quality variables were created: 1) gravida, parity, age, cervical/vaginal hematoma, laparotomy, hypogastric artery ligation, uterine artery embolization, uterine artery ligation, uterine atony, distance from outer center, lowest hemoglobin, preoperative platelets, endometritis, preoperative white blood cells; 2) lowest fibrinogen, highest fibrinogen, type of birth, placenta invasion anomaly, Bakri balloon tamponade, postpartum hysterectomy, preoperative activated partial thromboplastin time (APTT), preoperative international normalized ratio (INR), placental abruption, in-utero ex fetus; 3) postoperative APTT, postoperative INR, maternal mortality, erythrocyte transfusion, plasma transfusion, hospital stay time, disseminated intravascular coagulation/HELLP syndrome, highest hemoglobin, blood group, postoperative platelets, platelet transfusion, pre-eclampsia/eclampsia, fibrinogen extract. CONCLUSION According to the cluster analysis, we should keep fibrinogen extract in the foreground especially in the treatment of hemorrhage in patients with variable conditions. As a result, we can determine whether fibrinogen extract, which has a high economic cost, should be kept at each center. We can also direct which patient will be referred in accordance with the referral steps.
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Affiliation(s)
- Emsal P T Yilmaz
- Department of Gynecology and Obstetrics, Atatürk University School of Medicine, Erzurum, Turkey
| | - Yusuf Celik
- Department of Biostatistics, Biruni University School of Medicine, Istanbul, Turkey
| | - Yunus E Topdagi
- Department of Gynecology and Obstetrics, Sanko University School of Medicine, Gaziantep, Turkey
| | - Ali I Guzel
- Special obstetrics and gynecology doctor, Izmir, Turkey
| | - Ragıp A Al
- Department of Gynecology and Obstetrics, Atatürk University School of Medicine, Erzurum, Turkey
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16
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Saito K, Onishi E, Itagaki J, Toda N, Haitani A, Yamauchi M. Perioperative anesthetic management for cesarean delivery of severe Wilson’s disease with liver failure: a case report. JA Clin Rep 2019; 5:75. [PMID: 32026097 PMCID: PMC6966748 DOI: 10.1186/s40981-019-0294-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 10/15/2019] [Indexed: 01/11/2023] Open
Abstract
Background Wilson’s disease is a rare autosomal recessive disorder affecting copper metabolism, which presents liver and brain dysfunction caused by abnormal copper accumulation. We report a patient who showed exacerbation of liver failure during pregnancy. Case presentation A 24-year-old woman with Wilson’s disease was scheduled for emergency cesarean delivery at 30 weeks of gestation. The patient exhibited severe coagulopathy and prominent body weight gain (+ 30 kg) caused by systemic edema and ascites. We decided to perform emergency cesarean delivery under general anesthesia. We used platelet concentrates, cryoprecipitate, and fibrinogen concentrate. Intraoperative hemorrhage was well controlled. On the 15th postpartum day, weight was reduced by 20 kg and liver function had improved. She and her baby were discharged without complications. Conclusions The appropriate continued treatment of Wilson’s disease and supplementation of coagulation factors and/or platelets when indicated greatly increase the likelihood of a successful pregnancy, even in patients with liver failure exacerbation.
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17
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Assessing and managing hypovolemic shock in puerperal women. Best Pract Res Clin Obstet Gynaecol 2019; 61:89-105. [DOI: 10.1016/j.bpobgyn.2019.05.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/20/2019] [Accepted: 05/20/2019] [Indexed: 12/17/2022]
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18
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Okada A, Okada Y, Inoue M, Narumiya H, Nakamoto O. Lactate and fibrinogen as good predictors of massive transfusion in postpartum hemorrhage. Acute Med Surg 2019; 7:e453. [PMID: 31988765 PMCID: PMC6971467 DOI: 10.1002/ams2.453] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/30/2019] [Indexed: 11/12/2022] Open
Abstract
Aim This study aims to identify the clinical factors that can predict the requirement of massive transfusion among patients with postpartum hemorrhage (PPH). Methods Consecutive anonymized patients with PPH who were treated at the emergency department of our perinatal medical center were examined. Patients who had received transfusions before admission, those who had cardiac arrest on arrival, and those without history of blood gas analysis were excluded. Our primary outcome was the requirement of massive transfusion defined as packed red blood cells of ≥10 units/24 h. Univariable logistic analysis was carried out to identify the odds ratio and 95% confidence interval (CI) of the explanatory variables for the outcome. Results A total of 31 patients (massive transfusion, n = 19) were included in the main analysis. The crude odds ratio for fibrinogen per mg/dL and lactate per mmol/L were calculated as 0.98 (95% CI, 0.97–0.99) and 1.62 (95% CI, 1.08–3.02), respectively. The area under the curves for fibrinogen and lactate were 0.814 and 0.734, respectively, and optimal cut‐off values for fibrinogen and lactate were 211 mg/dL and 4 mmol/L, respectively. Conclusion These findings suggest that lactate and fibrinogen can be predictors for the requirement of massive transfusion in patients with PPH.
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Affiliation(s)
- Asami Okada
- Department of Emergency Medicine and Clinical Care Japanese Red Cross Society Kyoto Daini Red Cross Hospital Kyoto Japan.,Department of Obstetrics Osaka City General Hospital Osaka-shi Japan
| | - Yohei Okada
- Department of Emergency Medicine and Clinical Care Japanese Red Cross Society Kyoto Daini Red Cross Hospital Kyoto Japan
| | - Motoi Inoue
- Department of Obstetrics Osaka City General Hospital Osaka-shi Japan
| | - Hiromichi Narumiya
- Department of Emergency Medicine and Clinical Care Japanese Red Cross Society Kyoto Daini Red Cross Hospital Kyoto Japan
| | - Osamu Nakamoto
- Department of Obstetrics Osaka City General Hospital Osaka-shi Japan
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19
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Borovac-Pinheiro A, Ribeiro FM, Morais SS, Pacagnella RC. Shock index and heart rate standard reference values in the immediate postpartum period: A cohort study. PLoS One 2019; 14:e0217907. [PMID: 31185036 PMCID: PMC6559711 DOI: 10.1371/journal.pone.0217907] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 05/22/2019] [Indexed: 11/30/2022] Open
Abstract
Objective To determine Shock Index (SI) reference values in the first two hours of the postpartum period after objectively measuring postpartum bleeding. Materials and methods A complementary analysis using data from a prospective cohort study at Women’s Hospital of the University of Campinas, Brazil, between 1 February 2015 and 31 March 2016. It included women giving birth vaginally unless they had one of these conditions: gestational age below 34 weeks, hypertension, hypo- or hyperthyroidism without treatment, any cardiac disease, infections with fever or sepsis, history of coagulopathy or delivery by C-section. Blood loss was measured by adding the blood volume collected in the drape placed under the women’s buttocks and the weight of gauzes and compresses used (excluding the dry weight). Vital signs were measured every 5–15 min after delivery. Exploratory data analysis was performed to assess the mean, standard deviation, median, and percentiles (5th, 10th, 25th, 50th, 75th, 90th, 95th). To identify variation among the periods after delivery, the mean SI and heart rate (HR) values observed for the following intervals were used in the analysis: 0–20 min, 21–40 min, 41–60 min, 61–90 min and 91–120 min. Results One hundred eighty-six women were included. The mean age ± SD was 24.9 ± 6.1 years and the mean gestational age at birth was 39.2 ± 1.8 weeks. At the puerperal period, the mean SI values ranged from 0.68 ± 0.14 to 0.74 ± 0.15. The percentile distribution ranged from 0.46 (5th percentile) to 1.05 (95th percentile). The mean HR values ranged from 80.8 ± 12.7 bpm to 92.3 ± 14.4 bpm. The percentile distribution ranged from 62.0 bpm (5th percentile) to 117 bpm (95th percentile). Conclusion Reference ranges were established for SI and HR values which showed small variations throughout the postpartum period.
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Affiliation(s)
- Anderson Borovac-Pinheiro
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas, Campinas (SP), Brazil
- * E-mail:
| | - Filipe Moraes Ribeiro
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas, Campinas (SP), Brazil
| | - Sirlei Siani Morais
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas, Campinas (SP), Brazil
| | - Rodolfo Carvalho Pacagnella
- Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas, Campinas (SP), Brazil
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20
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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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21
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A systematic review of massive transfusion protocol in obstetrics. Taiwan J Obstet Gynecol 2018; 56:715-718. [PMID: 29241907 DOI: 10.1016/j.tjog.2017.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2017] [Indexed: 12/30/2022] Open
Abstract
Post-partum obstetric haemorrhage is a leading cause of mortality among Japanese women, generally treated with haemostatic measures followed by supplementary transfusion. Commonly used in the setting of severe trauma, massive transfusion protocols (MTPs), preparations of red blood cell concentrate (RBC) and fresh frozen plasma (FFP) with additional supplements, have proved effective in decreasing patient mortality following major obstetric bleeding events. Although promising, the optimal configuration of RBC and FFP utilized for obstetric bleeding needs to be verified. Here, we conducted a systematic literature review to define the optimal ratio of RBC to FFP for transfusion therapy during instances of obstetric bleeding. Our analysis extracted four retrospective, observational studies, all demonstrating that an FFP/RBC ratio of ≥1 was associated with improved patient outcomes following obstetric haemorrhage. We therefore conclude that, from the standpoint of haemostatic resuscitation, an FFP/RBC ratio of ≥1 is a necessary condition for optimal clinical management during MTP administration in the field of obstetrics. Hence, we further propose an optimized MTP strategy to be utilized in the setting of severe obstetric bleeding.
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22
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Flint AWJ, McQuilten ZK, Wood EM. Massive transfusions for critical bleeding: is everything old new again? Transfus Med 2018; 28:140-149. [PMID: 29607593 DOI: 10.1111/tme.12524] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/11/2017] [Accepted: 03/07/2018] [Indexed: 12/19/2022]
Abstract
Massive transfusion or major haemorrhage protocols have been widely adopted in the treatment of critically bleeding patients. Following evidence that higher ratios of transfused plasma and platelets to red blood cells may offer survival benefits in military trauma patients, these ratios are now commonly incorporated into massive transfusion protocols. They more closely resemble the effects of whole blood transfusion, which in the second half of last century was largely replaced by individual blood component transfusion based on laboratory-guided indicators. However, high-quality evidence to guide transfusion support for critically bleeding patients across the range of bleeding contexts is lacking, including for both trauma and non-trauma patients. More data on major haemorrhage support and clinical outcomes are needed to inform guidelines and practice.
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Affiliation(s)
- A W J Flint
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Royal Australian Navy, Australian Defence Force, Canberra, Australian Capital Territory, Australia
| | - Z K McQuilten
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Health, Melbourne, Victoria, Australia
| | - E M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Health, Melbourne, Victoria, Australia
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23
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Schroll R, Swift D, Tatum D, Couch S, Heaney JB, Llado-Farrulla M, Zucker S, Gill F, Brown G, Buffin N, Duchesne J. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury 2018; 49:15-19. [PMID: 29017765 DOI: 10.1016/j.injury.2017.09.015] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/07/2017] [Accepted: 09/14/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Various scoring systems have been developed to predict need for massive transfusion in traumatically injured patients. Assessments of Blood Consumption (ABC) score and Shock Index (SI) have been shown to be reliable predictors for Massive Transfusion Protocol (MTP) activation. However, no study has directly compared these two scoring systems to determine which is a better predictor for MTP activation. The primary objective was to determine whether ABC or SI better predicted the need for MTP in adult trauma patients with severe hemorrhage. METHODS This was a retrospective cohort study which included all injured patients who were trauma activations between January 1, 2009 and December 31, 2013 at an urban Level I trauma center. Patients <18 years old or with traumatic brain injury (TBI) were excluded. ABC and SI were calculated for each patient. MTP was defined as need for >10 units PRBC transfusion within 24h of emergency department arrival. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were used to evaluate scoring systems' ability to predict effective MTP utilization. RESULTS A total of 645 patients had complete data for analysis. Shock Index ≥1 had sensitivity of 67.7% (95% CI 49.5%-82.6%) and specificity of 81.3% (95% CI 78.0%-84.3%) for predicting MTP, and ABC score ≥2 had sensitivity of 47.0% (95% CI 29.8%-64.9%) and specificity of 89.8% (95% CI 87.2%-92.1%). AUROC analyses showed SI to be the strongest predictor followed by ABC score with AUROC values of 0.83 and 0.74, respectively. SI had a significantly greater sensitivity (P=0.035), but a significantly weaker specificity (P<0.001) compared to ABC score. CONCLUSION ABC score and Shock Index can both be used to predict need for massive transfusion in trauma patients, however SI is more sensitive and requires less technical skill than ABC score.
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Affiliation(s)
| | - David Swift
- Tulane School of Medicine, New Orleans, LA, United States
| | - Danielle Tatum
- Our Lady of the Lake Regional Medical Center-Trauma Specialist Program, Baton Rouge, LA, United States
| | - Stuart Couch
- Tulane School of Medicine, New Orleans, LA, United States
| | | | | | - Shana Zucker
- Tulane School of Medicine, New Orleans, LA, United States
| | - Frances Gill
- Tulane School of Medicine, New Orleans, LA, United States
| | - Griffin Brown
- Tulane School of Medicine, New Orleans, LA, United States
| | | | - Juan Duchesne
- Tulane School of Medicine, New Orleans, LA, United States
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24
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Borovac-Pinheiro A, Pacagnella RC, Puzzi-Fernandes C, Cecatti JG. Case-control study of shock index among women who did and did not receive blood transfusions due to postpartum hemorrhage. Int J Gynaecol Obstet 2017; 140:93-97. [PMID: 28990187 DOI: 10.1002/ijgo.12343] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 08/12/2017] [Accepted: 10/06/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare shock index (SI) values between women who required blood transfusion due to postpartum hemorrhage (PPH) and women who did not. METHODS In a case-control study, clinical data were assessed from the medical records of women requiring blood transfusion for PPH at a center in Brazil between 2012 and 2015 (n=105). A control group was randomly selected from women who did not receive blood transfusion (n=129). RESULTS Compared with women who did not receive a transfusion after delivery, women who did receive one had significantly higher SI values 10 minutes after delivery (0.81 ± 0.27 vs 0.72 ± 0.16; P=0.012), at 30 minutes (0.83 ± 0.26 vs 0.71 ± 0.15; P<0.001), and at 2 hours (0.84 ± 0.27 vs 0.70 ± 0.14; P=0.032). For vaginal deliveries, SI values were significantly different at 30 minutes (0.88 ± 0.26 vs 0.71 ± 0.14; P<0.001) and 2 hours (0.90 ± 0.23 vs 0.72 ± 0.14; P=0.001). No significant differences were found for cesarean delivery. CONCLUSION The SI might be useful to identify early vital sign changes due to PPH. Increased SI values were associated with need for transfusion in vaginal deliveries.
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Affiliation(s)
- Anderson Borovac-Pinheiro
- Department of Obstetrics and Gynaecology, School of Medical Sciences - Women's Hospital, University of Campinas, Campinas, Brazil
| | - Rodolfo C Pacagnella
- Department of Obstetrics and Gynaecology, School of Medical Sciences - Women's Hospital, University of Campinas, Campinas, Brazil
| | - Carolina Puzzi-Fernandes
- Department of Obstetrics and Gynaecology, School of Medical Sciences - Women's Hospital, University of Campinas, Campinas, Brazil
| | - José G Cecatti
- Department of Obstetrics and Gynaecology, School of Medical Sciences - Women's Hospital, University of Campinas, Campinas, Brazil
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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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Wang L, Matsunaga S, Mikami Y, Takai Y, Terui K, Seki H. Pre-delivery fibrinogen predicts adverse maternal or neonatal outcomes in patients with placental abruption. J Obstet Gynaecol Res 2016; 42:796-802. [DOI: 10.1111/jog.12988] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 12/28/2015] [Accepted: 02/07/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Liangcheng Wang
- 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
| | - Yukiko Mikami
- 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
| | - Katsuo Terui
- Department of Anesthesiology; 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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Hirose N, Ohkuchi A, Baba Y, Usui R, Hirashima C, Watanabe T, Matsubara S. Mismatch between estimated blood loss and shock index in transferred women with postpartum hemorrhage. HYPERTENSION RESEARCH IN PREGNANCY 2016. [DOI: 10.14390/jsshp.hrp2015-014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Noriko Hirose
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine
| | - Akihide Ohkuchi
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine
| | - Yosuke Baba
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine
| | - Rie Usui
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine
| | - Chikako Hirashima
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine
| | - Takashi Watanabe
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine
| | - Shigeki Matsubara
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine
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Honda M, Matsunaga S, Era S, Takai Y, Baba K, Seki H. Intrapartum anti-disseminated intravascular coagulation therapy leading to successful vaginal delivery following intrauterine fetal death caused by placental abruption: a case report. J Med Case Rep 2014; 8:461. [PMID: 25532532 PMCID: PMC4307188 DOI: 10.1186/1752-1947-8-461] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 11/10/2014] [Indexed: 11/14/2022] Open
Abstract
Introduction Disseminated intravascular coagulation due to placental abruption with intrauterine fetal death is not uncommon. It can result in increased maternal mortality rates and the need for hysterectomy or greater transfusion volumes if the delivery is not completed within six to eight hours. However, consensus is lacking regarding the delivery approach for cases in which delivery is prolonged. Case presentation A 37-year-old Japanese woman was transported to our tertiary center two and a half hours after the onset of labor because of a diagnosis of placental abruption with intrauterine fetal death at 40 weeks and three days’ gestation. On arrival, although severe hypofibrinogenemia was observed, there was no external hemorrhage. Because her cervical canal dilation was good (Bishop score, 7), labor was induced using oxytocin. Anti-disseminated intravascular coagulation therapy was simultaneously started via transfusion. After her hypofibrinogenemia resolved, delivery progressed rapidly, and the fetus was delivered approximately 10 hours after the onset. To reduce postpartum hemorrhage, 6g of fibrinogen concentrate and tranexamic acid, an antifibrinolytic agent, were administered immediately before extraction of the dead fetus and placenta. Although the amount of intrapartum hemorrhage was 1824g, there was no abnormal bleeding after delivery, and our patient was discharged three days later. Conclusion In cases of placental abruption complicated with disseminated intravascular coagulation, intrapartum administration of coagulation factors can simultaneously promote effective labor and correct hypofibrinogenemia, enabling minimally invasive vaginal delivery.
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Affiliation(s)
| | - Shigetaka Matsunaga
- Center of Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan.
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