Risk factors for transfusion in cesarean section deliveries at a tertiary hospital

Effectiveness of a fetal magnetic resonance imaging scoring system for predicting the prognosis of pernicious placenta previa: A retrospective study

Background: The value of multiple magnetic resonance imaging (MRI) signs in predicting pernicious placenta previa (PPP) with placenta accreta spectrum disorders (PAS) is still controversial. This study aimed to investigate the value of a self-made fetal magnetic resonance imaging scoring system in predicting the different types of PAS in pernicious placenta previa and its associated risk of bleeding.

Methods: This retrospective study included 193 patients diagnosed with PPP based on MRI findings before delivery. Based on pathological and intraoperative findings, we divided patients into four groups: non-PAS, placental adhesion, placental implantation, and placenta percreta. Receiver operator characteristic curves of the MRI total score and placental implantation type were drawn using pROC packages in the R Studio environment, and cutoff values of each type were calculated, as well as diagnostic evaluation indexes, such as sensitivity, specificity, and the Youden index. Hemorrhage during surgery was compared between the groups.

Results: The boundary value between the non-PAS and placental adhesion was 5.5, that between placental adhesion and placental implantation was 11.5, and that between placental implantation and placenta percreta was 15.5 points. The respective specificities were 0.700, 0.869, and 0.958, and the respective sensitivities were 0.994, 0.802, and 0.577. The Youden indices were 0.694, 0.671, and 0.535, respectively. The median (minimum, maximum) quantities of hemorrhage during the operation in the non-PAS, placental adhesion, placental implantation, and placenta percreta groups were 225 (100, 3700), 600 (200, 6000), 1500 (300, 7000), and 3000 (400, 6300) ml, respectively. Hemorrhage was significantly different between the four groups (p < 0.001).

Conclusion: These results suggest that the proposed MRI scoring system could be an effective diagnostic tool for assessing PPP types and predicting the associated bleeding risk.

Prevalence and Associated Factors for Post-Caesarean Delivery Blood Transfusion in Eastern Sudan: A Cross-Sectional Study

Background

Obstetric haemorrhage is a leading cause of maternal mortality and morbidity worldwide. Caesarean delivery (CD) is associated with significant blood loss, which may require blood transfusions. This study aimed to determine the prevalence and associated factors for post-CD transfusion.

Methods

A cross-sectional study was conducted in Gadarif maternity hospital, eastern Sudan, from March to September 2020. Sociodemographic, obstetric and clinical data, including pre- and postoperative haemoglobin levels, were collected. A multivariate logistic regression analysis was performed.

Results

A total of 539 women were enrolled in the study; the median (interquartile range) age of these women was 28.0 (8.0) years. The overall post-CD transfusion rate was 8.2%. Emergency CD (adjusted odds ratio [AOR]=2.57, 95% confidence interval [CI]=1.25‒5.28) and antepartum haemorrhage (AOR=44.70, 95% CI=11.18‒178.76) were associated with increased risk of post-CD blood transfusion. Preoperative haemoglobin (AOR=0.48, 95% CI=0.36‒0.64) and rural residence (AOR=0.45, 95% CI=0.22‒0.93) were associated with reduced risk for post-CD blood transfusion.

Conclusion

The overall prevalence of post-CD transfusion in this part of Sudan is 8.2%. Women with emergency CD, low preoperative haemoglobin levels and antepartum haemorrhage were at higher risk for post-CD transfusion. Risk identification and correction of antenatal anaemia can reduce the hazard of blood transfusion among CD women.

A risk prediction model of perinatal blood transfusion for patients who underwent cesarean section: a case control study

Background

Severe obstetric hemorrhage is a leading cause of severe maternal morbidity. A perinatal blood transfusion is the key factor in the treatment of severe obstetric hemorrhage. Our aim is to identify patients with a high risk of perinatal blood transfusions before Cesarean Section, which can promote the effectiveness of the treatment of severe obstetric hemorrhage, as well as improve obstetric preparations.

Methods

This study retrospectively analyzed the data of 71 perinatal blood transfusion patients and 170 controls, who were both underwent Cesarean Section from July 2018 to September 2019. These data were included in the training set to build the risk prediction model of needing blood transfusion. Additionally, the data of 148 patients with the same protocol from October 2019 to May 2020 were included in the validation set for model validation. A multivariable logistic regression model was used. A risk prediction nomogram was formulated per the results of the multivariate analysis.

Results

The strongest risk factors for perinatal blood transfusions included preeclampsia (OR = 6.876, 95% CI: 2.226–23.964), abnormal placentation (OR = 5.480, 95% CI: 2.478–12.591), maternal age (OR = 1.087, 95% CI: 1.016–1.166), predelivery hemoglobin (OR = 0.973, 95% CI: 0.948–0.998) and predelivery fibrinogen (OR = 0.479, 95% CI: 0.290–0.759). A risk prediction model of perinatal blood transfusions for cesarean sections was developed (AUC = 0.819; sensitivity: 0.735; specificity: 0.848; critical value: 0.287).

Conclusions

The risk prediction model can identify the perinatal blood transfusions before Cesarean Section. With the nomogram, the model can be further quantified and visualized, and clinical decision-making can subsequently be further simplified and promoted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04696-x.

Risk factors for blood transfusion in Cesarean section: A systematic review and meta-analysis

OBJECTIVE

The current study has been conducted to identify the risk factors associated with blood transfusion in women undergoing cesarean section (C-section). A detailed account of the risk factors associated withblood transfusion will ultimately prevent unnecessary crossmatching in hospitals , leading to the conservation of declining blood supplies and resources without subjugating the quality of care.

MATERIAL AND METHODS

We performed a rigorous literature search using electronic databases, including PubMed, Cochrane CENTRAL, and Embase, for studies evaluating the risk factors for blood transfusion in C-section published until March 31, 2021. The Newcastle-Ottawa Quality Assessment Scale was deployed to assess the methodologic quality of the included studies. Mean differences (MD) and odds ratios (OR) with 95% confidence intervals were calculated using Review Manager version 5.3.

RESULTS

The search yielded 1563 records, 22 of which were eligible for inclusion, representing 426,094 women (10,959 in the transfused group and 415,135 in the non-transfused group). Participants in the transfused group had lower mean preoperative hematocrit (MD=-3.71 [-4.46, -2.96]; p<0.00001; I²=88%). Placenta previa (OR=9.54 [7.23, 12.59]; p<0.00001; I²=88%), placental abruption (OR=6.77 [5.25, 8.73]; p<0.00001; I²=72%), emergency C-section (OR=1.92 [1.42, 2.60]; p<0.0001; I²=75%), general anesthesia (OR=8.43 [7.90, 9.00]; p<0.00001; I²=72%), multiple gestations (OR=1.60 [1.24, 2.06]; p=0.0003; I²=85%), preterm labor (OR=3.34 [2.75, 4.06]; p<0.00001; I²=85%), prolonged labor (OR=1.68 [1.44, 1.96]; p<0.00001; I²=78%), unbooked cases (OR=2.42 [1.22, 4.80]; p=0.01; I²=80%), hypertensive disorders of pregnancy (OR=1.81 [1.72, 1.90]; p<0.00001; I²=71%), and fibroids (OR=2.32 [1.55, 3.47]; p<0.0001; I²=72%) were significantly higher in the transfused group compared to the non-transfused group. Chronic hypertension (OR=0.67 [0.29, 1.55]; p=0.36; I²=90%), maternal age (MD=0.09 [-0.27, 0.45]; p=0.62; I²=50%), maternal body mass index (MD=-0.14 [-0.81, 0.53]; p=0.67, I²=86%), diabetes (OR=0.93 [0.75, 1.15]; p=0.51; I²=52%), and malpresentation (OR=0.65 [0.38, 1.11]; p=0.13; I²=64%) were not significantly associated with an increased risk of blood transfusion in C-section in the two groups.

CONCLUSION

Placenta previa, placental abruption, emergency C-section, booking status, multiple gestations, and preoperative hematocrit were the risk factors most significantly associated with blood transfusion, while a prior C-section did not increase the risk of transfusion.

Incidence, trends and risk factors for obstetric massive blood transfusion in China from 2012 to 2019: an observational study

OBJECTIVES

This study aims to use the high-quality national monitoring data from the China's National Maternal Near Miss Surveillance System (NMNMSS) to ascertain the incidence, trends and risk factors of obstetric massive blood transfusion (MBT) from 2012 to 2019 in China and determine its clinical outcomes.

SETTINGS

Observational study of hospitalised pregnancies who had given birth or ended their pregnancy among member hospitals of NMNMSS.

PARTICIPANTS

11 667 406 women were included in this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

We screened for the incidence, trends, risk factors and main reasons for obstetric MBT, and the outcomes after obstetric MBT. MBT was defined as the transfusion of ≥5 units of red blood cells or ≥1000 mL of whole blood. The incidence of MBT was defined as the MBT cases per 10 000 pregnancies.

RESULTS

Obstetric MBT occurred in 27 626 cases, corresponding to an incidence of 23.68 per 10 000 maternities, which exhibited an increasing trend in China during 2012-2019 (14.03-29.59 per 10 000 maternities, p for trend <0.001). Obstetric MBT was mainly associated with amniotic fluid embolism, uterine atony, abnormal placenta, severe anaemia, ectopic pregnancy, abortion, caesarean section, advanced maternal age and multiparous from biological effect. While from sociological effects, uterine atony, severe anaemia and placenta previa are the top three complications which more likely to undergo obstetric MBT in the Chinese population. Overall, the secular trends of hysterectomy incidence (25.07%-9.92%) and MMR during hospitalisation (21.41‰-7.48‰) among women who underwent MBT showed decreasing trends (p for trend <0.001).

CONCLUSION

To minimise the incidence of obstetric MBT, more attention should be paid to education on the importance of the antenatal visit, evidence-based transfusion practice and females who are multiparous and have an advanced age, amniotic fluid embolism, uterine atony, severe anaemia and placenta previa.

A Participant-assigned Interventional Research of Precesarean Internal Iliac Artery Balloon Catheterization for Managing Intraoperative Hemorrhage of Placenta Previa and Placenta Accreta Spectrum Disorders After Cesarean Section

Placenta accreta spectrum disorder (PASD) and placenta previa (PP) are two of the most hideous obstetric complications which are usually associated with a history of cesarean section (CS). Moreover, women with PASD, PP and/or a cesarean scarred uterus are more likely to have adverse pregnancy outcomes, including blood transfusion, hysterectomy, pelvic organs damage, postpartum hemorrhage, disseminated intravascular coagulation, multi-organ dysfunction syndrome and even maternal or fetal death. This study aimed to investigate the efficacy of precesarean internal iliac artery balloon catheterization (BC) for managing severe hemorrhage caused by PASD and PP with a history of CS. This participant-assigned interventional study was conducted in Tongji Hospital. We recruited 128 women with suspected PASD, PP and a history of CS. Women in the BC group accepted precesarean BC of bilateral internal iliac arteries before the scheduled cesarean delivery. Women in the control group underwent a conventional cesarean delivery. Intraoperative hemorrhage, transfusion volume, radiation dose, exposure time, complications and neonatal outcomes were discussed. There were significant differences in calculated blood loss (CBL) between BC group and control group (1015.0±144.9 vs. 1467.0±171.0 mL, P=0.04). Precesarean BC could reduce intraoperative red blood cell (RBC) transfusion as compared with control group (799.5±136.1 vs. 1286.0±161.6 mL, P=0.02) and lessen the rate of using blood products (57.1% vs. 76.4%, P=0.02). The incidence of hysterectomy was also lower in BC group than in control group. Postpartum outcomes showed no significant differences between the two groups, except that postoperation hospitalization was longer in BC group than in control group (6.7±0.4 vs. 5.8±0.2 days, P=0.03). Precesarean BC of internal iliac artery is an effective method for managing severe hemorrhage caused by PASD and PP with a cesarean scarred uterus, as it could reduce intraoperative blood loss, lessen intraoperative RBC transfusions and potentially decrease hysterectomies.

Effect of blood transfusion during cesarean section on postpartum hemorrhage in a tertiary hospital over a 4-year period

Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and death worldwide. The history of cesarean section and the occurrence of placenta previa were significantly associated with the increase in blood transfusion. Therefore, to prevent PPH, it is important to understand the effect of blood transfusion during cesarean section on postpartum hemorrhage. The purpose of this study is to determine the cause of blood transfusion during cesarean section, especially large amounts of blood transfusion, and to take measures to reduce the blood demand caused by PPH with limited blood supply.This study was a retrospective study of patients who underwent blood transfusion during cesarean section in Qilu Hospital of Shandong University (China) from January 2013 to December 2016. Red blood cell infusion ≥10 U during cesarean section was defined as massive blood transfusion. The study collected the demographics of pregnant women, obstetric characteristics and reasons for blood transfusions, as well as blood components and blood transfusion results. Multivariate regression analysis was performed for evaluating the risk factors of PPN.From 2013 to 2016, a total of 587 patients received blood transfusions during cesarean section. The proportion of women receiving blood transfusion during cesarean section increased (from 3.21% to 7.40%, P < .001). The history of cesarean section (P = .005) and the occurrence of placenta previa were positively correlated with the increase in blood transfusion (P = .016). There were 72 cases of massive blood transfusion, accounting for 12.27% of blood transfusion patients. Among mass blood transfusions, 93.1% of cases had prior cesarean delivery, and placenta previa accounted for 95.8%. 19.4% of patients receiving massive blood transfusions underwent hysterectomy. There was no significant difference in maternal BMI and gestational age between the mass blood transfusion group and the non-mass blood transfusion group.From 2013 to 2016, the demand for blood transfusion, especially the demand for massive blood transfusion, increased. Repeated cesarean section and placental previa combined with uterine scar are positively correlated with increased blood transfusion. Reducing the initial cesarean section should help reduce the massive blood transfusion caused by placenta previa with a history of cesarean section.

Enhancing the utilization of packed red blood cells stock in maternity hospitals

OBJECTIVES

To assess and enhance the efficiency of transfusion services in maternity hospitals.

METHODS

A case control study was conducted from January to December 2016. A corrective policy of replacing preoperative type and hold step with blood transfusion request (BTR) hold was used only on healthy patients undergoing elective cesarean sections (c-section). The crossmatch/transfusion (C:T) ratio and a cost comparison were the evaluating factors. Data were analyzed using an Excel spreadsheet and SPSS statistical software.

RESULTS

A total of 1,200 BTRs were analyzed, comprising 659 before implementation of the corrective policy and 541 blood transfusion requests after implementation of the corrective policy. From January to March, the C:T ratio of c-sections was nearly 7 times the American Association of Blood Banks recommended limit of 2.5. Most of the blood units (94%) were damaged due to repeated booking. After implementation, the cost-e ectiveness of erythrocyte transfusion was greatly enhanced as all the ordered blood units were used and the C:T ratio was reduced to the ideal limit of one. The number of destroyed units was drastically decreased from 450 units to zero; as a result, 83% of the transfusion costs were saved.

CONCLUSION

The policy enhances the cost-effectiveness of erythrocyte transfusion and laboratory testing, and saves on additional, unnecessary costs.

Factors associated with postcesarean blood transfusion: a case control study

Objective: Cesarean delivery (CD) is a known risk factor for postpartum hemorrhage. However, the characteristics associated with post-CD transfusion are not well-established. We aimed to assess blood transfusion rates and associated factors following CD.Methods: A retrospective case-control study of women who underwent CD at a university hospital. The study group comprised all women who received blood transfusion following surgery. A control group of women who did not receive postoperative blood transfusion was assigned in a two-to-one ratio.Results: During study period, the overall post-CD blood transfusion rate was 4.7%. The study group comprised 170 women, and the control group 340. Maternal age (aOR [95% CI]: 1.07 (1.03, 1.11), p = .001), parity (aOR [95% CI]: 1.26 (1.09, 1.47), p = .002), gestational hypertensive disorders (aOR [95% CI]: 4.07 (1.52, 10.91), p = .005), maternal comorbidities (aOR [95% CI]: 4.16 (1.88, 9.1), p < .001), lower predelivery hemoglobin level (aOR [95% CI]: 0.43 (0.34, 0.54), p < .001), and major placental abnormalities (aOR [95% CI]: 2.74 (1.04, 7.18), p = .04) were independently associated with blood transfusion requirement. Intrapartum characteristics associated with blood transfusion requirement included nonelective procedure (aOR [95% CI]: 3.21 (1.72, 5.99), p < .001), prolonged second stage of labor (aOR [95% CI]: 5.50 (2.57, 11.78), p < .001), longer duration of surgery (aOR [95% CI]: 1.03 (1.02, 1.04), p < .001), general anesthesia (aOR [95% CI]: 2.11 (1.14, 3.91), p = .02), and greater estimated operative blood loss (aOR [95% CI]: 5.72 (3.15, 10.36), p < .001).Conclusions: Among women who underwent CD, we identified 11 factors associated with blood transfusion following surgery. Prospective studies are warranted to assess the implementations of prophylactic interventions to reduce transfusion rates among those deemed at high risk for CD-related bleeding.

Blood transfusion and high-order cesarean delivery; Report from a developing country

Background and Objective:

Blood loss in cesarean deliveries has already been established in previous researches but a detailed insight into the correlates has not been done. This study examined whether the number of previous Cesarean sections is related to the need for blood transfusion, and risk factors for blood transfusion.

Methods:

A retrospective review of 239 females who had undergone two or more Cesarean sections during the time period of 2015-2018 was done. Data collected included type of surgery (elective or emergency), age, parity, body mass index, estimated blood loss, operating time, level of surgeon, presence or absence of adhesions and number of transfused packed cell volume.

Results:

About 9.2% patients received blood transfusion with an estimated average blood loss of 618.18 ml. Patients with adhesions from previous surgery, presence of placenta previa, multiparity were significantly likely to receive blood transfusion. It was found that women with more than two caesarian sections had high proportion of blood transfusion as compared to women who had two caesarian sections. However non-significant difference was observed in numbers of caesarean sections with blood transfusion.

Conclusion:

Women undergoing Cesarean sections combined with any of the risk factors like increased body mass index, dense adhesions, uterine atony, hypertension and presence of placenta previa, were found to be at increased risk for a need for blood transfusions.

Establishing a perinatal red blood cell transfusion risk evaluation model for obstetric patients: a retrospective cohort study

BACKGROUND

The ability to predict risk factors for blood transfusion after postpartum hemorrhage could enhance the performance of lifesaving procedures in patients who experience postpartum hemorrhage. Therefore, this study aimed to evaluate these risk factors and create a scoring system for blood transfusion evaluations and risk in obstetric patients.

STUDY DESIGN AND METHODS

Diagnosis and blood transfusion data of 14,112 women who delivered between January 1, 2015, and December 31, 2015, were analyzed. A binary logistic regression model was used. We conducted univariate analyses of each risk factor as well as multivariable logistic regression analysis. Data of obstetric patients in 2016 validated the receiver operating characteristic curve. A risk prediction score was generated from the transfusion risk factor β‐coefficients in the multivariable logistic regression model.

RESULTS

In total, 392 (2.94%) of 13,328 patients received transfusions. After multivariable adjustment, polyembryony, anemia, thrombocytopenia, preeclampsia, placenta previa, placental implantation, uterine scarring, uterine rupture, retained placenta, stillbirth, and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) were significantly associated with perinatal transfusion. Heart disease and hemophilia were not related to transfusion risk. The blood transfusion risk evaluation table was well calibrated.

CONCLUSIONS

Our retrospective analysis revealed that diagnoses including polyembryony, anemia, thrombocytopenia, preeclampsia, placenta previa, placenta implantation, uterine scarring, uterine rupture, retained placenta, stillbirth, and HELLP syndrome are significantly associated with perinatal transfusion and are risk factors for blood transfusion. The blood transfusion scoring system could be beneficial for evaluating blood transfusion risk.

A retrospective cohort study of risk factors and pregnancy outcomes in 14,014 Chinese pregnant women

This study aims to investigate major complications or symptoms of pregnant women, causes of maternal near-miss, and issues that are relevant to severe maternal disease.A retrospective analysis was performed in the "maternal individual investigation form," which included all critical maternity patients admitted to the First Affiliated Hospital of Anhui Medical University from January 1, 2012 to September 31, 2015.A total of 14,014 pregnant patients who delivered at 28 to 42 weeks of gestation were included. Eight thousand eighty-six patients experienced complications or symptoms, and top 7 of these were postpartum hemorrhage, hypertension during pregnancy, diabetes, anemia, hepatopathy, nephroma, and connective tissue disease, of which the morbidity were 11.92%, 10.15%, 9.34%, 8.57%, 3.13%. 0.56%, and 0.55%, respectively. Delivery times, gestational weeks, and informal pregnancy examinations had significant correlation with maternal near-miss (P < .05); nevertheless, the age at pregnancy, number of pregnancies, and education were not so significant (P > .05). Two hundred sixty-five patients had severe maternal diseases (maternal near miss), and the top 5 causes for severe maternal morbidity were massive blood transfusion, thrombocytopenia, clinical feature of shock, uterus removal induced by uterus infection or bleeding, and coagulation dysfunction, of which the morbidity were 24.15%, 18.87%, 13.58%, 9.43%, and 6.79%, respectively.Delivery times, gestational weeks, and informal pregnancy examinations should be considered in maternal near miss patients. Moreover, hypertensive disorders during pregnancy, postpartum hemorrhage, anemia, thrombocytopenia, hepatopathy, and cardiopathy were the principal causes of maternal near miss. Therefore, the monitoring of these principal causes of severe maternity near miss is important for reducing the maternal morbidity and mortality.

Clinical Analysis of Postpartum Hemorrhage Requiring Massive Transfusions at a Tertiary Center

Background:

The reports on massive transfusions (MTs) in obstetrics have recently been an increasing trend. We aimed to define the clinical features, risk factors, main causes, and outcomes of MTs due to severe postpartum hemorrhage (PPH) and the frequency trends over the past 10 years.

Methods:

We retrospectively analyzed the data of 3552 PPH patients who were at ≥28 weeks of gestation in the Obstetric Department of Peking University First Hospital from January 2006 to February 2015. The clinical records of patients receiving MT with ≥5 units (approximately 1000 ml) of red blood cells within 24 h of giving birth were included. The Pearson's Chi-square and Fisher's exact tests were used to compare the frequency distributions among the categorical variables of the clinical features.

Results:

One-hundred six women were identified with MT over the 10-year period. The MT percentage was stable between the first 5-year group (2006–2010) and the second 5-year group (2011–2015) (2.5‰ vs. 2.7‰, χ² = 154.85, P = 0.25). Although uterine atony remained the main cause of MT, there was a rising trend for placental abnormalities (especially placenta accreta) in the second 5-year group compared with the first 5-year group (34% vs. 23%, χ² = 188.26, P = 0.03). Twenty-four (23%) women underwent hysterectomy, and among all the causes of PPH, placenta accreta had the highest hysterectomy rate of 70% (17/24). No maternal death was observed.

Conclusions:

There was a rising trend for placental abnormalities underlying the stable incidence of MT in the PPH cases. Placenta accreta accounted for the highest risk of hysterectomy. It is reasonable to have appropriate blood transfusion backup for high-risk patients, especially those with placenta accreta.