Peripartum Haemorrhage: Haemostatic Aspects of the New German PPH Guideline

Short and long-term menstrual, reproductive, and mental health outcomes after the intrauterine use of chitosan tamponade or the Bakri balloon for severe postpartum hemorrhage: an observational study

OBJECTIVE

This retrospective follow-up study analyzes the effect of intrauterine postpartum hemorrhage (PPH) therapy on menstrual, reproductive, and mental health outcomes.

METHODS

All women who delivered at a university hospital between 2016 and 2021 with PPH and who needed intrauterine therapy were included. A questionnaire on well-being, menses, fertility, and reproductive outcomes was mailed to the patients. Those who did not reply were surveyed by telephone.

RESULTS

A total of 214 women treated with chitosan-covered gauze (group A) and 46 women treated with a balloon tamponade (group B) were recruited, and their short-term courses were analyzed. For long-term follow-up, 71 women of group A (33%) and 21 women of group B (46%) could be reached. A total of 89% of group A and 95% of group B had regular menstrual bleeding in the most recent 12 months; 27% (group A) and 29% (group B) were trying to conceive again, and all of them did so successfully. There were 12 deliveries, 3 ongoing pregnancies, 3 miscarriages, and 2 terminations of pregnancies (TOP) in group A and 4 deliveries, 1 miscarriage, and 2 TOPs in group B. More than half of our study participants was sorted into grade II or III of the Impact of Events Scale, indicating they experienced clinical impacts in the form of psychological sequelae. One-quarter of patients had symptoms of post-traumatic stress disorder.

CONCLUSION

Chitosan gauze as well as balloon tamponade appear to have few adverse effects on subsequent menstrual and reproductive function. Women after PPH are at increased risk of long-term adverse psychological outcomes.

Conservative approaches to postpartum haemorrhage

Postpartum haemorrhage (PPH) and PPH-related deaths are disproportionately higher in low-income countries, with sub-Saharan Africa and Southern Asia accounting for approximately 85% of the global burden of PPH-related maternal deaths. Although PPH-related mortality is directly related to the amount and duration of bleeding, the high maternal death burden in resource-limited countries suggests that a great majority of these deaths would be avoidable with the appropriate resources and effective use of evidence-based interventions. Non-surgical management is often the first-line approach for PPH, but conservative surgical interventions may be required if bleeding persists or if the underlying cause is not responsive to the initial conservative measures. The appropriate interventions should be selected based on the individual's specific circumstances and clinical condition.

Trimester-specific reference intervals and profile of coagulation parameters for Chinese pregnant women with diverse demographics and obstetric history: a cross-sectional study

BACKGROUND

Owing to the changes in childbirth policy in China, this work aimed to update the trimester-specific reference intervals (RIs) for Chinese pregnant women with diverse demographics and obstetric history. This study also investigated how advanced maternal age (AMA) (> 35 years old), gravity, and parity influence gestational coagulation parameters.

METHODS

In this prospective cross-sectional study, five coagulation parameters were measured using assays provided by Roche diagnostics on Cobas t 711: prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen (Fib), and D-dimer, and the trimester-specific 2.5th -97.5th and 95th (D-dimer only) percentiles RIs were established accordingly. Linear regressions were undertaken to analyze the association with demographic characteristics and obstetric history for each parameter.

RESULTS

893 eligible pregnant women in different trimesters and at AMA/non-AMA and 275 non-pregnant healthy women were enrolled. For the first, second, and third trimester, respectively, RIs were as follows: APTT (s): 24.8-35.7, 24.6-34.1, and 23.5-34.7; TT (s): 14.4-17.3, 14.1-16.7, and 14.2-17.5; PT (s): 8.30-10.20, 8.00-9.77, and 7.92-9.57; PT-INR: 0.86-1.06, 0.83-1.02, and 0.82-0.98; Fib (g/L): 2.76-4.97, 3.14-5.31, and 3.44-5.93; D-dimer (µg/ml): 0-0.969, 0-2.14, and 0-3.28. No statistically significant differences were observed in TT, D-dimer, and APTT between the AMA and non-AMA women, while PT and PT-INR were shorter and Fib was higher in the AMA group. The association of gravidity and parity with each coagulation parameter is statistically significant (p < 0.05). PT and PT-INR were shortened and D-dimer decreased as gravidity increased. Longer PT and PT-INR, shorter APPT, higher D-Dimer, and lower Fib were associated with increasing parity.

CONCLUSIONS

This work updated the gestational coagulation profiles of Chinese pregnant women and established trimester-specific RIs accordingly. Establishing specific RIs based on AMA, parity, and gravidity might not be necessary.

Patient Blood Management in Pregnancy

BACKGROUND

Patient blood management (PBM) is a multidisciplinary and patient-centered treatment approach, comprising the detection and treatment of anemia, the minimization of blood loss, and the rational use of allogeneic transfusions. Pregnancy, delivery, and the puerperium are associated with increased rates of iron deficiency and anemia, which correlates with worse maternal and fetal outcomes and places pregnant women at increased risk of obstetric hemorrhage.

SUMMARY

Early screening for iron deficiency before the onset of anemia, as well as the use of oral and intravenous iron to treat iron deficiency anemia, has been shown to be beneficial. Anemia in pregnancy and the puerperium should be treated according to a staged regimen, administering either iron alone or in combination with an off-label use of human recombinant erythropoietin in selected patients. This regimen should be tailored to the needs of each individual patient. Postpartum hemorrhage (PPH) accounts for up to one-third of maternal deaths in both developing and developed countries. Bleeding complications should be anticipated and blood loss reduced by interdisciplinary preventive measures and individually tailored care. It is recommended that facilities have a PPH algorithm, primarily focusing on prevention through use of uterotonics, but also incorporating early diagnosis of the cause of bleeding, optimization of hemostatic conditions, timely administration of tranexamic acid, and integration of point-of-care tests to support the guided substitution of coagulation factors, alongside standard laboratory tests. Additionally, cell salvage has proven beneficial and should be considered for various indications in obstetrics including hematologic disturbances, as well as various forms of placental disorders.

KEY MESSAGE

This article reviews PBM in pregnancy, delivery, and the puerperium. The concept comprises early screening and treatment of anemia and iron deficiency, a transfusion and coagulation algorithm during delivery, as well as cell salvage.

Risk-factor model for postpartum hemorrhage after cesarean delivery: a retrospective study based on 3498 patients

This study aimed to investigate the risk factors of patients with postpartum hemorrhage (PPH) after cesarean delivery (CD) and to develop a risk-factor model for PPH after CD. Patients were selected from seven affiliated medical institutions of Chongqing Medical University from January 1st, 2015, to January 1st, 2020. Continuous and categorical variables were obtained from the hospital's electronic medical record systems. Independent risk factors were identified by univariate analysis, least absolute shrinkage and selection operator and logistic regression. Furthermore, logistic, extreme gradient boosting, random forest, classification and regression trees, as well as an artificial neural network, were used to build the risk-factor model. A total of 701 PPH cases after CD and 2797 cases of CD without PPH met the inclusion criteria. Univariate analysis screened 28 differential indices. Multi-variable analysis screened 10 risk factors, including placenta previa, gestational age, prothrombin time, thrombin time, fibrinogen, anemia before delivery, placenta accreta, uterine atony, placental abruption and pregnancy with uterine fibroids. Areas under the curve by random forest for the training and test sets were 0.957 and 0.893, respectively. The F1 scores in the random forest training and test sets were 0.708. In conclusion, the risk factors for PPH after CD were identified, and a relatively stable risk-factor model was built.

Factor XIII in the Acute Care Setting and Its Relevance in Obstetric Bleeding

Background

Major hemorrhage is one of the main causes of preventable mortality in either severe trauma, high-risk surgical patient, or the obstetric population. As underlined by the cell-based coagulation model, a resistant and stable clot is essential to prevent or to stop an ongoing bleeding. Coagulation factor XIII (FXIII) stabilizes the newly formed clot by cross-linking the fibrin monomers into a three-dimensional network and by impeding fibrinolysis. Thus, FXIII is an essential coagulation factor in the acutely bleeding patient.

Summary

Acquired FXIII deficiency is much more common than the inherited form. On the basis of acute tissue injury which leads to major bleeding, acquired FXIII deficiency is traditionally considered to be secondary to consumption. However, recent evidence in the field of obstetrics and high-risk surgery suggests that it might be an associated factor rather than a consequence of the bleeding, which would mean that early replacement of FXIII could potentially improve outcomes. However, FXIII measurement is not universally available. Assessing FXIII through viscoelastic assays seems feasible, though likely it is not yet accurate. Moreover, the target population at risk and the aimed FXIII level required to achieve hemostasis in each condition are yet to be defined.

Key Messages

FXIII should be assessed and replaced if necessary in the acutely bleeding patient. We recommend FXIII to be included in an escalating scheme of hemostatic therapies in the acute care setting.

Comparison of European recommendations about patient blood management in postpartum haemorrhage

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality and morbidity worldwide. Some documents with practical recommendations for the management of PPH do not include the most updated directives. This review offers a quality comparison of the recommendations stated in Europe since 2015. A literature search was conducted to identify the documents published in Europe from 2015 to 2020 containing recommendations about management of PPH. The search returned 10 publications. A narrative synthesis and a summary of the information about PPH definition and its management were performed. Differences in the definition of PPH were identified: some documents considered the delivery procedure, and many publications included severity criteria. The therapeutic goal for red blood cells transfusion ranged from 6 to 9 g/dl. There were divergences in the need for considering haemostatic results before fresh frozen plasma transfusion. The therapeutic goal of platelet transfusion ranged from 50 x 10⁹ to 100 x 10⁹  μ/L. There was a wide consensus about the therapeutic goal of fibrinogen replacement (>2 g/L), but not about its use in an unmonitored or pre-emptive manner. Most publications included therapeutic approaches such as tranexamic acid and recombinant factor VII activated, but not prothrombin complex concentrate or coagulation factor XIII. The recommendations about PPH management offered in European documents are heterogeneous and have changed over time. The standardisation of all them could be useful to make progress in PPH clinical management and research which, in turn, could strongly impact in patient outcomes.

The impact of acquired coagulation factor XIII deficiency in traumatic bleeding and wound healing

Factor XIII (FXIII) is a protein involved in blood clot stabilisation which also plays an important role in processes including trauma, wound healing, tissue repair, pregnancy, and even bone metabolism. Following surgery, low FXIII levels have been observed in patients with peri-operative blood loss and FXIII administration in those patients was associated with reduced blood transfusions. Furthermore, in patients with low FXIII levels, FXIII supplementation reduced the incidence of post-operative complications including disturbed wound healing. Increasing awareness of potentially low FXIII levels in specific patient populations could help identify patients with acquired FXIII deficiency; although opinions and protocols vary, a cut-off for FXIII activity of ~ 60–70% may be appropriate to diagnose acquired FXIII deficiency and guide supplementation. This narrative review discusses altered FXIII levels in trauma, surgery and wound healing, diagnostic approaches to detect FXIII deficiency and clinical guidance for the treatment of acquired FXIII deficiency.

Viscoelastic Hemostatic Assays for Postpartum Hemorrhage

This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.

Anesthetic management for Placenta Accreta

Дослідження виконані у 82 вагітних і породіль при кесаревому розтині з приводу передлежання плаценти з вростанням на 37–38 тижні. Органозберігаюча операція була виконана за такою методикою: лапаротомія за Джоель Кохен, донний кесарів розтин з залишенням плаценти, перев’язка трьох пар магістральних маткових судин і внутрішніх клубових артерій з обох сторін (поетапна деваскуляризація матки) з подальшим видаленням стінки матки (метропластика) при вростанні плаценти. Операції виконані в умовах спінальної анестезії (Сан) 0,5 % гіпербаричним розчином бупівакаїну. Інфузійна програма будувалася відповідно до рекомендацій з обмежувальної інфузії. Преінфузію проводили збалансованим кристалоїдом Реосорбілакт (10–15 мл/кг) з подальшим введенням на етапах операції збалансованого кристалоїду і компонентів крові за необхідності. Оцінювали гемодинаміку, КОР та електроліти крові. Оцінку крововтрати проводили гравіметричним способом. Дослідження показали, що Сан і Реосорбілакт у програмі малооб’ємної інфузійної терапії зберігають доставку кисню на фізіологічному рівні, стабілізують гемодинамічний профіль і КОР. При вростанні плаценти використання сучасних технологій в анестезіології реаніматології та акушерстві, з мультидисциплінарним підходом, дозволяють реалізувати органозберігаючу тактику у цієї категорії жінок

Red blood cell transfusion in obstetrics and its implication for patient blood management: a retrospective analysis in Switzerland from 1998 to 2016

PURPOSE

Peripartum hemorrhage (PPH) remains one of the main causes of maternal mortality worldwide. Treatment includes administration of packed red blood cells (RBC) in severe cases and patient blood management (PBM) may reduce it significantly. In our study, we wanted to retrospectively assess red blood cell administration in PPH to evaluate the impact of PBM in Switzerland.

METHODS

Using data from the Swiss obstetric hospital registry (Arbeitsgemeinschaft Schweizer Frauenkliniken, ASF), we included patients with deliveries from 1998 to 2016. We examined available obstetric data as well as blood loss and RBC administration in the acute and subacute peripartal phase. We categorized data into two time intervals: 1998-2011 and 2012-2016, as new PPH guidelines in Switzerland were established in 2012.

RESULTS

PPH incidence increased between 1998 and 2016 significantly. The number of vaginal instrumental deliveries and cesarean sections increased as well. Administration of three or more RBC units, as defined in the ASF registry, in the acute and subacute phase in Switzerland has decreased after 2012. Conversely, we saw an increase in the administration of one to two RBC units in the acute and subacute phase. Nevertheless, overall RBC administration has been decreasing from 1998 to 2016.

CONCLUSION

The increase of patients obtaining one or two units of RBC for PPH suggests that there may be a potential for effective implication of PBM in obstetrics. Reduction of RBC transfusion in the context of PPH may not only decrease maternal morbidity, but decrease economic costs as well.

Nomogram to predict postpartum hemorrhage in cesarean delivery for women with scarred uterus: A retrospective cohort study in China

AIM

To develop nomograms predicting the risk of postpartum hemorrhage (PPH) in cesarean delivery for singleton pregnant women with a scarred uterus in the north of China.

METHODS

A retrospective cohort study was conducted. Totally 3722 singleton pregnant women with a scarred uterus who underwent a cesarean delivery in a large teaching hospital of north China between January 2013 and December 2017 were enrolled. Nomograms, a kind of user-friendly tool, were developed to predict PPH (blood loss ≥1000 mL or accompanied by signs or symptoms of hypovolemia within 24 h after the birth process) based on the model generated by logistic regression analysis. The discrimination and calibration of models were evaluated, and decision curve analysis was developed.

RESULTS

Among 3722 enrolled women, 243 (6.53%) had PPH. There are six identified factors associated with PPH: maternal age, placental location, placenta previa, hypertensive disorders of pregnancy, fetal position and placenta accreta spectrum (PAS). The model achieved a good calibration (Hosmer-Lemeshow test P value 0.77) and discrimination (area under curve c-statistics 0.90, 95% confidence interval 0.86-0.93). Decision curve analysis showed the threshold probability by using our model is between 1.0% and 85.7%. A nomogram was developed accordingly. And another nomogram for women without placenta previa and PAS was also developed.

CONCLUSION

Two nomograms were first generated to predict PPH, respectively, for women with a scarred uterus and for women with a scarred uterus who do not have placenta previa or PAS. Placental location and fetal position were found to be closely related to PPH.

Successful Perioperative Management with Damage Control Surgery in a Patient with Massive Postpartum Hemorrhage of More Than 20,000 mL

Disseminated intravascular coagulation (DIC) in obstetrics is related to postpartum hemorrhage and has been a leading cause of maternal death. We here report a successful treatment, via damage control surgery (DCS), of a life-threatening massive hemorrhage of more than 20,000 mL due to DIC. A 30-year-old female was admitted to our hospital because of atonic bleeding. Since she was having a uterine rupture, an emergency hysterectomy was performed. Because of the severe DIC (fibrinogen, 65 mg/dL; platelet count, 6.0 × 10⁹/L), oozing persisted after the hysterectomy; thus, intraperitoneal gauze packing was performed as DCS. Afterwards, the coagulopathy was corrected, and the gauze was removed on the second postoperative day (POD 2). The patient was discharged without complications on POD 16. The present case demonstrated that performing DCS and waiting for improvement of the coagulation system can be one of the treatment options for management of patients with severe DIC.

Preoperative moderate thrombocytopenia is not associated with increased blood loss for low-risk cesarean section: a retrospective cohort study

BACKGROUND

The occurrence of thrombocytopenia is as high as 7-12% in pregnancy, yet minimum platelet count safe for cesarean section remains unknown.

METHODS

In this retrospective noninferior cohort study, we consecutively included patients undergoing cesarean section for a period of 6 years in a tertiary hospital and excluded patients at very high risk for excessive hemorrhage. The included patients with preoperative platelet count of 50-100 × 10⁹/L were defined as the thrombocytopenic group. The control group were eligible patients with preoperative platelet count>150 × 10⁹/L, matched to the thrombocytopenic group by age and operation timing in a 1:2 ratio. Mixed effect model was used to analyze the effect of thrombocytopenia based on a noninferiority assumption. The predefined noninferiority delta of bleeding was 50 mL.

RESULTS

There was no significant difference of the calculated blood loss between the thrombocytopenic and the control group (mean difference = 8.94, 95% CI - 28.34 mL to 46.09 mL). No statistical difference was observed in the requirement for blood transfusion, visually estimated blood loss, or the incidence of adverse events between groups. Although there were more patients admitted to intensive care unit (odds ratio = 12, 95% CI 2.69-53.62, p = 0.001) in the thrombocytopenic group, most of them required critical care for reasons other than hemorrhage. The thrombocytopenic group had longer length of hospital stay (mean difference = 0.40 days, 95% CI 0.09-0.71, p = 0.011), but the difference was considered as clinically insignificant.

CONCLUSIONS

Preoperative moderate thrombocytopenia is not associated with increased blood loss, blood transfusion, or occurrence of adverse events in patients undergoing cesarean section in absence of additional bleeding risk.