Evaluation of compliance and outcomes of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in Pakistan

Hospital Characteristics and Other Factors Associated with the Risk of Postpartum Hemorrhage in the United States

Background: Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality in the United States. It occurs when blood loss exceeds 1000mL regardless of the delivery route. Careful assessment of various causes and risk factors of PPH is essential to reduce and prevent further complications, avoid maternal morbidity and mortality, and better manage PPH. This study aimed to examine the associations of hospital characteristics and regions of hospital locations across the United States with PPH risk, as the outcomes of such an assessment may contribute to practice-relevant scientific evidence to improve policies and protocols regarding effective PPH management. Methods: This retrospective study used the 2018 National Inpatient Sample database from the Healthcare Cost and Utilization Project (HCUP) to examine the associations of PPH risk with characteristics and regions of hospital lections. Results: After controlling for clinical risk factors, the results showed that hospitals owned by private investors had significant associations with decreased risk of PPH. Conversely, large bed size, urban teaching status, and West and Midwest location were associated with an increased risk of PPH. Conclusion: Additional research is needed to determine whether these variations across regions and hospital characteristics are due to differences in obstetric practice and management.

Predictors of time to recovery from postpartum hemorrhage in Debre Markos comprehensive specialized hospital, Northwest, Ethiopia, 2020/21

Background

Postpartum hemorrhage is one of the leading causes of maternal deaths worldwide. Early recovery is a performance indicator and better health outcome of patients with postpartum hemorrhage. Therefore, this study aimed to assess time to recovery from postpartum hemorrhage and its predictors in Debre Markos Comprehensive Specialized Hospital, Ethiopia, 2020.

Methods

A retrospective follow-up study was conducted among 302 women who were diagnosed with postpartum hemorrhage from January 1, 2016 to December 31, 2020 at Debre Markos Comprehensive Specialized Hospital. Consecutive sampling technique was employed. To show the statistical significant difference between each group of variables, log rank test was used. Kaplan Meier analysis to estimate time to recovery and cox proportional-hazard regression analysis to determine independent predictors were carried out cautiously. Adjusted hazard ratio used to determine the strength of association.

Result

The median recovery time from postpartum hemorrhage was 13 h with range of (10 to 17 h). Blood transfusion (AHR: 1.8, 95% CI (1.39, 2.57)), NASG utilization (AHR: 6.5, 95% CI (4.58, 9.42)) fluid resuscitation (AHR 2.9, 95% CI (1.48, 5.54)), active management of third stage of labor (AHR: 1.7, 95% CI (1.18, 2.45)) and history of antenatal care follow-up (AHR: 2.6, 95% CI (1.91, 3.56)) were the predictors, which shorten the recovery time. Comorbidities like anemia at the time of admission (AHR: 0.62 95% CI (0.44, 0.89)), retroviral infection (AHR: 0.33, 95% CI (0.16, 0.67)) and Hepatitis B-Virus infection (AHR: 0.52, 95% CI (0.32, 0.82)) delay the recovery rate from postpartum hemorrhage.

Conclusion

Mothers in North-West Ethiopia stays morbid from postpartum hemorrhage for more than half a day. Their recovery time was affected by Non-Pneumatic Anti-Shock Garment utilization, implementation of emergency management components like blood transfusion and fluid resuscitation, history of antenatal care follow up, and being comorbid with viral infections. Non-pneumatic anti-shock garment application to every mother with postpartum hemorrhage and implementation of proper emergency management approach are vital for rapid recovery from postpartum hemorrhage.

Efficacy and Feasibility of Chhattisgarh Balloon and Conventional Condom Balloon Tamponade: A 2-Year Prospective Study

Objective

To evaluate the clinical efficacy of two types of condom uterine balloon tamponade systems, namely Chhattisgarh condom balloon device "CG balloon (CGB)" having a central drainage channel as well as indigenous tying system to fasten condom to the catheter and conventional condom uterine balloon device (C-UBT) as a second-line intervention in post-partum haemorrhage (PPH).

Materials and Methods

The present non-randomised prospective case series was carried out from December 2014 to September 2016 and included 60 women having PPH which was refractory to first-line management and who were treated with either of the two condom balloon tamponade devices prepared on spot. Women with allergy to latex, retained placenta, uterine rupture, anomaly, genital infection and/or malignancy were excluded. Case report forms were filled for all participants and analysed. Primary outcome was arrest of haemorrhage, and one of the secondary outcomes was cost and consistency of the devices.

Results

CGB was used in 46 and C-UBT in 14 women. The overall success rate was 98.33%. The mean blood loss was 1417 mL. Women of C-UBT group had greater blood loss, higher inflation volume and delays due to technical issues (OR 7.6). CGB was cheaper and more consistent than C-UBT by omitting the use of suture material.

Conclusion

CGB and conventional condom balloon tamponade both are easy to use, feasible and efficacious for control of PPH, but CGB condom balloon device has the advantage of a central drainage lumen for real-time assessment of blood loss and therefore early corrective action.

Major obstetric haemorrhage of 2000 ml or greater: a clinical audit

Haemorrhage remains a leading cause of maternal death. We conducted an audit to identify strategies to improve the management at our local NHS Trust. A data collection form was based on our local guideline. A coded database search was conducted for all deliveries where the estimated blood loss was ≥2000 ml (from June 1 2015 to December 31 2015), returning 68 search results (13.7/1000 births). Fifty-six records were included. Poor compliance (<75%) was seen in some key areas including the major obstetric haemorrhage (MOH) call activation (52%), the presence of an anaesthetic consultant (63%) and tranexamic acid administration (46%). Thirty out of 56 cases (54%) were acutely transfused. Women, who were not transfused acutely, appeared to be more likely to need a secondary transfusion if no MOH call had been activated (9/27 (33%) versus 3/29 (10%), p = .052). A key area for improvement was the activation of MOH calls. Following this audit, we adjusted our guideline to make it more clinically useful and staff training sessions were held, including simulation training. Impact statement What is already known on this subject? A postpartum haemorrhage (PPH) is an obstetric emergency. A structured approach is important to optimise the care of the mothers during this dangerous time, and has been shown to reduce the transfusion requirements. However, clinical practice may not adhere to the guideline recommendations. What the results of this study add? With the objective evidence of increased rates of PPH ≥2000 ml at our institution, our work identifying the flaws in management was a critical component of the work to improve the outcomes. This study gives impetus to find innovative ways to improve adherence to guidelines, and inspired an update of our local guideline to improve the applicability and utility. This project suggests a new marker for the adequacy of an acute management (a requirement for secondary blood transfusion without having received an acute transfusion), and raises questions about what constitutes optimum PPH management. What the implications are of these findings for clinical practice and/or further research? The primary and secondary transfusion data raised new questions to investigate in the future: does the involvement of consultants and the escalation of care via the instigation of major haemorrhage protocols improve decision-making and patient outcomes? Does the necessity for a secondary transfusion indicate a suboptimal acute care?

Maternal morbidity and associated factors at a tertiary care Centre in Karachi: A critical analysis

AIM

The study was conducted to identify maternal morbidity and associated factors such intensive care unit admission and surgical intervention.

METHODS

Pregnant and six-week post-partum women without any other comorbidy were recruited from January 2014 to December 2015 from the Department of Gynaecology and Obstetrics at Liaquat National Hospital, Karachi. A structurally designed questionnaire was used to record demographic data and factors related to the management and intervention of maternal conclusions.

RESULTS

A total of 213 patients were included in the study, with an average age of 27.87 ± 5.26 years, mean parity of 2.02 ± 1.88 and mean gestational period of 32.48 ± 7.93. The details of 186 neonatal cases were also recorded: 47 neonates were admitted to the intensive care unit, while 23 were kept on ventilation. The primary complication was post-partum hemorrhage. The most common intervention methods used was lower segment cesarean section.

CONCLUSION

The concept of maternal morbidity is developing as a new indicator for the assessment of maternal healthcare services. Public health awareness programs should be conducted for health professionals to combat the high incidence of maternal morbidity.

Evaluation of a multifaceted postpartum hemorrhage-management intervention in community hospitals in Southern Thailand

OBJECTIVE

To assess a multifaceted postpartum hemorrhage (PPH)-management intervention in community hospitals in Southern Thailand.

METHODS

The present prospective study was conducted from November 1, 2012 to April 30, 2015. The medical records of women with PPH were collected before (January 1, 2011, and October 31, 2012) and after (March 1, 2013, and December 31, 2014) the implementation of a multifaceted PPH-management intervention at three community hospitals in Southern Thailand; these patients were compared with patients diagnosed with PPH at three control hospitals in the same provinces during the same time periods. The intervention, delivered to general practitioners and nurses, utilized previously developed PPH-management guidelines. PPH management was compared between the intervention and control hospitals and factors associated with PPH management were evaluated using univariate and multiple logistic regressions.

RESULTS

The post-intervention median blood loss within 2 hours of delivery was lower in intervention hospitals (P<0.001) and post-intervention indwelling bladder catheterization was higher (P=0.004). Increased odds of indwelling bladder catheterization were recorded among patients treated at intervention hospitals (adjusted odds ratio [aOR] 2.79, 95% confidence interval [CI] 1.40-5.55) and patients who experienced more than 500 mL of blood loss (501-1000 mL [aOR 2.41, 95% CI 1.22-4.76] or >1000 mL [aOR 16.45, 95% CI 2.04-132.80]).

CONCLUSION

Implementation of the multifaceted intervention improved PPH management at community hospitals.

A global quantitative survey of hemostatic assessment in postpartum hemorrhage and experience with associated bleeding disorders

Purpose

Coagulopathy may be a serious complicating or contributing factor to postpartum hemorrhage (PPH), and should be promptly recognized to ensure proper bleeding management. This study aims to evaluate the approaches of obstetrician-gynecologists worldwide towards assessing massive PPH caused by underlying bleeding disorders.

Methods

A quantitative survey was completed by 302 obstetrician-gynecologists from 6 countries (the UK, France, Germany, Italy, Spain, and Japan). The survey included questions on the use of hematologic laboratory studies, interpretation of results, laboratory’s role in coagulation assessments, and experience with bleeding disorders.

Results

Overall, the most common definitions of “massive” PPH were >2,000 mL (39%) and >1,500 mL (34%) blood loss. The most common criteria for rechecking a “stat” complete blood count and for performing coagulation studies were a drop in blood pressure (73%) and ongoing visible bleeding (78%), respectively. Laboratory coagulation (prothrombin time/activated partial thromboplastin time [PT/aPTT]) and factor VIII/IX assays were performed on-site more often than were mixing studies (laboratory coagulation studies, 93%; factor VIII/IX assays, 63%; mixing studies, 22%). Most commonly consulted sources of additional information were colleagues within one’s own specialty (68%) and other specialists (67%). Most respondents had consulted with a hematologist (78%; least, Germany [56%]; greatest, UK [98%]). The most common reason for not consulting was hematologist unavailability (44%). The most commonly reported thresholds for concern with PT and aPTT were 13 to 20 seconds (36%) and 30 to 45 seconds (50%), respectively. Most respondents reported having discovered an underlying bleeding disorder (58%; least, Japan [35%]; greatest, Spain [74%]).

Conclusion

Global survey results highlight similarities and differences between countries in how PPH is assessed and varying levels of obstetrician-gynecologist experience with identification of underlying bleeding disorders and engagement of hematology consultants. Opportunities to improve patient management of PPH associated with bleeding disorders include greater familiarity with interpreting PT/aPTT test results and identification of and consistent consultation with hematologists with relevant expertise.

The impact of the implementation of the postpartum haemorrhage management guidelines at the first regional perinatal centre in Southern Kazakhstan

Background

Postpartum haemorrhage (PPH) remains one of the most common causes of maternal morbidity and mortality. Therefore, clearly written PPH management guidelines should be used in clinical practice. The aim of this study was to evaluate the effectiveness of the implementation of PPH management guidelines at the First Regional Perinatal Centre of Southern Kazakhstan (FRPC).

Methods

Between 2012 and 2013 an interventional study was performed whereby the PPH management guidelines were implemented at the FRPC. All of the deliveries that were complicated by PPH 8 months before and 8 months after the intervention were analysed. Prevalence and severity of PPH, and the change in prevention, diagnostics and management of PPH was evaluated and statistical analysis using the SPSS 22.0 was performed.

Results

There were in total 5404 and 5956 deliveries in the pre- and post-intervention periods, respectively. The rates of PPH and severe PPH decreased from 1.17 to 1.02 % (p = 0.94) and from 0.24 to 0.22 % (p = 0.94), respectively. Blood loss on average increased from 1055 to 1170 ml in the post-intervention period. The pharmacological treatment of postpartum haemorrhage with uterotonics was administered most frequently during both periods. After the implementation of the guidelines, the number of transfused units of packed red blood cells decreased from 4.76 to 2.48 units/case. In addition, the amount of transfused fresh frozen plasma decreased by 20 %. The number of conservative interventions and conservative operations increased from 7.9 to 52.7 % and from 3.9 to 48.6 %, respectively. The number of hysterectomies decreased from 23.7 % in pre-intervention to 8.1 % in the post-intervention period.

Conclusions

The implementation of the PPH management guidelines had a positive effect on PPH prevention, diagnostics and management. It led to a more conservative aproach to the treatment of PPH. Therefore, clearly written PPH management guidelines, adapted for a particular hospital, should be developed and used in clinical practice.

Hemostatic assessment, treatment strategies, and hematology consultation in massive postpartum hemorrhage: results of a quantitative survey of obstetrician-gynecologists

Objective

To assess potential diagnostic and practice barriers to successful management of massive postpartum hemorrhage (PPH), emphasizing recognition and management of contributing coagulation disorders.

Study design

A quantitative survey was conducted to assess practice patterns of US obstetrician-gynecologists in managing massive PPH, including assessment of coagulation.

Results

Nearly all (98%) of the 50 obstetrician-gynecologists participating in the survey reported having encountered at least one patient with “massive” PPH in the past 5 years. Approximately half (52%) reported having previously discovered an underlying bleeding disorder in a patient with PPH, with disseminated intravascular coagulation (88%, n=23/26) being identified more often than von Willebrand disease (73%, n=19/26). All reported having used methylergonovine and packed red blood cells in managing massive PPH, while 90% reported performing a hysterectomy. A drop in blood pressure and ongoing visible bleeding were the most commonly accepted indications for rechecking a “stat” complete blood count and coagulation studies, respectively, in patients with PPH; however, 4% of respondents reported that they would not routinely order coagulation studies. Forty-two percent reported having never consulted a hematologist for massive PPH.

Conclusion

The survey findings highlight potential areas for improved practice in managing massive PPH, including earlier and more consistent assessment, monitoring of coagulation studies, and consultation with a hematologist.

Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety

The purpose of this study was to assess the effectiveness of instituting a comprehensive protocol for the treatment of maternal hemorrhage within a large health care system. A comprehensive maternal hemorrhage protocol was initiated within a health care system with 29 different delivery units and with >60,000 annual births. Compliance with key elements of the protocol was assessed monthly by a dedicated perinatal safety nurse at each site and validated during site visits by system perinatal nurse specialist. Outcome variables were the total number of units of blood transfused and the number of puerperal hysterectomies. Three time points were assessed: (1) 2 months before implementation of the protocol, (2) a 2-month period that was measured at 5 months after implementation of the protocol, and (3) a 2-month period at 10 months after implementation. There were 32,059 deliveries during the 3 study periods. Relative to baseline, there was a significant reduction in blood product use per 1000 births (-25.9%; P < .01) and a nonsignificant reduction (-14.8%; P = .2) in the number of patients who required puerperal hysterectomy. Within a large health care system, the application of a standardized method to address maternal hemorrhage significantly reduced maternal morbidity, based on the need for maternal transfusion and peripartum hysterectomy. These data support implementation of standardized methods for postpartum care and treatment of maternal hemorrhage and support that this approach will reduce maternal morbidity.

Inter-facility transfer of surgical emergencies in a developing country: effects on management and surgical outcomes

OBJECTIVES

Outcomes of surgical emergencies are associated with promptness of the appropriate surgical intervention. However, delayed presentation of surgical patients is common in most developing countries. Delays commonly occur due to transfer of patients between facilities. The aim of the present study was to assess the effect of delays in treatment caused by inter-facility transfers of patients presenting with surgical emergencies as measured by objective and subjective parameters.

METHODS

We prospectively collected data on all patients presenting with an acute surgical emergency at Aga Khan University Hospital (AKUH). Information regarding demographics, social class, reason and number of transfers, and distance traveled were collected. Patients were categorized into two groups, those transferred to AKUH from another facility (transferred) and direct arrivals (non-transfers). Differences between presenting physiological parameters, vital statistics, and management were tested between the two groups by the chi square and t tests.

RESULTS

Ninety-nine patients were included, 49 (49.5 %) patients having been transferred from another facility. The most common reason for transfer was "lack of satisfactory surgical care." There were significant differences in presenting pulse, oxygen saturation, respiratory rate, fluid for resuscitation, glasgow coma scale, and revised trauma score (all p values <0.001) between transferred and non-transferred patients. In 56 patients there was a further delay in admission, and the most common reason was bed availability, followed by financial constraints. Three patients were shifted out of the hospital due to lack of ventilator, and 14 patients left against medical advice due to financial limitations. One patient died.

CONCLUSIONS

Inter-facility transfer of patients with surgical emergencies is common. These patients arrive with deranged physiology which requires complex and prolonged hospital care. Patients who cannot afford treatment are most vulnerable to transfers and delays.

The impact of postpartum haemorrhage management guidelines implemented in clinical practice: a systematic review of the literature

Postpartum haemorrhage (PPH) is an urgent obstetric condition requiring an immediate response and a multidisciplinary approach. The aim of this study was to review PPH management guidelines implemented in clinical practice, to evaluate their impact regarding prevention, diagnosis and treatment, and to analyze how the numbers of PPH cases changed in the post-intervention period. A systematic search in the PubMed database was performed. The references of all included articles were examined. Studies evaluating the management of PPH and the impact on the numbers of cases of this pathology after the implementation of new or updated guidelines were involved in the analysis. Two reviewers independently examined the titles and abstracts of all identified citations, selected potentially eligible studies, and evaluated their full-text versions. Methodological quality was assessed using a checklist based on the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement. We analyzed seven articles that evaluated the impact of new or updated guidelines for PPH management implemented in clinical practice. In four trials, the numbers of PPH cases declined after the intervention. Guidelines for PPH management can have a positive impact on the reduction of the number of PPH cases.

"Post partum hemorrhage: causes and management"

BACKGROUND

Post partum hemorrhage is defined as blood loss of 500 ml or above. It is the most common cause of pre-mature mortality of women world wide. Our objective was to evaluate the most common etiology and method of management of Post partum Hemorrhage in a tertiary care hospital of Karachi.

FINDINGS

It was a cross sectional study conducted at Liaquat National Hospital Karachi, during the period of July 2011 to May 2012. Review include mode of delivery, possible cause of postpartum hemorrhage, supportive, medical and surgical interventions. All the women admitted with post partum hemorrhage or develop PPH in hospital after delivery were included in our study. Bleeding disorder and use of anticoagulants were set as exclusion criteria. Diagnosis was made on the basis of blood loss assessment which was made via subjective and objective evaluation.

CONCLUSION

This study highlights the existing variable practices for the management of postpartum hemorrhage. Hemorrhage associated morbidity and mortality can be prevented by critical judgment, early referral and resuscitation by attendants. Introduction of an evidence-based management model can potentially reduce the practice variability and improve the quality of care.