Undiagnosed abnormal postpartum blood loss: Incidence and risk factors

Prognostic Role of Initial Thromboelastography in Emergency Department Patients with Primary Postpartum Hemorrhage: Association with Massive Transfusion

BACKGROUND

The early prediction of the need for massive transfusions (MTs) and the preparation of blood products are essential for managing patients with primary postpartum hemorrhage (PPH). Thromboelastography (TEG) enables a thorough evaluation of coagulation status and is useful for guiding the treatment of hemorrhagic events in various diseases. We investigated the role of TEG in predicting the need for MT in patients with primary PPH.

METHODS

A retrospective observational study was conducted in the emergency department (ED) of a university-affiliated, tertiary referral center between November 2015 and August 2023. TEG was performed upon admission. We defined MT as the requirement for transfusion of more than 10 units of packed red blood cells within the first 24 h. The primary outcome was the need for MT.

RESULTS

Among the 184 patients with initial TEG, 34 (18.5%) required MT. Except for lysis after 30 min, the MT and non-MT groups had significantly different TEG values. Based on multivariate analysis, an angle < 60 was an independent predictor of MT (odds ratio (OR) 7.769; 95% confidence interval (CI), 2.736-22.062), along with lactate (OR, 1.674; 95% CI, 1.218-2.300) and shock index > 0.9 (OR, 4.638; 95% CI, 1.784-12.056). Alpha angle < 60 degrees indicated the need for MT with 73.5% sensitivity, 72.0% specificity, and 92.3% negative predictive value.

CONCLUSIONS

Point-of-care testing of TEG has the potential to be a useful tool in accurately predicting the necessity for MT in ED patients with primary PPH at an early stage.

Shock index as a predictor of postpartum haemorrhage after vaginal delivery: Secondary analysis of a multicentre randomised controlled trial

OBJECTIVE

To describe the shock index (SI) distribution during the first 2 hours after delivery and to evaluate its performance when measured 15 and 30 minutes after delivery for predicting postpartum haemorrhage (PPH) occurrence in the general population of parturients after vaginal delivery.

DESIGN

Secondary analysis of a multicentre randomised controlled trial testing prophylactic administration of tranexamic acid versus placebo in addition to prophylactic oxytocin to prevent PPH.

SETTING

15 French maternity units in 2015-2016.

SAMPLE

3891 women with a singleton live fetus ≥35 weeks, born vaginally.

METHODS

For each PPH-related predicted outcome, we calculated the area under the receiver operating characteristic curve (AUROC) values of the SI at 15 and 30 minutes after delivery and its predictive performance for SI cut-off values of 0.7, 0.9 and 1.1.

MAIN OUTCOME MEASURES

Quantitative blood loss ≥1000 ml (QBL ≥1000 ml) measured in a graduated collector bag and provider-assessed clinically significant PPH (cPPH).

RESULTS

Prevalence of QBL ≥1000 ml and cPPH was respectively 2.7% (104/3839) and 9.1% (354/3891). The distributions of the SI at 15 and 30 minutes after delivery were similar with a median value of 0.73 and 97th percentile of 1.11 for both. The AUROC values of the 15-minute SI for discriminating QBL ≥1000 ml and cPPH were respectively 0.66 (lower limit of the 95% confidence interval [LCI] 0.60) and 0.56 (LCI 0.52); and for the 30-minute SI 0.68 (LCI 0.61) and 0.49 (LCI 0.43).

CONCLUSIONS

The shock index at 15 and 30 minutes after delivery did not satisfactorily predict either QBL ≥1000 ml or clinical PPH.

Induction of labor and risk of postpartum hemorrhage in women with vaginal delivery: A propensity score analysis

OBJECTIVE

To explore the association between induction of labor (IOL) and postpartum hemorrhage (PPH) after vaginal delivery.

METHODS

We included women from the merged database of three randomized prospective trials (TRACOR, CYTOCINON, and TRAAP) that measured postpartum blood loss precisely, with standardized methods. IOL was considered overall and according to its method. The association between IOL and PPH was tested by multivariate logistic regression modeling, adjusted for confounders, and by propensity score matching. The role of potential intermediate factors, i.e. estimated quantity of oxytocin administered during labor and operative vaginal delivery, was assessed with structural equation modeling.

RESULTS

Labor was induced for 1809 of the 9209 (19.6%) women. IOL was associated with a significantly higher risk of PPH of 500 mL or more (adjusted odds ratio 1.56, 95% confidence interval 1.42-1.70) and PPH of 1000 mL or more (adjusted odds ratio 1.51, 95% confidence interval 1.16-1.96). The risk of PPH increased similarly regardless of the method of induction. The results were similar after propensity score matching (odds ratio for PPH ≥500 mL 1.57, 95% confidence interval 1.33-1.87, odds ratio for PPH ≥1000 mL 1.57, 95% confidence interval 1.06-2.07). Structural equation modeling showed that 34% of this association was mediated by the quantity of oxytocin administered during labor and 1.3% by women who underwent operative vaginal delivery.

CONCLUSION

Among women with vaginal delivery, the risk of PPH is higher in those with IOL, regardless of its method, and after accounting for indication bias. The quantity of oxytocin administered during labor may explain one third of this association.

Comparison of quantitative and calculated postpartum blood loss after vaginal delivery

BACKGROUND

Because there is no consensus on the method of assessing postpartum blood loss, the comparability and relevance of the postpartum hemorrhage-related literature are questionable. Quantitative blood loss assessment using a volumetric technique with a graduated collector bag has been proposed to overcome limitations of intervention-based outcomes but remains partly subjective and potentially biased by amniotic fluid or missed out-of-bag losses. Calculated blood loss based on laboratory parameters has been studied and used as an objective method expected to reflect total blood loss. However, few studies have compared quantitative with calculated blood loss.

OBJECTIVE

This study aimed to compare the distribution of postpartum blood loss after vaginal delivery assessed by 2 methods-quantitative and calculated blood loss-and the incidence of abnormal blood loss with each method.

STUDY DESIGN

Data were obtained from the merged database of 3 multicenter, randomized controlled trials, all testing different interventions to prevent postpartum blood loss in individuals with a singleton live fetus at ≥35 weeks of gestation, born vaginally. All 3 trials measured blood loss volume by using a graduated collector bag. Hematocrit was measured in the eighth or ninth month of gestation and on day 2 postpartum. The 2 primary outcomes were: quantitative blood loss, defined by the total volume of blood loss measured in a graduated collector bag, and calculated blood loss, mathematically defined from the peripartum hematocrit change (estimated blood volume × [(antepartum hematocrit-postpartum hematocrit)/antepartum hematocrit], where estimated blood volume [mL]=booking weight [kg] × 85). We modeled the association between positive quantitative blood loss and positive calculated blood loss with polynomial regression and calculated the Spearman correlation coefficient.

RESULTS

Among the 8341 individuals included in this analysis, the median quantitative blood loss (100 mL; interquartile range, 50-275) was significantly lower than the median calculated blood loss (260 mL; interquartile range, 0-630) (P<.05). The incidence of abnormal blood loss was lower with quantitative blood loss than calculated blood loss for all 3 thresholds: for ≥500 mL, it was 9.6% (799/8341) and 32.3% (2691/8341), respectively; for ≥1000 mL, 2.1% (176/8341) and 11.5% (959/8341); and for ≥2000 mL, 0.1% (10/8341) and 1.4% (117/8341) (P<.05). Quantitative blood loss and calculated blood loss were significantly but moderately correlated (Spearman coefficient=0.44; P<.05). The association between them was not linear, and their difference tended to increase with blood loss. Negative calculated blood loss values occurred in 23% (1958/8341) of individuals; among them, >99% (1939/1958) had quantitative blood loss ≤500 mL.

CONCLUSION

Quantitative and calculated blood loss were significantly but moderately correlated after vaginal delivery. However, clinicians should be aware that quantitative blood loss is lower than calculated blood loss, with a difference that tended to rise as blood loss increased.

Family history of postpartum hemorrhage is a risk factor for postpartum hemorrhage after vaginal delivery: results from the French prospective multicenter Haemorrhages and Thromboembolic Venous Disease of the Postpartum cohort study

BACKGROUND

Postpartum hemorrhage is a major component of perinatal morbidity and mortality that affects young women worldwide and is still often unpredictable. Reducing the incidence of postpartum hemorrhage is a major health issue and identifying women at risk for postpartum hemorrhage is a key element in preventing this complication.

OBJECTIVE

This study aimed to estimate postpartum hemorrhage prevalence after vaginal delivery and to identify postpartum hemorrhage risk factors.

STUDY DESIGN

Unselected pregnant women ≥16 years of age admitted to 1 of 6 maternity wards in Brittany (France) for vaginal birth after 15 weeks of gestation were recruited in this prospective, multicenter cohort study between June 1, 2015, and January 31, 2019. Postpartum hemorrhage was defined as blood loss ≥500 mL in the 24 hours following delivery. Independent risk factors for postpartum hemorrhage were determined using logistic regression. Missing data were imputed using the Multivariate Imputation by Chained Equations method.

RESULTS

Among 16,382 included women, the postpartum hemorrhage prevalence was 5.37%. A first-degree family history of postpartum hemorrhage (adjusted odds ratio, 1.63; 95% confidence interval, 1.24-2.14) and a personal transfusion history (adjusted odds ratio, 1.90; 95% confidence interval, 1.23-2.92) were significantly associated with postpartum hemorrhage. The use of oxytocin during labor was also a risk factor for postpartum hemorrhage (adjusted odds ratio, 1.24; 95% confidence interval, 1.06-1.44). Inversely, smoking during pregnancy and intrauterine growth restriction were associated with a reduced risk for postpartum hemorrhage (adjusted odds ratio, 0.76; 95% confidence interval, 0.63-0.91, and 0.34; 95% confidence interval, 0.13-0.87, respectively).

CONCLUSION

In addition to classical risk factors, this study identified a family history of postpartum hemorrhage and personal transfusion history as new characteristics associated with postpartum hemorrhage after vaginal delivery. The association of postpartum hemorrhage with a family history of postpartum hemorrhage suggests a hereditary hemorrhagic phenotype and calls for genetic studies. Identifying women at risk for postpartum hemorrhage is a key element of being prepared for this complication.

Change in Hemoglobin Was Not a Reliable Diagnostic Screening Test for Postpartum Hemorrhage: A French Prospective Multicenter Cohort Study (HERA Study)

Changes between pre- and postpartum hemoglobin might be useful for optimizing the postpartum diagnosis of postpartum hemorrhage (PPH), defined as a blood loss exceeding 500 mL. This study's principal objective was to estimate the mean change in hemoglobin (between pre/post-delivery hemoglobin) among women with vaginal deliveries and PPH. The secondary objectives were to analyze: hemoglobin changes according to blood volume loss, the appropriateness of standard thresholds for assessing hemoglobin loss, and the intrinsic and extrinsic performances of these threshold values for identifying PPH. French maternity units (n = 182) participated in the prospective HERA cohort study. Women with a vaginal delivery at or after a gestation of 22 weeks with a PPH (n = 2964) were eligible. The principal outcome was hemoglobin loss in g/L. The mean hemoglobin change was 30 ± 14 g/L among women with a PPH. Overall, hemoglobin decreased by at least 10% in 90.4% of women with PPH. Decreases ≥ 20 g/L and ≥40 g/L were found, respectively, in 73.9% and 23.7% of cases. Sensitivity and specificity values for identifying PPH were always <65%, the positive predictive values were between 35% and 94%, and the negative predictive values were between 14% and 84%. Hemoglobin decrease from before to after delivery should not be used as a PPH diagnostic screening test for PPH diagnosis for all vaginal deliveries.

Influence of the maternity unit and region of delivery on episiotomy practice in France: a nationwide population-based study

INTRODUCTION

Our objective was to identify factors associated with episiotomy practice in France, in particular, characteristics of the maternity units and regions of delivery.

MATERIAL AND METHODS

We performed a national cross-sectional population-based study in all French maternity units in 2016 including 9284 women with vaginal delivery. Our outcome was the performance of an episiotomy. After stratification for parity, associations of episiotomy practice with individual and organizational characteristics and the region of delivery were estimated with multilevel logistic regression models. The variability in maternity unit episiotomy rates explained by the characteristics studied was estimated by the proportional change in variance.

RESULTS

A total of 19.9% of the women had an episiotomy. The principal factors associated with episiotomy practice were maternal and obstetric and delivery in a maternity unit with <2000 annual deliveries. After adjusting for individual, obstetric and organizational characteristics, the practice of episiotomy was strongly associated with women's region of delivery. Additionally, women's individual characteristics did not explain the significant variability in episiotomy rates between maternity units (P < 0.001) but maternity unit characteristics partly did (proportion of variance explained: 7.2% for primiparas and 13.6% for multiparas) and regional differences still more (18% and 30.7%, respectively).

CONCLUSIONS

Episiotomy practices in France in 2016 varied strongly between maternity units, largely due to regional differences. Targeted actions by the regional perinatal care networks may reduce the national episiotomy rate and standardize practices.

How to Improve the Care of Women after Childbirth in the Rooming-in Unit: A Prospective Observational Study

Rooming-in is the WHO-recommended care system for mothers in the puerperium and their babies. This system allows the newborn to stay with the mother in the same room, 24 h a day. We aimed to investigate the need to entrust a newborn (NEN) in the care of maternity rooming-in staff during the COVID-19 pandemic, and its relationship to pain, anxiety, and blood loss after delivery. A prospective study of 200 adult women in the maternity ward operating in the rooming-in system focussed on NEN in the care of maternity rooming-in staff on the first (T1) and the second day of puerperium (T2). Women who declared having NEN were compared with women without NEN for anxiety, pain, and a drop in haemoglobin in the blood after delivery. In T1, 34% and in T2, 27% of women felt NEN in the care of maternity rooming-in staff. The NEN of women after a cesarean section was higher on both days than the NEN of women after vaginal delivery. Women with NEN had higher levels of pain, state anxiety, and higher levels of postpartum anxiety than women without NEN. Further research should be warranted to investigate whether women who give birth in hospitals that satisfy the NEN in the care of maternity rooming-in staff in their rooming-in units experience less pain and anxiety in comparison to those who give birth in hospital units without such a possibility and whether this factor is an important element in reducing anxiety and pain during puerperium.

Midwives’ ability during third stage of childbirth to estimate postpartum haemorrhage

Objective

Correctly assessing the amount of blood loss is crucial in order to adequately treat postpartum haemorrhage (PPH) at an early stage and diminish any related symptoms and/or complications.

The aim of our study is to analyse correctness in visually estimated blood loss during labour and to measure the differences between subjectively measured and weighted blood losses (ml).

Design

Cross-sectional study

Setting

A Swedish maternity unit with 6000 annual births

Participants

Midwives employed at a big maternity unit at a hospital in northern Stockholm, Sweden.

Intervention

Midwives assisting 192 vaginal births were asked to visually estimate the blood loss from the assisted delivery. Coasters and sanitary pads were weighed following the birth. We analysed if there were any differences between subjective measured blood loss (ml) and weighted blood loss. These two methods were also compared to quantify concordance between estimated blood volume and the actual volume.

Findings

The number of overestimates of blood loss was 45.3 % (n=87) with an average of 72.9 ml; the number of underestimates was 49.4 % (n=95) with an average of 73.8 ml. Exact correct estimations of blood loss were done in 5.2 % of the cases (n=10).

The largest overestimation of a postpartum bleeding was by 520 ml; the largest underestimation was by 745 ml.

Conclusion

There was both underestimation and overestimation of blood loss. We found small but significant overestimates in PPH < 300 ml (16 ml). In PPH > 300 ml, there was a small but not significant underestimates (34 ml). Based upon our findings, we conclude that it is reasonable to start weighing blood loss when it exceeds 300 ml.

•

Both underestimating and overestimating blood loss was done.

•

Exact correct estimates of PPH were done in 5.2 % of the cases (n=10).

•

In 83 % of the cases (n=160), the absolute estimation error is less than 120 ml.

Episiotomy for Medical Indications during Vaginal Birth-Retrospective Analysis of Risk Factors Determining the Performance of This Procedure

The WHO (World Health Organization) recommends that the percentage of perineal incisions should not exceed 10%, indicating that this is a good goal to achieve, despite the fact that it is still a frequently used medical intervention in Poland. The risk factors for perineal incision that have been analyzed so far in the literature allow, among others, to limit the frequency of performing this procedure. Are they still valid? Have there been new risk factors that we should take into account? We have conducted this study to find the risk factors for performing perineal incision that would reduce the frequency of this procedure. The aim of the study was to check whether the risk factors that were analyzed in the literature are still valid, to find new risk factors for perineal incisions and to compare them among Polish women. This was a single-center retrospective case-control study. The electronic patient records of Saint Sophia's Hospital in Warsaw, Poland, a tertiary hospital was used to create an anonymous retrospective database of all deliveries from 2015 to 2020. The study included the analysis of two groups, the study group of patients who had had an episiotomy, and the control group-patients without an episiotomy in cases where an episiotomy was indicated. A logistic regression model was developed to assess the risk factors for perineal laceration. Independent risk factors for episiotomy in labor include oxytocin use in the second stage of labor (OR (Odds Ratio) = 6.00; 95% CI (Confidence Interval): 4.76-7.58), the supply of oxytocin in the first and the second stage of labor (OR = 3.18; 95% CI: 2.90-3.49), oxytocin use in the first stage of labor (OR = 2.72; 95% CI: 2.52-3.51), state after cesarean section (OR = 2.97; 95% CI: 2.52-3.51), epidural anesthesia use (OR = 1.77; 95% CI: 1.62-1.93), male gender (OR = 1.10; 95% CI: 1.02-1.19), and prolonged second stage of labor (OR = 1.01; 95% CI: 1.01-1.01). A protective factor against the use of an episiotomy was delivery in the Birth Centre (OR = 0.43; 95% CI: 0.37-0.51) and mulitpara (OR = 0.31; 95% CI: 0.27-0.35). To reduce the frequency of an episiotomy, it is necessary consider the risk factors of performing this procedure in everyday practice, e.g., limiting the use of oxytocin or promoting alternative places of delivery.

Risk factors for postpartum hemorrhage in patients with retained placenta: building a predict model

OBJECTIVES

Among patients with placenta retention, the risk factors of massive blood loss remain unclear. In this study, a secondary data analysis was conducted to construct a predictive risk model for postpartum hemorrhage (PPH) in this particular population.

METHODS

A prediction model based on the data of 13 hospitals in the UK, Uganda, and Pakistan, from December 2004, to May 2008 was built. A total of 516 patients and 14 potential risk factors were analyzed. The least absolute shrinkage and selection operator regression (LASSO) model was used to optimize feature selection for the PPH risk model. Multivariable logistic regression analysis was applied to build a prediction model incorporating the LASSO model. Discrimination and calibration were assessed using C-index and calibration plot.

RESULTS

Among patients with placenta retention, the incidence of PPH was 62.98% (325/526). Risk factors in the model were country, number of past deliveries, previous manual removal of placenta, place of placenta delivery, and how the placenta was delivered. In these factors, patients in the low-income country (i.e., Uganda) (OR: 1.753, 95% CI=1.055-2.915), retained placentas delivered in the theater (OR: 2.028, 95% CI=1.016-4.050), and having placentas partially removed by controlled cord traction (cct), completely removed manually (OR: 4.722, 95% CI=1.280-17.417) were independent risk factors. The C-statistics was 0.702.

CONCLUSIONS

By secondary data analysis, our study constructed a prediction model for PPH in patients with placenta retention, and identified the independent risk factors.

Prevalence of post-partum anemia and associated factors among women attending public primary health care facilities: An institutional based cross-sectional study

Background

Severe post-partum anemia is an important cause of maternal deaths and severe morbidity in sub-Saharan Africa. In Tanzania, little information is available to guide health care professionals in ensuring good health of women after delivery. The objective of our study was to determine the prevalence of post-partum anemia and associated factors among women attending public primary health care facilities.

Materials and methods

An institutional based cross sectional study was carried out. Women in post-partum period (the period from child birth to six weeks after delivery) attending the public primary health care facilities from October to December 2019 for children vaccination were recruited. The prick method was used to obtain blood for haemoglobin estimation. Post-partum anemia was defined as a haemoglobin level of less than 11g/dl. Participants found anaemic were asked to undertake malaria and helminths parasites tests from blood and stool samples respectively. The samples were examined by an experienced laboratory scientist on study sites according to the Tanzania national standard for medical laboratories protocols.

Results

A total of 424 women were enrolled with mean age of 27.8 years (SD 5.93). Most of the participants 234(55.2%) had primary education and nearly half 198(46.7%) of them were house wives. The overall prevalence of post-partum anemia was 145(34.2%). Among the anaemic participants, 34(23.5%) had positive blood slide for malaria parasite while 15(10.3%) had positive test for stool helminths infection. Delivery by vaginal route and low parity were protective against post-partum anemia (p<0.001).Other factors that were associated with post-partum anemia included absence of a marital partner (p<0.001) and inter pregnancy interval of less than two years (p<0.001). The risk of post-partum anemia in women with less than two years interval between their last two pregnancies was about 18 times more as compared to women with more than two years interval between their last two pregnancies, (COR = 18; 95% CI 8.617–38.617).Women without marital partners were 10 times more likely to get anemia as compared to married women, (COR = 10; 01.910–54.935).

Conclusions

The prevalence of anaemia among post-partum women found in this study points to a situation of public health problem according to WHO cut-off values for the public health significance of anaemia. Inter pregnancy interval of less than two years and absence of a marital partner were associated with post-partum anemia while delivery by vaginal route and low parity were protective against post-partum anemia. Strategies should therefore be put in place to encourage thorough health education and promotion programs among both pregnant and post-partum women.

Delta neutrophil index and shock index can stratify risk for the requirement for massive transfusion in patients with primary postpartum hemorrhage in the emergency department

Background

Postpartum hemorrhage (PPH) constitutes a major risk for maternal mortality and morbidity. Unfortunately, the severity of PPH can be underestimated because it is difficult to accurately measure blood loss by visual estimation. The delta neutrophil index (DNI), which reflects circulating immature granulocytes, is automatically calculated in hematological analyzers. We evaluated the significance of the DNI in predicting hemorrhage severity based on the requirement for massive transfusion (MT) in patients with PPH.

Methods

We retrospectively analyzed data from a prospective registry to evaluate the association between the DNI and MT. Moreover, we assessed the predictive ability of the combination of DNI and shock index (SI) for the requirement for MT. MT was defined as a transfusion of ≥10 units of red blood cells within 24 h of PPH. In total, 278 patients were enrolled in this study and 60 required MT.

Results

Multivariable logistic regression revealed that the DNI and SI were independent predictors of MT. The optimal cut-off values of ≥3.3% and ≥1.0 for the DNI and SI, respectively, were significantly associated with an increased risk of MT (DNI: positive likelihood ratio [PLR] 3.54, 95% confidence interval [CI] 2.5–5.1 and negative likelihood ratio [NLR] 0.48, 95% CI 0.4–0.7; SI: PLR 3.21, 95% CI 2.4–4.2 and NLR 0.31, 95% CI 0.19–0.49). The optimal cut-off point for predicted probability was calculated for combining the DNI value and SI value with the equation derived from logistic regression analysis. Compared with DNI or SI alone, the combination of DNI and SI significantly improved the specificity, accuracy, and positive likelihood ratio of the MT risk.

Conclusion

The DNI and SI can be routinely and easily measured in the ED without additional costs or time and can therefore, be considered suitable parameters for the early risk stratification of patients with primary PPH.

Risk Factors for Carbetocin Failure after a Cesarean Section: Is Obesity One of Them?

Obese pregnant women have increased rates of fetal macrosomia, long labor, and cesarean sections, which lead to an increased risk of postpartum hemorrhage (PPH). Carbetocin is useful for the prevention of PPH after a cesarean section. Our study aimed to investigate predictors of carbetocin failure after a cesarean section, and specifically whether obesity is associated with carbetocin failure. We retrospectively analyzed all women who received carbetocin after a cesarean section. Carbetocin failure was defined as changes in hematocrit and hemoglobin, blood loss ≥ 1000 mL, and the need for an additional uterotonic agent or second-line therapies for persistent PPH. Univariate and multivariate analyses were performed to investigate predictors of carbetocin failure. The study included 600 women, with 131 (21.8%) obese women. Overall, 44 (7.3%) carbetocin failures were reported, and rates of obese women were similar between groups (carbetocin failure, 11.4% vs. 22.9%; p = 0.08). Previous PPH (p < 0.001), a cesarean section during labor (p = 0.01), cervical ripening (p = 0.02), and birthweight (p = 0.01) were significantly different between groups. In the multivariable logistic regression analysis adjusted for potential confounders, cervical ripening (adjusted odds ratio (OR) 2.23, 95% confidence interval (CI) 1.01–4.80), compared with spontaneous labor, was significantly associated with carbetocin failure. Obesity was not associated with carbetocin failure after cesarean sections.

The definition, screening, and treatment of postpartum anemia: A systematic review of guidelines

BACKGROUND

Postpartum anemia can negatively affect maternal health and interfere with early parenting. Thus, it is important to have clear, evidence-informed recommendations on its diagnosis and treatment.

OBJECTIVE

To compare global recommendations regarding the appropriate management of postpartum anemia and to highlight similarities and differences.

METHODS

Systematic searches were conducted in the databases PubMed, CINAHL, LILACS, TRIP database, and Scopus, and in the websites of health institutions and scientific societies. Search terms were related to anemia and the postpartum period. Two hundred and eighty papers were identified; the full texts of 30 sets of guidelines were reviewed, with seven being included in the final analysis. Recommendations were extracted through an evaluation of the evidence on the definition, screening, and diagnosis of anemia. The quality of the guidelines was assessed using the AGREE II instrument.

RESULTS

Two sets of guidelines have been elaborated by international organizations, and the rest were produced by professional associations within high-resource countries. The discrepancies found in the guidelines are important and affect the definition of anemia, the criteria for screening asymptomatic women, or the criteria guiding treatment. The quality of the guidelines commonly scored between 4 and 6 on a scale of 0 to 7. Recommendations with poor-quality evidence predominated over recommendations with high-quality evidence.

CONCLUSIONS

This review highlights the need to reach a consensus on the definition of postpartum anemia, to agree on what constitutes a problem for maternal health, and to provide recommendations that reach greater consensus on its diagnosis and treatment.

Uncontrolled before-after study adding carbetocin in addition to oxytocin decreases blood loss for cesarean section in twin pregnancies

PURPOSE

To evaluate the effectiveness of adding carbetocin to regular uterotonic agents for prevention of postpartum hemorrhage (PPH) after cesarean section for twin pregnancies.

METHODS

This is a retrospective uncontrolled before-after study done in a tertiary center in Taiwan, 2010-2017. Women with twin pregnancies that underwent cesarean section were enrolled. The control group (n = 114) received oxytocin infusion and direct uterine injection. In addition to these, the study group (n = 127) received 100ug of intravenous carbetocin. Primary endpoint was the change in hemoglobin. Secondary endpoints included risk of PPH and undiagnosed PPH (Hb dropped more than 2 g/dL), blood loss, the need for additional uterotonic maneuvers, and blood transfusion. Hemodynamic changes were also investigated.

RESULTS

After adjusting for confounding factors, the change in Hb (0.35 g/dL, 95% CI: -0.03∼0.74) and incidence of PPH (OR 0.30, 95% CI: 0.03∼3.28) were comparable in both groups. However, women with undiagnosed PPH decreased (OR 0.43, 95% CI:0.22∼0.85). Total blood loss in 24 h after delivery also decreased (-40.33 mL, 95%CI: -80.32∼ -0.34). The use of extra uterotonic medications and the need for blood transfusion did not differ. The systolic blood pressure 4 h after childbirth was higher in the carbetocin group (6.71, 95% CI: 2.27∼11.15).

CONCLUSION

The use of carbetocin in addition to regular uterotonic agents decreased total blood loss and undiagnosed PPH. Also, systolic blood pressure 4 h after childbirth is higher in the carbetocin group. There was no significant difference in hemoglobin change and risk of PPH.

Factors affecting third-stage management and postpartum hemorrhage in planned midwife-led home and birth center births in the United States

BACKGROUND

Postpartum hemorrhage (PPH) is a potential childbirth complication. Little is known about how third-stage labor is managed by midwives in the United States, including use of uterotonic medication during community birth. Access to uterotonic medication may vary based on credentials of the midwife or state regulations governing midwifery.

METHODS

Using data from the Midwives of North America 2.0 database (2004-2009), we describe the PPH incidence for women giving birth in the community, their demographic and clinical characteristics, and methods used by midwives to address PPH. We also examined PPH rates by midwifery credentials and by the presence of regulations for legal midwifery practice.

RESULTS

Of the 17 836 vaginal births, 15.9% had blood loss of over 500 mL and 3.3% had 1000 mL or greater blood loss. Midwives used pharmaceuticals to prevent or treat postpartum bleeding in 6.3% and 13.9% of births, respectively, and the rate of hospital transfer after birth was 1.4% (n = 247). In adjusted analyses, PPH was less likely when births occurred at home vs a birth center, if the midwife had a CNM/CM credential vs a CPM/LM/LDM credential, or if the woman was multiparous without a history of PPH or prior cesarean birth. PPH was more likely in states with barriers to midwifery practice compared with regulated states (OR: 1.26; 95% CI, 1.16-1.38).

CONCLUSIONS

Women giving birth in the community experienced low overall incidence of PPH-related hospital transfer. However, the occurrence of PPH itself would likely be reduced with improved legal access to uterotonic medication.

Prevention and management of primary postpartum hemorrhage among puerperae in a teaching hospital in São Paulo, Brazil: a best practice implementation project

OBJECTIVES

The aim of this project was to develop and implement strategies to promote standardization and formal documentation of increased bleeding within the first 24 h after birth, in compliance with best practice.

INTRODUCTION

Official data from Brazil shows a maternal mortality rate of around 52 to 75 deaths per 100,000 live births, 8% of which are caused by hemorrhage. Early diagnosis is promoted through standardization and formal documentation of the first signs of hemorrhage.

METHODS

The current implementation project used the Joanna Briggs Institute Practical Application of Clinical Evidence System, a baseline audit was conducted on a sample size of 108 patients and 67 nursing staff. Based on the results of the baseline audit, strategies to address non-compliance were developed and implemented. A follow-up audit was conducted on a sample size of 110 patients and 68 nursing staff, using the same audit criteria.

RESULTS

The baseline audit showed poor compliance with evidence-based best practice in every criterion. The implemented protocol for postpartum hemorrhage was well received by the nursing staff, promoting early diagnosis of increased bleeding within 24 h after birth and providing support for further medical treatment. There were significant improvements in every best practice criterion in the follow-up audit.

CONCLUSION

The current implementation project managed to improve the nursing staff professional practice, reducing the absence of records while promoting greater awareness of the first signs of primary postpartum hemorrhage.

A cluster-randomized, non-inferiority trial comparing use of misoprostol for universal prophylaxis vs. secondary prevention of postpartum hemorrhage among community level births in Egypt

Background

Previous community-based research shows that secondary prevention of postpartum hemorrhage (PPH) with misoprostol only given to women with above-average measured blood loss produces similar clinical outcomes compared to routine administration of misoprostol for prevention of PPH. Given the difficulty of routinely measuring blood loss for all deliveries, more operational models of secondary prevention are needed.

Methods

This cluster-randomized, non-inferiority trial included women giving birth with nurse-midwives at home or in Primary Health Units (PHUs) in rural Egypt. Two PPH management approaches were compared: 1) 600mcg oral misoprostol given to all women after delivery (i.e. primary prevention, current standard of care); 2) 800mcg sublingual misoprostol given only to women with 350-500 ml postpartum blood loss estimated using an underpad (i.e. secondary prevention). The primary outcome was mean change in pre- and post-delivery hemoglobin. Secondary outcomes included hemoglobin ≥2 g/dL and other PPH interventions.

Results

Misoprostol was administered after delivery to 100% (1555/1555) and 10.7% (117/1099) of women in primary and secondary prevention clusters, respectively. The mean drop in pre- to post-delivery hemoglobin was 0.37 (SD: 0.91) and 0.45 (SD: 0.76) among women in primary and secondary prevention clusters, respectively (difference adjusted for clustering = 0.01, one-sided 95% CI: < 0.27, p = 0.535). There were no statistically significant differences in secondary outcomes, including hemoglobin drop ≥2 g/dL, PPH diagnosis, transfer to higher level, or other interventions.

Conclusions

Misoprostol for secondary prevention of PPH is comparable to universal prophylaxis and can be implemented using local materials, such as underpads.

Trial registration

Clinicaltrials.gov NCT02226588, date of registration 27 August 2014.

Maternal death and postpartum hemorrhage in sub-Saharan Africa - A pilot study in metropolitan Mozambique

BACKGROUND

Maternal mortality in sub-Saharan Africa is approximately 500 to 1000 per 100 000 births (vs. approximately 5-20 in developed countries). Postpartum hemorrhage (PPH) is deemed responsible for 30% to 50% of the deaths.

OBJECTIVE

To study PPH, risk factors, and mortality in metropolitan Mozambique to inform future studies and intervention strategies.

MATERIALS/METHODS

Retrospective cross-sectional data extraction from all charts available to us (n = 495) recording deliveries between January and June 2018 at Maputo Central Hospital. Data included age, maternal survival, HIV status, parity, delivery mode, complications, vital signs, laboratory values, and maternal/fetal data. PPH was determined by charted diagnosis, interventions for hemorrhaging, placental abruption, transfusion, or blood loss. Autopsy reports from all deceased patients (n = 35) were examined.

RESULTS

Median age was 29 years with 17% HIV prevalence. Risk factors for PPH (frequency, 12%) included parity (adjusted odds ratios (AORs) for 3+ versus nulliparity, 7.20 (95% confidence interval [CI], 2.46-21.10), gestation length (AOR, 0.86; CI, 0.81-0.92 per week), and body temperature (AOR, 1.10; CI, 1.04-1.16 per 0.1°C). Maternal mortality was strongly associated with PPH (AOR, 5.22; 95% CI, 2.26-12.08) and HIV (AOR, 11.66; 95% CI, 4.72-28.78). Laboratory values (n = 241) were available from mothers experiencing complications (approximately 50%). Anemia (prevalence 54%) was a strong predictor of PPH with an inverse relationship between hemoglobin levels on admission (AOR, 0.62; 95% CI, 0.50-0.77 per g/dL higher hemoglobin) and the probability of later suffering from PPH. Mothers who died following PPH had lower median hemoglobin (6.2 g/dL) than mothers who survived (9.2 g/dL). Protocols to estimate peripartum blood loss were not used; antifibrinolytics and/or cryoprecipitate were unavailable.

CONCLUSION

Postpartum hemorrhage is a serious problem even in metropolitan areas of sub-Saharan Africa, and anemia influenced bleeding and death substantially. To address this problem, it is critical to raise awareness and region-specific prevention and intervention protocols.

The experience of postpartum bleeding in women with inherited bleeding disorders

INTRODUCTION

Postpartum hemorrhage (PPH) affects 6% of all deliveries and is the leading cause of maternal death worldwide (19.7%). The incidence of PPH in women with inherited bleeding disorders is substantially greater than in unaffected women; however, estimates of relative risk are highly variable. To date, their experience with postpartum bleeding has not been well studied.

OBJECTIVE

We set out to explore the experience with, understanding of, and attitudes regarding postpartum bleeding among women with inherited bleeding disorders.

METHODS

This qualitative study involved focused interviews of women with inherited bleeding disorders about postpartum bleeding. Women followed at a multidisciplinary clinic for women with inherited bleeding disorders who have experienced childbirth within the last 5 years were included in the study. The interview style was semistructured. Interviews continued until the point of saturation of themes. All interviews were transcribed and then analyzed using qualitative descriptive analysis.

RESULTS

We interviewed 10 women with inherited bleeding disorders. Themes that emerged were normalization of excessive vaginal bleeding, difficulty distinguishing normal from abnormal postpartum bleeding, and empowerment of women by having a clear delivery care plan.

CONCLUSION

In this study, women with inherited bleeding disorders were desensitized to heavy vaginal blood loss. As a result, excessive postpartum bleeding was not recognized by many of the women we interviewed. Results highlight the importance of a multidisciplinary delivery care plan for these women. Findings revealed key areas for targeted multidisciplinary intervention.

How well do postpartum blood loss and common definitions of postpartum hemorrhage correlate with postpartum anemia and fall in hemoglobin?

Objective

We aimed to better understand how well postpartum blood loss and common postpartum hemorrhage (PPH) definitions (i.e. blood loss ≥500ml = PPH, ≥1000ml = “severe” PPH) correlate with postpartum anemia and fall in hemoglobin.

Methods

Secondary analysis of data from three randomized trials that objectively measured postpartum blood loss and pre- and post-delivery hemoglobin among vaginal deliveries: one trial included 1056 home-births in Pakistan and two multi-country hospital-based trials included 1279 women diagnosed with PPH. We calculated Spearman’s correlation coefficients (r_s) for blood loss with hemoglobin drop and postpartum hemoglobin, and we compared PPH blood loss markers (≥500ml, ≥1000ml) with large hemoglobin drops (≥2 g/dL) and the threshold for moderate postpartum anemia (<10g/dL).

Results

In the Pakistan study and the multi-country trials, blood loss was weakly correlated with hemoglobin drop (Pakistan: r_s = -0.220, multi-country trials: r_s = -0.271) and postpartum hemoglobin (Pakistan: r_s = -0.220, multi-country trials: r_s = -0.316). In both the Pakistan and multi-country trials, hemoglobin drop ≥2 g/dL occurred in less than half of women with 500–999 ml blood loss (55/175 [31%] and 302/725 [42%], respectively) and was more common among women who bled ≥1000ml (19/28 [68%] and 347/554 [63%], respectively). Similarly, in the Pakistan and multi-country trials, postpartum anemia <10 g/dL was less frequent among women who bled 500–999 ml (55/175 [31%] and 390/725 [54%], respectively) and more frequent among women with ≥1000ml blood loss (20/28 [71%] and 416/554 [75%], respectively).

Conclusions

Postpartum morbidity as measured by hemoglobin markers was common for women with blood loss ≥1000ml and relatively infrequent among women with blood loss 500-999ml. These findings reinforce the importance of severe PPH as the preferred outcome to be used in research. The weak correlation between blood loss and hemoglobin markers also suggests that this relationship is not straightforward and should be carefully interpreted.

Physiologic childbirth and active management of the third stage of labor: A latent class model of risk for postpartum hemorrhage

BACKGROUND

Postpartum hemorrhage (PPH) is a threat to maternal mortality worldwide. Evidence supports active management of third stage labor (AMTSL) for preventing PPH. However, trials of AMTSL include women at varying risk levels, such as women undergoing physiologic labor and those with labor complications. Counseling women about their risk for PPH and AMTSL is difficult as many women who appear low-risk can still have PPH.

METHODS

This study uses outcomes of 2322 vaginal births from a hospital midwifery service in the United States to examine risks for PPH and effectiveness of AMTSL. Using a latent class analysis approach, physiologic birth practices and other risk factors for PPH were analyzed to understand if discrete classes of clinical characteristics would emerge. The effect of AMTSL on the PPH outcome was also considered by class.

RESULTS

A four-class solution best fit the data; each class was clinically distinct. The two largest Classes (A and B) represented women with term births and lower average parity, with higher rates of nulliparity in Class B. Class A women had more physiologic birth elements and less labor induction or labor dysfunction compared with Class B. PPH and AMTSL use was higher in Class B. In Class B, AMTSL lowered risk for PPH. However, in Class A, AMTSL was associated with higher risk for PPH and delayed placental delivery (>30 minutes).

DISCUSSION

AMTSL may not be as beneficial to women undergoing physiologic birth. Further study of the etiology of PPH in these women is indicated to inform preventive care.

[Fetal expulsion: Which interventions for perineal prevention? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVE

The objective for all obstetricians and midwifes who intervene during the release of the fetal presentation is to prevent at best the perineal lesions. This work consisted in analyzing the literature, researching and evaluating interventions that reduce this perineal risk during the release.

METHODS

A keyword search for each medical intervention during the expulsion phase was conducted by selecting studies assessing perineal risk. Interventions during pregnancy and during delivery before the expulsion phase were specifically addressed in other sections of the recommendations.

RESULTS

Firstly, the degree of perineal stretching during the second stage of labour does not appear to be a risk factor for OASIS, postpartum incontinence, or sexual disorders (LE3) and that a substantial stretching of the perineum is not an indication of episiotomy (Professional consensus). Then, manual control of the expulsion of the fetus at the end of the second stage of labour and support of the posterior perineum during this time appear to reduce the rate of OASIS (LE3). The crowning of the baby's head should be manually controlled and the posterior perineum manually supported manually to reduce the risk of OASIS (GradeC). There is no recognised benefit to episiotomy in normal deliveries (LE1); the liberal practice of episiotomy results in fewer intact perineums than its restrictive practice, and the latter does not result in increasing the number of cases of OASIS. No evidence indicates that an episiotomy for women with a breech presentation, twin pregnancy, or posterior position prevents OASIS (LE3). Indication for episiotomy during delivery depends on individual risk factors and obstetric conditions (Professional consensus). It is recommended that the indication for episiotomy be explained and the woman's consent received before its performance. The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). The liberal practice of episiotomy to prevent OASIS is not recommended for women with a breech presentation, twin pregnancy, or posterior position (GradeC). Episiotomy during an instrumental delivery appears to be associated with a reduction of the risk of OASIS (LE3). The vacuum extractor appears to induce fewer cases of OASIS than other instruments (LE3). Episiotomy may be indicated in instrumental deliveries to avoid OASIS (GradeC). Training in perineal protection in obstetrics is recommended (Grade B). In operative vaginal deliveries when several instruments can be used, a vacuum extractor is preferentially recommended to reduce the risk of OASIS (GradeC). When forceps or spatulas are used, it is preferable that they be withdrawn just before cephalic deflexion so that the fetal head is not "capped" with these instruments at birth (Professional consensus). Couder's maneuver, which consists of lowering the forearm during the release of the fetal shoulders, appears to decrease the rate of second-degree perineal tears and increase the rate of intact perineum (LE3).

CONCLUSION

Manual control of the expulsion and perineal support reduce the risk of perineal injury. There is no benefit to episiotomy in normal delivery, nor in special cases such the breech presentation for example. On the other hand, in case of instrumental delivery, an episiotomy may be indicated to avoid OASIS (GradeC), and it is recommended if it is possible to use the ventouse preferentially. The Couder's maneuver seems to reduce the rate of 2^nd degree perineal lesions (LE3). Finally, training in perineal obstetric protection is recommended (Grade B).