What measured blood loss tells us about postpartum bleeding: a systematic review

BACKGROUND

Meta-analyses of postpartum blood loss and the effect of uterotonics are biased by visually estimated blood loss.

OBJECTIVES

To conduct a systematic review of measured postpartum blood loss with and without prophylactic uterotonics for prevention of postpartum haemorrhage (PPH).

SEARCH STRATEGY

We searched Medline and PubMed terms (labour stage, third) AND (ergonovine, ergonovine tartrate, methylergonovine, oxytocin, oxytocics or misoprostol) AND (postpartum haemorrhage or haemorrhage) and Cochrane reviews without any language restriction.

SELECTION CRITERIA

Refereed publications in the period 1988-2007 reporting mean postpartum blood loss, PPH (> or =500 ml) or severe PPH (> or =1000 ml) following vaginal births.

DATA COLLECTION AND ANALYSIS

Raw data were abstracted into Excel by one author and then reviewed by a co-author. Data were transferred to SPSS 17.0, and copied into RevMan 5.0 to perform random effects meta-analysis.

MAIN RESULTS

The distribution of average blood loss (29 studies) is similar with any prophylactic uterotonic, and is lower than without prophylaxis. Compared with no uterotonic, oxytocin and misoprostol have lower PPH (OR 0.43, 95% CI 0.23-0.81; OR 0.73, 95% CI 0.50-1.08, respectively) and severe PPH rates (OR 0.61, 95% CI 0.29-1.29; OR 0.74, 95% CI 0.52-1.04, respectively). Oxytocin has lower PPH (OR 0.65, 95% CI 0.60-0.70) and severe PPH (OR 0.71, 95% CI 0.56-0.91) rates than misoprostol, but not in developing countries.

CONCLUSION

Oxytocin is superior to misoprostol in hospitals. Misoprostol substantially lowers PPH and severe PPH. A sound assessment of the relative merits of the two drugs is needed in rural areas of developing countries, where most PPH deaths occur.

The effect of live and web-based education on the accuracy of blood-loss estimation in simulated obstetric scenarios

OBJECTIVE

Visual estimation of blood loss has been shown to be inaccurate. The objective of this study was to evaluate the impact of a didactic training program on the accuracy of the estimation of blood loss and to compare the effectiveness of training provided by a web-based vs live session.

STUDY DESIGN

Multidisciplinary labor and delivery unit personnel participated in live or web-based training. Both sessions comprised a 5-station pretest and posttest. The primary outcome was the accuracy of estimated blood loss in the pretest compared with the posttest with the use of the Mann-Whitney U test.

RESULTS

Among 372 providers, the median improvement between pre- and posttest results was 34% (95% confidence interval, 10-57%; P < .001). This improvement did not differ significantly between the live sessions and web-based sessions (4%; 95% confidence interval, -10% to 12%).

CONCLUSION

Our study supports the use of live or web-based training to improve blood loss estimation accuracy.

Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group

BACKGROUND

Postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Several recent publications have noted an increasing trend in incidence over time. The international PPH collaboration was convened to explore the observed trends and to set out actions to address the factors identified.

METHODS

We reviewed available data sources on the incidence of PPH over time in Australia, Belgium, Canada, France, the United Kingdom and the USA. Where information was available, the incidence of PPH was stratified by cause.

RESULTS

We observed an increasing trend in PPH, using heterogeneous definitions, in Australia, Canada, the UK and the USA. The observed increase in PPH in Australia, Canada and the USA was limited solely to immediate/atonic PPH. We noted increasing rates of severe adverse outcomes due to hemorrhage in Australia, Canada, the UK and the USA.

CONCLUSION

Key Recommendations 1. Future revisions of the International Classification of Diseases should include separate codes for atonic PPH and PPH immediately following childbirth that is due to other causes. Also, additional codes are required for placenta accreta/percreta/increta. 2. Definitions of PPH should be unified; further research is required to investigate how definitions are applied in practice to the coding of data. 3. Additional improvement in the collection of data concerning PPH is required, specifically including a measure of severity. 4. Further research is required to determine whether an increased rate of reported PPH is also observed in other countries, and to further investigate potential risk factors including increased duration of labor, obesity and changes in second and third stage management practice. 5. Training should be provided to all staff involved in maternity care concerning assessment of blood loss and the monitoring of women after childbirth. This is key to reducing the severity of PPH and preventing any adverse outcomes. 6. Clinicians should be more vigilant given the possibility that the frequency and severity of PPH has in fact increased. This applies particularly to small hospitals with relatively few deliveries where management protocols may not be defined adequately and drugs or equipment may not be on hand to deal with unexpected severe PPH.

Diagnosis and treatment of peripartum bleeding

Severe peripartum hemorrhage (PPH) contributes to maternal morbidity and mortality and is one of the most frequent emergencies in obstetrics, occurring at a prevalence of 0.5-5.0%. Detection of antepartum risk factors is essential in order to implement preventive measures. Proper training of obstetric staff and publication of recommendations and guidelines can effectively reduce the frequency of PPH and its resulting morbidity and mortality. Therefore, an interdisciplinary expert committee was formed, with members from Germany, Austria, and Switzerland, to summarize recent scientific findings. An up-to-date presentation of the importance of embolization and of the diagnosis of coagulopathy in PPH is provided. Furthermore, the committee recommends changes in the management of PPH including new surgical options and the off-label use of recombinant factor VIIa.

Some hemostasis variables at the end of the population distributions are risk factors for severe postpartum hemorrhages

BACKGROUND

Severe postpartum hemorrhages (PPH) represent a significant cause of maternal morbidity/mortality, but little is known about its hemostasis-related risk factors. Among the 32 463 women enrolled in the NOHA First cohort, 317 developed severe PPH (S-PPH group), 1269 non-severe PPH (NS-PPH group) and the remaining individuals were considered as control women (C group).

METHODS

We performed a case-control study, including 317 triplets of women allocated from the three groups that shared the same clinical characteristics as the S-PPH group.

RESULTS

From values obtained 6-9 months after delivery, low (but not-deficient) levels of fibrinogen, von Willebrand factor (VWF) antigen, factor (F) XI, platelet CD42b, TRAP-induced increase of platelet CD41a and high values of serum residual prothrombin activity or closure aperture times using the collagen-ADP cartridge on the PFA-100 system, and blood group O, were independently associated with a significant risk of severe PPH. Being positive for at least two of these eight variables was found in 1.6%, 3.5% and 20.8% of the women from the C, the NS-PPH and the S-PPH groups, respectively, the odds ratio for S-PPH in such a case being 16.4, 95%CI (6.5-41), P < 0.0001.

CONCLUSIONS

Women with some hemostasis-related variables at the low or high end of the population distributions are prone to the severe forms of PPH. Clinical trials will allow us to know if acting on these risk factors can lower the clinical severity of PPH.

Blind on table internal iliac artery embolization in severe post partum hemorrhage: a case report

A case of a woman that had been transferred to our hospital in hemorrhagic shock secondary to post partum hemorrhage due to uterine atony, automatic abortion and extended vaginal lacerations has been described. Subtotal hysterectomy had already been performed but failed to control bleeding. The authors performed on table blind embolisation of internal iliac arteries in order to control hemorrhage as a life-saving procedure that was successful.

Efficacy of rectal misoprostol as second-line therapy for the treatment of primary postpartum hemorrhage

OBJECTIVE

To assess the efficacy of rectal misoprostol as second-line therapy in the management of primary postpartum hemorrhage (PPH) as compared to methylergonovine maleate.

STUDY DESIGN

This was a retrospective cohort study. Charts from July 2000 to February 2005 were reviewed. Inclusion criteria were patients between 37 and 42 weeks' gestational age who received a clinical diagnosis of PPH following delivery of a singleton pregnancy and who required a second uterotonic following initial oxytocin therapy. The control group represented those receiving methylergonovine maleate (18 patients), and the study group consisted of those receiving misoprostol (40 patients).

RESULTS

There was no significant difference in maternal age, gestational age, parity or type of delivery between the 2 groups. There was no significant difference between the 2 groups in the need for blood transfusion (methylergonovine maleate group, 0/18 [0%], misoprostol group, 5/40 [12.5%] [p = 0.11]), the need for third-line medical therapy (methylergonovine maleate group, 10/18 [55.5%], misoprostol group, 22/40 [55%] [p = 0.961) or the need for any surgical intervention (methylergonovine maleate, 4/18 [22.2%], misoprostol 5/40 [12.5%] [p = 0.51]).

CONCLUSION

This limited study suggests that rectal misoprostol is comparable to methergine as second-line therapy for the treatment of 1 primary postpartum hemorrhage.

Uterine artery pseudoaneurysm: unusual cause of delayed postpartum hemorrhage

We describe a case of uterine artery pseudoaneurysm in a 21-year-old woman with postpartum hemorrhage. This condition is easily diagnosed with duplex Doppler sonography and can be treated with embolization, but only if delayed postpartum hemorrhage is considered in the differential diagnosis.

An audit of primary post partum hemorrhage

BACKGROUND

Postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality. Its causes & risk factors are important for its prevention and management. Poor, unhealthy, high parity women delivering away from health facility are usual victims. The purpose of this study is to determine causes of PPH, risk factors, preventable factors and to assess treatment measures adopted.

METHODS

This retrospective study is carried out in Gynaecology 'B' unit of Ayub Teaching Hospital Abbottabad. All patients admitted with PPH or developed PPH within hospital from 1st Jan-31st Dec 2006 are included. Exclusion criteria were patients with bleeding disorders and on anticoagulants. Records of admissions, deliveries, caesareans, major & minor procedures and history charts were thoroughly evaluated for details. Details included age, parity, socioeconomic status, transportation facility, distance from hospital, onset of labours, birth attendant skilled/unskilled, evaluation of risk factors, duration of labour and mode of delivery. Patient's general health, anaemia, shock, abdominal and pelvic examination and laboratory findings were also taken in to account. Treatment measures including medical, surgical, blood transfusions were evaluated.

RESULTS

The most important cause was uterine atony, 96 (70.5%) and traumatic lesions of genital tract, 40 (29.4%). Factors causing uterine atony were augmented labour 20 (20.9%), prolonged labour 21 (21.9%), retained placental tissues, 11 (12.5%), retained placenta, 11 (11.4%) Couvelliar uterus, 10 (10.4%), placenta preavia, 8 (8.3%), placenta increta, 7 (7.3%), chorioamnionitis 5 (5.2%), and multiple pregnancy, 2 (2.1%). Risk factors, grand multiparity 70 (51.5%), antepartum haemorrhage 12 (8.9%), instrumental delivery 10 (7.3%), previous PPH, 6 (4.5%), choreoamnionitis, 5 (3.6%), multiple pregnancy, 2 (1.5%), no risk factor, 21 (15.4%). Socioeconomic status was poor (75) & lower middle class (61). Induced labour, 33 (24.3%), augmented labour 62 (45.5%). Uterotonics used for prophylaxis in 30 (22%), for treatment of PPH, 106 (78%). Patients delivered by traditional birth attendants 70 (51.4%), lady health workers 40 (29.4%) & doctors 26 (19.2%). Uterine massage performed in 30 (22%), minor surgical procedures 33 (24.3%), manual removal of retained placenta, 11 (8%), hysterectomy, 50 (36.7%), & compression sutures were applied in 3 (2.2%). Maternal deaths due to PPH were 6 (40%).

CONCLUSIONS

PPH can be prevented by avoiding unnecessary inductions/augmentations of labour, risk factors assessment and active management of 3rd stage of labour. It needs critical judgment, early referral and early resuscitation by birth attendant. There is room for temponade and compression sutures. Hysterectomy should be the last option.

Clinical characteristics and outcomes of obstetric patients requiring ICU admission

OBJECTIVES

To review a series of critically ill obstetric patients admitted to our ICU to assess the spectrum of disease, required interventions, and fetal/maternal mortality, and to identify conditions associated with maternal death.

DESIGN

Retrospective cohort.

SETTING

Medical-surgical ICU in a university-affiliated hospital.

PATIENTS

Pregnant/postpartum admissions between January 1, 1998, and September 30, 2005.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We studied 161 patients (age, 28 +/- 9 years; mean gestational age, 29 +/- 9 weeks) [mean +/- SD], constituting 10% of 1,571 hospital admissions. APACHE (acute physiology and chronic health evaluation) II score was 14 +/- 8, with 24% predicted mortality; sequential organ failure assessment score was 5 +/- 3; and therapeutic intervention scoring system at 24 h was 25 +/- 9. Forty-one percent of patients required mechanical ventilation (MV). ARDS, shock, and organ dysfunction were present in 19%, 25%, and 48% of patients, respectively. Most patients (63%) were admitted postpartum, and 74% of admissions were of obstetric cause. Hypertensive disease (40%), major hemorrhage (16%), septic abortion (12%), and nonobstetric sepsis (10%) were the principal diagnoses. Maternal mortality was 11%, with multiple organ dysfunction syndrome (44%) and intracranial hemorrhage (39%) as main causes. There were no differences in death rate in patients admitted for obstetric and nonobstetric causes. Fetal mortality was 32%. Only 30% of patients received antenatal care, which was more frequent in survivors (33% vs 6% nonsurvivors, p = 0.014).

CONCLUSIONS

Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients.

[Diagnostics and therapy of acute peripartal life threatening bleeding]

OBJECTIVE

Review of contemporary knowledge of the management of the acute life threatening peripartal hemorrhage and incorporatening f rVIIa in to the treatment design.

TYPE OF THE STUDY

Review.

SETTING

Department of OB/GYN 2nd Medical Faculty Charles Uni Prague and Teaching Hospital Motol.

METHODS

Meta-analysis of the medical databases articles.

CONCLUSIONS

The article forms the basssis for designing the concise guidelines.

Prevention and management of postpartum hemorrhage

Postpartum hemorrhage, the loss of more than 500 mL of blood after delivery, occurs in up to 18 percent of births and is the most common maternal morbidity in developed countries. Although risk factors and preventive strategies are dearly documented, not all cases are expected or avoidable. Uterine atony is responsible for most cases and can be managed with uterine massage in conjunction with oxytocin, prostaglandins, and ergot alkaloids. Retained placenta is a less common cause and requires examination of the placenta, exploration of the uterine cavity, and manual removal of retained tissue. Rarely, an invasive placenta causes postpartum hemorrhage and may require surgical management. Traumatic causes include lacerations, uterine rupture, and uterine inversion. Coagulopathies require dotting factor replacement for the identified deficiency. Early recognition, systematic evaluation and treatment, and prompt fluid resuscitation minimize the potentially serious outcomes associated with postpartum hemorrhage.

Estimating blood loss after birth: using simulated clinical examples

AIM

To determine the accuracy of the estimation of blood loss using simulated clinical examples.

SETTING

Over 100 attendees came together at a seminar about postpartum haemorrhage in June 2006. Five blood loss assessment stations were constructed, each containing a simulated clinical example. Each station was numbered and was made up of a variety of equipment used in birthing suites. Over 5L of 'artificial' blood was made. The artificial blood was similar to the colour and consistency of real blood.

SAMPLE

A convenience sample of 88 participants was given a response sheet and asked to estimate blood loss at each station. Participants included midwives, student midwives and an obstetrician.

RESULTS

Blood in a container (bedpan, kidney dish) was more accurately estimated than blood on sanitary pads, sheets or clothing. Lower volumes of blood were also estimated correctly by more participants than the higher volumes.

DISCUSSION

Improvements are still needed in visual estimation of blood loss following childbirth. Education programs may increase the level of accuracy.

CONCLUSION

We encourage other clinicians and educators to embark upon a similar exercise to assist midwives and others to improve their visual estimation of blood loss after birth. Accurate estimations can ensure that women who experience significant blood loss can receive appropriate care and the published rates of postpartum haemorrhage are correct.

The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage

BACKGROUND

Postpartum hemorrhage (PPH) is a major source of maternal morbidity.

OBJECTIVES

This study's objective was to determine whether changes in hemostasis markers during the course of PPH are predictive of its severity.

PATIENTS AND METHODS

We enrolled 128 women with PPH requiring uterotonic prostaglandin E2 (sulprostone) infusion. Two groups were defined (severe and non-severe PPH) according to the outcome during the first 24 hours. According to our criteria, 50 of the 128 women had severe PPH. Serial coagulation tests were performed at enrollment (H0), and 1, 2, 4 and 24 hours thereafter.

RESULTS

At H0, and through H4, women with severe PPH had significantly lower fibrinogen, factor V, antithrombin activity, protein C antigen, prolonged prothrombin time, and higher D-dimer and TAT complexes than women with non-severe PPH. In multivariate analysis, from H0 to H4, fibrinogen was the only marker associated with the occurrence of severe PPH. At H0, the risk for severe PPH was 2.63-fold higher for each 1 gL(-1) decrease of fibrinogen. The negative predictive value of a fibrinogen concentration >4 gL(-1) was 79% and the positive predictive value of a concentration

CONCLUSION

These findings indicate that a simple fibrinogen measurement can anticipate the risk of severe bleeding in PPH.

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MESH Headings

• Adult
• Biomarkers/analysis
• Blood Coagulation Tests
• Dinoprostone/administration & dosage
• Dinoprostone/analogs & derivatives
• Female
• Fibrinogen/analysis
• Humans
• Postpartum Hemorrhage/diagnosis
• Predictive Value of Tests
• Pregnancy
• Severity of Illness Index
• Time Factors
• Treatment Outcome

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Postpartum ultrasound in women with postpartum endometritis, after cesarean section and after manual evacuation of the placenta

OBJECTIVES

To measure anteroposterior (AP) diameters, and to describe qualitative findings of the uterus and the uterine cavity in women with postpartum endometritis, after caesarean section (CS) and after manual evacuation of the placenta, and to compare these women with those in a normal puerperium.

METHODS

A prospective, descriptive, observational study of 103 postpartum women was conducted. Fifty-five women had clinical symptoms of postpartum endometritis, 28 had undergone CS, and 20 had manual placental evacuation. Ultrasound examinations were scheduled for days 1, 3, 7, 14, 28 and 56 postpartum. Women with endometritis underwent their first examination on the day they presented with clinical symptoms.

RESULTS

The AP diameters of the uterus and uterine cavity in all three groups overlapped considerably with the reference values. On day 56 postpartum, the uterus had achieved the same dimensions as found in our reference population. Compared with the reference group, during early puerperium, an empty cavity was less common among women with the three study conditions, and gas was present more often after CS and after manual evacuation of the placenta. An anteverted position of the uterus was less common among women with endometritis on day 14 and 28 postpartum, and among women delivered by CS on days 7, 14 and 28 postpartum. The incision site in the lower uterine segment was visible after CS.

CONCLUSION

The ultrasonic findings in women with postpartum endometritis, after CS and after manual evacuation of the placenta, do not differ substantially from those during an uncomplicated puerperium. A delayed uterine involution process might explain the slight morphological differences observed.