Obstetric Hemorrhage

Assessment of haemostasis in pregnant women: A retrospective evaluation of the diagnostic performance of the HEMSTOP standardised questionnaire

BACKGROUND

Contemporary guidelines pertaining to the evaluation of bleeding risk recommend conducting a comprehensive examination of both personal and family histories concerning haemorrhagic diatheses.

OBJECTIVES

We employed the standardised HEMSTOP (Hematoma, hEmorrhage, Menorrhagia, Surgery, Tooth extraction, Obstetrics, Parents) questionnaire in pregnant women to evaluate its efficacy in detecting a haemostatic disorder and predicting the risk of haemorrhage associated with delivery.

DESIGN

A single-centre retrospective observational cohort study.

SETTING

Brugmann Hospital, a tertiary university institution.

PATIENTS

All full-term parturients who underwent vaginal or caesarean delivery in our hospital between January 2020 and December 2021 were included in the study. A total of 3588 patients were enrolled.

MAIN OUTCOME MEASURES

The primary aim of this study was to assess the sensitivity and specificity of the HEMSTOP questionnaire in identifying individuals with an abnormal primary haemostatic profile. The secondary objective was to evaluate the sensitivity and specificity of the HEMSTOP questionnaire in predicting postpartum haemorrhage (PPH; defined as blood loss >1000 ml). Additionally, positive-predictive values and negative-predictive values (NPVs) were calculated.

RESULTS

The specificity and sensitivity of the HEMSTOP questionnaire to predict an abnormal standard coagulation test in pregnant women are respectively 96% [95% confidence interval (CI), 0.95 to 0.97] and 39% (95% CI, 0.20 to 0.61). Its NPV is 100%. The specificity and sensitivity of the HEMSTOP questionnaire to predict postpartum bleeding risk are respectively 96% (95% CI, 0.95 to 0.97) and 8% (95% CI, 0.06 to 0.11).

CONCLUSION

In the conditions of our study, the HEMSTOP questionnaire enables the prediction of a primary haemostatic anomaly with a specificity and sensitivity comparable to routine haemostatic assessments. These findings concur with the recommendation against the routine prescription of laboratory tests for patients lacking a history of bleeding diathesis.

TRIAL REGISTRATION

Clinical Trial NCT05191251.

Peripartum Hysterectomy Outcomes: Our Eleven-Year Experience at a Tertiary Care Hospital

Aim

To investigate the outcomes of peripartum hysterectomies (PHs) conducted to prevent maternal morbidity and mortality at a tertiary care hospital with 15,000 deliveries per year.

Method

Patients who underwent PHs during delivery and/or within 24 h of delivery between the years 2011-2022 were retrospectively evaluated. Hysterectomies not performed in the peripartum period, cases that were managed by methods such as balloon tamponade, compression suture, or arterial ligation rather than hysterectomy, and hysterectomies performed before 20 weeks were excluded. Obstetric and demographic characteristics of the cases, as well as indications and outcomes of PH, were investigated.

Results

Among the 130 patients who underwent PH, 4 (3.04%) patients delivered vaginally, 1 (0.7%) patient delivered vaginally after cesarean section, 12 (9.2%) patients delivered by primary cesarean section, and 113 (86.9%) patients delivered by secondary cesarean section. Placenta accreta spectrum disorder was the reason for PH in 54.6% (n = 71) of the cases while 16.1% (n = 21) underwent PH due to uterine atony. The PH rate was 0.75 per 1000 births, and the maternal mortality rate was 7.6 per 1000 hysterectomies in this study.

Conclusion

Obstetricians in developed/ing countries support the active management of the third stage of labor mainly to mitigate the preventable risk factors of post-/peri-partum hemorrhage. The current study suggests that obstetricians need to focus on the placenta in order to reduce PH.

Prevalence of maternal mortality causes based on ICD-MM: a systematic review and meta-analysis

BACKGROUND

Maternal mortality is a universal public health challenge. ICD-Maternal Mortality (ICD-MM) was introduced in 2012 to facilitate the gathering, analysis, and interpretation of data on maternal deaths worldwide. The present study aimed to estimate the global prevalence of maternal death causes through a systematic review and meta-analysis.

METHODS

A systematic literature search was conducted using various databases, including Web of Science, PubMed, Scopus, ScienceDirect, Cochrane Library, as well as Persian databases such as MagIran and Scientific Information Database (SID). The search encompassed articles published until August 21, 2022. Thirty-four eligible articles were included in the final analysis. Analysis was performed using a meta-analysis approach. The exact Clopper-Pearson confidence intervals, heterogeneity assessment, and random effects models with Mantel-Haenszel methods were employed using the STATA software version 14.2.

RESULTS

The most prevalent causes of maternal deaths, listed in descending order from highest to lowest prevalence, were non-obstetric complications (48.32%), obstetric hemorrhage (17.63%), hypertensive disorders of pregnancy, childbirth, and the puerperium (14.01%), other obstetric complications (7.11%), pregnancy with abortive outcome (5.41%), pregnancy-related infection (5.26%), unanticipated complications of management (2.25%), unknown/undetermined causes (2.01%), and coincidental causes (1.59%), respectively.

CONCLUSION

Non-obstetric complications, obstetric hemorrhage, and hypertensive disorders of pregnancy, childbirth, and puerperium were the most common causes of maternal deaths. To reduce the burden of maternal mortality causes, increasing awareness and promoting self-care management among women of reproductive age, and implementing effective screening mechanisms for high-risk mothers during pregnancy, childbirth, and the puerperium can play a significant role. ICD-MM enables the uniform collection and comparison of maternal death information at different levels (local, national, and international) by facilitating the consistent collection, analysis, and interpretation of data on maternal deaths. Our findings can be utilized by policymakers and managers at various levels to facilitate necessary planning aimed at reducing the burden of maternal mortality causes.

A Nationwide Study of the “July Effect” Concerning Postpartum Hemorrhage and Its Risk Factors at Teaching Hospitals across the United States

Objective To assess the “July effect” and the risk of postpartum hemorrhage (PPH) and its risk factors across the U.S. teaching hospitals. Method This study used the 2018 Nationwide Inpatient Sample (NIS) and included 2,056,359 of 2,879,924 single live-birth hospitalizations with low-risk pregnancies across the U.S. teaching hospitals. The International Classification of Diseases, Tenth Revision (ICD-10) from the American Academy of Professional Coders (AAPC) medical coding was used to identify PPH and other study variables. Multivariable logistic regression models were used to compare the adjusted odds of PPH risk in the first and second quarters of the academic year vs. the second half of the academic year. Results Postpartum hemorrhage occurred in approximately 4.19% of the sample. We observed an increase in the adjusted odds of PPH during July through September (adjusted odds ratios (AOR), 1.05; confidence interval (CI), 1.02–1.10) and October through December (AOR, 1.07; CI, 1.04–1.12) compared to the second half of the academic year (January to June). Conclusions This study showed a significant “July effect” concerning PPH. However, given the mixed results concerning maternal outcomes at the time of childbirth other than PPH, more research is needed to investigate the “July effect” on the outcomes of the third stage of labor. This study’s findings have important implications for patient safety interventions concerning MCH.

Temporary cervical sling and uterine twist before B-Lynch for massive uterine bleeding after delivery

Massive uterine bleeding occurring after delivery is in most cases unpredictable and can have fatal consequences. This article presents the technique of combining the twisting of uterus on a 90° rotation on its axis and positioning a sling around the cervix, allowing to decrease incoming blood flow from uterine and ovarian arteries. The aim of this easy-to-use procedure is to enable surgeons and anaesthesiologists to respectively ensure the presence of an experienced surgeon and to stabilise the haemodynamic of the patient. It is a modus operandi of particular interest in resources' challenged environments.

Latest advances in postpartum hemorrhage management

Hemorrhage is the leading cause of maternal mortality worldwide. A maternal health priority is improving how healthcare providers prevent and manage postpartum hemorrhage (PPH). Because anesthesiologists can help facilitate how hospitals develop approaches for PPH prevention and anticipatory planning, we review the potential utility of PPH risk-assessment tools, bundles, and protocols. Anesthesiologists rely on clinical and diagnostic information for initiating and evaluating medical management. Therefore, we review modalities for measuring blood loss after delivery, which includes visual, volumetric, gravimetric, and colorimetric approaches. Point-of-care technologies for assessing changes in central hemodynamics (ultrasonography) and coagulation profiles (rotational thromboelastometry and thromboelastography) are also discussed. Anesthesiologists play a critical role in the medical and transfusion management of PPH. Therefore, we review blood ordering and massive transfusion protocols, fixed-ratio vs. goal-directed transfusion approaches, coagulation changes during PPH, and the potential clinical utility of the pharmacological adjuncts, tranexamic acid, and fibrinogen concentrate.

Pr-AKI: Acute Kidney Injury in Pregnancy – Etiology, Diagnostic Workup, Management

Despite significant improvements in inpatient and outpatient management, pregnancy-related acute kidney injury (Pr-AKI) remains an important risk factor for early and late maternal and fetal morbidity and mortality. There is a discrepancy between the incidence of Pr-AKI in developing and in developed countries, with the former experiencing a decrease and the latter an increase in Pr-AKI in recent decades. Whereas septic and hemorrhagic complications predominated in the past, nowadays hypertensive disorders and thrombotic microangiopathy are the leading causes of Pr-AKI. Modern lifestyles and the availability and widespread use of in-vitro fertilization techniques in industrialized countries have allowed more women of advanced age to become pregnant. This has led to a rise in the percentage of high-risk pregnancies due to the disorders and comorbidities inherent to or accompanying aging, such as diabetes, arterial hypertension and preexisting chronic kidney disease. Last but not least, the heterogeneity of symptoms, the often overlapping clinical and laboratory characteristics and the pathophysiological changes related to pregnancy make the diagnosis and management of Pr-AKI a difficult and challenging task for the treating physician. In addition to general supportive management strategies such as volume substitution, blood pressure control, prevention of seizures or immediate delivery, each disease entity requires a specific therapy to reduce maternal and fetal complications. In this review, we used the current literature to provide a summary of the physiologic and pathophysiologic changes in renal physiology which occur during pregnancy. In the second part, we present common and rare disorders which lead to Pr-AKI and provide an overview of the available treatment options.