Can measuring blood loss at delivery reduce hemorrhage-related morbidity?

Assessment of Structural and Process Readiness for Postpartum Haemorrhage Care in Uganda and Ghana: A Mixed Methods Study

OBJECTIVE

To determine structural and process readiness for postpartum haemorrhage (PPH) care at referral-level facilities in Ghana and Uganda to identify opportunities for strengthening.

DESIGN

Mixed-methods cross-sectional study.

SETTING

Three districts in Ghana and two in Uganda.

POPULATION OR SAMPLE

Nine hospitals in Ghana and seven in Uganda; all hospitals had theoretical capacity for caesarean section and blood transfusion.

METHODS

We deployed a modular quantitative health facility assessment to explore structural readiness (drugs, equipment, staff) complemented by in-depth interviews with maternity health service providers to understand process readiness (knowledge, attitudes, and practices as related to World Health Organization [WHO] guidance on PPH care).

MAIN OUTCOME MEASURES

Availability of essential structural components needed to support key PPH processes of care.

RESULTS

In both countries, there was generally good structural readiness for PPH care. However, key common gaps included inadequate staffing (especially specialist physicians), and unavailability of blood for transfusion. Interviews highlighted particularly good process readiness in the provision of uterotonics, recognising and responding to retained placenta, and repairing tears. However, there were clear gaps in the utilisation of tranexamic acid and uterine balloon tamponade.

CONCLUSIONS

We have identified good structural and process readiness across both Ghanaian and Ugandan health facilities to support PPH responses. However, some key missed opportunities-to align with current WHO guidance on providing bundles of interventions for PPH care-could be strengthened with minimal investment but promising impact.

Is There an Association between Platelet Count and Blood Loss in the Parturient? A Retrospective Study

OBJECTIVE

The influence of thrombocytopenia on blood loss and postpartum hemorrhage (PPH) has been conflicting. Our aim was to determine if there is an association between predelivery platelet count and quantitative blood loss (QBL) and PPH in both vaginal (VD) and cesarean deliveries (CD).

STUDY DESIGN

We conducted a retrospective database study at a single institution from April 1, 2017 to September 9, 2020. The platelet count closest to time of delivery and the QBL was assessed separately for VD and CD.

RESULTS

A total of 22,479 records were reviewed, of which 16,822 (75%) were VD and 5,657 (25%) were CD. A total of 2,600 (12%) patients had thrombocytopenia, defined as a platelet count <150,000/mm3. Of these, 1,980 (76%) had a VD and 620 (24%) had CD. We found a statistically significant difference in QBL between parturients with thrombocytopenia compared with those without, with a median estimated difference in QBL of 25 (95% confidence interval [CI]: 16-32) and 57 mL (95% CI: 31-87) in VD and CD patients, respectively. We also found a statistically significant difference in QBL when comparing patients among all the platelet count ranges except in the lowest platelet count range of 50,000 to 69,999/mm3 with a mean difference of 52 (95% CI: 25-81) and 107 mL (95% CI: 39-180) in the VD and CD patients, respectively in the platelet count range of 70,000 to 99,999/mm3 . We also found the incidence of PPH was greater in those with thrombocytopenia, p < 0.001, but the median difference in QBL in all platelet groups was small.

CONCLUSION

We found a statistically significant association between lower predelivery platelet counts and QBL and PPH. The clinical significance of these results is debatable, because at all platelet count ranges, differences in blood loss were small.

KEY POINTS

· Hemorrhage is etiology of morbidity and mortality in obstetric parturients.. · We found a small increase in blood loss in those with thrombocytopenia.. · The clinical relevance of these findings is debatable since the increased blood loss was small..

Epidemiology and definition of PPH worldwide

Postpartum/peripartum hemorrhage (PPH) is an obstetric emergency complicating 1-10% of all deliveries and is a leading cause of maternal mortality and morbidity worldwide. However, the incidence of PPH differs widely according to the definition and criteria used, the way of measuring postpartum blood loss, and the population being studied with the highest numbers in developing countries. Despite all the significant progress in healthcare, the incidence of PPH is rising due to an incomplete implementation of guidelines, resulting in treatment delays and suboptimal care. A consensus clinical definition of PPH is needed to enable awareness, early recognition, and initiation of appropriate intensive treatment. Unfortunately, the most used definition of PPH based on blood loss ≥500 ml after delivery suffers from inaccuracies in blood loss quantification and is not clinically relevant in most cases, as the amount of blood loss does not fully reflect the severity of bleeding.

Maternal body weight and estimated circulating blood volume: a non-linear approach

Postpartum haemorrhage continues to be a leading cause of morbidity and mortality in the obstetric population worldwide, especially in patients at extremes of body weight. Quantification of blood loss has been considered extensively in the literature. However, these volumes must be contextualised to appreciate the consequences of blood loss for individual parturients. Knowledge of a patient's peripartum circulating blood volume is essential to allow accurate interpretation of the significance of haemorrhage and appropriate resuscitation. Greater body weight in obesity can lead to overestimation of blood volume, resulting in inappropriately high thresholds for blood product transfusion and delays in treatment. The most recent Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) surveillance report demonstrated the risk to this population, with more than half of all maternal mortality recorded in parturients who were either overweight or obese. Current linear calculations used to estimate circulating blood volumes based on patients' weights could be contributing to this phenomenon, as blood volume increases at a disproportional rate to body composition. In this review, we summarise the relevant physiology and explore the existing literature on the estimation of circulating blood volume, both during pregnancy and in obesity. Building on key works and principal findings, we present a practical, nonlinear approach to the adjustment of estimated blood volume with increasing body mass. This clinical tool aims to reduce the clinical bias influencing the management of obstetric haemorrhage in a population already at increased risk of morbidity and mortality. Discussion of the limitations of this approach and the call for further research within this field completes this review.

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.

Effectiveness of emergency obstetric care training at the regional level in Ukraine: a non-randomized controlled trial

BACKGROUND

Emergency obstetric care training, using Advances in Labour and Risk Management (ALARM) International Program (AIP) was implemented in Ukraine, a country with universal access to skilled perinatal and obstetric care but restricted resources. A total of 577 providers (65.5% of total) from 28 maternal clinics attended a 5-day training session focused on the five main causes of maternal mortality, with hands-on skill workshops, pre- and post- tests, and an objective structured clinical examination. The effects of this emergency obstetric care training on maternal outcomes is the subject of this paper.

METHODS

A non-randomized controlled trial was conducted. The pilot areas where the training was implemented consisted of 64 maternity clinics of which 28 were considered as cases and 36 non-participating clinics were the referents. Data on maternal outcomes were collected for a 2-year span (2004-2005) prior to the trainings, which took place 2006-2007 and again after implementation of the trainings, from 2008 to 2009. Information was collected from 189,852 deliveries. Outcomes for the study were incidences of operative delivery and postpartum hemorrhage. Non-parametric statistics, meta-analyses, and difference in difference (DID) estimation were used to assess the effect of the AIP on maternal indices.

RESULTS

DID analysis showed that after the training, compared to the referents, the cases had significant reduction of blood transfusions (OR: 0.56; 95%CI: 0.48-0.65), plasma transfusions (OR: 0.70; 95%CI: 0.63-0.78), and uterus explorations (OR: 0.64; 95%CI: 0.59-0.69). We observed a non-significant reduction of postpartum hemorrhage ≥1000 ml (OR: 0.92; 95%CI: 0.81-1.04; P = 0.103). Utilization of vacuum extraction for vaginal delivery increased (OR: 2.86; 95%CI: 1.80-4.57), as well as forceps assisted delivery (OR: 1.80; 95%CI: 1.00-3.25) and cesarean section (OR: 1.11; 95%CI: 1.06-1.17). There was no change in the occurrence of postpartum hysterectomy and maternal mortality.

CONCLUSIONS

After one week of Emergency Obstetrics Care training of the obstetric staff in a setting with universal access to perinatal and obstetric care but restricted resources, an association with the reduction of postpartum hemorrhage related interventions was observed. The effects on the use of vacuum extraction and cesarean section were minimal.

TRIAL REGISTRATION

Retrospectively registered 071212007807 from 07/12/2012.