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Brandt JS, Ananth CV. Placental abruption at near-term and term gestations: pathophysiology, epidemiology, diagnosis, and management. Am J Obstet Gynecol 2023; 228:S1313-S1329. [PMID: 37164498 PMCID: PMC10176440 DOI: 10.1016/j.ajog.2022.06.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 05/12/2023]
Abstract
Placental abruption is the premature separation of the placenta from its uterine attachment before the delivery of a fetus. The clinical manifestations of abruption typically include vaginal bleeding and abdominal pain with a wide variety of abnormal fetal heart rate patterns. Clinical challenges arise when pregnant people with this condition present with profound vaginal bleeding, necessitating urgent delivery, especially when there is a concern for maternal and fetal compromise and coagulopathy. Abruption occurs in 0.6% to 1.2% of all pregnancies, with nearly half of abruption occurring at term gestations. An exposition of abruption at near-term (defined as the late preterm period from 34 0/7 to 36 6/7 weeks of gestation) and term (defined as ≥37 weeks of gestation) provides unique insights into its direct effects, as risks associated with preterm birth do not impact outcomes. Here, we explore the pathophysiology, epidemiology, and diagnosis of abruption. We discuss the interaction of chronic processes (decidual and uteroplacental vasculopathy) and acute processes (shearing forces applied to the abdomen) that underlie the pathophysiology. Risk factors for abruption and strengths of association are summarized. Sonographic findings of abruption and fetal heart rate tracings are presented. In addition, we propose a management algorithm for acute abruption that incorporates blood loss, vital signs, and urine output, among other factors. Lastly, we discuss blood component therapy, viscoelastic point-of-care testing, disseminated intravascular coagulopathy, and management of abruption complicated by fetal death. The review seeks to provide comprehensive, clinically focused guidance during a gestational age range when neonatal outcomes can often be favorable if rapid and evidence-based care is optimized.
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Affiliation(s)
- Justin S Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
| | - Cande V Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ; Cardiovascular Institute of New Jersey and Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Yurashevich M, Rosser M, Small M, Grotegut C, Kota N, Toffaletti J, Allen T. Evaluating the Association Between Fibrinogen and Rotational Thromboelastometry and the Progression to Severe Obstetric Hemorrhage. Clin Appl Thromb Hemost 2023; 29:10760296231175089. [PMID: 37186763 DOI: 10.1177/10760296231175089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
AIM This study aims to investigate the ability of fibrinogen and rotational thromboelastometry (ROTEM) parameters measured at obstetric hemorrhage protocol initiation to predict severe hemorrhage. METHODS In this retrospective study we included patients whose hemorrhage was managed with an obstetric massive transfusion protocol. Fibrinogen and ROTEM parameters EXTEM clotting time (CT), clot formation time (CFT), alpha angle, A10, A20, lysis index 30 min after CT (LI30), FIBTEM A10, A20, were measured at initiation of the protocol with transfusion based on a predefined algorithm. Patients were grouped into either severe or nonsevere hemorrhage based on: peripartum fall in hemoglobin ≥4 g/dL, transfusion of ≥4 units of blood product, invasive procedures for hemorrhage control, intensive care unit admission, or death. RESULTS Of the 155 patients included, 108 (70%) progressed to severe hemorrhage. Fibrinogen, EXTEM alpha angle, A10, A20, FIBTEM A10, A20 were significantly lower in the severe hemorrhage group while the CFT was significantly prolonged in the severe hemorrhage group. In univariate analysis, predicted progression to severe hemorrhage yielded areas under the receiver operating characteristic curve (95% confidence interval [CI]) of: fibrinogen: 0.683 (0.591-0.776), CFT: 0.671 (0.553, 0.789), EXTEM alpha angle: 0.690 (0.577-0.803), A10: 0.693 (0.570-0.815), A20: 0.678 (0.563-0.793), FIBTEM A10: 0.726 (0.605-0.847), and A20: 0.709 (0.594-0.824). In a multivariable model, fibrinogen was independently associated with severe hemorrhage (odds ratio [95% CI] = 1.037 [1.009-1.066]) for every 50 mg/dL decrease in fibrinogen drawn at obstetric hemorrhage massive transfusion protocol initiation. CONCLUSION Both fibrinogen and ROTEM parameters measured at the initiation of an obstetric hemorrhage protocol are useful parameters for predicting severe hemorrhage.
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Affiliation(s)
- Mary Yurashevich
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Morgan Rosser
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Maria Small
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Chad Grotegut
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Nancy Kota
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - John Toffaletti
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | - Terrence Allen
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
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Dulaney BM, Elkhateb R, Mhyre JM. Optimizing systems to manage postpartum hemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:349-357. [PMID: 36513430 DOI: 10.1016/j.bpa.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022]
Abstract
Systems to optimize the management of postpartum hemorrhage must ensure timely diagnosis, rapid hemodynamic and hemostatic resuscitation, and prompt interventions to control the source of bleeding. None of these objectives can be effectively completed by a single clinician, and the management of postpartum hemorrhage requires a carefully coordinated interprofessional team. This article reviews systems designed to standardize hemorrhage diagnosis and response.
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Affiliation(s)
- Breyanna M Dulaney
- Department of Anesthesiology, University of Arkansas for Medical Sciences, 4301 W. Markham St. #515, Little Rock, AR 72205, USA
| | - Rania Elkhateb
- Department of Anesthesiology, University of Arkansas for Medical Sciences, 4301 W. Markham St. #515, Little Rock, AR 72205, USA
| | - Jill M Mhyre
- Department of Anesthesiology, University of Arkansas for Medical Sciences, 4301 W. Markham St. #515, Little Rock, AR 72205, USA.
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Robinson D, Basso M, Chan C, Duckitt K, Lett R. Guideline No. 431: Postpartum Hemorrhage and Hemorrhagic Shock. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:1293-1310.e1. [PMID: 36567097 DOI: 10.1016/j.jogc.2022.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE This guideline aims to provide evidence for prevention, recognition, and treatment of postpartum hemorrhage including severe hemorrhage leading to hemorrhagic shock. TARGET POPULATION All pregnant patients. BENEFITS, HARMS, AND COSTS Appropriate recognition and treatment of postpartum hemorrhage can prevent serious morbidity while reducing costs to the health care system by minimizing more costly interventions and length of hospital stays. EVIDENCE Medical literature, PubMed, ClinicalTrials.gov, the Cochrane Database, and grey literature were searched for articles, published between 2012 and 2021, on postpartum hemorrhage, uterotonics, obstetrical hemorrhage, and massive hemorrhage protocols. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE All members of the health care team who care for labouring or postpartum women, including, but not restricted to, nurses, midwives, family physicians, obstetricians, and anesthesiologists. RECOMMENDATIONS
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Robinson D, Basso M, Chan C, Duckitt K, Lett R. Directive clinique n o 431 : Hémorragie post-partum et choc hémorragique. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:1311-1329.e1. [PMID: 36567098 DOI: 10.1016/j.jogc.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Latest advances in postpartum hemorrhage management. Best Pract Res Clin Anaesthesiol 2022; 36:123-134. [PMID: 35659949 DOI: 10.1016/j.bpa.2022.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/20/2022]
Abstract
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.
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Zhu XL, Feng R, Huang QS, Liang MY, Jiang M, Liu H, Liu Y, Yao HX, Zhang L, Qian SX, Yang TH, Zhang JY, Shen XL, Yang LH, Hu JD, Huang RW, Jiang ZX, Wang JW, Zhang HY, Xiao Z, Zhan SY, Liu HX, Wang XL, Chang YJ, Wang Y, Kong Y, Xu LP, Liu KY, Zhang XH, Yin CH, Li YY, Wang QF, Wang JL, Huang XJ, Zhang XH. Prednisone plus IVIg compared with prednisone or IVIg for immune thrombocytopenia in pregnancy: a national retrospective cohort study. Ther Adv Hematol 2022; 13:20406207221095226. [PMID: 35510211 PMCID: PMC9058461 DOI: 10.1177/20406207221095226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 03/16/2022] [Indexed: 01/05/2023] Open
Abstract
Background: The responses of intravenous immunoglobulin (IVIg) or corticosteroids as the initial treatment on pregnancy with ITP were unsatisfactory. This study aimed to assess the safety and effectiveness of prednisone plus IVIg versus prednisone or IVIg in pregnant patients with immune thrombocytopenia (ITP). Methods: Between 1 January 2010 and 31 December 2020, 970 pregnancies diagnosed with ITP at 19 collaborative centers in China were reviewed in this observational study. A total of 513 pregnancies (52.89%) received no intervention. Concerning the remaining pregnancies, 151 (33.04%) pregnancies received an initial treatment of prednisone plus IVIg, 105 (22.98%) pregnancies received IVIg alone, and 172 (37.64%) pregnancies only received prednisone. Results: Regarding the maternal response to the initial treatment, no differences were found among the three treatment groups (41.1% for prednisone plus IVIg, 33.1% for prednisone, and 38.1% for IVIg). However, a significant difference was observed in the time to response between the prednisone plus IVIg group (4.39 ± 2.54 days) and prednisone group (7.29 ± 5.01 days; p < 0.001), and between the IVIg group (6.71 ± 4.85 days) and prednisone group (p < 0.001). The median prednisone duration in the monotherapy group was 27 days (range, 8–195 days), whereas that in the combination group was 14 days (range, 6–85 days). No significant differences were found among these three treatment groups in neonatal outcomes, particularly concerning the neonatal platelet counts. The time to response in the combination treatment group was shorter than prednisone monotherapy. The duration of prednisone application in combination group was shorter than prednisone monotherapy. The combined therapy showed a lower predelivery platelet transfusion rate than IVIg alone. Conclusion: These findings suggest that prednisone plus IVIg may represent a potential combination therapy for pregnant patients with ITP.
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Affiliation(s)
- Xiao-Lu Zhu
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Ru Feng
- Departments of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Qiu-Sha Huang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Mei-Ying Liang
- Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, P.R. China
| | - Ming Jiang
- Center of Hematologic Diseases, First Affiliated Hospital of Xinjiang Medical University, Ürümqi, P.R. China
| | - Hui Liu
- Departments of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Yi Liu
- Department of Hematology, Navy General Hospital, Beijing, P.R. China
| | - Hong-Xia Yao
- Department of Hematology, People’s Hospital of Hainan Province, Haikou, P.R. China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Shen-Xian Qian
- Department of Hematology, First People’s Hospital of Hangzhou, Hangzhou, P.R. China
| | - Tong-Hua Yang
- Department of Hematology, First People’s Hospital of Yunnan Province, Kunming, P.R. China
| | - Jing-Yu Zhang
- Department of Hematology, Hebei Institute of Hematology, The Second Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Xu-Liang Shen
- Department of Hematology, He Ping Central Hospital of the Changzhi Medical College, Changzhi, P.R. China
| | - Lin-Hua Yang
- Department of Hematology, Second Hospital of Shanxi Medical University, Taiyuan, P.R. China
| | - Jian-Da Hu
- Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, P.R. China
| | - Ren-Wei Huang
- Department of Hematology, Third Affiliated Hospital of Southern Medical University, Guangzhou, P.R. China
| | - Zhong-Xing Jiang
- Department of Hematology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, P.R. China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Beijing, P.R. China
| | - Hong-Yu Zhang
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Zhen Xiao
- Department of Hematology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, P.R. China
| | - Si-Yan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, P.R. China
| | - Hui-Xin Liu
- Department of Clinical Epidemiology, Peking University People’s Hospital, Beijing, P.R. China
| | - Xing-Lin Wang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Ying-Jun Chang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Yu Wang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Yuan Kong
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Lan-Ping Xu
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Kai-Yan Liu
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Xiao-Hong Zhang
- Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, P.R. China
| | - Cheng-Hong Yin
- Department of Internal Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, P.R. China
| | - Yue-Ying Li
- CAS Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, China National Center for Bioinformation, Beijing, P.R. China
| | - Qian-Fei Wang
- CAS Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, China National Center for Bioinformation, Beijing, P.R. China
| | - Jian-Liu Wang
- Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, P.R. China
| | - Xiao-Jun Huang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Xiao-Hui Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing 100044, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, P.R. China
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Crosby J, Plested M, Hardas A, Olivares G. Severe thrombocytopenia due to subinvolution of placental sites in a Maltese terrier. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Mark Plested
- Royal Veterinary College London UK
- Lumbry Park Veterinary Specialists Alton Hampshire UK
| | | | - Gerard Olivares
- Royal Veterinary College London UK
- Eastcott Referrals Swindon Wiltshire UK
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10
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Bell SF, Roberts TCD, Freyer Martins Pereira J, De Lloyd L, Amir Z, James D, Jenkins PV, Collis RE, Collins PW. The sensitivity and specificity of rotational thromboelastometry (ROTEM) to detect coagulopathy during moderate and severe postpartum haemorrhage: a prospective observational study. Int J Obstet Anesth 2021; 49:103238. [PMID: 34840018 DOI: 10.1016/j.ijoa.2021.103238] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 10/23/2021] [Accepted: 10/31/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Point-of-care viscoelastic haemostatic assays such as rotational thromboelastometry (including ROTEM and TEG) have been used in the management of postpartum haemorrhage (PPH). This study compared results obtained from the automated ROTEM Sigma with laboratory tests of coagulation and platelet count during PPH. METHODS A prospective observational cohort study recruited women with PPH ≥1000 mL (or clinical concern of bleeding). The Fibtem A5, Extem CT and Pltem (Extem A5 - Fibtem A5) results were compared with laboratory tests of fibrinogen, prothrombin time (PT), activated partial thromboplastin time (APTT) and platelet count. RESULTS 521 women were recruited, including 274/277 (98.9%) of women with PPH ≥1500 mL. Fibtem A5 results were matched with laboratory fibrinogen in 552/644 (85.7%) samples. The incidence of abnormal laboratory results was low: fibrinogen ≤2 g/L 23/464 (5.0%), PT or APTT >1.5 × midpoint of reference range 4/464 (0.9%), and platelet count <75 × 109/L 11/477 (2.3%). Area-under- the-receiver operator characteristic curve for Fibtem A5 to detect fibrinogen ≤2 g/L was 0.96 (95% Confidence Intervals (CI) 0.94 to 0.98, P<0.001), with sensitivity and specificity of Fibtem A5 ≤11 mm to detect fibrinogen ≤2 g/L of 0.76 and 0.96. Prolonged Extem CT results improved after treatment of hypofibrinogenaemia alone. Intervention points for platelet and fresh frozen plasma (FFP) transfusion based on ROTEM Sigma parameters could not be established. CONCLUSION During PPH (≥1000 mL or cases of clinical concern about bleeding), ROTEM Sigma Fibtem A5 can detect fibrinogen ≤2 g/L and guide targeted fibrinogen replacement. Laboratory results should continue to be used to guide platelet and FFP transfusion.
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Affiliation(s)
- S F Bell
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK.
| | - T C D Roberts
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK
| | | | - L De Lloyd
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK
| | - Z Amir
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK
| | - D James
- Department of Maternity, Cardiff and Vale University Health Board, Cardiff, UK
| | - P V Jenkins
- Haemostasis and Thrombosis, Cardiff and Vale University Health Board, Cardiff, UK
| | - R E Collis
- Department of Anaesthetics, Cardiff and Vale University Health Board, Cardiff, UK
| | - P W Collins
- School of Medicine, Cardiff University, Cardiff, UK
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Roberts TCD, De Lloyd L, Bell SF, Cohen L, James D, Ridgway A, Jenkins V, Field V, Collis RE, Collins PW. Utility of viscoelastography with TEG 6s to direct management of haemostasis during obstetric haemorrhage: a prospective observational study. Int J Obstet Anesth 2021; 47:103192. [PMID: 34144351 DOI: 10.1016/j.ijoa.2021.103192] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 04/29/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The TEG 6s is an automated cartridge-based device with limited description of use in obstetric haemorrhage. The aim of this analysis was to describe the utility of TEG 6s in identifying abnormal laboratory results of coagulation and platelet count, and inform an interventional treatment algorithm for postpartum haemorrhage. METHODS A prospective observational cohort study of 521 women with moderate to severe obstetric haemorrhage (>1000 mL blood loss), including 372 women with at least one TEG 6s test. A non-pregnant control group was used for reference. TEG 6s test parameters Citrated Functional Fibrinogen (CFF), Citrated Kaolin TEG (CK) and Citrated Rapid TEG (CRT) were compared with paired laboratory tests of fibrinogen, PT/aPTT and platelet count, obtained during haemorrhage. RESULTS Among 456 TEG 6s tests, 389 were matched with laboratory coagulation results. The receiver operator characteristic area-under-the-curve (95% CI) for CFF amplitude by 10 min to detect Clauss fibrinogen ≤2 g/L was 0.95 (0.91 to 0.99) (P<0.0001, sensitivity 0.74 and specificity 0.97 at ≤17 mm). False positives had median (IQR) Clauss fibrinogen of 2.4 (2.3-2.7) g/L. The CK-R time had some utility for detecting prolonged PT/aPTT, however a threshold for fresh frozen plasma transfusion was not established. A CRT maximum amplitude <57 mm, when CFF was ≥15 mm, identified four of eight samples with platelet count <75 × 109/L. CONCLUSION The TEG 6s CFF can be used to identify low fibrinogen during obstetric haemorrhage. A value to identify transfusion thresholds for PT/aPTT and platelets was not established, and laboratory results should continue to be used.
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Affiliation(s)
- T C D Roberts
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
| | - L De Lloyd
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
| | - S F Bell
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
| | - L Cohen
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
| | - D James
- Midwifery, Cardiff & Vale University Health Board, UK
| | - A Ridgway
- Midwifery, Cardiff & Vale University Health Board, UK
| | - V Jenkins
- Haemostasis and Thrombosis, Cardiff & Vale University Health Board, UK
| | - V Field
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
| | - R E Collis
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
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Abstract
: Thrombocytopenia is defined as a platelet count less than 150 000/μl and it is the most common hematologic disease after anemia in pregnancy. This study aims to investigate pregnant women with severe thrombocytopenia (platelet count <50 000/μl). In the relevant literature, few studies have addressed severe thrombocytopenia in pregnancy. This is a retrospective study based on the data from a reference center in Ankara, Turkey between January 2016 and December 2017. The study group consisted of 51 pregnant women who had two platelet counts lower than 50 000/μl. Descriptive statistical methods were utilized to analyze the results. The study analyzed the causes of severe thrombocytopenia, maternal and fetal-neonatal outcomes, and the management of the patients. The common causes of severe thrombocytopenia were hypertensive disorders (66.7%), immune thrombocytopenia (13.7%), massive obstetric hemorrhage (7.8%), and disseminated intravascular coagulation (5.9%). The preterm delivery occurred in 58.8% of the patients, and 46 live-births (two twins), six stillbirths, and one pregnancy termination emerged. Postpartum hemorrhage occurred in four (0.08%) patients, and blood transfusion was performed in 15 (29.4%) patients. The platelet transfusion was required to increase the platelet count of 30 (58.8%) patients. The study showed that the incidence of causes in severe thrombocytopenia in pregnancy varied considerably from mild and moderate thrombocytopenia. Despite severe thrombocytopenia, maternal and neonatal bleeding complications were infrequent in the study group.
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13
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Bell SF, Collis RE, Pallmann P, Bailey C, James K, John M, Kelly K, Kitchen T, Scarr C, Watkins A, Edey T, Macgillivray E, Greaves K, Volikas I, Tozer J, Sengupta N, Roberts I, Francis C, Collins PW. Reduction in massive postpartum haemorrhage and red blood cell transfusion during a national quality improvement project, Obstetric Bleeding Strategy for Wales, OBS Cymru: an observational study. BMC Pregnancy Childbirth 2021; 21:377. [PMID: 33992094 PMCID: PMC8126150 DOI: 10.1186/s12884-021-03853-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 05/05/2021] [Indexed: 12/22/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality and its incidence is increasing in many countries despite management guidelines. A national quality improvement programme called the Obstetric Bleeding Strategy for Wales (OBS Cymru) was introduced in all obstetric units in Wales. The aim was to reduce moderate PPH (1000 mL) progressing to massive PPH (> 2500 mL) and the need for red cell transfusion. Methods A PPH care bundle was introduced into all 12 obstetric units in Wales included all women giving birth in 2017 and 2018 (n = 61,094). The care bundle prompted: universal risk assessment, quantitative measurement of blood loss after all deliveries (as opposed to visual estimation), structured escalation to senior clinicians and point-of-care viscoelastometric-guided early fibrinogen replacement. Data were submitted by each obstetric unit to a national database. Outcome measures were incidence of massive PPH (> 2500 mL) and red cell transfusion. Analysis was performed using linear regression of the all Wales monthly data. Results Uptake of the intervention was good: quantitative blood loss measurement and risk assessment increased to 98.1 and 64.5% of all PPH > 1000 mL, whilst ROTEM use for PPH > 1500 mL increased to 68.2%. Massive PPH decreased by 1.10 (95% CI 0.28 to 1.92) per 1000 maternities per year (P = 0.011). Fewer women progressed from moderate to massive PPH in the last 6 months, 74/1490 (5.0%), than in the first 6 months, 97/1386 (7.0%), (P = 0.021). Units of red cells transfused decreased by 7.4 (95% CI 1.6 to 13.2) per 1000 maternities per year (P = 0.015). Red cells were transfused to 350/15204 (2.3%) and 268/15150 (1.8%) (P = 0.001) in the first and last 6 months, respectively. There was no increase in the number of women with lowest haemoglobin below 80 g/L during this time period. Infusions of fresh frozen plasma fell and there was no increase in the number of women with haemostatic impairment. Conclusions The OBS Cymru care bundle was feasible to implement and associated with progressive, clinically significant improvements in outcomes for PPH across Wales. It is applicable across obstetric units of widely varying size, complexity and staff mixes. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03853-y.
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Affiliation(s)
- Sarah F Bell
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Rachel E Collis
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Philip Pallmann
- Deputy Director Research Design and Conduct Centre, Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Christopher Bailey
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Kathryn James
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Miriam John
- Department of Emergency Medicine, Aneurin Bevan University Health Board, Newport, UK
| | - Kevin Kelly
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Thomas Kitchen
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Cerys Scarr
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Adam Watkins
- Improvement Cymru, Public Health Wales, Cardiff, UK
| | - Tracey Edey
- Department of Midwifery, Singleton Hospital, Swansea, UK
| | | | - Kathryn Greaves
- Department of Obstetrics and Gynaecology, Cwm Taf Morgannwg Health Board, Merthyr Tydfil, UK
| | - Ingrid Volikas
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - James Tozer
- Department of Anaesthetics and Intensive Care, Aneurin Bevan University Health Board, Newport, UK
| | - Niladri Sengupta
- Department of Obstetrics and Gynaecology, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Iolo Roberts
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Claire Francis
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Peter W Collins
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK.
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14
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Bell SF, Collis RE, Bailey C, James K, John M, Kelly K, Kitchen T, Scarr C, Macgillivray E, Collins PW. The incidence, aetiology, and coagulation management of massive postpartum haemorrhage: a two-year national prospective cohort study. Int J Obstet Anesth 2021; 47:102983. [PMID: 33994274 DOI: 10.1016/j.ijoa.2021.102983] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 02/23/2021] [Accepted: 03/14/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Between 2017 and 2018 a national quality improvement initiative was introduced incorporating point-of-care viscoelastic haemostatic assays (VHA) to guide blood product transfusion. Laboratory coagulation profiles, use and results of VHA, and administration of blood products were investigated. METHODS A two-year prospective cohort study of maternal outcomes of women experiencing massive postpartum haemorrhage (PPH) >1000 mL in Wales. In this study, cases of massive PPH (≥2500 mL and/or ≥5 units red blood cell (RBC) transfusion) were identified. RESULTS Massive PPH occurred in 349 of 60 914 maternities (rate 5.7 per 1000). There were no deaths from PPH. Intensive care unit admission and/or hysterectomy occurred in 34/311 (10.9%) and 16/347 (4.6%), respectively. The leading cause of massive PPH was genital tract trauma (107/349, 30.6%). Two hundred and seventy-nine (80.6%) required RBC transfusion and 79/345 (22.9%) received at least one blood coagulation product. Results of VHA were recorded in 245/349 (70.2%), with 44/98 (44.9%) women tested in the first six months vs 63/77 (81.8%) in the final six months. Hypofibrinogenaemia (Clauss fibrinogen <2 g/L or FIBTEM A5 <12 mm) was observed in 56/328 (17.1%) of women, thrombocytopaenia (count <75 × 109/L) in 17/334 (5.1%) and either PT or aPTT >1.5×reference range in 10/293 (3.4%). CONCLUSION In Wales, the use of VHA in cases of massive PPH increased over time, enabling clinicians to adopt a targeted, patient-specific approach to blood product administration, with only 22.9% of women receiving blood coagulation products and 17.1% having a documented clotting abnormality.
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Affiliation(s)
- S F Bell
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK.
| | - R E Collis
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - C Bailey
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - K James
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - M John
- Department of Emergency Medicine, Aneurin Bevan University Health Board, Newport, UK
| | - K Kelly
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - T Kitchen
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - C Scarr
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | - P W Collins
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
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15
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Collis RE, Kenyon C, Roberts TCD, McNamara H. When does obstetric coagulopathy occur and how do I manage it? Int J Obstet Anesth 2021; 46:102979. [PMID: 33906823 DOI: 10.1016/j.ijoa.2021.102979] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/20/2021] [Accepted: 03/08/2021] [Indexed: 01/22/2023]
Abstract
Anticipating obstetric coagulopathy is important when obstetric anaesthetists are involved in the clinical management of women with postpartum haemorrhage. Although the incidence of coagulopathy in women with postpartum haemorrhage is low, significant hypofibrinogenaemia is associated with major haemorrhage-related morbidity and thus early identification and treatment is essential to improve outcomes. Point-of-care viscoelastic haemostatic assays, including thromboelastography and rotational thromboelastometry, provide granular information about alterations in clot formation and hypofibrinogenaemia, allow near-patient interpretation of coagulopathy, and can guide goal-directed treatment. If these assays are not available, anaesthetists should closely monitor the maternal coagulation profile with standard laboratory testing during the active phase of postpartum bleeding in order to rule coagulopathy 'in or out', decide if pro-haemostatic therapies are indicated, and assess the response to haemostatic support.
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Affiliation(s)
- R E Collis
- University Hospital of Wales, Cardiff, UK.
| | - C Kenyon
- Liverpool Women's Hospital NHS Trust, Liverpool, UK
| | | | - H McNamara
- Liverpool Women's Hospital NHS Trust, Liverpool, UK
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16
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Butwick A, Lyell D, Goodnough L. How do I manage severe postpartum hemorrhage? Transfusion 2020; 60:897-907. [PMID: 32319687 DOI: 10.1111/trf.15794] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 02/06/2023]
Abstract
In the United States, postpartum hemorrhage (PPH) accounts for 4.6% of all maternal deaths and is responsible for major peripartum medical and surgical morbidity. Therefore, a national health priority is to ensure that women who experience severe PPH receive timely, appropriate, and effective treatment. In this article, we describe our system-wide approach for the planning and delivery of women with suspected placenta accreta spectrum disorder, a condition associated with life-threatening blood loss at the time of delivery. We also highlight current evidence related to transfusion decision making and hemostatic monitoring during active postpartum bleeding. Specifically, we describe how we activate and use the massive transfusion protocol to obtain sufficient volumes and types of blood products. We also describe how we use viscoelastic monitoring (thromboelastography) and standard laboratory tests to assess the maternal coagulation profile. Finally, we review the findings of recent studies examining the potential efficacy of tranexamic acid and fibrinogen concentrate as adjuncts for PPH prevention and treatment. We describe how we have incorporated these drugs into PPH treatment protocols at our institution.
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Affiliation(s)
- Alexander Butwick
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Deirdre Lyell
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Lawrence Goodnough
- Department of Pathology and Medicine (Hematology), Stanford University School of Medicine, Stanford, California, USA
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17
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Newland A, Bentley R, Jakubowska A, Liebman H, Lorens J, Peck-Radosavljevic M, Taieb V, Takami A, Tateishi R, Younossi ZM. A systematic literature review on the use of platelet transfusions in patients with thrombocytopenia. ACTA ACUST UNITED AC 2020; 24:679-719. [PMID: 31581933 DOI: 10.1080/16078454.2019.1662200] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective: Investigate globally, current treatment patterns, benefit-risk assessments, humanistic, societal and economic burden of platelet transfusion (PT). Methods: Publications from 1998 to June 27, 2018 were identified, based on databases searches including MEDLINE®; Embase and Cochrane Database of Systematic Reviews. Data from studies meeting pre-specified criteria were extracted and validated by independent reviewers. Data were obtained for efficacy and safety from randomized controlled trials (RCTs); data for epidemiology, treatment patterns, effectiveness, safety, humanistic and societal burden from real-world evidence (RWE) studies; and economic data from both. Results: A total of 3425 abstracts, 194 publications (190 studies) were included. PT use varied widely, from 0%-100% of TCP patients; 1.7%-24.5% in large studies (>1000 patients). Most were used prophylactically rather than therapeutically. 5 of 43 RCTs compared prophylactic PT with no intervention, with mixed results. In RWE studies PT generally increased platelet count (PC). This increase varied by patient characteristics and hence did not always translate into a clinically significant reduction in bleeding risk. Safety concerns included infection risk, alloimmunization and refractoriness with associated cost burden. Discussion: In RCTs and RWE studies there was significant heterogeneity in study design and outcome measures. In RWE studies, patients receiving PT may have been at higher risk than those not receiving PT creating potential bias. There were limited data on humanistic and societal burden. Conclusion: Although PTs are used widely for increasing PC in TCP, it is important to understand the limitations of PTs, and to explore the use of alternative treatment options where available.
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Affiliation(s)
- Adrian Newland
- Barts Health National Health Service (NHS) Trust , London , UK
| | | | | | - Howard Liebman
- Jane Anne Nohl Division of Hematology, USC Norris Cancer Hospital , Los Angeles , CA , USA
| | | | - Markus Peck-Radosavljevic
- Department of Gastroenterology & Hepatology, Endocrinology and Nephrology, Klinikum Klagenfurt , Klagenfurt , Austria.,Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna , Vienna , Austria
| | | | - Akiyoshi Takami
- Department of Internal Medicine, Division of Hematology, Aichi Medical University School of Medicine , Nagakute , Japan
| | - Ryosuke Tateishi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
| | - Zobair M Younossi
- Department of Medicine, Inova Fairfax Hospital , Falls Church , VA , USA
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18
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Management of postpartum haemorrhage: from research into practice, a narrative review of the literature and the Cardiff experience. Int J Obstet Anesth 2019; 37:106-117. [DOI: 10.1016/j.ijoa.2018.08.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/16/2018] [Accepted: 08/19/2018] [Indexed: 01/02/2023]
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19
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Henriquez DDCA, Bloemenkamp KWM, van der Bom JG. Management of postpartum hemorrhage: how to improve maternal outcomes? J Thromb Haemost 2018; 16:S1538-7836(22)02220-6. [PMID: 29883040 DOI: 10.1111/jth.14200] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Indexed: 01/18/2023]
Abstract
Postpartum hemorrhage is the leading cause of maternal mortality and severe morbidity. Despite efforts to improve maternal outcomes, management of postpartum hemorrhage still faces at least four challenges, discussed in this review. First, current definitions for severe postpartum hemorrhage hamper early identification of women with a high risk of adverse outcomes. Adaptations to the definitions and the use of clinical tools such as shock index and early warning systems may facilitate this early identification. Second, surgical and radiological interventions to prevent hysterectomy are not always successful. More knowledge on the influence of patient and bleeding characteristics on the success rates of these interventions is necessary. Scarce data suggest that early timing of intrauterine balloon tamponade may improve maternal outcomes, whereas early timing of arterial embolization seems to be unrelated to maternal outcomes. Third, fluid resuscitation with crystalloids and colloids is unavoidable in the early phases of postpartum hemorrhage but may result in dilutional coagulopathy. Effects of different volumes of clear fluids on the occurrence of dilutional coagulopathy and maternal outcomes is unknown. Fourth, a better understanding of diagnosis and correction of coagulopathy during postpartum hemorrhage is needed. Low plasma fibrinogen levels at the start of postpartum hemorrhage predict progression to severe hemorrhage, but standard coagulation screens are time consuming. A solution may be point-of-care coagulation testing; however, clinical usefulness during postpartum hemorrhage has not been demonstrated. To date, early administration of tranexamic acid is the only hemostatic intervention that was proven to improve outcomes in women with postpartum hemorrhage.
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Affiliation(s)
- D D C A Henriquez
- Center for Clinical Transfusion Research, Sanquin Research and Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics, Birth Center, Wilhelmina's Children Hospital, Division Woman and Baby, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J G van der Bom
- Center for Clinical Transfusion Research, Sanquin Research and Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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20
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Roberts I, Shakur H, Fawole B, Kuti M, Olayemi O, Bello A, Ogunbode O, Kotila T, Aimakhu CO, Olutogun T, Hunt BJ, Huque S. Haematological and fibrinolytic status of Nigerian women with post-partum haemorrhage. BMC Pregnancy Childbirth 2018; 18:143. [PMID: 29743045 PMCID: PMC5941626 DOI: 10.1186/s12884-018-1794-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 04/30/2018] [Indexed: 12/31/2022] Open
Abstract
Background Early treatment with tranexamic acid reduces deaths due to bleeding after post-partum haemorrhage. We report the prevalence of haematological, coagulation and fibrinolytic abnormalities in Nigerian women with postpartum haemorrhage. Methods We performed a secondary analysis of the WOMAN trial to assess laboratory data and rotational thromboelastometry (ROTEM) parameters in 167 women with postpartum haemorrhage treated at University College Hospital, Ibadan, Nigeria. We defined hyper-fibrinolysis as EXTEM maximum lysis (ML) > 15% on ROTEM. We defined coagulopathy as EXTEM clot amplitude at 5 min (A5) < 40 mm or prothrombin ratio > 1.5. Results Among the study cohort, 53 (40%) women had severe anaemia (haemoglobin< 70 g/L) and 17 (13%) women had severe thrombocytopenia (platelet count < 50 × 109/L). Thirty-five women (23%) had ROTEM evidence of hyper-fibrinolysis. Based on prothrombin ratio criteria, 16 (12%) had coagulopathy. Based on EXTEM A5 criteria, 49 (34%) had coagulopathy. Conclusion Our findings suggest that, based on a convenience sample of women from a large teaching hospital in Nigeria, hyper-fibrinolysis may commonly occur in postpartum haemorrhage. Further mechanistic studies are needed to examine hyper-fibrinolysis associated with postpartum haemorrhage. Findings from such studies may optimize treatment approaches for postpartum haemorrhage. Trial registration The Woman trial was registered: NCT00872469; ISRCTN76912190 (Registration date: 22/03/2012).
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Affiliation(s)
- Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Haleema Shakur
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Bukola Fawole
- Department of Obstetrics & Gynaecology, National Institute of Maternal and Child Health, College of Medicine, University of Ibadan, Orita-Mefa, Ibadan, Nigeria
| | - Modupe Kuti
- Department of Chemical Pathology, College of Medicine, University of Ibadan, Orita-Mefa, Ibadan, Nigeria
| | - Oladapo Olayemi
- Department of Obstetrics & Gynaecology, College of Medicine, University of Ibadan, Orita-Mefa, Ibadan, Nigeria
| | - Adenike Bello
- Department of Obstetrics & Gynaecology, College of Medicine, University of Ibadan, Orita-Mefa, Ibadan, Nigeria
| | - Olayinka Ogunbode
- Department of Obstetrics & Gynaecology, College of Medicine, University of Ibadan, Orita-Mefa, Ibadan, Nigeria
| | - Taiwo Kotila
- Department of Haematology, College of Medicine, University of Ibadan, Orita-Mefa, Ibadan, Nigeria
| | - Chris O Aimakhu
- Department of Obstetrics & Gynaecology, College of Medicine, University of Ibadan, Orita-Mefa, Ibadan, Nigeria
| | - Tolulase Olutogun
- Department of Haematology, College of Medicine, University of Ibadan, Orita-Mefa, Ibadan, Nigeria
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, Guy's & St Thomas' Trust, St Thomas' Hospital, Lambeth Palace Road, London, UK
| | - Sumaya Huque
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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21
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Collis R, Guasch E. Managing major obstetric haemorrhage: Pharmacotherapy and transfusion. Best Pract Res Clin Anaesthesiol 2017. [DOI: 10.1016/j.bpa.2017.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Affiliation(s)
- Jason Papazian
- Department of Anesthesiology, University of Colorado School of Medicine, 12401 East 17th Avenue, Mailstop B113, Aurora, CO 80045, USA
| | - Rachel M Kacmar
- Department of Anesthesiology, University of Colorado School of Medicine, 12401 East 17th Avenue, Mailstop B113, Aurora, CO 80045, USA.
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Dallaku K, Shakur H, Edwards P, Beaumont D, Roberts I, Huque S, Delius M, Mansmann U. Statistical analysis plan for the WOMAN-ETAPlaT study: Effect of tranexamic acid on platelet function and thrombin generation. Wellcome Open Res 2016. [DOI: 10.12688/wellcomeopenres.10105.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background. Postpartum haemorrhage (PPH) is a potentially life-threatening complication for women, and the leading cause of maternal mortality. Tranexamic acid (TXA) is an antifibrinolytic used worldwide to treat uterine haemorrhage and to reduce blood loss in general surgery. TXA may have effects on thrombin generation, platelet function and coagulation factors as a result of its inhibition on the plasmin. Methods. WOMAN ETAPlaT is a sub-study of the World Maternal Antifibrinolitic trial (WOMAN trial). All adult women clinically diagnosed with PPH after a vaginal delivery or caesarean section, are eligible for inclusion in the study. Blood samples will be collected at the baseline and 30 minutes after the first dose of study treatment is given. Platelet function will be evaluated in whole blood immediately after sampling with Multiplate® tests (ADPtest and TRAPtest). Thrombin generation, fibrinogen, D-dimer, and coagulation factors vW, V and VIII will be analysed using platelet poor plasma. Results. Recruitment to WOMAN ETAPlaT started on 04 November 2013 and closed on 13 January 2015, during this time 188 patients were recruited. The final participant follow-up was completed on 04 March 2015. This article introduces the statistical analysis plan for the study, without reference to unblinded data. Conclusion. The data from this study will provide evidence for the effect of TXA on thrombin generation, platelet function and coagulation factors in women with PPH. Trial registration: ClinicalTrials.gov Identifier: NCT00872469; ISRCTN76912190
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Dallaku K, Shakur H, Edwards P, Beaumont D, Roberts I, Huque S, Delius M, Mansmann U. Statistical analysis plan for the WOMAN-ETAPlaT study: Effect of tranexamic acid on platelet function and thrombin generation. Wellcome Open Res 2016; 1:30. [PMID: 28413832 PMCID: PMC5390850 DOI: 10.12688/wellcomeopenres.10105.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background. Postpartum haemorrhage (PPH) is a potentially life-threatening complication for women, and the leading cause of maternal mortality. Tranexamic acid (TXA) is an antifibrinolytic used worldwide to treat uterine haemorrhage and to reduce blood loss in general surgery. TXA may have effects on thrombin generation, platelet function and coagulation factors as a result of its inhibition on the plasmin. Methods. WOMAN ETAPlaT is a sub-study of the World Maternal Antifibrinolitic trial (WOMAN trial). All adult women clinically diagnosed with PPH after a vaginal delivery or caesarean section, are eligible for inclusion in the study. Blood samples will be collected at the baseline and 30 minutes after the first dose of study treatment is given. Platelet function will be evaluated in whole blood immediately after sampling with Multiplate® tests (ADPtest and TRAPtest). Thrombin generation, fibrinogen, D-dimer, and coagulation factors vW, V and VIII will be analysed using platelet poor plasma. Results. Recruitment to WOMAN ETAPlaT started on 04 November 2013 and closed on 13 January 2015, during this time 188 patients were recruited. The final participant follow-up was completed on 04 March 2015. This article introduces the statistical analysis plan for the study, without reference to unblinded data. Conclusion. The data from this study will provide evidence for the effect of TXA on thrombin generation, platelet function and coagulation factors in women with PPH. Trial registration: ClinicalTrials.gov Identifier: NCT00872469; ISRCTN76912190
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Affiliation(s)
- Kastriot Dallaku
- Institute for Medical Information Sciences, Biometry and Epidemiology, Klinikum Großhadern, Ludwig-Maximilian University, Munich, Germany.,University Hospital of Obstetrics Gynaecology "Koco Gliozheni, Tirana, Albania
| | - Haleema Shakur
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Phil Edwards
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Danielle Beaumont
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Sumaya Huque
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Maria Delius
- Department of Obstetrics and Gynaecology, Ludwig Maximilian University of Munich, Munich, Germany
| | - Ulrich Mansmann
- Institute for Medical Information Sciences, Biometry and Epidemiology, Klinikum Großhadern, Ludwig-Maximilian University, Munich, Germany
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