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Abstract
Postpartum hemorrhage is a common and potentially life-threatening obstetric complication, with successful management relying heavily on early identification of hemorrhage and prompt intervention. This article will review the management of postpartum hemorrhage, including initial steps, exam-specific interventions, medical therapy, minimally invasive, and surgical interventions.
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Affiliation(s)
- Sara E Post
- Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, Ohio
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2
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Ducloy-Bouthors AS, Mercier FJ, Grouin JM, Bayoumeu F, Corouge J, Le Gouez A, Rackelboom T, Broisin F, Vial F, Luzi A, Capronnier O, Huissoud C, Mignon A. Early and systematic administration of fibrinogen concentrate in postpartum haemorrhage following vaginal delivery: the FIDEL randomised controlled trial. BJOG 2021; 128:1814-1823. [PMID: 33713384 DOI: 10.1111/1471-0528.16699] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/30/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the benefits and safety of early human fibrinogen concentrate in postpartum haemorrhage (PPH) management. DESIGN Multicentre, double-blind, randomised placebo-controlled trial. SETTING 30 French hospitals. POPULATION Patients with persistent PPH after vaginal delivery requiring a switch from oxytocin to prostaglandins. METHODS Within 30 minutes after introduction of prostaglandins, patients received either 3 g fibrinogen concentrate or placebo. MAIN OUTCOME MEASURES Failure as composite primary efficacy endpoint: at least 4 g/dl of haemoglobin decrease and/or transfusion of at least two units of packed red blood cells within 48 hours following investigational medicinal product administration. Secondary endpoints: PPH evolution, need for haemostatic procedures and maternal morbidity-mortality within 6 ± 2 weeks after delivery. RESULTS 437 patients were included: 224 received FC and 213 placebo. At inclusion, blood loss (877 ± 346 ml) and plasma fibrinogen (4.1 ± 0.9 g/l) were similar in both groups (mean ± SD). Failure rates were 40.0% and 42.4% in the fibrinogen and placebo groups, respectively (odds ratio [OR] = 0.99) after adjustment for centre and baseline plasma fibrinogen; (95% CI 0.66-1.47; P = 0.96). No significant differences in secondary efficacy outcomes were observed. The mean plasma FG was unchanged in the Fibrinogen group and decreased by 0.56 g/l in the placebo group. No thromboembolic or other relevant adverse effects were reported in the Fibrinogen group versus two in the placebo group. CONCLUSIONS As previous placebo-controlled studies findings, early and systematic administration of 3 g fibrinogen concentrate did not reduce blood loss, transfusion needs or postpartum anaemia, but did prevent plasma fibrinogen decrease without any subsequent thromboembolic events. TWEETABLE ABSTRACT Early systematic blind 3 g fibrinogen infusion in PPH did not reduce anaemia or transfusion rate, reduced hypofibrinogenaemia and was safe.
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Affiliation(s)
- A S Ducloy-Bouthors
- Pole anesthésie réanimation, maternité Jeanne de Flandre, CHRU Lille, Lille, France.,ULR 7365 Université Lille, Lille, France
| | - F J Mercier
- Hôpital Antoine Béclère, Assistance Publique Hôpitaux de Paris, Clamart, France
| | - J M Grouin
- Inserm U1219, Population Health, Bordeaux, France
| | - F Bayoumeu
- Hôpital Paule de Viguier, CHU Toulouse, Toulouse, France
| | - J Corouge
- Pole anesthésie réanimation, maternité Jeanne de Flandre, CHRU Lille, Lille, France
| | - A Le Gouez
- Hôpital Antoine Béclère, Assistance Publique Hôpitaux de Paris, Clamart, France
| | - T Rackelboom
- Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - F Broisin
- Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - F Vial
- Maternité Adolphe Pinard, CHU de Nancy, Nancy, France
| | - A Luzi
- CHU Sud, St Pierre-de-la-Réunion, France
| | | | - C Huissoud
- Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,INSERM U846, Stem Cell and Brain Research Institute, Bron, France
| | - A Mignon
- Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
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Wei CN, Chang XY, Dong JH, Zhou QH. Remifentanil for Carboprost-Induced Adverse Reactions During Cesarean Delivery Under Combined Spinal-Epidural Anesthesia. Front Pharmacol 2020; 11:980. [PMID: 32695003 PMCID: PMC7338600 DOI: 10.3389/fphar.2020.00980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/17/2020] [Indexed: 11/16/2022] Open
Abstract
Purpose Carboprost may induce adverse reactions when used to treat postpartum hemorrhage. We aimed to explore the effects of intravenous infusion of low-dose remifentanil to prevent such reactions. Methods We enrolled parturient patients scheduled for elective cesarean section. Anesthesiologist administered combined spinal epidurals at the L3/4 interspace, with 0.5% hyperbaric bupivacaine subarachnoid space injections (1.5–2.5 ml). We randomly divided parturient patients, administered carboprost during surgery, into the remifentanil group (group R) and the control group (group C). Patients in group R received an intravenous target-controlled infusion of remifentanil (target effect-site concentration, 1.5 ng/ml) simultaneously with a carboprost tromethamine injection (250 µg). Patients in group C received a normal saline infusion with carboprost. We recorded and analyzed the incidence of carboprost-related adverse reactions (vomiting, nausea, chest congestion, flushing, hypertension, tachycardia, cough, and shivering), and assessed patient comfort using a numerical rating scale ([NRS], on which 0 was very uncomfortable and 10 was very comfortable). Results After applying inclusion and exclusion criteria, we conducted statistical analysis of the data from 70 women. The incidence of vomiting was significantly lower in group R than in group C (14.3 vs. 51.4%, p < 0.01); and the incidence of nausea, chest congestion, facial flushing, and hypertension were significantly lower in group R than in group C (all p < 0.01). Furthermore, the patients’ comfort scores were significantly higher in group R than in group C (8.0 ± 1.8 vs. 3.6 ± 2.1, p < 0.01). Conclusion Our results demonstrate that an intravenous low-dose remifentanil infusion can effectively prevent carboprost-related adverse reactions during cesarean delivery under combined spinal and epidural anesthesia. Clinical Trial Registration We pre-registered this study at http://www.chictr.org.cn/showproj.aspx?proj=27707 (ChiCTR1800016292).
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Affiliation(s)
- Chang-Na Wei
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Xiang-Yang Chang
- Department of Anesthesia, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Jin-Hua Dong
- Department of Obstetrics, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, China
| | - Qing-He Zhou
- Department of Anesthesia, Affiliated Hospital of Jiaxing University, Jiaxing, China
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Reale SC, Easter SR, Xu X, Bateman BT, Farber MK. Trends in Postpartum Hemorrhage in the United States From 2010 to 2014. Anesth Analg 2020; 130:e119-e122. [DOI: 10.1213/ane.0000000000004424] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Yoon HJ. Coagulation abnormalities and bleeding in pregnancy: an anesthesiologist's perspective. Anesth Pain Med (Seoul) 2019; 14:371-379. [PMID: 33329765 PMCID: PMC7713810 DOI: 10.17085/apm.2019.14.4.371] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 10/01/2019] [Indexed: 11/25/2022] Open
Abstract
During pregnancy, the procoagulant activity increases (manifested by elevation in factor VII, factor VIII, factor X, and fibrinogen levels), while the anticoagulant activity decreases (characterized by reduction in fibrinolysis and protein S activity), resulting in hypercoagulation. Standard coagulation tests, such as prothrombin time or activated partial thromboplastin time, are still used despite the lack of evidence supporting its accuracy in evaluating the coagulation status of pregnant women. Thromboelastography and rotational thromboelastometry, which are used to assess the function of platelets, soluble coagulation factors, fibrinogen, and fibrinolysis, can replace standard coagulation tests. Platelet count and function and the effect of anticoagulant treatment should be assessed to determine the risk of hematoma associated with regional anesthesia. Moreover, anesthesiologists should monitor patients for postpartum hemorrhage (PPH), and attention should be paid when performing rapid coagulation tests, transfusions, and prohemostatic pharmacotherapy. Transfusion of a high ratio of plasma and platelets to red blood cells (RBCs) showed high hemostasis success and low bleeding-related mortality rates in patients with severe trauma. However, the effects of high ratios of plasma and platelets and the ratio of plasma to RBCs and platelets to RBCs in the treatment of massive PPH were not established. Intravenous tranexamic acid should be administered immediately after the onset of postpartum bleeding. Pre-emptive treatment with fibrinogen for PPH is not effective in reducing bleeding. If fibrinogen levels of less than 2 g/L are identified, 2–4 g of fibrinogen or 5–10 ml/kg cryoprecipitate should be administered.
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Affiliation(s)
- Hea-Jo Yoon
- Department of Anesthesiology and Pain Medicine, Ilsan Jeil Hospital, Goyang, Korea
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6
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Abstract
Agreement between estimated fibrinogen concentration via thromboelastography and traditional assays is not established in the parturient. We therefore recruited 56 parturients and performed Clauss and functional fibrinogen level (FLEV) tests. Mean difference of measurements was 36.8 mg/dL (95% CI, 21.8-51.9) with a standard deviation of 52.8 mg/dL. Calculated limits of agreement were 140.2 mg/dL (95% CI, 166.3-114.6) and -66.6 mg/dL (95% CI, -40.8 to -92.5), within the maximum allowable difference of 165 mg/dL. We therefore conclude that while most measurements fell within the limits of agreement, more work is needed to clearly define the role of this test in the obstetric population.
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Affiliation(s)
- Daniel Katz
- From the Department of Anesthesiology, Pain, and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Weiniger CF, Yakirevich-Amir N, Sela HY, Gural A, Ioscovich A, Einav S. Retrospective study to investigate fresh frozen plasma and packed cell ratios when administered for women with postpartum hemorrhage, before and after introduction of a massive transfusion protocol. Int J Obstet Anesth 2018; 36:34-41. [PMID: 30245260 DOI: 10.1016/j.ijoa.2018.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 07/21/2018] [Accepted: 08/02/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Administration of packed red blood cells (PRBC) and fresh frozen plasma (FFP) to women with postpartum hemorrhage (PPH) before and after introduction of a massive transfusion protocol. METHODS The retrospective PPH study cohort of two tertiary centers was identified using blood bank records, verified by patient electronic medical records. We identified women transfused with ≥3 units PRBC in a short time period within 24 hours of delivery. Since 2010, both centers have used a protocol using 1:1 FFP:PRBC ratios. Demographic, obstetric, and blood management data were retrieved from medical records. Outcome measures included estimated blood loss, blood product administration, and hematologic variables. RESULTS 273 women were included, 112 (41.0%) prior to introduction of the protocol (2004-2009) and 161 (59.0%) afterwards (2010-2014). The frequency of women managed with 1:1 FFP:PRBC ratios was similar before 55/112 (49.1%) and after 83/161 (51.6%) introduction of the protocol (P=0.69). There was strong correlation between PRBC units transfused and the FFP:PRBC transfusion ratio (R-square 0.866, P <0.0001), demonstrating that as the number of transfused PRBC units increased, FFP:PRBC ratios became closer to 1:1. There were no outcome differences between women managed before and after introduction of the protocol. CONCLUSIONS Among women with PPH receiving ≥3 PRBC units within a short period of time, it appears that factors other than the existence of our massive transfusion protocol influence the number and ratio of PRBC and FFP units transfused. Blood products were not transfused according to exact ratios, even when guided by a protocol.
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Affiliation(s)
- C F Weiniger
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center and Division of Anesthesia, Critical Care and Pain, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
| | | | - H Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Israel
| | - A Gural
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - A Ioscovich
- Department of Anesthesiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - S Einav
- Intensive Care Unit of the Shaare Zedek Medical Center and Hebrew University School of Medicine, Jerusalem, Israel
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Yazer MH, Dunbar NM, Cohn C, Dillon J, Eldib H, Jackson B, Kaufman R, Murphy MF, O'Brien K, Raval JS, Seheult J, Staves J, Waters JH. Blood product transfusion and wastage rates in obstetric hemorrhage. Transfusion 2018. [DOI: 10.1111/trf.14571] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mark H. Yazer
- Department of Pathology; Pittsburgh Pennsylvania
- The Institute for Transfusion Medicine; Pittsburgh Pennsylvania
| | - Nancy M. Dunbar
- Department of Pathology and Laboratory Medicine; Dartmouth-Hitchcock Medical Center; Lebanon New Hampshire
| | - Claudia Cohn
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Jessica Dillon
- Department of Pathology and Laboratory Medicine; Dartmouth-Hitchcock Medical Center; Lebanon New Hampshire
| | - Howida Eldib
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Bryon Jackson
- Department of Pathology and Laboratory Medicine; Emory University School of Medicine; Atlanta Georgia
| | - Richard Kaufman
- Brigham and Women's Hospital Adult Transfusion Service; Boston Massachusetts
| | - Michael F. Murphy
- NHS Blood & Transplant, Oxford University Hospitals, and University of Oxford; Oxford UK
| | - Kerry O'Brien
- Department of Pathology; Beth Israel Deaconess Medical Center; Boston Massachusetts
| | - Jay S. Raval
- Department of Pathology and Laboratory Medicine; University of North Carolina, Chapel Hill, North Carolina; the McGowan Institute for Regenerative Medicine; Pittsburgh Pennsylvania
| | | | | | - Jonathan H. Waters
- Departments of Anesthesiology and Bioengineering; University of Pittsburgh; Pittsburgh Pennsylvania
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Abstract
The incidence of morbidly adherent placenta (MAP) has risen 13-fold since the early 1900s and is directly correlated with the rising rate of cesarean delivery. It is important for clinicians to screen all pregnancies for MAP at the time of routine second-trimester ultrasonography. In addition, patients with risk factors (e.g., multiple prior cesarean deliveries) should undergo targeted screening for MAP. Optimal maternal and fetal outcomes for these high-risk pregnancies result from accurate prenatal diagnosis and comprehensive multidisciplinary preparation and delivery between 34 and 36 weeks of gestation. There continue to be large knowledge gaps with respect to the optimal management of this condition especially around diagnosis, obstetric care, timing of delivery, and surgical management. Accordingly, most recommendations are based on expert opinion rather than on high-quality evidence. Prospective clinical trials are needed to address knowledge gaps and to continue to improve outcomes.
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Affiliation(s)
- Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Anesthesiology, Baylor College of Medicine, Houston, TX; Baylor College of Medicine, Texas Children's Hospital, Houston, TX.
| | - Alireza A Shamshirsaz
- Division of Maternal-Fetal Medicine, Department of OB-GYN, Baylor College of Medicine/TCH Pavilion for Women, Houston, TX
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of OB-GYN, Baylor College of Medicine/TCH Pavilion for Women, Houston, TX
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High-dose Versus Low-dose Tranexamic Acid to Reduce Transfusion Requirements in Pediatric Scoliosis Surgery. J Pediatr Orthop 2017; 37:e552-e557. [PMID: 29120963 DOI: 10.1097/bpo.0000000000000820] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Our objective was to quantify blood loss and transfusion requirements for high-dose and low-dose tranexamic acid (TXA) dosing regimens in pediatric patients undergoing spinal fusion for correction of idiopathic scoliosis. Previous investigators have established the efficacy of TXA in pediatric scoliosis surgery; however, the dosing regimens vary widely and the optimal dose has not been established. METHODS We retrospectively analyzed electronic medical records for 116 patients who underwent spinal fusion surgery for idiopathic scoliosis by a single surgeon and were treated with TXA. In total, 72 patients received a 10 mg/kg loading dose with a 1 mg/kg/h maintenance dose (low-dose) and 44 patients received 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose (high-dose). Estimated blood loss and transfusion requirements were compared between dosing groups. RESULTS Patient characteristics were nearly identical between the 2 groups. Compared with the low-dose TXA group, the high-dose TXA group had decreased estimated blood loss (695 vs. 968 mL, P=0.01), and a decrease in both intraoperative (0.3 vs. 0.9 units, P=0.01) and whole hospitalization (0.4 vs. 1.0 units, P=0.04) red blood cell transfusion requirements. The higher-dose TXA was associated with decreased intraoperative (P=0.01), and whole hospital transfusion (P=0.01) requirements, even after risk-adjustment for potential confounding variables. CONCLUSIONS High-dose TXA is more effective than low-dose TXA in reducing blood loss and transfusion requirements in pediatric idiopathic scoliosis patients undergoing surgery. LEVEL OF EVIDENCE Level-III, retrospective cohort study.
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Shaylor R, Weiniger CF, Austin N, Tzabazis A, Shander A, Goodnough LT, Butwick AJ. National and International Guidelines for Patient Blood Management in Obstetrics: A Qualitative Review. Anesth Analg 2017; 124:216-232. [PMID: 27557476 DOI: 10.1213/ane.0000000000001473] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In developed countries, rates of postpartum hemorrhage (PPH) requiring transfusion have been increasing. As a result, anesthesiologists are being increasingly called upon to assist with the management of patients with severe PPH. First responders, including anesthesiologists, may adopt Patient Blood Management (PBM) recommendations of national societies or other agencies. However, it is unclear whether national and international obstetric societies' PPH guidelines account for contemporary PBM practices. We performed a qualitative review of PBM recommendations published by the following national obstetric societies and international groups: the American College of Obstetricians and Gynecologists; The Royal College of Obstetricians and Gynecologists, United Kingdom; The Royal Australian and New Zealand College of Obstetricians and Gynecologists; The Society of Obstetricians and Gynecologists of Canada; an interdisciplinary group of experts from Austria, Germany, and Switzerland, an international multidisciplinary consensus group, and the French College of Gynaecologists and Obstetricians. We also reviewed a PPH bundle, published by The National Partnership for Maternal Safety. On the basis of our review, we identified important differences in national and international societies' recommendations for transfusion and PBM. In the light of PBM advances in the nonobstetric setting, obstetric societies should determine the applicability of these recommendations in the obstetric setting. Partnerships among medical, obstetric, and anesthetic societies may also help standardize transfusion and PBM guidelines in obstetrics.
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Affiliation(s)
- Ruth Shaylor
- From the *Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel; †Departments of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California; ‡Department of Anesthesiology, Critical Care Medicine, Pain Management and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey; §Departments of Anesthesiology, Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, New York; and ‖Department of Pathology, Stanford University School of Medicine, Stanford, California
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Kennedy BB, McMurtry Baird S. Collaborative Strategies for Management of Obstetric Hemorrhage. Crit Care Nurs Clin North Am 2017; 29:315-330. [PMID: 28778291 DOI: 10.1016/j.cnc.2017.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Obstetric hemorrhage is a significant cause of perinatal morbidity and mortality that requires prompt recognition and collaborative intervention to prevent poor outcomes. Medical and surgical management goals include controlling bleeding, supporting tissue oxygenation and perfusion, and monitoring for coagulopathies and complications.
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Affiliation(s)
- Betsy Babb Kennedy
- Vanderbilt University School of Nursing, 204 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240, USA.
| | - Suzanne McMurtry Baird
- Clinical Concepts in Obstetrics, Inc, Nashville, TN, USA; Labor and Delivery, Vanderbilt University Medical Center, Vanderbilt University School of Nursing, Nashville, TN, USA
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Toledano RD, Leffert LR. Anesthetic and Obstetric Management of Placenta Accreta: Clinical Experience and Available Evidence. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0200-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ducloy-Bouthors AS, Mignon A, Huissoud C, Grouin JM, Mercier FJ. Fibrinogen concentrate as a treatment for postpartum haemorrhage-induced coagulopathy: A study protocol for a randomised multicentre controlled trial. The fibrinogen in haemorrhage of DELivery (FIDEL) trial. Anaesth Crit Care Pain Med 2016; 35:293-8. [DOI: 10.1016/j.accpm.2015.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 10/18/2015] [Accepted: 10/30/2015] [Indexed: 10/22/2022]
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Massive transfusion: red blood cell to plasma and platelet unit ratios for resuscitation of massive hemorrhage. Curr Opin Hematol 2016; 22:533-9. [PMID: 26390160 DOI: 10.1097/moh.0000000000000184] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The aim of this short study is to review recently published data bearing on how to resuscitate massive uncontrolled hemorrhage. RECENT FINDINGS New data inform our understanding of the mechanisms of the acute coagulopathy of trauma, the median time to death of trauma patients with uncontrolled hemorrhage, the effects of blood product composition on the coagulation capacity of infused resuscitation mixtures, the outcomes of patients resuscitated according to common massive transfusion protocols in clinical situations associated with massive hemorrhage, and who might benefit from balanced, blood-product-based resuscitation. Importantly, the trial methods, blood bank methods, and primary outcomes of the Pragmatic Randomized Optimal Plasma and Platelet Ratios (PROPPR) trial were recently published. Resuscitation with a 1 : 1 : 1 ratio of units of plasma and platelets to red blood cells was well tolerated and reduced hemorrhagic mortality during resuscitation in the PROPPR trial. SUMMARY The bulk of currently available data support the use of a 1 : 1 : 1 ratio for the resuscitation of patients with severe injury, shock, and uncontrolled hemorrhage. The application of this formulaic approach to massive blood product-based resuscitation in other clinical situations is less well supported in the literature.
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Massive obstetric hemorrhage: Current approach to management. Med Intensiva 2016; 40:298-310. [PMID: 27184441 DOI: 10.1016/j.medin.2016.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 02/11/2016] [Accepted: 02/18/2016] [Indexed: 01/25/2023]
Abstract
Massive obstetric hemorrhage is a major cause of maternal mortality and morbidity worldwide. It is defined (among others) as the loss of>2,500ml of blood, and is associated to a need for admission to critical care and/or hysterectomy. The relative hemodilution and high cardiac output found in normal pregnancy allows substantial bleeding before a drop in hemoglobin and/or hematocrit can be identified. Some comorbidities associated with pregnancy can contribute to the occurrence of catastrophic bleeding with consumption coagulopathy, which makes the situation even worse. Optimization, preparation, rational use of resources and protocolization of actions are often useful to improve outcomes in patients with postpartum hemorrhage. Using massive obstetric hemorrhage protocols is useful for facilitating rapid transfusion if needed, and can also be cost-effective. If hypofibrinogenemia during the bleeding episode is identified, early fibrinogen administration can be very useful. Other coagulation factors in addition to fibrinogen may be necessary during postpartum hemorrhage replacement measures in order to effectively correct coagulopathy. A hysterectomy is recommended if the medical and surgical measures prove ineffective.
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Ioscovich A, Shatalin D, Butwick AJ, Ginosar Y, Orbach-Zinger S, Weiniger CF. Israeli survey of anesthesia practice related to placenta previa and accreta. Acta Anaesthesiol Scand 2016; 60:457-64. [PMID: 26597396 DOI: 10.1111/aas.12656] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 07/12/2015] [Accepted: 09/24/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anesthesia practices for placenta previa (PP) and accreta (PA) impact hemorrhage management and other supportive strategies. We conducted a survey to assess reported management of PP and PA in all Israeli labor and delivery units. METHODS After Institutional Review Board waiver, we surveyed all 26 Israeli hospitals with a labor and delivery unit by directly contacting the representatives of obstetric anesthesiology services in every department (unit director or department chair). Each director surveyed provided information about the anesthetic and transfusion management in their labor and delivery units for three types of abnormal placentation based on antenatal placental imaging: PP, low suspicion for PA, and high suspicion for PA. The primary outcome was use of neuraxial or general anesthesia for PP and PA Cesarean delivery. Univariate statistics were used for survey responses using counts and percentages. RESULTS The response rate was 100%. Spinal anesthesia is the preferred anesthetic mode for PP cases, used in 17/26 (65.4%) of labor and delivery units. By comparison, most representatives reported that they perform general anesthesia for patients with PA: 18/26 (69.2%) for all low suspicion cases of PA and 25/26 (96.2%) for all high suspicion cases of PA. Although a massive transfusion protocol was available in the majority of hospitals (84.6%), the availability of thromboelastography and cell salvage was much lower (53.8% and 19.2% hospitals respectively). CONCLUSIONS In our survey, representatives of anesthesia labor and delivery services in Israel are almost exclusively using general anesthesia for women with high suspicion for PA; however, almost two-thirds use spinal anesthesia for PP without suspicion of PA. Among representatives, we found wide variations in anesthesia practice patterns with regard to anesthesia mode, multidisciplinary management, and hemorrhage anticipation strategies.
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Affiliation(s)
- A. Ioscovich
- Department of Anesthesiology; Perioperative Medicine and Pain Treatment; Shaare Zedek Medical Center; Hebrew University; Jerusalem Israel
| | - D. Shatalin
- Department of Anesthesiology; Perioperative Medicine and Pain Treatment; Shaare Zedek Medical Center; Hebrew University; Jerusalem Israel
| | - A. J. Butwick
- Department of Anesthesia; Stanford University School of Medicine; Stanford California USA
| | - Y. Ginosar
- Department of Anesthesiology and Critical Care Medicine; Hadassah-Hebrew University Medical Center; Ein Kerem Jerusalem Israel
| | - S. Orbach-Zinger
- Department of Anesthesia; Rabin Medical Center (Beilinson Campus); Petah Tikvah; Tel Aviv University; Tel Aviv Israel
| | - C. F. Weiniger
- Department of Anesthesiology and Critical Care Medicine; Hadassah-Hebrew University Medical Center; Ein Kerem Jerusalem Israel
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Abstract
Placental disorders such as placenta previa, placenta accreta, and vasa previa are all associated with vaginal bleeding in the second half of pregnancy. They are also important causes of serious fetal and maternal morbidity and even mortality. Moreover, the rates of previa and accreta are increasing, probably as a result of increasing rates of cesarean delivery, maternal age, and assisted reproductive technology. The routine use of obstetric ultrasonography as well as improving ultrasonographic technology allows for the antenatal diagnosis of these conditions. In turn, antenatal diagnosis facilitates optimal obstetric management. This review emphasizes an evidence-based approach to the clinical management of pregnancies with these conditions as well as highlights important knowledge gaps.
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Main EK, Goffman D, Scavone BM, Low LK, Bingham D, Fontaine PL, Gorlin JB, Lagrew DC, Levy BS. National Partnership for Maternal Safety. Anesth Analg 2015; 126:155-62. [DOI: 10.1097/aog.0000000000000869] [Citation(s) in RCA: 245] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Main EK, Goffman D, Scavone BM, Low LK, Bingham D, Fontaine PL, Gorlin JB, Lagrew DC, Levy BS. National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage. J Obstet Gynecol Neonatal Nurs 2015; 44:462-470. [DOI: 10.1111/1552-6909.12723] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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22
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Hebbar L, Terry J, McLaurin SS, Powelson A. Other new players in medical management of postpartum hemorrhage? Anesth Analg 2015; 120:956. [PMID: 25790217 DOI: 10.1213/ane.0000000000000623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Latha Hebbar
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina,
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23
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Ducloy-Bouthors AS, Vallet B, Susen S, Wong CA, Butwick A, Lockhart E. In response. Anesth Analg 2015; 120:956-7. [PMID: 25790218 DOI: 10.1213/ane.0000000000000621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Anne-Sophie Ducloy-Bouthors
- Pole d'Anesthésie-Réanimation, Academic Hospital Lille, Lille, France, Pole d'Hématologie Transfusion, Academic Hospital Lille, Université Lille Nord de France, Lille, France Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois Department of Anesthesia, Stanford University School of Medicine, Stanford, California Transfusion Service, University of New Mexico, Albuquerque, New Mexico
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24
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Medical Advances in the Treatment of Postpartum Hemorrhage. Anesth Analg 2015. [DOI: 10.1213/ane.0000000000000602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Lockhart E. Postpartum hemorrhage: a continuing challenge. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:132-137. [PMID: 26637712 DOI: 10.1182/asheducation-2015.1.132] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Obstetric hemorrhage remains a leading cause of maternal morbidity and mortality worldwide. Many postpartum hemorrhages (PPHs) do not have identifiable risk factors; maternity units should therefore have obstetric hemorrhageprotocols in place for all parturients as every pregnancy has the potential to be complicated by hemorrhage. This review will examine the epidemiology of PPH as well as current recommendations for key elements in obstetric hemorrhage protocols. Recent advances in hematologic management of PPH will be also be reviewed, including: (1) recognition of hypofibrinogenemia as a risk factor for severe PPH, (2) use of antifibrinolytic therapy, and (3) strategies for fibrinogen replacement therapy.
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Affiliation(s)
- Evelyn Lockhart
- University of New Mexico Health Science Center, Departments of Pathology and Obstetrics & Gynecology, Albuquerque, NM
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