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Bonnet MP, de Vries PLM, Levet S, Saucedo M, Morau E, Dreyfus M, Goffinet F, Deneux-Tharaux C. Trends in Maternal Mortality From Obstetric Hemorrhage in France: 15 Years of Confidential Enquiry Into Maternal Deaths. Anesth Analg 2024:00000539-990000000-00822. [PMID: 38781094 DOI: 10.1213/ane.0000000000006864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND The aim of this study was to assess temporal trends in incidence and underlying causes of maternal deaths from obstetric hemorrhage in France and to describe clinical care before and after implementation of the first national guidelines published in 2004 and updated in 2014. METHODS Data from all hemorrhage-related maternal deaths between 2001 and 2015 were extracted from the French Confidential Enquiry into Maternal Deaths. We compared the maternal mortality ratio (MMR), cause of obstetric hemorrhage, and death preventability by triennium. Critical care, transfusion, and obstetric management among women who died were described for 2001 to 2003 and 2013 to 2015. RESULTS The MMR from obstetric hemorrhage significantly decreased over time from 2.3 of 100,000 livebirths (54 of 2,391,551) in 2001 to 2003 to 0.8 of 100,000 livebirths (19 of 2,412,720) in 2013 to 2015. In 2001 to 2003, uterine atony accounted for 50% (27 of 54) of maternal deaths vs 21% (4 of 19) in 2013 to 2015. As compared to 2001 to 2003, an increased proportion of women had hemodynamic continuous monitoring in 2013 to 2015 (30%, 9 of 30, vs 47%, 8 of 18) and received vasopressor infusion therapy (57%, 17 of 30, vs 72%, 13 of 18), and a smaller proportion was extubated during active hemorrhage (17%, 5 of 30, vs 0 of 18). Transfusion therapy was initiated more frequently and earlier in 2013 to 2015 (71 vs 58 minutes). In 2013 to 2015, 88% of maternal deaths due to hemorrhage remained preventable. The main identified improvable care factors were related to delays in diagnosis and surgical management, particularly after cesarean delivery. CONCLUSIONS Maternal mortality by obstetric hemorrhage decreased dramatically in France between 2001 and 2015, particularly mortality due to uterine atony. Among women who died, we detected fewer instances of substandard transfusion management or critical care. Nevertheless, opportunities for improvement were observed in most of the recent cases.
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Affiliation(s)
- Marie-Pierre Bonnet
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
- Department of Anesthesia and Critical Care, Armand-Trousseau Hospital, Sorbonne Université, Paris, France
| | - Pauline L M de Vries
- Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Obstetrics, Port-Royal Maternity Unit, Cochin Hospital, Paris, France
| | - Solène Levet
- Department of Obstetrics, Port-Royal Maternity Unit, Cochin Hospital, Paris, France
| | - Monica Saucedo
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
| | - Estelle Morau
- Department of Anesthesia and Critical Care, Nîmes University Hospital, Nîmes, France
| | - Michel Dreyfus
- Department of Gynecology and Obstetrics, Caen University Hospital, Caen, France
| | - François Goffinet
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
- Department of Obstetrics, Port-Royal Maternity Unit, Cochin Hospital, Paris, France
| | - Catherine Deneux-Tharaux
- From the Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Université Paris Cité, INSERM, INRAE, Paris, France
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Caram-Deelder C, McKinnon Edwards H, Zdanowicz JA, van den Akker T, Birkegård C, Blatný J, van der Bom JG, Colucci G, van Duuren D, van Geloven N, Henriquez DDCA, Knight M, Korsholm L, Landorph A, Lavigne Lissalde G, McQuilten ZK, Surbek D, Wellard C, Wood EM, Mercier FJ. Efficacy and Safety Analyses of Recombinant Factor VIIa in Severe Post-Partum Hemorrhage. J Clin Med 2024; 13:2656. [PMID: 38731185 PMCID: PMC11084845 DOI: 10.3390/jcm13092656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/09/2024] [Accepted: 04/27/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Despite a range of available treatments, it is still sometimes challenging to treat patients with severe post-partum hemorrhage (sPPH). Objective: This study evaluated the efficacy and safety of recombinant activated factor VIIa (rFVIIa) in sPPH management. Methods: An open-label, multi-center, randomized controlled trial (RCT; NCT00370877) and four observational studies (OS; OS-1 (NCT04723979), OS-2, OS-3, and OS-4) were analyzed regarding efficacy (need for subsequent invasive procedures, including uterine compression sutures, uterine or iliac artery ligations, arterial embolization, or hysterectomy) and safety (incidence of thromboembolic events (TE) and maternal mortality) of rFVIIa for sPPH. The RCT, and OS-1 and OS-2, included a control group of women who did not receive rFVIIa (with propensity score-matching used in OS-1 and OS-2), whereas OS-3 and OS-4 provided descriptive data for rFVIIa-exposed women only. Results: A total of 446 women exposed to rFVIIa and 1717 non-exposed controls were included. In the RCT, fewer rFVIIa-exposed women (50% [21/42]) had an invasive procedure versus non-exposed women (91% [38/42]; odds ratio: 0.11; 95% confidence interval: 0.03-0.35). In OS-1, more rFVIIa-exposed women (58% [22/38]) had an invasive procedure versus non-exposed women (35% [13.3/38]; odds ratio: 2.46; 95% confidence interval: 1.06-5.99). In OS-2, 17% (3/18) of rFVIIa-exposed women and 32% (5.6/17.8) of non-exposed women had an invasive procedure (odds ratio: 0.33; 95% confidence interval: 0.03-1.75). Across all included women, TEs occurred in 1.5% (0.2% arterial and 1.2% venous) of rFVIIa-exposed women and 1.6% (0.2% arterial and 1.4% venous) of non-exposed women with available data. Conclusions: The positive treatment effect of rFVIIa on the RCT was not confirmed in the OS. However, the safety analysis did not show any increased incidence of TEs with rFVIIa treatment.
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Affiliation(s)
| | - Hellen McKinnon Edwards
- Department of Obstetrics and Gynaecology, Copenhagen University Hospital Herlev, 2730 Herlev, Denmark
| | - Jarmila A. Zdanowicz
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Thomas van den Akker
- Leiden University Medical Center, 2333 Leiden, The Netherlands
- Athena Institute, Vrije Universiteit, 1081 Amsterdam, The Netherlands
| | | | - Jan Blatný
- Department of Paediatric Oncology, University Hospital Brno, and Masaryk University, 625 00 Brno, Czech Republic
| | | | - Giuseppe Colucci
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Clinica Sant’Anna, 6924 Sorengo, Switzerland
- University of Basel, 4001 Basel, Switzerland
| | | | - Nan van Geloven
- Leiden University Medical Center, 2333 Leiden, The Netherlands
| | - Dacia D. C. A. Henriquez
- Leiden University Medical Center, 2333 Leiden, The Netherlands
- Amsterdam University Medical Center, University of Amsterdam, 1105 Amsterdam, The Netherlands
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | | | | | | | - Zoe K. McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia
- Department of Haematology, Monash Health, Melbourne 3004, Australia
| | - Daniel Surbek
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Cameron Wellard
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia
| | - Erica M. Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia
- Department of Haematology, Monash Health, Melbourne 3004, Australia
| | - Frederic J. Mercier
- Hôpital Antoine Béclère, Assistance Publique–Hôpitaux de Paris, Université Paris Saclay, 92140 Clamart, France
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de Vries P, Deneux-Tharaux C, Caram-Deelder C, Goffinet F, Henriquez D, Seco A, van der Bom J, van den Akker T. Severe postpartum hemorrhage and the risk of adverse maternal outcome: A comparative analysis of two population-based studies in France and the Netherlands. Prev Med Rep 2024; 40:102665. [PMID: 38435415 PMCID: PMC10907197 DOI: 10.1016/j.pmedr.2024.102665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
Objectives Among women with severe PPH (sPPH) in France and the Netherlands, we compared incidence of adverse maternal outcome (major obstetric hemorrhage (≥2.5L blood loss) and/or hysterectomy and/or mortality) by mode of delivery. Second, we compared use and timing of resuscitation and transfusion management, second-line uterotonics and uterine-sparing interventions (intra-uterine tamponade, compression sutures, vascular ligation, arterial embolization) by mode of delivery. Methods Secondary analysis of two population-based studies of women with sPPH in France and the Netherlands. Women were selected by a harmonized definition for sPPH: (total blood loss ≥ 1500 ml) AND (blood transfusion of ≥ 4 units packed red blood cells and/or multicomponent blood transfusion). Findings Incidence of adverse maternal outcome after vaginal birth was 793/1002, 9.1 % in the Netherlands versus 88/214, 41.1 % in France and 259/342, 76.2% versus 160/270, 59.3% after cesarean. Hemostatic agents such as fibrinogen were administered less frequently (p < 0.001) in the Netherlands (vaginal birth: 83/1002, 8.3% versus 105/2014, 49.5% in France; cesarean: 47/342, 13.7% and 152/270, 55.6%). Second-line uterotonics were started significantly later after PPH-onset in the Netherlands than France (vaginal birth: 46 versus 25 min; cesarean: 45 versus 18 min). Uterine-sparing interventions were less frequently (p < 0.001) applied in the Netherlands after vaginal birth (394/1002,39.3 %, 134/214, 62.6%) and cesarean (133/342, 38.9 % and 155/270, 57.4%), all initiated later after onset of refractory PPH in the Netherlands. Interpretation Incidence of adverse maternal outcome was higher among women with sPPH in the Netherlands than France regardless mode of birth. Possible explanatory mechanisms are earlier and more frequent use of second-line uterotonics and uterine-sparing interventions in France compared to the Netherlands.
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Affiliation(s)
- P.L.M. de Vries
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Port-Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - C. Deneux-Tharaux
- Université Paris Cité, Inserm, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), CRESS UMR 1153, Paris, France
| | - C. Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - F. Goffinet
- Port-Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, Inserm, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), CRESS UMR 1153, Paris, France
| | - D.D.C.A. Henriquez
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - A. Seco
- Clinical Research Unit Necker Cochin, APHP, Paris, France
| | - J.G. van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - T. van den Akker
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
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Bell S, Collis R, Collins P. Comparison of haematological indices and transfusion management in severe and massive postpartum haemorrhage: analysis of a two-year national prospective observational study. Int J Obstet Anesth 2022; 50:103547. [DOI: 10.1016/j.ijoa.2022.103547] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 03/02/2022] [Accepted: 03/24/2022] [Indexed: 11/25/2022]
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McQuilten ZK, Flint AW, Green L, Sanderson B, Winearls J, Wood EM. Epidemiology of Massive Transfusion - A Common Intervention in Need of a Definition. Transfus Med Rev 2021; 35:73-79. [PMID: 34690031 DOI: 10.1016/j.tmrv.2021.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 12/28/2022]
Abstract
While massive transfusion (MT) recipients account for a small proportion of all transfused patients, they account for approximately 10% of blood products issued. Furthermore, MT events pose organizational and logistical challenges for health care providers, laboratory and transfusion services. Overall, the majority of MT events are to support major bleeding in surgical patients, trauma and gastrointestinal hemorrhage. The clinical context in which the bleeding event occurred, the number of blood products required, patient age and comorbidities are the most important predictors of outcomes for short- and long-term survival. These data are important to inform blood services, clinicians and health care providers in order to improve care and outcomes for patients with major bleeding. There is no standard accepted definition of MT, with most definitions based on number of blood components administered within a certain time-period or activation of MT protocol. The type of definition used has implications for the clinical characteristics of MT recipients included in epidemiological and interventional studies. In order to understand trends in incidence of MT, variation in blood utilization and patient outcomes, and to harmonize research outcomes, a standard and universally accepted definition of MT is urgently required.
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Affiliation(s)
- Zoe K McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Clinical Haematology, Monash Health, Melbourne, Australia; The Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Andrew Wj Flint
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Intensive Care Unit, Royal Darwin Hospital, Northern Territory, Australia
| | - Laura Green
- Blizard Institute, Queen Mary University of London, London, UK; NHS Blood and Transplant, London, UK; Barts Health NHS Trust, London, UK
| | - Brenton Sanderson
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia; Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - James Winearls
- Department of Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Australia; School of Medicine, University of Queensland, Brisbane, Australia; School of Medical Sciences, Griffith University, Gold Coast, Australia; Department of Intensive Care Unit, St Andrew's War Memorial Hospital, Brisbane, Australia
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Clinical Haematology, Monash Health, Melbourne, Australia
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