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Yang F, Wang H, Shen M. Effect of preoperative prophylactic intravenous tranexamic acid on perioperative blood loss control in patients undergoing cesarean delivery: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2023; 23:420. [PMID: 37280562 DOI: 10.1186/s12884-023-05753-9] [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: 02/16/2023] [Accepted: 06/02/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is one of the important risk factors leading to maternal mortality and intervention is essential. Oxytocin therapy is widely used clinically, but the effect is unsatisfactory. The efficacy of tranexamic acid (TXA) in hemostasis is notable, whereas its use in preventing PPH warrants exploration. AIMS To evaluate the effect of prophylactic administration of TXA on perioperative blood loss in women undergoing cesarean section by systematic review and meta-analysis of published studies. METHODS Bibliographic databases were screened from their inception to December 2022 to retrieve relevant studies. Study outcomes including blood loss during cesarean section, 2-h postpartum blood loss, total blood loss (during cesarean section and 2-h postpartum), and 6-h postpartum, as well as hemoglobin changes were extracted and compared. RESULTS A total of 21 studies, nine randomized clinical trials and 12 cohort studies, involving 1896 patients given TXA prophylactically and 1909 patients given placebo or no treatment, were analyzed. Compared with the control group, the preoperative prophylactic intravenous administration of TXA significantly reduced the intraoperative (RCT: P < 0.00001, cohort studies: P < 0.00001), 2-h postpartum (RCT: P = 0.02, cohort studies: P < 0.00001) and total blood loss (RCT: P < 0.00001, cohort studies: P = 0.0002), and reduced the decline in hemoglobin (RCT: P < 0.00001, cohort studies: P = 0.0001), but did not significantly affect blood loss at 6-h postpartum (P = 0.05). CONCLUSION Prophylactic intravenous TXA before cesarean section is helpful in preventing perioperative bleeding in women. TRIAL REGISTRATION http://www.crd.york.ac.uk/PROSPERO , identifier: CRD 42022363450.
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Affiliation(s)
- Fan Yang
- Department of Intensive Care Unit, Women's Hospital, School of Medicine, Zhejiang University, Zhejiang Province, Hangzhou, 310003, People's Republic of China
| | - Han Wang
- Department of Gynecology and Obstetrics, Women's Hospital, School of Medicine, Zhejiang University, Zhejiang Province, Hangzhou, 310003, People's Republic of China
| | - Mengdie Shen
- Department of Internal Medicine, Women's Hospital, School of Medicine, Zhejiang University, Zhejiang Province, Hangzhou, 310003, People's Republic of China.
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2
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Lv Y, Zhang X, Xu Q, Wu J. Factors associated with poorer childbirth outcomes in pregnant women diagnosed with placenta previa. Taiwan J Obstet Gynecol 2023; 62:423-428. [PMID: 37188447 DOI: 10.1016/j.tjog.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE Placenta previa is a health issue during pregnancy when the placenta wholly or partially covers the opening of the uterus. It can result in bleeding during pregnancy or after delivery, and preterm delivery. This study aimed to investigate the risk factors correlated with poorer childbirth outcomes of placenta previa. MATERIALS AND METHODS Between May 2019 and January 2021, pregnant women diagnosed with placenta previa in our hospital were enrolled. Outcomes were postpartum hemorrhage after childbirth, and lower Apgar score and preterm delivery of the neonate. Laboratory blood examination data preoperatively were collected from medical records. RESULTS A total of 131 subjects were included, with a median age 31 years. Multivariate analysis showed that fibrinogen reduced risk for postpartum hemorrhage (adjusted odds ratio (aOR): 0.45, 95% confidence interval (CI): 0.26-0.79, p = 0.005). Homocysteine (aOR: 0.73, 95% CI: 0.54-0.99, p = 0.04) reduced the risk while D-dimer (aOR: 1.19, 95% CI: 1.02-1.37, p = 0.02) increased the risk for low Apgar score. Age (aOR: 0.86, 95% CI: 0.77-0.96, p = 0.005) decreased the risk but history of full-term pregnancy more than twice (aOR: 8.58, 95% CI: 2.32-31.71, p = 0.001) increased the risk for preterm delivery. CONCLUSION The findings suggest that poorer childbirth outcomes in pregnant women with placenta previa are associated with young age, history of full-term pregnancy, and preoperative concentrations of low fibrinogen, low homocysteine and high D-dimer. This provides obstetricians adjunctive information for early screening of high-risk population and relevant treatment arrangement in advance.
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Affiliation(s)
- Yuqiong Lv
- Department of Obstetrics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, 362000, China
| | - Xueya Zhang
- Department of Hematology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, 362000, China
| | - Qiuxia Xu
- Department of Pharmacy, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, 362000, China
| | - Jingjing Wu
- Department of Obstetrics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, 362000, China.
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3
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Ljubić A, Bozanovic T, Piperski V, Đurić E, Begovic A, Sikiraš M, Perovic A, Vukovic J, Abazović D. Biological therapies in the prevention of maternal mortality. J Perinat Med 2023; 51:253-260. [PMID: 36437561 DOI: 10.1515/jpm-2022-0403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/13/2022] [Indexed: 11/29/2022]
Abstract
Although the maternal mortality rate has decreased and significant improvements have been made in maternal care, maternal death remains one of the substantial problems of our society. The leading causes of maternal death are postpartum hemorrhage, the most important cause of death in developing countries, and preeclampsia and venous thromboembolism, which are more prevalent in developed countries. To treat these conditions, a variety of therapeutic approaches, including pharmacologic agents and surgical techniques, have been adopted. However, a certain number of pregnant women do not respond to any of these options. That is the main reason for developing new therapeutic approaches. Biological medications are isolated from natural sources or produced by biotechnology methods. Heparin is already successfully used in the therapy of deep venous thrombosis and pulmonary embolism. Blood derivatives, used in an autologous or allogenic manner, have proven to be efficacious in achieving hemostasis in postpartum hemorrhage. Mesenchymal stem cells, alpha-1-microglobulin, and antithrombin exhibit promising results in the treatment of preeclampsia in experimental models. However, it is essential to evaluate these novel approaches' efficacy and safety profile throughout clinical trials before they can become a standard part of patient care.
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Affiliation(s)
- Aleksandar Ljubić
- Biocell Hospital, Belgrade, Serbia.,Special Gynecology Hospital with Maternity Ward Jevremova, Belgrade, Serbia.,Libertas International University, Dubrovnik, Croatia
| | - Tatjana Bozanovic
- Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Emilija Đurić
- Biocell Hospital, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
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4
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Lord MG, Calderon JA, Ahmadzia HK, Pacheco LD. Emerging technology for early detection and management of postpartum hemorrhage to prevent morbidity. Am J Obstet Gynecol MFM 2023; 5:100742. [PMID: 36075527 DOI: 10.1016/j.ajogmf.2022.100742] [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: 04/29/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
Despite advances in hemorrhage detection and management, postpartum hemorrhage remains the single leading cause of maternal death worldwide. Within the United States, hemorrhage is the leading cause of maternal death on the day of delivery and within the first week after delivery. Blood transfusion after hemorrhage represents a large proportion of severe maternal morbidity during and after delivery. Blood loss during delivery has historically been assessed visually by inspecting soiled pads, linens, and laparotomy sponges. These methods underestimate the volume of blood loss by as much as 40%, becoming increasingly inaccurate as blood loss increases. Young, healthy obstetrical patients compensate for blood loss via peripheral vasoconstriction, maintaining heart rate and blood pressure in a normal range until over 1 L of blood has been lost. A significant decrease in blood pressure along with marked tachycardia (>120 bpm) may not be seen until 30% to 40% of blood volume has been lost, or 2.0 to 2.6 L in a healthy term pregnant patient, after which the patient may rapidly decompensate. In resource-poor settings especially, the narrow window between the emergence of significant vital sign abnormalities and clinical decompensation may prove catastrophic. Once hemorrhage is detected, decisions regarding blood product transfusion are routinely made on the basis of inaccurate estimates of blood loss, placing patients at risk of underresuscitation (increasing the risk of hemorrhagic shock and end-organ damage) or overresuscitation (increasing the risk of transfusion reaction, fluid overload, and alloimmunization). We will review novel technologies that have emerged to assist both in the early and accurate detection of postpartum hemorrhage and in decisions regarding blood product transfusion.
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Affiliation(s)
- Megan G Lord
- Division of Maternal-Fetal Medicine, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI (Dr Lord).
| | - Joaquin A Calderon
- Division of Maternal-Fetal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (Drs Calderon and Ahmadzia)
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (Drs Calderon and Ahmadzia)
| | - Luis D Pacheco
- Divisions of Maternal-Fetal Medicine and Surgical Critical Care, University of Texas Medical Branch, Galveston, TX (Dr Pacheco)
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5
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Point-of-care coagulation testing for postpartum haemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:383-398. [PMID: 36513433 DOI: 10.1016/j.bpa.2022.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/03/2022] [Accepted: 08/05/2022] [Indexed: 12/15/2022]
Abstract
The use of viscoelastic haemostatic assays (VHAs) to guide blood product replacement during postpartum haemorrhage is expanding. Rotem and TEG devices can be used to detect and treat clinically significant hypofibrinogenaemia, although evidence to support the role of VHAs for guiding fresh frozen plasma and platelet transfusion is less clear. If Rotem/TEG traces are normal, clinicians should investigate for another cause of bleeding, and haemostatic support is not required. Guidelines support the use of VHAs during postpartum haemorrhage as part of locally agreed algorithms. There is a wide consensus that fibrinogen replacement is needed if the Fibtem A5 is <12 mm and if there is ongoing bleeding. Guidelines recommend against using VHAs to guide tranexamic acid infusion, and this drug should be given as soon as bleeding is recognised, irrespective of the Rotem/TEG traces. The cost-effectiveness of VHAs during postpartum haemorrhage needs to be addressed.
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Ramler PI, Gillissen A, Henriquez DDCA, Caram‐Deelder C, Markovski AA, de Maat MPM, Duvekot JJ, Eikenboom JCJ, Bloemenkamp KWM, van Lith JMM, van den Akker T, van der Bom JG. Clinical value of early viscoelastometric point-of-care testing during postpartum hemorrhage for the prediction of severity of bleeding: A multicenter prospective cohort study in the Netherlands. Acta Obstet Gynecol Scand 2021; 100:1656-1664. [PMID: 33999407 PMCID: PMC8453832 DOI: 10.1111/aogs.14172] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/01/2021] [Accepted: 05/04/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION To evaluate rotational fibrin-based thromboelastometry (ROTEM® FIBTEM) with amplitude of clot firmness at 5 min (A5) as an early point-of-care parameter for predicting progression to severe postpartum hemorrhage, and compare its predictive value with that of fibrinogen. MATERIAL AND METHODS Prospective cohort study in the Netherlands including women with 800-1500 ml of blood loss within 24 h following birth. Blood loss was quantitatively measured by weighing blood-soaked items and using a fluid collector bag in the operating room. Both FIBTEM A5 values and fibrinogen concentrations (Clauss method) were measured between 800 and 1500 ml of blood loss. Predictive accuracy of both biomarkers for the progression to severe postpartum hemorrhage was measured by area under the receiver operating curves (AUC). Severe postpartum hemorrhage was defined as a composite endpoint of (1) total blood loss >2000 ml, (2) transfusion of ≥4 packed cells, and/or (3) need for an invasive intervention to cease bleeding. RESULTS Of the 391 women included, 72 (18%) developed severe postpartum hemorrhage. Median (IQR) volume of blood loss at blood sampling was 1100 ml (1000-1300) with a median (interquartile range [IQR]) fibrinogen concentration of 3.9 g/L (3.4-4.6) and FIBTEM A5 value of 17 mm (13-20). The AUC for progression to severe postpartum hemorrhage was 0.53 (95% confidence interval [CI] 0.46-0.61) for FIBTEM A5 and 0.58 (95% CI 0.50-0.65) for fibrinogen. Positive predictive values for progression to severe postpartum hemorrhage for FIBTEM A5 ≤12 mm was 22.5% (95% CI 14-33) and 50% (95% CI 25-75) for fibrinogen ≤2 g/L. CONCLUSIONS The predictive value of FIBTEM A5 compared to fibrinogen concentrations measured between 800 and 1500 ml of blood loss following childbirth was poor to discriminate between women with and without progression towards severe postpartum hemorrhage.
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Affiliation(s)
- Paul I. Ramler
- Center for Clinical Transfusion ResearchSanquin ResearchLeidenthe Netherlands
- Department of ObstetricsLeiden University Medical CenterLeidenthe Netherlands
| | - Ada Gillissen
- Center for Clinical Transfusion ResearchSanquin ResearchLeidenthe Netherlands
- Department of ObstetricsLeiden University Medical CenterLeidenthe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Dacia D. C. A. Henriquez
- Center for Clinical Transfusion ResearchSanquin ResearchLeidenthe Netherlands
- Department of ObstetricsLeiden University Medical CenterLeidenthe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Camila Caram‐Deelder
- Center for Clinical Transfusion ResearchSanquin ResearchLeidenthe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | | | - Moniek P. M. de Maat
- Department of HematologyErasmus University Medical CenterRotterdamthe Netherlands
| | - Johannes J. Duvekot
- Department of ObstetricsErasmus University Medical CenterRotterdamthe Netherlands
| | | | - Kitty W. M. Bloemenkamp
- Department of ObstetricsDivision Woman and BabyBirth Center Wilhelmina Children HospitalUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Jan M. M. van Lith
- Department of ObstetricsLeiden University Medical CenterLeidenthe Netherlands
| | - Thomas van den Akker
- Department of ObstetricsLeiden University Medical CenterLeidenthe Netherlands
- Athena InstituteFaculty of ScienceVU University Medical CenterAmsterdamthe Netherlands
- National Perinatal Epidemiology UnitUniversity of OxfordOxfordUnited Kingdom
| | - Johanna G van der Bom
- Center for Clinical Transfusion ResearchSanquin ResearchLeidenthe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
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7
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Liew-Spilger AE, Sorg NR, Brenner TJ, Langford JH, Berquist M, Mark NM, Moore SH, Mark J, Baumgartner S, Abernathy MP. Viscoelastic Hemostatic Assays for Postpartum Hemorrhage. J Clin Med 2021; 10:3946. [PMID: 34501395 PMCID: PMC8432102 DOI: 10.3390/jcm10173946] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 12/15/2022] Open
Abstract
This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.
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Affiliation(s)
- Alyson E. Liew-Spilger
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA;
| | - Nikki R. Sorg
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Toby J. Brenner
- Division of Natural Sciences, Indiana Wesleyan University, Marion, IN 46953, USA;
| | - Jack H. Langford
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN 46208, USA;
| | - Margaret Berquist
- College of Science, University of Notre Dame, Notre Dame, IN 46556, USA;
| | - Natalie M. Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Spencer H. Moore
- Marian University College of Osteopathic Medicine, Indianapolis, IN 46222, USA;
| | - Julie Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Sara Baumgartner
- Department of Obstetrics and Gynecology, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Mary P. Abernathy
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
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8
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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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9
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Wawer AA, Hodyl NA, Fairweather-Tait S, Froessler B. Are Pregnant Women Who Are Living with Overweight or Obesity at Greater Risk of Developing Iron Deficiency/Anaemia? Nutrients 2021; 13:1572. [PMID: 34067098 PMCID: PMC8151407 DOI: 10.3390/nu13051572] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 12/14/2022] Open
Abstract
Low-grade inflammation is often present in people living with obesity. Inflammation can impact iron uptake and metabolism through elevation of hepcidin levels. Obesity is a major public health issue globally, with pregnant women often affected by the condition. Maternal obesity is associated with increased pregnancy risks including iron deficiency (ID) and iron-deficiency anaemia (IDA)-conditions already highly prevalent in pregnant women and their newborns. This comprehensive review assesses whether the inflammatory state induced by obesity could contribute to an increased incidence of ID/IDA in pregnant women and their children. We discuss the challenges in accurate measurement of iron status in the presence of inflammation, and available iron repletion strategies and their effectiveness in pregnant women living with obesity. We suggest that pre-pregnancy obesity and overweight/obese pregnancies carry a greater risk of ID/IDA for the mother during pregnancy and postpartum period, as well as for the baby. We propose iron status and weight gain during pregnancy should be monitored more closely in women who are living with overweight or obesity.
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Affiliation(s)
- Anna A. Wawer
- Department of Anaesthesia, Lyell McEwin Hospital, Elizabeth Vale, SA 5112, Australia;
- Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA 5005, Australia;
| | - Nicolette A. Hodyl
- Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA 5005, Australia;
| | - Susan Fairweather-Tait
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK;
| | - Bernd Froessler
- Department of Anaesthesia, Lyell McEwin Hospital, Elizabeth Vale, SA 5112, Australia;
- Discipline of Acute Care Medicine, Adelaide Medical School, University of Adelaide, Adelaide, SA 5005, Australia
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10
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Roberts LN. Tranexamic acid in acute gastrointestinal bleeding - A cautionary tale. J Thromb Haemost 2020; 18:2440-2443. [PMID: 32856769 DOI: 10.1111/jth.15046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, UK
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11
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Richards JE, Samet RE, Koerner AK, Grissom TE. Tranexamic Acid in the Perioperative Period: Yes, No, Maybe? Adv Anesth 2019; 37:87-110. [PMID: 31677661 DOI: 10.1016/j.aan.2019.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Ron E Samet
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - A Kennedy Koerner
- Department of Anesthesiology, University of Maryland School of Medicine, Center for the Sustainment of Trauma and Readiness Skills (CSTARS)-Baltimore, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA.
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12
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Othman M, Han K, Elbatarny M, Abdul-Kadir R. The use of viscoelastic hemostatic tests in pregnancy and puerperium: review of the current evidence - communication from the Women's Health SSC of the ISTH. J Thromb Haemost 2019; 17:1184-1189. [PMID: 31127695 DOI: 10.1111/jth.14461] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/28/2019] [Accepted: 04/11/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Canada
- School of Baccalaureate Nursing, St Lawrence College, Kingston, Canada
| | - Katharina Han
- School of Baccalaureate Nursing, St Lawrence College, Kingston, Canada
| | | | - Rezan Abdul-Kadir
- Katharine Dormandy Haemophilia and Thrombosis Centre and Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation hospital, London, UK
- University College, London, UK
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13
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Wang Y, Liu S, He L. Prophylactic use of tranexamic acid reduces blood loss and transfusion requirements in patients undergoing cesarean section: A meta-analysis. J Obstet Gynaecol Res 2019; 45:1562-1575. [PMID: 31237747 DOI: 10.1111/jog.14013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/15/2019] [Indexed: 12/01/2022]
Abstract
AIM Tranexamic acid (TXA) has been used to treat peripartum hemorrhage, while preoperative use of TXA in cesarean section (CS) remains controversial. To assess the effectiveness and safety of prophylactic application of TXA, a meta-analysis was performed. METHODS Electronic databases (MEDLINE [PubMed], Cochrane central register of controlled trials and Embase) were searched up to November 2018. The relevant data and quality of included trail were analyzed by RevMan 5.3. The study was registered at PROSPERO (CRD42018111165). RESULTS Twenty-one randomized controlled trials with a total of 3852 patients were included. Only one research reported thromboembolic events. Compared with control groups, the intra-operative blood loss (mean difference [MD] -155.23 mL, 95% confidence interval [CI] -195.64 - 114.81; P<0.01), postoperative blood loss (MD -26.67 mL, 95% CI -32.98 to -20.36; P<0.01), total blood loss (MD -184.88 mL, 95% CI -218.83 to -150.94; P<0.01), transfusion requirements (relative risk [RR] 0.29, 95% CI 0.18-0.49, P<0.01), massive hemorrhage (RR 0.39, 95% CI 0.30 to 0.51; P<0.01) and additional uterotonic agents use (RR 0.40, 95% CI 0.30-0.55, P<0.01) were markedly reduced in TXA-treated patients. Besides, TXA yielded a significant reduction in hemoglobin drop (MD -0.80 g/dL, 95% CI -1.07 to -0.53; P<0.01) and hematocrit drop (MD -2.05, 95% CI -3.09 to -1.01; P<0.01) compared with control groups. CONCLUSION Prophylactic application of TXA can decrease perioperative blood loss and transfusion requirements in patients undergoing CS. More high-quality researches are needed to determine optimal dose of the drug.
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Affiliation(s)
- Yongjun Wang
- Transfusion Department, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Siyuan Liu
- Transfusion Department, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Li He
- Transfusion Department, The Second Xiangya Hospital, Central South University, Changsha, China
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14
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Abstract
Background Postpartum hemorrhage (PPH) is related to several factors but is frequently associated with coagulopathy with maternal mortality. Fibrinogen is a very important agent for bleeding. When its concentration is decreased, severe surgical blood loss may occur. Here, we investigate the association of postpartum bleeding characteristics with evolution of PPH in patients who were taking fibrinogen concentrate (FC). Material/Methods PPH patients’ demographic parameters, outcome variables, and laboratory findings before and at ICU were recorded between January 2015 and July 2017. The duration of ICU stay and plasmapheresis, renal replacement therapy, maternal-fetal deaths, RBC, FFP, and PC replacement were calculated. Results Group I: Fibrinogen levels were ≤150 mg/dl (n: 31), Group II: Fibrinogen levels were >151 mg/dl (n: 18). In the peroperative period, there was no difference between the 2 groups in terms of RBC, FFP, or PC transfussion. In intraoperative and ICU admission period, patients in Group I had higher INR, APTT, and PT values than in the other group. FC replacement according to fibrinogen level was given, ranging from to 1 to 6 gr in Group I and 1–2 gr in Group II intraoperatively and at ICU 2–8 gr FC was given in both groups. In the intraoperative and ICU admission period, blood transfusion requirements of patients after fibrinogen replacement were evaluated and there was no statistically significant difference between groups. There were no differrences between groups in duration of intensive care unit stay, hospital stay, and mechanical ventilation. Conclusions Adequate FC therapy prevents unnecessary RBC, FFP, and PC replacement and prevents complications and volume overload.
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Affiliation(s)
- Ayca Sultan Sahin
- Department of Anesthesiology and Reanimation, SBU Kanuni Sultan Suleyman Education and Training Hospital, Istanbul, Turkey
| | - Sureyya Ozkan
- Department of Anesthesiology and Reanimation, SBU Kanuni Sultan Suleyman Education and Training Hospital, Istanbul, Turkey
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15
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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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16
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Pohlman TH, Fecher AM, Arreola-Garcia C. Optimizing transfusion strategies in damage control resuscitation: current insights. J Blood Med 2018; 9:117-133. [PMID: 30154676 PMCID: PMC6108342 DOI: 10.2147/jbm.s165394] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
From clinical and laboratory studies of specific coagulation defects induced by injury, damage control resuscitation (DCR) emerged as the most effective management strategy for hemorrhagic shock. DCR of the trauma patient who has sustained massive blood loss consists of 1) hemorrhage control; 2) permissive hypotension; and 3) the prevention and correction of trauma-induced coagulopathies, referred to collectively here as acute coagulopathy of trauma (ACOT). Trauma patients with ACOT have higher transfusion requirements, may eventually require massive transfusion, and are at higher risk of exsanguinating. Distinct impairments in the hemostatic system associated with trauma include acquired quantitative and qualitative platelet defects, hypocoagulable and hypercoagulable states, and dysregulation of the fibrinolytic system giving rise to hyperfibrinolysis or a phenomenon referred to as fibrinolytic shutdown. Furthermore, ACOT is a component of a systemic host defense dysregulation syndrome that bears several phenotypic features comparable with other acute systemic physiological insults such as sepsis, myocardial infarction, and postcardiac arrest syndrome. Progress in the science of resuscitation has been continuing at an accelerated rate, and clinicians who manage catastrophic blood loss may be incompletely informed of important advances that pertain to DCR. Therefore, we review recent findings that further characterize the pathophysiology of ACOT and describe the application of this new information to optimization of resuscitation strategies for the patient in hemorrhagic shock.
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Affiliation(s)
- Timothy H Pohlman
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN, USA,
| | - Alison M Fecher
- Department of Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN, USA
| | - Cecivon Arreola-Garcia
- Department of Surgery, Section of Acute Care Surgery, Indiana University Health, Indianapolis, IN, USA
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17
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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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18
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Flint AWJ, McQuilten ZK, Wood EM. Massive transfusions for critical bleeding: is everything old new again? Transfus Med 2018; 28:140-149. [PMID: 29607593 DOI: 10.1111/tme.12524] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/11/2017] [Accepted: 03/07/2018] [Indexed: 12/19/2022]
Abstract
Massive transfusion or major haemorrhage protocols have been widely adopted in the treatment of critically bleeding patients. Following evidence that higher ratios of transfused plasma and platelets to red blood cells may offer survival benefits in military trauma patients, these ratios are now commonly incorporated into massive transfusion protocols. They more closely resemble the effects of whole blood transfusion, which in the second half of last century was largely replaced by individual blood component transfusion based on laboratory-guided indicators. However, high-quality evidence to guide transfusion support for critically bleeding patients across the range of bleeding contexts is lacking, including for both trauma and non-trauma patients. More data on major haemorrhage support and clinical outcomes are needed to inform guidelines and practice.
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Affiliation(s)
- A W J Flint
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Royal Australian Navy, Australian Defence Force, Canberra, Australian Capital Territory, Australia
| | - Z K McQuilten
- The Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Health, Melbourne, Victoria, Australia
| | - E M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Monash Health, Melbourne, Victoria, Australia
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19
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Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomized controlled trial. Br J Anaesth 2017; 119:411-421. [DOI: 10.1093/bja/aex181] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2017] [Indexed: 12/25/2022] Open
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20
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Collins P, Cannings-John R, Bruynseels D, Mallaiah S, Dick J, Elton C, Weeks A, Sanders J, Aawar N, Townson J, Hood K, Hall J, Harding K, Gauntlett R, Collis R. Viscoelastometry guided fresh frozen plasma infusion for postpartum haemorrhage: OBS2, an observational study. Br J Anaesth 2017; 119:422-434. [DOI: 10.1093/bja/aex245] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 12/22/2022] Open
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22
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Abstract
Hemorrhage is a major contributor to morbidity and mortality during the perioperative period. Current methods of diagnosing coagulopathy have various limitations including long laboratory runtimes, lack of information on specific abnormalities of the coagulation cascade, lack of in vivo applicability, and lack of ability to guide the transfusion of blood products. Viscoelastic testing offers a promising solution to many of these problems. The two most-studied systems, thromboelastography (TEG) and rotational thromboelastometry (ROTEM), offer similar graphical and numerical representations of the initiation, formation, and lysis of clot. In systematic reviews on the clinical efficacy of viscoelastic tests, the majority of trials analyzed were in cardiac surgery patients. Reviews of the literature suggest that transfusions of packed red blood cells (pRBC), plasma, and platelets are all decreased in patients whose transfusions were guided by viscoelastic tests rather than by clinical judgement or conventional laboratory tests. Mortality appears to be lower in the viscoelastic testing groups, despite no difference in surgical re-intervention rates and massive transfusion rates. Cost-effectiveness studies also seem to favor viscoelastic testing. Viscoelastic testing has also been investigated in small studies in other clinical contexts, such as sepsis, obstetric hemorrhage, inherited bleeding disorders, perioperative thromboembolism risk assessment, and management of anticoagulation for patients on mechanical circulatory support systems or direct oral anticoagulants (DOACs). While the results are intriguing, no systematic, larger trials have taken place to date. Viscoelastic testing remains a relatively novel method to assess coagulation status, and evidence for its use appears favorable in reducing blood product transfusions, especially in cardiac surgery patients.
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Affiliation(s)
- Liang Shen
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Sheida Tabaie
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Natalia Ivascu
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
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23
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24
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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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25
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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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26
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Shreeve NE, Barry JA, Deutsch LR, Gomez K, Kadir RA. Changes in thromboelastography parameters in pregnancy, labor, and the immediate postpartum period. Int J Gynaecol Obstet 2016; 134:290-3. [DOI: 10.1016/j.ijgo.2016.03.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/23/2016] [Accepted: 05/16/2016] [Indexed: 11/28/2022]
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27
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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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28
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Jones RM, de Lloyd L, Kealaher EJ, Lilley GJ, Precious E, Burckett st Laurent D, Hamlyn V, Collis RE, Collins PW. Platelet count and transfusion requirements during moderate or severe postpartum haemorrhage. Anaesthesia 2016; 71:648-56. [DOI: 10.1111/anae.13448] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2016] [Indexed: 11/30/2022]
Affiliation(s)
- R. M. Jones
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - L. de Lloyd
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - E. J. Kealaher
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - G. J. Lilley
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - E. Precious
- Institute of Infection and Immunity; School of Medicine; Cardiff University; Cardiff UK
| | - D. Burckett st Laurent
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - V. Hamlyn
- Department of Anaesthetics and Pain Control; Cardiff and Vale University Health Board; Cardiff UK
| | - R. E. Collis
- Department of Anaesthetics and Pain Control; 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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29
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Hans GA, Besser MW. The place of viscoelastic testing in clinical practice. Br J Haematol 2016; 173:37-48. [DOI: 10.1111/bjh.13930] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Gregory A. Hans
- Department of Anaesthesia and Intensive Care Medicine; CHU of Liege; Liege Belgium
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30
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Collins P, Abdul-Kadir R, Thachil J. Management of coagulopathy associated with postpartum hemorrhage: guidance from the SSC of the ISTH. J Thromb Haemost 2016; 14:205-10. [PMID: 27028301 DOI: 10.1111/jth.13174] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 10/11/2015] [Indexed: 08/31/2023]
Affiliation(s)
- P Collins
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - R Abdul-Kadir
- The Royal Free Foundation Hospital, University College London, London, UK
| | - J Thachil
- Haemostasis and Thrombosis Unit, Manchester Royal Infirmary, Manchester, UK
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31
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Green L, Knight M, Seeney F, Hopkinson C, Collins PW, Collis RE, Simpson NAB, Weeks A, Stanworth SJ. The haematological features and transfusion management of women who required massive transfusion for major obstetric haemorrhage in the UK: a population based study. Br J Haematol 2015; 172:616-24. [DOI: 10.1111/bjh.13864] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/12/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Laura Green
- Barts Health NHS Trust & NHS Blood and Transplant; London UK
| | - Marian Knight
- National Perinatal Epidemiology Unit; University of Oxford; Oxford UK
| | - Frances Seeney
- Statistics and Clinical Studies; NHS Blood and Transplant; Bristol UK
| | - Cathy Hopkinson
- Statistics and Clinical Studies; NHS Blood and Transplant; Bristol UK
| | | | - Rachel E. Collis
- Department of Anaesthetics; Cardiff and Vale University Health Board; Cardiff UK
| | | | - Andrew Weeks
- Department of Women's and Children's Health; University of Liverpool; Liverpool UK
| | - Simon J. Stanworth
- NHS Blood and Transplant; Oxford & Oxford University Hospitals NHS Trust; Oxford UK
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32
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To the rescue: the role of intravenous iron in the management of severe anaemia in the peri-partum setting. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:150-2. [PMID: 25636130 DOI: 10.2450/2014.0220-14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 09/24/2014] [Indexed: 11/21/2022]
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33
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García Erce JA, Peral García AI, Bueno Cabrera JL. «Patient Blood Management» in obstetric hemorrhage. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:231-232. [PMID: 25443865 DOI: 10.1016/j.redar.2014.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 09/03/2014] [Indexed: 06/04/2023]
Affiliation(s)
- J A García Erce
- Servicio de Hematología y Hemoterapia, Hospital San Jorge, Huesca, España; AWGE-GIEMSA; IdiPAZ 49.
| | - A I Peral García
- Unidad de Ahorro de Sangre, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - J L Bueno Cabrera
- Servicio Transfusión, Servicio de Hematología y Hemoterapia, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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34
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Collis RE, Collins PW. Haemostatic management of obstetric haemorrhage. Anaesthesia 2014; 70 Suppl 1:78-86, e27-8. [DOI: 10.1111/anae.12913] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2014] [Indexed: 11/26/2022]
Affiliation(s)
- R. E. Collis
- Department of Anaesthetics, Intensive Care and Pain Medicine; Cardiff and Vale University Health Board; Cardiff UK
| | - P. W. Collins
- Institute of Infection and Immunity; Critical Illness Research Group; Cardiff University School of Medicine; Cardiff UK
- Department of Haematology; Cardiff and Vale University Health Board; Cardiff UK
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Rocha Filho EA, Costa ML, Cecatti JG, Parpinelli MA, Haddad SM, Sousa MH, Melo EF, Surita FG, Souza JP. Contribution of antepartum and intrapartum hemorrhage to the burden of maternal near miss and death in a national surveillance study. Acta Obstet Gynecol Scand 2014; 94:50-8. [PMID: 25327163 DOI: 10.1111/aogs.12529] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 10/13/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the occurrence of severe obstetric complications associated with antepartum and intrapartum hemorrhage among women from the Brazilian Network for Surveillance of Severe Maternal Morbidity. DESIGN Multicenter cross-sectional study. SETTING Twenty-seven obstetric referral units in Brazil between July 2009 and June 2010. POPULATION A total of 9555 women categorized as having obstetric complications. METHODS The occurrence of potentially life-threatening conditions, maternal near miss and maternal deaths associated with antepartum and intrapartum hemorrhage was evaluated. Sociodemographic and obstetric characteristics and the use of criteria for management of severe bleeding were also assessed in these women. MAIN OUTCOME MEASURES The prevalence ratios with their respective 95% confidence intervals adjusted for the cluster effect of the design, and multiple logistic regression analysis were performed to identify factors independently associated with the occurrence of severe maternal outcome. RESULTS Antepartum and intrapartum hemorrhage occurred in only 8% (767) of women experiencing any type of obstetric complication. However, it was responsible for 18.2% (140) of maternal near miss and 10% (14) of maternal death cases. On multivariate analysis, maternal age and previous cesarean section were shown to be independently associated with an increased risk of severe maternal outcome (near miss or death). CONCLUSION Severe maternal outcome due to antepartum and intrapartum hemorrhage was highly prevalent among Brazilian women. Certain risk factors, maternal age and previous cesarean delivery in particular, were associated with the occurrence of bleeding.
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Affiliation(s)
- Edilberto A Rocha Filho
- Department of Obstetrics and Gynecology, State University of Campinas (UNICAMP), School of Medicine, Campinas, SP, Brazil
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Pinas Carillo A, Chandraharan E. Postpartum haemorrhage and haematological management. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.ogrm.2014.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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