Clinical interventions are more accurate than quantitative measurements for defining hemorrhage with dilation and evacuation

Abstract

ObjectivesTo assess if quantitative blood loss (QBL) with dilation and evacuation (D&E) procedures correlated with clinically relevant outcomes or hemorrhage. Study designWe used a de-identified database to review D&E procedures performed at UC Davis Health from April 2019 through March 2020. Surgeons determined QBL during procedures and estimated blood loss, when excessive, during post-procedure recovery. We extracted patient demographic and procedure-related information. We defined clinically relevant bleeding as cases with bleeding-related interventions within 24 hours post-procedure including use of ≥2 uterotonics, tranexamic acid administration, cervical injury requiring repair, uterine balloon tamponade, blood transfusion, uterine artery embolization, hospitalization, or return to operating room; the latter 5 criteria defined hemorrhage. We used χ2 test for trend to evaluate bleeding outcomes. ResultsWe evaluated 431 procedures with a mean gestational age of 19 weeks and 3 days. Clinically relevant bleeding outcomes occurred in 6/319 (2%), 15/97 (15%) and 7/12 (58%) patients with total blood loss <250mL, 250−500mL and >500mL, respectively (p<0.0001); 11 had bleeding related to cervical injuries. Hemorrhage occurred in 0, 4/97 (4%) and 5/12 (42%) patients, respectively (p<0.0001). Patients with relevant bleeding outcomes had QBLs ranging from 150−1800mL (median QBL 312.5mL, interquartile range [IQR] 250−550mL) while those without clinically relevant bleeding ranged from 10−900mL (median QBL 150mL, IQR 75−200mL). ConclusionMost patients (75%) with clinically relevant bleeding outcomes had QBL ≤500mL. Although higher QBL correlates with clinical interventions, the need for significant interventions rather than a single blood loss amount should be used to define hemorrhage with D&E procedures. ImplicationsClinical hemorrhage is best defined by the necessary clinical interventions required to manage bleeding rather than any quantified amount of blood loss.