Abstract
BackgroundObstetric hemorrhage is the leading cause of maternal mortality globally. The Non-pneumatic Anti-Shock Garment (NASG) is a low-technology, first-aid compression device which, when added to standard hypovolemic shock protocols, may improve outcomes for women with hypovolemic shock secondary to obstetric hemorrhage in tertiary facilities in low-resource settings.MethodsThis study employed a pre-intervention/intervention design in four facilities in Nigeria and two in Egypt. Primary outcomes were measured mean and median blood loss, severe end-organ failure morbidity (renal failure, pulmonary failure, cardiac failure, or CNS dysfunctions), mortality, and emergency hysterectomy for 1442 women with ≥750 mL blood loss and at least one sign of hemodynamic instability. Comparisons of outcomes by study phase were assessed with rank sum tests, relative risks (RR), number needed to treat for benefit (NNTb), and multiple logistic regression.ResultsWomen in the NASG phase (n = 835) were in worse condition on study entry, 38.5% with mean arterial pressure <60 mmHg vs. 29.9% in the pre-intervention phase (p = 0.001). Despite this, negative outcomes were significantly reduced in the NASG phase: mean measured blood loss decreased from 444 mL to 240 mL (p < 0.001), maternal mortality decreased from 6.3% to 3.5% (RR 0.56, 95% CI 0.35-0.89), severe morbidities from 3.7% to 0.7% (RR 0.20, 95% CI 0.08-0.50), and emergency hysterectomy from 8.9% to 4.0% (RR 0.44, 0.23-0.86). In multiple logistic regression, there was a 55% reduced odds of mortality during the NASG phase (aOR 0.45, 0.27-0.77). The NNTb to prevent either mortality or severe morbidity was 18 (12-36).ConclusionAdding the NASG to standard shock and hemorrhage management may significantly improve maternal outcomes from hypovolemic shock secondary to obstetric hemorrhage at tertiary care facilities in low-resource settings.
Highlights
Obstetric hemorrhage is the leading cause of maternal mortality globally
Results from the use of the Non-pneumatic AntiShock Garment (NASG) (Zoex Corporation, Ashland, OR) to stabilize women with obstetric hemorrhage have been published in a case series, a pilot study, and two small comparative studies [3,4,5,6,7]
Unlike the Pneumatic Anti-Shock Garment (PASG or medical anti-shock trousers MAST), previously used in the U.S for pre-hospital trauma firstaid, there are no manometers, stop cocks or inflation devices; pressures applied by the NASG do not exceed 70 mmHg, avoiding potential ischemia or compartment syndrome
Summary
The Non-pneumatic AntiShock Garment (NASG) is a low-technology, first-aid compression device which, when added to standard hypovolemic shock protocols, may improve outcomes for women with hypovolemic shock secondary to obstetric hemorrhage in tertiary facilities in low-resource settings. Obstetric hemorrhage is the leading cause of maternal mortality globally. In the absence of hemodynamic stability provided by those transfusions, anesthetists and surgeons (if they are available) will not consider performing necessary hemostatic surgery. In some settings, if the woman is eligible for surgery, it is more feasible to perform an emergency hysterectomy than the more time and skill intensive devascularization. In a 2003 Bellagio meeting on the problem of maternal mortality and morbidity due to hemorrhage, experts suggested trying anti-shock garments (ASG) for stabilization to help women survive delays [2]
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