Management Of Major Obstetric Haemorrhage Research Articles

Cost analysis of care and blood transfusions in patients with Major Obstetric Haemorrhage in Ireland.

Obstetric haemorrhage is the leading cause of maternal morbidity and mortality worldwide. We aimed to estimate the economic cost of Major Obstetric Haemorrhage (MOH) and the cost of therapeutic blood components used in the management of MOH in Ireland. We performed a nationwide cross-sectional study utilising top-down and bottom-up costing methods on women who experienced MOH during the years 2011-2013. Women with MOH were allocated to Diagnostic Related Groups (DRGs) based on the approach to MOH management (MOH group). The total number of blood components used for MOH treatment and the corresponding costs were recorded. A control group representative of a MOH-free maternity population was designed with predicted costs. All costs were expressed in Euro (€) using 2022 prices and the incremental cost of MOH to maternity costs was calculated. Cost contributions are expressed as percentages from the estimated total cost. A total of 447 MOH cases were suitable for sorting into DRGs. The estimated total cost of managing women who experienced MOH is approximately €3.2 million. The incremental cost of MOH is estimated as €1.87 million. The estimated total cost of blood components used in MOH management was €1.08 million and was based on an estimated total of 3997 products transfused. Red blood cell transfusions accounted for the highest contribution (20.22%) to MOH total cost estimates compared to other blood components. The total cost of caring for women with MOH in Ireland was approximately €3.2 million with blood component transfusions accounting for between one third and one half of the cost.

P.61 Evaluation of major obstetric haemorrhage management in a tertiary unit

Introduction: Major obstetric haemorrhage (MOH) is a leading cause maternal morbidity/mortality. [1] Knight M, Bunch K, Tuffnell D et al. (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care- Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015 –17. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2019. Google Scholar Optimal blood and blood product transfusion is pivotal to preventing coagulopathy, and complements pharmacological/surgical treatments. We reviewed management of MOH in our unit.

Protocol Based Blood Management in Major Obstetric Haemorrhage- A Case Series

Major obstetric haemorrhage remains the leading cause of maternal mortality globally. Irrespective of the etiology of haemorrhage, rapid and efficient intervention using proactive standardised protocols should gain precedence in the management of major obstetric haemorrhage. As the available resources vary between institutions, protocol specific to each institution is important for timely intervention. This case series reports a few successfully managed cases of obstetric haemorrhage by the implementation of institution based Massive Transfusion Protocol (MTP). Two antenatally diagnosed patients with placenta percreta had elective hysterectomy with bladder repair. The massive haemorrhages in both these cases were managed efficiently with the use of MTP without any sequelae. Another case of atonic Postpartum Haemorrhage (PPH) which did not respond to first line management also was treated successfully with the prompt activation of protocol. A case of uterine rupture with haemorrhagic shock was managed with massive transfusion according to protocol and vasopressors and she survived with no major side effects. A case of traumatic PPH which presented with severe anaemia (Hb 4.6 gm/dL) could also be successfully resuscitated by the timely activation of MTP.

Референсные интервалы параметров ротационной тромбоэластометрии у беременных и родильниц: одноцентровое рандомизированное исследование

Введение: В последнее время стали востребованы интегральные тесты оценки системы гемостаза у женщин во время беременности, а также во время акушерских операций, связанных с кровотечением. В нашей стране отсутствуют работы по определению популяционных норм ротационной тромбоэластометрии (РОТЕМ) у беременных, рожениц и родильниц. Цель исследования: определить пределы референсных интервалов показателей РОТЕМ во время физиологически протекающей беременности и в раннем послеродовом периоде и провести корреляционный анализ со стандартными показателями коагулограммы. Материалы и методы: Обследовано 229 женщин Красноярского края, которые были поделены на 5 групп: небеременные (контроль), беременные II и III триместров, женщины раннего послеродового периода после операции кесарева сечения и естественных родов. Все женщины были сопоставимы по возрасту, индексу массы тела, сопутствующей патологии. Референсные интервалы рассчитывали либо через среднее и стандартное отклонение (для нормального распределения), либо через медиану и 2,5 и 97,5% перцентили (для ненормального распределения). Результаты: В процессе исследования подтвердилось, что во время беременности и в раннем послеродовом периоде происходят изменения в системе гемостаза в сторону гиперкоагуляции. Показатели ROTЕM у женщин в III триместре беременности и раннем послеродовом периоде существенно отличаются от показателей небеременных в популяции. У женщин после родов вне зависимости от способа родоразрешения различий между параметрами ROTЕM не установлено. Корреляция между параметрами ROTЕM и традиционными лабораторными тестами коагуляции выявила взаимосвязь между амплитудой плотности сгустка в тесте FIBTEM и уровнем фибриногена по Клаусу. Заключение: Представлены референсные интервалы параметров РОТЕМ у женщин Красноярского края. Найдена корреляция между параметрами РОТЭМ и уровнем фибриногена. Background: Recently, integral tests for hemostasis assessment in pregnant women as well as during obstetric surgery associated with bleeding have become popular. In our country, there are no studies of population norms for rotational thromboelastometry (ROTEM) in pregnant women, parturients and puerperants. Objectives: to identify reference intervals limits for ROTEM parameters during physiological pregnancy and in early postpartum period and to carry out correlation analysis with standard coagulogram parameters. Patients/Methods: We examined 229 women in Krasnoyarsk region; they were divided into 5 groups: nonpregnant (control), pregnant women in II and III trimesters, women in early postpartum period after cesarean section and after vaginal delivery. All women were comparable in age, body mass index, and concomitant pathology. Reference intervals were calculated either as the mean and standard deviation (for normal distribution), or as the median and 2.5 and 97.5% percentiles (for abnormal distribution). Results: The study confirmed hemostasis hypercoagulation changes during pregnancy and in early postpartum period. ROTEM parameters in women in III trimester of pregnancy and in early postpartum period differ significantly from those in non-pregnant women. Differences between ROTEM parameters in puerperants, regardless of the delivery method, not found. The correlation between ROTEM parameters and traditional laboratory coagulation tests revealed a relationship between clot density amplitude in FIBTEM test and Klaus fi brinogen level. Conclusions: Reference intervals of ROTEM parameters in women of Krasnoyarsk region are presented. A correlation was found between ROTEM parameters and fibrinogen level

Obstetric intra-operative cell salvage: a review of an established cell salvage service with 1170 re-infused cases.

The use of cell salvage during caesarean section has been increasing steadily, although there are concerns relating to cost, a perceived risk of amniotic fluid embolism, and fetal red cell sensitisation. We present observational data from almost a decade of use of intra-operative cell salvage in obstetrics. By the end of this period, we set up cell salvage collection for >98% of all caesarean sections. From 2008 to 2017, 1170 women have had a re-infusion of cell salvaged blood with no clinical safety concerns; the median (IQR [range]) volume was 231 (154-306 [80-1690]) ml. During this time there has been a marked reduction in the number of women who were transfused allogeneic blood, as well as the amount of blood transfused. In total, 647 (55%) women have had alloimmunisation testing, with two positive cases. Quality control data indicate that the quality of blood processed from partial first bowls is no worse than that from full bowls. We discuss the costs of providing this service with regard to: staffing costs; single suction; leucodepletion filters; selectivity in the processing of collected blood; and the use of partial first bowls.

Management of Major Obstetric Haemorrhage using ROTEM Point-of-Care Haemostasis Analysers Can Reduce Blood Product usage Without Increasing Fibrinogen Replacement Therapy

Major obstetric haemorrhage (MOH) is a leading cause of maternal death and morbidity, with the majority of deaths occurring within four hours of delivery. Therefore, prompt identification of women at risk of MOH is crucial for the rapid assessment and management of blood loss to urgently restore haemodynamic stability. Furthermore, as the rate of blood loss during MOH can increase rapidly in the time when laboratory results are awaited, the management of MOH could benefit from point-of-care coagulation testing by the ROTEM analyser which has a quicker turnaround time compared to standard laboratory coagulation tests. A number of studies indicate that ROTEM-based management of MOH has resulted in a significant reduction in massive transfusions and decreased transfusion of concentrated red cells (CRC) and fresh frozen plasma (FFP) due to a reduction in total blood loss. Several reports which have linked MOH to the depletion of fibrinogen reserves indicate that the reduction in CRC and FFP transfusions is largely due to an increase in early fibrinogen replacement therapy which corrects hypofibrinogenemia. This short report discusses preliminary findings on the impact of ROTEM point-of-care haemostasis analyser on the transfusion of various blood products to obstetric women experiencing MOH at the Royal Gwent Hospital in South wales. The number of blood products transfused following decisions based on the ROTEM analyser measurements (ROTEM group) was compared to historical transfusion data before the ROTEM analyser became available (Pre-ROTEM group). Blood product transfusion in the Pre-ROTEM group was guided by measurements of standard laboratory coagulation tests in conjunction with the established major haemorrhage protocols at the time. The findings indicate that the ROTEM analyser was effective in managing MOH at point-of-care and led to a reduction in the transfusion of CRC, FFP and platelets. However, contrary to published studies, the reduction in blood product usage was not accompanied by an increase in fibrinogen replacement transfusion therapy, suggesting that the ROTEM’s FIBTEM assay accurately quantified fibrinogen levels based on fibrin-clot firmness to enable an early diagnosis of hypofibrinogenemia. Early establishment of the absence of hypofibrinogenemia helped to prevent unnecessary transfusion of fibrinogen concentrate in this study. These findings support the adoption of routine use of ROTEM analysers at point-of-care on labour wards to manage MOH and reduce fibrinogen replacement therapy. The ease of use and rapidity of ROTEM tests could enable departure from globally directed correction of coagulopathy during MOH to a more focussed and precise target transfusion therapy, which will ultimately reduce blood product wastage (including fibrinogen concentrate) whilst minimising transfusion-associated side effects such as alloimmunisation, circulatory overload and dilutional coagulopathy.

Management of major obstetric haemorrhage.

One of the most important causes of maternal mortality is major obstetric haemorrhage. Major haemorrhage can occur in parturients either during the antepartum period, during delivery, or in the postpartum period. Early recognition and a multidisciplinary team approach in the management are the cornerstones of improving the outcome of such cases. The management consists of fluid resuscitation, administration of blood and blood products, conservative measures such as uterine cavity tamponade and sutures, and finally hysterectomy. Blood transfusion strategies have changed over the last decade with emphasis on use of fresh frozen plasma, platelets, and fibrinogen. Point-of-care testing for treating coagulopathies promptly and interventional radiological procedures have further revolutionized the management of such cases.

Haemostatic management of obstetric haemorrhage.

The haemostatic management of major obstetric haemorrhage remains challenging, and current published guidance relies heavily on experience from the non-pregnant population and expert opinion. In recent years, an interest in the implications of relative hypofibrinogenaemia, point-of-care monitoring of coagulation abnormalities, and the potential to give goal-directed therapy to correct coagulopathies, have created the possibility of significantly challenging and changing guidance. There is evidence that the haemostatic impairment in the pregnant population is different from trauma-induced bleeding, and the type and rate of onset of coagulopathies differ depending on the underlying cause. This review examines areas such as possible intervention points, describes evidence for over-transfusion of fresh frozen plasma in some situations and challenges conventional thinking on formulaic management. It also examines the rationale for other therapeutic options, including fibrinogen concentrate and tranexamic acid.

PLD.38 Major Obstetric Haemorrhage in a Tertiary Maternity Unit in Scotland: Review of Practice and Future Implications

BackgroundThe incidence of major obstetric haemorrhage (MOH), defined as ≥2.5 litres of blood loss, is rising. It is a leading cause of significant maternal morbidity.1ObjectivesTo review the management of MOH...

586: Severe maternal morbidity and management of major obstetric haemorrhage in Ireland

586: Severe maternal morbidity and management of major obstetric haemorrhage in Ireland

The economic benefits of cell salvage in obstetric haemorrhage

BackgroundCell salvage is increasingly used in the management of major obstetric haemorrhage. Its financial considerations were evaluated over a 5-year period. MethodCell salvage was introduced in the Liverpool Women’s NHS Foundation Trust in 2006. Data were collected from all cases in which it was set-up and included the volume of blood processed and returned and whether surgery was elective or emergency. ResultsBetween 1st January 2006 and 30th June 2011, cell salvage for collection was set-up 587 times and blood was returned in 137 patients. Total volume of blood returned was 47143mL, equivalent to 189 units of packed red cells. The return rate was higher for emergency than elective cases (P=0.03). As the use of cell salvage has extended over time to include a greater proportion of patients, return rates have decreased (P<0.0001). The volume of blood returned from cell salvage was significantly related to the estimated blood loss (P<0.00001), with a best fit line described by estimated blood loss=3.45x+454, where x was the volume of blood returned. In 2011 total costs of cell salvage were £9245 for the equivalent of 83 units of blood. At the current price of £125 per unit of allogeneic blood this would have cost £10375: a saving of £1130. No intraoperative or postoperative complications associated with cell salvage were seen. ConclusionThe routine use of cell salvage was associated with more salvaged blood being returned to patients, which offset the cost of collection sets when compared to the cost of using allogeneic blood. Cell salvage is an appropriate expenditure to reduce the use of allogeneic blood.

Consultant presence during major obstetric haemorrhage

BackgroundConsultant presence on labour ward can improve patient outcomes, with recommendations for on-site cover of 60 hours/week in units with ≥5,000 births/year. The study aims to assess the potential impact...

The anaesthetic management of caesarean section in the interventional radiology suite

Interventional radiology has been used in the last decade for the management of major obstetric haemorrhage particularly when the placenta is pathologically adherent (accreta) or for postpartum haemorrhage when a bleeding vessel is suspected. This review describes the radiological, obstetric and anaesthetic interventions which are often carried out in the radiology suite. The incidence of placenta accreta is increasing as the caesarean section rate rises. Pre-delivery diagnosis has been facilitated by the use of ultrasound and magnetic resonance imaging. The use of interventional radiology for elective caesarean sections with suspected placenta accreta is mainly restricted to larger centres and the evidence base for its use is currently weak. The actual location of the surgery remains controversial. Some centres with expertise perform the caesarean section in the radiology suite with obstetric, anaesthetic and neonatal teams in attendance. Robust communication is essential, especially when working in sites remote to the usual place of care. This review describes the management of patients who are amenable to prophylactic or emergency radiological intervention for obstetric haemorrhage in the radiology suite. Controversy surrounds the optimum place for surgery and the most suitable mode of anaesthesia in these patients.

Recombinant Activated Factor VII (rFVIIa) in the Management of Major Obstetric Haemorrhage: A Case Series and a Proposed Guideline for Use

Major obstetric haemorrhage remains a significant cause of maternal morbidity and mortality. Previous case reports suggest the potential benefit of recombinant activated factor VII (rFVIIa: NovoSevenR) as a haemostatic agent. We performed a retrospective review of the use of rVIIa in major obstetric haemorrhage in the Northern Region between July 2004 and February 2007. Fifteen women received rFVIIa. The median patient age was 34 years. Major haemorrhage occurred antepartum (5 patients), intrapartum (1), and postpartum (9). All women received an initial dose of 90 mcg/kg rFVIIa and one received 2 further doses. Bleeding stopped or decreased in 12 patients (80%). Additional measures included antifibrinolytic and uterotonic agents, Rusch balloon insertion, uterine curettage/packing, and vessel embolisation. Eight patients required hysterectomy. All women survived to discharge from hospital. No adverse events, including thrombosis, were recorded. This study provides further support for the safety and efficacy of rFVIIa as adjunct therapy in major obstetric haemorrhage.

Use of recombinant activated factor VII in massive obstetric haemorrhage

Massive obstetric haemorrhage is a life-threatening emergency that remains a major cause of maternal mortality. Conventional management is aimed at optimising uterine tone, replacing circulating volume and blood products, and surgery to achieve haemostasis. Recently there have been numerous reports of the (unlicensed) use of recombinant activated factor VII in the management of major obstetric haemorrhage. We report our experience of using it in the treatment of major post-partum haemorrhage in four previously healthy parturients. The published reports of recombinant activated factor VII use in post-partum haemorrhage (unrelated to pre-existing coagulopathies) are compared.

Survey of surgical experience during training in obstetrics and gynaecology in the UK

SummaryThe 2002 RCOG survey of training reported that the percentage of obstetric and gynaecology trainees who class their operative training as good or very good has declined from 45% in 1995, to 39% in 2002; reduction in years of training and number of working hours may have further impact on the surgical experience. In this study, we have attempted to assess the level of surgical confidence reported by senior and recently accredited trainees in obstetrics and gynaecology in the UK via an anonymised postal questionnaire. A total of 103 replies were received from 202 questionnaires. Some 99% of the respondents said they felt competent to carry out a simple total abdominal hysterectomy; 61.2% could confidently dissect the ureter and 55.3% could repair major damage to the bladder. However, when managing major obstetric haemorrhage, only 44.6% of respondents felt confident to perform a caesarean hysterectomy; 27.1% could dissect the ureter and 41.7% could apply a B-Lynch suture to the uterus. The level of competence increased with seniority and also with additional time spent in research, subspecialty training or other specialties. There appears to be an appropriate level of confidence in carrying out gynaecological surgical procedures by senior trainees and new consultants. However, surprisingly few respondents were confident in performing any surgical procedure necessary in the management of major obstetric haemorrhage. This may have serious implications in the provision of out of hours senior cover for maternity units in the future.

The management of major obstetric haemorrhage

There are few controlled trials of treatment options in this field due to the relative rarity of cases, the urgent nature of the condition, and the difficulty in obtaining ethical approval and consent for trials during pregnancy. Some information may be gained from assessing recent advances in related fields such as haemorrhage due to trauma, 27 although the major cardiovascular and haematological changes of pregnancy, and the particular pathologies unique to pregnancy such as pre-eclampsia, contribute additional challenges and require additional understanding. The presence of the fetus can raise dilemmas where an option beneficial to the fetus may increase risk for the mother. Finally the isolation of many obstetric theatres, and the frequent lack of facilities for major monitoring and rapid transfusion as found in most cardiac or major trauma theatres, require careful planning to allow optimal care during these occasional but lifethreatening emergencies.