Management Of Obstetric Hemorrhage Research Articles

Impact of the 2017 revised Japanese obstetric hemorrhage management guidelines on tranexamic acid use in patients undergoing cesarean delivery: an interrupted time series analysis

BackgroundTranexamic acid is one component of a complex management algorithm for postpartum hemorrhage. In Japan, the 2010 obstetric hemorrhage management guidelines was revised in 2017, adding the recommendation for the administration of tranexamic acid for postpartum hemorrhage. This research aims to delineate the temporal trends in tranexamic acid administration in patients undergoing cesarean deliveries and to examine the impact of the obstetric hemorrhage management guidelines implementation. MethodsAn interrupted time series analysis was conducted on data from patients who underwent cesarean deliveries from April 2012 to August 2021, sourced from Japan’s nationwide health insurance claims database. We examined the trends of tranexamic acid usage and blood transfusion use before and after the implementation of the revised guidelines in 2017. ResultsThe study cohort comprised 91 166 cesarean deliveries. Prior to the guideline implementation, the rate of tranexamic acid usage decreased. Post-guidelines implementation, there was a statistically significant increase in the rate of tranexamic acid use, with a quarterly percentage change of 0.48% (95% confidence interval: 0.36 to 0.60; P < 0.001). The guidelines implementation in 2017 was not significantly associated with a change in the rate of transfusions. ConclusionsThis interrupted time series analysis demonstrated a significant increase in the rate of tranexamic acid administration following the implementation of the revised guidelines, reversing the previously observed downward trend. Our findings could reflect the impact of the revised guideline on the use of tranexamic acid for postpartum hemorrhage, but this did not translate to fewer blood transfusions.

Evolution of the Use of Therapeutic Fibrinogen Concentrate in the Massive Bleeding Guidelines

Fibrinogen concentrate was approved for the first time in the European Union by the German Federal Ministry of Health on January 4th, 1966. Since then, its use has been shown to be effective and well-tolerated in numerous clinical studies with congenital or acquired fibrinogen deficiency. In this review, we analyze the evolution of the indications for the use of fibrinogen concentrate in massive bleeding guidelines in three main clinical scenarios of acquired hypofibrinogenemia, such as cardiac, obstetric, and polytrauma patients. In cardiac surgery, the administration of fibrinogen has become a noteworthy tool in the management of perioperative haemostasis. The implementation of therapeutic algorithms, together with the use of viscoelastic coagulation tests, has allowed a faster and more personalized diagnosis and treatment of perioperative bleeding. In obstetrics, fibrinogen administration has evolved significantly over the years to a part of the management of massive obstetric haemorrhage, with early administration of fibrinogen now considered important in cases of hypofibrinogenemia during haemorrhage, helping to effectively correct coagulopathy and improve maternal outcomes. Currently, the implementation of protocols based on point-of-care viscoelastic testing has proven to be useful in the management of obstetric haemorrhage. In polytrauma patients with severe bleeding, fibrinogen administration is recommended based on clinical criteria and prior to laboratory test outcomes. After this first approach, guidelines recommend goal-directed coagulation management based on the results of viscoelastic tests and, in their absence, classical laboratory tests are recommended.

Nonpneumatic anti-shock garment utilization for obstetric hemorrhage management and its predictors among obstetric care providers in Ethiopia: a systematic review and meta-analysis

IntroductionNon-pneumatic Anti-Shock Garment (NASG) is a lightweight, reusable first aid compression device that squeezes blood from the lower extremities and centralizes blood circulation to vital organs of the body. Postpartum hemorrhage followed by severe preeclampsia/eclampsia is the leading primary cause of maternal death (A reduction in extreme maternal adverse outcomes and faster recovery from shock are more likely to occur with earlier NASG intervention. The median blood loss reduced by half when the NASG was used for obstetric hemorrhage management, which was associated with significantly reduced maternal mortality among the most severe cases.ObjectiveTo estimate the pooled prevalence of NASG utilization and its predictors in Ethiopia.MethodsAppropriate and comprehensive searches of PubMed, MEDLINE, EMBASE, Google Scholar, HINARI, and Scopus were performed. The electronic literature search was last performed on November 18/2023. All observational study designs were eligible for this SRMA. All cross sectional studies reporting the prevalence/proportion of NASG utilization for obstetric hemorrhage management among obstetric care providers and associated factors were included in this SRMA. Primary studies lacking the outcome of interest were excluded from the SRMA. The extracted Microsoft Excel spreadsheet data were imported into STATA software version 17 (STATA Corporation, Texas, USA) for analysis. A random-effects model was used to estimate the pooled prevalence of NASG utilization among obstetric care providers in Ethiopia. The Cochrane Q-test and I2 statistics were computed to assess the heterogeneity among the studies included in the SRMA.ResultA total of 1623 articles were found by using our search strategies and seven studies comprising 2335 participants were ultimately included in the SRMA. The pooled prevalence of NASG utilization for obstetric hemorrhage in Ethiopia was 43.34% (95% CI: 35.25, 51.42%). The findings of this subgroup analysis by sample size showed that the pooled prevalence of NASG utilization for obstetric hemorrhage was greater in studies with sample sizes of less than the mean sample size (48.6%; 95% CI: 32.34, 64.86%). Receiving training (AOR = 3.88, 95% CI: 2.08–5.37), having good knowledge (AOR = 1.99, 95% CI: 1.28–3.16), positive attitude (AOR = 2.16, 95% CI: 1.62–2.75) and having available NASGs in the facility (AOR = 4.89, 95%CI: 2.88–8.32) were significantly associated with the use of NASGs for obstetric hemorrhage management.ConclusionThe level of NASG utilization for obstetric hemorrhage in Ethiopia is low. Receiving training, good knowledge, positive attitudes and availability of NASG were significantly associated with the utilization of NASG. Therefore, policy makers and other stakeholders should emphasize enhancing the knowledge and attitudes of obstetric care providers through continuous support and training. At the same time, they should work strictly in providing devices for all the health facilities.

The Role Anesthesiologist in Management of Obstetric Haemorrhage: A Literature Review

Hemorrhagic shock in obstetrics is still a major cause of maternal mortality and morbidity worldwide. Recognition of bleeding in obstetric patients is complicated by the normal physiologic changes that occur during pregnancy. Visual estimates of blood loss are often erroneous and underestimated because of contamination with amniotic fluid, or internal or hidden blood loss. Thus, careful clinical observation and a high index of suspicion are required for the early detection and management of obstetric hemorrhage. The usage of ultrasound (US) is considered as the first line method for detecting abnormal condition which might serve as a predictor for hemorrhagic shock. Despite of careful risk assessment given, obstetric-specific bleeding protocols, such as resuscitation and blood transfusion, are required to facilitate the integration and timely escalation interventions. The intervention of choice for hemorrhagic shock in obstetrics encompasses a wide variety of options, such as the usage of tranexamic acid, cell salvage, resuscitative endovascular balloon occlusion of the aorta (REBOA), anesthetic management, and surgical, as well as radiological provides multiple available approach, each with their own risk and advantages. The purpose of this review is to describe the management of obstetric hemorrhage from anesthetic point of view, encompassing the identification of patients at risk, resuscitative management, and perioperative management.

The importance of simulation-based multi professional training in obstetric anesthesia: an update.

Simulation-based training remains an integral component of medical education by providing a well tolerated, controlled, and replicable environment for healthcare professionals to enhance their skills and improve patient outcomes. Simulation technology applied to obstetric anesthesiology continues to evolve as a valuable tool for the training and assessment of the multidisciplinary obstetric care team. Simulation-based technology has continued to play a role in training and assessment, including recent work on interdisciplinary communication, recognition, and management of obstetric hemorrhage, and support in the low or strained resource setting. The COVID-19 pandemic has accelerated the evolution of simulation-based training away from a reliance on in-situ or high-fidelity manikin-based approaches toward an increasing utilization of modalities that allow for remote or asynchronous training. The evolution of simulation for interdisciplinary training and assessment in obstetric anesthesia has accelerated, playing a greater role in aspects of communication, management of hemorrhage and supporting low or strained resource settings. Augmented reality, virtual reality and mixed reality have advanced dramatically, spurred on by the need for remote and asynchronous simulation-based training during the pandemic.

Distribution of ABO and Rhesus ‘D’ Blood Groups among Pregnant Women in a Tertiary Hospital in Rivers State, Southern Nigeria

Background: In recent times, the role of ABO and Rhesus grouping in clinical practice has increased widely. There is a paucity of literature on blood group distribution, and its distribution has not been studied in our centre. This study aimed to determine the distribution of ABO, Rh D blood groups and haemoglobin genotype among pregnant women initiating antenatal care in Rivers State University Teaching Hospital (RSUTH). Methods: This was a cross-sectional study among antenatal clinic attendees in RSUTH, over 6 months. At booking 3ml of venous blood was collected in Ethylenediaminetetraacetic acid (EDTA) vacutainer from the pregnant women, and ABO and Rh D typing was done by tile methods forward and reverse grouping methods and confirmed by microscopy. Haemoglobin genotype was done by electrophoresis. Data collected were analyzed using IBM Statistical Product and Service Solution (SPSS), version 25.0 (Armonk, New York). Results: One thousand one hundred and forty -seven patients were recruited for the study. Their mean age and mean gestational age at booking were 31.6 SD 4.6 years (95% CI: 31.3,31.8), and 21.1 SD 18.6 weeks respectively. Modal parity was para 1. The predominant blood group among pregnant women at the RSUTH was O [667 (58.2%)], followed by A [286 (24.9%)], B [171(14.9%)], and AB [23(2%)]. The prevalences of Rhesus D positive and Rhesus D negative blood group were 95.2% and 4.8% respectively. Concerning genotype, the most predominant was AA 898 (78%) followed by AS [245 (21.4)], SS [4 (0.4%)], and AC [2 (0.2%]. Conclusion: The predominant blood group and genotype among pregnant women in our centre is O Rh D positive and AA respectively. The findings from this study would help plan transfusion services antepartum and post-partum. This will be relevant in transfusion and coagulation management of obstetric haemorrhage.

Understanding Transfusion Therapy in Obstetrics: Ensuring Maternal and Fetal Health

Transfusion therapy plays a pivotal role in obstetrics, serving as a critical intervention to address various maternal and fetal health challenges. The review encompasses the indications, types, and implications of transfusion therapy, aiming to provide a thorough understanding of its role in ensuring optimal outcomes for both mother and fetus. Obstetric hemorrhage remains a leading cause of maternal morbidity and mortality globally. Transfusion therapy, involving the administration of blood and blood products, emerges as a cornerstone in the management of obstetric hemorrhage, offering a lifeline in critical situations. This abstract delves into the specific scenarios, such as postpartum hemorrhage and placental abruption, where timely transfusions are essential to prevent severe complications. Anemia, a prevalent concern in pregnancy, necessitates a nuanced approach to transfusion therapy. Understanding the thresholds for transfusion in the context of pregnancy-related anemia is crucial for balancing the benefits against potential risks. This review discusses the challenges in managing anemia, exploring the role of transfusion in alleviating symptoms and optimizing maternal and fetal health. In conclusion, this paper synthesizes the current knowledge on transfusion therapy in obstetrics, emphasizing its pivotal role in managing obstetric hemorrhage, anemia, and blood disorders. By elucidating the intricacies of transfusion therapy and its implications for maternal and fetal health, this review aims to guide healthcare professionals in making informed decisions, ultimately contributing to enhanced obstetric care and improved outcomes for pregnant individuals and their infants.

The impact of a blended multidisciplinary training for the management of obstetric haemorrhage in Mbeya, Tanzania.

The Maternal Mortality Rate (MMR) in Tanzania is 78 times higher than that of the UK. Obstetric haemorrhage accounts for two-thirds of these deaths in Mbeya, Tanzania. A lack of healthcare providers' (HCPs') competencies has been the key attribute. This study measured the impact on HCP's competencies from a blended training programme on obstetric haemorrhage. A "before and after" cohort study was undertaken with HCPs in 4 hospitals in the Mbeya region of Tanzania between August 2021 and April 2022. A multidisciplinary cohort of 34 HCPs (doctors, nurses, midwives, anaesthetists and radiologists) were enrolled on a blended face-to-face and virtual training course. The training was delivered by a multidisciplinary team (MDT) from London, UK, assisted by local multidisciplinary trainers from Mbeya, Tanzania and covered anaesthetic, obstetrics, haematology and sonographic use. There were 33 HCP in the cohort of trainees where 30/33 (90.9%) of HCPs improved their Anaesthesia skills with a mean score improvement of 26% i.e., 0.26 (-0.009 -0.50), 23 HCPs (69.7%) improved obstetric skills 18% i.e., 0.18 (-0.16 to 0.50), 19 (57.6%), (57.6%) improved competences in Haematology 15%.i.e., 0.15 (-0.33 to 0.87), 20 out of 29 HCPs with ultrasound access (68.8%) improved Sonographic skills 13%.i.e., 0.13 (-0.31 to 0.54). All 33 HCPs (100%) presented a combined change with the mean score improvement of difference of 25% i.e., 0.25 (0.05-0.66). The deaths attributed to obstetric haemorrhage, the mortality rate declined from 76/100,000 to 21/100,000 live births. Actual number of deaths due to obstetric haemorrhage declined from 8 before training to 3 after the completion of the training. This comprehensive blended training on anaesthetic surgical, haematological, and sonographic management of obstetric haemorrhage delivers a significant positive impact on the detection, management and outcomes of obstetric haemorrhage.

Maternal outcomes following postpartum autotransfusion of blood lost during vaginal obstetric hemorrhage.

Autotransfusion following vaginal delivery has not been as widely adopted and existing data on this topic are limited to small case series. This is a single-center retrospective matched cohort study. Deliveries exposed to autotransfusion during obstetric hemorrhage were matched to unexposed controls with obstetric hemorrhage who did not receive autotransfusion. The primary outcome was allogeneic transfusion of packed red blood cells. Planned secondary analyses included change in hemoglobin following delivery, composite maternal safety outcomes, and unplanned postpartum health care utilization. Thirty-six deliveries exposed to autotransfusion were matched to 144 unexposed controls. There was no significant difference in allogenic transfusion of packed red blood cells in the patients exposed to autotransfusion red with unexposed controls (adjusted OR 1.1; 95% CI 0.5-2.4). Deliveries that received autotransfusion had a less severe pre- to post-delivery decline in hemoglobin compared with unexposed controls across all values of QBL (p = .003). There were no significant differences in maternal morbidity outcomes evaluated in exposed versus unexposed deliveries. Autotransfusion in cases of vaginal obstetric hemorrhage did not attenuate rates of allogenic packed red blood cell transfusion but did result in a less severe pre- to postdelivery decline in hemoglobin at discharge. Autotransfusion cases did not have any markers of increased maternal morbidity when compared with a control group. These findings support emerging evidence indicating that autotransfusion of blood lost during vaginal obstetric hemorrhage is a safe and potentially effective tool for use in the management of obstetric hemorrhage.

Factors associated with perioperative blood transfusion in women who had postpartum haemorrhage following caesarean delivery

Background: Caesarean delivery is associated with intraoperative blood loss and is a common risk factor for blood transfusion in obstetric practice. Delayed diagnosis and management of obstetric haemorrhage contributes greatly to maternal morbidity and mortality, but patient safety can be enhanced by identifying those at risk. Objective: To evaluate postpartum haemorrhage patients at greater risk for perioperative blood transfusion at caesarean delivery. Methods: A retrospective study was conducted over a two-year period from 1st June 2021 to 31st May 2023. The study population were all consecutive women who underwent caesarean delivery after 28 weeks of gestation, diagnosed as having postpartum haemorrhage (estimated blood loss ≥1000 ml). Women were considered as having the primary outcome if they had intraoperative blood transfusion and/or postoperative transfusion within 24 hours. Data were analyzed with SPSS for Windows version 23. Association between variables were determined using the Chi-square test or Fisher’s exact test as appropriate, and a p-value &lt;0.05 was considered significant. Results: Out of the study population, 55.6% had blood transfusion (43/76). These women received a total of 72 pints of whole blood, with 58.1% (25/43) receiving only one pint. There was a significant relationship between blood transfusion and the type of pregnancy, whether singleton or multiple gestation (P=0.032), placenta previa (P=0.002), and abruptio placenta (P=0.033). Conclusion: Among women who underwent caesarean delivery and had postpartum haemorrhage the prevalence of blood transfusion was high, and placenta previa and abruptio placenta were associated factors for perioperative blood transfusion.

A survey evaluating practice pattern in management of obstetric hemorrhage.

Hemorrhage anticipation and management has shifted significantly over the past decade due to evolution of data surrounding management of obstetric hemorrhage. Limited data exists which describe the practical use and clinical application of hemorrhage management. Our goal was to identify obstetric hemorrhage management patterns in a cohort of practicing Maternal Fetal Medicine physicians. We administered a survey to Maternal Fetal Medicine (MFM) fellows and faculty that addressed the management of hemorrhage including risk assessment, uterotonic use, antifibrinolytic use, cell saver use, and abnormal placentation management. An email was sent out regarding the survey to a listserv of all Maternal Fetal Medicine fellow program coordinators to disseminate to their faculty and fellows. Eighty responses were obtained. A total of 78 surveys were analyzed. Participants preferred methylergonovine as a first line agent (n = 57; 73%, n = 62; 80%). Most participants would consider using cell salvage when also activating MTP (28, 48%) or during scheduled deliveries who are high risk of hemorrhage (40, 69%). Approximately a third of providers would use TXA (tranexamic acid) prophylactically (n = 21; 28%). Only 26% of MFM fellows felt comfortable performing cesarean hysterectomy without Gynecologic Oncology. In comparison to prior reports, TXA use has increased substantially. Further, when looking at the management of abnormal placentation, the use of magnetic resonance imaging and embolization have both increased. Possibly due to the rise in centers of excellence for treatment of accreta spectrum disorders, Maternal Fetal Medicine fellows still feel largely unprepared to perform a cesarean hysterectomy without Gynecologic Oncology.

Quantification of blood loss in obstetric haemorrhage: implications on intervention and transfusion

Key content Postpartum haemorrhage accounts for 27% of all maternal deaths. Incorrect quantification of blood loss can lead to unnecessary interventions, such as the transfusion of blood products, which is not without risk. During pregnancy, cardiovascular changes may explain how blood loss can occur rapidly, with pregnant women tolerating large volumes of blood loss before a change in clinical signs is seen. Several methods are used to quantify blood loss, such as visual estimation, volumetric, gravimetric, colorimetric and photometric. The Obstetric Bleeding Strategy for Wales (OBS Cymru) project, which standardised management of obstetric haemorrhage in Wales using a four‐stage approach, showed a statistically significant improvement in outcomes. Different definitions of postpartum haemorrhage make it difficult to compare available evidence. Further studies are required combining the use of point‐of‐care tests and quantitative techniques to help improve morbidity and mortality associated with obstetric haemorrhage. Learning objectives To understand the physiological changes in pregnancy and how they affect postpartum haemorrhage. To know the different available methods of quantifying blood loss. To review the point‐of‐care tests used to guide transfusion and management of postpartum haemorrhage. Ethical issues Understanding the advantages and disadvantages of different methods of quantifying blood loss is essential to providing appropriate and safe care. Inaccuracy in measurement increases the risk of morbidity and mortality, in addition to complications of unnecessary treatments.

Improving Health Care Responses to Obstetric Hemorrhage.

Obstetric hemorrhage is one of the most commonly encountered obstetrical complications. Decreases in maternal mortality and severe maternal morbidity have continued to be achieved despite the increasing incidence of obstetric hemorrhage over time through the diligent efforts of quality improvement initiatives. Approaches currently advocated to optimize the management of obstetrical hemorrhage are presented and discussed in this chapter focusing on readiness, recognition and prevention, clinical response, patient support, and tracking and monitoring outcome and performance measures over time. Readers are encouraged to access publicly available programs from state-based perinatal quality collaboratives and national programs designed to support and structure such efforts.

Utilization of non-pneumatic anti-shock garment for the management of obstetric hemorrhage among healthcare providers in north Shewa zone, Ethiopia.

Global maternal deaths have either increased or stagnated tragically. Obstetric hemorrhage (OH) remains the major cause of maternal deaths. Non-Pneumatic Anti-Shock Garment (NASG) has several positive results in the management of obstetric hemorrhage in resource-limited settings where getting definitive treatments are difficult and limited. Therefore, this study aimed to assess the proportion and factors associated with the utilization of NASG for the management of obstetric hemorrhage among healthcare providers in the North Shewa zone, Ethiopia. A cross-sectional study was conducted at health facilities of the north Shewa zone, Ethiopia from June 10th-30th/2021. A simple random sampling (SRS) technique was employed among 360 healthcare providers. Data were collected using a pretested self-administered questionnaire. EpiData version 4.6 and SPSS 25 were used for data entry and analysis, respectively. Binary logistic regression analyses were undertaken to identify associated factors with the outcome variable. The level of significance was decided at a value of p of <0.05. The utilization of NASG for the management of obstetric hemorrhage among healthcare providers was 39% (95%CI: 34-45). Healthcare providers who received training on NASG (AOR = 3.3; 95%CI: 1.46-7.48), availability of NASG in the health facility (AOR = 9.17; 95%CI: 5.10-16.46), diploma (AOR = 2.63; 95%CI: 1.39-3.68), bachelor degree (AOR = 7.89; 95%CI: 3.1-16.29) and those healthcare providers who have a positive attitude toward utilization of NASG (AOR = 1.63; 95%CI: 1.14-2.82) were variables positively associated with the utilization of NASG. In this study, almost two-fifths of healthcare providers used NASG for the management of obstetrics hemorrhage. Arranging educational opportunities and continuous professional development training for healthcare providers, providing in-service and refresher training, and making it available at health facilities may help healthcare providers to effectively use the device, thereby reducing maternal morbidity and mortality.

Contemporary medical management of obstetrical hemorrhage during cesarean delivery

Contemporary medical management of obstetrical hemorrhage during cesarean delivery

Major obstetric hemorrhage management

Postpartum hemorrhage (PPH) is to this day one of the leading causes of maternal death and its diagnosis is still highly subjective, as it relies on unprecise estimates of the amount of blood loss. There are three areas in which PPH outcomes can be improved: prevention, treatment and rescue. PPH can escalate to a graver clinical picture of Severe Acute Maternal Morbidity (SAMM) due to an inaccurate estimate of the blood loss, inability to identify an at-risk patient, delays in testing and availability of hemoderivatives, and lack of clear guidelines and interdisciplinary communication. Many factors can predispose to PPH and in clinical practice the many causes of its insurgence are summarized with the 4T formula: Tone (uterine atony), Trauma (laceration/hematoma), Tissue (retained tissue/invasive placenta), Thrombin (coagulation). Some precautions can be taken in preventing PPH such as the use of uterotonics, the administration of oxytocin, the timing of umbilical cord clamping, and the monitoring of anemia and the platelet to fibrinogen concentration ratio. In recent years studies have been published with the goal of leading PPH diagnosis and management through universal guidelines, point-of-care testing and interdisciplinary approaches. The proposed algorithms, albeit not yet validated, are useful in the clinical practice; similarly beneficial is the use of reliable predictive panels such as the Modified Early Obstetric Warning System.

Maternal Race and Clinical Vigilance in Obstetric Hemorrhage Management [A147

INTRODUCTION: Non-White maternal race has been associated with an increased risk for severe morbidity from obstetric hemorrhage (OBH). In the present study, we investigate the hypothesis that such disparities could be secondary to delay in the administration of standard third stage oxytocin or decreased use of additional hemorrhage interventions for pregnant patients of color compared to White patients. METHODS: We performed a retrospective cohort of all deliveries from 2018 to 2019 at our institution. The two groups compared were 1) Hispanic White or non-White race (HW/NWR) pregnant people and 2) non-Hispanic White (NHW) pregnant people. The primary outcome was time from delivery to first dose of postpartum oxytocin; secondary outcome was the frequency of additional hemorrhage interventions. Groups were compared using t test and chi-square or Fisher’s exact tests. RESULTS: Of 3,832 patients who delivered a live infant between January 1, 2018, and December 31, 2019, with self-identified race and ethnicity recorded in their patient record, 644 patients identified as NHW and 3,188 patients identified as HW/NWR. There was no difference in time to first dose of postpartum oxytocin (P=.51). There was also no difference in frequency of administration of any individual uterotonics, tranexamic acid, transfusion, uterine artery embolization, or hemorrhage-related surgical techniques. CONCLUSION: There was no delay in the administration of postpartum oxytocin when comparing non-White and Hispanic White patients to non-Hispanic White patients. Additional research is needed to continue to explore systemic causes of and solutions for racial disparities in obstetric hemorrhage.

Point-of-Care Viscoelastic Tests in the Management of Obstetric Hemorrhage.

Obstetric hemorrhage remains the leading cause of maternal morbidity and mortality worldwide. Thromboelastography and rotational thromboelastometry are laboratory methods of assessing the kinetics of blood clot formation through real-time measurement of viscoelastic clot strength and may aid in management of severe hemorrhage. Although first described more than 70 years ago, viscoelastic testing devices are now available that allow for rapid point-of-care use of this technology to aid in real-time management of blood product replacement in cases of severe hemorrhage. These devices can be used to visually estimate multiple facets of hemostasis-coagulation, platelet function, and fibrinolysis-within 10-20 minutes. They have been used successfully in cardiac surgery, trauma, and liver transplantation and have potential for use in management of obstetric hemorrhage. Goals with their use include targeted transfusion of blood and its components for specific coagulation deficiencies. To date, however, published experiences with the use of these viscoelastic tests for obstetric hemorrhage have been limited. Because of the increasing use of the point-of-care tests by anesthesiologists, surgeons, and intensivists, the purpose of this report is to familiarize obstetricians with the technology involved and its use in severe hemorrhage complicating pregnancy.

Serum Lactate Level as a Predictor for Blood Transfusion in Postpartum Hemorrhage.

Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. At present, there are no reliable clinical or laboratory indicators to identify which patients might require blood transfusions during a PPH. Serum lactate has long been used as an early biomarker of tissue hypoperfusion in trauma settings. The aim of this study is to understand serum lactate's role in the management of obstetric hemorrhage. A retrospective chart review was performed of women who delivered between 2016 and 2019 at our institution and experienced a PPH. The patients were divided into two groups: those with a normal serum lactate level, defined as ≤2 mmol/L, and those with an abnormal serum lactate level, defined as >2 mmol/L. Need for packed red blood cell transfusion, as part of the resuscitation, was assessed for both groups. During the study period, 938 women experienced PPH. Of these, 108 (11.5%) had a normal serum lactate, ≤2 mmol/L, and 830 (88.5%) had an abnormal lactate, >2 mmol/L. Women with elevated lactate levels were more likely to receive a blood transfusion versus those with a normal lactate level (57.0 vs. 46.3%, p = 0.035, respectively). Additionally, the average number of blood transfusions administered was significantly higher in the abnormal lactate group versus in the normal lactate group (1.34 vs. 0.97, respectively, p = 0.004). In a multivariable linear regression model, increasing serum lactate levels were found to be predictive of requiring more than 1 unit of blood (p < 0.001). Women with elevated serum lactate levels were more likely to require blood transfusions during a PPH versus those with a normal serum lactate level. Thus, serum lactate levels are useful as an early indicator of requirement for blood transfusion in the management of obstetric hemorrhage. · Lactate is a biomarker for blood transfusion in trauma.. · Lactate's role in PPH is unknown.. · Elevated lactate predicts receiving more blood transfusions..

Postpartum Hemorrhage Management and Role of Interventional Radiology Clinical Review

Postpartum hemorrhage is the main source of maternal morbidity and mortality around the world, and rate in the United States, in spite of the fact that lower than in some resource limited countries, stays high. Women of color are at risk of develop a life-threatening postpartum hemorrhage. Risk assessment tools are available but since they need specificity and sensitivity, all pregnant women are considered at risk. Early identification and intervention in a hemorrhage require an interdisciplinary team to care and can save the lives of thousands of women every year. Over the past two decades, the role of pelvic blood vessel embolization has developed from a novel treatment option to assuming a critical part in the management of obstetric hemorrhage. Interventional radiology offers a minimal invasive, fertility- preserving option in conventional surgical treatment.