Massive Obstetric Haemorrhage Research Articles

Эффективность и безопасность применения терлипрессина при кесаревом сечении у беременных с высоким риском кровотечения: многоцентровое всенаправленное когортное исследование Terli-Bleed. Часть III

The search for new means of prevention and treatment of massive obstetric haemorrhage is a priority task for the world scientific community, both obstetricians and anesthesiologists. Previously, we have shown the preventive efficiency of terlipressin, which helps to reduce the volume of blood loss during caesarean section (CS), and its lack of systemic hemodynamic effects when used topically. Objective. To evaluate changes in clinical and laboratory parameters when using terlipressin topically as a means of preventing postpartum haemorrhage during CS in high-risk pregnant women. Patients and methods. This publication is a continuation of our multicenter comprehensive cohort study of Terli-Bleed. The study included 454 pregnant women at high risk for haemorrhage who delivered by CS. They were divided into two groups: a control group (n = 351) and a study group (n = 103), with topical administration of terlipressin injected into the myometrium. Complete blood count, acid-base balance, lactate and hemostasis parameters were analyzed. Results. The levels of hemoglobin, platelets, fibrinogen, lactate, and blood pH were different in the groups during the postoperative follow-up period (p < 0.05). Conclusion. The analysis of clinical and laboratory parameters indicates the preventive ability of terlipressin to reduce the volume of intra- and postoperative haemorrhage without affecting the hemostasis system. Key words: terlipressin, caesarean section, postpartum haemorrhage, clinical and laboratory parameters

Total Placenta Previa with High-risk MAP and Transverse Lie Fetal Position

Placenta accreta is one of the emergency conditions and has resulted in increased mortality and morbidity of pregnant women due to the massive obstetric hemorrhage. Placenta accreta can lead to secondary complications including coagulopathy, multisystem organ failure, acute respiratory distress syndrome, need for repeat surgery, and death. Assessment by anesthesia should be carried out as early as possible before surgery to reduce or even eliminate morbidity and mortality. In this report, we present the case of a patient with total placenta previa and high-risk MAP score with a transverse lie fetal position. The various anesthetic treatments and transfusion strategies are discussed with a multidisciplinary approach to delivery.

Emergency bilateral internal iliac artery ligation in massive obstetric haemorrhage: 5 years experience At Tertiary Care Hospital.

Objectives: To study the efficacy and safety of emergency bilateral internal iliac artery ligation (BIAL) in arresting massive obstetric haemorrahge. Study Design: Retrospective study. Setting: Department of Obstetrics and Gynaecology Unit-I, Allied Hospital, Faisalabad. Period: January 2014 to December 2018. Material & Methods: Fifty eight (58) patients with obstetric haemorrhage were included in this retrospective study. Bilateral internal iliac artery ligation was performed to control massive postpartum haemorrhage, post-operative internal haemorrhage. Results: The fifty eight (58) women underwent BIAl. Booked cases were onlhy (27%) and (73%) were unbooked. Out of 58 women 16(27%) women were with morbid adherent placenta, 14(24%) with uterine atony, 11(19%) uterine rupture, 9(17%) post-operative internal haemorrhage and 8(13%) coagulopathy were underwent BIAL. Out of 58 women 15(36%) ended in hysterectomy because of failure to control bleeding and uterus preserved in (64%). Overall efficacy in term of saving maternal life was 90%. One women had ureteric injury that was managed by Urologist. One another patient required re-laparotomy for persistant internal haemorrahge. Conclusion: Bilateral internal iliac artery ligation is safe and effective technique to control massive obstetric haemorrhage. Timely decision is also important to prevent hysterectomy. BIAL should include in algorithm to control intractable obstetric haemorrhage and consultant obstetricians and gynaecologist should learn that technique.

Compression of the lower uterine segment (COLUS) is an effective method of bleeding cessation during caesarean section on the background of placenta previa

Objective: to study the hemostatic efficacy of compression of the lower uterine segment (COLUS) as a new method to stopping bleeding during cesarean section on the background of placenta previa.Materials and methods. The main group included 30 women with placenta previa, who were routinely delivered by cesarean section and using the COLUS technique after separation and isolation of placenta during a gestation period of 36 weeks – 36 weeks + 6 days. The control group consisted of 31 pregnant women with placenta previa, who had a planned delivery by сesarean section using the classical technique of suturing the uterus at a gestational age of 38–39 weeks. After separation and isolation of the placenta placental bleeding was stopped by flashing and coagulation of bleeding vessels in lower uterine segment.Results. In the control group after standard caesarean section technique a high percentage of blood loss from 1000 ml or more was observed, that is typical for operations performed with placenta previa. In the main group a significantly smaller number of cases of blood loss from 1000 ml or more were observed. The average volume of blood loss in the control group was 1277 ± 119 ml, and 697 ± 139 ml in the main group, that is indicates the high efficiency of the COLUS technique. This technique allows to reduce blood loss by 45% of the blood loss of the control group. There was no significant difference in the condition of the newborns in both groups.Conclusions. The data obtained indicate the advisability of delivery of pregnant women with placenta previa in the gestation period of 36 weeks – 36 weeks + 6 days. Performing a cesarean section in the absence of a developed lower uterine segment in combination with the COLUS technique is an effective and safe surgical method for prevention of blood loss in a complex of therapeutic measures to prevent massive obstetric bleeding. It is an addition to surgical means to stop bleeding from the lower uterine segment after separation and removal of the underlying placenta

Massive obstetric bleeding: optimization of total hysterectomy surgery technique and conservative treatment

Objective. Reducing maternal mortality during massive obstetric bleeding (MOB) through optimizing total hysterectomy technique and improving the quality of infusion therapy.
 Materials and methods. The analysis and evaluation of the results of MOB treatment in a comparative aspect were carried out in retrospective and prospective groups from 2014 to 2019 in Urgench perinatal center and three maternity complexes of Khorezm region, Uzbekistan. The retrospective group included 72 pregnant women with an average blood loss of 2450.0±80.0 ml, while the prospective group included 78 pregnant women with an average blood loss of 2530.0±70.0 ml.
 Results and discussion. 1,419 (6.2 %) cases out of 22,896 deliveries in the retrospective group were accompanied by abnormal blood loss, and the MOB frequency of more than 1500.0 ml was determined in 0.3 % of all deliveries. 5 (62.5 %) of 8 cases of maternal mortality were directly related to MOB. In the retrospective group, a total hysterectomy was performed using traditional method for MOB, with an interoperable blood loss of 860.0±110.0 (p<0.05). Qualitative and quantitative composition of infusion therapy in this group averaged: saline sodium chloride solution 4350,0±350.0; Heloplasm (INN) -500,0±100,0; hydroxyethylated starch 1800.0±150.0; Rheosorbilact 400.0±50.0 and fresh frozen plasma (FFP) 1650.0±110.0. Optimized version of total hysterectomy in a prospective group differs from the traditional with one “hemostatic suture” imposed on all three formations (fallopian tube, own and round ligament). Imposed first in the distal, then proximal, and on descending and ascending departments a. uterinae during the operation. The optimized version of total hysterectomy resulted in reduction of interoperative blood loss by an average of 340.0±60.0 ml in MOB and reduction of operation time by 22.0±4.0 min, thereby improving the outcome of the operation. Amount of saline sodium chloride solution was injected in average by 1900.0; Refortan by 600.0; FFP by 230.0 less, and INN, Gelofuzin by 500.0 and Rheosorbilact by 400.0 more in the prospective group than in the retrospective group.
 Conclusions. Optimized version of total hysterectomy with improved qualitative and quantitative composition of infusion therapy for MOB contributed to reduction of maternal mortality by 19.7 % in the prospective group compared to the retrospective group.

Results of prevention of massive postural bleeding in women with preeclampsy

Objective. To evaluate the effectiveness of a tranexamic acid for the prevention of critical bleeding in women with preeclampsia.
 Materials and methods. 31 puerperas with postpartum hypotonic bleeding. Inclusion criteria: reproductive age, severe preeclampsia, postpartum hemorrhage, volume of blood loss – 700 ml, voluntary consent to the administration of the tranexamic acid. Exclusion criteria: delivery by the caesarean section. When providing emergency care, along with other standard measures, 14 women (the main group) were injected with the tranexamic acid when blood loss reached 700 ml, 17 women (the comparison group) did not receive the tranexamic acid. Research methods: measurement of the volume of blood loss (by the calculation method and by the method of measuring blood loss), statistical analysis – comparison of populations by qualitative characteristics.
 Results and discussion. A bleeding with a blood loss of 700-800 ml was registered in 7 women of the main group and in 6 women of the comparison group, with a blood loss of 800-900 ml – in 6 and 4 women, with the blood loss 900-1000 ml – in 1 and 7 women, respectively. There was a significant difference in outcomes (blood loss – 900-1000 ml) depending on the use of the tranexamic acid (Fisher’s exact test – 0.04537; p<0.05). Evaluation of the strength of the relationship between the frequency of aggravation of bleeding and the use of the tranexamic acid for the prevention of massive bleeding established a relationship of average strength (Cramer’s criterion – 0.387). Pregnant women with severe preeclampsia are at risk of the developing obstetric bleeding, which is associated with secondary changes in the hemostatic system in women with preeclampsia. With obstetric bleeding in women with preeclampsia, the balance between the coagulation, anti-coagulation and fibrinolytic systems is disturbed faster. Fibrinolysis is activated faster due to the limitation of thrombus formation due to the breakdown of fibrin in thrombi and the fibrinolytic properties of the fibrin breakdown products themselves. The use of the tranexamic acid in the obstetric bleeding is justified by the antifibrinolysis effect of the drug. Further research on the use of the tranexamic acid for the prevention of massive bleeding, confirmed by laboratory data, is highly relevant.
 Conclusions. The use of tranexamic acid with the onset of obstetric bleeding in women with risk factors for the secondary thrombocytopathy will prevent the aggravation of coagulopathy and reduce the incidence of massive obstetric bleeding caused by a disseminated intravascular coagulation.

Anatomy of Internal Iliac Artery and Its Ligation to Control Pelvic Hemorrhage.

Pelvic hemorrhage is a major cause of maternal morbidity and mortality in developing countries. A sound clinical judgment, adequate assessment, and preparation of the patient are the best preoperative means to avoid its occurrence. Bilateral internal iliac artery ligation is a life-saving procedure to control massive obstetric and gynecological hemorrhage when other measures fail. This procedure significantly reduces the pulse pressure and rate of blood flow abolishing the‘triphammer effect’ of arterial pulsation and subsequently resulting in sluggish blood flow allowing effective thrombosis within the small bleeding vessels. This has helped to save many lives and uteruses for more than a century. No tissue necrosis occurs due to ample collateral circulation in the pelvis from the major pelvic anastomoses. An increased understanding of retroperitoneal anatomy and regional variations of the internal iliac artery is needed to reduce the risk of intraoperative and postoperative complications. Keywords: internal iliac artery ligation;operative complications;pelvic anastomoses;pelvic hemorrhage;retroperitoneal anatomy.

Experience of performing organ-preserving surgeries in patients with true ingrowth of placenta in perinatal center of Samara Regional Clinical Hospital named after V.D. Seredavin

In modern obstetrics, an abnormal placental invasion is a serious problem associated with the following high perinatal losses: massive obstetric bleeding that leads to the death of both the mother and the fetus.
 Objective. The purpose of the study was to analyze the methods of delivery in patients with placenta accreta.
 Materials and methods. The study group consisted of 31 patients aged 25 to 42 years with placenta ingrowth, who underwent metroplasty in the Perinatal Center of V. D. Seredavin Samara Regional Clinical Hospital in the period from May 2018 to December 2019. Most often, placental ingrowth was detected in the second trimester of pregnancy (41.94 %). In 5 cases, placental ingrowth was diagnosed in the operating room (16.3 %). On average, the time of detection of ingrowth is 24.96 weeks of gestation.
 Results. Out of 31 patients we observed, 27 underwent metroplasty using complex compression hemostasis, and 1 patient underwent temporary balloon occlusion of the internal iliac arteries. The total volume of blood loss was 1625 485 ml, and the median was 1455 ml. Only 5 (17.24 %) patients had a blood loss of more than 2000 ml, and there was no blood loss of more than 3000 ml.
 Conclusions. Introduction of organ-preserving operations allows maintaining a woman's reproductive health, avoiding massive blood loss, and improving perinatal outcomes. Patients with a scar on the uterus after cesarean section, with placentation on the anterior wall and in the area of the scar on the uterus should be immediately sent to the third level of rendering specialized medical care.

Efficacy of resuscitative infusion with hemoglobin vesicles in rabbits with massive obstetric hemorrhage

Hemoglobin vesicles have been developed as artificial oxygen carriers, and they have the potential to serve as a substitute for red blood cell transfusion. This study aimed to evaluate the efficacy of hemoglobin vesicle infusion for the initial treatment instead of red blood cell transfusion in rabbits with massive obstetric hemorrhage. Pregnant New Zealand white rabbits (28th day of pregnancy; normal gestation period, 29-35 days) underwent uncontrolled hemorrhage to induce shock by transecting the right midartery and concomitant vein in the myometrium. Subsequently, rabbits received isovolemic fluid resuscitation through the femoral vein with an equivalent volume of hemorrhage every 5 minutes. Resuscitative infusion regimens included 5% human serum albumin (n=6), stored washed red blood cells with plasma (vol/vol=1:1; n=5), and hemoglobin vesicle with 5% human serum albumin (vol/vol=4:1; n=5). A total of 60 minutes after the start of bleeding, rabbits underwent surgical hemostasis by ligation of the bleeding vessels and then were monitored for survival within 24 hours. During fluid resuscitation, hemoglobin vesicle infusion and red blood cell transfusion maintained a mean arterial pressure of >50 mm Hg and a hemoglobin concentration of >9 g/dL and prevented the elevation of plasma lactate. In contrast, resuscitation with 5% human serum albumin alone could not prevent hemorrhagic shock as evidenced by a low mean arterial pressure (40 mm Hg), a low hemoglobin concentration (2 g/dL), and a marked elevation of plasma lactate. All animals in the red blood cell group and the hemoglobin vesicle group survived more than 8 hours, whereas all animals in the 5% human serum albumin group died within 8 hours. Hemoglobin vesicle infusion may be effective in the initial management of massive obstetric hemorrhage.

Severe thrombocytopenia in pregnancy: a retrospective study

: Thrombocytopenia is defined as a platelet count less than 150 000/μl and it is the most common hematologic disease after anemia in pregnancy. This study aims to investigate pregnant women with severe thrombocytopenia (platelet count <50 000/μl). In the relevant literature, few studies have addressed severe thrombocytopenia in pregnancy. This is a retrospective study based on the data from a reference center in Ankara, Turkey between January 2016 and December 2017. The study group consisted of 51 pregnant women who had two platelet counts lower than 50 000/μl. Descriptive statistical methods were utilized to analyze the results. The study analyzed the causes of severe thrombocytopenia, maternal and fetal-neonatal outcomes, and the management of the patients. The common causes of severe thrombocytopenia were hypertensive disorders (66.7%), immune thrombocytopenia (13.7%), massive obstetric hemorrhage (7.8%), and disseminated intravascular coagulation (5.9%). The preterm delivery occurred in 58.8% of the patients, and 46 live-births (two twins), six stillbirths, and one pregnancy termination emerged. Postpartum hemorrhage occurred in four (0.08%) patients, and blood transfusion was performed in 15 (29.4%) patients. The platelet transfusion was required to increase the platelet count of 30 (58.8%) patients. The study showed that the incidence of causes in severe thrombocytopenia in pregnancy varied considerably from mild and moderate thrombocytopenia. Despite severe thrombocytopenia, maternal and neonatal bleeding complications were infrequent in the study group.

The consistent use of recombinant and plasma coagulation factors in the intensive care of massive obstetric hemorrhage

Massive obstetric hemorrhage is one of the most threatening complications of pregnancy, delivery and early postpartum period, which are part of the triad of leading causes of maternal mortality both in the world and in the Russian Federation. In recent years, to stop coagulopathy, which is one of the clinical manifestations of massive obstetric hemorrhage, recombinant and plasma factors of the blood coagulation system are successfully used, which include a concentrate of prothrombin complex and activated coagulation factor VII (eptacog alfa activated). The authors present results of successful consistent use of the blood coagulation system factors within comprehensive intensive care of coagulopathy in a patient with massive obstetric hemorrhage.

Application of the rotational thromboelastography/thromboelastometry for assessment of massive obstetric blood loss in a high risk group

Here, we discuss blood management upon a risk of massive obstetric hemorrhage by describing a clinical case of female patient with obstetric complications of pregnancy such as severe preeclampsia and chronic placental insufficiency with fetal malnutrition examined by using thromboelastometry to assess a risk of developing massive obstetric hemorrhage. A rotational thromboelas-tography/thromboelastometry technology as well as available publications related to using it in obstetrics are outlined.

Disseminated intravascular coagulation in perinatal medicine

Introduction. Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by intravascular activation of blood clotting without specific localization and arising from various causes. DIC is the most complex and high-priority problem in contemporary clinical medicine including obstetrics and perinatology. DIC significance is related to its peak perinatal mortality, as well as a large rate of complications during childbirth and postpartum period. Aim: to conduct comprehensive data assessment related to DIC pathogenesis and management in pregnant women and newborns. Materials and methods . A search for DIC-related publications within the past 10 years was conducted in international research databases: Scientific Electronic Library Online eLibrary, Google Scholar, ScienceDirect, Cochrane Library, PubMed/Medline. The data regarding DIC diagnostic criteria and markers, as well as current approach to its treatment are presented. Results. DIC may be considered as one of the causes resulting in massive obstetric bleeding. The majority of pregnancy-related complications is manifested as preeclampsia, premature detachment of normally situated placenta and anaphylactoid syndrome of pregnancy. Any massive bleeding should be perceived as hemorrhage resulting from the DIC progression. Conclusion. Knowledge of the DIC pathogenetic mechanisms is necessary for conducting a differential diagnosis and applying timely treatment.

Features of the treatment of massive obstetric bleeding in a retrospective group

Features of the treatment of massive obstetric bleeding in a retrospective group

ОСОБЕННОСТИ ДИАГНОСТИКИ И ЛЕЧЕНИЯ АКУШЕРСКИХ КРОВОТЕЧЕНИЙ, СОПРОВОЖДАЮЩИХСЯ КОАГУЛОПАТИЕЙ

The literature of recent years on modern methods of diagnosing and treating coagulation disorders in obstetric bleeding (OB) were studied and analyzed. The literature is presented on the frequency and structure of OB in the world and countries with different levels of development. It has been shown that massive OB is often accompanied by impaired blood clotting and lead to maternal mortality. In the structure of causes of maternal mortality in the world, OB is in the leading position. A theoretical and critical analysis of the literature on modern methods of diagnosing and treating coagulation disorders in OB has shown that it is necessary to continue further research on optimization of diagnostics and individual approaches in infusion-transfusion therapy of women with massive OB. Optimization of the methods of diagnosis and treatment of OB will improve obstetric outcomes in this complication. Keywords: Obstetric bleeding, maternal mortality, coagulopathy, diagnostics, treatment

Haematological features, transfusion management and outcomes of massive obstetric haemorrhage: findings from the Australian and New Zealand Massive Transfusion Registry

Massive obstetric haemorrhage (MOH) is a leading cause of maternal morbidity and mortality world-wide. Using the Australian and New Zealand Massive Transfusion Registry, we performed a bi-national cohort study of MOH defined as bleeding at ≥20weeks' gestation or postpartum requiring ≥5 red blood cells (RBC) units within 4h. Between 2008 and 2015, we identified 249 cases of MOH cases from 19 sites. Predominant causes of MOH were uterine atony (22%), placenta praevia (20%) and obstetric trauma (19%). Intensive care unit admission and/or hysterectomy occurred in 44% and 29% of cases, respectively. There were three deaths. Hypofibrinogenaemia (<2g/l) occurred in 52% of cases in the first 24h after massive transfusion commenced; of these cases, 74% received cryoprecipitate. Median values of other haemostatic tests were within accepted limits. Plasma, platelets or cryoprecipitate were transfused in 88%, 66% and 57% of cases, respectively. By multivariate regression, transfusion of ≥6 RBC units before the first cryoprecipitate (odds ratio [OR] 3·5, 95% CI: 1·7-7·2), placenta praevia (OR 7·2, 95% CI: 2·0-26·4) and emergency caesarean section (OR 4·9, 95% CI: 2·0-11·7) were independently associated with increased risk of hysterectomy. These findings confirm MOH as a major cause of maternal morbidity and mortality and indicate areas for practice improvement.

Protocolo de transfusión masiva en obstetricia

La hemorragia obstétrica es la causa más común de mortalidad materna en el mundo. Durante las últimas décadas, nuestro conocimiento de la fisiopatología y manejo del shock hemorrágico se ha incrementado de manera significativa. Una de las estrategias que más impacto ha tenido en la supervivencia de estas pacientes es la transfusión de productos sanguíneos. Debido a ello, es crucial contar con un protocolo de transfusión masiva en caso de hemorragia obstétrica masiva.

Massive obstetric hemorrhage during cesarean section in a patient after conception by frozen-thawed embryo transfer: a case report

BackgroundPlacenta accreta is a major cause of massive obstetric hemorrhage during cesarean section. In recent years, pregnancy by in vitro fertilization-embryo transfer has been reported as a risk factor for placenta accreta.Case presentationA 36-year-old G1P0 woman with systemic lupus erythematosus became pregnant by frozen-thawed embryo transfer. Emergency cesarean section was performed under general anesthesia due to the diagnosis of non-reassuring fetal status. The placenta invaded the myometrium and completely covered the entire anterior uterine wall. Following birth, 3000 mL of blood loss required rapid fluid infusion and blood transfusion. Total hysterectomy was performed because the placenta could not be separated from the uterine wall. Histological examination revealed placenta accreta/increta.ConclusionsWhen performing cesarean section on patients who have undergone frozen-thawed embryo transfer, preoperative examinations to assess for placenta accreta should be performed, and the anesthetic management should include sufficient planning for massive obstetric hemorrhage.

Clinical features of dilutional coagulopathy in massive obstetrical hemorrhage: A multicenter retrospective case series study

Clinical features of dilutional coagulopathy in massive obstetrical hemorrhage: A multicenter retrospective case series study

COMPARATIVE ANALYSIS OF INTRAOPERATIVE BLOOD LOSS DURING THЕ CLASSICAL CESAREAN SECTION DE SCRIBED BY M. STARK AND THE MODIFIED CESAREAN SECTION

Introduction: According to the WHO, obstetric bleeding keeps a leading position among the top three causes of maternal mortality. The incidence of abnormal blood loss (BL) varies widely from 1.5% to 22%, and the incidence of acute blood loss reaches up to 1,7%, with the variation from 0% to 4%. Every year, this complication causes death in 128 women that amounts to 1.7% per 1,000 deliveries The aim of this study is a comparative analysis of intraoperative blood loss during the classical cesarean section described by M. Stark and modified cesarean section was performed. Materials and metods: The study has been conducted on the basis of the Obstetrics department of the Kherson regional clinical hospital. Patients were selected according to the type of surgery (the classical technique described by M. Stark or the modified method) for the period from 2015 to 2018. The formation of the clinical groups was performed in accordance with the retrospective data retrieved from the labor and delivery records of 205 patients, who delivered via cesarean section. The comparative estimation of intraoperative blood loss volumes was carried out using a direct (gravimetric) method. Results: The proposed modification of abdominal delivery is based on the rational teamwork of a surgeon and an assistant, with the modernization of the surgical stages allowed halving the surgery duration as compared to the classical cesarean section technique introduced by M. Stark. Аnd the improved surgical technique of abdominal delivery contributes to the reduction in the volume of intraoperative blood loss by 200 ml (p < 0,001). Conclusions: Modified cesarean section allows avoiding massive obstetric hemorrhage, thereby creating an additional reserve for improving the safety of the operative delivery in general.