Antepartum and Postpartum Hemorrhage

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality. Little is known about transfusion practices in patients requiring blood tansfusions following cesarean delivery. The objective of this study is to describe the use of blood products, clotting factors, colloids, and antifibrinolytics in a contemporary cohort of patients with hemorrhage during cesarean and compare blood product use with a historic cohort of patients with a similar diagnosis. Secondary analysis of a multicenter trial of tranexamic acid versus placebo to prevent PPH during cesarean delivery. Patients with qualitative estimated intraoperative blood loss (EBL) of more than 1 L were included in this analysis. Variables analyzed included transfusion of blood products, ratio of transfused packed red blood cell (PRBC) to fresh frozen plasma (FFP) and platelets, and use of clotting factors, anti-fibrinolytics, and colloids. Transfusion strategies were also compared with a historic cohort from the APEX study. Of the 707 (7.7%) who had EBL of greater than 1 liter, packed red cells were transfused in 21.1%, FFP in 5.4%, platelets in 2.4%, and cryoprecipitate in 2.3%. Among patients who received both PRBC and FFP, three quarters had a PRBC:FFP ratio between 1:1 and 2:1. Patients receiving both PRBC and platelets had a 1:1 ratio or less in 76.5% of cases. Clotting factor concentrates were not used in any case. Albumin was administered in 10.2% of cases. When compared with the historic cohort with an EBL > 1 L during cesarean, no differences in the use of blood products was noted. 1 in 5 patients with intraoperative EBL > 1 L received PRBC transfusion. The use of other blood products was rare. There was no difference in transfusion strategies overtime when compared with a similar historic cohort. Obstetrical hemorrhage in patients undergoing cesarean delivery rarely involves intensive transfusion therapy. · A total of 21% of patients with hemorrhage during cesarean received packed red cells.. · Use of other blood products was rare.. · Pathological activation of the clotting cascade is unlikely.. · No difference in transfusion strategies was noted overtime..

Variable Association of Physiologic Changes With Electrographic Seizure-Like Events in Infants Born Preterm

Obstetric hemorrhage is the leading cause of maternal mortality and morbidity worldwide. This study was carried out to investigate the effect of obstetric hemorrhage on the prothrombin time (PT), activated partial thromboplastin time (APTT), and platelet count (PLC). Women with obstetric hemorrhage were divided into two categories, women with antepartum hemorrhage (APH) and those with postpartum hemorrhage (PPH). Pregnant women without hemorrhage were included as controls. Eighty-six pregnant women aged 18–45 years (mean age 36.25 ± 10.50 years) were presented to the Obstetrics and Gynaecology Department of Maryam Abacha Women and Children Hospital in Sokoto Metropolis, Sokoto State, Nigeria with history of obstetric hemorrhage. Forty-three age-matched nonhemorrhaging parturient women were included as controls. The determination of PT and APTT was done by manual methods using commercially prepared Diagen reagent kits, whereas PLC was done by manual methods using a hemocytometer. The results of PT and APTT were significantly higher among women with APH (20.7 ± 4.226 seconds and 46.04 ± 8.689 seconds, respectively) and among women with PPH (23.17 ± 2.708 seconds and 53.78 ± 4.089 seconds, respectively) compared to normal pregnant women (15.85 ± 0.8930 seconds and 36.225 ± 5.010 seconds, respectively) (P = 0.0001). Similarly, the PLC was significantly higher among normal pregnant women compared to those with APH and PPH (291.425 ± 75.980 × 109 compared to 154.83 ± 47.019 × 109 and 136.43 ± 43.894 × 109, respectively) (P = 0.0001). The PT and APTT of women who presented with PPH were significantly higher compared to those who presented with APH (23.17 ± 2.708 seconds and 53.78 ± 4.089 seconds versus 20.7 ± 4.226 seconds and 46.04 ± 8.689 seconds, respectively) (P = 0.02 and P = 0.04, respectively). The PLC was significantly higher among women who presented with APH compared to those who presented with PPH (P = 0.01). The PT and APTT values were higher in the third trimester among women with APH (24.38 ± 2.33 seconds and 52.25 ± 6.71 seconds, respectively), PPH (24.75 ± 2.63 seconds and 58.25 ± 2.53 seconds, respectively), and control women (16.00 ± 0.82 seconds and 34.42 ± 5.59 seconds, respectively) compared to those in first and second trimester. The PLC was significantly lower in the third trimester among APH, PPH, and normal pregnant women (131 ± 23.02 × 109, 99 ± 21.46 × 109, and 192.86 ± 25.44 × 109, respectively). PT and APTT values correlated positively and significantly with trimester (r = 0.52 and 0.65, respectively; P = 0.01). The PLC of women with APH, PPH, and normal control women correlated negatively with trimester (r = −0.36, −0.54, and −0.28, respectively; P = 0.05). Obstetrics hemorrhage compounded the hemostatic status of pregnant women in Sokoto, Nigeria. There is need for the provision of rapid diagnosis of coagulopathy to guide the provision of best therapeutic management options.

Globally, postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. In the current treatment of severe PPH, first-line therapy includes transfusion of packed cells and fresh-frozen plasma in addition to uterotonic medical management and surgical interventions. In persistent PPH, tranexamic acid, fibrinogen, and coagulation factors are often administered. Secondary coagulopathy due to PPH or its treatment is often underestimated and therefore remains untreated, potentially causing progression to even more severe PPH. In most cases, medical and transfusion therapy is not based on the actual coagulation state because conventional laboratory test results are usually not available for 45 to 60 minutes. Thromboelastography and rotational thromboelastometry are point-of-care coagulation tests. A good correlation has been shown between thromboelastometric and conventional coagulation tests, and the use of these in massive bleeding in nonobstetric patients is widely practiced and it has been proven to be cost-effective. As with conventional laboratory tests, there is an influence of fluid dilution on coagulation test results, which is more pronounced with colloid fluids. Fibrinogen seems to play a major role in the course of PPH and can be an early predictor of the severity of PPH. The FIBTEM values (in thromboelastometry, reagent specific for the fibrin polymerization process) decline even more rapidly than fibrinogen levels and can be useful for early guidance of interventions. Data on thromboelastography and thromboelastometry in pregnant women are limited, particularly during the peripartum period and in women with PPH, so more research in this field is needed.

Background: Postpartum haemorrhage (PPH) remains a major cause of maternal morbidity and mortality, particularly in low-resource settings. Early identification of risk factors and timely intervention are essential to improving outcomes. This study investigates the aetiologies, risk factors, management patterns, and outcomes of PPH in a tertiary care centre. Methods: A prospective observational study was conducted on 80 cases of PPH among 14, 442 deliveries between August 2022 and July 2024. Detailed clinical assessment, quantification of blood loss, laboratory evaluation, and management according to institutional protocols were undertaken. The findings were compared with established national and international literature. Results: Primary PPH accounted for 92.5% of cases. Emergency or referred admissions constituted 80%, while 20% were registered patients. Most affected women were aged 25-30 years (50%). Uterine atony was the predominant cause (64.86%), followed by traumatic PPH (27.02%). Significant risk factors included previous caesarean section (25%), multigravidity (16.66%), placenta previa (12.5%), anaemia (14.5%), preeclampsia (8.3%), and placental abruption (8.3%). Medical management alone was effective in 32.5% of atonic PPH cases, primarily using oxytocin and misoprostol; uterine tamponade was used in selected cases. Surgical intervention was required in 67.5% of cases, including uterine artery ligation, internal iliac ligation, repair of genital tract injuries, manual removal of placenta, and one hysterectomy. Postoperative complications occurred in 18 patients. Maternal mortality was 2.5%, with deaths due to acute renal failure with DIC and dilated cardiomyopathy. Blood component therapy was required in most patients. Conclusion: PPH is a preventable emergency requiring rapid recognition, coordinated multidisciplinary care, and access to effective medical and surgical interventions. Strengthening antenatal care and emergency referral systems can significantly reduce PPH-related maternal morbidity and mortality.

Background/Aims: This study aims to evaluate potential safety events and vital sign changes during active mobilization physical therapy (PT) in critically ill patients undergoing continuous renal replacement therapy (CRRT). Methods: A retrospective review was performed on 29 patients who were treated with CRRT and who underwent 81 PT sessions in a medical intensive care unit at a single referral hospital; 15 patients underwent 33 sessions with passive range of motion (PROM) and 17 patients underwent 48 active mobilization PT sessions. Three patients received both types of PT including 8 PROM and 5 active mobilization PT sessions. The occurrences of safety events and vital sign changes during active mobilization PT sessions were evaluated. Results: The safety events did not develop during 33 sessions with PROM. However, there were 2 safety events (4.1%) during 48 active mobilization PT sessions including one session with mobilization in the bed and the other in a sitting position on the edge of the bed. These safety events exclusively developed during active mobilization PT sessions, in which concomitant extracorporeal membrane oxygenation (ECMO) support and CRRT were delivered. Regarding vital sign changes during PT sessions, there were no significant differences in systolic blood pressure (BP), diastolic BP, mean arterial pressure, heart rate, respiratory rate, or peripheral oxygen saturation before and after both PROM and active mobilization PT sessions. Conclusions: This study showed that active mobilization PT can be performed safely in patients who are being treated with CRRT without a significant hemodynamic change. However, the development of potential safety events in patients with ECMO needs to be monitored carefully.

Montefiore Medical Center’s Initiative to Reduce Maternal Hemorrhage

To determine temporal patterns of vital sign and Cardiac Arrest Risk Triage score changes over the 48-hour period preceding cardiac arrest in an ICU setting. Vital sign instability usually occurs prior to cardiac arrest. However, few studies have been conducted on the temporal patterns of individual vital signs preceding cardiac arrest. A retrospective case-control study. The study subjects were 140 ICU patients (1 June 2011-31 December 2012): 46 died of cardiac arrest (case group), 45 died of other illnesses (control I group) and 49 were discharged after recovering (control II group). Initial detectable changes in blood pressure appeared 18-20 hours and became dramatic at 5-10 hours before cardiac arrest. Noticeable changes in heart rates began at 4 hours and became more prominent at 2 hours pre-arrest. No apparent patterns in respiratory rate changes were observed. Body temperatures usually indicated a hypothermic state pre-arrest. Cardiac Arrest Risk Triage scores were 16-18 at 48 hours pre-arrest and then continuously increased to 20. Only mean values of systolic blood pressures were significantly different between the three study groups. Mean diastolic blood pressures, heart rates, respiratory rates and Cardiac Arrest Risk Triage scores differed between the case and control II groups and between the control I and II groups. The study demonstrates vital sign instability preceded cardiac arrest and that the temporal patterns of changes in individual vital signs and Cardiac Arrest Risk Triage scores differed between groups. The findings of this study may aid the development of management strategies for cardiac arrest.

The study was designed to evaluate the ability of a novel electronic automatic notification system (EANS) to detect significant changes in transfusion-associated vital signs (VSs) during transfusion and to determine whether the EANS improved acute transfusion reaction (ATR) detection rates and suspected ATR reporting rates. VSs were measured three times per unit or batch product transfused:-before, 15 minutes after commencement, and at the completion of the transfusion-and recorded on the EANS. Significant changes in VSs were defined as increased temperature (≥38°C or ≥1°C change in baseline temperature), 20 mm Hg or 20% increase or decrease in systolic blood pressure, or 20% increase in pulse rate. The 6-month periods preceding and after the introduction of the EANS were defined as "before" and "after." Data from these periods were used for comparison and evaluation. During the after period, 945 notifications were reported from the EANS and 521 suspected ATR were detected. The suspected ATR reporting rates for the before and after were 0.29% (73/25 213) and 2.06% (521/25 304, P < .001) and the ATR detection rates before and after were 0.13% (33/25 213) and 0.49% (116/25 304, P < .001), respectively. Among 116 ATR cases, 49.1% could be detected only by significant changes in VSs. The EANS was very effective in detecting ATRs that could have been overlooked by medical staff. Further data are needed to demonstrate the extent to which the introduction of an EANS may improve the safety of transfused patients.

In developed countries1, pregnancy-related transfusion accounts for about 6 percent of red blood cell (RBC) units transfused. This means that, for example, in the UK as a whole, approximately 70,000 units of RBC are transfused to obstetric patients each year2. The pattern of blood usage is very different in countries in which diagnostic and treatment options are more limited, with 37 percent of transfusions being given to women with obstetric emergencies1. Obstetric haemorrhage is a leading cause of maternal and perinatal mortality3. Placental abruption and placenta praevia/accreta can present as antepartum haemorrhage and are risk factors for post-partum haemorrhage (PPH). Uterine atony, inversion, retained products of conception and genital tract trauma all cause PPH and account for the majority of cases of major haemorrhage. Uterine rupture is an infrequent cause of haemorrhage and maternal death and can occur spontaneously or at the site of previous uterine surgery (caesarean section or retained placenta)3. During the triennium 2006–2008, the rate of deaths from hemorrhage in the UK was 0.39 per 100,000 maternities4. The incidence of severe bleeding in childbirth has been estimated in various surveys and is approximately one in 200 to 250 deliveries4. In developed countries treatment is generally effective with an approximate case fatality rate between 1 in 600 to 800 cases of obstetric bleeding5–7. Various blood conservation techniques can reduce exposure to allogeneic blood. These include pre-operative autologous blood donation (PABD), acute normovolaemic haemodilution (ANH) and intra-operative blood salvage (IBS). PABD may cause anaemia, does not eliminate transfusion risk, cannot be used in an emergency, is not acceptable to Jehovah’s Witnesses and should be reserved for exceptional circumstances8,9. ANH may induce anaemia and cardiac failure, cannot be used in an emergency and may have a limited role in combination with other techniques9. The use of IBS has increased substantially during the last two decades and the re-infusion of shed washed blood is commonplace in many types of surgical operations in which heavy blood loss is anticipated10,11. In this technique, blood shed at the time of surgery is collected and washed, and RBC are returned to the patient as an ongoing process (Figure 1)12,13. In skilled hands, blood salvage can be quickly set up and the final product returned to the patient within minutes of collection. In addition, this technique is also acceptable to some Jehovah’s Witnesses, provided the equipment is set up in continuity with the circulation (Figure 1)14, but consent needs to be obtained on an individual basis. Figure 1 Schematic representation of a blood salvage system with a double suction setup to reduce the possible contamination of the blood suctioned from the surgical field138. In this setup, one suction line is connected to the collection reservoir and used for ... However, the safety of IBS in obstetrics has been questioned and its introduction in this clinical arena has been delayed because of theoretical concerns stemming from the historical and ongoing dispute focused on the risk of maternal-foetal anti-Rh(D) alloimmunisation and the risk of contamination of the cell-saved blood with traces of amniotic fluid (AF)15,16. The objective of this article is to review the role of autologous blood conservation techniques in obstetrics focusing on the currently available evidence regarding IBS. An overview of current European regulatory requirements on IBS will also be provided.

Patients hospitalized outside of monitored environments may experience sudden clinical worsening requiring transfer to the Intensive Care Unit. Early detection based on the clinical nurse's identification of the risk of clinical deterioration represents an opportunity to prevent serious adverse events. Nurse worry is defined as the use of clinical reasoning combined with intuition that precedes the patient's clinical deterioration. The objective of this study was to evaluate nurse worry as a trigger for rapid response team activation in patients hospitalized in non-critical units and its association with the need in ICU admission. This retrospective cohort study utilized data retrieved from an anonymized institutional database used to monitor the actions of the rapid response team. Data collected from January 2021 to December 2022 were analyzed, encompassing patients over 18 years old admitted to non-critical units and evaluated by the rapid response team. Analyzed variables included demographic characteristics, MEWS score, and causes for activating the rapid response team, such as changes in vital signs and nurse worry. Main outcomes assessed were transfer to the ICU, medical procedures, and drug administration. Patients were divided into three groups for analysis: those triggered for RRT assessment exclusively by changes in vital signs, those triggered exclusively by nurse worry and those triggered by the nurse worry combined with changes in vital signs. A total of 4634 rapid response team consultations were included, with 1574 triggered by changes in vital signs, 1263 triggered by nurse worry and 1797 triggered by the nurse worry associated with changes in vital signs. The group with nurse concern showed a lower need for transfers to the ICU (40%) compared to the group with changes in vital signs (50%) p < 0.001 although there was no difference in relation to the need for medical procedures,17% in both groups. The NW emerges as a relevant factor in triggering RRT and may be associated with improved outcomes, such as reduced need for ICU transfers. However, the observational design of the study does not allow for establishing causal relationships.

A Retrospective Analysis on the Effectiveness of a Maternal Hemorrhage Plan

Obstetric haemorrhage is the leading cause of maternal death worldwide (27.1%) and more than 66% of its deaths were classified as postpartum haemorrhage (PPH). The most common cause of PPH...

Olanzapine in ED patients: differential effects on oxygenation in patients with alcohol intoxication

605: Subsequent pregnancy outcome after B-Lynch suture placement