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Postpartum haemorrhage in high-resource settings: Variations in clinical management and future research directions based on a comparative study of national guidelines
de Vries, P. L. M., Deneux-Tharaux, C., Baud, D., Chen, K. K., Donati, S., Goffinet, F., Knight, M., D'Souzah, R., Sueters, M., van den Akker, T.
BJOG : an international journal of obstetrics and gynaecology. 2023
Abstract
OBJECTIVE To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH. DESIGN Comparative study. SETTING High-resource countries. POPULATION Women with PPH. METHODS Systematic comparison of guidance on PPH from eight high-income countries. MAIN OUTCOME MEASURES Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour. CONCLUSIONS Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines. RESULTS Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.
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Quantification of blood loss for the diagnosis of postpartum hemorrhage: a systematic review and meta-analysis
Ruiz, M. T., Azevedo, N. F., Resende, C. V., Rodrigues, W. F., Meneguci, J., Contim, D., Wernet, M., Oliveira, C. J. F.
Revista brasileira de enfermagem. 2023;76(6):e20230070
Abstract
OBJECTIVE to compare the effectiveness of different diagnostic methods to estimate postpartum blood volume loss. METHODS a systematic review of effectiveness according to PRISMA and JBI Protocol. Searches in PubMed/MEDLINE, LILACS, Scopus, Embase, Web of Science and CINAHL, with descriptor "Postpartum Hemorrhage" associated with keyword "Quantification of Blood Loss". Tabulated extracted data, presented in metasynthesis and meta-analysis was applied to quantitative data. To assess risk of bias, JBI Appraisal Tools were applied. RESULTS fourteen studies were included, published between 2006 and 2021. Quantification of loss by any method was superior to visual estimation and is highly recommended, however the studies' high heterogeneity did not allow estimating this association. CONCLUSION the studies' high heterogeneity, with a probable margin of error given the uncontrolled factors, indicates the need for further studies, however quantification proved to be effective in relation to visual estimate. PROSPERO registration CRD 42021234486.
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The role of point of care thromboelastography (TEG) and thromboelastometry (ROTEM) in management of Primary postpartum haemorrhage: A meta-analysis and systematic review
Khanna P, Sinha C, Singh AK, Kumar A, Sarkar S
Saudi journal of anaesthesia. 2023;17(1):23-32
Abstract
BACKGROUND The utility of instantaneous evaluation of coagulation during primary postpartum haemorrhage (PPH) is paramount in the context of empirical blood product transfusion-related risk of dilutional and consumptive coagulopathy and circulatory overload. METHODS A profound screening of electronic databases till August 15, 2022 was carried out after being enlisted in PROSPERO (CRD42021275514). Randomized control studies, comparative cohort studies, and cross-sectional studies comparing point-of-care viscoelastic test guided blood product transfusion with empirical transfusion in patients with PPH were included. RESULTS We retrieved five studies, with a total of 1914 parturient with PPH. Patients receiving transfusion based upon point of care viscoelastic tests had lesser risk of having emergency hysterectomy (Odds ratio (OR) = 0.55, 95% CI 0.32-0.95, I(2) = 7%), transfusion-associated circulatory overload (TACO) (OR = 0.03, 95% CI 0.00-0.50), reduced transfusion of fresh frozen plasma (OR = 0.07, 95% CI 0.04-0.14, I(2) = 89%), platelets (OR = 0.51, 95% CI 0.28-0.91, I(2) = 89%), packed red blood cell transfusion (OR = 0.70, 95% CI 0.55-0.88, I(2) = 89%), and had better cost-effective treatment [Mean difference (MD) = -357.5, 95% CI - 567.75 to -147.25, I(2) = 93%] than patient received empirical transfusion. However, there was no significant difference in the requirement of ICU admissions (OR = 0.77, 95% CI = 0.46-1.29, I(2) = 82%). No mortality was detected across the studies. CONCLUSIONS Point of care viscoelastic assessment guided transfusion in PPH confederates with reduced morbidity. Nevertheless, more studies on the triggering values for transfusion, long-term survival, and cost-benefit in patients with PPH are warranted to establish its utility.
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Variation of outcome reporting in studies of interventions for heavy menstrual bleeding: a systematic review
Cooper NAM, Papadantonaki R, Yorke S, Khan KS
Facts, views & vision in ObGyn. 2022;14(3):205-218
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) detrimentally effects women. It is important to be able to compare treatments and synthesise data to understand which interventions are most beneficial, however, when there is variation in outcome reporting, this is difficult. OBJECTIVES To identify variation in reported outcomes in clinical studies of interventions for HMB. MATERIALS AND METHODS Searches were performed in medical databases and trial registries, using the terms 'heavy menstrual bleeding', menorrhagia*, hypermenorrhoea*, HMB, "heavy period "period", effective*, therapy*, treatment, intervention, manage* and associated MeSH terms. Two authors independently reviewed and selected citations according to pre-defined selection criteria, including both randomised and observational studies. The following data were extracted- study characteristics, methodology and quality, and all reported outcomes. Analysis considered the frequency of reporting. RESULTS There were 14 individual primary outcomes, however reporting was varied, resulting in 45 specific primary outcomes. There were 165 specific secondary outcomes. The most reported outcomes were menstrual blood loss and adverse events. CONCLUSIONS A core outcome set (COS) would reduce the evident variation in reporting of outcomes in studies of HMB, allowing more complete combination and comparison of study results and preventing reporting bias. WHAT IS NEW? This in-depth review of past research into heavy menstrual bleeding shows that there is the need for a core outcome set for heavy menstrual bleeding.
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Reproductive health and haemostatic issues in women and girls with congenital FVII deficiency: A systematic review
Kadir RA, Gomez K
Journal of thrombosis and haemostasis : JTH. 2022
Abstract
BACKGROUND Congenital factor VII (FVII) deficiency is an inherited bleeding disorder, with heterogenous bleeding symptoms. Women with FVII deficiency face haemostatic challenges during menstruation, ovulation, and childbirth. This systematic review evaluated prevalence and management of bleeding symptoms associated with gynaecological and obstetric issues in women with FVII deficiency. METHODS Databases (BIOSIS Previews, Current Contents Search, Embase and Medline) were searched for studies reporting FVII deficiency and gynaecological or obstetric issues in women. Articles were screened using Joanna Briggs institute checklists and relevant data extracted. RESULTS 114 women were identified from 62 publications. 46 women had severe deficiency (FVII:C <5% or <5 IU/dL). Heavy menstrual bleeding (HMB) was the most common bleeding symptom, (n=94; 82%); Hospitalisation and urgent medical/surgical interventions for acute HMB episodes were required in 16 women (14%). Seven women reported ovarian bleeding (6%); other bleeding symptoms varied. Patient management was inconsistent and included haemostatic and hormonal treatments. Only four women (7%) reporting vaginal bleeding during pregnancy. Postpartum haemorrhage (PPH) occurred following 12/45 deliveries (27%) (five [42%] requiring blood transfusion) and was not necessarily prevented by prophylaxis (eight women). CONCLUSION Women with congenital FVII deficiency have an increased risk of HMB, ovarian bleeding and PPH, impacting quality of life. Recognition of a bleeding disorder as the cause is often delayed. Management of bleeding complications is heterogeneous due to lack of treatment guidelines. Harmonising severity classification of FVII deficiency may help standardise treatment strategies and development of specific guidelines for these women. FUNDING Novo Nordisk. Registered at PROSPERO (CRD42021218888).
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Postpartum hemorrhage drills or simulations and adverse outcomes: a systematic review and Bayesian meta-analysis
Mendez-Figueroa H, Bell CS, Wagner SM, Pedroza C, Gupta M, Mulder I, Lee K, Blackwell SC, Bartal MF, Chauhan SP
The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2022;:1-12
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Editor's Choice
Abstract
OBJECTIVE To compare the rates of adverse outcomes with postpartum hemorrhage (PPH) before and after implementation of drills or simulation exercises. STUDY ELIGIBILITY CRITERIA We included all English studies that reported on rates of PPH and associated complications during the pre- and post-implementation of interventional exercises. STUDY APPRASIAL AND SYNTHESIS METHODS Two investigators independently reviewed the abstracts, and full articles for eligibility of all studies. Inconsistencies related to study evaluation or data extraction were resolved by a third author. The co-primary outcomes were the rate of PPH and of any transfusion; the secondary outcomes included admission to the intensive care unit (ICU), transfusion ≥ 4 units of packed red blood cells, hysterectomy, or maternal death. Study effects were combined by Bayesian meta-analysis and reported as risk ratios (RR) and 95% credible intervals (Cr). RESULTS We reviewed 142 full length articles. Of these, 18 publications, with 355,060 deliveries-150,562 (42%) deliveries during the pre-intervention and 204,498 (57.6%) deliveries in the post-interventional period-were included in the meta-analysis. Using the Newcastle-Ottawa Scale, only three studies were considered good quality, and none of them were done in the US. The rate of PPH prior to intervention was 5.06% and 5.46% afterwards (RR 1.09, 95% CI 0.87-1.36; probability of reduction in the diagnosis being 21%). The likelihood of transfusion decreased from 1.68% in the pre-intervention to 1.27% in the post-intervention period (RR 0.80, 95% Cr 0.57-1.09). The overall probability of reduction in transfusion was 93%, albeit it varied among studies done in non-US countries (96%) versus in the US (23%). Transfusion of 4 units or more of blood occurred in 0.44% of deliveries before intervention and 0.37% afterwards (RR of 0.85, 95% CI 0.50-1.52), with the overall probability of reduction being 72% (76% probability of reduction in studies from non-US countries and 49% reduction with reports from the US). Surgical interventions to manage PPH, which was not reported in any US studies, occurred in 0.14% before intervention and 0.28% afterwards (RR 1.29; 95% CI 0.56-3.06; probability of reduction 27%). Admission to the ICU occurred in 0.10% before intervention and 0.08% subsequently (RR 0.92, 95% CI 0.58-1.43), with the overall probability of reduction being 65% (81% in studies from non-US countries and 27% from the study done in the US). Maternal death occurred in 0.17% in the pre-intervention period and 0.09% during the post-intervention (RR 0.62, 95% CI 0.33-1.05; probability of reduction 93% in studies from non-US countries and 82% in one study from the US). CONCLUSIONS Interventions to reduce the sequelae of PPH are associated with decrease in adverse outcomes. The conclusion, however, ought not to be accepted reflexively for the US population. All of the studies on the topic done in the US are of poor quality and the associated probability of reduction in sequelae are consistently lower than those done in other countries. SYNOPSIS Since the putative benefits of PPH drills or simulation exercises are based on poor quality pre- and post-intervention trials, policies recommending them ought to be revisited.
PICO Summary
Population
Postpartum haemorrhage patients (PPH), (18 studies with 355,060 deliveries).
Intervention
Systematic review and Bayesian meta-analysis to compare the rates of adverse outcomes with (PPH) before and after implementation of drills or simulation exercises.
Comparison
Outcome
The meta-analysis included 150,562 (42%) deliveries during the pre-intervention and 204,498 (57.6%) deliveries in the post-interventional period. The rate of PPH prior to intervention was 5.06% and 5.46% afterwards (RR 1.09, 95% CI 0.87-1.36; probability of reduction in the diagnosis being 21%). The likelihood of transfusion decreased from 1.68% in the pre-intervention to 1.27% in the post-intervention period (RR 0.80, 95% Cr 0.57-1.09). The overall probability of reduction in transfusion was 93%, albeit it varied among studies done in non-US countries (96%) versus in the US (23%). Transfusion of 4 units or more of blood occurred in 0.44% of deliveries before intervention and 0.37% afterwards (RR of 0.85, 95% CI 0.50-1.52), with the overall probability of reduction being 72% (76% probability of reduction in studies from non-US countries and 49% reduction with reports from the US). Surgical interventions to manage PPH, which was not reported in any US studies, occurred in 0.14% before intervention and 0.28% afterwards (RR 1.29; 95% CI 0.56-3.06; probability of reduction 27%). Admission to the ICU occurred in 0.10% before intervention and 0.08% subsequently (RR 0.92, 95% CI 0.58-1.43), with the overall probability of reduction being 65% (81% in studies from non-US countries and 27% from the study done in the US). Maternal death occurred in 0.17% in the pre-intervention period and 0.09% during the post-intervention (RR 0.62, 95% CI 0.33-1.05; probability of reduction 93% in studies from non-US countries and 82% in one study from the US).
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Predicting postpartum haemorrhage: A systematic review of prognostic models
Carr BL, Jahangirifar M, Nicholson AE, Li W, Mol BW, Licqurish S
The Australian & New Zealand journal of obstetrics & gynaecology. 2022
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Editor's Choice
Abstract
BACKGROUND Postpartum haemorrhage (PPH) remains a leading cause of maternal mortality and morbidity worldwide, and the rate is increasing. Using a reliable predictive model could identify those at risk, support management and treatment, and improve maternal outcomes. AIMS To systematically identify and appraise existing prognostic models for PPH and ascertain suitability for clinical use. MATERIALS AND METHODS MEDLINE, CINAHL, Embase, and the Cochrane Library were searched using combinations of terms and synonyms, including 'postpartum haemorrhage', 'prognostic model', and 'risk factors'. Observational or experimental studies describing a prognostic model for risk of PPH, published in English, were included. The Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist informed data extraction and the Prediction Model Risk of Bias Assessment Tool guided analysis. RESULTS Sixteen studies met the inclusion criteria after screening 1612 records. All studies were hospital settings from eight different countries. Models were developed for women who experienced vaginal birth (n = 7), caesarean birth (n = 2), any type of birth (n = 2), hypertensive disorders (n = 1) and those with placental abnormalities (n = 4). All studies were at high risk of bias due to use of inappropriate analysis methods or omission of important statistical considerations or suboptimal validation. CONCLUSIONS No existing prognostic models for PPH are ready for clinical application. Future research is needed to externally validate existing models and potentially develop a new model that is reliable and applicable to clinical practice.
PICO Summary
Population
Pregnant women (16 studies from eight different countries).
Intervention
Systematic review to identify and appraise existing prognostic models for post-partum haemorrhage (PPH) and ascertain suitability for clinical use.
Comparison
Various prognostic models for PPH, (e.g., based on prior hospital admissions for chronic diseases, based on medical history and clinical characteristics, using available antenatal and intrapartum variables, using prepartum fibrinogen levels).
Outcome
All studies were hospital settings. Models were developed for women who experienced vaginal birth (n= 7), caesarean birth (n= 2), any type of birth (n= 2), hypertensive disorders (n= 1) and those with placental abnormalities (n= 4). All studies were at high risk of bias due to use of inappropriate analysis methods or omission of important statistical considerations or suboptimal validation.
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Improving the recognition and management of hemorrhage: A scoping review of nursing and midwifery education
Lavoie, P., Lapierre, A., Maheu-Cadotte, M. A., Rodriguez, D., Lavallée, A., Mailhot, T.
Nurse Education Today. 2022;113:105361
Abstract
BACKGROUND Hemorrhage is a frequent complication that nurses and midwives must recognize and manage to avoid life-threatening consequences for patients. There is currently no synthesis of evidence on educational interventions in nursing and midwifery regarding hemorrhage, thus limiting the definition of best practices. OBJECTIVE To map the literature on nursing and midwifery education regarding the recognition and management of hemorrhage. DESIGN Scoping review based on the Joanna Briggs Institute guidelines. DATA SOURCES Quantitative studies evaluating the effect of educational interventions with students, nurses, or midwives published in English or French, with no time limit. REVIEW METHODS Study selection, data extraction, and quality assessment were conducted by two independent reviewers. We characterized educational interventions based on the Guideline for Reporting Evidence-Based Practice Educational Interventions and Teaching. We categorized learning outcomes using the New World Kirkpatrick Model. Methodological quality appraisal was performed with tools from the Joanna Briggs Institute. Findings were synthesized using descriptive statistics and graphical methods RESULT Most of the 38 studies used a single-group design (n = 26, 68%) and were conducted with professionals (n = 28, 74%) in hospital settings (n = 20, 53%). Most were of low (n = 14; 37%) or moderate (n = 18, 47%) methodological quality. Most interventions focused on postpartum hemorrhage (n = 34, 89%) and combined two or more teaching strategies (n = 25, 66%), often pairing an informational segment (e.g., lecture, readings) with a practical session (e.g., workshop, simulation). Learning outcomes related to the management (n = 27; 71%) and recognition of hemorrhage (n = 19, 50%), as well as results for patients and organizations (n = 9, 24%). CONCLUSION Considerable heterogeneity in interventions and learning outcomes precluded conducting a systematic review of effectiveness. High-quality, controlled studies are needed, particularly in surgery and trauma. Reflection on the contribution of nurses and midwives to the detection, monitoring, and management of hemorrhage could enrich the content and expected outcomes of hemorrhage education.
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Predictive accuracy of the shock index for severe postpartum hemorrhage in high-income countries: A systematic review and meta-analysis
Makino Y, Miyake K, Okada A, Ikeda Y, Okada Y
The journal of obstetrics and gynaecology research. 2022
Abstract
AIM: The shock index has been suggested as a screening tool for predicting postpartum hemorrhage (PPH); however, there is little comprehensive evidence regarding its predictive accuracy. This systematic review and meta-analysis aim to investigate the predictive accuracy of the shock index for severe PPH in high-income countries. METHODS A comprehensive search was conducted on MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science (from inception to June 2021). Studies assessing the predictive performance of the shock index for PPH in high-income countries were included. Two or more reviewers independently extracted the data and assessed the risk of bias and applicability concerns using the modified Quality Assessment of Diagnostic Accuracy Studies 2 tool. PPH requiring higher-level care, such as blood transfusions, were considered as primary analyses. We described the hierarchical summary receiver-operating characteristic curve for data synthesis. RESULTS Nine studies were included after the eligibility assessment. All studies were considered to either have a high risk of bias or high applicability concerns. The sensitivity of the four studies that defined severe PPH as PPH requiring blood transfusion ranged from 0.51 to 0.80, whereas their specificity ranged from 0.33 to 0.92. CONCLUSIONS This review shows that the predictive performance of the shock index for severe PPH is inconsistent. Therefore, the evidence for using the shock index alone as a screening tool for PPH in high-income countries is insufficient. STUDY REGISTRATION This review was prospectively registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000044230).
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Hemostasis in Neonates with Perinatal Hypoxia-Laboratory Approach: A Systematic Review
Tsaousi M, Iliodromiti Z, Iacovidou N, Karapati E, Sulaj A, Tsantes AG, Petropoulou C, Boutsikou T, Tsantes AE, Sokou R
Seminars in thrombosis and hemostasis. 2022
Abstract
Birth asphyxia, with an estimated prevalence of 1 to 6 per 1,000 live births, may lead to multiorgan dysfunction due to impaired oxygen and/or blood supply to various organ systems, including the hemostatic system. Coagulopathy, a common complication of perinatal asphyxia, has been described since the 1960s. The aim of this study was to systematically review the literature for records on the use of hemostasis tests in the evaluation of coagulation disorders, in neonates who had suffered from perinatal hypoxia or asphyxia. We identified published studies by searching PubMed and Scopus, up until April 2022. The literature search retrieved 37 articles fulfilling the inclusion criteria of the review. According to the bibliography, thrombocytopenia is commonly associated with perinatal hypoxia/asphyxia. The thrombocytopenia is usually described as mild and platelets return to normal levels by the 10th day of life. Additionally, hypoxic neonates usually present with a hypocoagulable profile, as reflected by the prolongation of standard coagulation tests, including prothrombin time, activated partial thromboplastin time, and international normalized ratio, findings commonly associated with disseminated intravascular coagulation, and by the reduction of the levels of the physiologic inhibition of coagulation system. A few studies thus far using ROTEM/TEG in hypoxic neonates have come to the same conclusion as well; hypoxic newborns seem to be characterized by a hypocoagulable profile compared with healthy neonates. It should be emphasized, however, that standard coagulation tests provide only a rough estimation of the true bleeding or thrombotic risk of hypoxic neonates. On the contrary, viscoelastic methods seem to be more precise in the early detection of hemostasis disorders in the neonatal population. However, until now, there was uncertainty as to the most appropriate coagulation assays for diagnosis and management of coagulation derangement in neonates with perinatal hypoxia indicating the need for further research on this field.