Background Women who undergo intrapartum caesarean delivery (CD) are at increased risk of postpartum hemorrhage (PPH) compared to those undergoing prelabor CD. To determine whether the presence and strength of the associations between individual risk factors and severe PPH vary among women undergoing prelabor CD or intrapartum CD, stratified analyses are needed according to CD subtype. Methods To identify risk factors for severe PPH within two distinct CD populations: prelabor CD and intrapartum CD, we performed two case-control studies. Women in each study cohort delivered at a tertiary obstetric center in the United States between 2002 and 2012. For each study, cases were women who had a blood loss ≥1500 ml or who received an intraoperative or postoperative transfusion up to 48 hr after delivery. Risk factors for severe PPH among women undergoing prelabor CD or intrapartum CD were examined in separate logistic regression models. Results For prelabor CD, we identified 269 cases and 550 controls. Clinical factors with the highest adjusted odds for severe PPH during prelabor CD were: general anesthesia (adjusted odds ratio (aOR) = 22.3; 95% confidence intervals (CI) = 4.9 – 99.9; reference group = spinal anesthesia), multiple pregnancy (aOR = 8.0; 95% CI = 4.2 – 15.0; reference group = singleton pregnancy), and placenta previa (aOR = 6.3; 95% CI = 3.4 – 11.8). For intrapartum CD, we identified 278 cases and 572 controls. Clinical factors with the highest adjusted odds for severe PPH during intrapartum CD were: general anesthesia (aOR = 5.4; 95% CI = 1.7 – 17.1); multiple pregnancy (aOR = 3.2; 95% CI = 1.7 – 6.3); and a predelivery hemoglobin≤9.9 g/dl (aOR = 3.0; 95% CI = 1.3 – 6.9; reference group = predelivery hemoglobin≥11 g/dl). Conclusion Women who undergo prelabor CD and intrapartum CD have several shared risk factors for severe PPH (general anesthesia and multiple pregnancy). However, the risk factor profiles for severe PPH differed between these CD cohorts. Recognizing these differences may be important when planning resources and interventions for high-risk patients undergoing either prelabor or intrapartum CD.
Postpartum anemia has been associated with postpartum morbidities, such as depression and poor cognition. However, it is unclear whether postpartum anemia is associated with reduced health-related quality of life. We performed a prospective study to examine the relations between postpartum Hb levels with postpartum HRQoL. We collected data from sixty women intending vaginal delivery, and assessed HRQoL and maternal fatigue on admission and on the first postpartum day using the RAND 36-Item Short-Form Health Survey (SF-36) and the Multidimensional Fatigue Inventory (MFI), respectively. Maternal Hb levels were measured on admission and on the first postpartum day. We also assessed patients for postpartum depression using the Edinburgh Postpartum Depression Scale (EPDS). We performed unadjusted and multivariate linear regression (adjusting for maternal age, parity, mode of delivery, and race) to assess the associations between post-delivery Hb with each subscale of the SF-36 and MFI. The mean predelivery and postpartum Hb levels were 12.3 (1.2) g/dl and 10.8 (1.4) g/dl, respectively. In our unadjusted and adjusted regression analyses, we observed no statistically significant associations between postpartum Hb level with any SF-36 or MFI subscale (P>0.05). Based on the EPDS, only one patient was depressed; her postpartum Hb was 11.2 g/dl. Our findings suggest that postpartum Hb levels may not influence HRQoL or fatigue. However, our findings may only apply to women without predelivery anemia, severe blood loss or moderate-to-severe anemia after delivery. Future studies are needed to determine whether postpartum Hb influences HRQoL among women with moderate or severe postpartum anemia.
Introduction Oxytocin is routinely used as prophylaxis against uterine atony. During elective cesarean delivery (CD), an oxytocin bolus is used to initiate adequate uterine tone, followed by an oxytocin infusion to maintain uterine contractility. However, it is unclear whether oxytocin maintenance infusion rate influences total estimated blood loss (EBL). Methods We performed a prospective, randomized, double-blind trial in 51 women undergoing elective CD. Women were randomized to receive an oxytocin maintenance infusion of 2.5 u/hr or 15 u/hr. All women received an oxytocin 1 u bolus to initiate adequate uterine tone. The primary outcome was EBL. EBL values between groups were compared using a Mann-Whitney U test; P<0.05 as statistically significant. The median EBL difference with 95% confidence intervals (CI) was also calculated. Secondary outcomes included: adequacy of uterine tone, use of additional uterotonics, and oxytocin related side-effects, including hypotension. Results Of 51 women, 24 received a low rate infusion and 27 received a high rate infusion. Median [interquartile range] EBL values in the low rate and high rate groups were: 634 [340 – 886] ml vs. 512 [405 – 740] ml, respectively; P=0.7). The median difference in EBL between groups was 22 ml; 95% CI=−158 – 236 ml. The rate of postpartum hemorrhage did not differ between groups (low rate group: 4/24 (16.7%) vs. high rate group: 4/26 (15.4%)). There were no between-group differences over time (first 20 min after commencing infusion) in the incidence of adequate uterine tone (P=0.72) or hypotension (P=0.32). Conclusion Among women undergoing elective CD receiving an oxytocin maintenance infusion, EBL and uterine tone did not differ between women receiving 2.5 u/hr oxytocin to those receiving 15 u/hr oxytocin. Our findings suggest that efficacy can be obtained with a low oxytocin maintenance infusion rate, however dose-finding studies are needed to determine the infusion rate that optimizes drug efficacy whilst minimizing side effects.
(Anesth Analg. 2017;124(3):857–862) Oxytocin is routinely used for prophylaxis against uterine atony after vaginal or cesarean delivery (CD), as it has been shown to decrease the risk of postpartum hemorrhage (PPH). In fact, a low dose delivered during elective CD can initiate adequate uterine tone after placental delivery. However, consensus is lacking on the effective oxytocin infusion rate for achieving this outcome and there exists marked variation in prescribed oxytocin regimens. The authors of the present study thus evaluated the effect of a high-rate (15 U/h) versus low-rate (2.5 U/h) infusion of oxytocin on total estimated blood loss (EBL).
BACKGROUND: Mail order pharmacy (MOP) use has been linked to improved medication adherence and health outcomes among patients with diabetes. However, no largescale intervention studies have assessed the effect of encouraging MOP use on medication adherence. OBJECTIVE: To assess an intervention to encourage MOP services to increase its use and medication adherence. DESIGN: Randomized encouragement trial. PATIENTS: 63,012 diabetes patients from three health care systems: Kaiser Permanente Northern California (KPNC), Kaiser Permanente Hawaii (KPHI), and Harvard Pilgrim Health Care (HPHC) who were poorly adherent to at least one class of cardiometabolic medications and had not used MOP in the prior 12 months. INTERVENTION: Patients were randomized to receive either usual care (control arm) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use (intervention arm). HPHC intervention patients received the letter only. MEASUREMENTS: We compared the percentages of patients that began using MOP and that became adherent to cardiometabolic medication classes during a 12-month follow-up period. We also conducted a race/ethnicitystratified analysis. RESULTS: During follow-up, 10.6% of intervention patients began using MOP vs. 9.3% of controls (p < 0.01); the percent of cardiometabolic medication delivered via mail was 42.1% vs. 39.8% (p < 0.01). Metformin adherence improved in the intervention arm relative to control at the two KP sites (52% vs. 49%, p < 0.01). Stratified analyses suggested a significant positive effect of the intervention in White (RR: 1.12, 95% CI: 1.03, 1.22) and Asian (RR: 1.30, 95% CI: 1.17, 1.45) patients. CONCLUSION: This pragmatic trial showed that simple outreach to encourage MOP modestly increased its use and improved adherence measured by refills to a key class of diabetes medications in some settings. Given its minimal cost, clinicians and health systems should consider outreach interventions to actively promote MOP use among diabetes patients.
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