National and International Guidelines for Patient Blood Management in Obstetrics: A Qualitative Review

Shaylor, Ruth; Weiniger, Carolyn F.; Austin, Naola; Tzabazis, Alexander; Shander, Aryeh; Goodnough, Lawrence T.; Butwick, Alexander J.

doi:10.1213/ane.0000000000001473

Cited by 86 publications

(40 citation statements)

References 96 publications

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“…40 Furthermore, several obstetric societies, including The Royal College of Obstetricians and Gynecologists (UK) and the French College of Gynecologists and Obstetricians, have published PPH guidelines recommending that a Hb level above 8 g/dl is a therapeutic goal. 41 These observations, coupled with our findings, have important clinical relevance for several reasons. Firstly, antenatal anemia is a modifiable risk factor for transfusion.…”

Section: Discussionsupporting

confidence: 75%

Risk Factors for Severe Postpartum Hemorrhage After Cesarean Delivery: Case-Control Studies

Butwick

Ramachandran

Hegde

et al. 2017

Anesthesia &Amp; Analgesia

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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.

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Section: Discussionsupporting

confidence: 75%

Risk Factors for Severe Postpartum Hemorrhage After Cesarean Delivery: Case-Control Studies

Butwick

Ramachandran

Hegde

et al. 2017

Anesthesia &Amp; Analgesia

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“…Maternal hematologic physiology differs from the nonpregnant state; severe obstetric hemorrhage is more likely to be associated with early hypofibrinogenemia. 190,191 In the setting of postpartum hemorrhage, early assessment of fibrinogen levels should be undertaken; levels < 200 mg/dL should prompt aggressive monitoring and treatment. The American Society of Anesthesiologists guidelines specify that fibrinogen levels should be treated early in obstetric hemorrhage.…”

Section: Anesthesiology Contributions To Maternal Safetymentioning

confidence: 99%

A Review of the Impact of Obstetric Anesthesia on Maternal and Neonatal Outcomes

et al. 2018

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Obstetric anesthesia has evolved over the course of its history to encompass comprehensive aspects of maternal care, ranging from cesarean delivery anesthesia and labor analgesia to maternal resuscitation and patient safety. Anesthesiologists are concerned with maternal and neonatal outcomes, and with preventing and managing complications that may present during childbirth. The current review will focus on recent advances in obstetric anesthesia, including labor anesthesia and analgesia, cesarean delivery anesthesia and analgesia, the effects of maternal anesthesia on breastfeeding and fever, and maternal safety. The impact of these advances on maternal and neonatal outcomes is discussed. Past and future progress in this field will continue to have significant implications on the health of women and children.

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“…In future studies, we suggest to consider the time point for rFVIIa administration which represents another important difference between this protocol and international guidelines advocating the use of rFVIIa for ongoing PPH 8 or as a last resort after conventional therapies fail. 33 In this study, we can observe that administration of rFVIIa after a long-lasting and massive blood loss, as a last resort to prevent hysterectomy (as performed in the historical cohort 1) and particularly its liberal use in the absence of any guideline (as in the historical cohort 2), was less efficacious. Of particular note, the smaller amount of blood products transfused in the study cohort (Table 2) was due to less blood products transfused before—and not after—additional hemostatic intervention (Table 4).…”

Section: Discussionmentioning

confidence: 84%

Standardized Management Protocol in Severe Postpartum Hemorrhage: A Single-Center Study

Colucci

Helsing

Biasiutti

et al. 2018

Clin Appl Thromb Hemost

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Severe postpartum hemorrhage (sPPH) is an obstetric emergency that needs prompt and effective therapy to reduce the risk of complications. In this study, women who developed sPPH (study cohort, n = 27) were treated according to a standardized management protocol prescribing sequential administration of uterotonic drugs, crystalloids, tranexamic acid, labile blood products, low-dose fibrinogen, and recombinant activated factor VII (rFVIIa). This group was compared to patients treated with different strategies during 2 preceding periods: an in-house guideline regulating the administration of rFVIIa (historical cohort 1, n = 20) and no specific guideline (historical cohort 2, n = 27). The management protocol was used over 33 months. The study cohort had a lower estimated blood loss ( P = .004) and required less red blood cell concentrates ( P = .007), fresh frozen plasma units ( P = .004), and platelet concentrates ( P = .020) compared to historical cohort 1 and historical cohort 2, respectively. The necessity of emergency postpartum hysterectomy was lower in the study group ( P = .012). In conclusion, in patients with sPPH treated with this standardized management protocol, we observed a decreased requirement of labile blood products and lower need to proceed to emergency postpartum hysterectomy.

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National and International Guidelines for Patient Blood Management in Obstetrics: A Qualitative Review

Cited by 86 publications

References 96 publications

Risk Factors for Severe Postpartum Hemorrhage After Cesarean Delivery: Case-Control Studies

Risk Factors for Severe Postpartum Hemorrhage After Cesarean Delivery: Case-Control Studies

A Review of the Impact of Obstetric Anesthesia on Maternal and Neonatal Outcomes

Standardized Management Protocol in Severe Postpartum Hemorrhage: A Single-Center Study

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