Restrictive versus liberal fluid resuscitation strategy, influence on blood loss and hemostatic parameters in mild obstetric hemorrhage: An open-label randomized controlled trial. (REFILL study)

Abstract

Background Evidence for optimal hemostatic resuscitation in postpartum hemorrhage (PPH) is lacking. Liberal fluid administration may result in acidosis, hypothermia and coagulopathy. Objective We hypothesize that in early PPH a restrictive fluid administration results in less progression to moderate PPH. Study design In four Dutch hospitals we recruited women of 18 years and over, and more than 24 weeks pregnant. Exclusion criteria were: anticoagulant therapy, known coagulation disorders, pre-eclampsia, antenatal diagnosis of abnormally adhesive placenta, and a contraindication for liberal fluid therapy. We blindly randomized participants at 500 mL and ongoing blood loss in the third stage of labor between restrictive fluid administration (clear fluids 0.75–1.0 times the volume of blood lost) and liberal fluid administration (clear fluids 1.5–2.0 times the volume of blood lost). The primary outcome was progression to more than 1000 mL blood loss. Analyses were according to the intention-to-treat principle. Results From August 2014 till September 2019, 5190 women were informed of whom 1622 agreed to participate. A total of 252 women were randomized of which 130 were assigned to the restrictive group and 122 to the liberal group. In the restrictive management group 51 of the 130 patients (39.2%) progressed to more than 1000 mL blood loss versus 61 of the 119 patients (51.3%) in the liberal management group (difference, -12.0% [95%-CI -24.3% to 0.3%], p = 0.057). There was no difference in the need for blood transfusion, coagulation parameters, or in adverse events between the groups. Conclusions Although a restrictive fluid resuscitation in women with mild PPH could not been proven to be superior, it does not increase the need for blood transfusion, alter coagulation parameters, or cause a rise in adverse events. It can be considered as an alternative treatment option to liberal fluid resuscitation. Trial registration NTR3789.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

“…Especially volumes greater than 4l of crystalloids and colloids are associated with increased adverse maternal outcomes 845 . A restrictive resuscitation with crystalloids appears to be equal to a liberal strategy in mild PPH 846 …”

“…845 A restrictive resuscitation with crystalloids appears to be equal to a liberal strategy in mild PPH. 846 Platelet count Low platelet count is associated with increased risk of severe PPH, RBC and FFP transfusion. [847][848][849][850][851][852] Mild prepartum thrombocytopenia (<150 Â 10 9 l À1 ) and lower platelet counts are associated with gradually increasing risk of severe PPH following vaginal delivery and caesarean section.…”

Effect of Intra-operative glove changing during Cesarean on Post-operative Complication (Clinical Trial)

“…As pointed out through the study conducted by 4 Cesarean section is a bloody procedure; between 750 to 1000 mL of blood are lost during most operations, and over 1000 mL of blood must be lost in order for the patient to be classified as having a postpartum haemorrhage (PPH). 13 The aim of our study is to study, investigate, evaluate the effect of changed surgical gloves post placental delivery intra -operative cesarean section versus usual care.This randomized controll study was conducted in the obestetric ward of Al Hussin Hospital to estimate the effect of intra-operative glove changing during cesarean section on postoperative complication(clinical trial).…”

Postpartum Hemorrhage—Epidemiology, Risk Factors, and Causes

“…Restrictive fluid administration was defined as clear fluids at 0.75 to 1.0 times the volume of blood lost, and liberal fluid administration was clear fluids at 1.5 to 2.0 times the volume lost. The authors found that there was no statistical difference between progression to blood loss greater than 1000 mL, need for blood transfusion, alteration in coagulation parameters, or adverse events between the 2 groups 57…”

“…The authors found that there was no statistical difference between progression to blood loss greater than 1000 mL, need for blood transfusion, alteration in coagulation parameters, or adverse events between the 2 groups. 57…”