Published September 29, 2023 | Version v1
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A COMPREHENSIVE APPROACH TO THE PREVENTION AND TREATMENT OF MASSIVE OBSTETRIC HEMORRHAGE

Authors/Creators

  • 1. Shupik National Healthcare University of Ukraine, Kyiv, Ukraine
  • 2. Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
  • 3. LLC «ISIDA-IVF», Kyiv, Ukraine
  • 4. Kyiv Regional Perinatal Center, Kyiv , Ukraine
  • 5. Сommunal Non-Commercial Enterprise «Vyshgorod District Hospital», Vyshgorod, Ukraine

Description

In the case of progression of obstetric haemorrhage (OH) and non-effective preventive and therapeutic measures during childbirth and after delivery, the volume of blood loss can increase and exceed > 1.5% of body weight (25–30% of circulating blood volume – CBV). In such cases that we are talking about massive obstetric haemorrhage (MOH), which leads to an increase in the frequency of maternal morbidity and mortality.
The objective: determine the effectiveness of various approaches to the restoration of blood loss in the cases of MOH development, which occurred to various etiological factors, with the introduction of the modern concept of damage control resuscitation (DCR) and innovative methods of surgical hemostasis.
Materials and methods. During 2015–2023 years at five clinical bases of the Department of Obstetrics and Gynecology N1 of Shupyk National Healthcare University of Ukraine we analyzed 165 cases of MOH. In all MOH cases, an integrated approach was used to stop haemorrhage using both drug therapy and modern methods of surgical hemostasis in accordance with the regulatory documents of the Ukrainian Ministry of Healthcare.
In main group of 59 women in labor with the MOH (2020–2023 years) an integrated approach to stop haemorrhage and restore the blood loss according to DCR concept with the priority of high-quality and rapid CBV restoration with blood products and minimization of infusion therapy was used. The comparison group consisted of 106 women in labor with MOH (2015–2019 years) and similar methods of haemorrhage termination to restore blood loss in accordance with the order N 205 of the Ukrainian Ministry of Healthcare «Obstetric haemorrhage» with the priority of rapid restoration of blood loss by crystalloids (during 2015–2019 years).
Results. The mean blood loss, time till haemorrhage is stopped, and the duration of surgery in the main group were significantly lower than in the comparison group (p<0.05). In the postpartum period the number of cases with severe anemia was significantly more often in the comparison group – 47.2% versus 11.9% in the main group (OR 6.6 CI 2.7–15.9; p<0.01), as well as the frequency of hysterectomy – 50.9% versus 28.8% (OR 2.6 CI 1.3–5.1; p<0.01).
An early onset and a significantly higher rate of transfusions of fresh frozen plasma and erythrocyte mass were found in the main group – respectively 88.1% versus 38.7% in the comparison group (OR 11.7, CI: 4.8–28.4; p<0.001). This resulted in a significantly lower volume of blood loss, duration of surgical intervention, and average time for haemorrhage stop in the main group compared to the comparison group (p<0.05).
Conclusions. The use of modern uterotonic agents (carbetocin), tranexamic acid preparations, innovative surgical technologies and early initiation of transfusion therapy with blood preparations with minimization of crystalloid infusion and according to the DCR concept for the development of MOH allows to reduce the volume of blood loss, the frequency of severe postpartum complications, and to prevent maternal morbidity and death.

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References

  • Escobar MF, Nassar AH, Theron G, Barnea ER, Nicholson W, Ramasauskaite D, et al. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet. 2022;157(1):3-50. doi: 10.1002/ijgo.14116.
  • World Health Organization. WHO Model List of Essential Medicines [Internet]. Geneva: WHO; 2021. Available from: https://www.who.int/groups/expert-committee-on-selection-and-use-of-essential-medicines/essentialmedicines-lists.
  • Mukherjee S, Arulkumaran S. Postpartum haemorrhage. Obstet Gynaecol Reprod Med. 2009;19:121-6.
  • Cannon JW. Hemorrhagic shock. N Engl J Med. 2018;378:370-9.
  • Zhang Y, Yan J, Han Q, Yang T, Cai L, Fu Y, et al. Emergency obstetric hysterectomy for life-threatening postpartum hemorrhage: A 12-year review. Medicine (Baltimore). 2017;96(45):e8443. doi: 10.1097/MD.0000000000008443.
  • Bateman BT, Mhyre JM, Callaghan WM, Kuklina EV. Peripartum hysterectomy in the United States: nationwide 14 year experience. Am J Obstet Gynecol. 2012;206(1):63.e1-8. doi: 10.1016/j.ajog.2011.07.030.
  • Mhyre JM, Bateman BT, Leffert LR. Influence of patient comorbidities on the risk of near-miss maternal morbidity or mortality. Anesthesiol. 2011;115(5):963-72. doi: 10.1097/ALN.0b013e318233042d.
  • Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017;130(4):e168-86. doi: 10.1097/AOG.0000000000002351.
  • Kogutt BK, Vaught AJ. Postpartum hemorrhage: Blood product management and massive transfusion. Semin Perinatol. 2019;43(1):44-50. doi: 10.1053/j.semperi.2018.11.008.
  • Ministry of Health. Clinical protocol «Obstetric bleeding». 2014. Order No. 205. 2014 Mar 24. Kyiv: Ministry of Health; 2014. 81 p.
  • Posohova SP, Ryazantsev II, Bailo NV, Feshchenko IV. «Rational blood management» strategy in pregnant women at risk of massive obstetric bleeding. Reprod Women's Health. 2021;6(51):50-5.
  • WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-16. doi: 10.1016/S0140-6736(17)30638-4.
  • Pabinger I, Fries D, Schöchl H, Streif W, Toller W. Tranexamic acid for treatment and prophylaxis of bleeding and hyperfibrinolysis. Wien Klin Wochenschr. 2017;129(9-10):303-16. doi: 10.1007/s00508-017-1194-y.
  • Shakur H, Elbourne D, Gülmezoglu M, Alfirevic Z, Ronsmans C, Allen E, et al. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010;11:40. doi: 10.1186/1745-6215-11-40.
  • Owattanapanich N, Chittawatanarat K, Benyakorn T, Sirikun J. Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis. Scand J Trauma Resusc Emerg Med. 2018;26:107.
  • Zwinkels RLJ, Endeman H, Hoeks SE, de Maat MPM, den Hartog D, Stolker RJ. The clinical effect of hemostatic resuscitation in traumatic hemorrhage; a before-after study. J Crit Care. 2020;56:288-93. doi: 10.1016/j.jcrc.2019.11.013.
  • Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019;23(1):98. doi: 10.1186/s13054-019-2347-3.
  • Holcomb JB, Tilley BC, Baraniuk S, Fox EE, Wade CE, Podbielski JM, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-82. doi: 10.1001/jama.2015.12.
  • British Committee for Standards in Haematology; Stainsby D, MacLennan S, Thomas D, Isaac J, Hamilton PJ. Guidelines on the management of massive blood loss. Br J Haematol. 2006;135(5):634-41. doi: 10.1111/j.1365-2141.2006.06355.x.
  • Johansson PI, Stensballe J, Oliveri R, Wade CE, Ostrowski SR, Holcomb JB. How I treat patients with massive hemorrhage. Blood. 2014;124(20):3052-8. doi: 10.1182/blood-2014-05-575340.
  • Kozek-Langenecker SA. Fluids and coagulation. Curr Opin Crit Care. 2015;21(4):285-91. doi: 10.1097/MCC.0000000000000219.
  • Stein P, Kaserer A, Sprengel K, Wanner GA, Seifert B, Theusinger OM, Spahn DR. Change of transfusion and treatment paradigm in major trauma patients. Anaesthesia. 2017;72(11):1317-26. doi: 10.1111/anae.13920.
  • Nunn A, Fischer P, Sing R, Templin M, Avery M, Christmas AB. Improvement of Treatment Outcomes after Implementation of a Massive Transfusion Protocol: A Level I Trauma Center Experience. Am Surg. 2017;83(4):394-8.
  • Cherkas D. Traumatic hemorrhagic shock: advances in fluid management. Emerg Med Pract. 2011;13(11):1-19.
  • Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019;23(1):98. doi: 10.1186/s13054-019-2347-3.
  • Cotton BA, Reddy N, Hatch QM, LeFebvre E, Wade CE, Kozar RA, et al. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg. 2011;254(4):598-605. doi: 10.1097/SLA.0b013e318230089e.
  • Gonzalez EA, Moore FA, Holcomb JB, Miller CC, Kozar RA, Todd SR, et al. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma. 2007;62(1):112-9. doi: 10.1097/01.ta.0000250497.08101.8b.
  • National Institute for Health and Care Excellence. Major trauma: assessment and initial management: NICE Guideline, No. 39 [Internet]. London: NICE; 2016. Available from: https://www.nice.org/uk/guidance/ng39.
  • Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GD. An update on the use of massive transfusion protocols in obstetrics. Am J Obstet Gynecol. 2016;214(3):340-4. doi: 10.1016/j.ajog.2015.08.068.
  • Carvajal JA, Ramos I, Kusanovic JP, Escobar MF. Damage-control resuscitation in obstetrics. J Matern Fetal Neonatal Med. 2022;35(4):785-98. doi: 10.1080/14767058.2020.1730800.
  • Gillissen A, van den Akker T, Caram-Deelder C, Henriquez DDCA, Bloemenkamp KWM, van Roosmalen JJM, et al. Association between fluid management and dilutional coagulopathy in severe postpartum haemorrhage: a nationwide retrospective cohort study. BMC Pregnancy Childbirth. 2018;18(1):398. doi: 10.1186/s12884-018-2021-9.
  • Henriquez DDCA, Bloemenkamp KWM, Loeff RM, Zwart JJ, van Roosmalen JJM, Zwaginga JJ, et al. Fluid resuscitation during persistent postpartum haemorrhage and maternal outcome: A nationwide cohort study. Eur J Obstet Gynecol Reprod Biol. 2019;235:49-56. doi: 10.1016/j.ejogrb.2019.01.027.
  • Tanaka H, Matsunaga S, Yamashita T, Okutomi T, Sakurai A, Sekizawa A, et al. A systematic review of massive transfusion protocol in obstetrics. Taiwan J Obstet Gynecol. 2017;56(6):715-8. doi: 10.1016/j.tjog.2017.10.001.
  • Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol. 2015;212(3):272-80. doi: 10.1016/j.ajog.2014.07.012.
  • Alexander JM, Sarode R, McIntire DD, Burner JD, Leveno KJ. Whole blood in the management of hypovolemia due to obstetric hemorrhage. Obstet Gynecol. 2009;113(6):1320-6. doi: 10.1097/AOG.0b013e3181a4b390.
  • Zielinski MD, Jenkins DH, Hughes JD, Badjie KS, Stubbs JR. Back to the future: the renaissance of whole-blood transfusions for massively hemorrhaging patients. Surgery. 2014;155(5):883-6. doi: 10.1016/j.surg.2014.01.017.
  • Spinella PC, Pidcoke HF, Strandenes G, Hervig T, Fisher A, Jenkins D, et al. Whole blood for hemostatic resuscitation of major bleeding. Transfusion. 2016;56(2):190-202. doi: 10.1111/trf.13491.
  • Golyanovskiy OV, Kulchytskiy DV, Rubinshtein AM. Combined staged surgical hemostasis in a case of Placenta previa and Placenta accreta spectrum disorders. Reprod Women's Health. 2022;4(59):13-8.
  • American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Obstetric Care Consensus No. 7: Placenta Accreta Spectrum. Obstet Gynecol. 2018;132(6):e259-75. doi: 10.1097/AOG.0000000000002983.
  • Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol. 2005;192(5):1458-61. doi: 10.1016/j.ajog.2004.12.074.
  • Jauniaux E, D'Antonio F, Bhide A, Prefumo F, Silver RM, Hussein AM, et al. Modified Delphi study of ultrasound signs associated with placenta accreta spectrum. Ultrasound Obstet Gynecol. 2023;61(4):518-25. doi: 10.1002/uog.26155.
  • Eller AG, Bennett MA, Sharshiner M, Masheter C, Soisson AP, Dodson M, et al. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet Gynecol. 2011;117(2 Pt 1):331-7. doi: 10.1097/AOG.0b013e3182051db2.
  • Balayla J, Bondarenko HD. Placenta accreta and the risk of adverse maternal and neonatal outcomes. J Perinat Med. 2013;41(2):141-9. doi: 10.1515/jpm-2012-0219.
  • Stotler B, Padmanabhan A, Devine P, Wright J, Spitalnik SL, Schwartz J. Transfusion requirements in obstetric patients with placenta accreta. Transfusion. 2011;51:2627-33.
  • Panigrahi AK, Yeaton-Massey A, Bakhtary S, Andrews J, Lyell DJ, Butwick AJ, et al. A Standardized Approach for Transfusion Medicine Support in Patients With Morbidly Adherent Placenta. Anesth Analg. 2017;125(2):603-08. doi: 10.1213/ANE.0000000000002050.
  • Golyanovsky OV, Dyadyk OO, Oshovsky VI, Heintz NE, Mehedko VV, Kachur OJ. Clinical case of delivery of a pregnant woman with Vasa previa on the background of Placenta previa/accreta. Reprod Women's Health. 2021;4(49):23-9.
  • Golyanovsky OV, Goncharenko AO, Kachur OJ. Prevention and therapy of massive obstetric bleeding in cases of placenta percreta 3b. Reprod Women's Health. 2022;2(57):8-16.