The aim of the study was to determine whether the fibrinogen level at diagnosis of postpartum haemorrhage (PPH) is associated with the severity of bleeding.
This is a secondary analysis of a ...population-based study in 106 French maternity units identifying cases of PPH prospectively. PPH was defined by a blood loss exceeding 500 ml during the 24 h after delivery or a peripartum haemoglobin decrease of more than 20 g litre−1. This analysis includes 738 women with PPH after vaginal delivery. Fibrinogen levels were compared in patients whose PPH worsened and became severe and those whose PPH remained non-severe. Severe PPH was defined as haemorrhage by occurrence of one of the following events: peripartum haemoglobin decrease ≥40 g litre−1, transfusion of concentrated red cells, arterial embolization or emergency surgery, admission to intensive care, or death.
The mean fibrinogen concentration at diagnosis was 4.2 g litre−1 standard deviation (sd)=1.2 g litre−1 among the patients without worsening and 3.4 g litre−1 (sd=0.9 g litre−1) (P<0.001) in the group whose PPH became severe. The fibrinogen level was associated with PPH severity independently of other factors adjusted odds ratio=1.90 (1.16–3.09) for fibrinogen between 2 and 3 g litre−1 and 11.99 (2.56–56.06) for fibrinogen <2 g litre−1.
The fibrinogen level at PPH diagnosis is a marker of the risk of aggravation and should serve as an alert to clinicians.
Objectives To establish whether reagent‐supported thrombelastometry with the rotation thrombelastometry system (ROTEM®) point‐of‐care device correlated with fibrinogen level in postpartum ...haemorrhages.
Design Prospective observational study.
Population and setting Ninety‐one women at the third trimester of pregnancy: 37 with postpartum haemorrhage (study group) and 54 without abnormal bleeding (control group).
Methods Standard laboratory test results were compared with those obtained at bedside from the ROTEM with the FIBTEM® test (54 tests in the control group and 51 in the study group).
Main outcome measures Analysis of correlations between fibrinogen levels and FIBTEM test results: clotting time (CT), clot amplitude at 5 and 15 minutes (CA5; CA15) and maximal amplitude maximum clot firmness (MCF).
Results Median fibrinogen level was significantly lower in the haemorrhage group than in the control group (3.4 and 5.1 g/l, respectively, P < 0.0001). Median CT was higher in the haemorrhage group than in the control group (P = 0.05). CA5, CA15 and MCF were significantly lower in the haemorrhage group than in controls (P < 0.0001) and strongly correlated with fibrinogen levels in both groups (r = 0.84–0.87, P < 0.0001). A cut‐off value of CA5 at 5 mm and CA15 at 6 mm presented an excellent sensitivity (100% for both parameters) and a good specificity (respectively 85 and 88%) to detect fibrinogen levels <1.5 g/l in postpartum haemorrhage.
Conclusions The early parameters obtained from the FIBTEM test correlated well with fibrinogen levels. ROTEM might be helpful in guiding fibrinogen transfusion during postpartum haemorrhage.
Objective
To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean ...section.
Design
Prospective population‐based study.
Setting
All 176 maternity hospitals of eight French regions.
Population
Two hundred and forty‐nine women with PAS, from a source population of 520 114 deliveries.
Methods
Women with PAS were classified into two risk‐profile groups, with or without the high‐risk combination of placenta praevia (or an anterior low‐lying placenta) and at least one prior caesarean. These two groups were described and compared.
Main outcome measures
Population‐based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes.
Results
The PAS population‐based incidence was 4.8/10 000 (95% CI 4.2–5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally.
Conclusion
More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean.
Tweetable
Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.
Tweetable
Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.
Summary
Anaemia is frequently diagnosed during pregnancy. However, there are few data regarding its incidence, and the association with severe maternal morbidity remains uncertain and potentially ...biased in high‐resource countries. The purpose of this study was to explore the association between gestational anaemia and severe acute maternal morbidity during and after delivery. We performed a cohort‐nested case‐control analysis from the epidemiology of severe maternal mortality (EPIMOMS) prospective study conducted in six French regions (2012–2013, n = 182,309 deliveries). There were 1669 women with severe acute maternal morbidity during or after delivery, according to a standardised definition obtained by expert consensus. The control group were randomly selected among women without severe morbidity who delivered in the same health centres (n = 3234). We studied the association between gestational anaemia and severe acute maternal morbidity during or after delivery overall, by cause, and by mode of delivery, using multivariable logistic regression and multiple imputation. Gestational anaemia was significantly more frequent in women with severe acute maternal morbidity (25.3%) than in controls (16.3%), p < 0.001, and mostly mild in both groups. After adjustment for confounders, women with gestational anaemia were at increased risk of overall severe acute maternal morbidity during and after delivery (adjusted OR (95%CI) 1.8 (1.5–2.1)). This association was also found for severe postpartum haemorrhage (adjusted OR (95%CI) 1.7 (1.5–2.0)), even after omitting the transfusion criterion (adjusted OR (95%CI) 1.9 (1.6–2.3)), and for severe acute maternal morbidity secondary to causes other than haemorrhage or pregnancy‐related hypertensive disorders (adjusted OR (95%CI) 2.7 (1.9–4.0)). These results highlight the importance of optimising the diagnosis and management of anaemia during pregnancy.
Essentials
Pregnancy is a risk factor for thrombosis.
Management of thrombosis risk in pregnancy remains a challenge.
Prophylaxis needs to be personalized.
Our score may be a helpful tool for the ...management of pregnancies at high risk of thrombosis.
Summary
Background
Patients with thrombophilia and/or a history of venous thromboembolism (VTE) are at risk of thrombosis during pregnancy. A risk score for pregnancies with an increased risk of VTE was previously described by our group (Lyon VTE score).
Objectives
The aim of this prospective study was to assess the efficacy and safety of our score‐based prophylaxis strategy in 542 pregnancies managed between 2005 and 2015 in Lyon University Hospitals.
Patients/Methods
Of 445 patients included in the study, 36 had several pregnancies during the study period. Among these 445 patients, 279 had a personal history of VTE (62.7%), 299 patients (67.2%) had a thrombophilia marker, and 131 (29.4%) thrombophilic women had a personal history of VTE. During pregnancy, patients were assigned to one of three prophylaxis strategies according to the risk scoring system.
Results
In the antepartum period, low molecular weight heparin (LMWH) prophylaxis was prescribed to 64.5% of patients at high risk of VTE. Among them, 34.4% were treated in the third trimester only, and 30.1% were treated throughout pregnancy. During the postpartum period, all patients received LMWH for at least 6 weeks. Two antepartum‐related VTEs (0.37%; one with a score of < 3 and the other with a score of > 6) and four postpartum‐related VTEs (0.73%; three with scores of 3–5 and one with a score of > 6) occurred. No case of pulmonary embolism was observed during the study period. The rate of bleeding was 0.37%. No serious bleeding requiring transfusions or surgery occurred during the study period.
Conclusion
The use of a risk score may provide a rational decision process to implement safe and effective antepartum thromboprophylaxis in pregnant women at high risk of VTE.
Objective
To describe the characteristics, management, and outcomes of women undergoing invasive therapies for primary postpartum haemorrhage (PPH).
Design
A population‐based observational study.
...Setting
All 106 maternity units of six French regions.
Population
A total of 146 781 women delivering between 2004 and 2006.
Methods
Prospective identification of women with PPH managed with invasive therapies, including uterine suture, pelvic vessel ligation, arterial embolisation, and hysterectomy.
Main outcome measures
Rate of use and failure rate of invasive therapies, with 95% confidence intervals (95% CIs).
Results
An invasive therapy was used in 296 of 6660 women with PPH (4.4%, 95% CI 4.0–5.0), and in 0.2% of deliveries (95% CI 0.18–0.23). A hysterectomy was performed in 72/6660 women with PPH (1.1%, 95% CI 0.8–1.4%), and in 0.05% of deliveries (95% CI 0.04–0.06). A conservative invasive therapy was used in 262 women, including 183 (70%) who underwent arterial embolisation and 79 (30%) who had conservative surgery as the first‐line therapy. Embolisation was more frequently used after vaginal than caesarean delivery, and when arterial embolisation was available on site. The failure rate of conservative invasive therapies was 41/262 (15.6%, 95% CI 11.5–20.6) overall, and was higher after surgical than after embolisation procedures, in particular for vaginal deliveries.
Conclusions
Both maternal mortality as a result of obstetric haemorrhage and the rate of invasive therapies used for PPH are high in France. These findings suggest flaws in the initial management of PPH and/or the inadequate use of invasive procedures.
Tweetable
Maternal mortality as a result of haemorrhage and the rate of invasive therapies used for PPH are high in France.
Tweetable
Maternal mortality as a result of haemorrhage and the rate of invasive therapies used for PPH are high in France.
Evaluate the prevalence of uterine synechia after total uterine ligation (TUL) in comparison to TUL associated with compression-penetrating-sutures (CPS) in the conservative surgical management of ...severe postpartum hemorrhage (PPH).
Prospective observational study of pregnant women that underwent conservative surgical management for PPH in a single French tertiary referral center. We compared the risk of uterine synechia with TUL, in comparison to performing TUL in addition to CPS. The synechia rate was calculated after uterine cavity assessment by 3D hysterosonography. Hysterectomies, women with placenta accreta spectrum and patients that received additional embolization treatment were excluded.
Over 6 years, 36 pregnant women underwent surgical treatment for PPH in 21,944 deliveries (1.64 per 1000). The median blood loss was 2700 1570–3000 milliliters. Twenty-eight (77.7%) women underwent TUL, 8/36 (22.2%) underwent TUL in addition to CPS. Thirty-four (94,4%) cavity assessments were performed 2-to-6 months after delivery, since one woman of each group was lost to follow-up. When TUL was performed in addition to CPS, the prevalence of synechia was 42.9% (n = 3/7), versus 3.7% (n = 1/27) in TUL (p = 0.021; RR = 16.88, 95%CI 1.1–1051). Synechia was absent in 30/34 (88.2%) women.
The prevalence of synechia was very low after TUL unlike CPS. Further studies should evaluate TUL in the conservative surgical management of PPH, to confirm the lower prevalence of synechiae in TUL and evaluate its impact on fertility.
To assess the obstetric outcome of pregnancies occurring after a complete uterine rupture.
Descriptive study of a series of 11 pregnancies after complete uterine rupture.
This study includes 10 women ...with 11 pregnancies. There were no recurrences of complete uterine rupture. All women had cesarean deliveries between 32 and 37 weeks’ gestation. There were no cases of either severe hemorrhage or placenta accreta and no maternal or neonatal deaths. All women had close clinical and ultrasound monitoring and were hospitalized during the third trimester.
Women with a history of complete uterine rupture can have a subsequent pregnancy with a thoroughly favorable outcome with appropriate care conditions, including prophylactic caesarean section.
PDF
