Carinne Meyer

Community-based distribution of misoprostol for treatment or prevention of postpartum hemorrhage: Cost-effectiveness, mortality, and morbidity reduction analysis

To compare the cost‐effectiveness of community‐based distribution of misoprostol for prevention with misoprostol for treatment of postpartum hemorrhage (PPH).

Obstetric hemorrhage and shock management: using the low technology Non-pneumatic Anti-Shock Garment in Nigerian and Egyptian tertiary care facilities

BackgroundObstetric hemorrhage is the leading cause of maternal mortality globally. The Non-pneumatic Anti-Shock Garment (NASG) is a low-technology, first-aid compression device which, when added to standard hypovolemic shock protocols, may improve outcomes for women with hypovolemic shock secondary to obstetric hemorrhage in tertiary facilities in low-resource settings.MethodsThis study employed a pre-intervention/intervention design in four facilities in Nigeria and two in Egypt. Primary outcomes were measured mean and median blood loss, severe end-organ failure morbidity (renal failure, pulmonary failure, cardiac failure, or CNS dysfunctions), mortality, and emergency hysterectomy for 1442 women with ≥750 mL blood loss and at least one sign of hemodynamic instability. Comparisons of outcomes by study phase were assessed with rank sum tests, relative risks (RR), number needed to treat for benefit (NNTb), and multiple logistic regression.ResultsWomen in the NASG phase (n = 835) were in worse condition on study entry, 38.5% with mean arterial pressure <60 mmHg vs. 29.9% in the pre-intervention phase (p = 0.001). Despite this, negative outcomes were significantly reduced in the NASG phase: mean measured blood loss decreased from 444 mL to 240 mL (p < 0.001), maternal mortality decreased from 6.3% to 3.5% (RR 0.56, 95% CI 0.35-0.89), severe morbidities from 3.7% to 0.7% (RR 0.20, 95% CI 0.08-0.50), and emergency hysterectomy from 8.9% to 4.0% (RR 0.44, 0.23-0.86). In multiple logistic regression, there was a 55% reduced odds of mortality during the NASG phase (aOR 0.45, 0.27-0.77). The NNTb to prevent either mortality or severe morbidity was 18 (12-36).ConclusionAdding the NASG to standard shock and hemorrhage management may significantly improve maternal outcomes from hypovolemic shock secondary to obstetric hemorrhage at tertiary care facilities in low-resource settings.

Assessing the role of the non-pneumatic anti-shock garment in reducing mortality from postpartum hemorrhage in Nigeria.

Background/Aims: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality. The non-pneumatic anti-shock garment (NASG), a first-aid lower-body pressure device, may decrease mortality. Methods: This pre-intervention/NASG study of 288 women was conducted in four referral facilities in Nigeria, 2004–2008. Entry criteria: women with PPH due to uterine atony, retained placenta, ruptured uterus, vaginal or cervical lacerations or placenta accreta with estimated blood loss of ≧750 ml and one clinical sign of shock. Differences in demographics, conditions on study entry, treatment and outcomes were examined. t tests and relative risks with 95% confidence intervals were calculated for primary outcomes – measured blood loss and mortality. Multiple logistic regression analysis was performed to examine independent association of the NASG with mortality. Results: Mean measured blood loss decreased by 80% between phases. Women experienced 350 ml of median blood loss after study entry in the pre-intervention and 50 ml in the NASG phase (p < 0.0001). Mortality decreased from 18% pre-intervention to 6% in the NASG phase (RR = 0.31, 95% CI 0.15–0.64, p = 0.0007). In a multiple logistic regression model, the NASG was associated with reduced mortality (odds ratio 0.30; 95% CI 0.13–0.68, p = 0.004). Conclusion: The NASG shows promise for reducing mortality from PPH in referral facilities in Nigeria.

Impact of the Non-pneumatic Antishock Garment on pelvic blood flow in healthy postpartum women.

OBJECTIVE The Non-pneumatic Antishock Garment (NASG) is a compression device that has shown significantly decreased blood loss in cases of obstetric hemorrhage. However, there are no physiologic studies of the NASG in postpartum women. This study used Doppler ultrasound to measure the resistive index (RI) in the internal iliac artery, thus approximating blood flow to the pelvis with and without the garment applied. STUDY DESIGN In this study, RI of the internal iliac artery was measured in a sample of 10 postpartum volunteers with and without the NASG applied. Median RI was calculated and compared between baseline and full application. RESULTS Internal iliac artery median RI was 0.83 (SD 0.11) at baseline and increased to 1.05 (SD 0.15) with full NASG application (P = .02). CONCLUSION This study suggests a significant increase in internal iliac artery RI with NASG application and provides a physiological explanation of how the NASG might reduce postpartum hemorrhage.

Nonatonic Obstetric Haemorrhage: Effectiveness of the Nonpneumatic Antishock Garment in Egypt

The study aims to determine if the nonpneumatic antishock garment (NASG), a first aid compression device, decreases severe adverse outcomes from nonatonic obstetric haemorrhage. Women with nonatonic aetiologies (434), blood loss > 1000 mL, and signs of shock were eligible. Women received standard care during the preintervention phase (226) and standard care plus application of the garment in the NASG phase (208). Blood loss and extreme adverse outcomes (EAO-mortality and severe morbidity) were measured. Women who used the NASG had more estimated blood loss on admission. Mean measured blood loss was 370 mL in the preintervention phase and 258 mL in the NASG phase (P < 0.0001). EAO decreased with use of the garment (2.9% versus 4.4%, (OR 0.65, 95% CI 0.24–1.76)). In conclusion, using the NASG improved maternal outcomes despite the worse condition on study entry. These findings should be tested in larger studies.

The Non-pneumatic Anti-Shock Garment: How Applier Strength and Body Mass Index Affect External Abdominal Pressure

Objective: To assess the amount of abdominal pressure generated by the Non-pneumatic Anti-Shock Garment (NASG), a first-aid counter pressure device for obstetric hemorrhage, and to evaluate if body mass index (BMI) and ap- plier strength, affect pressure. Study Design: A pilot study convenience sample of 20 non-pregnant volunteers underwent external abdominal pressure monitoring with NASG placement. Mean pressure and the effects of BMI and applier strength were examined. Results: The mean external abdominal pressure significantly increased from 1.0 mmHg at baseline to 67 mmHg on NASG application, returning to 1.0 mmHg upon removal (p=0.005). Greater mean pressure was exerted by a strong applier ver- sus a weak applier, irrespective of BMI (p<0.001). Pressure had an inverse relationship with BMI, particularly with a strong applier (r=-0.905, p<0.001). The difference between pressures achieved in an underweight patient with a strong ap- plier and an overweight patient with a weak applier was significant (73.2 vs 35.7 mmHg; p=0.051). Conclusion: This pilot study demonstrates a significant increase in abdominal pressure with device application and sig- nificant variation with BMI and applier strength. These findings may have important implications for optimizing device usage.

O614 Non-pneumatic anti-shock garment (NASG) reduces extreme adverse outcomes from obstetric hemorrhage and shock in Egyptian hospitals

diagnoses, operative deliveries, neonatal diagnoses, interdelivery intervals and number of children was investigated. Results: Of 901370 women with 2049115 deliveries, 106192 were diagnosed with dystocia (D) during their first delivery (11.8%). In the dystocia group 12.5% were delivered by caesarean and 51.6% had an instrumental delivery vs. 6.6% and 6.8% in the non-dystocia group (ND). In the D-group 25.2% of the children had a neonatal diagnosis such as asphyxia, cerebral functional disturbances etc. vs. 14.7% in the ND group. All the differences between the groups are significant (p < 0.001). Maternal age, maternal height, BMI, gestational length, fetal gender, fetal weight and fetal head circumference were all independently related to an increased risk of dystocia. The interval to the next delivery was 41.6 months in the D-group vs. 42.5 in the ND-group, but the D-group had significantly fewer children; 2.19 children vs. 2.30 children in the ND-group (p < 0.001). There was an increase in the diagnosis of dystocia over the study period and a great variation between different delivery wards. Conclusion: Women with a diagnosis of dystocia at their first delivery have an increased risk of operative delivery and they have significantly fewer children. Their newborns have more complications regarding general condition, circulation, and respiratory function.

O704 Non-pneumatic anti-shock garment (NASG) reduces maternal mortality in four facilities in Nigeria

O704 Non-pneumatic anti-shock garment (NASG) reduces maternal mortality in four facilities in Nigeria O. Ojengbede, I. Morhason-Bello, H. Galadanci, T. Fabamwo, D. Nsima, J. Turan, C. Meyer, S. Miller. Department of Obstetrics & Gynaecology, University College Hospital, Ibadan Nigeria, Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano Nigeria, Department of Obstetrics and Gynaecology, Lagos State University Teaching Hospital, Ikeja Nigeria, Katsina General Hospital, Katsina Nigeria, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA