Corinne Dupont

Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial

BACKGROUND 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. METHODS 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. RESULTS 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)]. CONCLUSIONS The fibrinogen level at PPH diagnosis is a marker of the risk of aggravation and should serve as an alert to clinicians.

Postpartum hemorrhage resulting from uterine atony after vaginal delivery: factors associated with severity.

OBJECTIVE: To identify factors associated with severity of postpartum hemorrhage among characteristics of women and their delivery, the components of initial postpartum hemorrhage management, and the organizational characteristics of maternity units. METHODS: This population-based cohort study included women with postpartum hemorrhage due to uterine atony after vaginal delivery in 106 French hospitals between December 2004 and November 2006 (N=4,550). Severe postpartum hemorrhage was defined by a peripartum change in hemoglobin of 4 g/dL or more. A multivariable logistic model was used to identify factors independently associated with postpartum hemorrhage severity. RESULTS: Severe postpartum hemorrhage occurred in 952 women (20.9%). In women with postpartum hemorrhage, factors independently associated with severity were: primiparity; previous postpartum hemorrhage; previous cesarean delivery; cervical ripening; prolonged labor; and episiotomy; and delay in initial care for postpartum hemorrhage. Also associated with severity was 1) administration of oxytocin more than 10 minutes after postpartum hemorrhage diagnosis: 10–20 minutes after, proportion with severe postpartum hemorrhage 24.6% compared with 20.5%, adjusted OR 1.38, 95% CI 1.03–1.85; more than 20 minutes after, 31.8% compared with 20.5%, adjusted OR 1.86, CI 1.45–2.38; 2) manual examination of the uterine cavity more than 20 minutes after (proportion with severe postpartum hemorrhage 28.2% versus 20.7%, adjusted OR 1.83, 95% CI 1.42–2.35); 3) call for additional assistance more than 10 minutes after (proportion with severe postpartum hemorrhage 29.8% versus 24.8%, adjusted OR 1.61, 95% CI 1.23–2.12 for an obstetrician, and 35.1% compared with 29.9%, adjusted OR 1.51, 95% CI 1.14–2.00 for an anesthesiologist); 4) and delivery in a public non-university hospital. Epidural analgesia was found to be a protective factor against severe blood loss in women with postpartum hemorrhage. CONCLUSION: Aspects of labor, delivery, and their management; delay in initial care; and place of delivery are independent risk factors for severe blood loss in women with postpartum hemorrhage caused by atony. LEVEL OF EVIDENCE: II

Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case–control study

Objectives Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental studies support the hypothesis that oxytocin administration during labour, a common although not evidence-based practice, may increase the risk of atonic PPH. The clinical studies, however, are inconclusive. The objectives of this study was to investigate the association between the level of oxytocin exposure during labour and the risk of severe PPH and to explore whether the prophylactic use of oxytocin after birth modifies this association. Design Population-based, cohort-nested case–control study. Setting 106 French hospitals from December 2004 through November 2006. Participants Women with term singleton vaginal deliveries, after an uncomplicated pregnancy. Cases were 1483 women with severe PPH, defined by peripartum change in haemoglobin of ≥4 g/dl or need for blood transfusion. Controls were 1758 women from a random sample of parturients without PPH. Main outcome measures The independent association between the level of oxytocin during labour and the risk of severe PPH was tested and quantified with ORs through two-level multivariable logistic regression modelling. Results Oxytocin was administered during labour to 73% of cases and 61% of controls (crude OR: 1.7, 95% CI 1.5 to 2.0). After adjustment for all potential confounders, oxytocin during labour was associated with a significantly higher risk of severe PPH (adjusted OR: 1.8, 95% CI 1.3 to 2.6) in women who did not receive prophylactic oxytocin after delivery; the OR for haemorrhage increased from 1 to 5 according to the level of oxytocin exposure. In women who had prophylactic oxytocin after delivery, this association was significant only for the highest exposure categories. Conclusions Oxytocin during labour appears to be an independent risk factor for severe PPH. The results emphasise the need for guidelines clarifying the evidence-based indications for this procedure and the minimal useful regimens.

Multifaceted intervention to decrease the rate of severe postpartum haemorrhage: the PITHAGORE6 cluster‐randomised controlled trial

Please cite this paper as: Deneux‐Tharaux C, Dupont C, Colin C, Rabilloud M, Touzet S, Lansac J, Harvey T, Tessier V, Chauleur C, Pennehouat G, Morin X, Bouvier‐Colle M, Rudigoz R. Multifaceted intervention to decrease the rate of severe postpartum haemorrhage: the PITHAGORE6 cluster‐randomised controlled trial. BJOG 2010;117:1278–1287.

Postpartum hemorrhage: guidelines for clinical practice from the French ă College of Gynaecologists and Obstetricians (CNGOF) in collaboration ă with the French Society of Anesthesiology and Intensive Care (SFAR)

Postpartum haemorrhage (PPH) is defined as blood loss ≥500mL after delivery and severe PPH as blood loss ≥1000mL, regardless of the route of delivery (professional consensus). The preventive administration of uterotonic agents just after delivery is effective in reducing the incidence of PPH and its systematic use is recommended, regardless of the route of delivery (Grade A). Oxytocin is the first-line prophylactic drug, regardless of the route of delivery (Grade A); a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM (professional consensus). After vaginal delivery, routine cord drainage (Grade B), controlled cord traction (Grade A), uterine massage (Grade A), and routine bladder voiding (professional consensus) are not systematically recommended for PPH prevention. After caesarean delivery, placental delivery by controlled cord traction is recommended (grade B). The routine use of a collector bag to assess postpartum blood loss at vaginal delivery is not systematically recommended (Grade B), since the incidence of severe PPH is not affected by this intervention. In cases of overt PPH after vaginal delivery, placement of a blood collection bag is recommended (professional consensus). The initial treatment of PPH consists in a manual uterine examination, together with antibiotic prophylaxis, careful visual assessment of the lower genital tract, a uterine massage, and the administration of 5-10 IU oxytocin injected slowly IV or IM, followed by a maintenance infusion not to exceed a cumulative dose of 40IU (professional consensus). If oxytocin fails to control the bleeding, the administration of sulprostone is recommended within 30minutes of the PPH diagnosis (Grade C). Intrauterine balloon tamponade can be performed if sulprostone fails and before recourse to either surgery or interventional radiology (professional consensus). Fluid resuscitation is recommended for PPH persistent after first line uterotonics, or if clinical signs of severity (Grade B). The objective of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8g/dL. During active haemorrhaging, it is desirable to maintain a fibrinogen level ≥2g/L (professional consensus). RBC, fibrinogen and fresh frozen plasma (FFP) may be administered without awaiting laboratory results (professional consensus). Tranexamic acid may be used at a dose of 1 g, renewable once if ineffective the first time in the treatment of PPH when bleeding persists after sulprostone administration (professional consensus), even though its clinical value has not yet been demonstrated in obstetric settings. It is recommended to prevent and treat hypothermia in women with PPH by warming infusion solutions and blood products and by active skin warming (Grade C). Oxygen administration is recommended in women with severe PPH (professional consensus). If PPH is not controlled by pharmacological treatments and possibly intra-uterine balloon, invasive treatments by arterial embolization or surgery are recommended (Grade C). No technique for conservative surgery is favoured over any other (professional consensus). Hospital-to-hospital transfer of a woman with a PPH for embolization is possible once hemoperitoneum is ruled out and if the patients hemodynamic condition so allows (professional consensus).

Red, orange and green Caesarean sections: A new communication tool for on-call obstetricians

OBJECTIVE To evaluate the effect of a novel communication tool, related to the degree of urgency for Caesarean sections (CSs), on the decision-to-delivery interval for emergency CS. STUDY DESIGN Red CS are very urgent cases corresponding to life-threatening maternal or foetal situations, orange CS are urgent cases and green CS are non-urgent intrapartum CS. We carried out this cohort study in a French maternity hospital. The study included all emergency Caesarean sections during two 6-month periods, before and after introduction of the code. We compared the decision-to-delivery interval of the two study periods. RESULTS Our study included 174 emergency CS. The mean decision-to-delivery interval after introduction of the code was 31.7 min, significantly shorter (p=0.02) than the 39.6 min interval before introduction of the colour code. Except for the preparation time, each time interval decreased. This included transporting the patient into the operating theatre, and the incision-to-delivery time interval. CONCLUSION This study suggests that the use of the three-colour code could significantly shorten the decision-to-delivery interval in emergency CS. Further prospective studies are needed to confirm this result.

Induction of labor and risk of postpartum hemorrhage in low risk parturients.

Objective Labor induction is an increasingly common procedure, even among women at low risk, although evidence to assess its risks remains sparse. Our objective was to assess the association between induction of labor and postpartum hemorrhage (PPH) in low-risk parturients, globally and according to its indications and methods. Method Population-based case-control study of low-risk women who gave birth in 106 French maternity units between December 2004 and November 2006, including 4450 women with PPH, 1125 of them severe, and 1744 controls. Indications for labor induction were standard or non-standard, according to national guidelines. Induction methods were oxytocin or prostaglandins. Multilevel multivariable logistic regression modelling was used to test the independent association between induction and PPH, quantified as odds ratios. Results After adjustment for all potential confounders, labor induction was associated with a significantly higher risk of PPH (adjusted odds ratio, AOR1.22, 95%CI 1.04–1.42). This excess risk was found for induction with both oxytocin (AOR 1.52, 95%CI 1.19–1.93 for all and 1.57, 95%CI 1.11–2.20 for severe PPH) and prostaglandins (AOR 1.21, 95%CI 0.97–1.51 for all and 1.42, 95%CI 1.04–1.94 for severe PPH). Standard indicated induction was significantly associated with PPH (AOR1.28, 95%CI 1.06–1.55) while no significant association was found for non-standard indicated inductions. Conclusion Even in low risk women, induction of labor, regardless of the method used, is associated with a higher risk of PPH than spontaneous labor. However, there was no excess risk of PPH in women who underwent induction of labor for non-standard indications. This raises the hypothesis that the higher risk of PPH associated with labor induction may be limited to unfavorable obstetrical situations.

Transfusion practices in postpartum hemorrhage: a population‐based study

To describe transfusion practices and anemia in women with postpartum hemorrhage (PPH), according to the clinical context.

Incidence, étiologies et facteurs de risque de l’hémorragie du post-partum : étude en population dans 106 maternités françaises

OBJECTIVE To estimate the incidence, to describe the aetiology and to identify the risk factors of postpartum haemorrhage (PPH). MATERIAL AND METHOD Prospective study conducted in 106 French maternity units of six perinatal networks between December 2004 and November 2006. PPH was defined by a blood loss superior to 500 mL or necessitating an examination of the uterus, or a peripartum haemoglobin drop superior to 2 g/dL. Severe PPH was defined by at least one of these criteria : peripartum haemoglobin drop superior or equal to 4 g/dL, embolization, conservative surgical procedure, hysterectomy, transfusion, transfer to intensive care or death. RESULTS The incidence of PPH was 6.4% [CI 95% 6.3-6.5] with variations between maternity units from 1.5% to 22.0%; incidence of severe PPH was 1.7% [CI 95% 1.6-1.8] with variations between units from 0% to 4%. Atony was the main aetiology of PPH, whatever the mode of delivery and severity. The risk factors identified were those classically described in the literature. CONCLUSION In these six French perinatal networks, in 2005-2006, the PPH profile was characterized by an incidence of severe forms higher than previous population-based estimates from other countries. This suggests a more frequent aggravation of PPH and the implication of inadequate PPH management.

Prostaglandin E2 Analogue Sulprostone for Treatment of Atonic Postpartum Hemorrhage

OBJECTIVES: Use of prostaglandins, including sulprostone (an E2 analog), is recommended for second-line uterotonic treatment of atonic postpartum hemorrhage and might be considered as an indicator of quality of care in severe atonic postpartum hemorrhage management. Our objective was to estimate whether sulprostone was appropriately used and how it was tolerated in women with atonic postpartum hemorrhage. METHODS: This large population-based study (146,781 deliveries) included 4,038 women with clinically assessed atonic postpartum hemorrhage in 106 French hospitals during 1 year. Severe postpartum hemorrhage was defined as one of the following: hemoglobin decline of 4 g/dL or more, transfusion, arterial embolization, surgical procedures, transfer to intensive care unit, or death. Sulprostone use in severe atonic postpartum hemorrhage was analyzed according to the mode of delivery and the characteristics of the maternity units. RESULTS: Rates of sulprostone use were only 33.9% (n=1,370) and 53.5% (n=657) among women with atonic (n=4,038) and severe atonic (n=1,227) postpartum hemorrhage, respectively. In the latter population, sulprostone administration was less frequent after vaginal delivery than after cesarean delivery (45.6% compared with 86.5%, P<.01) in units performing fewer than 1,500 annual deliveries in public nonuniversity hospitals and in units where the obstetrician or anesthesiologist was not present 24 hours per day, 7 days per week. Fifty-one of the 1,370 women with sulprostone-treated atonic postpartum hemorrhage (3.7%, 95% confidence interval [CI] 2.7–4.7) experienced side effects, including seven (0.5%, 95% CI 0.2–1.0) with severe cardiovascular or respiratory symptoms that resolved when the hypovolemic shock was corrected and drug administration was stopped. CONCLUSION: Sulprostone is underused for treating severe atonic postpartum hemorrhage after vaginal delivery, despite low rates of severe side effects in this population-based study. LEVEL OF EVIDENCE: III