Risk factors for massive transfusion in obstetrical hemorrhage and consideration of a whole blood program.

BACKGROUND: Postpartum hemorrhage (PPH) is one of the leading causes of obstetric complications. The goal of this study was to identify risk factors for obstetric (OB) massive transfusion (MT) and determine the feasibility of developing a low-titer group O RhD-positive whole blood (LTO + WB) protocol for OB hemorrhage. STUDY DESIGN AND METHODS: A retrospective study of OB patients who received transfusion within 24 h. MT patients were those who received >3 U of pRBC within 1 h or > 10 U in 24 h. Patient demographics, OB history, comorbidities, blood type, antibody status, and known risk factors for PPH and maternal-fetal outcomes were compared. Logistic regression was used for univariate and multivariate analyses. RESULTS: Of the 610 transfused OB patients, 12.0% (n = 73) required MT. Groups were well matched for body mass index (BMI), maternal comorbidities, and history of spontaneous vaginal deliveries. The incidence of the previous cesarean section was higher in the MT group. Exactly 93.9% of patients were RhD-positive and 3.77% of all patients possessed an antibody on pretransfusion testing. Patients with MT had a longer length of stay (LOS), higher rate of intensive care unit (ICU) admission, fetal death, and hysterectomy. Multivariate analysis found age >35, PPH, placenta percreta, accreta, and increta to be significant (p < .05) risk factors for MT. DISCUSSION: Patients over 35 years and those with abnormal placentation are at increased risk of requiring MT. With a time to delivery of 2 days, potential MT patients can be identified early, and with a 94% rate of RhD-positive+, they are eligible to receive low-titer O whole blood (LTOWB) providing hemostatic resuscitation with reduced donor exposure.

Whole blood for postpartum hemorrhage: early experience at two institutions.

BACKGROUND: Death from postpartum hemorrhage (PPH) remains a significant preventable problem worldwide. Cold-stored, low-titer, type-O whole blood (LTOWB) is increasingly being used for resuscitation of injured patients, but it is uncommon in PPH patients, and it is unclear what its role may be in this population. STUDY DESIGN AND METHODS: Brief report of the early experience of WB use for PPH in two institutions, one university hospital and one private hospital. RESULTS: Different approaches have been implemented at the two institutions, one designed for emergency release, uncrossmatched transfusion of LTOWB as part of a massive transfusion protocol (MTP) and one for high-risk obstetric patients with known placental abnormalities. A total of 7 PPH patients have received a total of 17 units of LTOWB between the two institutions. No severe adverse transfusion reactions were observed clinically in either institution and the clinical outcomes were favorable in all cases. CONCLUSION: In our early experience, LTOWB can be implemented for two different PPH clinical scenarios. Larger studies are needed to compare outcomes between LTOWB and traditional component resuscitation strategies.

Prehospital Transfusion of Low-Titer O + Whole Blood for Severe Maternal Hemorrhage: A Case Report.

Introduction: Beginning in 2017, multiple stakeholders within the Southwest Texas Regional Advisory Council for Trauma collaborated to incorporate cold-stored low-titer O RhD-positive whole blood (LTO + WB) into all phases of their trauma system, including the prehospital phase of care. Although the program was initially focused on trauma resuscitation, it was expanded to included non-traumatic hemorrhagic shock patients that may benefit from whole blood resuscitation.Case Report: We report the case of a patient with severe maternal hemorrhage secondary to placenta accreta who received a prehospital transfusion of LTO + WB. We believe this to be the first reported case of post-partum hemorrhage resuscitated out of hospital with whole blood.Discussion: This case highlights the potential benefits of a prehospital whole blood program as well as the controversy surrounding a LTO + WB program that includes females of childbearing age.

Comparison of obstetric to institutional antibiogram as an approach to advance antimicrobial stewardship in maternal care.

OBJECTIVE: To create an antibiogram derived exclusively from our obstetric population and compare the clinical isolates and susceptibilities to our institutional antibiogram. METHODS: Data collected by the University Hospital Clinical Microbiology Laboratory in SSC Soft from 01/01/2018 to 12/31/2018 was used to generate our institutional antibiogram. For comparison, we created an obstetric (OB) antibiogram using all clinical isolates collected during the same time interval from OB triage, labor & delivery, antepartum and postpartum wards. The antibiotic susceptibilities of the OB clinical isolates were compared to the institutional clinical isolates. RESULTS: In total, we identified 929 clinical isolates from our OB population in 2018. Urine was the predominant source of clinical isolates (76.3%). The remaining sources included wound (10.1%), genital (9.0%), blood and other fluids (4.6%). Escherichia coli (E. coli) accounted for nearly half of all isolates (48.7%) followed by Group B Streptococcus (10.7%), Enterococcus spp. (9%), and Klebsiella pneumoniae (7.2%). There was no difference in susceptibilities of Gram-positive organisms in the OB antibiogram compared to the institutional antibiogram. Conversely, common Gram-negative organisms demonstrated less antibiotic resistance in the OB antibiogram compared to the institutional antibiogram. Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis were significantly more susceptible in the OB antibiogram compared to the institutional antibiogram to most antimicrobials tested. CONCLUSION: Compared to our institutional antibiogram, gram-negative clinical isolates in our OB population exhibit less antibiotic resistance. Creation of an OB-specific antibiogram, which more accurately reflects antibiotic resistance patterns within our unique patient population, may promote appropriate antimicrobial use by assisting in more informed antibiotic selection and limit unnecessary use of broad-spectrum antibiotics.

Whole blood transfusion reduces overall component transfusion in cases of placenta accreta spectrum: a pilot program.

OBJECTIVE: Placenta accreta spectrum (PAS) is a group of placental invasion pathologies associated with significant morbidity to both mother and fetus. The majority of patients with PAS will require a blood transfusion at time of delivery and subsequent cesarean hysterectomy. The optimal approach to maternal acute blood loss resuscitation is currently unknown. METHODS: Here, we present a cohort analysis of 34 patients with pathology-confirmed PAS treated with either whole blood (n = 16) or component therapy (n = 18) for initial intraoperative resuscitation. RESULTS: We observed comparable results in post-operative outcomes with fewer overall transfusions and subsequently, lower volumes of resuscitation (p=.03) with whole blood initial resuscitation. CONCLUSIONS: Whole blood transfusion may represent a viable option for initial resuscitation with lower resuscitation volumes and transfusion-associated complications without directly effecting post-operative outcomes in cases of PAS.

The late preterm birth rate and its association with comorbidities in a population-based study.

We sought to identify rates, associated morbidities, and preventable causes of late preterm birth (LPB) in a defined population. We conducted a retrospective cross-sectional analysis using deidentified delivery data for all who delivered in San Antonio/Bexar County, Texas between 2000 and 2008 (N = 259,576). LPB was defined as a live birth from 34(0/7) to 36(6/7) weeks. Variables analyzed included age, race/ethnicity, weight gain, hypertensive disease, diabetes, and preterm labor including premature rupture of membranes. From 2000 to 2006, the LPB rate in San Antonio/Bexar County, Texas, was slightly higher than the national average, 9% versus 8.7% (P < 0.01). From 2000 to 2008, 23,312 LPBs occurred in San Antonio/Bexar County and 53% experienced at least one studied comorbidity. Using logistic regression comparing LPB to term, variables associated with an increased risk of LPB were black race, age < 17, age ≥ 35, gestational hypertension, eclampsia, chronic hypertension, and diabetes. LPB was higher than the national average in our population, and preventable causes of LPB (extremes of age, hypertensive disease, and diabetes) were commonly associated with LPB. We speculate that teenage pregnancy prevention, counseling regarding risks associated with advanced maternal age, and improved management and prevention of hypertensive disease and diabetes should prove beneficial in decreasing the LPB rate.

Prehospital low-titer cold-stored whole blood: Philosophy for ubiquitous utilization of O-positive product for emergency use in hemorrhage due to injury.

The mortality from hemorrhage in trauma patients remains high. Early balanced resuscitation improves survival. These truths, balanced with the availability of local resources and our goals for positive regional impact, were the foundation for the development of our prehospital whole blood initiative-using low-titer cold-stored O RhD-positive whole blood. The main concern with use of RhD-positive blood is the potential development of isoimmunization in RhD-negative patients. We used our retrospective massive transfusion protocol (MTP) data to analyze the anticipated risk of this change in practice. In 30 months, of 124 total MTP patients, only one female of childbearing age that received an MTP was RhD-negative. With the risk of isoimmunization very low and the benefit of increased resources for the early administration of balanced resuscitation high, we determined that the utilization of low-titer cold-stored O RhD-positive whole blood would be safe and best serve our community.

The association between glucose challenge test, obesity and pregnancy outcome in 6390 non-diabetic women.

OBJECTIVE: To evaluate the association between obesity, glucose challenge test (GCT) and pregnancy outcome. METHODS: A prospective cohort study of 6854 consecutive gravid patients screened for gestational diabetes (GDM) using 50-gram GCT, at 24-28 weeks' gestation was performed. A screening value 130 mg/dl was followed by 100 gr oral GTT. Patients who were diagnosed with GDM were excluded. For purpose of analysis patients were categorized by prepregnancy BMI and by different GCT thresholds. Maternal outcome was defined by rate of preeclampsia, gestational age at delivery, cesarean section (CS) rate and the need for labor induction. Neonatal outcome was defined by fetal size (macrosomia/LGA), arterial cord pH, respiratory complications and neonatal intensive care unit (NICU) admission. RESULTS: Overall, a positive GCT result (GCT > or = 130 mg/dl) was identified in 2541/6854 (37%) women. GDM was further diagnosed in 464/6854 (6.8%) of subjects. In both groups of screening results ( > 130 mg/dl and < 130 mg/dl), the obese women were significantly older, gained more weight during pregnancy and had a lower rate of nulliparity in comparison to the non obese women. The obese women had higher rates of macrosomia, LGA and induction of labor. No difference was found in mean birth weight, the total rate of cesarean section, preterm delivery, 5 minute Apgar score < or = 7, mean arterial cord pH, NICU admission and a need for respiratory support in comparison to non obese women in both groups of screening results. A gradual increase in the rate of macrosomia, LGA and cesarean section was identified in both obese and non-obese women in relation to increasing GCT severity categories. CONCLUSION: Fetal size and cesarean section rate are associated with the degree of carbohydrate intolerance (screening results). Furthermore, obesity remains the main contributor impacting fetal size.

Glucose screening in Mexican-American women.

OBJECTIVE: We sought to describe the predictive value for gestational diabetes mellitus (GDM) using different glucose challenge test thresholds in Mexican-American women. METHODS: A prospective population-based study of 6,857 gravid women, who were tested with a 50-g glucose challenge test at 24-28 weeks of gestation, was performed. A screening value of 130 mg/dL or greater was followed by a 3-hour, 100-g oral glucose tolerance test. Gestational diabetes mellitus was diagnosed by 2 or more abnormal values using the Carpenter and Coustan criteria. For purpose of analysis, GDM diagnosis was categorized with glucose challenge test values in 10-mg/dL increments. A comparison between Carpenter-Coustan and the National Diabetic Data Group criteria for GDM diagnosis was performed for each glucose challenge test threshold category. Sensitivity and specificity for GDM diagnosis were further calculated for different glucose challenge test thresholds (130, 135, and 140 mg/dL). RESULTS: Overall, GDM was diagnosed in 469 of 6,857 (6.8%) women, and one abnormal oral glucose tolerance test value was tested in 351 of 6,857 women (5.1%). Normal glucose challenge test results (threshold less than 130 mg/dL) were obtained in 4,316 of 6,857 women. An elevated glucose challenge test value increases the risk of GDM, but even in high glucose challenge test thresholds (more than 180 mg/dL), the predictive value for GDM was only 50%. The sensitivity and specificity for GDM diagnosis using 3 different glucose challenge test thresholds were as follows: threshold 130 mg/dL or more: 97% and 63%; threshold 135 mg/dL or more: 91% and 73%; and threshold 140 mg/dL or more: 85% and 78%, respectively. CONCLUSION: Data suggests that an elevated glucose challenge test level cannot be used as a single diagnostic tool for GDM even in high test thresholds. A threshold of 130 mg/dL may be recommended as a screening threshold for GDM in Mexican-American women. LEVEL OF EVIDENCE: II-3

Neonatal intensive care unit admissions and their associations with late preterm birth and maternal risk factors in a population-based study.

OBJECTIVE: To assess the association of late preterm births (LPB [34(0/7)-36(6/7)]) and maternal risk factors with Neonatal Intensive Care Unit (NICU) admissions. METHODS: A retrospective cross-sectional analysis was conducted using data of all who delivered between 2000 and 2008. Statistical analysis was done using Chi-square and multivariable logistic regression. RESULTS: During the study period, 259,576 babies were delivered, and 11.6% were admitted to the NICU. Using logistic regression (NICU admission vs. no NICU admission), there was a 9-fold increased risk associated with preterm labor including preterm premature rupture membranes (PTL/PPROM) while LPB and essentially all other maternal risk factors were not significant. CONCLUSIONS: In our study, NICU admissions are more associated with PTL/PPROM rather than LPB and maternal risk factors.

The outpatient institutional antibiogram does not accurately reflect the susceptibility of prepartum group B streptococcal isolates to erythromycin and clindamycin.

This study compared the antimicrobial susceptibilities of 100 nonduplicate group B streptococcal (GBS) isolates from screening cultures of women attending OB-GYN clinics to a similar number of outpatient infection isolates recorded on the institutional antibiogram of a university teaching hospital. The screening GBS isolates were significantly more susceptible to erythromycin (72% versus 45%) and clindamycin (77% versus 48%) than the infection isolates.

The use of laparoscopic surgery in pregnancy: evaluation of safety and efficacy.

BACKGROUND: Laparoscopic surgery in pregnant women has become increasingly more common since the 1990s; however, the safety of laparoscopy in this population has been widely debated, particularly in emergent and urgent situations. METHODS: A retrospective chart review of all pregnant women following a nonobstetric abdominal operation at a University hospital between 1993 and 2007. Perioperative morbidity and mortality for the mother and fetus were evaluated. RESULTS: Ninety-four subjects were identified; 53 underwent laparoscopic procedures and 41 underwent open procedures. Cholecystectomy and appendectomy were performed in both groups with salpingectomy/ovarian cystectomy only in the laparoscopic group. No maternal deaths occurred, while fetal loss occurred in 3 cases within 7 days of the operation and in 1 case 7 weeks postoperatively. This and other perinatal complications occurred in 36.7% of the laparoscopic group and 41.7% of the open group. CONCLUSION: Laparoscopic appendectomy and cholecystectomy appear to be as safe as the respective open procedures in pregnant patients; however, this population in particular remains at risk for perinatal complications regardless of the method of abdominal access.

Overweight and obese in gestational diabetes: the impact on pregnancy outcome.

OBJECTIVE: We sought to investigate the relationship between prepregnancy weight, treatment modality (diet or insulin), level of glycemic control, and pregnancy outcome. STUDY DESIGN: We recruited women with gestational diabetes (GDM) from inner city prenatal clinics. All women were instructed in the use of an intensified management protocol using memory reflectance meters. Outcomes were analyzed according to maternal prepregnancy body mass index (BMI, kg/m 2 ) categories: normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), and obese (BMI > or =30), and by diet or insulin therapy and glycemic control (mean blood glucose <100 mg/dL = good control). Pregnancy outcome variables included a composite outcome (at least 1 of the following: neonatal metabolic complications, large-for-gestational age or macrosomic infants, NICU admission for >24 hours, and the need for respiratory support) (not including oxygen therapy). In addition to composite outcome, a bivariate analysis was performed for each single variable, including preeclampsia and cesarean section delivery. RESULTS: Four thousand and one women were enrolled. Obese women who achieved targeted levels of glycemic control had comparable pregnancy outcomes to normal weight and overweight women only when they were treated with insulin. Normal weight women treated with diet therapy who achieved targeted levels of glycemic control had good outcomes, but obese women treated with diet therapy who achieved targeted levels of glycemic control, nevertheless, had a 2- to 3-fold higher risk for adverse pregnancy outcome when compared with overweight and normal weight patients with well-controlled GDM. Women with GDM who failed to achieve established levels of glycemic control had significantly higher adverse pregnancy outcomes in all 3 maternal weight groups. CONCLUSION: In obese women with BMI > or =30 with GDM, achievement of targeted levels of glycemic control was associated with enhanced outcome only in women treated with insulin.

Insulin and glyburide therapy: dosage, severity level of gestational diabetes, and pregnancy outcome.

OBJECTIVE: We sought to investigate the association between glyburide dose, degree of severity in gestational diabetes mellitus (GDM), level of glycemic control, and pregnancy outcome in insulin- and glyburide-treated patients. STUDY DESIGN: In a secondary analysis of our previous randomized study, 404 women were analyzed. The association among glyburide dose, severity of GDM, and selected maternal and neonatal factors was evaluated. Severity levels of GDM were stratified by fasting plasma glucose (FPG) from the oral glucose tolerance test (OGTT). Infants with birth weight at or above the 90th percentile were considered large-for-gestational age (LGA). Macrosomia was defined as birth weight > or =4000 g. Well-controlled was defined as mean blood glucose < or =95 mg/dL. The association between glyburide- and insulin-treated patients by severity of GDM and neonatal outcome was evaluated. RESULTS: The dose received for the glyburide-treated patients was 2.5 mg-32%; 5 mg-23%; 10 mg-17%; 15 mg-8%; and 20 mg-20%. Patients were grouped into low (< or =10 mg) and high (>10 mg) daily dose of glyburide. A comparison between severity of the disease (fasting plasma glucose categories) and highest dose of glyburide revealed a significant difference between the low-95 FPG and the other severity categories (P = .02). Of patients in the well-controlled glycemic group, only 6% required the high dose of glyburide (>10 mg). In patients with poor glycemic control (mean blood glucose >95 mg/dL), 38% received the high dose of glyburide (P = .0001). Comparison between the high glyburide (>10 mg) and the low glyburide dosages (< or =10 mg) revealed that the rate of macrosomia was 16% vs 5% and LGA 22% vs 8%, (P = .01), respectively. No significant difference was found in composite outcome, metabolic complications, and Ponderal Index between the 2 dose groups. Stratification by disease severity revealed a significantly lower rate of LGA for both the glyburide- and insulin-treated subjects. No significant difference was found between metabolic, respiratory, and neonatal intensive care unit (NICU) for patients within each fasting plasma glucose severity category. CONCLUSION: Glyburide and insulin are equally efficient for treatment of GDM in all levels of disease severity. Achieving the established level of glycemic control, not the mode of pharmacologic therapy, is the key to improving the outcome in GDM.

Gestational diabetes: the consequences of not treating.

OBJECTIVE: Untreated gestational diabetes mellitus carries significant risks of perinatal morbidity at all severity levels; treatment will enhance outcome. STUDY DESIGN: A matched control of 555 gravidas, gestational diabetes mellitus diagnosed after 37 weeks, were compared with 1110 subjects treated for gestational diabetes mellitus and 1110 nondiabetic subjects matched from the same delivery year for obesity, parity, ethnicity, and gestational age at delivery. The nondiabetic subjects and those not treated for gestational diabetes mellitus were matched for prenatal visits. RESULTS: A composite adverse outcome was 59% for untreated, 18% for treated, and 11% for nondiabetic subjects. A 2- to 4-fold increase in metabolic complications and macrosomia/large for gestational age was found in the untreated group with no difference between nondiabetic and treated subjects. Comparison of maternal size, parity, and disease severity revealed a 2- to 3-fold higher morbidity rate for the untreated groups, compared with the other groups. CONCLUSION: Untreated gestational diabetes mellitus carries significant risks for perinatal morbidity in all disease severity levels. Timely and effective treatment may substantially improve outcome.

The association between preeclampsia and the severity of gestational diabetes: the impact of glycemic control.

OBJECTIVES: We sought to determine if the rate of preeclampsia is related to the severity of gestational diabetes mellitus (GDM), and if it can be decreased by optimizing glycemic control. STUDY DESIGN: A retrospective analysis of prospectively collective data of 1813 patients with GDM was performed to determine the rate of preeclampsia. Patients were stratified after treatment was begun by level of glycemic control (well controlled was defined as mean blood glucose <95 mg/dL). The extent of hyperglycemia was analyzed by the level of the abnormality in the oral GTT and by the degree of abnormality of daily glucose control after treatment has begun. Severity of GDM was categorized using fasting plasma glucose (FPG) on a 3-hour oral GTT by 10 mg/dL increments. RESULTS: Overall, preeclampsia was diagnosed in 9.6% (174/1813) of diabetic patients. The GDM subjects who developed preeclampsia were significantly younger, had a higher nulliparity rate, were more obese, and gained significantly more weight during pregnancy. However, no difference was found in glycemic profile characteristics between the 2 groups. A comparison between patients with FPG <105 and FPG >105 revealed that the rate of preeclampsia increased significantly, 7.8% vs 13.8%, (O.R 1.81, 95%CI 1.3-2.51). For GDM patients with only mild hyperglycemia (FPG <105 mg/dL), no significant difference was found in the rate of preeclampsia. Preeclampsia rate was further evaluated in relation to level of glycemic control; for the well-controlled patients (mean blood glucose [MBG] <95 mg/dL, n=994), similar rates of preeclampsia were found between each category of FPG severity. In contrast, in poorly controlled patients (MBG >95 mg/dL, n=819), a comparison between severity threshold of FPG <115 and FPG >115 revealed that the preeclampsia rate was 9.8% vs 18% (O.R 2.56, 95%C.I. 1.5-4.3). In a logistic regression model, only prepregnancy BMI (O.R 2.3, 95%CI 1.16-2.30) and severity of GDM (O.R 1.7, 95%CI 1.21-2.38) were independently and significantly associated with an increased risk of preeclampsia. CONCLUSION: The rate of preeclampsia is influenced by the severity of GDM and prepregnancy BMI. Optimizing glucose control during pregnancy may decrease the rate of preeclampsia, even in those with a greater severity of GDM.