Body mass index and severe postpartum hemorrhage.

BACKGROUND/AIMS: The purpose of this study was to determine the relationship between maternal characteristics and severe postpartum hemorrhage (PPH). METHODS: Medical records of women who delivered at Duke University Hospital between 2001 and 2004 with an ICD-9 code for PPH were reviewed. Women with PPH who received blood component therapy (severe PPH) were selected as cases and compared with controls matched for age, parity and mode of delivery. RESULTS: Among 12,476 deliveries, there were 109 women with severe PPH. Hispanic women had an almost fourfold increase in the odds of severe PPH [OR 3.9 (1.8, 8.7)] that persisted when controlling for other significant predictors of PPH. Women with PPH were almost two times more likely [OR 1.8 (1.1, 3.1)] to have a BMI <30 when controlling for Hispanic ethnicity, oxytocin exposure, labor induction, treatment with magnesium and chorioamnionitis. CONCLUSION: Systemic factors as well as obstetrical factors modify the risk of severe PPH. Hispanic women and women with a BMI <30 are more likely to have severe PPH. When mode of delivery is controlled for, BMI ≥30 is associated with a reduced risk of severe PPH.

Oxytocin exposure during labor among women with postpartum hemorrhage secondary to uterine atony.

OBJECTIVE: We sought to determine if women with severe postpartum hemorrhage (PPH) secondary to uterine atony received greater amounts of oxytocin during labor compared to women without PPH. STUDY DESIGN: Subjects with severe PPH secondary to uterine atony, who received a blood transfusion, were compared to matched controls. Total oxytocin exposure was calculated as the area under the concentration curve (mU/min*min). Variables were compared using paired t test, χ², and logistic regression. RESULTS: Women with severe PPH had a mean oxytocin area under the curve of 10,054 mU compared to 3762 mU in controls (P < .001). After controlling for race, body mass index, admission hematocrit, induction status, magnesium therapy, and chorioamnionitis using logistic regression, oxytocin area under the curve continued to predict severe PPH. CONCLUSION: Women with severe PPH secondary to uterine atony were exposed to significantly more oxytocin during labor compared to matched controls.

Blood component therapy in postpartum hemorrhage.

BACKGROUND: The purpose of this study was to examine blood component therapy in the treatment of postpartum hemorrhage. STUDY DESIGN AND METHODS: Records were reviewed for subjects who delivered during the 5-year period between January 1, 2000, and December 31, 2004, at Duke University Medical Center and had postpartum hemorrhage coded as International Classification of Diseases Version 9 (ICD-9) codes 666.0 X, 666.1X, and 666.2X. Records were reviewed to determine whether blood components had been transfused. Data were analyzed using descriptive statistics and the chi-square test. RESULTS: During the 5-year period from January 1, 2000, to December 31, 2004, there were 12,476 deliveries at Duke University Medical Center. A total of 671 or 5.4% had a diagnosis of postpartum hemorrhage. A total of 108 (0.87%) required blood component therapy, 106 received red blood cells (RBCs), and 30 (0.24%) received components other than RBCs. Of these 30, all received fresh-frozen plasma (1-20 units); eight received one to two transfusions of cryoprecipitate (each containing 10 units); and five received between one and three transfusions of apheresis or pooled whole blood platelets. None of the women received hemostatic agents such as antifibrinolytic medication, DDAVP, recombinant Factor VIIa, or clotting factor concentrates. None of the women experienced thromboembolic events postpartum. There were no deaths and none of the women developed organ dysfunction as a result of hemorrhage. CONCLUSION: Among 12,476 deliveries at a major United States medical center with a modern blood bank and readily available blood component therapy, there were no deaths or organ dysfunction as a consequence of severe postpartum hemorrhage.

Characterization of antithrombin levels in pregnancy.

OBJECTIVE: To characterize antithrombin (AT) levels in normal pregnancy. METHODS: We performed secondary analyses with data from 3 studies. Using a single measurement from each subject in the first analysis (cross-sectional), we correlated AT levels with gestational age from the middle of the second trimester throughout the third trimester of pregnancy. Using serial measurements in a second analysis (cohort), we compared AT levels between the late first and second trimesters of pregnancy and baseline (the level at 6 weeks postpartum). Using serial measurements in a third analysis (cohort), we analyzed the pattern of change in AT levels in the immediate postpartum period. Assays of AT activity were performed using the Dade Behring (Siemens) Berichrom Antithrombin III Chromogenic Assay. AT levels were correlated with gestational age using the Pearson correlation coefficient and compared between the different time points using one-way ANOVA. RESULTS: Overall, AT levels were 20% lower than baseline during pregnancy (p<0.01). There was no significant difference between AT levels obtained between late first trimester and late second trimester. From midtrimester to term, however, AT levels were negatively correlated with gestational age with a 13% drop during this period of time (r=-0.26 [-0.39, -0.11]; p<0.01). Immediately after childbirth, AT levels fell precipitously to 30% below baseline (p<0.05) and reached a nadir 12 hours postpartum before rising and returning to baseline by 72 hours postpartum. CONCLUSION: It appears that antithrombin (AT) is consumed at the time of delivery. Our findings have implications for AT replacement or even anticoagulation at the time of delivery.

Near-miss maternal mortality: cardiac dysfunction as the principal cause of obstetric intensive care unit admissions.

OBJECTIVE: Evaluation of "near-miss" maternal mortality is a robust surveillance method to assess the quality of obstetric care and determinants of poor maternal outcome. To evaluate near-miss maternal mortality, we examined patient characteristics and maternal and neonatal outcomes for an obstetric population admitted to intensive care units (ICUs) in a tertiary care center. METHODS: Pregnant and postpartum patients admitted to Duke University Medical Center ICUs from January 2005 to April 2011 were enrolled. Demographic, diagnostic, and outcome data were abstracted from the medical records for analysis. RESULTS: A total of 86 women were included in the study. No participants were included more than once. The mean maternal age (±standard deviation) was 29.8±7.2 years. When racial and ethnic differences were examined, African American women were more likely to be admitted to the ICU. Significant ethnic differences in body mass index (BMI) were noted with African American women (mean BMI 35) and Hispanic women (mean BMI 36) having significantly higher BMIs than white women (mean BMI 28). The majority of patients (87%) were admitted postpartum. The mean length of stay was 10 days. The leading reason for admission to the ICUs was maternal cardiac disease (36%) followed by complications from hemorrhage (29%), sepsis (9%), and hypertensive disorders (9%). No significant racial or ethnic differences in maternal medical comorbidities or neonatal outcome were noted. CONCLUSION: In this obstetric population, the leading reason for ICU admissions was cardiac disease. The increasing prevalence of advanced maternal age, congenital heart disease, obesity, diabetes, and hypertension among women who are of childbearing age may be contributing factors. LEVEL OF EVIDENCE: III.

Lack of genomic imprinting of DNA primase, polypeptide 2 (PRIM2) in human term placenta and white blood cells.

PRIM2, encoding a subunit of primase involved in DNA replication and transcription, is expressed in the placenta and is crucial for mammalian development and growth. Its role in placental function is not well understood. Recently, PRIM2 was reported as imprinted in human white blood cells (WBC). We report here our failure to confirm imprinting of the PRIM2 locus in human placenta or WBC. The discordance between our results and those of others are likely due to an incorrectly annotated PRIM2 pseudogene found in the human genome database.