Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage.

BACKGROUND: Delays in the detection or treatment of postpartum hemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and early diagnosis of postpartum hemorrhage, and delayed or inconsistent use of effective interventions may be able to be addressed by a treatment bundle. METHODS: We conducted an international, cluster-randomized trial to assess a multicomponent clinical intervention for postpartum hemorrhage in patients having vaginal delivery. The intervention included a calibrated blood-collection drape for early detection of postpartum hemorrhage and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation), supported by an implementation strategy (intervention group). Hospitals in the control group provided usual care. The primary outcome was a composite of severe postpartum hemorrhage (blood loss, ≥1000 ml), laparotomy for bleeding, or maternal death from bleeding. Key secondary implementation outcomes were the detection of postpartum hemorrhage and adherence to the treatment bundle. RESULTS: A total of 80 secondary-level hospitals across Kenya, Nigeria, South Africa, and Tanzania, in which 210,132 patients underwent vaginal delivery, were randomly assigned to the intervention group or the usual-care group. Among hospitals and patients with data, a primary-outcome event occurred in 1.6% of the patients in the intervention group, as compared with 4.3% of those in the usual-care group (risk ratio, 0.40; 95% confidence interval [CI], 0.32 to 0.50; P<0.001). Postpartum hemorrhage was detected in 93.1% of the patients in the intervention group and in 51.1% of those in the usual-care group (rate ratio, 1.58; 95% CI, 1.41 to 1.76), and the treatment bundle was used in 91.2% and 19.4%, respectively (rate ratio, 4.94; 95% CI, 3.88 to 6.28). CONCLUSIONS: Early detection of postpartum hemorrhage and use of bundled treatment led to a lower risk of the primary outcome, a composite of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding, than usual care among patients having vaginal delivery. (Funded by the Bill and Melinda Gates Foundation; E-MOTIVE ClinicalTrials.gov number, NCT04341662.).

Is estimated peri-operative glomerular filtration rate associated with post-operative mortality in fractured neck of femur patients?

AIM: Comparison of renal function in patients who died within 30 days of surgery for hip fractures with surviving patients matched for age, type of surgery, type of anaesthesia and clinical assessment of fitness for surgery. MATERIALS & METHODS: A retrospective case-control study of 80 patients was performed. Pre- and post-operative urea, creatinine, estimated glomerular filtration rate (eGFR), sodium and potassium of 40 patients who died within 30 days post-surgery (cases) were compared with 40 patients who survived matched for age, sex, surgical procedure and pre-operative ASA grade (controls). Statistical analysis involved univariable analysis by paired t-test and logistic conditional regression analysis. RESULTS: Pre- and post-operative mean serum creatinine were significantly higher in patients who died compared with surviving controls (pre-op 108.2 vs. 90.2 micromol/l [p=0.002], post-op 103.9 vs. 87.1 micromol/l [p=0.003]). However, mean creatinine values for both groups were still within normal laboratory reference ranges. Mean serum urea was also higher in patients who died (pre-op 8.81 vs. 6.75 mmol/l [p=0.010] and post-op 9.30 vs. 6.63 mmol/l [p=0.004], respectively). Pre- and post-operative eGFR was significantly lower in those patients who died within 30 days of hip fracture surgery (pre-op 61.75 vs. 68.78 ml/min per 1.73 m(2) [p=0.011], post-op 63.03 vs. 76.03 ml/min per 1.73 m(2) [p=0.009]). The mean eGFR values for survivors and non-survivors fell in the chronic kidney disease mild renal impairment category. There were no significant differences in mean serum sodium or potassium concentration between groups. Stepwise conditional logistic regression analysis, showed that after allowing for creatinine, urea was no longer significantly related to mortality. CONCLUSION: These results suggest that when allowance is made for demography, fitness for surgery and surgical procedure, subtle reductions in eGFR are still associated with mortality risk. However, these are of questionable clinical use.