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BACKGROUND: The aim of our study is to describe maternal and neonatal morbidity and mortality in patients undergoing trial of labor after cesarean from the Consortium on Safe Labor. METHODS: This was a secondary analysis of the Consortium on Safe Labor database, a retrospective cohort study over a 7 year study period. Maternal and neonatal outcomes were evaluated based on desired delivery mode: planned elective repeat cesarean delivery or trial of labor after cesarean. RESULTS: Of 9858 patients in our analysis, our study population had 4400 patients (45%) who desired trial of labor after cesarean and 5458 patients (55%) who desired elective repeat cesarean delivery. Women who attempted trial of labor after cesarean compared to those who had an elective repeat cesarean delivery were more likely to have an obstetric hemorrhage (adjusted odds ratio 1.6; 95% CI 1.3 -2.0) and blood transfusion (adjusted odds ratio 2.3; 95% CI 1.6 -3.2). CONCLUSION: Maternal morbidity in women undergoing trial of labor after cesarean was predominantly hemorrhage-related.
Subject(s)
Labor, Obstetric , Trial of Labor , Pregnancy , Infant, Newborn , Humans , Female , Retrospective Studies , HemorrhageABSTRACT
BACKGROUND: Hemorrhage anticipation and management has shifted significantly over the past decade due to evolution of data surrounding management of obstetric hemorrhage. Limited data exists which describe the practical use and clinical application of hemorrhage management. Our goal was to identify obstetric hemorrhage management patterns in a cohort of practicing Maternal Fetal Medicine physicians. METHODS: We administered a survey to Maternal Fetal Medicine (MFM) fellows and faculty that addressed the management of hemorrhage including risk assessment, uterotonic use, antifibrinolytic use, cell saver use, and abnormal placentation management. An email was sent out regarding the survey to a listserv of all Maternal Fetal Medicine fellow program coordinators to disseminate to their faculty and fellows. Eighty responses were obtained. RESULTS: A total of 78 surveys were analyzed. Participants preferred methylergonovine as a first line agent (nâ=â57; 73%, nâ=â62; 80%). Most participants would consider using cell salvage when also activating MTP (28, 48%) or during scheduled deliveries who are high risk of hemorrhage (40, 69%). Approximately a third of providers would use TXA (tranexamic acid) prophylactically (nâ=â21; 28%). Only 26% of MFM fellows felt comfortable performing cesarean hysterectomy without Gynecologic Oncology. CONCLUSION: In comparison to prior reports, TXA use has increased substantially. Further, when looking at the management of abnormal placentation, the use of magnetic resonance imaging and embolization have both increased. Possibly due to the rise in centers of excellence for treatment of accreta spectrum disorders, Maternal Fetal Medicine fellows still feel largely unprepared to perform a cesarean hysterectomy without Gynecologic Oncology.
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OBJECTIVE: The objective of this study is to develop a model that will help predict the risk of blood transfusion using information available prior to delivery. STUDY DESIGN: The study is a secondary analysis of the Consortium on Safe Labor registry. Women who had a delivery from 2002 to 2008 were included. Pre-delivery variables that had significant associations with transfusion were included in a multivariable logistic regression model predicting transfusion. The prediction model was internally validated using randomly selected samples from the same population of women. RESULTS: Of 156,572 deliveries, 5,463 deliveries (3.5%) required transfusion. Women who had deliveries requiring transfusion were more likely to have a number of comorbidities such as preeclampsia (6.3% versus 4.1%, OR 1.21, 95% CI 1.08-1.36), placenta previa (1.8% versus 0.4%, OR 4.11, 95% CI 3.25-5.21) and anemia (10.6% versus 5.4%, OR 1.30, 95% CI 1.21-1.41). Transfusion was least likely to occur in university teaching hospitals compared to community hospitals. The c statistic was 0.71 (95% CI 0.70-0.72) in the derivation sample. The most salient predictors of transfusion included type of hospital, placenta previa, multiple gestations, diabetes mellitus, anemia, asthma, previous births, preeclampsia, type of insurance, age, gestational age, and vertex presentation. The model was well-calibrated and showed strong internal validation. CONCLUSION: The model identified independent risk factors that can help predict the risk of transfusion prior to delivery. If externally validated in another dataset, this model can assist health care professionals counsel patients and prepare facilities/resources to reduce maternal morbidity.
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INTRODUCTION: Although antifibrinolytic agents are used to prevent and treat hemorrhage, there are concerns about a potential increased risk for peripartum venous thromboembolism. We sought to determine the impact of tranexamic acid and É-aminocaproic acid on in vitro clotting properties in pregnancy. METHODS: Blood samples were obtained from healthy pregnant, obese, and preeclamptic pregnant women (nâ=â10 in each group) prior to delivery as well as from healthy non-pregnant controls (nâ=â10). Maximum clot firmness (MCF) and clotting time (CT) were measured using rotation thromboelastometry in the presence of tranexamic acid (3, 30, or 300 µg/mL) or É-aminocaproic acid (30, 300, or 3000 µg/mL). ANOVA and regression analyses were performed. RESULTS: Mean whole blood MCF was significantly higher in healthy pregnant vs. non-pregnant women (66.5 vs. 57.5âmm, pâ<â0.001). Among healthy pregnant women, there was no significant difference between mean MCF (whole blood alone, and with increasing tranexamic acid dosesâ=â66.5, 66.1, 66.4, 66.3âmm, respectively; pâ=â0.25) or mean CT (409, 412, 420, 424âsec; pâ=â0.30) after addition of tranexamic acid. Similar results were found using É-aminocaproic acid. Preeclamptic women had a higher mean MCF after the addition of É-aminocaproic acid and tranexamic acid (pâ=â0.05 and pâ=â0.04, respectively) compared to whole blood alone. CONCLUSIONS: Pregnancy is a hypercoagulable state, as reflected by an increased MCF compared to non-pregnant women. Addition of antifibrinolytic therapy in vitro does not appear to increase MCF or CT for non-pregnant, pregnant, and obese women. Whether antifibrinolytics are safe in preeclampsia may require further study.
Subject(s)
Aminocaproic Acid/pharmacology , Antifibrinolytic Agents/pharmacology , Blood Coagulation/drug effects , Fibrinolytic Agents/pharmacology , Tissue Plasminogen Activator/pharmacology , Tranexamic Acid/pharmacology , Adult , Aminocaproic Acid/therapeutic use , Antifibrinolytic Agents/therapeutic use , Case-Control Studies , Female , Humans , In Vitro Techniques , Obesity/blood , Peripartum Period , Postpartum Hemorrhage/drug therapy , Postpartum Hemorrhage/prevention & control , Pre-Eclampsia/blood , Pregnancy , Pregnancy Complications/blood , Pregnancy Trimester, Third , Thrombelastography , Tranexamic Acid/therapeutic use , Young AdultABSTRACT
OBJECTIVE: To evaluate experiences related to obstetric hemorrhage and suspected abnormal placentation among first year maternal-fetal medicine fellows. STUDY DESIGN: A cross-sectional anonymous survey was administered at the Society for Maternal-Fetal Medicine fellow retreat in March 2013. Fellows were asked about management strategies that reflected both their individual and institutional practices. RESULTS: There was a 56% response rate (55/98). In cases of postpartum hemorrhage due to uterine atony, there was variable use of the uterine tamponade device. The median incremental time for balloon deflation was every 5 hours (IQRâ=â2-12). Compared to the east coast, fellows from the west coast performed more hysterectomies (mean±SD; 2.9±2.4 vs. 1.2±1.2, pâ=â0.004). During a peripartum hysterectomy, 29% of fellows used a handheld cautery device such as Ligasure® or Gyrus®. Fifty-six percent responded that their institution never recommend planned delayed hysterectomies for abnormal placental implantation. CONCLUSION: There is wide variation in practice among first year maternal-fetal medicine fellows in management of peripartum hysterectomy and postpartum hemorrhage.