RESUMO
Objectives: Among women with severe PPH (sPPH) in France and the Netherlands, we compared incidence of adverse maternal outcome (major obstetric hemorrhage (≥2.5L blood loss) and/or hysterectomy and/or mortality) by mode of delivery. Second, we compared use and timing of resuscitation and transfusion management, second-line uterotonics and uterine-sparing interventions (intra-uterine tamponade, compression sutures, vascular ligation, arterial embolization) by mode of delivery. Methods: Secondary analysis of two population-based studies of women with sPPH in France and the Netherlands. Women were selected by a harmonized definition for sPPH: (total blood loss ≥ 1500 ml) AND (blood transfusion of ≥ 4 units packed red blood cells and/or multicomponent blood transfusion). Findings: Incidence of adverse maternal outcome after vaginal birth was 793/1002, 9.1 % in the Netherlands versus 88/214, 41.1 % in France and 259/342, 76.2% versus 160/270, 59.3% after cesarean. Hemostatic agents such as fibrinogen were administered less frequently (p < 0.001) in the Netherlands (vaginal birth: 83/1002, 8.3% versus 105/2014, 49.5% in France; cesarean: 47/342, 13.7% and 152/270, 55.6%). Second-line uterotonics were started significantly later after PPH-onset in the Netherlands than France (vaginal birth: 46 versus 25 min; cesarean: 45 versus 18 min). Uterine-sparing interventions were less frequently (p < 0.001) applied in the Netherlands after vaginal birth (394/1002,39.3 %, 134/214, 62.6%) and cesarean (133/342, 38.9 % and 155/270, 57.4%), all initiated later after onset of refractory PPH in the Netherlands. Interpretation: Incidence of adverse maternal outcome was higher among women with sPPH in the Netherlands than France regardless mode of birth. Possible explanatory mechanisms are earlier and more frequent use of second-line uterotonics and uterine-sparing interventions in France compared to the Netherlands.
RESUMO
Postpartum hemorrhage is the leading cause of maternal mortality and severe morbidity. Despite efforts to improve maternal outcomes, management of postpartum hemorrhage still faces at least four challenges, discussed in this review. First, current definitions for severe postpartum hemorrhage hamper early identification of women with a high risk of adverse outcomes. Adaptations to the definitions and the use of clinical tools such as shock index and early warning systems may facilitate this early identification. Second, surgical and radiological interventions to prevent hysterectomy are not always successful. More knowledge on the influence of patient and bleeding characteristics on the success rates of these interventions is necessary. Scarce data suggest that early timing of intrauterine balloon tamponade may improve maternal outcomes, whereas early timing of arterial embolization seems to be unrelated to maternal outcomes. Third, fluid resuscitation with crystalloids and colloids is unavoidable in the early phases of postpartum hemorrhage but may result in dilutional coagulopathy. Effects of different volumes of clear fluids on the occurrence of dilutional coagulopathy and maternal outcomes is unknown. Fourth, a better understanding of diagnosis and correction of coagulopathy during postpartum hemorrhage is needed. Low plasma fibrinogen levels at the start of postpartum hemorrhage predict progression to severe hemorrhage, but standard coagulation screens are time consuming. A solution may be point-of-care coagulation testing; however, clinical usefulness during postpartum hemorrhage has not been demonstrated. To date, early administration of tranexamic acid is the only hemostatic intervention that was proven to improve outcomes in women with postpartum hemorrhage.
