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Criteria for transfusion in severe postpartum hemorrhage: analysis of practice and risk factors
European Journal of Obstetrics & Gynecology and Reproductive Biology 112 (2004) 61–64
Criteria for transfusion in severe postpartum hemorrhage: analysis of practice and risk factors Fabien Reyal, Olivier Sibony*, Jean-Franc¸ois Oury, Dominique Luton, Jacques Bang, Philippe Blot Hoˆpital Robert Debre´, 48 Boulevard Se´rurier, 75019 Paris, France Received 6 August 2002; accepted 17 April 2003
Abstract Objective: To analyze the accuracy of postpartum hemorrhage risk factors to determine patients at risk of severe postpartum hemorrhage and transfusion. Population and methods: Retrospective cohort study from a database in one high-risk obstetric unit over a 7-year period. Results: In a cohort of 19,204 deliveries, 44 patients were transfused of whom five were given frozen fresh plasma only. Of the 39 who received red blood cells, 35 received at least three units. Multivariate analysis of postpartum hemorrhage risk factors revealed a significant role of placenta previa/accreta, cesarean section, multiple pregnancy, prematurity and vascular disease. Nevertheless 28% of women transfused had none of these risk factors. Conclusion: The percentage of patients transfused has probably decreased markedly with improved prevention, surveillance and treatment. This study emphasizes that the transfusion risk in the presence of anomalous placental insertion justifies special obstetrical and anesthetic management. # 2003 Published by Elsevier Ireland Ltd. Keywords: Transfusion; Postpartum hemorrhage; Risk factors
1. Introduction Human immunodeficiency virus, hepatitis B and C and more recently Prion diseases have led to major changes in blood transfusion practices despite clear improvements in the safety of biological products. The continuing risk of contamination complicates blood transfusion decisions, particularly during pregnancy. Transfusion is one of the main tool for the treatment of severe postpartum hemorrhage. It’s a life-saving procedure and an important criteria of quality of care of pregnant women. We consider that severe postpartum hemorrhage is well defined by the use of postpartum transfusion. Its reduction can be analyzed as an amelioration of health care service. We describe here our transfusion practice associated with severe postpartum hemorrhage between 1992 and 1998 at the Robert Debre´ University Teaching Hospital in Paris. We analyze the accuracy of postpartum hemorrhage risk factors to determine patients at risk of severe postpartum hemorrhage and transfusion. We speculate to our ability to reduce them by prevention
* Corresponding author. Tel.: þ33-140032454; fax: þ33-140032480. E-mail address: [email protected] (O. Sibony).
0301-2115/$ – see front matter # 2003 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejogrb.2003.04.001
methods. We discuss the opportunity to use predelivery blood ordering, auto-transfusion program or cell saver.
2. Materials and methods We conducted a retrospective cohort study of patients who gave birth between 1st January 1992 and 31st December 1998 at the maternity ward of the Robert Debre´ University Teaching Hospital in Paris. Our unit is located in pediatrics hospital with neonatal intensive care unit and significant prenatal diagnosis activity. By this way, our patients compose a high risk population. For this purpose we used a database established using Microsoft Access 2000 (Microsoft1) and updated daily since 1992. The inclusion criteria were singleton or multiple pregnancy, delivery after 24 weeks of amenorrhea, transfusion of red blood cells and/ or frozen plasma in the 21 days following delivery in the presence of a hemorrhagic complication. The indications for transfusion in our department were identical to the United States guidelines: Acute blood loss of many amount if there is clinical evidence of inadequate oxygen-carrying capacity; a Hb of <7 g/dl (hematocrit of 0.21) if not due to a treatable cause; symptomatic anemia
62
F. Reyal et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 112 (2004) 61–64
regardless of Hb level; patients receiving general anesthesia if their preoperative Hb is <7 g/dl; a major blood letting operation and a Hb of <10 g/dl (hematocrit of <0.30). The exclusion criteria were elective termination of pregnancy, delivery before 24 weeks of amenorrhea, transfusion in the absence of hemorrhage. The control population was analyzed by means of the databank. The population of transfused patients was studied directly by complete review of the medical records. The list of transfused patients was checked against the register kept by the anesthetists and the blood bank register and none transfusion was missed. The hemorrhagic risk factors were chosen on the basis of literature data [1,2]: grand multiparity (three or more children), multiple pregnancy, vascular disease (pre-eclampsia, HELLP syndrome, acute hepatic steatosis, placental abruption), maternal thrombopenia below 150,000 mm3, placenta previa/accreta, prematurity, hyperthermia above 38 8C during labor, forceps delivery, cesarean section, birth weight above 4000 g. Results are expressed as mean S:D: or percentage, as appropriate. Categorical variables were analyzed by chisquare test or Fisher exact test. Odds-ratio are reported with 95% confidence intervals. A P-value of 0.05 or less was considered to indicate statistical significance. Multivariate logistic regression was realized by the means of SPSS 10.0 software; few interaction were consider in the model.
3. Results The control group included a total of 19,138 deliveries. The mean age of the patients was 30:2 4:8 years and mean parity was 1:8 1:14. There were 18,610 singleton pregnancies (97.2%), 478 twin pregnancies (2.5%) and 51 triplet pregnancies (0.3%). 16,891 patients were delivered vaginally (88%). 8048 patients presented no hemorrhagic risk factor (42%). 11,090 patients had at least one hemorrhagic risk factor (58%). Hence, 4523 patients underwent a forceps delivery (24%), 3813 had at least three children (20%), 2248 underwent cesarean section (12%), 1612 had a scarred uterus (9%), 1503 gave birth prematurely (8%), 1277 had a newborn of birth weight above 4000 g (7%), 960 had hyperthermia above 38 8C during labor (5%), 815 had thrombopenia below 150,000 mm3 (4%), 780 had vascular disease (4%), 528 had a multiple pregnancy (3%) and 154 placenta praevia/accreta (0.8%). Sixty-six (0.34%) patients were transfused during the study period, of whom 44 (0.23%) were included in the study and 22 were excluded on the basis of the previously defined criteria (5 medical interruption of pregnancy, 5 cervical maturation and induction of labor for unexplained in utero fetal death without initial disseminated intravascular coagulopathy, 10 before labor transfusion without postpartum hemorrhage; 5 sickle cell disease, 1 Willebrand disease,
4 thrombopenia; 2 autotransfusion after delivery without hemorrhagic situation). Twenty-three patients among 10,000 deliveries received transfusions. The distribution of hemorrhagic risk factors in transfused patients was as follows: 12 patients had at least three children (27%), 7 had a multiple pregnancy (16%), 16 gave birth prematurely (36%), 11 were delivered by forceps (25%), 26 underwent cesarean section (59%), 10 had vascular disease (23%), 4 thrombopenia below 150,000 mm3 (9%), 9 a scarred uterus (20%) and 6 placenta previa and/or accreta (14%). One newborn weighed over 4000 g (2%). None had hyperthermia during labor. The etiologies underlying hemorrhage in transfused patients were as follows: isolated uterine atony (14 cases, 32%), pre-eclampsia and/or placental abruption (10 cases, 23%), cervical and vaginal tears (8 cases, 18%), placenta previa and/or accreta (6 cases, 14%), poorly tolerated postpartum anemia (6 cases, 14%). No patient died. Three patients were transferred to intensive care because of severe pre-eclampsia (7%). Three patients (7%), underwent hysterectomy to ensure hemostasis, two because of placenta accreta and one due to uterine atony resistant to medical treatment together with type IV Ehlers-Danlos syndrome. Thirty-nine patients received red blood cells transfusion and five were given frozen fresh plasma only. Two to nine units of red blood cells were transfused. Among the 39 patients, 35 received at least three units and 19 also received frozen plasma. Eleven patients received transfusions of red blood cells alone at least 24 h after delivery. One to 18 units of frozen plasma were transfused in 24 of 44 patients. In all cases, transfusion was immediately postpartum and in 5 of 24 cases was not combined with transfusion of red blood cells. Mean hemoglobin in the 44 transfused patients was 5.8 g/dl 1:76. The mean prothrombin time in the patients with disseminated intravascular coagulation (DIVC) was 36:9 13:14% and the mean platelet count was 73,187 35,523 units/mm3. Univariate analysis of severe postpartum hemorrhage/ transfusion risk factors showed that multiple pregnancy, prematurity, vascular disease, placenta previa and/or accreta, scarred uterus and cesarean section were significantly associated with an increased risk of severe postpartum hemorrhage and transfusion (Table 1). In contrast, multiparity of three or more, primiparity, maternal thrombopenia below 150,000 mm3, forceps delivery and birth weight above 4000 g were not associated with an increased risk of severe postpartum hemorrhage and transfusion. Analysis of confounding factors and interaction factors was limited by the small number of patients transfused and the consequent lack of statistical power. We can, nonetheless, assert that part of the morbidity associated with transfusion in the case of premature delivery was linked to the performance of cesarean section. There was a likely interaction between the cesarean section factor and the vascular disease, scarred uterus and placenta previa and/or accreta factors. There was
F. Reyal et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 112 (2004) 61–64
63
Table 1 Hemorrhage risks factors in transfused patients: univariate and multivariate logistic regression analysis Risk factors
Multiple pregnancy Multiparity Primiparity Prematurity Hypertension Thrombopenia Scarred uterus Placenta previa and/or accreta Forceps delivery Cesarean section Birth weight 4000 g
Control group (n ¼ 19138)
Transfused group (n ¼ 44)
Univariate analysis OR
95% CI
OR
95% CI
529 3813 8786 1503 780 815 1612 154 4523 2248 1277
7 12 19 16 10 4 9 6 11 26 1
6.67 1.51 0.9 6.7 6.9 2.25 2.8 19.5 1.1 10.8 0.3
3.0–15 0.8–2.9 0.5–1.6 3.7–12.6 3.4–14 0.8–6.3 1.3–5.7 7.9–45.5 0.5–2.1 5.9–19.6 0.04–2.4
3.2
1.3–7.8
3.0 2.9
1.5–6.2 1.3–6.3
1.3 7.2
0.6–2.8 2.8–18.3
5.8
2.9–11.6
Multivariate analysis
OR: Odds-ratio; CI: confidence interval; () reference groups were transfused group.
Table 2 Distribution of hemorrhage risks factors in transfused patients Number of risk factors
Patients (n ¼ 44)
Percent
0 1 2 3 4
13 8 10 12 1
29.5 18.2 22.7 27.3 2.3
also an interaction between the prematurity factor and the multiple pregnancy, vascular disease and scarred uterus factors. Multivariate logistic regression analysis showed that scarred uterus was not a significant risk factor for postpartum transfusion (Table 1). The placenta previa/accreta, cesarean section, multiple pregnancy, prematurity and vascular disease were significantly associated with the risk of postpartum transfusion. The precision of these measurements is modest given the lack of power and the confidence interval for the different results. We studied in the transfused patients the distribution of severe postpartum risk factors chosen after multivariate analysis (Table 2). Thirteen (29.7%) patients had no risk factor, eight (18.2%) had one risk factor and 31 (70.3%) had at least one.
4. Discussion The frequency of transfusion of red blood cells or of frozen plasma due to severe postpartum hemorrhage was 0.23% over a 7-year period. This result is in accord with the data of Klapholz [3] and of Sherman et al. [4] showing a decrease in the use of transfusion from 4.6% in 1976 to 1.9% in 1986 and 0.9% in 1990. This particularly low percentage is probably due to various factors: changes in transfusion procedures [5,6], improvement in monitoring of pregnancies, demonstration of the risk factors of postpartum hemorrhage [1,2,7], heightened monitoring of labor and delivery
and increased postpartum monitoring, active management of delivery [8–10], postpartum use of oxytocin, wider use of prostaglandin (Sulprostone) in the case of hemorrhage. Analysis of the etiologies suggests that this result can be improved further. We used the quality of care criteria for severe obstetrical hemorrhage defined by a French Expert Committee [13]. Three levels of care were defined: appropriate, inadequate or mixed. Inadequate and mixed care were both considered substandard. Review of the medical records of 44 patients indicated that severe postpartum hemorrhage and transfusion were avoidable in 10 cases (23%): diagnostic delay (one uterine rupture, two vulvovaginal thrombi, one cervical-vaginal tear), initial therapeutic error and then diagnostic delay (three cervical-vaginal tears, three anterior abdominal wall hematomas). We think that transfusion was potentially avoidable in 13 cases of uterine atony (30%). Improved surveillance and faster implementation of therapeutic measures should reduce the role of this etiology in severe postpartum hemorrhage and transfusion. Taking into account these various considerations, we can therefore hope for a 50% reduction in severe postpartum hemorrhage and transfusions in the future. Multivariate logistic analysis of hemorrhage risk factors reveals the statistically significant role of placenta previa/ accreta (OR ¼ 7:2, 95% CI, 2.8–18.3), cesarean section (OR ¼ 5:8, 95% CI, 2.9–11.6), multiple pregnancy (OR ¼ 3:2, 95% CI, 1.3–7.8), prematurity (OR ¼ 3, 95% CI, 1.5–6.2) and vascular disease (OR ¼ 2:9, 95% CI, 1.3– 6.3). Thirteen patients had none of these five risk factors. Because of infrequency of placenta praevia accreta associated with high risk of severe hemorrhage, we think that anomalies of placental insertion justify special transfusion procedures, such as prior ordering of phenotyped blood (not limiting the transfusion risk), auto-transfusion, or use of a cell-saver. Auto-transfusion alone remains a debatable technique because over three units of packed cells were transfused in 50% of our patients with placenta previa/accreta [11]. Combined use of the cell-saver and transfusion seems possible, but costly. Over 300 patients were treated without
64
F. Reyal et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 112 (2004) 61–64
complications by this technique for hemorrhage during cesarean section [12]. However, in view of the extreme rarity of amniotic embolism, all authors consider that more follow-up experience is needed. We believe that all risk factors of postpartum hemorrhage, and not just placental anomalies, require active surveillance before, during and after labor. In conclusion, the percentage of patients transfused has probably decreased markedly since 1976, and improved prevention, surveillance and treatment based on knowledge of the severe postpartum hemorrhage and transfusion risk factors should enable this decrease to be sustained. This decrease is essential because of the persistence of infectious but also non-infectious risks associated with transfusion (transfusion errors, shivering-hyperthermia reaction following anti-HLA immunization, acute or delayed hemolysis, acute pulmonary edema) [5,6]. This study emphasizes that the transfusion risk in the presence of anomalous placental insertion is great and justifies special obstetrical and anesthetic management.
References [1] Combs CA, Murphy EL, Laros Jr. RK. Factors associated with hemorrhage in cesarean deliveries. Obstet Gynecol 1991;77:77–82. [2] Combs CA, Murphy EL, Laros Jr. RK. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77:69–76.
[3] Klapholz H. Blood transfusion in contemporary obstetric practice. Obstet Gynecol 1990;75:940–3. [4] Sherman SJ, Greenspoon JS, Nelson JM, Paul RH. Obstetric hemorrhage and blood utilization. J Reprod Med 1993;38:929–34. [5] Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. Transfusion medicine. First of two parts—blood transfusion. N Engl J Med 1999;340:438–47. [6] Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. Transfusion medicine. Second of two parts—blood conservation. N Engl J Med 1999;340:525–33. [7] Stones RW, Paterson CM, Saunders NJ. Risk factors for major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol 1993; 48:15–8. [8] Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. Lancet 1998;351:693–9 [see comments]. [9] Thilaganathan B, Cutner A, Latimer J, Beard R. Management of the third stage of labour in women at low risk of postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol 1993;48:19–22. [10] Pierre F, Mesnard L, Body G. For a systematic policy of i.v. oxytocin inducted placenta deliveries in a unit where a fairly active management of third stage of labour is yet applied: results of a controlled trial. Eur J Obstet Gynecol Reprod Biol 1992; 43:131–5. [11] Combs CA, Murphy EL, Laros Jr. RK. Cost-benefit analysis of autologous blood donation in obstetrics. Obstet Gynecol 1992;80: 621–5. [12] Rainaldi MP, Tazzari PL, Scagliarini G, Borghi B, Conte R. Blood salvage during caesarean section. Br J Anaesth 1998;80:195–8. [13] Bouvier-Colle MH, El Joud D, Varnoux N, Goffinet F, Alexander S, Bayoumeu E, et al. Evaluation of the quality of care for severe obstetrical haemorrhage in the French regions. Br J Obstet Gynaecol 2001;108:898–903.
Criteria for transfusion in severe postpartum hemorrhage: analysis of practice and risk factors Fabien Reyal, Olivier Sibony*, Jean-Franc¸ois Oury, Dominique Luton, Jacques Bang, Philippe Blot Hoˆpital Robert Debre´, 48 Boulevard Se´rurier, 75019 Paris, France Received 6 August 2002; accepted 17 April 2003
Abstract Objective: To analyze the accuracy of postpartum hemorrhage risk factors to determine patients at risk of severe postpartum hemorrhage and transfusion. Population and methods: Retrospective cohort study from a database in one high-risk obstetric unit over a 7-year period. Results: In a cohort of 19,204 deliveries, 44 patients were transfused of whom five were given frozen fresh plasma only. Of the 39 who received red blood cells, 35 received at least three units. Multivariate analysis of postpartum hemorrhage risk factors revealed a significant role of placenta previa/accreta, cesarean section, multiple pregnancy, prematurity and vascular disease. Nevertheless 28% of women transfused had none of these risk factors. Conclusion: The percentage of patients transfused has probably decreased markedly with improved prevention, surveillance and treatment. This study emphasizes that the transfusion risk in the presence of anomalous placental insertion justifies special obstetrical and anesthetic management. # 2003 Published by Elsevier Ireland Ltd. Keywords: Transfusion; Postpartum hemorrhage; Risk factors
1. Introduction Human immunodeficiency virus, hepatitis B and C and more recently Prion diseases have led to major changes in blood transfusion practices despite clear improvements in the safety of biological products. The continuing risk of contamination complicates blood transfusion decisions, particularly during pregnancy. Transfusion is one of the main tool for the treatment of severe postpartum hemorrhage. It’s a life-saving procedure and an important criteria of quality of care of pregnant women. We consider that severe postpartum hemorrhage is well defined by the use of postpartum transfusion. Its reduction can be analyzed as an amelioration of health care service. We describe here our transfusion practice associated with severe postpartum hemorrhage between 1992 and 1998 at the Robert Debre´ University Teaching Hospital in Paris. We analyze the accuracy of postpartum hemorrhage risk factors to determine patients at risk of severe postpartum hemorrhage and transfusion. We speculate to our ability to reduce them by prevention
* Corresponding author. Tel.: þ33-140032454; fax: þ33-140032480. E-mail address: [email protected] (O. Sibony).
0301-2115/$ – see front matter # 2003 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejogrb.2003.04.001
methods. We discuss the opportunity to use predelivery blood ordering, auto-transfusion program or cell saver.
2. Materials and methods We conducted a retrospective cohort study of patients who gave birth between 1st January 1992 and 31st December 1998 at the maternity ward of the Robert Debre´ University Teaching Hospital in Paris. Our unit is located in pediatrics hospital with neonatal intensive care unit and significant prenatal diagnosis activity. By this way, our patients compose a high risk population. For this purpose we used a database established using Microsoft Access 2000 (Microsoft1) and updated daily since 1992. The inclusion criteria were singleton or multiple pregnancy, delivery after 24 weeks of amenorrhea, transfusion of red blood cells and/ or frozen plasma in the 21 days following delivery in the presence of a hemorrhagic complication. The indications for transfusion in our department were identical to the United States guidelines: Acute blood loss of many amount if there is clinical evidence of inadequate oxygen-carrying capacity; a Hb of <7 g/dl (hematocrit of 0.21) if not due to a treatable cause; symptomatic anemia
62
F. Reyal et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 112 (2004) 61–64
regardless of Hb level; patients receiving general anesthesia if their preoperative Hb is <7 g/dl; a major blood letting operation and a Hb of <10 g/dl (hematocrit of <0.30). The exclusion criteria were elective termination of pregnancy, delivery before 24 weeks of amenorrhea, transfusion in the absence of hemorrhage. The control population was analyzed by means of the databank. The population of transfused patients was studied directly by complete review of the medical records. The list of transfused patients was checked against the register kept by the anesthetists and the blood bank register and none transfusion was missed. The hemorrhagic risk factors were chosen on the basis of literature data [1,2]: grand multiparity (three or more children), multiple pregnancy, vascular disease (pre-eclampsia, HELLP syndrome, acute hepatic steatosis, placental abruption), maternal thrombopenia below 150,000 mm3, placenta previa/accreta, prematurity, hyperthermia above 38 8C during labor, forceps delivery, cesarean section, birth weight above 4000 g. Results are expressed as mean S:D: or percentage, as appropriate. Categorical variables were analyzed by chisquare test or Fisher exact test. Odds-ratio are reported with 95% confidence intervals. A P-value of 0.05 or less was considered to indicate statistical significance. Multivariate logistic regression was realized by the means of SPSS 10.0 software; few interaction were consider in the model.
3. Results The control group included a total of 19,138 deliveries. The mean age of the patients was 30:2 4:8 years and mean parity was 1:8 1:14. There were 18,610 singleton pregnancies (97.2%), 478 twin pregnancies (2.5%) and 51 triplet pregnancies (0.3%). 16,891 patients were delivered vaginally (88%). 8048 patients presented no hemorrhagic risk factor (42%). 11,090 patients had at least one hemorrhagic risk factor (58%). Hence, 4523 patients underwent a forceps delivery (24%), 3813 had at least three children (20%), 2248 underwent cesarean section (12%), 1612 had a scarred uterus (9%), 1503 gave birth prematurely (8%), 1277 had a newborn of birth weight above 4000 g (7%), 960 had hyperthermia above 38 8C during labor (5%), 815 had thrombopenia below 150,000 mm3 (4%), 780 had vascular disease (4%), 528 had a multiple pregnancy (3%) and 154 placenta praevia/accreta (0.8%). Sixty-six (0.34%) patients were transfused during the study period, of whom 44 (0.23%) were included in the study and 22 were excluded on the basis of the previously defined criteria (5 medical interruption of pregnancy, 5 cervical maturation and induction of labor for unexplained in utero fetal death without initial disseminated intravascular coagulopathy, 10 before labor transfusion without postpartum hemorrhage; 5 sickle cell disease, 1 Willebrand disease,
4 thrombopenia; 2 autotransfusion after delivery without hemorrhagic situation). Twenty-three patients among 10,000 deliveries received transfusions. The distribution of hemorrhagic risk factors in transfused patients was as follows: 12 patients had at least three children (27%), 7 had a multiple pregnancy (16%), 16 gave birth prematurely (36%), 11 were delivered by forceps (25%), 26 underwent cesarean section (59%), 10 had vascular disease (23%), 4 thrombopenia below 150,000 mm3 (9%), 9 a scarred uterus (20%) and 6 placenta previa and/or accreta (14%). One newborn weighed over 4000 g (2%). None had hyperthermia during labor. The etiologies underlying hemorrhage in transfused patients were as follows: isolated uterine atony (14 cases, 32%), pre-eclampsia and/or placental abruption (10 cases, 23%), cervical and vaginal tears (8 cases, 18%), placenta previa and/or accreta (6 cases, 14%), poorly tolerated postpartum anemia (6 cases, 14%). No patient died. Three patients were transferred to intensive care because of severe pre-eclampsia (7%). Three patients (7%), underwent hysterectomy to ensure hemostasis, two because of placenta accreta and one due to uterine atony resistant to medical treatment together with type IV Ehlers-Danlos syndrome. Thirty-nine patients received red blood cells transfusion and five were given frozen fresh plasma only. Two to nine units of red blood cells were transfused. Among the 39 patients, 35 received at least three units and 19 also received frozen plasma. Eleven patients received transfusions of red blood cells alone at least 24 h after delivery. One to 18 units of frozen plasma were transfused in 24 of 44 patients. In all cases, transfusion was immediately postpartum and in 5 of 24 cases was not combined with transfusion of red blood cells. Mean hemoglobin in the 44 transfused patients was 5.8 g/dl 1:76. The mean prothrombin time in the patients with disseminated intravascular coagulation (DIVC) was 36:9 13:14% and the mean platelet count was 73,187 35,523 units/mm3. Univariate analysis of severe postpartum hemorrhage/ transfusion risk factors showed that multiple pregnancy, prematurity, vascular disease, placenta previa and/or accreta, scarred uterus and cesarean section were significantly associated with an increased risk of severe postpartum hemorrhage and transfusion (Table 1). In contrast, multiparity of three or more, primiparity, maternal thrombopenia below 150,000 mm3, forceps delivery and birth weight above 4000 g were not associated with an increased risk of severe postpartum hemorrhage and transfusion. Analysis of confounding factors and interaction factors was limited by the small number of patients transfused and the consequent lack of statistical power. We can, nonetheless, assert that part of the morbidity associated with transfusion in the case of premature delivery was linked to the performance of cesarean section. There was a likely interaction between the cesarean section factor and the vascular disease, scarred uterus and placenta previa and/or accreta factors. There was
F. Reyal et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 112 (2004) 61–64
63
Table 1 Hemorrhage risks factors in transfused patients: univariate and multivariate logistic regression analysis Risk factors
Multiple pregnancy Multiparity Primiparity Prematurity Hypertension Thrombopenia Scarred uterus Placenta previa and/or accreta Forceps delivery Cesarean section Birth weight 4000 g
Control group (n ¼ 19138)
Transfused group (n ¼ 44)
Univariate analysis OR
95% CI
OR
95% CI
529 3813 8786 1503 780 815 1612 154 4523 2248 1277
7 12 19 16 10 4 9 6 11 26 1
6.67 1.51 0.9 6.7 6.9 2.25 2.8 19.5 1.1 10.8 0.3
3.0–15 0.8–2.9 0.5–1.6 3.7–12.6 3.4–14 0.8–6.3 1.3–5.7 7.9–45.5 0.5–2.1 5.9–19.6 0.04–2.4
3.2
1.3–7.8
3.0 2.9
1.5–6.2 1.3–6.3
1.3 7.2
0.6–2.8 2.8–18.3
5.8
2.9–11.6
Multivariate analysis
OR: Odds-ratio; CI: confidence interval; () reference groups were transfused group.
Table 2 Distribution of hemorrhage risks factors in transfused patients Number of risk factors
Patients (n ¼ 44)
Percent
0 1 2 3 4
13 8 10 12 1
29.5 18.2 22.7 27.3 2.3
also an interaction between the prematurity factor and the multiple pregnancy, vascular disease and scarred uterus factors. Multivariate logistic regression analysis showed that scarred uterus was not a significant risk factor for postpartum transfusion (Table 1). The placenta previa/accreta, cesarean section, multiple pregnancy, prematurity and vascular disease were significantly associated with the risk of postpartum transfusion. The precision of these measurements is modest given the lack of power and the confidence interval for the different results. We studied in the transfused patients the distribution of severe postpartum risk factors chosen after multivariate analysis (Table 2). Thirteen (29.7%) patients had no risk factor, eight (18.2%) had one risk factor and 31 (70.3%) had at least one.
4. Discussion The frequency of transfusion of red blood cells or of frozen plasma due to severe postpartum hemorrhage was 0.23% over a 7-year period. This result is in accord with the data of Klapholz [3] and of Sherman et al. [4] showing a decrease in the use of transfusion from 4.6% in 1976 to 1.9% in 1986 and 0.9% in 1990. This particularly low percentage is probably due to various factors: changes in transfusion procedures [5,6], improvement in monitoring of pregnancies, demonstration of the risk factors of postpartum hemorrhage [1,2,7], heightened monitoring of labor and delivery
and increased postpartum monitoring, active management of delivery [8–10], postpartum use of oxytocin, wider use of prostaglandin (Sulprostone) in the case of hemorrhage. Analysis of the etiologies suggests that this result can be improved further. We used the quality of care criteria for severe obstetrical hemorrhage defined by a French Expert Committee [13]. Three levels of care were defined: appropriate, inadequate or mixed. Inadequate and mixed care were both considered substandard. Review of the medical records of 44 patients indicated that severe postpartum hemorrhage and transfusion were avoidable in 10 cases (23%): diagnostic delay (one uterine rupture, two vulvovaginal thrombi, one cervical-vaginal tear), initial therapeutic error and then diagnostic delay (three cervical-vaginal tears, three anterior abdominal wall hematomas). We think that transfusion was potentially avoidable in 13 cases of uterine atony (30%). Improved surveillance and faster implementation of therapeutic measures should reduce the role of this etiology in severe postpartum hemorrhage and transfusion. Taking into account these various considerations, we can therefore hope for a 50% reduction in severe postpartum hemorrhage and transfusions in the future. Multivariate logistic analysis of hemorrhage risk factors reveals the statistically significant role of placenta previa/ accreta (OR ¼ 7:2, 95% CI, 2.8–18.3), cesarean section (OR ¼ 5:8, 95% CI, 2.9–11.6), multiple pregnancy (OR ¼ 3:2, 95% CI, 1.3–7.8), prematurity (OR ¼ 3, 95% CI, 1.5–6.2) and vascular disease (OR ¼ 2:9, 95% CI, 1.3– 6.3). Thirteen patients had none of these five risk factors. Because of infrequency of placenta praevia accreta associated with high risk of severe hemorrhage, we think that anomalies of placental insertion justify special transfusion procedures, such as prior ordering of phenotyped blood (not limiting the transfusion risk), auto-transfusion, or use of a cell-saver. Auto-transfusion alone remains a debatable technique because over three units of packed cells were transfused in 50% of our patients with placenta previa/accreta [11]. Combined use of the cell-saver and transfusion seems possible, but costly. Over 300 patients were treated without
64
F. Reyal et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 112 (2004) 61–64
complications by this technique for hemorrhage during cesarean section [12]. However, in view of the extreme rarity of amniotic embolism, all authors consider that more follow-up experience is needed. We believe that all risk factors of postpartum hemorrhage, and not just placental anomalies, require active surveillance before, during and after labor. In conclusion, the percentage of patients transfused has probably decreased markedly since 1976, and improved prevention, surveillance and treatment based on knowledge of the severe postpartum hemorrhage and transfusion risk factors should enable this decrease to be sustained. This decrease is essential because of the persistence of infectious but also non-infectious risks associated with transfusion (transfusion errors, shivering-hyperthermia reaction following anti-HLA immunization, acute or delayed hemolysis, acute pulmonary edema) [5,6]. This study emphasizes that the transfusion risk in the presence of anomalous placental insertion is great and justifies special obstetrical and anesthetic management.
References [1] Combs CA, Murphy EL, Laros Jr. RK. Factors associated with hemorrhage in cesarean deliveries. Obstet Gynecol 1991;77:77–82. [2] Combs CA, Murphy EL, Laros Jr. RK. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77:69–76.
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