Postpartum hemorrhage. Click here to see the Library ]]. Secondary postpartum haemorrhage. Hypogastric ligation for obstetric hemorrhage.
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All relevant data are within the paper and its supporting information files. Abstract Background Accurate estimation of blood loss is central to prompt diagnosis and management of post-partum hemorrhage PPH , which remains a leading cause of maternal mortality in low-resource countries. In such settings, blood loss is often estimated visually and subjectively by attending health workers, due to inconsistent availability of laboratory infrastructure.
We evaluated the diagnostic accuracy of weighed blood loss WBL versus changes in peri-partum hemoglobin to detect PPH. Blood samples for complete blood count were drawn on admission and again prior to hospital discharge or before blood transfusion.
During delivery, women were placed on drapes and had pre-weighed sanitary towels placed around their perineum. Blood was then drained into a calibrated container and the sanitary towels were added to estimate WBL, where each gram of blood was estimated as a milliliter.
Results A total of 1, women were enrolled in the study, of whom Although WBL is not useful for excluding PPH, this low-cost, simple and reproducible method is promising as a reasonable method to identify significant PPH in such settings where quantifiable red cell indices are unavailable. Introduction Accurate estimation of blood loss is key to prompt prediction, diagnosis and management of life-threatening post-partum hemorrhage PPH , which remains a leading cause of maternal morbidity and mortality in low-resource countries LRC [ 1 ].
Accurate quantification of massive blood loss may prevent hypovolemia, hypotension, tachycardia and consequently organ failure and death as a result of tissue hypoxia. Early diagnosis of hypovolemic shock is therefore of utmost importance especially in settings with large amounts of bleeding.
Although hypovolemic shock is detectable by changes in vital signs like tachycardia, hypotension as well as poor tissue oxygenation like pallor, blue lips, and changes in mental status and poor capillary refill, its actual measure and quantification is still vital in prompt diagnosis of PPH. In LRC settings, blood loss is often estimated by visual estimation by attending health workers HWs , due to lack of neither adequate skilled labor nor reliable laboratory infrastructure to quantify blood loss.
Attempts to standardize this visual inspection method by training HWs to estimate soakage have not been successful, because it has been found to have poor validity and reliability[ 1 , 2 ]. As such, strategies to simplify blood loss estimation in LRC that allow measurement of blood loss without expensive supplies, complex human resource inputs, or laboratory infrastructure are needed.
Some proposed strategies include calculation of total blood volume[ 4 — 7 ], direct estimation of blood loss using bedpans, fixed-sized gauze pads, calibrated delivery drapes and shallow bed pans[ 8 — 13 ], or transparent collector bags [ 14 ].
These direct techniques have been hypothesized to reduce the likelihood of underestimation, leading to improved detection, diagnosis and management of PPH [ 2 , 15 ]. However, most have not been validated against a quantified measurement of blood loss, such as change in peri-partum hemoglobin, which remains the reference standard in high resource settings[ 16 ]. In contrast, change in peri-partum hemoglobin, unlike other methods, detects all forms of blood loss, including hemolysis and internal formation of hematomas[ 18 ].
Although direct measurement of blood loss is a potentially cost-effective method to detect PPH in resource limited settings, its diagnostic accuracy remain largely untested. We sought to evaluate the diagnostic accuracy of the weighed blood loss method as compared to quantitative changes in hemoglobin as a reference standard.
Our overarching goal was to evaluate if a weighed blood loss method could serve as a valid, low-cost, measure of PPH for use in LRC where laboratory testing is not available. All study procedures were conducted at the Mbarara Regional Referral Hospital, a publically-funded teaching hospital in rural south-western Uganda serving 10 districts with a population of over 5 million people.
Participants and Recruitment Full study procedures have been described previously[ 19 ]. Trained midwife research assistants MRAs screened labouring mothers in early active labour on arrival to the prenatal ward. Eligibility criteria were 1 age above 18 years, 2 38—41 weeks of amenorrhea and 3 anticipated uncomplicated vaginal delivery as assessed by hospital staff. MRAs obtained written informed consent from all eligible participants after the birth was determined to likely be uncomplicated vaginal delivery.
All consenting participants gave written informed consent, or for those who could not write, a thumbprint was made on the consent form.
Further care was provided by the hospital clinical care team in collaboration with MRAs in accordance with national guidelines which recommends administration of a repeat dose of parenteral oxytocics along with bladder emptying, management of lacerations, and uterine massage if bleeding persists.
Mothers were monitored for 24 hours postpartum before discharge. Study Measures Two blood samples for complete blood count CBC were drawn 1 immediately after admission and 2 prior to hospital discharge or before the first blood transfusion, for participants who received one.
After the baby was born, the amniotic fluid was drained from the plastic sheet immediately. Blood collected onto the plastic sheet during delivery was drained into a standard calibrated measuring jar[ 20 ] Additionally, mothers were given pre-weighed standard sanitary mops to place in the perineum during the entire postpartum period. These pads were collected, weighed and added onto the volume of blood from the plastic sheet. To improve consistency in estimation of blood loss, standardized electronic scales were used to weigh soiled mops.
Mops were weighed hourly for the first six hours, and then every six hours until 24 hours postpartum. At the conclusion of the hour postpartum period, remaining pads were collected, weighed and added to the volume of blood from the plastic sheet. We estimated blood loss as 1 mL per each gram of weighed mop, subtracted from the dry mop weight, as previously described[ 21 ]. Study staff who performed laboratory tests and directly measured blood loss were blinded to treatment allocation.
Statistical Analysis We described demographic and clinical data for the cohort using standard summarization techniques. Our primary aim was to assess the diagnostic validity of weighted blood loss method WBL versus quantified blood loss.
Our reference standard was hemoglobin Hb drop, which is the usual means of measuring blood loss accurately and indirectly, with direct clinical relevance to the risk of myocardial infarction[ 16 ]. To describe the performance of the WBL compared to hemoglobin change, we estimated sensitivity and specificity of each volume-time combination e.
All consenting participants gave written informed consent, or for those who could not write, a thumbprint was made on the consent form as approved by the ethics committees. All authors report no conflicts of interest. Results One thousand one hundred and forty participants were randomized and enrolled in the study and had paired haemoglobin and blood loss measured by the WBL.
The mean age of participants was Mean haemoglobin and hematocrit at admission were Other baseline characteristics are presented in Table 1. In the full cohort, Using the WBL method, Table 1 Participant baseline demographic and clinical characteristics.
Hémorragie du Post-Partum : prévention et prise en charge
All relevant data are within the paper and its supporting information files. Abstract Background Accurate estimation of blood loss is central to prompt diagnosis and management of post-partum hemorrhage PPH , which remains a leading cause of maternal mortality in low-resource countries. In such settings, blood loss is often estimated visually and subjectively by attending health workers, due to inconsistent availability of laboratory infrastructure. We evaluated the diagnostic accuracy of weighed blood loss WBL versus changes in peri-partum hemoglobin to detect PPH. Blood samples for complete blood count were drawn on admission and again prior to hospital discharge or before blood transfusion. During delivery, women were placed on drapes and had pre-weighed sanitary towels placed around their perineum. Blood was then drained into a calibrated container and the sanitary towels were added to estimate WBL, where each gram of blood was estimated as a milliliter.
Hémorragie du post-partum
Warkus A. Denys P. Hohlfeld S. Gerber Rev Med Suisse ; volume 1. Figure 4.
Prise en charge de l’hémorragie du post-partum
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