Background The absence of a uniform and clinically relevant definition of severe postpartum haemorrhage hampers comparative studies and optimization of clinical management. The concept of... Show moreBackground The absence of a uniform and clinically relevant definition of severe postpartum haemorrhage hampers comparative studies and optimization of clinical management. The concept of persistent postpartum haemorrhage, based on refractoriness to initial first-line treatment, was proposed as an alternative to common definitions that are either based on estimations of blood loss or transfused units of packed red blood cells (RBC). We compared characteristics and outcomes of women with severe postpartum haemorrhage captured by these three types of definitions. Methods In this large retrospective cohort study in 61 hospitals in the Netherlands we included 1391 consecutive women with postpartum haemorrhage who received either >= 4 units of RBC or a multicomponent transfusion. Clinical characteristics and outcomes of women with severe postpartum haemorrhage defined as persistent postpartum haemorrhage were compared to definitions based on estimated blood loss or transfused units of RBC within 24 h following birth. Adverse maternal outcome was a composite of maternal mortality, hysterectomy, arterial embolisation and intensive care unit admission. Results One thousand two hundred sixty out of 1391 women (90.6%) with postpartum haemorrhage fulfilled the definition of persistent postpartum haemorrhage. The majority, 820/1260 (65.1%), fulfilled this definition within 1 h following birth, compared to 819/1391 (58.7%) applying the definition of >= 1 L blood loss and 37/845 (4.4%) applying the definition of >= 4 units of RBC. The definition persistent postpartum haemorrhage captured 430/471 adverse maternal outcomes (91.3%), compared to 471/471 (100%) for >= 1 L blood loss and 383/471 (81.3%) for >= 4 units of RBC. Persistent postpartum haemorrhage did not capture all adverse outcomes because of missing data on timing of initial, first-line treatment. Conclusion The definition persistent postpartum haemorrhage identified women with severe postpartum haemorrhage at an early stage of haemorrhage, unlike definitions based on blood transfusion. It also captured a large majority of adverse maternal outcomes, almost as large as the definition of >= 1 L blood loss, which is commonly applied as a definition of postpartum haemorrhage rather than severe haemorrhage. Show less
Postpartum haemorrhage, in this thesis defined as blood loss above 1000mL within the first 24 hours after birth, remains a major cause of maternal morbidity and mortality with an incidence that... Show morePostpartum haemorrhage, in this thesis defined as blood loss above 1000mL within the first 24 hours after birth, remains a major cause of maternal morbidity and mortality with an incidence that seems to be increasing over the last decade. In this thesis we focussed on improvement of prognostic and diagnostic strategies for major obstetric haemorrhage, which may subsequently lead to a reduction of severe maternal morbidity, mortality and need for surgical interventions. In pursuit of this aim, research questions were posed corresponding to all three phases leading up to adverse outcome due to postpartum haemorrhage: pregnancy (prior to childbirth), early postpartum haemorrhage and persistent postpartum haemorrhage. In the first part of this thesis we focused on prediction of postpartum haemorrhage.Bleeding assessment tools were found to have no predictive value for postpartum haemorrhage. The change of coagulation parameters during the course of postpartum haemorrhage was described, and fibrinogen was found to be an early predictor of a worse outcome of postpartum haemorrhage. The association between fibrinogen measured by the Clauss method and ROTEM Fibtem was described in this thesis. Show less
The aim of this dissertation is outlined in the introduction, which includes a paragraph on physiology and pathophysiology of the third stage of labour. The next paragraph handles the management of... Show moreThe aim of this dissertation is outlined in the introduction, which includes a paragraph on physiology and pathophysiology of the third stage of labour. The next paragraph handles the management of the third stage of labour. Furthermore, the clinical problems __retained placenta__ and __puerperal uterine inversion__ are outlined. In the last paragraph, the terms __quality of life__ and __illness perceptions__ are clarified. Part 2 of this dissertation contains the Dutch contribution to explore a possible global rise in incidence of postpartum haemorrhage (chapter 1). The current knowledge and practice regarding active management of the third stage of labour in midwifery practices and obstetric departments in the Netherlands is presented (chapter 2). In part 3 of this dissertation, the problems associated with abnormal placentation are explored. Misoprostol turned out not to be beneficial over placebo in the management of retained placenta (chapter 3 and 4). In chapter 5, a cohort of fifteen women with puerperal inversion of the uterus is presented. Experiencing an event such as major obstetric haemorrhage does not seem to be associated with diminished quality of life. Clinical characteristics imply a big impact of the event on women and their partners. Show less
Smit, M.; Sindram, S.I.C.; Woiski, M.; Middeldorp, J.M.; Roosmalen, J. van 2013
