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Retrospective review of time to uterotonic administration and maternal outcomes following post-partum hemorrhage

  • William Knoll
    Affiliations
    Queen’s University School of Medicine, Department of Anesthesiology and Perioperative Medicine, Department of Molecular and Biological Sciences, Queen’s University, Botterell Hall, 18 Stuart Street, Kingston ON K7L 3N6 Canada
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  • Rachel Phelan
    Affiliations
    Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston ON K7L 2V7 Canada
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  • Wilma M. Hopman
    Affiliations
    Kingston Health Sciences Research Institute, KGHRI, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
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  • Anthony M.-H. Ho
    Affiliations
    Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
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  • Marta Cenkowski
    Affiliations
    Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
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  • Glenio B. Mizubuti
    Affiliations
    Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
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  • Author Footnotes
    ∗ These authors made equal contributions to this work
    Nader Ghasemlou
    Footnotes
    ∗ These authors made equal contributions to this work
    Affiliations
    Department of Molecular and Biological Sciences, Department of Anesthesiology and Perioperative Medicine, ueen’s University, Botterell Hall, 18 Stuart Street, Kingston ON K7L 3N6 Canada
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  • Author Footnotes
    ∗ These authors made equal contributions to this work
    Gregory Klar
    Correspondence
    Corresponding Author: Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada, Tel: (613) 929-4150
    Footnotes
    ∗ These authors made equal contributions to this work
    Affiliations
    Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital site, Kingston Health Sciences Centre, 76 Stuart Street Kingston, ON K7L 2V7 Canada
    Search for articles by this author
  • Author Footnotes
    ∗ These authors made equal contributions to this work
Published:November 26, 2021DOI:https://doi.org/10.1016/j.jogc.2021.11.011

      ABSTRACT

      Objective

      Despite advances in health care and ample resources, post-partum hemorrhage (PPH) rates are increasing in high income countries. Although guidelines recommend therapeutic uterotonics, timing of administration is open to judgement and most often based on (inherently inaccurate) visual estimates of blood loss. With severe hemorrhage, every minute of delay can have significant consequences. Our objective was to examine the timing of uterotonic administration and its impact upon maternal outcomes. We hypothesized that increased time to uterotonic administration following the identification of PPH, would be associated with a greater decline in hemoglobin (Hb) and higher odds of hypotension and transfusion.

      Methods

      We reviewed all cases of PPH that occurred at an academic centre between June 2015 and September 2017. All cases of primary PPH (i.e., those declared within 24 h of delivery with estimated blood loss [EBL] >500 mL for vaginal and >1000 mL for cesarean deliveries) were analyzed. Patient records were excluded if they were missing information regarding time of PPH declaration, uterotonic administration, and/or Hb measures, or if a pre-existing medical condition could have contributed to PPH.

      Results

      Of 4397 births, there were 259 (5.9%) cases of primary PPH, of which 128 were included in this analysis. For these patients, each 5-minute delay in uterotonic treatment was associated with 26% higher odds of hypotension following delivery of any type. For vaginal deliveries (n = 86), each 5-minute delay was associated with 31% and 34% higher odds of hypotension and transfusion, respectively.

      Conclusion

      In this study, delay in administration of therapeutic uterotonics was associated with a higher incidence of hypotension and transfusion in primary PPH patients.

      RÉSUMÉ

      Objectif

      Malgré les progrès réalisés en matière de soins de santé et les ressources suffisantes, le taux d’hémorragies post-partum (HPP) est en augmentation dans les pays à revenu élevé. Bien que les lignes directrices recommandent le recours aux utérotoniques thérapeutiques, le moment de l’administration est laissé au jugement du professionnel et repose le plus souvent sur l’estimation visuelle (essentiellement inexacte) de la perte sanguine. En cas d’hémorragie sévère, chaque minute de report peut avoir des conséquences importantes. Notre objectif était d’examiner le moment d’administration d’un utérotonique et les conséquences du moment d’administration sur les issues maternelles. Nous avons émis l’hypothèse qu’un long délai d’administration d’un utérotonique après le constat de l’HPP serait associé à une diminution importante du taux d’hémoglobine (Hb) et à une augmentation des risques d’hypotension et de transfusion.

      Méthodologie

      Nous avons examiné tous les cas d’HPP survenus dans un centre universitaire entre juin 2015 et septembre 2017. Tous les cas d’HPP primaire (c.-à-d. ceux déclarés dans les 24 heures suivant l’accouchement et dont la perte sanguine estimée était de > 500 ml pour les accouchements vaginaux et de > 1 000 ml pour les césariennes) ont été analysés. Le dossier médical de la patiente a été exclu lorsque l’information était manquante concernant le moment du constat de l’HPP, le moment d’administration d’un utérotonique ou le dosage de l’Hb ou lorsqu’un problème de santé préexistant pourrait être en cause dans la manifestation de l’HPP.

      Résultats

      Sur 4 397 accouchements, 259 cas (5,9 %) d’HPP primaire ont été recensés; de ce nombre, 128 cas ont satisfait aux critères d’inclusion pour l’analyse. Pour ces patientes, chaque report de 5 minutes dans le traitement utérotonique a été associé à une augmentation de 26 % du risque d’hypotension après l’accouchement, tous modes confondus. Pour les accouchements vaginaux (n = 86), chaque report de 5 minutes a été associé à une augmentation du risque de 31 % et de 34 % respectivement pour l’hypotension et la transfusion.

      Conclusion

      Dans cette étude, le report d’administration d’un utérotonique thérapeutique a été associé à une augmentation de l’incidence de l’hypotension et de la transfusion chez les patientes manifestant une HPP primaire.

      Keywords

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