Critical Conditions in Obstetrics 2022: What is Available in the Czech Republic for Managing Peripartum Life-Threatening Bleeding?
On December 10, 2022, a professional meeting entitled Critical Conditions in Obstetrics 2022 was held in the lecture hall of the new building of the National Museum in Prague. Prof. MUDr. Antonín Pařízek, CSc., from the Department of Gynecology and Obstetrics of the 1st Faculty of Medicine, Charles University, and General University Hospital in Prague, gave a presentation addressing the issue of peripartum life-threatening bleeding (PLTB), the necessities for its management, and provided an overall perspective on the current situation in obstetrics in our country.
Incidence and Etiology of PLTB
Data on the incidence of PLTB varies depending on the criteria used to diagnose the pathology. Estimates range from 1–5%, but prospective studies indicate 10%, suggesting an occurrence in about 7–8% of deliveries. However, this incidence is currently rising due to more frequent pregnancies at an advanced maternal age, obesity, comorbidities, post-surgical conditions of the uterus or cesarean sections, morbid placenta placement, and the use of in vitro fertilization techniques, which are associated with a higher incidence of multiple pregnancies. Therefore, personal and family history plays an important role. Certain medications, such as antidepressants—especially selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), muscle relaxants, or antithrombotics, can also be risk factors.
The causes of peripartum hemorrhage (PPH) can be summarized as 4T – tone, trauma (birth injury), tissue pathology, thrombin (coagulopathy), with uterine tone disorders (hypotonia/atonia; 70–80%) being the most common. The pathogenesis in most cases lies in the disruption of mechanical or coagulation hemostasis, or both. There are many definitions of PPH; in the Czech Republic, it is currently defined as a less severe blood loss of 500–1000 ml, severe blood loss > 1000 ml up to ≤ 1500 ml, and PLTB > 1500 ml.
Current Recommendations and Possibilities
Regarding resources for managing PLTB and their availability in the Czech Republic, all necessary elements are present—knowledge, recommended procedures, necessary medications, and modern technology, whether surgical or intensive care.
For prevention, antenatal anemia treatment is recommended. Pregnant women should receive iron supplements if their hemoglobin level drops below 110 g/l in the first trimester or below 105 g/l in the 28th week of pregnancy. It is also suggested to consider parenteral iron administration in women with iron deficiency anemia unresponsive to oral supplementation. Current guidelines from the Czech Gynecological and Obstetric Society (2018) emphasize the importance of timely blood loss estimation and organizational principles. In cases of physiological blood loss, the presence of a midwife is sufficient; for less severe cases, an obstetrician should be called; for severe cases, an anesthesiologist should be called; and for peripartum life-threatening bleeding, a crisis plan and crisis team with clearly defined roles should be prepared.
A new addition to PPH management is the inclusion of recombinant activated coagulation factor VII (rFVIIa). For all PLTB cases due to uterine hypotonia or atonia where standard surgical procedures fail or cannot be performed, radiological interventional methods (selective pelvic artery embolization) are recommended if available. Identifying the type of coagulation disorder is crucial, for which viscoelastic methods (TEG, ROTEM) are suitable and well-accessible today.
New Challenges and the Ongoing Need for “Drill”
New challenges in this area arise from the fact that although PPH cannot be entirely preventable, early identification of blood loss and mobilization of resources can prevent undesirable outcomes. The speaker emphasized the importance of multidisciplinary plans, bleeding protocols, and management protocols for high-risk patients, as well as the crucial role of simulation, such as practicing various birth-related scenarios on highly realistic simulators. The need for “drill” arises from the fact that modern obstetrics fortunately has very few opportunities to experience real acute conditions, resulting in limited personal experience for obstetricians in managing such cases. Hence, practicing procedures in simulated events is the main means of education, enabling quick and accurate blood loss estimation and the proper use of therapeutic strategies. Quality practice is reflected in the speed of healthcare response.
Summary and Conclusion
Peripartum life-threatening bleeding remains the leading cause of maternal mortality related to childbirth in our country. Therefore, continuously updating knowledge on preventive measures and treatment options, timely blood loss estimation, mastery of appropriate therapeutic strategies, and rapid response in emergencies are vital. Practicing life-saving procedures using simulators and “drill” techniques is of key importance.
Eva Srbová
proLékaře.cz editorial team
Source: Pařízek A. Peripartální krvácení – aktuality. Kritické stavy v porodnictví 2022, Praha, 10. 12. 2022.
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