The efficacy of antenatal maternal hemogram and coagulation test parameters in predicting atony-related postpartum hemorrhage

Abstract

This study aims to evaluate the efficacy of maternal hemogram parameters in PPH in term pregnancies. A retrospective analysis was conducted on 84 patients with atony-related PPH and 96 control patients with healthy deliveries, who presented to the Gynecology and Obstetrics Clinic of Samsun Education and Research Hospital between January 1, 2008, and December 31, 2023. Patients' data were retrieved from the hospital's information system. Exclusion criteria included pregnant women under 18 years, those with preeclampsia, chronic hypertension, or bleeding disorders. Evaluated parameters included age, BMI, gravida, parity, gestational age, mode of delivery, prepartum and postpartum hemogram and coagulation parameters, and neonatal outcomes. The mean age was 32.1±6.9 years in the PPH group and 30.1±5.8 years in the control group. Hemoglobin and hematocrit levels were significantly lower in the PPH group (Hb: 9.4±1.0 ng/ml) compared to the control group (Hb: 11.5±1.4 ng/ml, p<0.001). Plasma fibrinogen levels were also significantly lower in the PPH group (392.6±69.2 mg/dl) compared to the control group (467.2±69.6 mg/dl, p<0.001). A significant positive correlation was observed between plasma fibrinogen levels and 1- and 5-minute Apgar scores (p=0.002 and p<0.0001, respectively). BMI ≥28.8 was associated with a higher risk of hemorrhage. Maternal hemogram parameters, particularly hemoglobin, hematocrit, and fibrinogen levels, are effective predictors of postpartum hemorrhage. The study emphasizes the importance of monitoring these parameters to identify and manage at-risk pregnancies, thereby reducing maternal morbidity and mortality associated with PPH.

Keywords

• postpartum hemorrhage
• fibrinogen
• hemorrhage risk factors
• blood coagulation tests

References

1. Hazra S, Chilaka VN, Rajendran S, Konje JC. Massive postpartum haemorrhage as a cause of maternal morbidity in a large tertiary hospital. J Obstet Gynaecol. 2004;24(5):519-520.
2. Zhang WH, Alexander S, Bouvier-Colle MH, Macfarlane A. Incidence of severe preeclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European population-based study: the MOMS-B survey. BJOG. 2005;112(1):89-96.
3. Knight M, Callaghan WM, Berg C, Alexander S, Bouvier-Colle MH, Ford JB, et al. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth. 2009;9:55.
4. Langer B, Boudier E, Haberstich R, Dreyfus M; Collège National des Gynécologues et Obstétriciens Français; Agence Nationale d'Accréditation et d'Evaluation en Santé. Prise en charge obstétricale en cas d'hémorragie du post-partum qui persiste malgré les mesures initiales ou qui est grave d'emblée [Obstetrical management in the event of persistent or worsening postpartum hemorrhage despite initial measures]. J Gynecol Obstet Biol Reprod (Paris). 2004 Dec;33(8 Suppl):4S73-4S79. French.
5. Rizvi F, Mackey R, Barrett T, McKenna P, Geary M. Successful reduction of massive postpartum haemorrhage by use of guidelines and staff education. BJOG. 2004;111(5):495-498.
6. Charbit B, Mandelbrot L, Samain E, Baron G, Haddaoui B, Keita H, et al.; PPH Study Group. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost. 2007;5(2):266-273.
7. Bremme KA. Haemostatic changes in pregnancy. Best Pract Res Clin Haematol. 2003;16(2):153-168.
8. Brenner B. Haemostatic changes in pregnancy. Thromb Res. 2004;114(5-6):409-414.

9. Huissoud C, Carrabin N, Benchaib M, Fontaine O, Levrat A, Massignon D, et al. Coagulation assessment by rotation thrombelastometry in normal pregnancy. Thromb Haemost. 2009;101(4):755-761.
10. Cortet M, Deneux-Tharaux C, Dupont C, Colin C, Rudigoz RC, Bouvier-Colle MH, et al. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. Br J Anaesth. 2012;108(6):984-989.
11. Bihan L, Nowak E, Anouilh F, Tremouilhac C, Merviel P, Tromeur C, et al. Development and Validation of a Predictive Tool for Postpartum Hemorrhage after Vaginal Delivery: A Prospective Cohort Study. Biology (Basel). 2022;12(1):54.
12. Muluye G, Gashaw A, Woretaw L, Girma B, Tumebo T. Risk factors of primary postpartum hemorrhage among postnatal mothers in the public hospital of southern Tigray, Ethiopia, 2019: A case-control study. Front Glob Womens Health. 2023;4:1039749.
13. Corbetta-Rastelli CM, Friedman AM, Sobhani NC, Arditi B, Goffman D, Wen T. Postpartum Hemorrhage Trends and Outcomes in the United States, 2000-2019. Obstet Gynecol. 2023;141(1):152.
14. World Health Organization. Maternal mortality [Internet]. 2018 [updated 2024 Apr 26; cited 2024 Jun 15]. Available from: http://www.who.int/en/news-room/fact-sheets/detail/maternal-mortality
15. Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007;75(6):875-882.
16. Gayat E, Resche-Rigon M, Morel O, Rossignol M, Mantz J, Nicolas-Robin A, et al. Predictive factors of advanced interventional procedures in a multicentre severe postpartum haemorrhage study. Intensive Care Med. 2011;37(11):1816-1825.
17. Geeraedts LM Jr, Kaasjager HA, van Vugt AB, Frölke JP. Exsanguination in trauma: a review of diagnostics and treatment options. Injury. 2009;40(1):11-20.
18. Ohkuchi A, Onagawa T, Usui R, Koike T, Hiratsuka M, Izumi A, et al. Effect of maternal age on blood loss during parturition: a retrospective multivariate analysis of 10,053 cases. J Perinat Med. 2003;31(3):209-215.
19. Ijaiya MA, Abojeyi AP, Abubakar D. Analysis of 348 consecutive cases of primary postpartum hemorrhage at a tertiary hospital in Nigeria. J Obstet Gynaecol. 2003;23(4):356-359.
20. Okogbenin SA, Gharoro EP, Otoide VO. Obstetric hysterectomy: fifteen years experience in a Nigerian tertiary centre. J Obstet Gynaecol. 2003;23(4):356-359.
21. Zakaria AEM, Sedek AMAE. Serum fibrinogen as detection of severity of postpartum hemorrhage. Egypt J Hosp Med. 2019;76:4189-4194.
22. Kınay T, Özelci R, Dilbaz B. Relationship between gestational weight gain amount of postpartum bleeding. J Contemp Med. 2020;10:365-369.
23. Budwick AJ, Abreo A, Bateman BT, Lee HC. Effect of maternal body mass index on postpartum hemorrhage. Anesthesiology. 2018;128:774-783.
24. Kavle JA, Stoltzfus RJ, Witter F, Tielsch JM, Khalfan SS, Caulfield LE. Association between anemia during pregnancy and blood loss at and after delivery among women with vaginal births in Pemba Island, Zanzibar, Tanzania. J Health Popul Nutr. 2008;25(2):232-240.
25. Jaleel R, Khan A. Severe anemia and adverse pregnancy outcome. J Surg Pak. 2008;13(4):147-150.
26. Kreuz W, Meili E, Peter-Salonen K, Dobrkovská A, Devay J, Haertel S, et al. Pharmacokinetic properties of a pasteurized fibrinogen concentrate. Transfus Apher Sci. 2005;32:239-246.
27. Roberts HR, Hoffman M, Monroe DM. A cell-based model of thrombin generation. Semin Thromb Hemost. 2006;32:32-38.
28. Abbassi-Ghanavati M, Greer LG, Cunningham FG. Pregnancy and laboratory studies: a reference table for clinicians. Obstet Gynecol. 2009;114:1326-1331.
29. Cortet M, Deneux-Tharaux C, Dupont C, Colin C, Rudigoz RC, Bouvier-Colle MH, et al. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. Br J Anaesth. 2012;108(6):984-989. doi: 10.1093/bja/aes096.
30. Kauffner L, Henkelmann A, Von Heymann C, Feldheiser A, Mickley A. Can prepartum thromboelastometry-derived parameters and fibrinogen levels really predict postpartum hemorrhage. J Perinat Med. 2017;45(4):427-435.
31. Karlsson O, Jeppsson A, Thornemo M, Lafrenz H, Radsröm H, Hellgren M. Fibrinogen plasma concentration before delivery is not associated with postpartum hemorrhage: a prospective observational study. Obstet Anesth Dig. 2016;36(3):134-135.
32. Finlayson K, Downe S, Vogel JP, Oladapo OT. What matters to women and healthcare providers in relation to interventions for the prevention of postpartum haemorrhage: a qualitative systematic review. PLoS One. 2019;14(5).