ObjectiveThere has been an appreciable rise in postpartum hemorrhage requiring blood transfusions in the United States. Our objective is to better define patients at greatest risk for peripartum transfusion at the time of cesarean in order to identify cases for early intervention and monitoring.MethodsOur study is a secondary analysis of a retrospective cohort study. Cases of intraoperative and immediate postpartum blood transfusion among women undergoing cesarean delivery were identified. Multivariable logistic regression models were used to identify antepartum and intrapartum risk factors that were independently associated with blood transfusion. A risk calculator was then developed to predict the need for transfusion.ResultsOf 56,967 women, 1488 (2.6%) required any blood transfusion. The strongest risk factors for peripartum blood transfusion included anemia (odds ratio [OR] 3.7, 95% CI 3.3–4.3), abruption on presentation (OR 3.3, CI 2.6–4.1), general anesthesia (OR 5.2, CI 4.4–6.1) and abnormal placentation (OR 92.0, CI 57.4–147.6). An antepartum (model 1) and combined antepartum plus intrapartum risk model (model 2) were developed (model 1 AUC = 0.77, model 2 AUC = 0.83) and internally validated.ConclusionsAmong women who required cesarean delivery, we were able to identify risk factors which predispose women to peripartum blood transfusion and developed a prediction model with good discrimination.

Importance Postpartum hemorrhage (PPH) remains a major cause of maternal mortality worldwide, occurring in both vaginal and cesarean deliveries. We have witnessed improvements in both prevention and treatment of PPH. Tranexamic acid (TXA) has been investigated as a potential adjunct therapy to uterotonics within this setting. Objective The aim of this article is to summarize existing recommendations on the use of TXA in obstetrics and review current data on clinical outcomes after TXA use. Evidence Acquisition We reviewed guidelines from a number of professional societies and performed an extensive literature search reviewing relevant and current data in this area. Results and Conclusions In the prevention of PPH, TXA use before both vaginal and cesarean deliveries reduces the amount of postpartum blood loss and should be considered in patients at higher risk for hemorrhage. In the treatment of PPH, TXA should be initiated early for maximal survival benefit from hemorrhage, and it provides no additional benefit if administered more than 3 hours from delivery. Overall, current evidence assessing the risks of TXA use in an obstetric population is reassuring. Target Audience Obstetricians and gynecologists, family physicians. Learning Objectives After completing this activity, the learner should be better able to: define the mechanism of action of TXA; evaluate the utility of TXA in prophylaxis and treatment of PPH; define common doses of TXA used in the peripartum period; and assess associated risk and possible adverse outcome when using TXA.

Objective Hemorrhage is a major cause of maternal morbidity and mortality prompting creation of innovative risk assessment tools to identify patients at highest risk. We aimed to investigate the association of hemorrhage risk assessment with maternal morbidity and to evaluate maternal outcomes after implementation of the risk assessment across hospital sites. Study Design We conducted a retrospective cohort analysis of a multicenter database including women admitted to labor and delivery from January 2015 to June 2018. The Association of Women's Health, Obstetric and Neonatal Nurses risk assessment tool was used to categorize patients as low, medium, or high risk for hemorrhage. Multivariate logistic regression was used to describe the association between hemorrhage risk score and markers of maternal morbidity and evaluate maternal outcomes before and after standardized implementations of the risk assessment tool. Results In this study, 14,861 women were categorized as low risk (26%), 26,080 (46%) moderate risk, and 15,730 (28%) high risk (N = 56,671 births). For women with high-risk scores, the relative risk (RR) ratio compared with low-risk women was 4.9 (RR: 95% confidence interval [CI]: 3.2–7.4) for blood transfusion and 5.2 (RR: 95% CI: 4.6–5.9) for estimated blood loss (EBL) ≥ 1,000 mL. For the second objective, 110,633 women were available for pre- and postimplementation analyses (39,027 and 71,606, respectively). A 20% reduction in rates of blood transfusion (0.5–0.4%, p = 0.02) and EBL ≥ 1,000 mL (6.3–5.9%, p = 0.014) was observed between pre- and postimplementations of the admission hemorrhage risk assessment tool. Conclusion Women who were deemed high risk for hemorrhage using a hemorrhage risk assessment tool had five times higher risk for blood transfusion and EBL ≥ 1,000 mL compared with low-risk women. Given the low incidence of the outcomes explored, the hemorrhage risk assessment works moderately well to identify patients at risk for peripartum morbidity. Key Points

Summary While endometrial neutrophils and plasma cells are criteria used to diagnose histologic endometritis in epidemiologic pelvic inflammatory disease (PID) research, plasma cell misidentification and nonspecificity may limit the accuracy of these criteria. Herein, we examined: 1) the identification of endometrial plasma cells with conventional methyl green pyronin-based methodology versus plasma cell-specific (CD138) immunostaining; 2) the prevalence of endometrial plasma cells among women at low risk for PID; and 3) endometrial leukocyte subpopulations among women diagnosed with acute or chronic histologic endometritis by conventional criteria. We observed an absence of CD138+ cells in 25% of endometrial biopsies in which plasma cells had been identified by conventional methodology, while additional immunohistochemical analyses revealed indistinguishable inflammatory infiltrates among women diagnosed with acute or chronic endometritis by conventional criteria. Among women considered at lower risk for PID development, flow cytometric analyses detected plasma cells in 30% of endometrial biopsy specimens, suggesting that these cells, even when accurately identified, only nonspecifically identify upper genital tract inflammatory processes. Combined, our findings underscore the limitations of the criteria used to diagnose histologic endometritis in PID-related research and suggest that satisfactory understanding of PID pathogenesis, treatment, and prevention is hindered by continued use of these criteria.

Objective To report maternal outcomes in a cohort of women who received autotransfusion of vaginally shed blood and to describe the feasibility of blood collection and cell salvage processing at the time of vaginal hemorrhage. Study Design and Methods We conducted a retrospective case series of patients who received autotransfusion of vaginally shed blood at the time of obstetric hemorrhage from January 2014 to August 2020. Maternal data and cell salvage utilization characteristics were abstracted from the electronic medical record. Results Sixty‐four cases were identified in which autotransfusion of vaginally shed blood occurred during an obstetric hemorrhage. Median quantitative blood loss was 2175 ml (interquartile range 1500–2250 ml) with 89% of cases having a blood loss greater than 1000 ml. Patients on average received approximately 1.3 units of autologous blood product (384 ml, interquartile range 244–520 ml) and no direct adverse events were observed during transfusion. We observed heterogeneity in autologous blood volume across all values of quantitative blood loss. The need for allogenic blood transfusion was common and occurred in 72% of all cases (N = 46). There were no documented cases of maternal sepsis or severe infectious morbidity. Conclusion In 64 cases where autotransfusion of vaginally shed blood occurred, autotransfusion was well tolerated. Heterogeneity in autologous blood volume collection likely represents the lack of standardized protocols for blood collection in the delivery room. Autotransfusion of vaginally shed blood is a feasible and reasonable technique to employ during severe obstetric hemorrhage.