Shock Index and Postpartum Hemorrhage in Vaginal Deliveries: A Multicenter Retrospective Study

Ushida, Takafumi; Kotani, Tomomi; Imai, Kenji; Nakano‐Kobayashi, Tomoko; Nakamura, Noriyuki; Moriyama, Yoshinori; Yoshida, Shigeru; Yamashita, Mamoru; Kajiyama, Hiroaki; Kikkawa, Fumitaka

doi:10.1097/shk.0000000000001634

Cited by 29 publications

(54 citation statements)

References 22 publications

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“…A previous study [22,23] showed that SI positively correlated with the volume of blood product transfusion and level of brinogen. Takafumi Ushida et al reported the cutoff points of SI for PPH (≥1,000 ml) was 0.86 (sensitivity, 53.9%; speci city, 76.0%) [13]. These observations suggested that SI correlated with the need for transfusion with high speci city and negative predictive value which could be used in excluding blood transfusion.…”

Section: Discussionmentioning

confidence: 97%

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The Ability of Shock Index In Detecting Postpartum Haemorrhage: A Retrospective Case-Control Study

Huang

Gan

Luo

et al. 2022

Preprint

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Background: shock index (SI), calculated as the ratio of heart rate (HR) to systolic blood pressure (SBP), is used to measure the degree of hypovolemia in shock states. Little literature reported on the role of SI in detecting postpartum haemorrhage (PPH) in obstetrics. This study aimed to determine whether SI was superior to clinical criteria to identify PPH, to identify independent risk factors of surgical intervention and blood transfusion.Materials and Methods: Records were retrospectively examined for patients who experienced PPH (n=305) or not (n=305). HR and SBP were recorded at five different time points from admission to postpartum 24 h. The performance of vital signs based on area under the receiver operating characteristic curve (AUROC) was used to evaluate the ability among peak SI, HR, SBP for estimating PPH. Two formulas using the fitted curve in a scatter plot (maximum SI and blood loss postpartum 24 h based on draps weighing method against blood loss postpartum 24 h with hemoglobinometry, respectively) were provided to determine the ability between SI and draps weighing method in detecting PPH. Univariate and logistic regression analyses were used to determine predictors of surgical intervention and blood transfusion. The sensitivity and specificity of SI for predicting transfusion were calculated. Results: SI had the highest AUROC of 0.646 [95% confidence interval (CI), 0.590-0.700] and 0.665 (95% CI, 0.582-0.748) for PPH of ≥1,000 and ≥1,500 ml. SI was inferior to drapes weighing method (coefficient of correlation, 0.351 vs 0.759) in estimating PPH. Caesarean delivery, placenta previa were independent risk factors for surgical interventions and transfusion. Body mass index(BMI) and peak SI ≥1 were also independent risk factors for transfusion. The SI ≥ 1 predicted transfusion with a specificity of 0.81, negative predictive value 82% but sensitivity of only 0.39. Conclusions: The peak SI may be superior to HR or SBP for detecting PPH. However, due to the low correlation with blood loss, the severity of PPH needs to be judged accompanied with other signs and symptoms. SI < 1 may indicate no blood transfusion needed.

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Section: Discussionmentioning

confidence: 97%

“…Laceration suture or hematoma removal should be performed when laceration of the cervix or vagina occurred. Postoperative adjuvant mifepristone or MTX was required when placental accreta occurred [13,14].…”

Section: Methodsmentioning

confidence: 99%

The Ability of Shock Index In Detecting Postpartum Haemorrhage: A Retrospective Case-Control Study

Huang

Gan

Luo

et al. 2022

Preprint

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“…Although unlikely, women could possibly receive a RBC transfusion between their baseline Hb test and randomisation, which is not recorded in the trial. While heart rate and blood pressure can be accurately measured, shock index is an imperfect physiological marker of postpartum blood loss with low sensitivity for PPH [ 27 ]. Maternal cardiovascular compensatory mechanisms like haemoconcentration and increased cardiac output after childbirth may obscure early physiologic signs of postpartum bleeding.…”

Section: Discussionmentioning

confidence: 99%

Postpartum haemorrhage in anaemic women: assessing outcome measures for clinical trials

Brenner

Roberts

Balogun

et al. 2022

Trials

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Background Postpartum haemorrhage (PPH) is a leading cause of maternal mortality worldwide. Maternal anaemia greatly increases the risk of PPH, and over a third of all pregnant women are anaemic. Because anaemia reduces the oxygen-carrying capacity of the blood, anaemic women cannot tolerate the same volume of blood loss as healthy women. Yet the same blood loss threshold is used to define PPH in all women. The lack of an established PPH definition in anaemic women means the most appropriate outcome measures for use in clinical trials are open to question. We used data from the WOMAN-2 trial to examine different definitions of PPH in anaemic women and consider their appropriateness as clinical trial outcome measures. Main body The WOMAN-2 trial is assessing tranexamic acid (TXA) for PPH prevention in women with moderate or severe anaemia at baseline. To obtain an accurate, precise estimate of the treatment effect, outcome measures should be highly specific and reasonably sensitive. Some outcome misclassification is inevitable. Low sensitivity reduces precision, but low specificity biases the effect estimate towards the null. Outcomes should also be related to how patients feel, function, or survive. The primary outcome in the WOMAN-2 trial, a ‘clinical diagnosis of PPH’, is defined as estimated blood loss > 500 ml or any blood loss within 24 h sufficient to compromise haemodynamic stability. To explore the utility of several PPH outcome measures, we analysed blinded data from 4521 participants. For each outcome, we assessed its: (1) frequency, (2) specificity for significant bleeding defined as shock index ≥1.0 and (3) association with fatigue (modified fatigue symptom inventory [MFSI]), physical endurance (six-minute walk test) and breathlessness. A clinical diagnosis of PPH was sufficiently frequent (7%), highly specific for clinical signs of early shock (95% specificity for shock index ≥1) and associated with worse maternal functioning after childbirth. Conclusion Outcome measures in clinical trials of interventions for PPH prevention should facilitate valid and precise estimation of the treatment effect and be important to women. A clinical diagnosis of PPH appears to meet these criteria, making it an appropriate primary outcome for the WOMAN-2 trial. Trial registration ClinicalTrials.gov NCT03475342, registered on 23 March 2018; ISRCTN62396133, registered on 7 December 2017; Pan African Clinical Trial Registry PACTR201909735842379, registered on 18 September 2019.

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“…Shock index is an imperfect physiological marker of postpartum blood loss with low sensitivity for PPH. (27) Maternal cardiovascular compensatory mechanisms like haemoconcentration and increased cardiac output after childbirth may obscure early physiologic signs of postpartum bleeding. Shock can be caused by other conditions like sepsis, although this affected < 1% of trial participants.…”

Section: Discussionmentioning

confidence: 99%

Postpartum Haemorrhage in Anaemic Women: Assessing Outcome Measures for Clinical Trials

Brenner¹,

Roberts²,

Balogun³

et al. 2021

Preprint

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Background: Post-partum haemorrhage (PPH) is a leading cause of maternal mortality worldwide. Maternal anaemia greatly increases the risk of PPH and over a third of all pregnant women are anaemic. Because anaemia reduces the oxygen-carrying capacity of the blood, anaemic women cannot tolerate the same volume of blood loss as healthy women. Yet the same blood loss threshold is used to define PPH in all women. The lack of an established PPH definition in anaemic women means the most appropriate outcome measures for use in clinical trials are open to question. We used data from the WOMAN-2 trial to examine different definitions of PPH in anaemic women and consider their appropriateness as clinical trial outcome measures. Main body: The WOMAN-2 trial is assessing tranexamic acid (TXA) for PPH prevention in women with moderate or severe anaemia at baseline. To obtain an accurate, precise estimate of the treatment effect, outcome measures should be highly specific and reasonably sensitive. Some outcome misclassification is inevitable. Low sensitivity reduces precision, but low specificity biases the effect estimate towards the null. Outcomes should also be related to how patients feel, function, or survive. The primary outcome in the WOMAN-2 trial, a ‘clinical diagnosis of PPH’, is defined as estimated blood loss >500 ml or any blood loss within 24 hours sufficient to compromise haemodynamic stability. To explore the utility of several PPH outcome measures, we analysed blinded data from 4,521 participants. For each outcome, we assessed its: 1) frequency, 2) specificity for significant bleeding defined as shock index ≥1.0, and 3) association with fatigue (modified fatigue symptom inventory [MFSI]), physical endurance (six-minute walk test) and breathlessness. A clinical diagnosis of PPH was sufficiently frequent (7%), highly specific for clinical signs of early shock (95% specificity for shock index ≥1) and associated with worse maternal functioning after childbirth.Conclusion: Outcome measures in clinical trials of interventions for PPH prevention should facilitate valid and precise estimation of the treatment effect and be important to women. A clinical diagnosis of PPH appears to meet these criteria, making it an appropriate primary outcome for the WOMAN-2 trial.Clinical trial registration: ClinicalTrials.gov NCT03475342, registered on 23 March 2018; ISRCTN62396133, registered on 7 December 2017; Pan African Clinical Trial Registry PACTR201909735842379, registered on 18 September 2019.

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Shock Index and Postpartum Hemorrhage in Vaginal Deliveries: A Multicenter Retrospective Study

Cited by 29 publications

References 22 publications

The Ability of Shock Index In Detecting Postpartum Haemorrhage: A Retrospective Case-Control Study

The Ability of Shock Index In Detecting Postpartum Haemorrhage: A Retrospective Case-Control Study

Postpartum haemorrhage in anaemic women: assessing outcome measures for clinical trials

Postpartum Haemorrhage in Anaemic Women: Assessing Outcome Measures for Clinical Trials

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