Primary postpartum haemorrhage in women with von Willebrand disease or carriership of haemophilia despite specialised care: a retrospective survey

Pregnant women with bleeding disorders require specialised peripartum care to prevent postpartum haemorrhage (PPH). If third trimester coagulation factor levels are <0.50 IU mL^?1, prophylactic treatment is indicated and administered according to international guidelines. However, optimal dose and duration are unknown and bleeding may still occur. The aim of this study was to investigate the outcome in women with von Willebrand disease (VWD) or haemophilia carriership treated according to current practice guidelines. From the period 2002–2011, 185 deliveries in 154 VWD women or haemophilia carriers were retrospectively included. Data on blood loss, bleeding disorder characteristics and obstetric risk factors were obtained. The outcome was primary PPH, defined as blood loss ≥500 mL within 24 h postpartum and severe PPH as blood loss ≥1000 mL. Primary PPH was observed in 62 deliveries (34%), 14 (8%) of which resulted in severe PPH. In 26 deliveries prophylactic treatment was administered due to factor levels below the 0.50 IU mL^?1 cut‐off in the third trimester, 14 of which (54%) were complicated by PPH. We found an increased PPH risk in deliveries given prophylactic treatment compared with deliveries without (OR 2.7, 95% CI 1.2–6.3). In conclusion, PPH incidence was highest in deliveries with the lowest factor levels in the third trimester. Currently, delivery outcome in women with bleeding disorders is unsatisfactory, given the high PPH incidence despite specialised care. Future studies are required to optimise management of deliveries in this patient population.     

Poor Health‐related Quality of Life After Severe Preeclampsia

Abstract: Background: Preeclampsia is a major complication of pregnancy associated with increased maternal morbidity and mortality, and adverse birth outcomes. The objective of this study was to describe changes in all domains of health‐related quality of life between 6 and 12 weeks postpartum after mild and severe preeclampsia; to assess the extent to which it differs after mild and severe preeclampsia; and to assess which factors contribute to such differences. Methods: We conducted a prospective multicenter cohort study of 174 postpartum women who experienced preeclampsia, and who gave birth between February 2007 and June 2009. Health‐related quality of life was measured at 6 and 12 weeks postpartum by the RAND 36‐item Short‐Form Health Survey (SF‐36). The population for analysis comprised women (74%) who obtained scores on the questionnaire at both time points. Results: Women who experienced severe preeclampsia had a lower postpartum health‐related quality of life than those who had mild preeclampsia (all p < 0.05 at 6 wk postpartum). Quality of life improved on almost all SF‐36 scales from 6 to 12 weeks postpartum (p < 0.05). Compared with women who had mild preeclampsia, those who experienced severe preeclampsia had a poorer mental quality of life at 12 weeks postpartum (p < 0.05). Neonatal intensive care unit admission and perinatal death were contributing factors to this poorer mental quality of life. Conclusions: Obstetric caregivers should be aware of poor health‐related quality of life, particularly mental health quality of life in women who have experienced severe preeclampsia (especially those confronted with perinatal death or their child’s admission to a neonatal intensive care unit), and should consider referral for postpartum psychological care. (BIRTH 38:3 September 2011)     

Caring for Children with an Autism Spectrum Disorder: Factors Associating with Health- and Care-Related Quality of Life of the Caregivers

Journal of Autism and Developmental Disorders - This study investigated the association of child, caregiver, and caregiving measurements with the quality of life (QoL) in 81 caregivers (mostly...     

Economic analysis comparing induction of labour and expectant management for intrauterine growth restriction at term (DIGITAT trial)

Objective

Pregnancies complicated by intrauterine growth restriction (IUGR) are at increased risk for neonatal morbidity and mortality. The Dutch nationwide disproportionate intrauterine growth intervention trial at term (DIGITAT trial) showed that induction of labour and expectant monitoring were comparable with respect to composite adverse neonatal outcome and operative delivery. In this study we compare the costs of both strategies.

Study design

A cost analysis was performed alongside the DIGITAT trial, which was a randomized controlled trial in which 650 women with a singleton pregnancy with suspected IUGR beyond 36 weeks of pregnancy were allocated to induction or expectant management. Resource utilization was documented by specific items in the case report forms. Unit costs for clinical resources were calculated from the financial reports of participating hospitals. For primary care costs Dutch standardized prices were used. All costs are presented in Euros converted to the year 2009.

Results

Antepartum expectant monitoring generated more costs, mainly due to longer antepartum maternal stays in hospital. During delivery and the postpartum stage, induction generated more direct medical costs, due to longer stay in the labour room and longer duration of neonatal high care/medium care admissions. From a health care perspective, both strategies generated comparable costs: on average €7106 per patient for the induction group (N = 321) and €6995 for the expectant management group (N = 329) with a cost difference of €111 (95%CI: €−1296 to 1641).

Conclusion

Induction of labour and expectant monitoring in IUGR at term have comparable outcomes immediately after birth in terms of obstetrical outcomes, maternal quality of life and costs. Costs are lower, however, in the expectant monitoring group before 38 weeks of gestation and costs are lower in the induction of labour group after 38 weeks of gestation. So if induction of labour is considered to pre-empt possible stillbirth in suspected IUGR, it is reasonable to delay until 38 weeks, with watchful monitoring.     

Volume-dependent echocardiographic parameters are not useful for estimating baseline blood volume but are useful for detecting acute changes in vascular filling state

Summary To assess the hypothesis that echocardiographic variables vary as a function of baseline blood volume and change in response to changes in vascular filling state, we evaluated the relationship between the atrial and ventricular dimensions and left ventricular function, as measured by combined Doppler and M-mode echocardiography on the one hand, and blood volume as measured by a standard radioactive isotope technique on the other. Furthermore, we determined the effect of an increment in vascular filling state induced by plasma volume expansion. Test subjects were ten male and six female volunteers. Blood volume/kg was the only factor not different between male and female subjects and therefore suitable for our study. None of the echocardiographic variables correlated with blood volume/kg. Volume loading increased stroke volume, left atrial diameter, right atrial area, left ventricular enddiastolic dimension, mean velocity of circumferential fiber shortening and left ventricular ejection time. It is concluded that echocardiographic variables are unsuitable for estimating blood volume. Serial measurements of atrial dimensions and left ventricular dimensions are useful for detecting rapid changes in vascular filling state.Supported by Schering Nederland BV     

Pregnancy and sickle cell disease: a combination with potentially serious complications

Three women with sickle cell disease were hospitalised during pregnancy. The first patient, 26 years old, was admitted with a sickle cell crisis at a gestational age of 23 weeks; she subsequently developed preeclampsia with foetal growth retardation. A stillborn foetus was delivered at 24 weeks after termination of pregnancy. Histopathology of the placenta showed multiple infarctions possibly due to sickle cell disease. The second patient, 22 years old, was treated for sickle cell crisis and preterm labour. She delivered healthy twins at 29 weeks by Caesarean section. Postoperatively, an acute chest syndrome was treated with antibiotics and erythrocytapheresis. The third patient, 25 years old, was treated post partum for multiple venous thromboembolic events. Management of sickle cell-related complications is the same in pregnant and nonpregnant women. We recommend counselling women with sickle cell disease prior to conception and testing partners for haemoglobinopathy. The pregnant sickle cell patient needs specialised care from a multidisciplinary team including obstetricians, haematologists, neonatologists and anaesthesiologists.