James Andra H, Cooper David L, Paidas Michael J
Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Duke University, Durham, NC.
Clinical, Medical and Regulatory Affairs, Novo Nordisk Inc., Plainsboro, NJ.
Int J Womens Health. 2017 Jul 3;9:477-485. doi: 10.2147/IJWH.S132135. eCollection 2017.
Coagulopathy may be a serious complicating or contributing factor to postpartum hemorrhage (PPH), and should be promptly recognized to ensure proper bleeding management. This study aims to evaluate the approaches of obstetrician-gynecologists worldwide towards assessing massive PPH caused by underlying bleeding disorders.
A quantitative survey was completed by 302 obstetrician-gynecologists from 6 countries (the UK, France, Germany, Italy, Spain, and Japan). The survey included questions on the use of hematologic laboratory studies, interpretation of results, laboratory's role in coagulation assessments, and experience with bleeding disorders.
Overall, the most common definitions of "massive" PPH were >2,000 mL (39%) and >1,500 mL (34%) blood loss. The most common criteria for rechecking a "stat" complete blood count and for performing coagulation studies were a drop in blood pressure (73%) and ongoing visible bleeding (78%), respectively. Laboratory coagulation (prothrombin time/activated partial thromboplastin time [PT/aPTT]) and factor VIII/IX assays were performed on-site more often than were mixing studies (laboratory coagulation studies, 93%; factor VIII/IX assays, 63%; mixing studies, 22%). Most commonly consulted sources of additional information were colleagues within one's own specialty (68%) and other specialists (67%). Most respondents had consulted with a hematologist (78%; least, Germany [56%]; greatest, UK [98%]). The most common reason for not consulting was hematologist unavailability (44%). The most commonly reported thresholds for concern with PT and aPTT were 13 to 20 seconds (36%) and 30 to 45 seconds (50%), respectively. Most respondents reported having discovered an underlying bleeding disorder (58%; least, Japan [35%]; greatest, Spain [74%]).
Global survey results highlight similarities and differences between countries in how PPH is assessed and varying levels of obstetrician-gynecologist experience with identification of underlying bleeding disorders and engagement of hematology consultants. Opportunities to improve patient management of PPH associated with bleeding disorders include greater familiarity with interpreting PT/aPTT test results and identification of and consistent consultation with hematologists with relevant expertise.
凝血功能障碍可能是产后出血（PPH）的一个严重并发症或促成因素，应及时识别以确保对出血进行恰当管理。本研究旨在评估全球妇产科医生评估由潜在出血性疾病导致的大量PPH的方法。
来自6个国家（英国、法国、德国、意大利、西班牙和日本）的302名妇产科医生完成了一项定量调查。该调查包括关于血液学实验室检查的使用、结果解读、实验室在凝血评估中的作用以及出血性疾病经验等问题。
总体而言，“大量”PPH最常见的定义是失血>2000 mL（39%）和>1500 mL（34%）。重新检查“即刻”全血细胞计数和进行凝血研究最常见的标准分别是血压下降（73%）和持续可见出血（78%）。实验室凝血（凝血酶原时间/活化部分凝血活酶时间[PT/aPTT]）和因子VIII/IX检测在现场进行的频率高于混合试验（实验室凝血研究，93%；因子VIII/IX检测，63%；混合试验，22%）。最常咨询的额外信息来源是本专业内的同事（68%）和其他专科医生（67%）。大多数受访者曾咨询血液科医生（78%；最少的是德国[56%]；最多的是英国[98%]）。不咨询的最常见原因是血液科医生无法提供服务（44%）。PT和aPTT最常报告的关注阈值分别为13至20秒（36%）和30至45秒（50%）。大多数受访者报告发现了潜在的出血性疾病（58%；最少的是日本[35%]；最多的是西班牙[74%]）。
全球调查结果凸显了各国在PPH评估方式上的异同，以及妇产科医生在识别潜在出血性疾病和聘请血液科顾问方面的不同经验水平。改善与出血性疾病相关的PPH患者管理的机会包括更熟悉解读PT/aPTT检测结果，以及识别并持续咨询具有相关专业知识的血液科医生。
