Haslinger Christian, Korte Wolfgang, Hothorn Torsten, Brun Romana, Greenberg Charles, Zimmermann Roland
Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland.
Center for Laboratory Medicine, Hemostasis and Hemophilia Center, St. Gallen, Switzerland.
J Thromb Haemost. 2020 Jun;18(6):1310-1319. doi: 10.1111/jth.14795. Epub 2020 Apr 16.
Postpartum hemorrhage (PPH), a major cause of maternal mortality, has several known risk factors but frequently occurs unexpectedly. PPH incidence and related maternal morbidity and mortality are rising worldwide.
To evaluate the impact of defined prepartum blood coagulation parameters on postpartum blood loss.
This single-center, prospective cohort study analyzed prepartum activities of coagulation factors II and XIII and fibrinogen levels in 1300 women. Blood samples were obtained at labor onset and analyzed only after the last patient had delivered, to prevent a potential treatment bias. Blood loss was quantified using a validated technique. The influence of coagulation factors on measured blood loss was assessed by continuous outcome logistic regression.
Prepartum factor XIII activity strongly influenced measured blood loss: every one unit (%) increase in prepartum factor XIII was associated with an odds ratio of 1.011 (95% confidence interval, 1.006-1.015; P < .001) to keep blood loss below any given cut-off level. For illustration, this suggests that a 30% increase in factor XIII activity increases the odds of not suffering PPH (defined as blood loss ≥500 mL) by 38.9%. This effect remained significant after stratification for the delivery mode, when correcting for other risk factors, and was independent of the statistical model used. Factor II but not fibrinogen had a partially comparable, but much less pronounced, effect.
In the largest population analyzed for the influence of prepartum coagulation factors on PPH to date, prepartum factor XIII activity had a strong impact on postpartum blood loss across every statistical model and clinical subgroup. Our hypothesis that early replenishment of factor XIII levels might constitute a new tool in the prevention and effective early treatment of PPH should be evaluated in future trials.
产后出血（PPH）是孕产妇死亡的主要原因，虽有多种已知风险因素，但仍常意外发生。全球范围内，PPH的发病率以及相关的孕产妇发病率和死亡率都在上升。
评估特定的产前凝血参数对产后失血的影响。
这项单中心前瞻性队列研究分析了1300名女性产前凝血因子II和XIII的活性以及纤维蛋白原水平。在临产时采集血样，仅在最后一名患者分娩后进行分析，以防止潜在的治疗偏倚。使用经过验证的技术对失血量进行量化。通过连续结果逻辑回归评估凝血因子对测得失血量的影响。
产前因子XIII活性对测得失血量有强烈影响：产前因子XIII每增加一个单位（%），将失血量控制在任何给定临界值以下的比值比为1.011（95%置信区间，1.006 - 1.015；P <.001）。举例来说，这表明因子XIII活性增加30%会使不发生PPH（定义为失血量≥500 mL）的几率增加38.9%。在按分娩方式分层、校正其他风险因素后，这种效应仍然显著，且与所使用的统计模型无关。因子II有部分类似但不太明显的作用，而纤维蛋白原则没有。
在迄今为止分析产前凝血因子对PPH影响的最大规模人群中，产前因子XIII活性在每个统计模型和临床亚组中对产后失血都有强烈影响。我们关于早期补充因子XIII水平可能成为预防和有效早期治疗PPH的新工具的假设，应在未来试验中进行评估。
