Scientific and Technological Research
Association between fibrinogen levels and the severity of postpartum haemorrhage
Asociacion entre el nivel de fibrinogeno y severidad en la hemorragia posparto
Victoria García Velásqueza,
, Marco González Agudelob, Arturo Cardona Ospinac, Ricardo Ardila Castellanosd
Corresponding author
victoriagarcia1982@hotmail.com
Corresponding author at: Departamento de Medicina Crítica y Cuidado Intensivo, Clínica del Prado, Medellín, Colombia. Carrera 50A #64-42 Unidad de Cuidados Intensivos Clínica del Prado.
Corresponding author at: Departamento de Medicina Crítica y Cuidado Intensivo, Clínica del Prado, Medellín, Colombia. Carrera 50A #64-42 Unidad de Cuidados Intensivos Clínica del Prado.
a Specialist in Obstetrics and Gynaecology, Critical Care Medicine and Intensive Care; Specialist at Women's ICU, Clínica del Prado, Medellín, Colombia
b Specialist in Internal Medicine, Critical Care Medicine and Intensive Care, Master in Epidemiology; Coordinator at Women's ICU, Clínica del Prado, Medellín, Colombia
c Specialist in Obstetrics and Gynaecology, Fetal Medicine, Maternal-Fetal Unit Coordinator, Clínica del Prado, Medellín, Colombia
d Specialist in Internal Medicine, Pulmonology, Epidemiology; Fellow in Critical Care Medicine and Intensive Care, UNAB, Colombia
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Carrera 50A #64-42 Unidad de Cuidados Intensivos Clínica del Prado." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Asociacion entre el nivel de fibrinogeno y severidad en la hemorragia posparto" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1258 "Ancho" => 2167 "Tamanyo" => 99718 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Causes of postpartum haemorrhage.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Worldwide, in developed as well as developing countries, obstetric haemorrhage continues to be a significant cause or mortality.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Postpartum bleeding is the main cause, and atony accounts for 70% of cases and continues to be the main trigger of massive postpartum haemorrhage (PPH) and complications due to coagulopathy.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The evaluation of postpartum bleeding includes clinical, haemodynamic and laboratory variables used to classify the severity<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> and assess patients that benefit from early massive transfusions<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> and admission to the intensive care unit, and women at risk of developing complications due to severe haemorrhagic shock. The most important cause of maternal mortality due to postpartum haemorrhage secondary to uterine atony is the inadequate use of transfusion therapy and insufficient intravascular volume replacement,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> as well as inadequate bleeding control in patients that appear clinically “stable”. Consequently, early identification of patients that may progress to organ dysfunction and increased risk to their lives is of critical importance.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Procoagulant activity increases two-fold towards the end of pregnancy and, therefore, when postpartum bleeding develops, thrombin and partial thromboplastin times may appear normal, masking patients that are evolving towards early coagulopathy. When fibrinogen values drop to <100<span class="elsevierStyleHsp" style=""></span>mg/dL they are associated with the loss of 1.4 blood volumes, establishing a relationship between fibrinogen values and the severity of postpartum haemorrhage.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of this study was to determine whether fibrinogen levels at the onset of postpartum bleeding are associated with the probability of maternal complications, and to define cut-off points related with the outcome.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Secondary analysis of a cohort study<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> with data collected prospectively in an obstetrical Intensive Care Unit in mothers presenting with a diagnosis of postpartum haemorrhage between February 1st, 2012 and January 31st, 2013. Based on the records of that cohort of patients, fibrinogen levels on admission were evaluated and outcomes were correlated with the presence or absence of complications secondary to the haemorrhage upon discharge from the unit. Postpartum haemorrhage was defined as every blood loss greater than 1000<span class="elsevierStyleHsp" style=""></span>mL following vaginal delivery or caesarean section, estimated by the attendant obstetrician at the time.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Bleeding severity was defined on the basis of the worst clinical parameter in the haemorrhagic shock classification (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) or an initial estimated blood loss of more than 2000<span class="elsevierStyleHsp" style=""></span>mL. Mothers with associated diseases such as sepsis, prior liver disease, ketoacidosis and heart disease were excluded, considering that the study was a secondary analysis of a study that assessed lactic acid as a prognostic marker in obstetric haemorrhage and the above disorders may elevate lactic acid levels. Moreover, these disorders are associated with altered coagulation parameters, leading to altered fibrinogen levels not related to the severity of postpartum bleeding.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Fibrinogen levels were measured once, at the onset of postpartum bleeding, in accordance with the protocol used at the Unit for the management of these patients. The initial value was then compared with the gold standard which, in this case, was clinical follow-up upon discharge, and the presence or absence of complications, defined as acute renal injury,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> disseminated intravascular coagulation (DIC),<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> death, reintervention for hysterectomy, and adult respiratory distress syndrome (ARDS).<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> The endpoint was the presence or absence of complications, not the degree of bleeding severity, which was classified according to the usual clinical standard previously described.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The ROC curve was performed in order to determine the diagnostic accuracy of fibrinogen levels in relation to the presence of complications upon patient discharge from the unit. The area under the curve was estimated in order to assess the accuracy of fibrinogen levels in evaluating the probability of complications in postpartum haemorrhage, and the cut-off point with the highest sensitivity and specificity was determined. A value of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05 was defined as significant. Version 17 of the SPSS package was used for the statistical analysis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Considering that the information was collected from records and there was no intervention or modification of patient variables, this study is considered as research with no risk.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> The study followed the ethical principles that apply to human research, stated in the Declaration of Helsinki by the World Medical Association,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> and data collection for the study was approved by the ethics and research committee of the institution.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">Data were collected for 79 patients with obstetric postpartum haemorrhage in the initial cohort, with a mean age of 24.6 years; 19 patients (24.1%) developed severe PPH compared with 60 patients (75.9%) who presented with mild and moderate PPH. All patient charts contained the initial fibrinogen value, hence their inclusion in the analysis.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The demographic characteristics are described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. No significant differences were found between age, number of previous pregnancies or route of delivery in relation to bleeding severity (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In terms of the causes of postpartum haemorrhage, the majority (62%) were due to uterine atony, followed by cervical or vaginal tear, 13.9%; abruptio placenta, uterine rupture, placenta accreta and placental retention, 5.1% each; placenta praevia, 2.5%; and uterine inversion, 1.3% (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). No relationship was found between the cause of the bleeding and its severity.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The main comorbidity was pregnancy-associated hypertensive disorder, found in 21 patients (26.6%); however, no relationship was found with bleeding severity in patients with this comorbidity. There were complications in 12 patients (15.2%), including 9 cases (11.4%) of acute renal injury (all AKIN I), 2 cases (2.5%) of disseminated intravascular coagulation, and 1 death (1.3%).</p><p id="par0070" class="elsevierStylePara elsevierViewall">Resuscitation treatment was similar in all patients, based on haemodynamic targets and perfusion parameters. The use of blood products was based on the judgement of the physician in charge of the unit, with a total of 30 patients (38%) receiving transfusion. Of them, 4 were classified as mild (12.9%), 11 as moderate (35.5%) and 15 as severe (88.2%). Some patients required additional procedures besides pharmacological treatment to control the bleeding (25.4%), including Bakri balloon placement in 7 (8.9%), use of B-Lynch suture in 10 (12.7%) and hysterectomy in 3 (3.8%).</p><p id="par0075" class="elsevierStylePara elsevierViewall">Al patients with fibrinogen levels equal to or lower than 200<span class="elsevierStyleHsp" style=""></span>mg/dL presented with severe haemorrhage, 12 of them with complications (12/19, 63%), accounting for 100% of all the patients who developed complications. However, 20.5% of patients with fibrinogen levels greater than 200<span class="elsevierStyleHsp" style=""></span>mg/dL were also classified as severe, but none of them had complications secondary to bleeding. The AUC-ROC for fibrinogen levels and their relationship to complications was 0.71, with a cut-off point ≤200<span class="elsevierStyleHsp" style=""></span>mg/dL for predicting complications (PPV 100%) and a cut-off point ≥515<span class="elsevierStyleHsp" style=""></span>mg/dL for predicting absence of complications following postpartum haemorrhage (71% sensitivity, 65% specificity) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Procoagulant activity increases two-fold towards the end of pregnancy as a way to respond to the need of providing fast and effective haemostasis at the time of placental detachment in order to prevent exsanguination. The main changes observed are increased plasma concentrations of fibrinogen, Factor-VIII and Von Willebrand's factor.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In cases of severe postpartum haemorrhage requiring massive amounts of infused intravascular volume, dilutional coagulopathy is usually observed with prolonged PTT and PT, and a drop in fibrinogen levels and platelet counts, the majority being late changes. Moreover, there is additional consumption of coagulation factors for thrombus formation at vascular injury sites, with plasma levels – fibrinogen included – dropping below the haemostatic threshold.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In our study, when initial fibrinogen values dropped below 200<span class="elsevierStyleHsp" style=""></span>mg/dL there was a correlation with the severity of the postpartum bleeding and the presence of complications, as described by Cortet et al.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> These authors found fibrinogen levels to be an independent factor for postpartum haemorrhage severity, with an OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.90 (95% CI: 1.16–3.09) for a fibrinogen value between 200 and 300<span class="elsevierStyleHsp" style=""></span>mg/dL, and a better correlation with fibrinogen levels under 200<span class="elsevierStyleHsp" style=""></span>mg/dL (OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11.99; 95% CI: 2.56–56.06).</p><p id="par0095" class="elsevierStylePara elsevierViewall">Along the same lines, Charbit et al.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> showed that a fibrinogen value <200<span class="elsevierStyleHsp" style=""></span>mg/dL had a 100% PPV for severe PPH. We found that this cut-off point in obstetrics, as well as in the studies mentioned above, is similar to the recommended cut-off point in trauma resuscitation in non-pregnant women, where the association with severity is found in patients with fibrinogen levels below 150–200<span class="elsevierStyleHsp" style=""></span>mg/dL.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The use of fibrinogen as a predictor of severe PPH is a reference tool in the identification and classification of severity in this group of patients, given the difficulty for the intensive care physician that has not been present at the onset of postpartum bleeding and may often underestimate the severity of the blood loss. This may result in suboptimal resuscitation, considering that physiological variables undergo late changes in this age group, in otherwise healthy patients with good cardiopulmonary reserve.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Additionally, the finding of a fibrinogen level <200<span class="elsevierStyleHsp" style=""></span>mg/dL at the onset of postpartum haemorrhage in a patient with hypovolemic shock secondary to severe PPH will facilitate adequate intravascular resuscitation therapy with other blood products besides red blood cells, such as fresh frozen plasma, cryoprecipitate or fibrinogen concentrate, as recommended in current massive transfusion protocols.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">18–20</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The study has some limitations, including the subjective assessment of the initial blood loss by the attendant obstetrician. This is a relevant fact in terms of the initial classification, although it is a recurrent finding in the vast majority of studies in patients with massive bleeding, obstetric or otherwise.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Despite the above, this subjectivity is actually found in daily practice in delivery rooms and intensive care units. In this sense, our study reflects the reality of mothers in our units and underscores the importance of an objective measurement to guide the physician in determining the true severity of the haemorrhage, as is the case with fibrinogen values at the onset of postpartum bleeding.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0120" class="elsevierStylePara elsevierViewall">Fibrinogen levels measured at the onset of bleeding may be used to guide treatment and resuscitation in patients with postpartum haemorrhage. A cut-off point of <200<span class="elsevierStyleHsp" style=""></span>mg/dL must warn the practitioner about the high risk of severe haemorrhage and complications despite the finding of stable physiological parameters and vital constants, and may be an indication for aggressive transfusion therapy with replacement of coagulation factors, including fibrinogen. In patients with fibrinogen values >200<span class="elsevierStyleHsp" style=""></span>mg/dL, clinical and physiological variables may continue to be used for severity classification, together with other paraclinical tissue perfusion parameters to help distinguish, early on, patients who will develop complications from those that will not.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors did not receive sponsorship to undertake this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical disclosures</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Protection of human and animal subjects</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Confidentiality of data</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Right to privacy and informed consent</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors report no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres474603" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec496796" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres474602" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec496797" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:3 [ "identificador" => "sec0040" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-04-24" "fechaAceptado" => "2014-12-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec496796" "palabras" => array:5 [ 0 => "Postpartum hemorrhage" 1 => "Fibrin fibrinogen degradation products" 2 => "Blood transfusion" 3 => "Blood coagulation" 4 => "Maternal mortality" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec496797" "palabras" => array:5 [ 0 => "Hemorragia postparto" 1 => "Productos de degradación de la fibrina-fibrinógeno" 2 => "Transfusión sanguínea" 3 => "Coagulación sanguínea" 4 => "Mortalidad materna" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine if the level of fibrinogen at the onset of postpartum haemorrhage is associated with bleeding severity and a higher number of complications; to determine outcome-related cut-off points.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Secondary analysis of a cohort study conducted with 79 mothers admitted to the Intensive Care Unit between February 1st, 2012 and January 31st, 2013, with a diagnosis of postpartum haemorrhage, defined as all cases of blood loss greater than 1000<span class="elsevierStyleHsp" style=""></span>mL. Fibrinogen levels were measured at the onset of the postpartum haemorrhage. Fibrinogen values were compared between patients with severe obstetric bleeding and those with mild-to-moderate bleeding, in order to establish the correlation with severity of blood loss and complications.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Overall, 24.1% of the patients showed severe postpartum haemorrhage compared to 75.9% of the patients classified as having mild-to-moderate haemorrhage. There were 12 complications (15.2%), including 9 cases of acute renal injury, 2 cases of disseminated intravascular coagulation, and one death, all of them only in patients with severe obstetric haemorrhage. Regarding the initial fibrinogen value, the AUC-ROC for fibrinogen levels and their relationship with the severity was 0.71, with a cut-off point of <200<span class="elsevierStyleHsp" style=""></span>mg/dL to predict severity (100% positive predictive value).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The initial fibrinogen level in obstetric postpartum haemorrhage is a predictor of severity that helps in alerting to the need for treatment in these patients.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">determinar si el nivel de fibrinógeno al inicio de la hemorragia posparto se asocia con la severidad del sangrado y mayor número de complicaciones; además definir los puntos de corte que se relacionan con el desenlace.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">análisis secundario de un estudio de cohortes realizado en 79 madres que ingresaron con diagnóstico de hemorragia posparto, definido como todo sangrado mayor de 1000<span class="elsevierStyleHsp" style=""></span>mL, a la Unidad de Cuidados Intensivos entre el 1 de febrero de 2012 al 31 de enero de 2013. Los niveles de fibrinógeno se realizaron al inicio de la hemorragia posparto. Se comparó el valor de fibrinógeno entre las pacientes que presentaron hemorragia obstétrica severa contra las hemorragias obstétricas leve-moderada, y de esta forma se correlaciona el valor del fibrinógeno con la severidad de la hemorragia y las complicaciones presentadas en las pacientes.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">el 24,1% de las pacientes presentaron hemorragia posparto severa y se comparó contra el 75,9% de las pacientes clasificadas como leve y moderada. Se presentaron 12 complicaciones (15,2%), 9 fueron injuria renal aguda, 2 coagulación intravascular diseminada y muerte en 1 paciente, sólo en las pacientes con hemorragia obstétrica severa. En cuanto al nivel inicial de fibrinógeno, el AUC-ROC para el valor de fibrinógeno y su relación con severidad fue de 0,71 con un punto de corte<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mg/dL para predecir severidad (valor predictivo positivo 100%)</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">el nivel de fibrinógeno inicial en hemorragia obstétrica posparto es un predictor de severidad que ayuda a alertar el tratamiento en estas pacientes.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García-Velásquez V, González-Agudelo M, Cardona-Ospina A, Ardila-Castellanos R. Asociacion entre el nivel de fibrinogeno y severidad en la hemorragia posparto. Rev Colomb Anestesiol. 2015;43:136–141.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1258 "Ancho" => 2167 "Tamanyo" => 99718 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Causes of postpartum haemorrhage.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1008 "Ancho" => 1616 "Tamanyo" => 47877 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ROC curve fibrinogen level and severity of PPH.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Modified from <a class="elsevierStyleCrossRef" href="#bib0115">[3]</a>." "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Volume loss \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sensory status \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Perfusion \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pulse \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Systolic blood pressure (mmHg) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Degree of shock \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Crystalloids to be infused over 1<span class="elsevierStyleHsp" style=""></span>h (cc) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">10–15%5001000cc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60–90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Compensated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">15–25%10001500cc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal and/or agitated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pallor cold \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91–100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80–90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mild \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3000–4500 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">26–35%15002000cc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Agitated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pallor cold sweating \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">101–120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70–79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4000–6000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">>35%>2000cc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lethargic or unconscious \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Capillary filling >3<span class="elsevierStyleHsp" style=""></span>s \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6000 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab745821.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Classification severity of shock.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">SVD: spontaneous vertex delivery, IVD: instrumented vertex delivery</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mild shock \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate shock \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Severe shock \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Age</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.2 (IC 95% 20.7–25.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.8 (IC 95% 23.07–28.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.1 (IC 95% 20.9–29.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Type of delivery</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>SVD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (58%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (48.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (58.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PVI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (9.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (9.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Caesarean section \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (32.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (41.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (41.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Number of prior pregnancies</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.52 (IC 95% 1.18–1.86) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.94 (IC 95% 1.36–2.51) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.35 (IC 95% 1.33–3.38) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Transfusion</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (12.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (35.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (88.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab745820.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Demographics.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "WHO analysis of cases of maternal death: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "K.S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 4 | 15 |
| 2024 October | 41 | 3 | 44 |
| 2024 September | 47 | 4 | 51 |
| 2024 August | 40 | 4 | 44 |
| 2024 July | 42 | 5 | 47 |
| 2024 June | 37 | 3 | 40 |
| 2024 May | 49 | 11 | 60 |
| 2024 April | 49 | 7 | 56 |
| 2024 March | 82 | 13 | 95 |
| 2024 February | 70 | 7 | 77 |
| 2024 January | 64 | 6 | 70 |
| 2023 December | 52 | 6 | 58 |
| 2023 November | 62 | 7 | 69 |
| 2023 October | 44 | 6 | 50 |
| 2023 September | 31 | 9 | 40 |
| 2023 August | 15 | 3 | 18 |
| 2023 July | 7 | 6 | 13 |
| 2023 June | 6 | 1 | 7 |
| 2023 May | 16 | 8 | 24 |
| 2023 April | 10 | 6 | 16 |
| 2023 March | 7 | 5 | 12 |
| 2023 February | 4 | 5 | 9 |
| 2023 January | 4 | 7 | 11 |
| 2022 December | 9 | 2 | 11 |
| 2022 November | 11 | 10 | 21 |
| 2022 October | 14 | 10 | 24 |
| 2022 September | 16 | 15 | 31 |
| 2022 August | 13 | 8 | 21 |
| 2022 July | 13 | 4 | 17 |
| 2022 June | 20 | 6 | 26 |
| 2022 May | 11 | 6 | 17 |
| 2022 April | 10 | 6 | 16 |
| 2022 March | 7 | 4 | 11 |
| 2022 February | 9 | 3 | 12 |
| 2022 January | 8 | 5 | 13 |
| 2021 December | 8 | 7 | 15 |
| 2021 November | 3 | 5 | 8 |
| 2021 October | 6 | 10 | 16 |
| 2021 September | 11 | 13 | 24 |
| 2021 August | 6 | 6 | 12 |
| 2021 July | 10 | 8 | 18 |
| 2021 June | 6 | 7 | 13 |
| 2021 May | 13 | 8 | 21 |
| 2021 April | 39 | 16 | 55 |
| 2021 March | 7 | 4 | 11 |
| 2021 February | 4 | 4 | 8 |
| 2021 January | 11 | 11 | 22 |
| 2020 December | 11 | 5 | 16 |
| 2020 November | 4 | 5 | 9 |
| 2020 October | 2 | 3 | 5 |
| 2020 September | 7 | 9 | 16 |
| 2020 August | 9 | 3 | 12 |
| 2020 July | 7 | 1 | 8 |
| 2020 June | 4 | 1 | 5 |
| 2020 May | 11 | 2 | 13 |
| 2020 April | 2 | 4 | 6 |
| 2020 March | 5 | 1 | 6 |
| 2020 February | 6 | 4 | 10 |
| 2020 January | 7 | 3 | 10 |
| 2019 December | 7 | 7 | 14 |
| 2019 November | 7 | 6 | 13 |
| 2019 October | 2 | 0 | 2 |
| 2019 September | 2 | 0 | 2 |
| 2019 August | 1 | 1 | 2 |
| 2019 July | 2 | 4 | 6 |
| 2019 June | 0 | 7 | 7 |
| 2019 May | 1 | 9 | 10 |
| 2018 November | 0 | 1 | 1 |
| 2018 October | 0 | 1 | 1 |
| 2018 September | 1 | 1 | 2 |
| 2018 June | 9 | 5 | 14 |
| 2018 May | 32 | 3 | 35 |
| 2018 April | 33 | 6 | 39 |
| 2018 March | 25 | 7 | 32 |
| 2018 February | 24 | 6 | 30 |
| 2018 January | 27 | 4 | 31 |
| 2017 December | 19 | 5 | 24 |
| 2017 November | 28 | 3 | 31 |
| 2017 October | 31 | 9 | 40 |
| 2017 September | 36 | 9 | 45 |
| 2017 August | 50 | 6 | 56 |
| 2017 July | 36 | 4 | 40 |
| 2017 June | 58 | 10 | 68 |
| 2017 May | 67 | 9 | 76 |
| 2017 April | 85 | 18 | 103 |
| 2017 March | 42 | 8 | 50 |
| 2017 February | 42 | 10 | 52 |
| 2017 January | 27 | 11 | 38 |
| 2016 December | 39 | 9 | 48 |
| 2016 November | 54 | 4 | 58 |
| 2016 October | 58 | 13 | 71 |
| 2016 September | 107 | 10 | 117 |
| 2016 August | 46 | 11 | 57 |
| 2016 July | 26 | 11 | 37 |
| 2016 May | 2 | 22 | 24 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 6 | 20 | 26 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 11 | 12 | 23 |
| 2015 November | 36 | 18 | 54 |
| 2015 October | 85 | 26 | 111 |
| 2015 September | 93 | 11 | 104 |
| 2015 August | 102 | 12 | 114 |
| 2015 July | 110 | 15 | 125 |
| 2015 June | 36 | 8 | 44 |
| 2015 May | 74 | 14 | 88 |
| 2015 April | 37 | 14 | 51 |
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