Abstract
Purpose
Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and morbidity. Our aim was to investigate the relationships between antenatal factor XIII (FXIII), fibrinogen levels, and blood loss at childbirth.
Methods
This prospective observational study evaluated an unselected cohort of pregnant women admitted for intended vaginal deliveries of singletons at term. To determine clotting factor levels, we obtained blood samples at a maximum of three days prior to vaginal delivery. A calibrated collecting drape was used to quantify blood loss in the third stage of labour. Moderate and severe PPH were diagnosed as blood losses ≥ 500 mL and ≥ 1000 mL, respectively. In a multiple logistic regression analysis, we determined whether coagulation factors and their interactions could independently predict (severe) PPH.
Results
We analysed 548 vaginal deliveries that occurred during the study period. Of those, 78 (14.2%) lost ≥ 500 mL and 18 (3.3%) lost ≥ 1000 mL of blood. The mean pre-delivery FXIII activity in women with PPH (79.33% ± 15.5) was significantly (p < 0.001) lower than in women without PPH (86.45% ± 14.6). A receiver operating characteristic curve analysis detected antenatal FXIII cutoff levels of 83.5% and 75.5% for PPH and severe PPH, respectively. The multiple logistic regression analysis showed that FXIII alone (p < 0.001) and its interaction with fibrinogen (p = 0.03) significantly predicted PPH. FXIII was not significantly correlated with blood loss among patients with severe PPH.
Conclusion
Our results suggested that antenatal FXIII levels may have a significant influence on PPH. The interaction between FXIII and fibrinogen might also provide slight advantages in forecasting PPH.
Similar content being viewed by others
References
Kominiarek MA, Kilpatrick SJ (2007) Postpartum hemorrhage: a recurring pregnancy complication. Semin Perinatol 31:159–166
Oyelese Y, Ananth CV (2010) Postpartum hemorrhage: epidemiology, risk factors, and causes. Clin Obstet Gynecol 53:147–156
Henrich W, Surbek D, Kainer F et al (2008) Diagnosis and treatment of peripartum bleeding. J Perinat Med 36:467–478
Huq FY, Kadir RA (2011) Management of pregnancy, labour and delivery in women with inherited bleeding disorders. Haemophilia 17(Suppl 1):20–30
Kadir R, Chi C, Bolton-Maggs P (2009) Pregnancy and rare bleeding disorders. Haemophilia 15:990–1005
Peyvandi F, Garagiola I, Menegatti M (2011) Gynecological and obstetrical manifestations of inherited bleeding disorders in women. J Thromb Haemost 9(Suppl 1):236–245
Gerlach R, Raabe A, Zimmermann M, Siegemund A, Factor Seifert V (2000) XIII deficiency and postoperative hemorrhage after neurosurgical procedures. Surg Neurol 54:260–264 (discussion 4–5)
Gerlach R, Tolle F, Raabe A, Zimmermann M, Siegemund A, Seifert V (2002) Increased risk for postoperative hemorrhage after intracranial surgery in patients with decreased factor XIII activity: implications of a prospective study. Stroke 33:1618–1623
Wettstein P, Haeberli A, Stutz M et al (2004) Decreased factor XIII availability for thrombin and early loss of clot firmness in patients with unexplained intraoperative bleeding. Anesth Analg 99:1564–1569 (table of contents)
Bremme KA (2003) Haemostatic changes in pregnancy. Best Pract Res Clin Haematol 16:153–168
Hellgren M (2003) Hemostasis during normal pregnancy and puerperium. Semin Thromb Hemost 29:125–130
Szecsi PB, Jorgensen M, Klajnbard A, Andersen MR, Colov NP, Stender S (2010) Haemostatic reference intervals in pregnancy. Thromb Haemost 103:718–727
Karlsson O, Jeppsson A, Hellgren M (2014) A longitudinal study of factor XIII activity, fibrinogen concentration, platelet count and clot strength during normal pregnancy. Thromb Res 134:750–752
Sharief LT, Lawrie AS, Mackie IJ, Smith C, Peyvandi F, Kadir RA (2014) Changes in factor XIII level during pregnancy. Haemophilia 20:e144–e148
Kaveney AD, Philipp CS (2016) Mild factor XIII deficiency and concurrent hypofibrinogenemia: effect of pregnancy. Blood Coagul Fibrinolysis 27:457–460
Bamberg C, Niepraschk-von Dollen K, Mickley L et al (2016) Evaluation of measured postpartum blood loss after vaginal delivery using a collector bag in relation to postpartum hemorrhage management strategies: a prospective observational study. J Perinat Med 44:433–439
Niepraschk-von Dollen K, Bamberg C, Henkelmann A et al (2016) Predelivery maternal fibrinogen as a predictor of blood loss after vaginal delivery. Arch Gynecol Obstet 294:745–751
Kaufner L, Henkelmann A, von Heymann C et al (2017) Can prepartum thromboelastometry-derived parameters and fibrinogen levels really predict postpartum hemorrhage? J Perinat Med 45:427–435
Kohler HP (2013) Interaction between FXIII and fibrinogen. Blood 121:1931–1932
Organization WH (2012) WHO recommendations for the prevention and treatment of postpartum haemorrhage
DGGG (2016) Peripartale Blutungen, Diagnostik und Therapie. Deutsche Gesellschaft für Gynäkologie und Geburtshilfe
Schlembach D, Mortl MG, Girard T et al (2014) Management of postpartum hemorrhage (PPH): algorithm of the interdisciplinary D-A-CH consensus group PPH (Germany–Austria–Switzerland). Anaesthesist 63:234–242
Karimi M, Bereczky Z, Cohan N, Muszbek L (2009) Factor XIII Deficiency. Semin Thromb Hemost 35:426–438
Abdul-Kadir R, McLintock C, Ducloy AS et al (2014) Evaluation and management of postpartum hemorrhage: consensus from an international expert panel. Transfusion 54:1756–1768
Asahina T, Kobayashi T, Takeuchi K, Kanayama N (2007) Congenital blood coagulation factor XIII deficiency and successful deliveries: a review of the literature. Obstet Gynecol Surv 62:255–260
Inbal A, Muszbek L (2003) Coagulation factor deficiencies and pregnancy loss. Semin Thromb Hemost 29:171–174
Chi C, Kadir RA (2012) Inherited bleeding disorders in pregnancy. Best Pract Res Clin Obstet Gynaecol 26:103–117
Sharief LA, Kadir RA (2013) Congenital factor XIII deficiency in women: a systematic review of literature. Haemophilia 19:e349–e357
Hsieh L, Nugent D (2008) Factor XIII deficiency. Haemophilia 14:1190–1200
Cantwell R, Clutton-Brock T, Cooper G et al (2011) Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 118(Suppl 1):1–203
Bouwmeester FW, Bolte AC, van Geijn HP (2005) Pharmacological and surgical therapy for primary postpartum hemorrhage. Curr Pharm Des 11:759–773
Funding
This study was funded by CSL Behring.
Author information
Authors and Affiliations
Contributions
CB: manuscript writing, data analysis, LM: manuscript writing, data collection, AH: data collection, KND: data collection, LK: manuscript editing, CvH: manuscript editing, WH: project development, FP: data analysis.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no conflict of interest related to this study. Trial registration: German Clinical Trials Register (7873).
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Bamberg, C., Mickley, L., Henkelmann, A. et al. The impact of antenatal factor XIII levels on postpartum haemorrhage: a prospective observational study. Arch Gynecol Obstet 299, 421–430 (2019). https://doi.org/10.1007/s00404-018-4980-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00404-018-4980-5