OB Hemorrhage - Anti-Shock Garments Resources

OBJECTIVES: Maternal death from hemorrhage in low resource settings is frequently due to long delays in transportation to referral centers and/or in obtaining blood and surgical interventions. This case series was designed to demonstrate the feasibility, efficacy and safety of the non-inflatable anti-shock garment (NI-ASG) for resuscitation and hemostasis in the initial management of obstetric hemorrhage and shock.
METHODS: Fourteen cases of obstetric hemorrhage and hypovolemic shock at Memorial Christian Hospital, Sialkot, Pakistan were managed with a specific clinical protocol based on using NI-ASG as the primary intervention.
RESULTS: The NI-ASG was used to resuscitate and stabilize women with hypovolemic shock from 18 to 57 h. Thirteen patients survived without evidence of morbidity, but one had prolonged shock followed by multiple organ failure and death.
CONCLUSIONS: This study confirmed that the NI-ASG quickly restored the vital signs of most women in severe hemorrhagic shock and stabilized them while awaiting blood transfusion.

OBJECTIVE: To evaluate the feasibility, safety and effectiveness of the non-pneumatic anti-shock garment for resuscitation and haemostasis following obstetric haemorrhage resulting in severe shock.
DESIGN: During a six-week period, the author served a locum tenens as the obstetrician consultant for the Memorial Christian Hospital, Sialkot, Pakistan. All women who suffered from severe obstetric haemorrhage were managed with the anti-shock garment as the first intervention. The data for this report were collected from hospital chart review.
SETTING: Sialkot is a city of about three million and Memorial Christian Hospital is one of two major obstetric hospitals. There is no blood bank at Memorial Christian Hospital or elsewhere in Sialkot. The Memorial Christian Hospital laboratory is able to draw donor blood, type and cross match blood, and process it for transfusion 24 hours per day.
POPULATION: During the six weeks of this study, in June and July 2001, there were 764 deliveries and 34 other admissions within a week following deliveries outside the hospital. Seven women with obstetric haemorrhage who developed severe shock were managed with the anti-shock garment. One woman, who was later found to have mitral stenosis, developed dyspnea upon placement of the anti-shock garment and therefore it was removed within 5 minutes. This report concerns the six women who were able to tolerate the anti-shock garment without untoward symptoms.
METHODS: As soon as severe shock was recognised in the hospital, the anti-shock garment was placed. Crystalloid solutions were given intravenously over the first hour at a rate of 1500 mL per estimated litre of blood loss, then at a maintenance rate of 150 mL/hour. Vital signs every 15 to 30 minutes, hourly urine output and intermittent oxygen saturation were used to monitor patients during the use of the anti-shock garment. When sufficient blood transfusion had been given to restore the haemoglobin to >7 g/dL, the anti-shock garment was removed in segments at 15-minute intervals with documentation of vital signs before removal of each subsequent portion.
MAIN OUTCOME MEASURES: Restoration of mean arterial pressure of 70 mmHg and clearing of sensorium were considered as signs of effective resuscitation. Haemorrhage was considered controlled if the blood loss was less than 25 mL/hour. Morbidity included any complications noted in the medical chart.
RESULTS: Restoration of blood pressure and improvement of mental status occurred within 5 minutes in two patients who were pulseless and three who were unconscious or confused. All patients had improvement of mean arterial pressure to greater than 70 mmHg within 5 minutes. Duration of anti-shock garment use ranged from 12 to 36 hours and none of the six women had significant further bleeding while the anti-shock garment was in place. Patients were comfortable during use of the anti-shock garment and no adverse effects were noted apart from a transient decrease in urine output.
CONCLUSIONS: The anti-shock garment rapidly restored vital signs in women with severe obstetric shock. There was no further haemorrhage during or after anti-shock garment use and the women experienced no subsequent morbidity. A prospective randomised study of the anti-shock garment for management of obstetric haemorrhage is needed to further document these observations.

OBJECTIVE: To evaluate the feasibility, safety and effectiveness of the non-pneumatic anti-shock garment for resuscitation and haemostasis following obstetric haemorrhage resulting in severe shock.
DESIGN: During a six-week period, the author served a locum tenens as the obstetrician consultant for the Memorial Christian Hospital, Sialkot, Pakistan. All women who suffered from severe obstetric haemorrhage were managed with the anti-shock garment as the first intervention. The data for this report were collected from hospital chart review.
SETTING: Sialkot is a city of about three million and Memorial Christian Hospital is one of two major obstetric hospitals. There is no blood bank at Memorial Christian Hospital or elsewhere in Sialkot. The Memorial Christian Hospital laboratory is able to draw donor blood, type and cross match blood, and process it for transfusion 24 hours per day.
POPULATION: During the six weeks of this study, in June and July 2001, there were 764 deliveries and 34 other admissions within a week following deliveries outside the hospital. Seven women with obstetric haemorrhage who developed severe shock were managed with the anti-shock garment. One woman, who was later found to have mitral stenosis, developed dyspnea upon placement of the anti-shock garment and therefore it was removed within 5 minutes. This report concerns the six women who were able to tolerate the anti-shock garment without untoward symptoms.
METHODS: As soon as severe shock was recognised in the hospital, the anti-shock garment was placed. Crystalloid solutions were given intravenously over the first hour at a rate of 1500 mL per estimated litre of blood loss, then at a maintenance rate of 150 mL/hour. Vital signs every 15 to 30 minutes, hourly urine output and intermittent oxygen saturation were used to monitor patients during the use of the anti-shock garment. When sufficient blood transfusion had been given to restore the haemoglobin to >7 g/dL, the anti-shock garment was removed in segments at 15-minute intervals with documentation of vital signs before removal of each subsequent portion.
MAIN OUTCOME MEASURES: Restoration of mean arterial pressure of 70 mmHg and clearing of sensorium were considered as signs of effective resuscitation. Haemorrhage was considered controlled if the blood loss was less than 25 mL/hour. Morbidity included any complications noted in the medical chart.
RESULTS: Restoration of blood pressure and improvement of mental status occurred within 5 minutes in two patients who were pulseless and three who were unconscious or confused. All patients had improvement of mean arterial pressure to greater than 70 mmHg within 5 minutes. Duration of anti-shock garment use ranged from 12 to 36 hours and none of the six women had significant further bleeding while the anti-shock garment was in place. Patients were comfortable during use of the anti-shock garment and no adverse effects were noted apart from a transient decrease in urine output.
CONCLUSIONS: The anti-shock garment rapidly restored vital signs in women with severe obstetric shock. There was no further haemorrhage during or after anti-shock garment use and the women experienced no subsequent morbidity. A prospective randomised study of the anti-shock garment for management of obstetric haemorrhage is needed to further document these observations.

OBJECTIVE: To compare the effect of non-pneumatic anti-shock garment (NASG) on blood loss from obstetric haemorrhage with standard management of obstetric haemorrhage.
DESIGN: Observational study of consecutive obstetric haemorrhage cases before and after introduction of the NASG.
SETTING: Four tertiary care maternity facilities in Egypt.
SAMPLE: The sample consisted of women with obstetric haemorrhage and signs of shock and the entry criteria were: >750 mL of blood loss and either pulse of >100 beats per minute or systolic blood pressure of <100 mmHg. A total of 158 women were in the preintervention group and 206 in the postintervention group.
METHODS: All the women with haemorrhage meeting the eligibility criteria were treated according to the standard protocol for 4 months (May-August 2004); blood loss was measured and recorded. The NASG was then introduced, and all the women meeting the eligibility criteria were treated according to the standard haemorrhage protocol plus the NASG for 4 months (September-December 2004).
MAIN OUTCOME MEASURES: Measured blood loss collected in a closed-end, graduated, plastic, under buttocks collection drape.
RESULTS: Median measured blood loss in the drape following study entry was 50% lower in those treated with the NASG (250 versus 500 mL, P < 0.001). There was also a non-statistically significant decrease in morbidity and mortality.
CONCLUSIONS: This is the first comparative study of the NASG with a standard obstetric haemorrhage treatment protocol. The NASG shows promise for management of obstetric haemorrhage, particularly in lower resource settings. Larger studies will be needed to determine if the NASG contributes to statistically significant decreases in morbidity and mortality.

Postpartum hemorrhage due to uterine atony is the primary direct cause of maternal mortality globally. Management strategies in developed countries involve crystalloid fluid replacement, blood transfusions, and surgery. These definitive therapies are often not accessible in developing countries. Long transports from home or primary health care facilities, a dearth of skilled providers, and lack of intravenous fluids and/or a safe blood supply often create long delays in instituting appropriate treatment. We review the evidence for active management of third-stage labor and for the use of specific uterotonics. New strategies to prevent and manage postpartum hemorrhage in developing countries, such as community-based use of misoprostol, oxytocin in the Uniject delivery system, the non-inflatable antishock garment to stabilize and resuscitate hypovolemic shock, and the balloon condom catheter to treat intractable uterine bleeding are reviewed. New directions for clinical and operations research are suggested.

Annually, over 500,000 women die from complications of pregnancy and childbirth; the majority die from hemorrhage and shock. Obstetrical hemorrhage of all etiologies, such as uterine atony, ruptured uterus, and ruptured ectopic, can cause massive blood loss resulting in severe shock. Unless women can access fluid replacement, blood transfusions, and, often, surgery, the shock leads to organ failure and death. Therefore, the majority of maternal hemorrhage deaths occur in developing countries. The non-pneumatic anti-shock garment (NASG) is a light-weight, reusable, neoprene and Velcro compression device that can be rapidly applied to a hemorrhaging woman to shunt blood from the lower extremities to the core organs, heart, lung and brain, and to decrease blood loss. We review literature on the history, mechanisms of action, and use of Anti-Shock Garments (ASGs) in emergency medicine, focusing on the use of inflatable or Pneumatic ASGs (PASGs) for obstetrical, gynecological, and urological hemorrhage. We describe similarities and differences between the PASG and the newer NASG. We then review recent studies on the NASG for obstetrical hemorrhage in Pakistan, Nigeria, and Egypt, and conclude with recommendations for the types of research necessary to bring the NASG into wider use.

Objective: To determine whether the non-pneumatic anti-shock garment (NASG) can improve maternal outcome. Methods: Women were enrolled in a pre-intervention phase (n=83) and an intervention phase (n=86) at a referral facility in Katsina, Nigeria, from November 2006 to November 2007. Entry criteria were obstetric hemorrhage (≥750 mL) and a clinical sign of shock (systolic blood pressure b100 mm Hg or pulse N100 beats per minute). To determine differences in demographics, condition on study entry, treatment, and outcome, t tests and χ2 tests were used. Relative risk (RR) and 95% confidence interval (CI) were estimated for the primary outcome, mortality. Results: Mean measured blood loss in the intervention phase was 73.5± 93.9 mL, compared with 340.4±248.2 mL pre- intervention (Pb0.001). Maternal mortality was lower in the intervention phase than in the pre-intervention phase (7 [8.1%]) vs 21 [25.3%]) (RR 0.32; 95% CI, 0.14–0.72). Conclusion: The NASG showed potential for reducing blood loss and maternal mortality caused by obstetric hemorrhage-related shock.

Obstetric haemorrhage is one of the leading causes of maternal mortality. In many lowresource settings, delays in transport to referral facilities and in obtaining lifesaving treatment, contribute to maternal deaths. The non-pneumatic anti-shock garment (NASG) is a low-technology pressure device that decreases blood loss, restores vital signs, and has the potential to improve adverse outcomes by helping women survive delays in receiving adequate emergency obstetric care. With brief training, even individuals without medical backgrounds can apply this first-aid device. In this secondary analysis of hospital data from a pre-post intervention study in Egypt (N
/364 women with obstetric haemorrhage and shock), 158 received standard care, while 206 received standard care plus the NASG. The NASG significantly reduced blood loss, time to recovery from shock, and, for those with postpartum haemorrhage due to uterine atony who received oxytocin, the NASG had a significant effect on blood loss independent of oxytocin. These results indicate that the NASG may be a valuable innovation for reducing maternal mortality in low-resource settings. Testing at community and household levels will be necessary in order to determine whether the NASG can help women survive the longest delays.