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Acta Obstet Gynecol Scand Downloaded from informahealthcare.com by Karolinska Institutet University Library on 11/29/12
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Estimation of blood loss after cesarean section and vaginal delivery has
low validity with a tendency to exaggeration
Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital, SE-182 88 Stockholm, Sweden,
Stockholm South General Hospital, Sweden, and 3University of Linkoping, Sweden
Abstract
Background . Excessive bleeding is one of the major threats to women at childbirth. The aim of this study was to validate
estimation of blood loss during delivery. Methods . Bleeding was estimated after 29 elective cesarean sections and 26 vaginal
deliveries and compared to blood loss measured by extraction of hemoglobin using the alkaline hematin method, according
to Newton. Results. Inter-individual agreement of estimation showed good results. Estimated loss in comparison with
measured loss resulted in an over-estimation. In vaginally delivered women, there was no correlation between estimated and
measured blood loss (r2 /0.13), and in women delivered by elective cesarean section, the correlation was moderate (r2 /
0.55). Agreement, according to Bland and Altman, indicated that measured blood loss could vary from 570 ml less to
342 ml more than estimated blood loss. Conclusions . The standard procedure of estimation of obstetric bleeding was found
to be unreliable. In this study, blood loss was over-estimated in cesareans. In vaginal deliveries, there seemed to be no
correlation. Estimated blood loss as a quality indicator or as a variable in studies comparing complications must be used with
caution. For clinical purposes, estimation of blood loss and measurement of post partum hemoglobin is of low value and
may lead to the wrong conclusions.
Key words: Blood loss, post partum hemorrhage, comparative study, B-hemoglobin, reproducibility of results, delivery
Introduction
Excessive bleeding after delivery is one of the top five
causes of maternal mortality in developed and
developing countries. Although pregnancy leads to
an increase of the blood volume by roughly 1 l,
control of hemorrhage is necessary. Bleeding from
lacerations or an atonic uterus may be profuse and
amount to a few liters within minutes. This can lead
to life-threatening situations, such as disseminated
intravascular coagulation.
Anemia increases the risk of infection and interferes with recovery after delivery (1). It may, therefore, impair early infant contact during this
important period (2).
Blood loss may be estimated in different ways. The
content of drainage bottles can be measured. Swabs,
pads and diapers can be weighed. In most deliveries,
Correspondence: C. Larsson MD, Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital, SE-182 88 Stockholm, Sweden. E-mail:
christina.larsson@ds.se
Acta Obstet Gynecol Scand Downloaded from informahealthcare.com by Karolinska Institutet University Library on 11/29/12
For personal use only.
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C. Larsson et al.
1600
1400
1400
1200
1000
Estimated
1000
800
600
800
600
400
400
200
200
0
Estimated
Measured
100
Method
Figure 1. Estimated and measured blood loss in women delivered
by cesarean section and vaginal delivery. Values are given as
median and percentiles with the ends of the box as the 25th and
75th percentiles and the 10th and 90th percentiles indicated.
200
300
400
500
600
700
800
Measured
Figure 3. Estimated and measured blood loss in women delivered
vaginally.
Estimated-measured
1500
Estimated
Acta Obstet Gynecol Scand Downloaded from informahealthcare.com by Karolinska Institutet University Library on 11/29/12
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Blood loss
1200
1000
500
600
400
200
0
-200
0
100 200 300 400 500 600 700 800 900 1000
Measured
-400
100 200 300 400 500 600 700 800 900 1000
Measured
Figure 2. Estimated and measured blood loss in women delivered
by cesarean section. Estimated blood loss is plotted as the
dependent variable and measured as the independent.
Measured-estimated
200
0
-200
-400
-600
Acta Obstet Gynecol Scand Downloaded from informahealthcare.com by Karolinska Institutet University Library on 11/29/12
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-800
-1000
200 300 400 500 600 700 800 900 1000
1200
Estimated+measured/2
Figure 5. Mean of difference between measured and estimated
blood loss for all women is /114 (SD 228) indicating that the
difference could vary between /570 ( /2 SD) and /342 (/2
SD) ml.
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Acta Obstet Gynecol Scand Downloaded from informahealthcare.com by Karolinska Institutet University Library on 11/29/12
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