| Backgrounds and Purpose:Twins account for 0.5-4.0%of all births,and twinning rates vary from race to race and country to country.Over the past four decades,the proportion of twin pregnancy in the global maternal population has been increasing due to the trend of giving birth at advanced ages and the development of assisted reproductive technology(ART).Twin pregnancy increases the risk of postpartum hemorrhage(PPH),resulting in the expansion of potential obstetric blood transfusion needs.However,the global blood supply has continued to be in shortage.Since 2019,the global pandemic of Coronavims Disease 2019(COVID-19)has not only aggravated ischemic problem,but also increased the risk of transfusion transmission,raising concerns about allogeneic blood transfusion.Intraoperative cell salvage(IOCS)is a common transfusion technique that uses scavenge blood from operative fields,and reinfuses the blood back into the patient.It is an effective means to solve the problem of blood shortage and disease transmission during operation.Previous studies have found that the use of IOCS in pregnant women with high risk of PPH such as placenta previa and placenta accreta has the advantages of reducing allogeneic blood transfusion and shortening hospital stay.However,for twin pregnant women,there is no special report on whether there are similar advantages in the use of IOCS in cesarean section.It is worth noting that major clinical bleeding occurs only in some twin pregnancies,and there is a certain degree of dislocation between the occurrence of PPH and IOCS reinfusion in twin pregnant women of cesarean section(CS).There are groups in which PPH occurs but IOCS is not used,or IOCS is used but PPH does not occur.This dislocation is closely related to the low accuracy of clinical prediction of PPH.By reviewing the clinical cases of single-center twin pregnant women of CS from January 2017 to August 2020,we tried to evaluate the effect of IOCS reinfusion and study the prediction model of postpartum hemorrhage in twin pregnant women of CS,in order to determine the actual effect of IOCS reinfusion in twin pregnancy cesarean section,and establish an accurate postpartum hemorrhage prediction model to guide the accurate and efficient clinical application of IOCS reinfusion.Materials and methods:The preoperative and intraoperative maternal information of cesarean delivery of twin with(IOCS reinfusion group)and without IOCS reinfusion in our hospital from January 2019 to August 2020 was collected,and a classification model for predicting IOCS reinfusion was established by artificial neural network(ANN)in IBM SPSS Statistics 20.Then the effectiveness of the model was analyzed and evaluated.According to the relevant indicators of IOCS reinfusion confirmed by the previous ANN model,the maternal information of cesarean delivery of twin was collected 2 years before the service of IOCS reinfusion group in the same hospital(during the period from January 2017 to December 2018,when IOCS service was not yet provided),and the model was used to identify the women who "IOCS reinfusion(actually no IOCS reinfusion)" in this population.The control group(IOCS control group)that had no significant difference in input information with the above-mentioned IOCS infusion group was obtained.The preoperative,intraoperative and postoperative clinical and laboratory indexes of the above two groups(IOCS reinfusion group and IOCS control group)were collected,and the relationships between IOCS reinfusion and the outcomes of cesarean section were analyzed.To eliminate the influence of confounding factors,we established a regression model for each outcome index.Linear regression was used to analyze the differences of total amount of allogeneic blood transfusion,fluid consumption,hemostatic drugs during operation and discharge,and postoperative recovery time,postoperative biochemical indexes between the two groups.Logistic regression was used to analyze the difference in rate of allogeneic transfusion and incidence of hemostasis operation(gauze packing,balloon tamponade,etc.)during operation and discharge between the two groups.Wilcoxon matched-pairs signed rank test was used to compare the difference of coagulation function between preoperative and postoperative(12-24 hours,before discharge)phase in the two groups.Linear regression was used to analyze the effect of IOCS reinfusion and the volume of reinfusion on postoperative coagulation function.Linear regression was used to analyze relationship between IOCS reinfusion and volume or rate of allogeneic blood transfusion in the PPH subgroup.Finally,based on the pre-delivery information of all twin pregnant women of CS from January 2019 to August 2020,the prediction models of PPH outcome of CS intwin pregnant women twin were established respectively through the two machine algorithms(gradient descent algorithm and conjugate gradient algorithm)of ANN neural network above-mentioned.Result:During 1280 twin pregnant women of CS during the period from January 2019 to August 2020(including IOCS reinfusion group)were included in the ANN model for predicting IOCS reinfusion.The established IOCS reinfusion ANN prediction model:the total prediction accuracy is 97.8%in the training group,93.1%in the test group,and the area under curve(AUC)of receiver operating characteristic is 0.990.The established IOCS reinfusion ANN model predicted 87 cases of "IOCS reinfusion"(IOCS control group)among 1290 twin pregnant women of CS in the same hospital from January 2017 to December 2018,and the corresponding comparison with 115 cases of actual IOCS reinfusion from January 2019 to August 2020(IOCS reinfusion group)showed that:● There were no significant differences in the amount of allogeneic blood transfusion,allogeneic blood transfusion rate,total volume of crystalloid and colloid infusion during operation-discharge period and postoperative hospital stay,ICU time between the two groups.● Compared with the control group,the IOCS reinfusion group’s hemoglobin level(105.77±15.62 g/L vs.95.03±16.74 g/L,t=6.141,P<0.001),hematocrit(0.31 ±0.05 vs.0.28±0.05,t=5.721,P<0.001)were significantly increased and serum potassium concentration(3.93±0.25 mmol/1 vs.4.01±0.28 mmol/L,t=-2.215,P<0.001)was significantly decreased 12-24 hours after CS;the IOCS reinfusion group’s prothrombin time was significantly shortened(13.02 ± 0.65s vs.13.10 ±0.65s,t=-2.231,P=0.027),activated partial thromboplastin time was significantly shortened(35.63±3.19s vs.36.78±3.45s,t=-2.637,P=0.009)and thrombin time was significantly prolonged(15.40± 1.07s vs.14.84±0.77s,t=2.810,P=0.001)1224h after operation.● Compared with the control group,the IOCS reinfusion group’s hemoglobin level(105.74±15.26 g/L vs.96.62±16.46 g/L,t=4.923,P<0.001)and hematocrit(0.32±0.04 vs.0.29±0.05,t=5.180,P<0.001)were significantly increased,and serum potassium(3.85±0.32 mmol/L vs.3.99±0.28 mmol/L,t=-2.808,P=0.005)was significantly decreased before discharge;the activated partial thromboplastin time was significantly shorter(35.85±3.84s vs.36.79±3.73s,t=-2.750,P=0.007),the thrombin time was significantly longer(15.17±1.06s vs.14.76±0.73s,t=2.650,P=0.009)before discharge.● The changes of prothrombin time,activated partial thromboplastin time,thrombin time,fibrinogen in the IOCS reinfusion group after operation(12-24h,before discharge)were not related to the reinfusion volume.● The application rate of IOCS in twin pregnant women with PPH of CS was 47.8%(43/90).The volume of allogeneic blood transfusion in the corresponding IOCS reinfusion group was significantly lower than that in PPH patients of cesarean delivery with twin without IOCS reinfusion(2.20±2.88u vs.2.98±2.29u,t=-2.260,P=0.027).The corresponding allogeneic blood transfusion rate was also significantly lower than that in PPH patients of cesarean delivery with twin without IOCS reinfusion(51.2%vs.76.2%,wals=4.596,OR=0.241,95%Cl:0.066-0.885,P=0.032).We established the ANN prediction model of PPH outcome of CS of twin pregnant women in IBM SPSS Statistics 20.The final independent variables included 10 maternal general information indicators(age,weight,body mass index,abdominal circumference,scarred uterus,history of blood transfusion,artificial insemination/conventional in vitro fertilization-embryo transfer/intracytoplasmic sperm injection/preimplantation genetic diagnosis);Chorionic index of twin pregnancy(double chorionic/single chorionic);19 preoperative indicators(preoperative labor induction,use of uterine contraction inhibitors,active bleeding/hypoproteinemia/severe intrahepatic cholestasis/preeclampsia/hypertension/HELLP syndrome,placental adhesion/implantation/abruption/low/marginal previa/partial/complete previa abnormality,uterine rupture,total estimated fetal weight,total protein,albumin).And 3 indexes of surgical plan(emergency cesarean section,days of hospitalization before operation,combined spinal-epidural anesthesia).The PPH prediction model of cesarean section of twin pregnant women established by the ANN gradient descent algorithm(IBM SPSS Statistics 20):in the training group,the positive predictive rate was 93.0%,the negative predictive rate was 96.9%,and the total accuracy was 96.7%;in test group,the positive predictive rate was 27.8%,the negative predictive rate was 94.2%,and the total accuracy was 90.9%;the corresponding AUC was 0.966.The PPH prediction model of cesarean section of twin pregnant women established by the corresponding ANN conjugate gradient algorithm(IBM SPSS Statistics 20):in the training group,the positive predictive rate was 94.6%,the negative predictive rate was 96.4%,and the total accuracy was 96.3%;in the test group,the positive predictive rate was 29.4%,the negative predictive rate was 94.2%,and the total accuracy was 91.2%;the corresponding AUC was 0.962.Conclusion:1.IOCS reinfusion cannot reduce the allogeneic blood transfusion volume,allogeneic blood transfusion rate and the use of corresponding crystalloid and colloid infusion in the total population of twin pregnant women undergoing cesarean section,but it can significantly reduce the allogeneic blood transfusion volume and rate of postpartum hemorrhage patients in this group.2.IOCS reinfusion can improve the blood coagulation function of twin pregnant women undergoing cesarean section and increase the level of hemoglobin after operation,but it does not shorten the hospitalization time.3.At present,the actual application rate of IOCS reinfusion in PPH patients with cesarean delivery of twin in the hospital is only 47.8%,and there is still considerable room for improvement in the corresponding clinical effect.4.In this study,two PPH prediction models(IBM SPSS Statistics 20)for twin pregnant women of cesarean section were established by using artificial neural network,which have good predictive efficiency and are expected to have a considerable clinical application prospect in improving the clinical effect of IOCS reinfusion. |
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