Non-pneumatic anti-shock garment

The Non-Pneumatic Anti-Shock Garment (NASG) is a low-technology first-aid device used to treat hypovolemic shock. It's efficacy for reducing maternal deaths due to obstetrical hemorrhage is being researched. Obstetrical hemorrhage is heavy bleeding of a woman during or shortly after a pregnancy. Current estimates suggest over 300,000 women die every year, of which 99% occurs in developing countries;^[1] most of which, are preventable. Many women in resource-poor settings deliver far from health-care facilities. Once hemorrhage has been identified, many women die before reaching or receiving adequate treatment. The NASG can be used to keep women alive until they can get the treatment they need.^[2]

Background

Every year, an estimated 342,900 women die from complications of pregnancy and childbirth, 99% of these deaths occur in developing countries.^[1] Worldwide, for every 100,000 live births, about 251 women die. In some industrialized countries such as the U.S, this is 13 deaths for every 100,000 live babies born with American women having a lifetime risk of 1 in 2,100 of dying from childbirth related complications. However, in some countries, such as Afghanistan up to 1,600 women die for every 100,000 live births and women have a 1 in 11 lifetime risk of maternal death.^[3]

For every woman who dies, there are 30 women who suffer a disability as a result of pregnancy or childbirth related complications (a maternal morbidity) and 10 who experience a ‘near miss mortality’ (a life threatening obstetric complication).^[4] Morbidities can be serious, lifelong ailments which compromise a woman's health, productivity, quality of life, family health and ability to participate in community life. If a mother dies after childbirth, the newborn is ten times more likely to die before the age of two, other children are more likely to suffer from decreased nutrition and decreased schooling. Many motherless families find it difficult to survive, often with older children having to drop out of school in order to work to help support the family or being sent to live with a relatives intact family.^[5] In addition to this, maternal and newborn deaths are estimated to cost the world $15 billion in lost productivity annually, with maternal health proven to support a country's economic growth and cut poverty.^[6] Maternal death and disability is a human rights issue. It also means hardships and loss of productivity for families, communities and nations. This is of such great concern that in 2000, world leaders decided that improving maternal health should be one of the 8 Millennium Development Goals for the international community.

The leading cause of maternal mortality (deaths from pregnancy and childbirth related complications) is obstetric hemorrhage in which a woman bleeds heavily, most often immediately after giving birth.^[7] A woman dies every 4 minutes from this kind of complication. A woman can bleed to death in two hours or less, and in rural areas, where hospitals may be days away, this leaves little hope for women suffering from hemorrhage.^[8] Also, in areas that have limited resources, clinics and hospitals might not have the staff or supplies needed to save a woman's life. Women die waiting for treatment.^[9]

There are some emerging technologies which are currently being researched and implemented that seek to prevent these unnecessary deaths.^[10] One of these is the NASG which is a low-technology first-aid device that can be placed around the lower body of a woman who has gone into shock from obstetric bleeding. This garment decreases blood loss, recovers women from shock and keeps them alive while they are traveling to a hospital or awaiting treatment.^[11]

Development of the NASG

In the 1900s an inflatable pressure suit was developed by George Crile.^[12] It was used to maintain blood pressure during surgery. In the 1940s and after undergoing numerous modifications, the suit was refined for use as an anti-gravity suit (G-suit). Further modification led to its use in the Vietnam War for resuscitating and stabilizing soldiers with traumatic injuries before and during transportation.^[13] In the 1970s the G-suit was modified into a half-suit which became known as MAST (Military anti-shock trousers) or PASG (Pneumatic Anti-Shock Garment).^[14] During the 1980s the PASG garment became used more and more by emergency rescue services to stabilize patients with shock due to lower body hemorrhage. During the 1990s the PASG was added to the American College of Obstetrics and Gynecology, making it part of the recommended treatment for use by obstetricians and gynecologists in the USA.^[15] However, it was removed from the guidelines later and is no longer on the ACOG guidelines.

From the 1970s, NASA/Ames was involved in developing a non-pneumatic version of the anti-shock garment. This was originally used for hemophiliac children, but has since been developed into the garment known as the Non-pneumatic Anti-Shock Garment (NASG).^[16]

The use of the garment for obstetrical hemorrhage in low-resource settings began in 2002 when Dr. Carol Brees and Dr. Paul Hensleigh introduced the garment into a hospital in Pakistan and reported on a case series of its use.^[17]

Dr. Suellen Miller [1] and colleagues in Mexico, Egypt and Nigeria have completed studies of the NASG (also named the LifeWrap [2]) for obstetric hemorrhage in hospitals in these countries ^{[2][18][19][20][21]} with studies ongoing at primary health care centers in Zambia and Zimbabwe.[3] An implementation program with the NASG as part of a Continuum of Care for Post-Partum Hemorrhage (CCPPH) has been underway since 2008 in India, Nigeria, Tanzania and Peru [4]. The NGO Pathfinder International is the lead implementing organization on the CCPPH project.

How it works

The NASG is a simple neoprene and Velcro device that looks like the bottom half of a wetsuit cut into segments. It can be used to treat shock, resuscitate, stabilize and prevent further bleeding in women with obstetric hemorrhage.

When in shock, the brain, heart and lungs are deprived of oxygen because blood accumulates in the lower abdomen and legs. The NASG reverses shock by returning blood to the heart, lungs and brain. This restores the woman's consciousness, pulse and blood pressure. Additionally, the NASG decreases bleeding from the parts of the body compressed under it.

Mechanisms of action are based upon laws of physics.^[22] Recent research has identified that the pressure applied by the NASG serves to significantly increase the resistive index of the internal iliac artery (which is responsible for supplying the majority of blood flow to the uterus via the uterine arteries).^[23] Another recent study has shown the NASG to decrease blood flow in the distal aorta.^[24]

After a simple training session, anyone can put the garment on a bleeding woman. Once her bleeding is controlled, she can be safely transported to a referral hospital for emergency obstetrical care.

The NASG is light, flexible and comfortable for the wearer. It has been designed to allow perineal access so that examinations and vaginal procedures can be performed without it being removed. Upon application a patient’s vital signs are often quickly restored and consciousness regained.

Research and Implementation

In Egypt and Nigeria, in separate and combined analyses, findings showed that women treated with the NASG fared much better than women who were not treated with the NASG. Results showed significant reductions in blood loss, rate of emergency hysterectomy and incidence of morbidity and mortality.^[2][25][26] Analyses examining the use of the NASG on cases of uterine atony, postpartum hemorrhage, and non-atonic etiologies (ante and postpartum) found similar results.^[21][27][28] Other analyses found that the NASG additionally resulted in a more rapid recovery from shock,^[27][29] helped women overcome treatment delays ^[30] and had a similarly strong ameliorative effect on women in severe shock.^[2]

A combined analysis on 1442 women recently published, examined the effect of the NASG on women with obstetric hemorrhage.^[2] Despite being in a worse condition at study entry, negative outcomes were significantly reduced in the NASG phase: mean measured blood loss decreased from 444 mL to 240 mL (p<0.001), maternal mortality decreased from 6.3% to 3.5% (RR 0.56, 95% CI 0.35-0.89), severe morbidities from 3.7% to 0.7% (RR 0.20, 95% CI 0.08-0.50), and emergency hysterectomy from 8.9% to 4.0% (RR 0.44, 0.23-0.86). In multiple logistic regression, there was a 55% reduced odds of mortality during the NASG phase (aOR 0.45, 0.27-0.77). The number needed to treat (NNT) to prevent either mortality or severe morbidity was 18 (12-36).

Qualitative research in Mexico and Nigeria has examined acceptance of the NASG and found that overall, there were positive reactions to the garment as a relevant technology for saving women’s lives.^[31][32][33]

Research is currently ongoing in Zambia and Zimbabwe to investigate whether the NASG is more successful if implemented at primary health care facilities where hemorrhage is first identified.[5]

References

1. ^ ^{a b} Hogan, Margaret C; Kyle J Foreman, Mohsen Naghavi, Stephanie Y Ahn, Mengru Wang, Susanna M Makela, Alan D Lopez, Rafael Lozano, Christopher JL Murray (8). "Maternal mortality for 181 countries, 1980—2008: a systematic analysis of progress towards Millennium Development Goal 5". Lancet 375 (9726): 1609–1623. doi:10.1016/S0140-6736(10)60518-1. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60518-1/fulltext?_eventId=login. Retrieved 29 August 2011. 
2. ^ ^{a b c d e} Miller, Suellen; Mohamed MF Fathalla, Oladosu A Ojengbede, Carol Camlin, Mohammed Mourad-Youssif, Imran O Morhason-Bello, Hadiza Galadanci, David Nsima, Elizabeth Butrick, Tarek al Hussaini, Janet Turan, Carinne Meyer, Hilarie Martin, Aminu I Mohammed (2010). "Obstetric hemorrhage and shock management: using the low technology Non-pneumatic AntiShock Garment in Nigerian and Egyptian tertiary care facilities". BMC Pregnancy and Childbirth 10 (64). http://www.biomedcentral.com/1471-2393/10/64. 
3. ^ UNICEF. Information by Country - Statistics - Women's Health. Accessed August 29, 2011 from http://www.unicef.org/infobycountry/index.html; 2010.
4. ^ WHO. Beyond the Numbers: Reviewing Maternal Deaths and Complications to Make Preganancy Safer. Geneva: WHO; 2004.
5. ^ Commission on Behavioral and Social Sciences and Education (CBASSE) (2000). The Consequences of Maternal Morbidity and Maternal Mortality: Report of a Workshop. Washington, D.C: The National Academies. http://www.nap.edu/openbook.php?record_id=9800&page=1. 
6. ^ USAID. "2004 Policy Budget: Program Highlights". http://www.usaid.gov/policy/budget/cbj2004/highlights.html. Retrieved 29 August 2011. 
7. ^ WHO, UNICEF, UNFPA. Maternal mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA; 2004.
8. ^ Maine D. Safe Motherhood Programs: Options and Issues. New York, NY: Center for Population and Family Health, Columbia University; 1993.
9. ^ AMDD. Workbook: Using the UN Process Indicators of Emergency Obstetric Services. Questions and Answers.: The Averting Maternal Death and Disability Program (AMDD); 2003 May.
10. ^ Tsu VD, Shane B. New and underutilized technologies to reduce maternal mortality: call to action from a Bellagio workshop. Int J Gynaecol Obstet. 2004 Jun;85 Suppl 1:S83-93
11. ^ Miller S, Ojengbede A, Turan JM, Ojengbede O, Butrick E, Hensleigh P. Anti-Shock Garments for Obstetric Hemorrhage. Current Women's Health Reviews. 2007;3(1):3-11.
12. ^ Vahedi M, Ayuyao A, Parsa M, Freeman H. Pneumatic Antishock Garment-Associated Compartment Syndrome in Uninjured Lower Extremities. J Trauma. 1995;384(4):616-8.
13. ^ Cutler BS, Daggett WM. Application of the "G-suit" to the control of hemorrhage in massive trauma. Ann Surg. 1971 Apr;173(4):511-4.
14. ^ Kaplan B, Poole F, Flagg J, inventors; David Clark Company Inc assignee. Medical pneumatic trouser for emergency autotransfusion. United States Patent 3933150. USA 02/08/1974.
15. ^ ACOS. American College of Surgeons, Committee on Trauma. Advanced Trauma Life Support Manual. Chicago: American College of Surgeons; 1992.
16. ^ Haggerty J. Anti Shock Garment. 1996 [cited; Available from: http://www.sti.nasa.gov/tto/spinoff1996/28.html
17. ^ Hensleigh PA. Anti-shock garment provides resuscitation and haemostasis for obstetric haemorrhage. BJOG. 2002 Dec;109(12):1377-84.
18. ^ Miller S, Hamza S, Bray E, Gipson R, Nada K, Fathalla MF, et al. First Aid for Obstetrical Hemorrhage: The Pilot Study of the Non-pneumatic Anti-Shock Garment (NASG) in Egypt. BJOG. 2006;113(4):424-9.
19. ^ Miller S, Turan J, Dau K, Fathalla M, Mourad M, Sutherland T, et al. Use of the non-pneumatic anti-shock garment (NASG) to reduce blood loss and time to recovery from shock for women with obstetric hemorrhage in Egypt. Global Public Health. 2007;2(2):110-24.
20. ^ Miller S, Turan JM, Ojengbede A, Ojengbede O, Fathalla MF, Morhason-Bello IO, et al. The pilot study of the non-pneumatic anti-shock garment (NASG) in women with severe obstetric hemorrhage: Combined results from Egypt and Nigeria. Int J Gynaecol Obstet. 2006;94(Supplement 2):S154-6.
21. ^ ^{a b} Mourad-Youssif, Mohammed; Oladosu A Ojengbede, Carinne D Meyer, Mohammad Fathalla, Imran O Morhason-Bello, Hadiza Galadanci, Carol Camlin, David Nsima, Tarek al Hussaini, Elizabeth Butrick, Suellen Miller (2010). Reproductive Health 7 (24). 
22. ^ Miller, Suellen; Aderinola Ojengbede, Janet Turan, Oladosu Ojengbede, Elizabeth Butrick, Paul Hensleigh (2007). "2007". Current Women’s Health Reviews 3. 
23. ^ Lester, Felicia; Amy Stenson, Carinne Meyer, Jessica L Morris, Juan Vargas, Suellen Miller (2011). "Impact of the Non-pneumatic Antishock Garment on pelvic blood flow in healthy postpartum women". Am J Obstet Gynecol 204 (5): e1-e5. 
24. ^ Hauswald, Mark; Michael R Williamson, Gillian M Baty, Nancy L Kerr, Victoria L Edgar-Mied (2010). "Use of an improvised pneumatic anti-shock garment and a non-pneumatic anti-shock garment to control pelvic blood flow". Int J Emerg Med 3 (3): 173–175. doi:10.1007/s12245-010-0191-y. 
25. ^ Suellen, Miller; Fathalla, MM; Youssif,MM; Turan, J; Camlin,C; Al-Hussaini, TK; Butrick, E; Meyer, C. (2010). "A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt". International Journal of Gynecology and Obstetrics 109 (1): 20–4. 
26. ^ Miller, Suellen; Ojengbede, O; Turan, J; Morhason-Bello, IO; Martin, H; Nsima, D. (2009). "A Comparative Study of the Non-pneumatic Anti-Shock Garment (NASG) for the Treatment of Obstetric Hemorrhage in Nigeria". International Journal of Gynecology and Obstetrics 107 (2): 121–5. 
27. ^ ^{a b} Morris, Jessica L; Meyer, C; Fathalla, MF; Youssif, MM; Al-Hussaini, TK; Camlin, C; Miller, S (2011). "Treating Uterine atony with the Anti-Shock garment in Egypt". S. African Journal of Midwifery & Women's Health 5 (1): 37–42. 
28. ^ Ojengbede, OA; Morhason-Bello, IO; Galadanci, H; Meyer, C; Nsima, D; Camlin,C; Butrick, E; Miller, S (2011). "Assessing the Role of the Non-Pneumatic Anti-Shock Garment in Reducing Mortality from Postpartum Hemorrhage in Nigeria". Gynecologic and Obstetric Investigation 71: 66–72. 
29. ^ Miller, Suellen; Turan, JM; Dau, K; Fathalla, M; Mourad, M; Sutherland, T; Hamza, S. et al. (2007). "Use of the non-pneumatic anti-shock garment (NASG) to reduce blood loss and time to recovery from shock for women with obstetric haemorrhage in Egypt". Global Public Health Journal 2 (2): 110–24.. 
30. ^ Turan, Janet; Ojengbede, O; Fathalla, M; Mourad-Youssif, M; Morhason-Bello, IO; Nsima, D; Morris, J; Butrick, E; Martin, H; Camlin, C;, Miller, S. (2011). "Positive Effects of the Non-pneumatic Anti-shock Garment on Delays in Accessing Care for Postpartum and Postabortion Hemorrhage in Egypt and Nigeria". J Womens Health 20 (1). 
31. ^ Berdichevsky, K; Tucker, C; Martinez, A; Miller, S (2010). "Acceptance of a New Technology for Management of Obstetric Hemorrhage: A Qualitative Study from Mexico". Health Care Women Int. 31 (5): 444–57. 
32. ^ Oshinowo, A (2007). "Overcoming Delays in Childbirth due to Hemorrhage: A Mixed Methods Study of the Non-pneumatic Anti-shock Garment (NASG) in Nigeria". Unpublished Dissertation. School of Public Health. Berkeley, University of California, Berkeley. 
33. ^ Liu, L (2009). "A mixed methods study of the implementation of two interventions to reduce maternal mortality in Ibadan, Oyo state, Nigeria". Unpublished Dissertation. University of Liverpool. 

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