The non-pneumatic anti-shock garment (NASG) is a first-aid device that reverses hypovolaemic shock and decreases obstetric haemorrhage. It consists of articulated neoprene segments that close tightly with Velcro, shunting blood from the lower body to the core organs, elevating blood pressure and increasing preload and cardiac output. This chapter describes the controversial history of the predecessors of NASG, pneumatic anti-shock garments (PASGs), relates case studies of PASG for obstetric haemorrhage, compares pneumatic and non-pneumatic devices and posits why the NASG is more appropriate for low-resource settings. This chapter discusses the only evidence available about NASGs for obstetric haemorrhage – two pre-post pilot trials and three case series – and describes recently initiated randomized cluster trials in Africa. Instructions and an algorithm for ASGs in haemorrhage and shock management are included. Much remains unknown about the NASG, a promising intervention for obstetric haemorrhage management.

Abstract: 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.

Obstetric haemorrhage is one of the leading causes of maternal mortality. In many low resource 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.

The leading cause of maternal mortality is hemorrhage, generally occurring in the postpartum period.  Current levels of PPH-related morbidity and mortality in low--resource settings result from institutional, environmental cultural and social barriers to providing skilled care and preventing, diagnosing and treating PPH.  Conventional uterotonics to prevent PPH are typically not available or practical for use in low-resource settings.  In such deliveries, most often taking place at home or in rural health centers, underestimation of blood loss leads to a delay in diagnosis.  Deficiencies in communication and transportation infrastructure impede transfer to a higher level of care.  Inability to stabilize a patient who is in hemorrhagic shock including routine use of prophylactic misoprostol or other appropriate uterotonic, a standardized means of blood loss assessment, availability of a non-pneumatic anti-shock garment, and systemization of communication, transpiration, and referral. Such a multifaceted, systematic, contextualized PPH continuum of care approach may have the freatest impact for savings women's lives.  This model should be developed and tested to be region0specific.

Objective: To assess the impact of the non-pneumatic anti-shock garment (NASG) on maternal outcome following severe obstetric hemorrhage. Methods: A non-randomized pre-intervention/intervention study was conducted in 2 tertiary hospitals in Egypt from June 2006 to May 2008. Women with obstetric hemorrhage (estimated blood loss ≥1000 mL and/or ≥1 sign of shock [systolic blood pressure b100 mm Hg or pulse N100 beats per minute]) were treated with either a standardized protocol (pre-intervention) or a standardized protocol plus the NASG (intervention). The primary outcome was extreme adverse outcome (EAO), combining maternal mortality and severe morbidity (cardiac, respiratory, renal, or cerebral dysfunction). Secondary outcomes were measured blood loss, urine output, emergency hysterectomy, and (individually) mortality or morbidity. Analyses were performed to examine independent association of the NASG with EAO. Results: Mean measured blood loss decreased from 379 mL pre-intervention to 253 mL in the intervention group (Pb0.01). In a multiple logistic regression model, the NASG was associated with reduced odds of EAO (odds ratio 0,38; 95% confidence interval, 0,17–0,85). Conclusion: The NASG, in addition to standardized protocols at tertiary facilities for obstetric hemorrhage and shock, resulted in lower measured blood loss and reduced EAO.

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.

 

We conducted a qualitative study to explore responses to a lowtechnology first-aid device for management of life-threatening obstetric hemorrhage in rural health facilities in Mexico. This entailed in-depth, semistructured interviews with clinical and administrative staff (n = 70) involved in pilot studies of the nonpneumatic antishock garment (NASG) at primary health care facilities and

rural hospitals. We found that staffs’ response fell into four categories: owning, doubting, resisting, and rejecting. Overall, there were positive reactions to the garment as a relevant technology for saving women’s lives. Findings will be used for future implementation of the garment and other new technologies.

 

 

Acceptance of a New Technology for Management of Obstetric Hemorrhage: A Qualitative Study from Mexico.  Berdichevsky, K; Tucker, C; Martinez, A; Miller, S. Health Care Women Int. May 2010, 31(5):444-57.

Antecedentes: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality and severe maternal morbidity. The Non-pneumatic Anti-Shock Garment (NASG), a first-aid lower-body compression device, may decrease adverse outcomes from obstetric hemorrhage. This article is the first to report the effect of the NASG for PPH. Methods: This pre-intervention/NASG study of 854 women was conducted in four referral facilities in Nigeria and two in Egypt between 2004-2008. Entry criteria were women with PPH due to uterine atony, retained placenta, ruptured uterus, vaginal or cervical lacerations or placenta accreta with estimated blood loss of ≥ 750 ml and one clinical sign of shock. Differences in demographics, conditions on study entry, treatment and outcomes were examined. The Wilcoxon rank-sum test and relative risks with 95% confidence intervals were calculated for primary outcomes – measured blood loss, emergency hysterectomy, mortality, morbidity (each individually), and a combined variable, “adverse outcomes”, defined as severe morbidity and mortality. A multiple logistic regression model was fitted to test the independent association between the NASG and the combined severe morbidity and mortality outcome. Results: Measured blood loss decreased by 50% between phases; women experienced 400 mL of median blood loss after study entry in the pre-intervention and 200mL in the NASG phase (p<0). As individual outcomes, mortality decreased from 9% pre-intervention to 3,1% in the NASG - 4 - phase (RR 0,35, 95% CI 0,19-0,62); severe morbidity decreased from 4,2% to 1%, in the NASG phase (RR 0,24, 95% CI 0,09-0,67). As a combination, “adverse outcomes,” decreased from 12,8% to 4,1% in the NASG phase (RR 0,32, 95% CI 0,19-0,53). In a multiple logistic regression model, the NASG was associated with the combined outcome of severe maternal morbidity and mortality (OR 0,42, 95% CI 0,18–0,99). Conclusion: In this non-randomized study, in which bias is inherent, the NASG showed promise for reducing blood loss, emergency hysterectomy, morbidity and mortality associated with PPH in referral facilities in Egypt and Nigeria. Can the Non-pneumatic Anti-Shock Garment (NASG) reduce adverse maternal outcomes from postpartum hemorrhage? Evidence from Egypt and Nigeria.

Mourad-Youssif, S; Ojengbede, OA; Meyer, CD; Fathalla, M; Morhason-Bello, IO; Galadanci, H; Camlin, C; Nsima, D; al Hussaini, T; Butrick, E & Miller, S (2010) Reproductive Health 7:24

Antecedentes: Obstetric hemorrhage is the leading cause of maternal mortality globally. The Non-pneumatic AntiShock Garment (NASG) is a low-technology, first-aid compression device which, when added to standard hypovolemic shock protocols, may improve outcomes for women with hypovolemic shock secondary to obstetric hemorrhage in tertiary facilities in low-resource settings. Methods: This study employed a pre-intervention/intervention design in four facilities in Nigeria and two in Egypt. Primary outcomes were measured mean and median blood loss, severe end-organ failure morbidity (renal failure, pulmonary failure, cardiac failure, or CNS dysfunctions), mortality, and emergency hysterectomy for 1442 women with ≥750 mL blood loss and at least one sign of hemodynamic instability. Comparisons of outcomes by study phase were assessed with rank sum tests, relative risks (RR), number needed to treat for benefit (NNTb), and multiple logistic regression. Results: Women in the NASG phase (n = 835) were in worse condition on study entry, 38,5% with mean arterial pressure <60 mmHg vs. 29,9% in the pre-intervention phase (p = 0,001). Despite this, 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="multiple" logistic regression, there was a 55% reduced odds of mortality during the NASG phase (aOR 0,45, 0,27-0,77). The NNTb to prevent either mortality or severe morbidity was 18 (12-36). Conclusion: Adding the NASG to standard shock and hemorrhage management may significantly improve maternal outcomes from hypovolemic shock secondary to obstetric hemorrhage at tertiary care facilities in lowresource settings.

 

Obstetric hemorrhage and shock management: using the low technology Non-pneumatic Anti-Shock Garment in Nigerian and Egyptian tertiary care facilities 
Miller, S; Fathalla, MMF; Ojengbede, OA; Camlin, C; Mourad-Youssif, M; Morhason-Bello, IO; Galadanci, H; Nsima, D; Butrick, E; al Hussaini, T; Turan, J; Meyer, C; Martin, H; Mohammed, AI (2010) BMC Pregnancy and Childbirth 10,64