title: A systematic review of the relationship between blood loss and clinical signs.
abstract: BACKGROUND
  This systematic review examines the relationship between blood loss and clinical signs and explores its use to trigger clinical interventions in the management of obstetric haemorrhage.
  
  
  METHODS
  A systematic review of the literature was carried out using a comprehensive search strategy to identify studies presenting data on the relationship of clinical signs & symptoms and blood loss. Methodological quality was assessed using the STROBE checklist and the general guidelines of MOOSE.
  
  
  RESULTS
  30 studies were included and five were performed in women with pregnancy-related haemorrhage (other studies were carried in non-obstetric populations). Heart rate (HR), systolic blood pressure (SBP) and shock index were the parameters most frequently studied. An association between blood loss and HR changes was observed in 22 out of 24 studies, and between blood loss and SBP was observed in 17 out of 23 studies. An association was found in all papers reporting on the relationship of shock index and blood loss. Seven studies have used Receiver Operating Characteristic Curves to determine the accuracy of clinical signs in predicting blood loss. In those studies the AUC ranged from 0.56 to 0.74 for HR, from 0.56 to 0.79 for SBP and from 0.77 to 0.84 for shock index. In some studies, HR, SBP and shock index were associated with increased mortality.
  
  
  CONCLUSIONS
  We found a substantial variability in the relationship between blood loss and clinical signs, making it difficult to establish specific cut-off points for clinical signs that could be used as triggers for clinical interventions. However, the shock index can be an accurate indicator of compensatory changes in the cardiovascular system due to blood loss. Considering that most of the evidence included in this systematic review is derived from studies in non-obstetric populations, further research on the use of the shock index in obstetric populations is needed.
authors.affiliation: Federal University of São Carlos, São Carlos, Brazil.
authors.forename: Rodolfo Carvalho
authors.initials: RC
authors.lastname: Pacagnella
authors.forename: João Paulo
authors.initials: JP
authors.lastname: Souza
authors.forename: Jill
authors.initials: J
authors.lastname: Durocher
authors.forename: Pablo
authors.initials: P
authors.lastname: Perel
authors.forename: Jennifer
authors.initials: J
authors.lastname: Blum
authors.forename: Beverly
authors.initials: B
authors.lastname: Winikoff
authors.forename: Ahmet Metin
authors.initials: AM
authors.lastname: Gülmezoglu
mesh_terms: D005260:Female; D006470:Hemorrhage / Q000401:mortality / Q000473:pathology*; D006801:Humans; D006473:Postpartum Hemorrhage / Q000401:mortality / Q000473:pathology; D011247:Pregnancy; D055986:Vital Signs