Clinicodemographic Risk Factors and Maternal Outcomes Associated with Primary Postpartum Hemorrhage. A Prospective Observational Study

Periconception care of the infertile patient: Are we doing enough?

Postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. We evaluated maternal and perinatal outcome of primary massive postpartum hemorrhage. In a restrospective case analysis of 33 women with intractable postpartum hemorrhage initially managed either by hysterectomy or a conservative approach in a tertiary referral center between January 1, 1991 to December 30, 1998, we reviewed the procedures used as a primary or secondary attempt to arrest the hemorrhage. Medical and surgical measures were successful in controlling hemorrhage in 21 (63.6%) of the 33 women. Hemorrhage was successfully arrested by conservative surgery in 13 cases, and by medical management in 8 cases. Emergency hysterectomy was performed in 12 cases (0.7 per 1000 deliveries) No maternal deaths occurred, but there were 2 early neonatal deaths (6.1 %). Atony of the uterus was the main cause of hemorrhage (n=15). Genital tract laceration was associated with a worse prognosis, but the time lapse between delivery and surgery appears to be the main prognostic factor. Uterine atony and morbid adherent placenta are major causes of massive obstetric hemorrhage. In our series, morbidity was high, but there was no mortality. Obstetricians should identify women at risk which is especially associated with a prior cesarean delivery, a current placenta previa and high parity. Early intervention and proper procedure could minimize the complications.

Objective: The aim of the study was to explore factors that worsen maternal outcome (maternal morbidity and mortality) in cases developed Primary Postpartum Hemorrhage (PPH). Methodology: Cross sectional observational study carried out during the period from July 2016 till June 2017, 387 cases were recruited in the study from those who developed 1ry PPH. All data concerning cases were recorded including personal, obstetric, medical history, details of medical services received, complications and maternal mortality. Analysis of data recorded was done to determine factors associated with worse maternal outcome (morbidity and mortality). Results: 387 cases developed 1ry PPH (either managed in or referred) to hospitals of Minia Governorate (two secondary hospitals and one tertiary hospital) during the period of the study. 87 cases were excluded due to incomplete records. 1y PPH was common in MG 53% , residents’ rural areas 63.7%, patients not booked for ANC 59.7% and anemic patients 67.9%. Bivariate correlation of factors that worsen maternal outcome showed positive correlation between maternal complications and maternal age, parity, residence (rural areas), distance between residence and hospital (far), positive history of medical problems (anemia), blood transfusion and number of blood units. Maternal complications developed in 13.3%, coagulopathy was the most common 37.5%. 9 cases developed maternal mortality (3%) most common cause of death was irreversible shock 44.4%. Conclusion: Factors that worsen the maternal outcome in patients who developed primary PPH are residence in rural areas, decrease awareness of ANC importance, high parity, advanced maternal age, prevalence of anemia and decrease number of well qualified hospitals.

To assess the association between advanced maternal age (AMA) and adverse pregnancy outcomes. Secondary analysis of the facility-based, cross-sectional data of the WHO Multicountry Survey on Maternal and Newborn Health. A total of 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East. A total of 308149 singleton pregnant women admitted to the participating health facilities. We estimated the prevalence of pregnant women with advanced age (35years or older). We calculated adjusted odds ratios of individual severe maternal and perinatal outcomes in these women, compared with women aged 20-34years, using a multilevel, multivariate logistic regression model, accounting for clustering effects within countries and health facilities. The confounding factors included facility and individual characteristics, as well as country (classified by maternal mortality ratio level). Severe maternal adverse outcomes, including maternal near miss (MNM), maternal death (MD), and severe maternal outcome (SMO), and perinatal outcomes, including preterm birth (<37weeks of gestation), stillbirths, early neonatal mortality, perinatal mortality, low birthweight (<2500g), and neonatal intensive care unit (NICU) admission. The prevalence of pregnant women with AMA was 12.3% (37787/308149). Advanced maternal age significantly increased the risk of maternal adverse outcomes, including MNM, MD, and SMO, as well as the risk of stillbirths and perinatal mortalities. Advanced maternal age predisposes women to adverse pregnancy outcomes. The findings of this study would facilitate antenatal counselling and management of women in this age category.

Objective: To determine the frequency, risk factors and existing practice for the management of massive primary postpartum hemorrhage (PPH). Study design: Retrospective cross-sectional study. Setting: Department of Obstetrics &amp; Gynaecology at Kuwait Teaching Hospital, Peshawar. Materials and methods: this study was performed from June 2008 to June 2010. Women who developed massive primary PPH after admission or were admitted with it, were included in the study. Medical record files of these women were reviewed for maternal mortality and morbidities which included mode of delivery, possible cause of postpartum hemorrhage, supportive medical and surgical intervention. Data was entered in the pre-structured proforma. Estimates of blood loss were made on history, visual parameters and patient’s condition. All the data was analyzed by using statistical computer soft ware SPSS 6. Results: During the study period total number of obstetrical admissions were 2944. Forty nine out of 2769 (1.76%) deliveries, developed massive primary PPH. The highest frequency of massive primary PPH was observed in grand multiparous patients. Uterine atony was the most common cause of the complication. Birth attendants other than doctor and delivery outside the study unit were significantly associated with the adverse outcome in these patients. Seventy five percent patients,(36/49) who had massive PPH, delivered vaginally. High dependency unit (HDU) was required in 12% (6/49) of women. Only one caesarian hysterectomy was done. There was one maternal mortality. Blood transfusions were required in 82% (40/49) of the patients. Conclusions: Postpartum hemorrhage can be a preventable condition if early identification and timely management of this complication and its risk factors is observed. Uterine atony is the leading cause of immediate PPH. The main risk factors for PPH due to uterine atony are high parity, a large fetus, multiple fetuses, hydramnios, or past history of PPH. Determining the frequency, risk factors and management of primary postpartum hemorrhage will help design stepwise protocols for prevention and management of primary PPH in our setup.

Objective To determine risks of severe adverse maternal and neonatal outcomes in women with repeated cesarean delivery (CD) and primary CD compared with those with vaginal delivery (VD). Methods Data of this cross-sectional study were extracted from 2,262 pregnant women who gave birth between August 2014 and December 2016, at Srinagarind Hospital, Khon Kaen University. Severe maternal outcomes were categorized based on the World Health Organization criteria. Adjusted odds ratio (aOR) and 95% confidence intervals (CI) were calculated to indicate the risk of severe adverse maternal and neonatal outcomes among women underwent CD compared with those who underwent VD. Results There were no cases of maternal death in this study. CD significantly increased risk of severe adverse maternal outcomes (SMO) (aOR 10.59; 95% CI, 1.19-94.54 for primary CD and aOR 17.21; 95% CI, 1.97-150.51 for repeated CD) compared with women who delivered vaginally. When compared with vaginal delivery, the risks of neonatal near miss (NNM) and severe adverse neonatal outcomes (SNO) were significantly higher in primary CD group (aOR 1.71; 95% CI 1.17-2.51 and aOR 1.66; 95% CI 1.14-2.43), respectively. For repeated CD, the risks were borderline significant (aOR, 1.58; 95% CI, 0.98-2.56 for NNM and aOR, 1.61; 95% CI, 0.99-2.60 for SNO). Conclusion Primary and repeated CD significantly increased the risk of SMO compared with VD. Risks of NNM and SNO were also significantly increased in women with primary CD. The risks of NNM and SNO for repeated CD trended toward a significant increase.

Objective: To evaluate the incidence, risk factors, and pregnancy outcomes of primary postpartum hemorrhage (PPH) after the implementation of postpartum drape with a calibrated bag (PDCB) after normal vaginal delivery.Methods: This retrospective chart review compared patients who had normal vaginal delivery in June 2012 prior to PDCB implementation with patients who had normal vaginal delivery in June 2014 after PDCB implementation at Siriraj Hospital.Results: In total, 856 patients were included in this study, with 458 and 398 patients delivered in June 2012 and June 2014, respectively. Baseline characteristics were comparable between the two groups. The incidence of primary PPH increased significantly after the implementation of PDCB (2.8% in 2012 vs. 8.5% in 2014; p &lt; 0.01). The incidence of severe PPH was also significantly increased (0.4% in 2012 vs. 2.3% in 2014; p = 0.02). Uterine atony was the most common cause and the diagnosis increased after PCDB implementation. The use of additional uterotonic drugs was also significantly increased after PDCB implementation (30.8% in 2012 vs. 85.3% in 2014; p &lt; 0.01). The blood transfusion rate was comparable between the two groups. No peripartum hysterectomy or ICU admission was observed in this study. After PDCB implementation, pregnancy-induced hypertension was found to be a significant risk factor for primary PPH (p &lt; 0.01).Conclusion: The incidence of primary and severe PPH, and the rate of the use of additional uterotonic drugs were all significantly increased after the implementation of PDCB. Pregnancy-induced hypertension was found to be a significant risk factor for primary PPH.

Electronic Poster Presentations, Maternal Fetal Medicine

Primary postpartum hemorrhage (PPH) remains a major contributor to maternal morbidity and mortality in resource-limited settings. In this case-control study of 318 women delivering vaginally at public hospitals in Lusaka, Zambia, prolonged third stage of labor and specific intrapartum complications were independently associated with primary PPH. Duration of the third stage of labor was associated with increased odds of PPH (adjusted odds ratio [aOR] 1.1, 95% CI 1.05 - 1.46, P = 0.048). Uterine atony (aOR 7.4, 95% CI 4.5 - 14.6, P < 0.0001) and cervical tears (aOR 11.3, 95% CI 7.9 - 21.7, P < 0.0001) were strongly associated with PPH. Retained placenta was also an independent predictor (aOR 4.3, 95% CI 3.4 - 9.7, P = 0.001). Socio-demographic factors showed no meaningful association with PPH after multivariable adjustment. Secondary outcomes observed among cases included hemorrhagic shock, hysterectomy, ICU admission, and maternal death. These results emphasize early recognition and prevention of modifiable intrapartum risk factors to reduce PPH-related morbidity and mortality.

Maternal Outcomes in Women with Bleeding Disorders According to Mode of Delivery: A Single-Center Retrospective Cohort Study

Background: Postpartum hemorrhage (PPH) is a significant contributor to maternal morbidity and mortality, specifically in low-resource settings like Pakistan. The advent of obstetric care has not removed the challenges of inadequate emergency response and insufficient blood transfusion. The risk factors, management strategies, urological complications, and maternal outcomes associated with PPH are evaluated in this study in a tertiary care setting. Objectives: The study aimed to analyse prevalence of PPH risk factors, effectiveness of medical and surgical management, associated urological complications, and maternal outcomes in Pakistani women. Methods: This retrospective study was conducted in tertiary care hospitals in Pakistan from August 2021 to August 2022, including a total of 100 postpartum hemorrhage (PPH) cases. Data on maternal demographics, risk factors, management approaches, and outcomes were analyzed using descriptive statistics in SPSS version 25.0. A p-value of &lt;0.05 was considered statistically significant. Results: The most common cause of PPH was uterine atony (45%), then placental abnormalities (15%), hypertensive disorders (12%), and previous cesarean delivery (32%). The most commonly used were oxytocin (92%) and misoprostol (70%), and 60% of cases required blood transfusions. In severe cases, surgical interventions, such as uterine tamponade (18%) and hysterectomy (6%) were employed. Acute kidney injury (10%) was the most frequent urological complication, but 25% of cases had complications involving the urological system. Eighty percent of maternal outcomes recovered, 12 percent required extended hospitalization, 6 percent were admitted to the ICU, and 2 percent died. Conclusion: In Pakistan, PPH is still a major obstetric challenge. Maternal morbidity and mortality can be reduced by strengthening emergency obstetric care, improving blood transfusion availability, and standardizing PPH management protocol. Keywords: Postpartum hemorrhage, uterine atony, cesarean section, hypertensive disorders, placental abnormalities, blood transfusion, urological complications, maternal mortality, obstetric emergency, Pakistan.

To determine the association between cultural abdominal massage (CAM) in pregnancy and adverse maternal and perinatal outcomes. In this prospective cohort study, eligible term pregnant women who underwent CAM (exposed, n = 160) and those who did not undergo CAM (unexposed, n = 160) in the index pregnancy were enrolled during labor. Participants were followed up and immediate adverse maternal outcomes, including abruptio placenta, primary postpartum hemorrhage (PPH), uterine rupture, cesarean hysterectomy, admission to a high-dependency unit (HDU), and maternal death, and adverse perinatal outcomes, including intrauterine fetal demise (IUFD), stillbirth, 5-min Apgar score below 7, admission to neonatal HDU, and neonatal death, were evaluated within the first 72 h of delivery. The association between CAM and adverse maternal and perinatal outcomes was assessed using binomial logistic regression adjusted for potential confounders to obtain adjusted risk ratios (aRRs) with corresponding 95% confidence intervals (CIs). Statistical significance was two-tailed at P ≤ 0.05. Compared with those who did not undergo CAM, women who underwent CAM in the index pregnancy had increased risk of primary PPH (adjusted risk ratio [ARR] 3.04, 95% CI 2.49-3.72, P < 0.001), uterine rupture (aRR 1.61, 95% CI 1.04-2.49, P = 0.031), stillbirth (aRR 1.54, 95% CI 1.09-2.16, P = 0.013) and 5-min Apgar score below 7 (aRR 2.11, 95% CI 1.78-2.51, P < 0.001). There was no association between CAM and abruptio placenta, cesarean hysterectomy, admission to HDU, or death. Women who underwent CAM were at increased risk of primary PPH, uterine rupture, stillbirth, and 5-min Apgar score below 7.

The effects of a peripartum strategy to prevent and treat primary postpartum haemorrhage at health facilities in Niger: a longitudinal, 72-month study

Postpartum haemorrhage complicates about 3 – 5% of deliveries. It is the leading cause of maternal morbidity and mortality worldwide, especially in sub-Saharan Africa (of which Nigeria is a part), where it significantly contributes to the burden of maternal and perinatal morbidity and mortality. The objective of this study was to determine the incidence, maternal and perinatal outcomes of postpartum haemorrhage and its maternal outcome at the Federal Medical Centre, Yenagoa, South-South, Nigeria. This retrospective survey was conducted between 1st January 2016 and 31st December 2020. Data were retrieved, entered into a pre-designed proforma, and analysed using IBM SPSS version 25.0. Results were presented in frequencies and percentages for categorical variables and mean and standard deviation for continuous variables. Out of 4,571 deliveries within the study period, postpartum haemorrhage complicated 66; representing a case incidence rate of 14.4 per 1,000 deliveries. Majority of the women were multiparous/grand-multiparous (53, 80.3%) and unbooked (56, 84.4%). Primary postpartum haemorrhage was the more common (56, 84.8%) type of postpartum haemorrhage, with uterine atony being the most (39, 59.1%) implicated aetiology. The most common (12, 18.2%) perinatal complications were birth asphyxia and admission into special care baby unit. There were 5 cases of maternal mortality giving a rate of 10.9 deaths per 10,000 pregnant women. Postpartum haemorrhage is one of the leading causes of maternal morbidity and mortality, especially in developing countries. Therefore, antenatal booking, recognition of risk factors and active management of third stage of labour are key in the prevention of postpartum haemorrhage and its associated complications. Women should be encouraged to book for antenatal care early and be regular at the visits, as this will help recognise danger signs early and establish plans to prevent postpartum haemorrhage.

ObjectiveTo determine the optimal vital sign predictor of adverse maternal outcomes in women with hypovolemic shock secondary to obstetric hemorrhage and to develop thresholds for referral/intensive monitoring and need for urgent intervention to inform a vital sign alert device for low-resource settings.Study DesignWe conducted secondary analyses of a dataset of pregnant/postpartum women with hypovolemic shock in low-resource settings (n = 958). Using receiver-operating curve analysis, we evaluated the predictive ability of pulse, systolic blood pressure, diastolic blood pressure, shock index, mean arterial pressure, and pulse pressure for three adverse maternal outcomes: (1) death, (2) severe maternal outcome (death or severe end organ dysfunction morbidity); and (3) a combined severe maternal and critical interventions outcome comprising death, severe end organ dysfunction morbidity, intensive care admission, blood transfusion ≥ 5 units, or emergency hysterectomy. Two threshold parameters with optimal rule-in and rule-out characteristics were selected based on sensitivities, specificities, and positive and negative predictive values.ResultsShock index was consistently among the top two predictors across adverse maternal outcomes. Its discriminatory ability was significantly better than pulse and pulse pressure for maternal death (p<0.05 and p<0.01, respectively), diastolic blood pressure and pulse pressure for severe maternal outcome (p<0.01), and systolic and diastolic blood pressure, mean arterial pressure and pulse pressure for severe maternal outcome and critical interventions (p<0.01). A shock index threshold of ≥ 0.9 maintained high sensitivity (100.0) with clinical practicality, ≥ 1.4 balanced specificity (range 70.0–74.8) with negative predictive value (range 93.2–99.2), and ≥ 1.7 further improved specificity (range 80.7–90.8) without compromising negative predictive value (range 88.8–98.5).ConclusionsFor women with hypovolemic shock from obstetric hemorrhage, shock index was consistently a strong predictor of all adverse outcomes. In lower-level facilities in low resource settings, we recommend a shock index threshold of ≥ 0.9 indicating need for referral, ≥ 1.4 indicating urgent need for intervention in tertiary facilities and ≥ 1.7 indicating high chance of adverse outcome. The vital sign alert device incorporated values 0.9 and 1.7; however, all thresholds will be prospectively validated and clinical pathways for action appropriate to setting established prior to clinical implementation.