Obstetric Haemorrhage and Retained Products of Conception

Simulation is beneficial training for low frequency high acuity events such as management of obstetric hemorrhage. Our objective was to evaluate perceived competency in management of obstetric and pelvic hemorrhage following training with low fidelity task trainers using inexpensive and common medical supplies. This was a prospective observational study of training residents for management of obstetric and pelvic hemorrhage using a brief didactic instruction and low-cost task trainers with inexpensive common medical supplies. Participants practiced placement of a uterine tamponade balloon, uterine packing with gauze, pelvic parachute packing and temporary abdominal closure. Following training, participants completed a self-report survey regarding perceived competency with each technique. The Wilcoxon Signed-Rank Test was used to compare results before and after training. Eighteen of 23 residents completed the training and completed the survey on perceived competencies. There was a statistically significant improvement in perceived competency for all participants before and after training, with scores improving by 1.5 points for Bakri placement, from 1.94 to 3.44 (p < 0.001), improving by 1.67 points for uterine packing, from 1.78 to 3.44 (p < 0.001), improving by 1.95 for pelvic parachute packing, from 1.16 to 3.11 (p < 0.001), and improving by 1.89 for temporary abdominal closure, from 1.22 to 3.11 (p < 0.001). Low-cost supplies and task trainers can be utilized to simulate postpartum hemorrhage and improve perceived competency in managing obstetric and pelvic hemorrhage. Similar training programs can be used in small community programs with limited resources.

An Interprofessional Collaboration to Implement an Obstetric Hemorrhage Protocol

The aim of this study was to assess whether inclusion of intrapartum risk factors improves our obstetric hemorrhage risk stratification tool in predicting obstetric hemorrhage, transfusion, and related severe morbidity. This is a retrospective cohort study using all live deliveries at a single institution over a 2-year period (n = 5,332). Obstetric hemorrhage risk factors, hemorrhage burden, and severe maternal morbidity index outcomes were assessed through chart abstraction. Hemorrhage risk was assessed at (1) "time of admission" through chart abstraction and (2) "predelivery" by calculation after inclusion of all abstracted intrapartum risk factors. Admission high risk was compared with predelivery high risk for sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio in predicting obstetric hemorrhage, obstetric hemorrhage requiring transfusion, and obstetric hemorrhage-related severe morbidity. Significance levels were calculated using descriptive statistical methods including chi-squared tests and McNemar's tests. The sensitivities of the risk assessment tool using admission risk classification for high-risk patients is 25% for obstetric hemorrhage, 37% for obstetric hemorrhage requiring transfusion, and 22% for obstetric hemorrhage-related severe morbidity. After intrapartum factor inclusion, the sensitivities increase to 55% for obstetric hemorrhage, 59% for obstetric hemorrhage requiring transfusion, and 47% for obstetric hemorrhage-related severe morbidity. This "predelivery" risk assessment is significantly more sensitive across all three end points (p < 0.001 for all three outcomes). While the positive likelihood ratios for obstetric hemorrhage are equal on admission and predelivery (2.10 on admission and predelivery), they increase after intrapartum factor inclusion for obstetric hemorrhage requiring transfusion and obstetric hemorrhage-related severe morbidity (on admission, 2.74 and 1.6, respectively, and predelivery: 4.57 and 3.58, respectively). Inclusion of intrapartum risk factors increases the accuracy of this obstetric hemorrhage risk stratification tool in predicting patients requiring hemorrhage management with transfusion and obstetric hemorrhage-related severe morbidity. · There are little data to validate intrapartum hemorrhage risk reassessment.. · Including intrapartum factors improves risk stratification for transfusion and related morbidity.. · Future research should clinically validate risk reassessment in the intrapartum period..

Globally, as in South Africa, obstetric hemorrhage (OH) remains a leading cause of maternal mortality and morbidity. Although blood transfusion is critical to OH management, the incidence and predictors of transfusion as well as their relation to human immunodeficiency virus (HIV) infection are poorly described. A cross-sectional study was conducted of all peripartum patients at four major hospitals in South Africa (April to July 2012). Comprehensive clinical data were collected on patients who sustained OH and/or were transfused. Logistic regression was used to model risk factors for OH and transfusion. A total of 15,725 peripartum women were evaluated, of whom 3969 (25.2%) were HIV positive. Overall, 387 (2.5%) women sustained OH and 438 (2.8%) received transfusions, including 213 (1.4%) women with both OH and transfusion. There was no significant difference in OH incidence between HIV-positive (2.8%) and HIV-negative (2.3%) patients (adjusted odds ratio [OR], 0.95; 95% confidence interval [CI], 0.72-1.25). In contrast, the incidence of blood transfusion was significantly higher in HIV-positive (3.7%) than in HIV-negative (2.4%) patients (adjusted OR, 1.52; 95% CI, 1.14-2.03). Other risk factors for transfusion included OH, low prenatal hemoglobin, the treating hospital, lack of prenatal care, and gestational age of not more than 34 weeks. In the South African obstetric setting, the incidence of peripartum blood transfusion is significantly higher than in the United States and other high-income countries while OH incidence is similar. While OH and prenatal anemia are major predictors of transfusion, HIV infection is a common and independent contributing factor.

Severe maternal morbidity contributed by obstetric hemorrhage: Maryland, 2020-2022.

Hemorrhage is a leading cause of maternal death worldwide, with increased risk in women with abnormal placentation. Aortic balloon occlusion (ABO), including resuscitative endovascular balloon occlusion, has been used for obstetrical hemorrhage for 20 years, and is associated with decreased operative blood loss, fewer transfusions, and lower rates of hysterectomy. However, the effect of aortic occlusion on fetal/neonatal outcomes is not well known. A literature review on ABO for obstetrical or traumatic hemorrhage was performed. Cases were included if fetal/neonatal outcomes were reported. Data were collected on timing of balloon inflation (predelivery or postdelivery), fetal/neonatal mortality, and Apgar scores. Secondary maternal outcomes included blood loss, need for hysterectomy, ABO-related complications, and mortality. Twenty-one reports of ABO in 825 cases of obstetrical hemorrhage were reviewed (nine case reports/series and twelve comparative studies). 13.5% (111/825) had aortic occlusion prior to delivery of the fetus. Comparative cohorts included 448 patients who underwent iliac artery balloon occlusion (n = 219) or no vascular balloon occlusion (n = 229). The most common neonatal outcome reported was Apgar scores, with no difference in fetal/neonatal outcomes between ABO and non-ABO patients in any study. One neonatal mortality occurred in the sole reported case of ABO use in a pregnant trauma patient at 24 weeks gestation. One maternal mortality occurred because of aortic dissection. Five comparative studies reported significantly decreased blood loss in ABO patients compared to non-ABO patients, and four studies reported significantly lower rates of hysterectomy in ABO patients. ABO-related complications were reported in 1.6% of patients (13/825). Obstetrical hemorrhage is a devastating complication, and ABO may potentially decrease blood loss and reduce the hysterectomy rate without compromising fetal and neonatal outcomes. Further research is needed to determine the safety of predelivery aortic occlusion as this occurred in 14% of the cases.

Background: In recent years, different international and national campaigns have been implemented to combat obstetric haemorrhage. Maternal mortality (MM) is one of the main concerns of public health and represents a good indicator to measure the quality of care, an indicator that also allows to establish the socioeconomic differences between countries. There are still many activities to be carried out and achieve the objective set by the World Health Organization (WHO) and the Latin American Federation of Societies in Obstetrics and Gynaecology (FLASOG) "Zero deaths due to haemorrhage". Objective: Based on the scientific evidence available, deepen the knowledge of the role of obstetric haemorrhage as the main avoidable cause of maternal morbidity and mortality. Methodology: retrospective study through the search of original articles and systematic reviews in: Elsevier, Lancet, Intramed, PubMed, EMBASE, ScienceDirect and Cochrane Library. The following keywords were used for all sites: "Obstetric haemorrhage", "Maternal mortality and obstetric haemorrhage", "Maternal morbidity and obstetric haemorrhage", "Postpartum, late, secondary haemorrhage". The items with the highest level of evidence were selected. Conclusions: Obstetric haemorrhage is still a potential cause of maternal and fetal morbidity and mortality. Its appearance at any time of pregnancy is a cause for concern and alarm. Despite advances in obstetric and anesthetic care, its treatment remains a challenge for the surgical team, anesthesiologist, gynaecologist and Pediatrician.

Objective To explore the risk factors of children with cerebral palsy during pregnancy and neonatal period in Xinxiang area. Methods A retrospective analysis of the relevant research data of cerebral palsy children in Xinxiang area was performed.The research objects were children with cerebral palsy born from May 1, 2005 to April 30, 2010.At the same time, 3 healthy children were selected as the control group to analyze the related risk factors causing cerebral palsy in children. Results The risk factors of children with cerebral palsy in Xinxiang city were as follows: maternal nutritional status, vaginal bleeding during pregnancy, pregnancy-induced hypertension syndrome, and abnormal production history were associated with cerebral palsy(χ2=2.313, 13.296, 5.034, 7.434, all P<0.05)during the perinatal period; related factors during neonatal period were premature birth, severe asphyxia, severe jaundice, and intracranial infection(χ2=4.637, 29.50, 4.633, 5.107, all P<0.05). Multivariate Logistic regression analysis showed the history of severe asphyxia(OR=2.340, 95%CI: 1.250-4.440), severe jaundice(OR=4.110, 95%CI: 2.430-6.740), premature birth(OR=2.570, 95%CI: 1.410-4.770), pregnancy-induced hypertension syndrome(OR=2.350, 95%CI: 1.020-5.440), vaginal bleeding during pregnancy(OR=73.600, 95%CI: 3.060-17.750) and abnormal production history(OR=5.710, 95%CI: 1.250-26.310) were independent risk factors causing children with cerebral palsy. Conclusions The history of severe asphyxia, severe jaundice, premature birth, pregnancy-induced hypertension syndrome, vaginal bleeding during pregnancy and congenital dysplasia are independent risk factors of children with cerebral palsy in Xinxiang area.It should be strengthened to screen and standardize the management of high-risk newborn infants with cerebral palsy, and do well management for perinatal high-risk pregnant women management.Early prevention can help to reduce the incidences of cerebral palsy in local area. Key words: Xinxiang area; Cerebral palsy; Risk factor; Pregnancy; Neonatal period

Impact on Patient Outcomes of Implementation of Ob Hemorrhage Safety Bundle With Multidisciplinary Simulations [16J

Anemia during pregnancy has been associated with adverse maternal and fetal outcomes. Although women with obstetrical bleeding are at increased risk for developing anemia, little is known about the prevalence and burden associated with anemia in hospitalized women with this condition. This study was conducted to estimate the prevalence, demographic characteristics, medical resource utilization, and hospitalization cost associated with a diagnosis of anemia in hospitalized women with obstetrical bleeding in the United States. The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (2003) was queried using ICD-9-CM codes to identify all pregnancy-related discharges as well as discharges with diagnosis codes for conditions associated with obstetrical bleeding. Descriptive statistics were used to evaluate demographic characteristics, medical resource utilization components and hospitalization cost for two groups: patients with a diagnosis of anemia and patients without a diagnosis of anemia. Of the estimated 4,525,714 pregnancy-related discharges in the United States in 2003, more than 250,000 recorded diagnosis codes associated with obstetrical bleeding. Nearly 1 in 5 of these women had an anemia diagnosis. A diagnosis of anemia in hospitalized women with obstetrical bleeding was associated with a 9-fold increase in blood transfusion (p < 0.0001), 33% longer average length of stay (p < 0.0001), and 50% higher average total cost per hospitalization (p < 0.0001). Anemia and blood transfusion are frequently observed in hospitalized women with obstetrical bleeding. To improve outcomes in these patients and alleviate the adverse impact of anemia on postpartum health status, greater provider awareness of the prevalence and burden of illness associated with a diagnosis of anemia in hospitalized women with obstetrical bleeding is warranted.

Impact of Anemia on Medical Resource Utilization and Hospitalization Cost in Women with Obstetrical Bleeding.

The United States has experienced a rising incidence of maternal deaths, including those attributable to obstetric hemorrhage (OBH). In response, the National Partnership for Maternal Safety developed a standardized OBH Consensus Bundle with the goal of universal adoption. In 2016 a large western Pennsylvania health system adopted the OBH Consensus Bundle across its 8 obstetrical units, with the goal to improve maternal outcomes. Gap analysis was used to identify differences between existing OBH protocols and the OBH Consensus Bundle from January to June 2016. Identified gaps as well as existing practices of success were used to systematically develop and implement a standardized system-wide OBH improvement initiative. Hospitals were then categorized by annual birth volume as high (> 2000), medium (500-2000), and low (< 500) with analysis performed across these groups to identify potential trends. All hospitals had individual successes as well as gaps that were used to direct the system-wide OBH improvement initiative. In some cases, individual plans were tailored to meet hospital resources. When hospitals were compared by annual birth volume, variation existed in their preparedness for, and management of OBH, with the single low-volume hospital having the most gaps. This gap analysis identified areas for improvement among all hospitals in a health system regardless of annual birth volume. This systematic approach of evaluation of current protocols and identification of improvement targets with implementation strategies may improve maternity outcomes. Additionally, these lessons described may provide a useful framework for other hospitals and health systems as they implement their own safety bundles.

357: Obstetrical hemorrhage: Risk stratification based on clinical, sociodemographic and intrapartum predictors

Introduction: Massive Obstetric Haemorrhage is the leading cause of maternal morbidity and mortality in sub-Saharan Africa. The management of obstetric haemorrhage requires a systematic and standardized approach to have a favourable maternal outcome. We describe the prevalence, aetiology, current management and outcomes of women with obstetric haemorrhage at Muhimbili National Hospital (MNH). Method: A two-year retrospective review of cases with a diagnosis of obstetric haemorrhage whose gestation age was ≥ 24 weeks and blood loss ≥ 2L or required a blood transfusion of ≥ 4L. Data were analysed using SPSS version 23 and summarized into proportions as well as measures of central tendencies (mean and median) where appropriate. The case fatality rate was calculated using the number of deaths of women with obstetric haemorrhage to the total number of women who were diagnosed to have obstetric haemorrhage. Results: The prevalence of women who had obstetric haemorrhage was 1%. Triggering of massive blood transfusion protocols by informing physician, blood bank, theatre team, pre-transfusion laboratory test and administration of intravenous fluid was performed in more than 98%. About 2.3% of patients received a proper ratio of blood and blood products during management. The percentage of patients with acute kidney injury (AKI), disseminated intravascular coagulopathy (DIC) and heart failure were 13.6%,7.0% and 4.3% respectively. Calcium gluconate was not administered to patients who had obstetric haemorrhage. During the study period the case fatality rate was 4.7%. Conclusion: Management of patients with obstetric haemorrhage was deficient resulting in high rates of maternal mortality and morbidity. Standardised practice by adopting and use of massive transfusion protocol should reduce the adverse maternal outcomes.

Objective Find out the maternal mortality obstetric hemorrhage causes of ob-stetric hemorrhage, make the practical interventions,in order to reduce the rate maternal mortality in Maoming city.Methdos Investigate the assessment results of the maternal mortality caused by obstetric hemorrhage of Maoming city during 2008 to 2009.Results Among 8 years,there were 157 cases of maternal mortality, the maternal mortality rate were 24.40/100000, of which obstetric hemorrhage in the constituent ratio of maternal deaths accounted for 45.22％.Weak uterine contraction was the major factor causing postpartum hemorrhage, it accounts 63.38％.Conclusions It should be harsh against illegal midwifery,increase the rate of hospital delivery,to strengthen the management of high-risk pregnancies and maternal tertiary referral, to improve the quality of management systems for the pregnant, to improve the ability of emergency obstetric, to reduce the incidence of obstetric hemorrhage. Key words: Maternal mortality ratio; Obstetric hemorrhage; Analyze