Prehospital emergency response and management of pregnancy-associated haemorrhage in KwaZulu-Natal Province, South Africa: A Retrospective Cross-Sectional Study

Aim: To analyse the measures taken for controlling primary Post-partum haemorrhage (PPH). Methods: A hospital based descriptive and retrospective study was carried out from 1st January 2005 to 31st December 2006 in the department of Obstetrics & Gynaecology at KMCTH. All patients of having primary Post-partum haemorrhage were analysed for the treatment they received. Results: There were 15 cases of primary Post-Partum Haemorrhage (PPH) from a total delivery of 700 in the year 2005. 9 cases were solely of atonic post-partum haemorrhage. 2 cases were genital tract injuries, 1 case of retained placenta, 1 case of vulval haematoma and 2 cases were of combined cervical tear and atonic primary post-partum haemorrhage. Atonic post-partum haemorrhage remained most important cause. The most common treatment was use of oxytocic. Surgical procedure bilateral uterine artery ligation was frequently performed in 6 cases but it was not effective as a single procedure. B-Lynch brace suture was applied in 5 cases and was successful without further intervention. There were 2 maternal deaths from post-partum haemorrhage. In the year 2006 total number of deliveries was 835 and there were total 11 cases of post partum haemorrhage. The trend changed to from atonic PPH to traumatic PPH. There were 8 cases of traumatic PPH and there were 2 cases of placenta accrete. There was one case of atonic PPH. The overall incidence in two years was 1.6%. Conclusion: Among the various surgical methods adopted B-Lynch brace suture was found to be simple, effective and minimally invasive. Keywords: Atonic post-partum haemorrhage (PPH), surgical management of PPH. doi:10.3126/njog.v3i1.1432 NJOG 2008 May-June; 3(1): 10 - 13

Although there has been some research on the impact of extreme weather on the number of ambulance call-out incidents, especially heat waves, there has been very little research on the...

OBJECTIVES/GOALS: Fibroids during pregnancy are associated with worse obstetric outcomes. However, theres no recommendation to guide counseling. We aimed to assess the cost-effectiveness of (1) treating prevalent fibroids before pregnancy and (2) screening and treatment of fibroids against the outcomes of postpartum hemorrhage (PPH) and fetal malpresentation. METHODS/STUDY POPULATION: A decision tree model was used to compare (1) preconception myomectomy for prevalent fibroids, without treatment and (2) preconception myomectomy for prevalent cases and universal ultrasound screening with subsequent myomectomy for incident cases. Probabilities and costs, calculated from the U.S. healthcare sectors perspective, were derived from the literature. Effectiveness was measured in incident PPH or malpresentation cases per 1,000 in the population. The incremental cost-effectiveness ratio (ICER) was measured in incremental cost per case averted. One-way and probabilistic sensitivity analyses were conducted to identify influential parameters and assess the impact of parameter uncertainty. RESULTS/ANTICIPATED RESULTS: Treating known fibroids prior to pregnancy averted 65.7 PPH cases at the cost of $8,773,094 and 91.08 malpresentations at the cost of $8,163,315 (ICERs, $133,532 vs $89,628 per case averted, respectively). Universal fibroid screening with treatment of incident and prevalent cases averted 7.34 PPH cases at the cost of $3,725,619 and 2.7 malpresentations at the cost of $3,477,033 (ICERs, US$507,450 vs US$1,335,771 per case averted, respectively). Sensitivity analyses showed cost-effectiveness improved with decreased cost of myomectomy and increased proportion of prevalent and incident cases. DISCUSSION/SIGNIFICANCE: Treatment alone costs $133,532 per PPH averted and $89,628 per malpresentation averted. Likewise, screening with treatment costs $507,450 per PPH averted and $1,335,771 per malpresentation averted. Additionally, ICERs may decrease when focusing on populations where fibroid incidence and prevalence is higher, for example, among Black women.

Obstetric haemorrhage is a recognised cause of maternal morbidity and mortality in the United Kingdom. Postpartum haemorrhage (PPH) of the massive type is the one most likely to result in either severe morbidity or mortality. In this retrospective study, we reviewed all cases of massive PPH in our unit over a 4-year period with the aim of characterising the factors associated with the haemorrhage, its management and associated morbidity. All cases of PPH were identified from the obstetric database of the Leicester Royal Infirmary for the period 1997–2001 (inclusive). Only those cases in which the estimated blood loss was at least 15 000 ml were included in the study. The case notes of the patients were retrieved and various variables collected for analyses. Over the 4-year period, there were 27 106 deliveries at the unit and 145 women suffered from massive PPH—an incidence of five per 1000 deliveries. Sixty-one (42%) were in multiparous women and of these, 12 were in those with four or more previous deliveries. There was associated antepartum haemorrhage in 12 cases, five of which were placental abruptions. Estimated blood loss was over 2000 ml in 46 cases. Risk factors included prolonged labour, emergency caesarean section for failure to progress especially in the second stage (34) and placental praevia (10). Four cases underwent an abdominal hysterectomy.

Successful treatment with recombinant blood factor VIIa in severe postpartum hemorrhage-induced disseminated intravascular coagulation

Objective To determine the association between fetal macrosomia (FM) and postpartum hemorrhage (PPH) in Latin American and Caribbean (LAC) women.Data Sources Studies evaluating the association between FM and PPH (≥ 500 ml) and severe PPH (≥ 1,000 ml) until November 4, 2021, indexed in CINHAL, Scopus, Embase, Cochrane Library, MEDLINE, LILACS, and SciELO.Selection of Studies Inclusion criteria were cohort and case-control studies that provided the number of PPH and FM cases. Exclusion criteria were studies lacking information about the number of cases, with a population of women who were not from LAC; published in a language other than English, Spanish, or Portuguese, and with a different design.Data Collection Data extraction was performed independently by two authors, and discrepancies were resolved with a third author. Data regarding FM and PPH cases were retrieved.Data Synthesis Of the 1,044 articles evaluated, 5 studies were included, from 6 different countries: Argentina and Uruguay (multi-country), West Indies, Antigua and Barbuda, French Guyana, and Suriname. The pooled odds ratio (OR) for FM and PPH in the meta-analysis (five studies) was 2.10 (95% confidence interval [CI]: 1.79–2.47; I2: 0%), with estimates within this 95% CI in the sensitivity analysis. The combined OR for severe PPH (3 studies) was 1.61 (95% CI: 0.40–6.48; I2: 91.89%), showing high heterogeneity.Conclusion There was a positive association between FM and PPH in the LAC, increasing the risk of the presence of this event 2-fold. The high heterogeneity of the studies that measured severe PPH does not allow drawing conclusions about the estimates obtained.

Agnostic identification of plasma biomarkers for postpartum hemorrhage risk

Post partum haemorrhage (PPH) is the leading cause of maternal death worldwide. PPH occurs in up to 18% of total births. Among different factors, PPH due to uterine atony is the primary and direct cause of maternal mortality comprising about 90%. The objective of the present study was to assess the prevalence, morbidity and management pattern of PPH in Dhulikhel Hospital. Hospital based retrospective study was carried out at Kathmandu University School of Medical Science, Dhulikhel Hospital from the period of January 2007 till October 2009. The study group included total of 60 patients. All women who had PPH both primary and secondary were studied. Information regarding total number of deliveries obtained from Obstetrics ward. The cases with PPH were identified and detail records were reviewed using standard format. The main outcome measures used for the analysis were amount of blood loss, cause of PPH and treatment methods. In Dhulikhel hospital, from January 2007 till October 2009 a total of 3805 deliveries took place. Out of which 60 women had PPH. The prevalence was 16/1000 deliveries. There are 41 (68.3%) cases of primary PPH and 19 (31.7%) cases of secondary PPH. PPH was found more in home deliveries, unbooked case and in multiparas. The mean blood loss was 1055 ml. As an aetiology, retained placenta and retained placental bits of tissue was found in 37(61.7%) cases, atonic uterus in 10 (16.7%) cases, genital tract trauma in 8(13.3%), sepsis of genital tract in 3(5%), case of ruptured uterus in one case and a case of angle bleeding from previous uterine scar following caesarean section. Among all 15 (25%) cases underwent manual removal of placenta, 5(8.3%) underwent controlled cord traction, 3 (5%) underwent manual removal of placenta followed by check curettage in cases of retained placenta, 16 (26.7%) cases were managed by check curettage for retained bits of placental tissue and membrane. Trauma in genital tract was managed by repair of trauma in 6 (10%) cases. Hysterectomy was required in 3 (5%) cases. Conservative management with uterotonics only required in 12 (20%) cases. Active management of third stage of labour can prevent PPH so delivery by skilled hand in hospital should be promoted. Secondary PPH besides primary can result in significant maternal morbidity. It also deserves similar attention.

Use of Recombinant Activated Factor VII in Severe Post-Partum Haemorrhage: Data From the Italian Registry. A Multicentric Observational Retrospective Study.

Background: Available evidence is that eye health care receives less attention compared to other allied health professions in public health services across South Africa, yet vision impairment is known to have significant social and economic consequences. Rural areas appear to be more affected, with KwaZulu-Natal (KZN) representing the second-most populous province in the country. The World Health Organization formulated a health systems framework which describes health systems in terms of six building blocks. This approach was applied in KZN, to assess the Department of Health’s capacity to provide comprehensive primary eye health services in KZN, South Africa. Aim: To determine the capacity for comprehensive primary eye care service delivery within the public health sector in KZN. Setting: All health disctrict in KwaZulu-Natal. Methods: An explorative-descriptive cross-sectional design, gathering both quantitative and qualitative data, was used. Data were collected utilising questionnaires, observation, and interviews. Results were analysed against the health systems framework. Results: A total of 28 optometrists responded to the survey, representing 60% of public health facilities that provide eye health care in KZN. The majority (53.6%) of optometrists were from district hospitals in rural areas. Facilities were generally inadequately equipped, with inefficiencies in service delivery including long waiting times and multi-tasking of clinicians. The absence of a financing model impacted the service at all levels. Conclusion: Policy development for eye health is necessary for KZN to deliver comprehensive eye health services. In particular, emphasis should be placed on the integration of eye health into primary health care and appropriate planning to foster accessibility and sustainability of services.

To investigate (1) the association between pre-hospital emergency medical resources and pre-hospital emergency medical system (EMS) response time among patients with Out-of-hospital cardiac arrest (OHCA); (2) whether the association differs between urban and suburbs. Densities of ambulances and physicians were independent variables, respectively. Pre-hospital emergency medical system response time was dependent variable. Multivariate linear regression was used to investigate the roles of ambulance density and physician density in pre-hospital EMS response time. Qualitative data were collected and analyzed to explore reasons for the disparities in pre-hospital resources between urban areas and suburbs. Ambulance density and physician density were both negatively associated with call to ambulance dispatch time, with odds ratios (ORs) 0.98 (95% confidence interval [CI] 0.96-0.99; P = 0.001) and 0.97 (95% CI; 0.93-0.99; P < 0.001), respectively. ORs of ambulance density and physician density in association with total response time were 0.99 (95% CI: 0.97-0.99; P = 0.013) and 0.90 (95% CI: 0.86-0.99; P = 0.048). The effect of ambulance density on call to ambulance dispatch time in urban areas was 14% smaller than that in suburb areas and that on total response time in urban areas was 3% smaller than the effect in suburbs. Similar effects were identified for physician density on urban-suburb disparities in call to ambulance dispatch time and total response time. The main reasons summarized from stakeholders for a lack of physicians and ambulances in suburbs included low income, poor personal incentive mechanisms, and inequality in financial distribution of the healthcare system. Improving pre-hospital emergency medical resources allocation can reduce system delay and narrow urban-suburb disparity in EMS response time for OHCA patients.

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.

Maternal mortality rate is still high. PPH is a major cause of maternal mortality in the world and in developing countries. Handling cases of postpartum hemorrhage is right in health facilities can reduce the incidence of maternal death from postpartum hemorrhage cases, therefore, required response time appropriate in health care facilities.This objective of this study is to determine the relationship of response time with the successful outcome of the handling of cases of PPH. An observational study design was used with case-control study design (case control study. The subjects were all mothers who referred to the Hospital of Purwokerto Soekardjo 2008-31Desember from 1 January 2011 due to PPH. Mechanical sampling with purposive sampling . Data collected by observation medical record and in-depth interviews, analysis of the data used to use univariable analysis, and multivariable bivariable.The results of X ² statistical test known value of 0.058 with p 0.810 (OR 1.22 95% CI 0.39 to 3.20) greater that 0.05 is not statistically significant meaning there is no relationship of response time to the successful outcome of treatment of bleeding post partum. Conclusion: There is no relationship of response time with the successful outcome of the handling of cases of postpartum hemorrhage in RSUMargono Soekardjo Purwokerto. Keywords: response time, postpartum hemorrhage

ObjectivePostpartum haemorrhage (PPH) is the most common obstetric emergency. A well-established postpartum haemorrhage protocol in the labour ward is crucial for effective treatment. The aim of the study was to investigate if practical obstetric team training improves the patient outcome and clinical management of PPH.SettingThe practical obstetric team training (PROBE) at Linköping University Hospital, Sweden, with approximate 3000 deliveries annually, was studied between the years of 2004–2011. Each team consisted of one or two midwives, one obstetrician or one junior doctor and one nurse assistant. Emergency obstetrics cases were trained in a simulation setting. PROBE was scheduled during work hours at an interval of 1.5 years.PopulationPre-PROBE women (N = 419 were defined as all women with vaginal birth between the years of 2004–2007 with an estimated blood loss of ≥1000 ml within the first 24 hours of delivery. Post-PROBE women (N = 483) were defined as all women with vaginal birth between the years of 2008–2011 with an estimated blood loss of ≥1000 ml within the first 24 hours of delivery. The two groups were compared regarding blood loss parameters and management variables using retrospective data from medical records.ResultsNo difference was observed in estimated blood loss, haemoglobin level, blood transfusions or the incidence of postpartum haemorrhage between the two groups. Post-PROBE women had more often secured venous access (p<0.001), monitoring of vital signs (p<0.001) and received fluid resuscitation (p<0.001) compared to pre-PROBE women. The use of uterine massage was also more common among the post-PROBE women compared with the pre-PROBE women (p<0.001).ConclusionPROBE improved clinical management but not patient outcome in women with postpartum haemorrhage in the labour ward. These new findings may have clinical implications since they confirm that training was effective concerning the management of postpartum haemorrhage. However, there is still no clear evidence that simulation training improve patient outcome in women with PPH.

Persistent Secondary Postpartum Hemorrhage after Uterine Artery Embolization