Atonic Postpartum Hemorrhage Research Articles

Increasing Trends in Atonic Postpartum Haemorrhage in Ireland

Please cite this paper as: Lutomski J, Byrne B, Devane D, Greene R. Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study. BJOG 2011; DOI: 10.1111/j.1471-0528.2011.03198.x Objective To derive nationally representative incidence rates of postpartum haemorrhage (PPH), and to investigate trends associated with method of delivery, blood transfusion and morbidly adherent placenta (accreta, percreta and increta). Design Population-based retrospective cohort study. Setting Republic of Ireland. Population Childbirth hospitalisations during the period 1999–2009. Methods International Classification of Diseases (ICD)-9-CM and ICD-10-AM diagnostic codes from hospital discharge records were used to identify cases of PPH. Significant temporal trends in PPH incidence were determined using Cochrane–Armitage tests for trend. Log-binomial regression was conducted to assess annual changes in the risk of PPH diagnosis, with adjustment for potential confounding factors. Main outcome measures PPH, uterine atony, blood transfusion and morbidly adherent placenta. Results A total of 649 019 childbirth hospitalisations were recorded; 2.6% (n = 16 909) included a diagnosis of PPH. The overall PPH rate increased from 1.5% in 1999 to 4.1% in 2009; atonic PPH rose from 1.0% in 1999 to 3.4% in 2009. Significant increasing trends in atonic PPH rates were observed across vaginal, instrumental, and emergency and elective caesarean deliveries (P < 0.001). The rate of atonic PPH co-diagnosed with blood transfusion also significantly increased (P < 0.001). Relative to 1999, the risk of atonic PPH in 2009 was three-fold increased (adjusted RR 3.03; 95% CI 2.76–3.34). Women diagnosed with a morbidly adherent placenta had a markedly higher risk of total PPH (unadjusted RR 13.14; 95% CI 11.43–15.11). Conclusions Increasing rates of atonic PPH highlight the pressing need for research and for clinical audit focusing on aetiological factors, preventative measures and quality of care, to guide current clinical practice.

Post B-lynch uterine rupture: case report and review of literature.

Postpartum hemorrhage (PPH) remains one of the three leading causes of maternal death and uterine atony accounts for 75–90 % of primary PPH. Apart from traditional conservative methods such as medical therapy, tamponades, the B-Lynch surgical technique has been widely used around the world. In 1997, Christopher B. Lynch devised these mechanical uterine compressing sutures to avoid hysterectomy in cases of severe PPH due to uterine atony, and since then, anecdotal evidence suggests that around 1,300 cases have been performed successfully worldwide including in India, Africa, North and South America, and Europe (Figs. 1, ​,22). Fig. 1 Ruptured uterus Fig. 2 Sutured uterus Case Report A 23-year G4P1L1A2 was admitted from casualty on November 5, 2011 with 4 months of amenorrhea and pain in the abdomen since the morning. She was very pale, had tachycardia, and a BP of 90/60 mmHg. There was abdominal tenderness and guarding. There was also a suprapubic transverse scar of a previous surgery. The uterine size could not be assessed due to extreme tenderness and guarding. At the time of the previous normal delivery, the patient had atonic PPH for which B-Lynch suturing was done. The suture material used for B-Lynch was Polyglactin No 1 (delayed absorbable suture material) on round body needle. The ultrasound showed moderate free fluid in the abdomen, the fetus lying outside the uterine cavity, and a 7 × 7 cm retro placental hemorrhage -s/o uterine rupture. Under general anesthesia, an exploratory laparotomy was performed. The uterine rupture was approximately 6 cm in length at the fundal region. The fetus with the amniotic sac lying out of ruptured site and around 1,500 ml of hemoperitoneum. The uterus was sutured with delayed absorbable sutures in three layers. Peritoneal lavage was given and an intraperitoneal drain was kept. The uterine height was marked and monitored postoperatively. She received five units of whole blood, fresh frozen plasma, and platelets intra- and postoperatively. The postoperative course was uneventful and she was discharged on seventh postoperative day. The risk of uterine rupture in future pregnancy was explained to the patient and her relatives.

A novel technique for modified B‐Lynch suture for the control of atonic postpartum haemorrhage

The B-Lynch brace suture technique is a life-saving procedure. It is a simple and safe alternative to hysterectomy. Thus, it preserves fertility with less surgical morbidity. In this case series, we evaluated the use of a novel modification of the B-Lynch brace suture to minimise its potential reported complications. Five women with intractable primary atonic postpartum haemorrhage were reported. They were initially managed with bilateral uterine artery ligation. The procedure was resorted to women who did not respond to ligation. The procedure is efficient. Women were followed up for up to 24 months to report any complications.

Obstetric hysterectomy: A life saving emergency

To study the cases of obstetric hysterectomy performed over a period of 1 year (January 2008 to December 2008) in tertiary care center to estimate the incidence, indications, and maternal outcome following the procedure. A retrospective analysis of 20 cases of emergency obstetric hysterectomies performed during the study period. During the study period, there were 11,356 deliveries and 20 emergency hysterectomies were done, giving an incidence of 0.17%. 75% cases were unbooked. Ruptured uterus was the most common indication for the procedure, followed by atonic Post-partum haemorrhage (PPH). Six out of 10 cases of rupture uterus had a previous cesarean delivery. Maternal mortality was 15% due to late referral. Emergency obstetric hysterectomy though a rare operation, still remains a life-saving procedure with which every obstetrician must be conversant. Regular antenatal care, identification of high-risk cases, and prompt referral can reduce the incidence of this operation.

Application of Uterine Compression Suture in Association With Intrauterine Balloon Tamponade (“Uterine Sandwich”) for Postpartum Hemorrhage

We evaluated in a prospective observational study the use of a 'uterine sandwich' technique (uterine compression sutures in association with intrauterine tamponade) in women who had had unsuccessful medical treatment for postpartum hemorrhage. Ten of the 11 patients had cesarean sections (complicated by placenta previa and uterine atony) and one had a normal delivery. The median estimated blood loss and units of blood transfused were 1500ml (range 750-4000ml) and two units (range 0-9), respectively. B-Lynch sutures were placed in two patients and Hayman's modification was used in nine. Bakri balloon tamponade was in place for a median of 22 hours (range 17-27 hours), while the median volume infused in the balloon was 300ml (range 150-350ml). The combined technique was successful in avoiding hysterectomy in all cases, and there was no documented postpartum morbidity. This is a simple and quick surgical technique that can be used to treat atonic postpartum hemorrhage, particularly in conjunction with placenta previa.

Cardiac arrest during sulprostone administration – a case report

Sulprostone, a synthetic prostaglandin analogue with potent uterotonic action, has been shown to have a low complication rate in a large series. We present a case of cardiac arrest in a parturient after Caesarean section during continuous infusion of intravenous sulprostone administered for atonic post-partum haemorrhage. She had cardiopulmonary resuscitation for 25 min before spontaneous circulation returned. The sequence of events, the results of investigations carried out during the intensive care unit stay, and the presence of multiple cardiovascular risk factors, suggest that sulprostone caused coronary spasm, bradycardia, and subsequent asystole, similar to other cases described in the literature.

Risk of postpartum uterine synechiae following uterine compression suturing during postpartum haemorrhage

Uterine compression suturing is considered a successful, safe, inexpensive and simple ‎method for the conservative treatment of atonic postpartum haemorrhage (PPH). However, insufficient data are available about the potential risk of subsequent intrauterine ‎synechiae (IUS). To determine the risk of postpartum uterine synechiae in women who received isolated uterine compression suturing for the management of major uncontrolled PPH. All women with major PPH from May 2005 to June 2011 were reviewed retrospectively. Diagnostic hysteroscopy was performed to assess the uterine cavity in the 27 women who successfully underwent isolated uterine compression suturing for major atonic PPH and fulfilled the study inclusion and exclusion criteria. Among the 27 women who underwent isolated uterine compression suturing, 5 (18.5%) were found to have IUS on hysteroscopic examination. The mode of delivery for all women who developed IUS was caesarean section. Among these five women, three had mild IUS, one had moderate IUS and one had severe IUS. All adhesions were later successfully resected by hysteroscopy, except for one case with dense IUS. Uterine compression suturing was found to be associated with a risk of postpartum uterine synechiae formation, which may subsequently affect future fertility.

A descriptive study on Hayman suture technique to control postpartum hemorrhage

<strong><em>Objective: </em></strong>To conduct a descriptive study on Hayman suture technique to control postpartum hemorrhage <strong><em>Method: </em></strong>Hayman suture was applied in 43 cases. A No-1 Vicryl suture was used on a round body or a straight needle. In 36 cases (83.72%) Hayman suture was the only intervention. In 4 cases (9.30%) uterine vessels and ovarian vessels were also ligated along with Hayman suture. In 3 cases (7%), along with Hayman suture, Gunasheila's circumferential sutures were taken. <strong><em>Results: </em></strong>None of the 43 patients required hysterectomy. <strong><em>Conclusion: </em></strong>Hayman suture technique is an easily and rapidly applied, effective, simple, safe, life saving and fertility preserving method to control atonic postpartum hemorrhage. DOI: <a href="http://dx.doi.org/10.4038/sljog.v34i3.4880">http://dx.doi.org/10.4038/sljog.v34i3.4880</a> <em>Sri Lanka Journal of Obstetrics and Gynaecology </em>2012; <strong>34</strong>: 79-83

Feasibility and clinical effects of laparoscopic abdominal cerclage: an observational study

To evaluate the effect of laparoscopic abdominal cerclage performed as an interval procedure in non-pregnant women at high risk of second trimester spontaneous abortion and early preterm birth. Observational study. Fifty-two consecutive patients at high risk of preterm birth. Department of Obstetrics and Gynecology, Aarhus University Hospital. Patients were registered prospectively. Indications for surgery included classical cervical insufficiency, preterm premature rupture of membranes (PPROM) or two conizations/cervical amputation. Outcome of subsequent pregnancies was registered. Gestational age in subsequent pregnancies. No operative or postoperative complications were observed. A total of 45 pregnancies were registered during the observation period. Among 36 pregnancies lasting beyond the 16th week of gestation, 30 women (83.3%) gave birth by cesarean section after 36 weeks of gestation and the overall mean gestational age was 37.4 weeks compared with a mean gestational age of 25.2 weeks of the pregnancies prior to the cerclage. The cesarean sections were uncomplicated in all but one patient, where a re-laparotomy was needed six hours later due to atonic postpartum hemorrhage without evident bleeding through the cervix. Laparoscopic abdominal cerclage is a feasible and safe procedure. Obstetrical outcomes are encouraging but prospective studies are needed to define the effectiveness of the laparoscopic cerclage compared with the traditional transvaginal approach.

Trends in postpartum hemorrhage from 2000 to 2009: a population-based study

BackgroundPostpartum hemorrhage, a major cause of maternal death and severe maternal morbidity, increased in frequency in Canada between 1991 and 2004. We carried out a study to describe the epidemiology of postpartum hemorrhage in British Columbia, Canada, between 2000 and 2009.MethodsThe study population included all women residents of British Columbia who delivered between 2000 and 2009. Data on postpartum hemorrhage by subtypes and severity were obtained from the British Columbia Perinatal Data Registry. Among women with postpartum hemorrhage, severe cases were identified by the use of blood transfusions or procedures to control bleeding. Rates of postpartum hemorrhage and changes over time were assessed using rates, rate ratios and 95% confidence intervals (CI).ResultsThe rate of postpartum hemorrhage increased by 27% (95% CI 21-34%) between 2000 and 2009 (from 6.3% to 8.0%), while atonic postpartum hemorrhage rates increased by 33% (95% CI 26-41%) from 4.8% to 6.4%. Atonic postpartum hemorrhage with blood transfusion increased from 17.8 to 25.5 per 10,000 deliveries from 2000 to 2009 and atonic postpartum hemorrhage with either suturing of the uterus, ligation of pelvic vessels or embolization increased from 1.8 to 5.6 per 10,000 deliveries from 2001 to 2009. The increase in atonic postpartum hemorrhage was most evident between 2006 and 2009 and occurred across regions, hospitals and various maternal, fetal and obstetric characteristics.ConclusionsAtonic postpartum hemorrhage and severe atonic postpartum hemorrhage increased in British Columbia between 2000 and 2009. Further research is required to identify the cause of the increase.

The Association of Maternal Race and Ethnicity and the Risk of Postpartum Hemorrhage

There are profound racial and ethnic disparities in obstetric outcomes in the United States, but little is known about disparities in risk of postpartum hemorrhage (PPH). We explored the association of race and ethnicity on the risk of PPH due to uterine atony with sequential adjustment for possible mediating factors. This analysis was based on the Nationwide Inpatient Sample, from between 2005 and 2008. The frequencies of atonic PPH and atonic PPH resulting in transfusion or hysterectomy were estimated. We developed multivariable logistic regression models to estimate the odds of these outcomes in maternal racial/ethnic groups by sequentially adding potential mediators. Hispanic ethnicity and Asian/Pacific Islander race were associated with a statistically significant increased odds of atonic PPH in comparison with Caucasians, despite adjustment for potential mediators (adjusted odds ratio [OR] for Hispanics: 1.21, 99% confidence interval [1.18, 1.25]; for Asians/Pacific Islanders: 1.31 [1.25, 1.38], with Caucasians as reference). Similar results were observed for these racial/ethnic groups for atonic PPH resulting in transfusion or hysterectomy. Hispanic ethnicity and Asian/Pacific Islander race are significant risk factors for atonic PPH independent of measured potential mediators; biological differences may play a role.

Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study

Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study

Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study

Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study

Embolismo del líquido amniótico: caso clínico y revisión de la literatura

Amniotic fluid embolism (AFE) is a rare but fatal syndrome occurring mostly during delivery or immediately postpartum. We report the case of a 33-year-old patient with no significant medical history. Coinciding with the rupture of the amniotic sac, the patient experienced dizziness that improved in the left lateral position with fluid therapy. Cardiac arrest occurred after delivery. After 45min of cardiopulmonary resuscitation, the patient recovered but developed an atonic postpartum hemorrhage reversible with methylergometrine and misoprostol and the placement of a Bakri balloon. Disseminated intravascular coagulation was suspected and the patient was transfused with eight packs of red blood cells, three plasma concentrates and 2000 IU of Octaplex. The patient was then transferred to our hospital and admitted to the intensive care unit with a suspected diagnosis of AFE. On admission, she showed active metrorrhagia and hematuric urine, hemoglobin levels of 7.9, thrombocytopenia and coagulopathy, requiring transfusion of packed red blood cells, 1 platelet pool, 750ml of plasma, fibrinogen and clotting factor VII. After correction of the coagulopathy, the bleeding stopped and the patient was discharged 6 days later.

MATERNAL NEAR-MISS –A CASE REPORT ON SUCCESSFUL MANAGEMENT OF INTRACTABLE ATONIC POST PARTUM HEMORRHAGE

Introduction :- Maternal near-miss refers to situations , where women experience severe life- threatening obstetric complications during pregnancy, delivery or post pregnancy, which they survive either by chance or because they receive good care at health facility. Cases of near-miss occur in larger numbers than maternal deaths. It has been estimated that up to 9 million women survive obstetric complications every year, and the consequences of these may be permanent and wide-reaching. Excessive hemorrhage during pregnancy or childbirth and severe hypertensive disorders contribute to large number of cases that result in to serious maternal morbidity. Case Report:- We present a case of a young primipara ,who reported to hospital in a condition of hemorrhagic shock with history of cardiac arrest before admission. She had intractable atonic postpartum hemorrhage, following full term vaginal delivery in private nursing home. She was resuscitated and operated for emergency obstetric hysterectomy with bilateral internal iliac ligation. She developed disseminated intravascular coagulation, which was treated by aggressive blood and component therapy. She went home in a hemodynamic ally stable condition. Conclusion:- Every obstetrician should intelligently anticipate and keep oneself prepared to tackle the problem of intractable postpartum hemorrhage. Prompt and aggressive management of post partum hemorrhage will save many young lives. A saying ‘ Delay means death holds true for such emergency situation.

Safety Pin Suture for Management of Atonic Postpartum Hemorrhage

Objective. To assess the efficacy of a new suture technique in controlling severe resistant uterine atonic postpartum hemorrhage. Patients and Methods. This is a retrospective observational study that included thirteen women with uterine atony and postpartum bleeding that did not react to usual medical management. All these women underwent compressing vertical suture technique in which the anterior and posterior walls of the uterus were attached so as to compress the uterus. The suture is transfixed at the uterine fundus, thus eliminating the risk of sutures sliding off at the uterine fundus (safety pin suture). Results. safety pin uterine compression suture was a sufficient procedure to stop the bleeding immediately in 92.2% of the women. None of the women developed complications related to the procedure. Conclusion. A new safety pin suture is a simple and effective procedure to control bleeding in patients with treatment-resistant, life-threatening atonic postpartum hemorrhage with the advantage of eliminating the risk of the sutures sliding off at the uterine fundus.

Total Uterine Necrosis: A Complication of B-Lynch Suture

ABSTRACT Uterine atony is the most common cause of postpartum hemorrhage (PPH) which leads to maternal mortality and morbidity. Herewith reporting a case of 35-year-old woman who underwent cesarean section for transverse lie with hand prolapse. She had atonic PPH for which uterine artery ligation was done along with B-lynch suture. She had subinvolution of uterus secondary to multiple abscesses in uterine wall. She underwent subtotal hystrectomy. Hispathology showed uterine necrosis. How to cite this article Somalwar SA, Joshi SA, Bhalerao AV, Kawthalkar AS, Jain S, Mahore S. Total Uterine Necrosis: A Complication of B-Lynch Suture. J South Asian Feder Obst Gynae 2012;4(1):61-63.

Increasing trends in atonic postpartum haemorrhage in Ireland: an 11‐year population‐based cohort study

To derive nationally representative incidence rates of postpartum haemorrhage (PPH), and to investigate trends associated with method of delivery, blood transfusion and morbidly adherent placenta (accreta, percreta and increta). Population-based retrospective cohort study. Republic of Ireland. Childbirth hospitalisations during the period 1999-2009. International Classification of Diseases (ICD)-9-CM and ICD-10-AM diagnostic codes from hospital discharge records were used to identify cases of PPH. Significant temporal trends in PPH incidence were determined using Cochrane-Armitage tests for trend. Log-binomial regression was conducted to assess annual changes in the risk of PPH diagnosis, with adjustment for potential confounding factors. PPH, uterine atony, blood transfusion and morbidly adherent placenta. A total of 649,019 childbirth hospitalisations were recorded; 2.6% (n = 16,909) included a diagnosis of PPH. The overall PPH rate increased from 1.5% in 1999 to 4.1% in 2009; atonic PPH rose from 1.0% in 1999 to 3.4% in 2009. Significant increasing trends in atonic PPH rates were observed across vaginal, instrumental, and emergency and elective caesarean deliveries (P < 0.001). The rate of atonic PPH co-diagnosed with blood transfusion also significantly increased (P < 0.001). Relative to 1999, the risk of atonic PPH in 2009 was three-fold increased (adjusted RR 3.03; 95% CI 2.76-3.34). Women diagnosed with a morbidly adherent placenta had a markedly higher risk of total PPH (unadjusted RR 13.14; 95% CI 11.43-15.11). Increasing rates of atonic PPH highlight the pressing need for research and for clinical audit focusing on aetiological factors, preventative measures and quality of care, to guide current clinical practice.

Raised nitric oxide levels may cause atonic postpartum hemorrhage in women with anemia during pregnancy

Objective To determine the association of hemoglobin (Hb) and plasma nitrite (PN) concentrations on admission to the delivery ward with the occurrence of atonic postpartum hemorrhage (PPH). Methods Of 319 women admitted to the Department of Obstetrics and Gynecology, Dayrout General Hospital, Assiut, Egypt, for delivery in July 2010, 200, who were not considered to be at risk of atonic PPH, were eligible for inclusion. Plasma levels of Hb and nitrite were measured on admission. The third stage of labor was actively managed. Results A total of 22 participants had significantly raised PN levels ( P < 0.001), 12 of whom developed PPH—with Hb levels of 9 g/dL or less and nitric oxide (NO) levels of 180 μM/L or greater. The other 10 women underwent over 6 hours of stressful labor prior to hospital admission. Conclusion Even moderate anemia can raise levels of NO and enhance its biologic effects, which in turn can result in uterine muscle relaxation and atonic PPH. Preventing or treating anemia during pregnancy could avoid these complications.

Trends in postpartum haemorrhage in Ireland: an eleven-year population-based cohort study

ObjectiveTo derive population-based incidence rates of postpartum haemorrhage (PPH) and to investigate trends associated with method of delivery and blood transfusion. Specific focus was given to PPH due to atonic...