Atonic Postpartum Hemorrhage Research Articles

Causes of Maternal Mortality Rate: Postpartum Haemorrhage - A Major Cause in Madhya Pradesh

Maternal mortality is an indicator of the state of maternal health services, status of women, women’s health, and above all development of the nation. 15% of global maternal deaths can be attributed to India alone. The lifetime risk of maternal death in India is 1 in 220 as compared to 1 in 5800 in the UK. The major burden of maternal mortality is in the Empowered Action Group (EAG) states. As per recent SRS data, 2014–2016, the Maternal mortality rate (MMR) observed in Madhya Pradesh (MP) was 173.Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide with a prevalence rate of approximately 6%; 50% of these are due to atonic PPH. According to WHO 2014- in India.

Race/Ethnicity as a Risk Factor in the Development of Postpartum Hemorrhage: A Thorough Systematic Review of Disparity in the Relationship Between Pregnancy and the Rate of Postpartum Hemorrhage.

Postpartum hemorrhage (PPH) is a major cause of maternal death and morbidity worldwide. Throughout the years, there have not been many studies looking into the association of race and ethnicity with the occurrence of PPH. The goal of this study was to assess race and ethnicity as risk factors in the development of PPH in pregnant women. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) standards, we conducted the analysis and conducted a literature search using Google Scholar and PubMed. After applying our inclusion and exclusion criteria, the search technique yielded a total of eight articles. The analysis included seven observational studies and one randomized controlled trial. The incidence of PPH was chosen as the major outcome measure. An evaluation of eight studies revealed that although Hispanics, Asians, Native Hawaiians, and other Pacific Islanders (NHOPI) have a higher chance of developing PPH caused by uterine atony, Caucasians had a greater rate of transfusion than the other groups. In addition, compared to Caucasians, African Americans or African descendants had a lower risk of atonic PPH but increased odds of atonic PPH requiring interventions. On the other hand, compared to non-native groups, Native Americans had increased odds of uterine atony. The results showed that, in contrast to other races/ethnicities, Caucasians had the lowest risk of PPH. Additionally, it was shown that African Americans or those descended from Africans had a higher chance of PPH but a lower risk of atonic PPH.

Uterine Packing with Gauze Versus Bakri Balloon for Arresting Atonic Postpartum Hemorrhage after Cesarean Delivery

Uterine Packing with Gauze Versus Bakri Balloon for Arresting Atonic Postpartum Hemorrhage after Cesarean Delivery

Use of Ellavi Balloon Tamponade Device for Management of Atonic PPH.

In this manuscript the authors describe the Ellavi balloon tamponade device and its use in the management of atonic postpartum hemorrhage. Additionally the manuscript discusses a case in which this device was used.

Resuscitative endovascular balloon occlusion of the aorta for life-threatening postpartum hemorrhage: A nationwide observational study in Japan.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used for postpartum hemorrhage (PPH), which is one of the leading causes of maternal mortality worldwide; however, its utility in the obstetrics setting remains unclear. Thus, this study aimed to describe the characteristics, demographics, and mortality of patients with PPH who underwent REBOA. We used the Japanese Diagnosis Procedure Combination inpatient database to identify patients with PPH who underwent REBOA from April 2012 to March 2020. We examined the patients' characteristics, interventions administered, and in-hospital mortality. We identified 143 patients with PPH who underwent REBOA. The most common cause of PPH was atonic postpartum hemorrhage (52.4%), followed by disseminated intravascular coagulation (29.4%) and amniotic fluid embolism documented (11.2%). Among patients who delivered at hospitals in which REBOA was performed (n = 55), 38.2% of patients experienced preterm births, and 70.9% delivered via cesarean delivery. The proportion of patients who underwent transcatheter arterial embolization and hysterectomy was 53.8% and 16.1%, respectively. In-hospital mortality was 7.0%. The results of the present study could be helpful in clinical decision making and providing patients and families with additional treatment options for PPH. Therapeutic/Care Management; Level IV.

Every Second Matters - uterine balloon tamponade implementation across ten medical colleges in Maharashtra and Madhya Pradesh in India: A qualitative study.

To understand facilitators, barriers, and perceptions of the Every Second Matters uterine balloon tamponade (ESM-UBT) package implemented across 10 medical colleges in India, 3years after the program was introduced. Semi-structured interviews were conducted until thematic saturation in March 2020. Multiple provider cadres, including nurses, Obstetrics/Gynecology residents, professors, and program leads, were eligible. Interviews were transcribed and thematically coded using an inductive method. Sixty-two obstetric providers were interviewed. Facilitators of implementation included recurrent training, improved teamwork and communication, strong program leadership, and involvement of lower-level facilities. Barriers to implementation included administrative hurdles, high staff turnover, language barriers, and resources required to reach and train lower-level facilities. Overall, the majority of clinicians viewed the ESM-UBT package as a useful intervention in aiding efforts to reduce maternal deaths from postpartum hemorrhage. Among 10 medical colleges in India the ESM-UBT package is seen as a beneficial intervention for managing refractory atonic postpartum hemorrhage, and for reducing maternal morbidity and mortality. Identified facilitators of and barriers to implementation of the ESM-UBT package in India should be used to guide future implementation efforts.

Arresting post-partum hemorrhage using the novel trans-vaginal uterine artery clamp

ObjectivesPost-partum hemorrhage (PPH) continues to be the leading cause of maternal mortality in low-resource settings. The commonest variant - Atonic PPH, is managed by additional pharmacological measures which may fail. Additional surgical interventions for hemostasis take time and are not universally available. Immediate arrest of bleeding was deemed essential and a novel Transvaginal Uterine Artery Clamp (TVUAC) was explored for its effectiveness in achieving immediate hemostasis in atonic and mixed post-partum hemorrhage. Study designA retrospective chart review was performed for all patients, who underwent vaginal delivery and developed immediate post-partum atonic PPH, in a tertiary care center in South India, between 1st April 2015 and 31st December 2020. As soon as excess bleeding was observed, two TVUACs were applied trans-vaginally at 3′ and 9′o clock position of the cervix to occlude the uterine arteries where it joins the isthmus of the uterus. ResultsOf 3999 vaginal deliveries, there were 251 patients who developed primary atonic PPH during the study period, of which 89 were managed by medical measures alone. Out of the remaining 162 patients, in 153 (94.4%) TVUAC helped to achieve hemostasis; with TVUAC alone in 120 patients (78.43%) and with an additional second line surgical intervention in 33 patients. In nine patients, TVUAC was not readily available and hence second line interventions alone were used. None required any third line surgical interventions (laparotomies) for hemostasis nor were there any incident of maternal mortality or consumptive coagulopathy. TVUAC was applied for a mean duration of 25 ± 10 min. Only 11.6% (29/251, 95% C.I 7.9–16.1%) of the patients required a blood transfusion with a median of 2 (1–4) units of packed RBC. No procedure related complications were reported up to a scheduled 6th week in-person follow-up. ConclusionThe novel TVUAC shows potential in limiting third line interventions, maternal morbidity and mortality. Its effectiveness and safety may be further explored as a first line surgical adjunct to medical measures, in PPH protocols in low-resource settings.

Peripheral limb ischemia- A rare side effect of ergometrine

: Drug induced vasculitis is an inflammation of blood vessels caused by use of various drugs like ergometrine, inotropes. The purpose of this review is to highlight the importance of ergotism as a cause of peripheral vascular ischemia and analyze the changes associated with this condition.Mrs. XX, 21 year old, P2L1 presented with history of normal delivery in PHC eight days back with complaints of breathlessness, fever and bluish grey discoloration of both lower extremities since her delivery. There was history of severe postpartum hemorrhage post delivery in the PHC and was medically managed with ergometrine and other oxytocics. On examination, patient had pallor, temperature and tachycardia. Dorsalis pedis pulsation was palpable in both lower limbs. Thorough workup was done which revealed hemoglobin 6.9 gm% and high total count. Doppler study of both lower limbs and ECHO were normal. Patient was managed conservatively after which she improved symptomatically but there was no improvement in the line of demarcation in both lower limbs. Due to financial constraints, patient decided to shift to government setup for further management.Ergometrine is recommended by ACOG and RCOG for use in the medical management of atonic postpartum hemorrhage after oxytocics. Ergometrine has a vasoconstrictive effect which causes progressive vasospasm leading to peripheral ischemia and gangrene which may lead to amputation of the limbs. Hence, management of postpartum hemorrhage with minimum effective dose of ergometrine should be emphasized and use of other oxytocics should be encouraged to prevent such major complications.

Uterine atony.

Postpartum hemorrhage (PPH) is the leading preventable cause of maternal morbidity and mortality worldwide. Uterine atony is identified as the underlying etiology in up to 80% of PPH. This serves as a contemporary review of the epidemiology, risk factors, pathophysiology, and treatment of uterine atony. Rates of postpartum hemorrhage continue to rise worldwide with the largest fraction attributed to uterine atony. A simple 0-10 numerical rating score for uterine tone was recently validated for use during cesarean delivery and may allow for more standardized assessment in clinical and research settings. The optimal prophylactic dose of oxytocin differs depending on the patient population, but less than 5 units and as low as a fraction of one unit is needed for PPH prevention, with an increased requirements within that range for cesarean birth, those on magnesium, and advanced maternal age. Carbetocin is an appropriate alternative to oxytocin. Misoprostol shows limited to no efficacy for uterine atony in recent studies. Several uncontrolled case studies demonstrate novel mechanical and surgical interventions for treating uterine atony. There is a critical, unmet need for contemporary, controlled studies to address the increasing threat of atonic PPH.

Efficacy of using controlled uterine balloon tamponade for stopping atonic postpartum hemorrhage

BACKGROUND: Obstetric hemorrhage remains the leading cause of maternal mortality in Uzbekistan, with uterine atony in the follow-up and postpartum periods being the most common cause.
 AIM: The aim of this study was to evaluate the effectiveness of using uterine balloon tamponade in atonic postpartum hemorrhage.
 MATERIALS AND METHODS: This clinical controlled study was conducted at the Republican Perinatal Center of the Ministry of Health of the Republic of Uzbekistan from 2016 to 2019. Uterine balloon tamponade using a Zhukovsky balloon was used in 50 puerperas with atonic postpartum hemorrhage, of whom 40 women had vaginal delivery and ten patients were delivered by caesarean section. The control group consisted of 50 puerperas with atonic postpartum hemorrhage, traditional therapy being carried out without the use of uterine balloon tamponade, of whom 40 women had vaginal delivery and ten patients were delivered by caesarean section.
 RESULTS: The total volume of blood loss in the main group was lower than in the control group: 998 142 ml vs. 1498 202 ml in vaginal delivery (Students t-test 2.01, p = 0.047563) and 1297 244 ml vs. 1988 226 ml at caesarean section (Students t-test 2.11, p = 0.039463), respectively. Uterine balloon tamponade allowed for stopping postpartum hemorrhage in the blood loss range of 750999 ml and 10001499 ml in 27.5% and 52.5% of cases in the main group and in 20% and 30% of cases in the control group (OR 1.517, 95 % CI 1.5364.293 and OR 2.579, 95% CI 1.0306.457, respectively). When using uterine balloon tamponade, the proportion of massive bleeding with blood loss over 1500 ml was 3.8 times lower than in the control group: 10.0% (5/50) and 38% (19/50), respectively. Hysterectomy due to bleeding was performed in one (2%) postpartum woman in the main group, and in five (10%) puerperas in the control group (OR 0.184, 95% CI 1.0216.133). The use of the tamponade test resulted in a significant decrease in the number of severe bleeding incidents (with blood loss of 1500 ml or more) by 90% during vaginal delivery (OR 0.077, 95% CI 0.0090.635) and elevated the effectiveness of organ-preserving surgeries by 2.9 times, thus increasing the frequency of women with preserved uterus.
 CONCLUSIONS: The effectiveness of uterine balloon tamponade in atonic postpartum hemorrhage was 88.0% (44/50). The simplicity and safety of using uterine balloon tamponade indicates the need for a wider introduction of this technology in postpartum hemorrhages, which will help to reduce their adverse outcomes.

Iron Deficiency Anaemia and Atonic Postpartum Haemorrhage Following Labour.

The purpose of this retrospective cohort study is to determine if iron deficiency anaemia (IDA) is associated with increased atonic postpartum haemorrhage (PPH) following labour. Women with singleton pregnancy carried to 24 or more weeks gestation, who were delivered under our care from 1997 to 2019, constituted the study population. A diagnosis of IDA was based on the finding of haemoglobin <10 g/dL and serum ferritin <15 μg/L in the absence of haemoglobinopathies. Women with elective caesarean section were excluded. Maternal characteristics, use of oxytocin, labour outcome and occurrence of PPH were compared between women with and without a diagnosis of IDA. The 1032 women (0.86%) with IDA exhibited slightly but significantly different maternal characteristics and had significantly higher incidence of total (4.5% versus 3.2%, p = 0.024) and atonic PPH (3.1% versus 2.0%, p = 0.011) despite similar incidences of labour induction, augmentation, and instrumental and intrapartum caesarean delivery. Multivariate analysis with adjustment for the effects of age, body mass index, height, parity, abortion history, labour induction and augmentation, instrumental delivery and infant macrosomia demonstrated that IDA was independently associated with total PPH (adjusted relative risk, aRR: 1.455, 95% confidence ratio, CI: 1.040-2.034) and atonic PPH (aRR: 1.588, 95% CI: 1.067-2.364). Our results indicate that despite the low prevalence in our population, IDA was independently associated with atonic PPH, probably consequent to placental adaptive changes in the presence of IDA. The correction and prevention of IDA could be the most important measure in countering the rising global prevalence of atonic PPH.

Massive Traumatic Postpartum Haemorrhage with Co-incidental Atypical Eclampsia and Abdominal Koch’s- A Maternal Near Miss

Obstetric haemorrhage is related with augmented risk of maternal morbidity and mortality and continues to be the second greatest direct cause of near miss and maternal death. Postpartum Haemorrhage (PPH) is the most common form of obstetric haemorrhage, atonic PPH being responsible for 80% cases. Traumatic PPH with massive vulval haematoma, an infrequent but possibly fatal condition if left undiagnosed and untreated. Hence, prompt recognition and management with simultaneous resuscitation and operative procedure is vital to save life of mother. A 24-year-old P1L1 female with traumatic haemorrhage with the formation of massive vulval haematoma, periurethral tears, extensive cervical and vaginal wall tears with hypovolemic shock with severe anaemia admitted to the tertiary care hospital. Immediate resuscitation measures were taken followed by vaginal exploration for the vulvovaginal haematoma and a multispeciality approach for the better outcome. However, postvaginal exploration after 24 hours, there was progression in vulvo vaginal haematoma size, with haemodynamic instability. Re-exploration under anaesthesia via abdominal approach was performed. The patient required a longer hospital stay. Thus, early diagnosis and treatment of puerperal haematomas can prevent significant complications.

Is there a relationship between plasma, cytokine concentrations, and the subsequent risk of postpartum hemorrhage?

Postpartum hemorrhage remains the leading cause of maternal mortality. However, there is an insufficient understanding of atonic postpartum hemorrhage. Uterine atony is the most common cause of postpartum hemorrhage. Although an association between myometrium inflammatory cytokines and atonic postpartum hemorrhage has been demonstrated preliminarily, it is not clinically useful in predicting postpartum hemorrhage. Plasma is more readily available, and the assessment of its inflammatory status is more relevant to biological markers of postpartum hemorrhage and might explain the pathophysiology of atonic postpartum hemorrhage. Our objective was to examine changes in maternal plasma cytokines in women with atonic postpartum hemorrhage. This was a retrospective longitudinal case-control study of pregnant women with singleton gestations at term undergoing vaginal delivery. Cases were women with atonic postpartum hemorrhage, and 1:1 propensity-score matching was used to match the control group. Maternal plasma was collected in the first trimester, early third trimester, and late third trimester, and multiplex Luminex assay was used to determine the cytokine concentrations. Multivariate logistic regressions were used to determine the association between maternal cytokines at different stages of pregnancy and atonic postpartum hemorrhage. A total of 36 pregnant women met the clinical diagnostic criteria for atonic postpartum hemorrhage, and 36 patients without postpartum hemorrhage were matched as the control group. Concentrations were lower for most cytokines in the atonic postpartum hemorrhage group in the first and early third trimester. However, in the late third trimester, higher plasma concentrations of basic fibroblast growth factor, interleukin-1 alpha, interleukin-1 beta, interleukin-1 receptor antagonist, interleukin-2 receptor alpha, interleukin-16, interleukin-18, macrophage colony stimulating factor, macrophage inflammatory protein-1 alpha, beta-nerve growth factor, tumor necrosis factor-related apoptosis-induced ligand, and stem cell factor were significantly associated with increased risk of atonic postpartum hemorrhage. Multiple testing correction showed that basic fibroblast growth factor (P<.001; fold change [FC]=1.16), macrophage inflammatory protein-1 alpha (P<.001; FC=1.15), and stem cell factor (P=.001; FC=1.25) had the most significant difference (P<.001). The prediction model of atonic postpartum hemorrhage constructed by these significantly changed cytokines had a high predictive efficiency (area under the curve, 0.84; sensitivity, 0.78; specificity, 0.83;+likelihood ratio, 4.66;-likelihood ratio, 0.27). Higher concentrations of maternal plasma cytokines in the late third trimester are associated with high risk of subsequent atonic postpartum hemorrhage. These indicators may be potential biomarkers for predicting atonic postpartum hemorrhage.

Efficacy of Hayman Suture in the Treatment of Atonic Postpartum Hemorrhage

Purpose: The study aims to investigate the effectiveness of Hayman’s suture in the management of Atonic postpartum hemorrhage. Subjects and Method: The study includes 37 patients who developed severe atonic PPH not responsive to pharmacological measures at the Department of Obstetrics and Gynecology at Aswan University hospital, in the period between Mars 2018 and December 2019. This is a case series study of 37 patients upon whom Hayman suture is applied when failed to respond to medical management, step-wise devascularization of the uterus is attempted when the suture cannot control the bleeding alone, reserving hysterectomy as a last resort when all measures are failed. Results: Results of the research None of the 37 patients of our study required hysterectomy to control the bleeding, Hayman suture succeeded solely to arrest the hemorrhage in 30 patients (81.1%), while 7 patients(18.9%) required step-wise devascularization of the uterus with Hayman suture to stop the bleeding. It is not uncommon for complications to be described with the use of uterine compression sutures. In our study, we did not report any complications. Conclusion: The application of Hayman’s suture is a fast, efficient, non-complex, lifesaving and fertility-sparing technique to control atonic postpartum hemorrhage.

Comparative study between intramyometrial oxytocin and oxytocin analogue (carbetocin) in prevention of postpartum hemorrhage following cesarean section

Background and aim This is a prospective randomized single-center study aimed to assess the efficacy of carbetocin versus intramyometrial oxytocin in the prevention of atonic postpartum hemorrhage following Cesarean section in high-risk women. Patients and methods A total of 160 women with gestational age more than 38 weeks at high risk for primary atonic postpartum hemorrhage undergoing elective or urgent cesarean section under regional or general anesthesia were randomly divided into two equal groups: group A included 80 patients, and they received oxytocin 20 IU intramyometrially. Group B included 80 patients, and they received carbetocin, 100 μg intravenously. Results There was no significant difference in the mean values of hematocrit before and 24 h after delivery (P&gt;0.05). Similarly, there was no significant difference in the estimated blood loss calculated by hematocrit values (P&gt;0.05). Moreover, it was shown that 17.5% of women in the carbetocin group needed additional uterotonics versus 25% of women in the oxytocin group. Therefore, there was no significant difference between both groups regarding needing additional uterotonics. There were eight cases that needed more surgical intervention. Conclusion Both drugs are equally effective in prevention of atonic postpartum hemorrhage. There is no significant difference between single injection of carbetocin and intramyometrial 20 IU oxytocin in reducing the use of additional oxytocic agents.

A Comparative Study of Active Management of the Third Stage of Labor IV Methergine and IM Oxytocin

Postpartum haemorrhage (PPH) has been more common over the last three decades, accounting for 11% of all pregnancy-related deaths in the United States. In the third stage of labour, risk classification and active management are crucial preventative techniques. To avoid negative effects, a multidisciplinary approach to PPH patient care is required. To treat uterine atony, uterotonic medicines like oxytocin are used in combination with manipulative procedures like uterine massage and balloon tamponade. The amount of blood loss, duration of the third stage, need for MRP, incidence of PPH, need for repeated oxytocics, and its side effects were measured in Group I 100 women who were administered injection oxytocin 10 IU injection methergin 0.2 mg IV within one minute of the baby's delivery. The mean blood loss at vaginal delivery in Group I was 100-150 ml and in group I P value 0.027, which was statistically significant .In Group II was 160-200 ml with P value 0.036, which was statistically significant. The mean duration of third stag labour in Group 1 was 124.6 min and Group 2 was 144.8 min intravenous methergin is a better uterotonic when compared to intramuscular oxytocin to reduce the amount of blood loss at delivery and prevent complications like atonic PPH.

COMPARATIVE STUDY BETWEEN CARBETOCIN VS COMBINATION OF ERGOMETRINE AND OXYTOCIN IN THE PREVENTION OF POST-PARTUM HEMORRHAGE AFTER CESAREAN SECTION

Background; Caesarean section is a known risk factor for Postpartum hemorrhage5, and the rate of caesarean births is on the rise around the world. The cesarean section is a bloody process; most surgeries lose between 750 and 1000 mL of blood and a postpartum hemorrhage (PPH) occurs when more than 1000 mL of blood is lost. Aim and objectives; is there is difference between carbetocin vs combination of ergometrine and oxytocin in the prophylaxis of (PPH) following cesarean section? Patient and methods; The study had been conducted at Obstetrics and Gynacology department, El-Hussein universal hospital included 200pregnant women All cases were selected from Obstatric and Gynacology department , El-Hussein universal hospital from January 2021 - June 2021. Result; Estimated blood loss in Group (A) was ranged between 532-821 with mean ±S.D. 688.98±58.363 while in Group (B) was ranged between 834-1301 with mean ±S.D. 1026.97±65.379. P Conclusion; Carbetocin has been shown to be effective in preventing atonic post-partum haemorrhage after cesarean section. It has the same potency as I.V. syntocinon and ergometrine combined. In comparison to the mixture of syntocinon and ergometrine, carbetocin alone had fewer maternal side effects such as increased blood pressure, nausea and vomiting. The carbetocin group uses less extra uterotonic medications than the syntocinon and ergometrine group. Compared to syntocinon and ergometrine.

Cost-effectiveness of uterine balloon tamponade devices in managing atonic post-partum hemorrhage at public health facilities in India.

ObjectivePost-partum hemorrhage (PPH) is the leading direct cause of maternal mortality in India. Uterine balloon tamponade (UBT) is recommended for atonic PPH cases not responding to uterotonics. This study assessed cost-effectiveness of three UBT devices used in Indian public health settings.MethodsA decision tree model was built to assess cost-effectiveness of Bakri-UBT and low-cost ESM-UBT alternatives as compared to the recommended standard of care i.e. condom-UBT intervention. A hypothetical annual cohort of women eligible for UBT intervention after experiencing atonic PPH in Indian public health facilities were evaluated for associated costs and outcomes over life-time horizon using a disaggregated societal perspective. Costs by undertaking primary costing and clinical parameters from published literature were used. Incremental cost per Disability Adjusted Life Years (DALY) averted, number of surgeries and maternal deaths with the interventions were estimated. An India specific willingness to pay threshold of INR 24,211 (USD 375) was used to evaluate cost-effectiveness. Detailed sensitivity analysis and expected value of information analysis was undertaken.ResultsESM-UBT at base-case Incremental Cost-Effectiveness Ratio (ICER) of INR -2,412 (USD 37) per DALY averted is a cost-saving intervention i.e. is less expensive and more effective as compared to condom-UBT. Probabilistic sensitivity analysis however shows an error probability of 0.36, indicating a degree of uncertainty around model results. Bakri-UBT at an ICER value of INR -126,219 (USD -1,957) per DALY averted incurs higher incremental societal costs and is less effective as compared to condom-UBT. Hence, Bakri-UBT is not cost-effective.ConclusionFor atonic PPH management in India, condom-UBT offers better value as compared to Bakri-UBT. Given the limited clinical effectiveness evidence and uncertainty in sensitivity analysis, cost-saving result for ESM-UBT must be considered with caution. Future research may focus on generating high quality comparative clinical evidence for UBT devices to facilitate policy decision making.

English

BACKGROUND The third stage of labour starts when the fetus has completely delivered and ends with the complete expulsion of the placenta. The third stage of labour is usually uneventful, although significant complications can occur in this period, the most common is postpartum haemorrhage (PPH). The purpose of this study was to identify the various third stage complications, their incidence, and associated risk factors in patients admitted to the centre. METHODS This is a prospective observational study performed in the Department of Obstetrics and Gynaecology, Gandhi Medical College and Sultania Zanana Hospital (SZH), Bhopal conducted from 1 st October 2010 to 30th September 2011. All patients who delivered in our centre or outside and developed a third stage complication were included in the study. RESULTS There were a total of 10,277 deliveries during the study period and 171 cases of third stage complications. The incidence of third stage complication was 1.66 %. The most common third stage complication was traumatic PPH (52.1 %) and the least common was inversion of uterus (2 %) but the case fatality rate (20 %) was higher in the latter. The incidence of traumatic PPH was highest among the primipara patients (72.9 %) and in the grand multipara, atonic PPH topped the list occurring in 57.8 % of the patients. CONCLUSIONS As third stage complications occur in approximately 1 in 60 deliveries and cause 19.3 % of the total maternal deaths, it is of utmost importance to outline an effective treatment for the management of postpartum haemorrhage. This could further help in reducing maternal mortality significantly. KEYWORDS Third Stage of Labour, Atonic Postpartum Haemorrhage, Traumatic Postpartum Haemorrhage, Retained Placenta, Uterine Inversion, Peripartum Hysterectomy

Effect of moderate iron deficiency anemia during pregnancy on maternal and fetal outcome.

Background: The most frequently identified dietary deficiency worldwide is iron deficiency, especially during pregnancy. Aim of the Work: To evaluate the impact of moderate maternal iron deficiency anemia on maternal outcome (atonic postpartum hemorrhage or postpartum infections after delivery), and fetal outcomes (neonatal weight and Apgar score). Patient and Methods: This study was carried out at El Hussein University Hospital and Om El-Masryeen General Hospital on 100 pregnant females, who were admitted to the labor ward for delivery. They were split into two equal groups after the assessment of hemoglobin levels. The first group included non-anemic pregnant women and the second group included pregnant women with moderate iron-deficiency anemia. After delivery, the maternal outcome was assessed for atonic postpartum hemorrhage or postpartum infections and all newborns were assessed for neonatal weight and Apgar score. Results: After delivery, the discrepancy in the rate of atonic postpartum hemorrhage, postpartum endometritis, post-cesarean wound infection, and episiotomy wound infection among both groups was statistically insignificant (P value 0.204, 0.307, 0.485, 0.481 respectively). There were positive correlations between maternal parameters (maternal serum hemoglobin, MCV, MCH, serum iron, and serum ferritin) and fetal outcomes (neonatal weight and Apgar score). There were negative correlations between maternal total iron-binding capacity (TIBC) and fetal outcomes (neonatal weight and Apgar score). Conclusion: Maternal iron deficiency anemia affects both maternal and fetal outcomes. Keywords: Iron deficiency anemia; Maternal outcome; Fetal outcome.