Atonic PPH Research Articles

A RETROSPECTIVE STUDY ON FETOMATERNAL OUTCOME IN SECOND STAGE CESAREAN-SECTION

Introduction:Second stage C-section are associated with poor fetomaternal outcome due to deeply engaged head ,less liquor,and thinned out LUS.This can lead to maternal morbidities like thinned out the lower uterine segment. This can lead to a high risk of maternal morbidities like an extension of the lower uterine segment incision, uterine atony, and injury to urinary bladder as well as neonatal morbidities such as birth asphyxia, NICU admission, and meconium aspiration syndrome. This study aims to observe the maternal and neonatal outcomes of cesarean delivery performed in the second stage of labor. Materials and Methods:This is a retrospective observational study conducted in a tertiary health center to study the fetomaternal outcome of all women with singleton, a cephalic fetus at term delivered by cesarean section in the second stage of labor over one year duration. Results:During this study period, there were 6200 deliveries C-section. Among emergency LSCS 50 (0.8%)were performed in the second stage of labor. Most common indication was NPOL A/W fetal distress 24 (44%)followed by Obstructed labor 10(20%). Most common Intraoperative complication noted was extension of uterine segment 8(16%) followed by atonic PPH. Postoperative maternal who had complications were prolong catheterization:25(50%), postoperative fever : 4(8%), haemorrhagic urine8(16%). In perinatal complications, meconium stained liquor: 22(44%),NNU admission8(16%), Apgar score <5 at 5 min : 8(16%), NICU admission : 12(24%), fresh stillbirth : 1(2%) were observed. Conclusion: Cesarean section in the 2nd stage of labor is associated with significantly increased maternal morbidity. Neonatal morbidity and mortality also increases. A proper judgment is required by a skilled obstetrician to take a decision for cesarean section at full cervical dilatation.

Reverse Breech Extraction versus Vaginal Push before Uterine Incision during Cesarean Section with Fully Dilated Cervix and Impacted Fetal Head

Purpose: To compare between the two commonly used methods to deliver the fetus in emergency cesarean section with fully dilated cervix and impacted fetal head; vaginal push up of the fetal head and reverse breech extraction regarding safety and efficacy. Methods: A retrospective observational study was conducted 152 women underwent emergency CS with fully dilated cervix and impacted fetal head were divided into two groups; Group 1, vaginal push (n = 96) and Group 2, reverse breech delivery (n = 56). Data variables were collected and analyzed to evaluate whether either method is more safe regarding maternal and fetal outcomes. Results: There was a significant higher percentage of extension of uterine incision in group 1 (p = 0.002). Also, there were significant higher mean values of operative time and operative blood loss in group 1 (p = 0.008 and 0.015; respectively). On the other hand, there was a significantly shorter uterotomy to delivery time in group 1 (p < 0.001). There was a significantly higher mean value of APGAR score at one minute in group 1 (p = 0.043) but no significant difference between the two groups regarding APGAR score at five minutes, atonic PPH, postoperative blood transfusion and hospital stay. Conclusion: Vaginal push technique was associated with significantly higher intraoperative maternal morbidity but postoperative maternal morbidity and fetal outcomes were comparable between both groups. Push method (after uterine incision) is still the preferable method and larger studies are required to assess the fetal safety with reverse breech extraction.

Prophylactic SR suction cannula application for high-risk women for atonic PPH: An interventional study

Prophylactic SR suction cannula application for high-risk women for atonic PPH: An interventional study

SAFETY, EFFICACY AND ADVANTAGES OF PROPHYLACTIC USE OF SINGLE DOSE OF INTRAVENOUS CARBETOCIN DURING CAESAREAN DELIVERY FOR PREVENTION OF PPH: AN OBSERVATIONAL STUDY AT A TERTIARY CARE HOSPITAL.

Background: Postpartum Haemorrhage is the leading cause of maternal mortality and morbidity in India with 38 % maternal deaths caused by it. Although most healthy women can cope well with blood loss after birth, some do not, and this can pose a serious risk to their health and even life. To reduce blood loss after birth, the routine administration of a drug to contract the uterus (uterotonic) has become standard practice across the world. We have developed numerous drugs which can be given prophylactically to prevent PPH and each of them have some advantages and disadvantages. The newest one is Carbetocin which is a long-acting synthetic oxytocin analogue with half-life of 40 minutes. Uterine contractions occur in less than 2 minutes after a single intravenous dose of 100microgram of Carbetocin. The present study was done to analyse safety, efcacy, and advantages of the Carbetocin, when administered to pregnant women at the time of caesarean delivery as a prophylaxis post-partum haemorrhage. Material and Methods: 200 pregnant women admitted for delivery at tertiary care hospital, who underwent caesarean section, both elective and emergency were included in the study. Inj Carbetocin, heat stable preparation ,100 mcg was diluted in 10 ml distilled water and given slow IV over 1 minute to all pregnant women at the time of caesarean section immediately after delivery of baby. Results: 84% of women had no atonic PPH and did not need any additional uterotonic drug for PPH. Remaining 16 % women who needed additional drugs for control of PPH had one or more risk factors responsible for PPH Conclusion: Single dose of 100 mcg IV Carbetocin is a safe and good drug for prophylactic use in pregnant women undergoing caesarean section for prevention of atonic PPH. Side effects are very less, advantages are many and overall results are promising.

Indications and outcome of emergency obstetrics hysterectomy in last 5 years at ACPM medical college Dhule

Emergency Obstetric Hysterectomy (EOH) is the process of surgical removal of the uterus after an unexpected & sudden event. EOH acts as a bridge between life-threatening postpartum hemorrhage & death. 1. To study the indications & risk factors responsible for emergency obstetrics hysterectomy. 2. To study the outcome of emergency obstetrics hysterectomy. The present study is a retrospective descriptive study conducted at the department of Obstetrics and Gynecology, ACPM Medical College, Dhule over a span of 5 years from 2016 to 2021. In the present study, out of the 6250 patients, 50 patients underwent EOH. The incidence rate was 8 per 1000 deliveries. 32 (64%) were within the age group of 26-30 years, with a mean age of 27.8 ± 2.4 years. Atonic PPH (48%) was the commonest indication. Previous LSCS (76%) & antepartum hemorrhage (48%) were found the main risk factors for EOH. Uterine atony & morbidly adherent placenta are the most common indications for EOH. Previous LSCS & antepartum hemorrhage were found the main risk factors. Needs much more research to decrease mortality and morbidity in cases requiring EOH cause of advances in interventional radiology.

Liver transaminase enzyme analysis as a predictor of poor maternal outcome in pregnant women with dengue

To find out predictive value of elevated liver transaminases as a predictor of poor maternal outcome in pregnant women with dengue infection.Our study was a retrospective study, conducted in a tertiary care centre of North India from July 1 to December 31, 2021. Data of all the pregnant women with dengue infection during the above period was screened for maternal and fetal outcomes. Elevated liver transaminases in women who developed DHF, DSS and maternal mortality were the main outcome measures. Mode of delivery, obstetric complications, medical complications (Dengue Hemorrhagic Fever, Dengue shock syndrome and Acute Respiratory Distress Syndrome) and KFT for prediction of maternal mortality were the secondary outcome measures.The association of liver transaminases derangement with stage of dengue at diagnosis were analysed using Fisher’s exact test. Data analysis was done with Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, USA, version 21. P value of less than 0.05 was considered statistically significant. A total of 35 women were included in the study. The mean age was 23.49 + 2.94 years. Acute respiratory distress syndrome, acute kidney injury, atonic PPH, and puerperal sepsis developed in 6(17.14%), 7(20%), 4(8.57%), and 10 (28.57%) women respectively. The maternal mortality rate was 25.71%. All women who developed DHF (3 women) and DSS (9 women) had altered liver enzymes. Alanine transaminase has very high sensitivity (100%) and specificity (76.92%) as a predictor of maternal mortality in pregnant women with dengue, (p<0.05). Similarly, serum creatinine levels at a value of more than 0.9 mg/dl had a sensitivity and specificity of 88.89% and 92.31%, respectively for predicting maternal mortality in pregnant women with dengue, (p<0.05). Conclusion: Elevated liver transaminases can be used as predictors of poor maternal outcome in pregnant women with dengue infection.

Comparison between oxytocin intravenous bolus, oxytocin intravenous bolus and infusion, rectal misoprostol and carbetocin infusion for the control of blood loss at elective cesarean section

Background: Uterine atony is the greatest typical etiology of primary PPH. Developed nations' atonic PPH rates are rising despite regular active control of the third stage of work. Primary PPH continues to be the greatest cause of maternal mortality in less developed nations. Aim and objectives: to assess the effectiveness of rectal misoprostol, oxytocin infusion, and oxytocin intravenous bolus and infusion in reducing blood loss during and after elective caesarean delivery. Subjects and methods: This prospective research included 200 pregnant patients who were hospitalized to the labor ward at the Al-Hussein University Hospital's Department of Obstetrics and Gynecology. Result: There was a substantial variation among included groups regarding Additional uterotonic use Intraoperatively as it was used in 17, 12, 13 and 5 respectively in groups 1,2,3 and 4. Conclusion: Compared to the Oxytocin and Misoprostol groups, Carbetocin is only effective in reducing postpartum bleeding and is related with a reduced requirement for further uterotonic medicines or surgical hemostatic treatments.

ROLE OF INNOVATIVE BALLOON TAMPONADE IN ATONIC POST PARTUM HAEMORRHAGE

Introduction: Postpartum hemorrhage is the major cause of maternal deaths, especially in the developing world. Uterine atony is the most common cause of PPH and when the hemorrhage is not controlled with medical management then Intrauterine balloon tamponade is one method that proves very effective and reduces the need for further surgical interventions. T Aims & Objectives: o evaluate the effectiveness of balloon tamponade in the management of atonic PPH. This prospective study was conducte Materials & Methods: d in the Department of Obstetrics & Gynaecology at Government Medical College and Rajendra Hospital, Patiala. We included 50 cases of atonic PPH in the study where medical management failed. Uterine tamponade was achieved by an innovative condom balloon catheter The success rate of balloon tamponade Results: in controlling bleeding came out to be 94%. We concluded that Uterine balloon tam Conclusions: ponade is effective, non-invasive, simple to use, easily available, and cost-effective method for the management of PPH. If we are unable to control bleeding with this method, it provides a temporary tamponade effect to gain time for surgical procedures or referral to a higher center if facilities are not available

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.

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.

Frequency of Jaundice in Pregnancy and its Maternal and Fetal Outcome

Background: During pregnancy, jaundice is important medical disorder more commonly seen in developing countries than developed one. Jaundice in pregnancy carries a grave for both the fetus and mother. This study is design to identify the frequency of jaundice in pregnancy and its maternal and fetal outcome to establish current local data for other health care providers. Aim: To determine the frequency of jaundice in pregnancy and its maternal and fetal outcome. Study Setting: This was a descriptive case series study conducted at the department of Obstetrics and gynecology of Civil hospital Karachi for the duration of 6 months from July 2018 to January, 2019. Subject and Methods: A total of 507 pregnant women were included in this study. The frequency of jaundice in pregnancy and its maternal and fetal outcome data was documented on pre designed proforma. Results: - The average age of the women was 25.91±4.46 years. Frequency of jaundice in pregnancy was 8.28%. Hepatic encephalopathy, disseminated intravascular coagulation, atonic PPH and maternal mortality was significantly high in those pregnant women who had jaundice. Similarly fetal outcome, still birth was 20% (20/40%) in which fresh still birth and macerated still birth was 15% and 5% which were not statistically significant while all were late neonatal death and which was significantly high in jaundice pregnant cases [45% vs. 9.7%; p=0.0005] . Conclusion: Jaundice in pregnancy is rare, but remains clinically important because of serious adverse effects on both the mother and the fetus. These disorders are complex and should be managed by experienced physicians in specialized centers. Keywords: Jaundice, disseminated intravascular coagulation, Atonic PPH

Study on Maternal and Neonatal Outcome of Women Undergoing Caesarean Section using NICE Classification in a Tertiary Care Hospital in Rural Area of Central India - An Observational Prospective Study

Background :Caesarean section is often perceived to be safer than vaginal delivery for mothers and neonates, and thus has become increasingly common around the globe. However, it may actually be detrimental to maternal and neonatal health while consuming valuable resources.Objective :The objective of this study was to categorize the caesarean sections performed in our rural institute into various categories using NICE classification and to study the maternal and neonatal outcome in them.Method :This was a prospective study of all women who underwent caesarean section over a period of 18 months. Data was retrieved from the files of women for morbiditiy and mortality in mothers and babies. Data was entered in MS excel sheet and analyzed with percentages and chi square test using SPSS ver.17.Results:Caesarean section rate (CSR) was 36.88%. All CS were classified into four categories based on urgency as per NICE guidelines. There were 22.62% women in Category I, 38.61% in category II, 28.37% in category III and 10.40% in Category IV. Adhesions, extension of angle, lacerations in lower segment, scar dehiscence, atonic PPH and bladder injury were noted in (12.83%), 11.81%, 6.83%, 4.08% , 1.53% and 0.08% CS respectively. Caesarean hysterectomy was done in 0.24% cases. Postoperative morbidity was febrile morbidity (11.93%), postdural puncture headache (13.85%), paralytic ileus (11.49%), wound infection (8.83%), ARDS (0.70%), sepsis (0.78%), pulmonary edema (0.47%) and pulmonary embolism (0.03%). Maternal mortality was 0.03%. Neonates born were 2577 (29 were twin deliveries). 82.46% neonates were healthy, 16.80% had morbidities and 0.74% were still born. Apgar score of less than 7 was in 10%. 16.80% neonates were admitted in NICU during their hospital stay. Neonatal mortality was 1.47%.Conclusion :Intraoperative and post-operative complication were more in caesarean sections of category I and II as compared to category III and category IV. Neonatal morbidity, mortality and admissions to NICU were more in caesarean sections of category I and II as compared to category III and category IV. Thus though caesarean section is an emergency lifesaving procedure for mother and baby it may prove detrimental to their health.

A STUDY ON FETO-MATERNAL OUTCOME IN A POSTDATED PREGNANCY

BACKGROUND: The objective of the study is to find out the fetal and maternal complications in post dated pregnancy. This is a prospective observational study. METHODS: Patients who have completed 40weeks of gestational age,meeting the inclusion criteria. RESULTS: Of 100 cases 74(74%) cases were under 20 to 25 years, majority cases were primigravida (66%), overall caesarean rate was 36%,Meconium-stained liquor with fetal distress was the most common indication for LSCS 9(25 %). Fetal distress was the most common fetal complications,number of induced labor is 71.4% at 41 weeks 1 day to 42 weeks CONCLUSION: In our study we concluded that prolonged pregnancy was associated with significant risk of perinatal complications like fetal distress, meconium aspiration syndrome and IUGR. There was significantly increased risk of obstetric complications like oligohydramnios,perineal tear,atonic PPH and shoulder dystocia.

Current trends in peripartum hysterectomy in a tertiary care hospital of Kolkata, India over a period of five years

Background: Emergency peripartum hysterectomy is a lifesaving procedure done as a last resort to save mother’s life. This study is to analyse the incidence, maternal characteristics, indications and complications following peripartum hysterectomy. Methods: A descriptive and retrospective study of obstetric hysterectomy was done at Medical College and Hospital, Kolkata, India from March 2016 to October 2021. Case records were analysed to record the incidence, indications, risk factors and complications associated with peripartum hysterectomy during the study period. Total 129 cases of obstetric hysterectomy fulfilling the inclusion criteria were included in the study. Template was generated in MS excel sheet and analysis was done on SPSS software. Results: Incidence of peripartum hysterectomy was 0.045%. The most common indication for peripartum hysterectomy was Placenta Percreta with 29 cases (22.5%) followed by 27 cases of Atonic PPH (20.9%). most common maternal complications were repeated transfusion 47 (36.4%), followed by shock 43 (33.3%). Most common fetal complications were Perinatal Asphyxia 37 (28.7%), followed by jaundice 12 (9.3%). Conclusions: Emergency peripartum hysterectomy remains a lifesaving procedure. Proper antenatal care, early referral, blood bank facilities and timely decision greatly influences maternal outcome.

Analysis of Indications and outcome of emergency obstetric hysterectomy

Introduction: Emergency hysterectomy is the surgical removal of the uterus following an unexpected and sudden event, which must be dealt with urgently by carrying out the procedure. When it is carried out in a woman with a pregnant uterus less than 24 hours after delivery, it is termed emergency peripartum hysterectomy. Peripartum Hysterectomy is an essential part of the obstetricians armamentarium. On one hand, it is the last resort to save a woman's life and on the other hand, her reproductive capability is sacrificed. Many times it is a very difficult decision and requires good clinical judgment.Objectives: To evaluate the indications, outcome and complications associated with peripartum hysterectomy procedures. Methods: A retrospective study of all cases of caesarean and postpartum hysterectomy between July 2019 and December 2020. Maternal characteristics, indications for hysterectomy and complications were reviewed.Results: The rate of peripartum hysterectomy was 1.32:1000 deliveries. Most were operative deliveries. The main indications were placenta accrete (36%), massive atonic PPH (32%) and uterine rupture (18%). Maternal morbidity was high and there were four maternal deaths (8%). All deaths were in patients brought in a critical condition to the hospital after massive blood loss.Conclusion: Peripartum hysterectomy is potentially a life saving procedure but the mortality and morbidity is high, especially if performed late when the hemodynamic instability has already set in.

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.

Intrauterine Suction for Control of Atonic PPH

Indian Journal of Scientific Research(IJSR):Calls for Unique, Unpublished research papers in Botany, Zoology, Chemistry, Physics, Mathematics, Medical Sciences, Agricultural Sciences, Environmental Sciences, Natural Sciences Technological Sciences and any other branch of related sciences

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.

IMPACT OF OBSTETRIC HEMORRHAGE ON "NEAR MISS" MORBIDITY IN A TERTIARY CARE HOSPITAL-... 'LEADING INDICATOR IN EVERY HUMANITARIAN CRISIS'

Background:To assess risk factors, and “near-miss” morbidity in Obstetric haemorrhage. Methods: This was a tertiary care based Observational Prospective Study design conducted between October 2018 to September 2020 to nd magnitude, morbidity associated with Obstetric haemorrhage. To study various Maternal outcomes and intervention for management of maternal near miss cases. Total 350 samples were selected by using concurrent sampling method for maternal near miss cases at tertiary care centre and who met the designed set of criteria. Result: Most common cause of MNM observed was Atonic PPH 224 (64%). 242 (69.14%) cases required blood transfusion and mean and SD of blood transfused was 10.98 ± 1.04. In our study, hemodynamic compromise was common cause of Systemic dysfunction, most common system involve in MNM observed was haematological 185 (52.86%). Overall, 218 (62.28%) cases required ICU monitoring. 166 (47.42%) cases needed emergency LSCS, Obstetric hysterectomy was performed on 56 (16%) of cases whereas 47 (13.43%) cases undergone Exploratory Laparotomy. The most common problem encountered by patients prior to hospital admissions was the unavailability of treatment at lower-level health facilities, affecting 248 out of 350 of study participants. Conclusion: Concluded from this study that Post-Partum Haemorrhage were the most common cause maternal morbidity in the study group. “Near-Miss” morbidity in PPH reect the level of obstetric care in the developing world. These need to be reduced by strengthening peripheral delivery facilities, active 3rd stage management and early referral.

Cost of managing atonic postpartum haemorrhage with uterine balloon tamponade devices in public health settings of Maharashtra, India: an economic microcosting study

ObjectivePostpartum haemorrhage (PPH) is the worldwide leading cause of preventable maternal mortality. India offers free treatment for pregnancy and related complications in its public health facilities. Management with uterine balloon...