Cases Of Postpartum Hemorrhage Research Articles

Predelivery Haemostatic Biomarkers in Women with Non-Severe Postpartum Haemorrhage.

Background: Postpartum haemorrhage (PPH) is a frequent complication of childbirth that is difficult to predict. Predelivery coagulation biomarkers may help to guide preventive strategies. Our objective was to evaluate the association of predelivery haemostatic biomarkers with non-severe PPH. Methods: A nested case-control study was conducted within the « Study of Biological Determinants of Bleeding Postpartum » in order to compare different haemostatic biomarkers in plasma from pregnant women with non-severe PPH (cases) and controls without PPH matched for age, body mass index, term, and mode of delivery. Blood was collected at entry in the delivery room. Global haemostatic assays (thrombin generation assay (TGA) and plasmin generation assay (PGA)) were then performed on freshly thawed aliquots of platelet-poor plasma. Results: A total of 370 pregnant women (185 cases and 185 controls) were included. Median [interquartile range] predelivery platelet count was lower in PPH cases than in controls (217 [181-259] versus 242 [196-280] G/L). TGA and PGA parameters were similar between cases and controls. In a subset analysis of vaginal deliveries (n = 144), median predelivery TGA thrombin peak was lower, and median predelivery PGA lag phase was longer in cases compared to controls. In multivariable analysis, only predelivery platelet count was independently associated with non-severe PPH. Conclusions: Predelivery platelet count is associated with non-severe PPH. Differences in other haemostatic parameters are tenuous, questioning their usefulness in predicting non-severe PPH.

A Retrospective Study of Cases of Postpartum Hemorrhage at Secondary Health Care Center

A Retrospective Study of Cases of Postpartum Hemorrhage at Secondary Health Care Center

Interpretable machine learning predicts postpartum hemorrhage with severe maternal morbidity in a lower-risk laboring obstetric population

BackgroundEarly identification of patients at increased risk for postpartum hemorrhage (PPH) associated with severe maternal morbidity (SMM) is critical for preparation and preventative intervention. However, prediction is challenging in patients without obvious risk factors for postpartum hemorrhage with severe maternal morbidity. Current tools for hemorrhage risk assessment use lists of risk factors rather than predictive models. ObjectiveTo develop, validate (internally and externally), and compare a machine learning model for predicting PPH associated with SMM against a standard hemorrhage risk assessment tool in a lower risk laboring obstetric population. Study DesignThis retrospective cross-sectional study included clinical data from singleton, term births (>=37 weeks’ gestation) at 19 US hospitals (2016–2021) using data from 58,023 births at 11 hospitals to train a generalized additive model (GAM) and 27,743 births at 8 held-out hospitals to externally validate the model. The outcome of interest was PPH with severe maternal morbidity (blood transfusion, hysterectomy, vascular embolization, intrauterine balloon tamponade, uterine artery ligation suture, uterine compression suture, or admission to intensive care). Cesarean birth without a trial of vaginal birth and patients with a history of cesarean were excluded. We compared the model performance to that of the California Maternal Quality Care Collaborative (CMQCC) Obstetric Hemorrhage Risk Factor Assessment Screen. ResultsThe GAM predicted PPH with an area under the receiver-operating characteristic curve (AUROC) of 0.67 (95% CI 0.64–0.68) on external validation, significantly outperforming the CMQCC risk screen AUROC of 0.52 (95% CI 0.50–0.53). Additionally, the GAM had better sensitivity of 36.9% (95% CI 33.01–41.02) than the CMQCC screen sensitivity of 20.30% (95% CI 17.40–22.52) at the CMQCC screen positive rate of 16.8%. The GAM identified in-vitro fertilization as a risk factor (adjusted OR 1.5; 95% CI 1.2–1.8) and nulliparous births as the highest PPH risk factor (adjusted OR 1.5; 95% CI 1.4–1.6). ConclusionOur model identified almost twice as many cases of PPH as the CMQCC rules-based approach for the same screen positive rate and identified in-vitro fertilization and first-time births as risk factors for PPH. Adopting predictive models over traditional screens can enhance PPH prediction.

Agnostic identification of plasma biomarkers for postpartum hemorrhage risk

Postpartum hemorrhage is difficult to predict, is associated with significant maternal morbidity, and is the leading cause of maternal mortality worldwide. The identification of maternal biomarkers that can predict increased postpartum hemorrhage risk would enhance clinical care and may uncover mechanisms that lead to postpartum hemorrhage. This retrospective case-control study employed agnostic proteomic profiling of maternal plasma samples to identify differentially abundant proteins in controls and postpartum hemorrhage cases. Maternal plasma samples were procured from a cohort of >60,000 participants in a single institution's perinatal repository. Postpartum hemorrhage was defined as a decrease in hematocrit of ≥10% or receipt of transfusion within 24 hours after delivery. Postpartum hemorrhage cases (n=30) were matched by maternal age and delivery mode (vaginal or cesarean) with controls (n=56). Mass spectrometry was used to identify differentially abundant proteins using integrated peptide peak areas. Statistically significant differences between groups were defined as P<.05 after controlling for multiple comparisons. By study design, cases and controls did not differ in race, ethnicity, gestational age at delivery, blood type, or predelivery platelet count. Cases had slightly but significantly lower predelivery and postdelivery hematocrit and hemoglobin. Mass spectrometry detected 1140 proteins, including 77 proteins for which relative abundance differed significantly between cases and controls (fold change >1.15, P<.05). Of these differentially abundant plasma proteins, most had likely liver or placental origins. Gene ontology term analysis mapped to protein clusters involved in responses to wound healing, stress response, and host immune defense. Significantly differentially abundant proteins with the highest fold change (prostaglandin D2 synthase, periostin, and several serine protease inhibitors) did not correlate with predelivery hematocrit or hemoglobin but identified postpartum hemorrhage cases with logistic regression modeling revealing good-to-excellent area under the operator receiver characteristic curves (0.802-0.874). Incorporating predelivery hemoglobin with these candidate proteins further improved the identification of postpartum hemorrhage cases. Agnostic analysis of maternal plasma samples identified differentially abundant proteins in controls and postpartum hemorrhage cases. Several of these proteins are known to participate in biologically plausible pathways for postpartum hemorrhage risk and have potential value for predicting postpartum hemorrhage. These findings identify candidate protein biomarkers for future validation and mechanistic studies.

Use of Postpartum Hemorrhage Checklist during Vaginal Deliveries: A Quality Improvement Study.

Postpartum hemorrhage (PPH) protocols improve patient safety and reduce utilization of blood products; however, few data exist on sustainability of PPH checklist use, how use affects care delivery, and variation of use among patient subgroups. This study aimed to (1) examine compliance with PPH checklist use during vaginal deliveries, (2) evaluate whether checklist use varied by patient and/or care team characteristics, and (3) evaluate whether checklist use was associated with increased use of recommended medications/interventions. This was a quality improvement study performed from April 2021 through June 2023. A multidisciplinary team developed a revised PPH checklist and used quality improvement methodology to increase checklist use following vaginal birth. Data were collected from medical records and clinician survey. Control charts were generated to track checklist use and evaluate special cause variation. Chi-square tests and logistic regression were used to evaluate variation in medications/interventions and across subgroups. During the study period, there were 342 cases of PPH at the time of vaginal birth. The checklist was used in 67% of PPH cases during the 20-month period after implementation in a setting where no checklist was previously being used. We found no statistically significant differences in checklist use by patient or health care team characteristics. Use of tranexamic acid, carboprost, and misoprostol were significantly associated with checklist use. This study demonstrated successful implementation of a checklist protocol where no checklist was previously being used, with sustained use in an average of 67% of PPH cases over 20 months. Checklist use was consistent across subgroups and was associated with higher use of interventions shown to lower blood loss. · Our study showed sustainability of PPH checklist use over a 20-month period.. · PPH checklist use was associated with increased use of interventions known to reduce blood loss.. · Checklist was used consistently across patient subgroups; may help address inequities in obstetric outcomes..

E-MOTIVE Trial: Sustaining capacity building of healthcare providers in the early detection and treatment of postpartum hemorrhage in 11 facilities in Kenya

Background: Training healthcare providers on early detection and use of the first response bundle for postpartum hemorrhage (PPH) cases was one of the key strategies used in the intervention facilities during the E-MOTIVE trial. Results published from the E-MOTIVE trial revealed a marked reduction of 60% in the severity of PPH, idicating the need to implement the same approaches in the 11 control arm facilities. Methods: Healthcare providers (HCPs) from the 11 sites were trained on the E-MOTIVE bundle and issued with PPH emergency trollies, mannequins, and blood pressure machines. The staff was also mentored on self-PPH audits and feedback mechanisms from the data generated monthly from the labor ward. Two days of on-site training were conducted for the staff, which included knowledge tests (before and after) and skills assessment (objective skilled clinical examinations (OSCES)). EMOTIVE champions were identified from the training to promote ongoing skills practice sessions at the facility level. Monthly follow-ups were cpnducted to track individual progress using the training tracking sheet. Results: The HCPs cited confidence in detecting and treating PPH after the training with the hospitals demonstrating readiness in managing PPH through the presence of PPH emergency trollies. There was increased teamwork among the HCPs with improved documentation practices in the labor wards. Conclusion: Adoption of a sustainable training approach for healthcare providers in the prevention, early detection, and treatment of PPH that incorporates evidence-based strategies is key to improving maternal outcomes. National and county ministries of health have demonstrated a commitment to leverage the E-MOTIVE bundle approach after remarkable findings.

Postpartum hemorrhage champions: Sustaining gains beyond the E-MOTIVE Trial

Background: Results published from the E-MOTIVE trial concluded that for women undergoing vaginal delivery, early detection of postpartum hemorrhage (PPH), combined with bundled treatment of PPH, reduced severe PPH and associated adverse outcomes. Eighty hospitals across Nigeria, Kenya, Tanzania, and South Africa and over 210,000 women participated in the randomized trial, which was designed to assess the effect of implementing the E-MOTIVE intervention to detect and treat PPH. The results showed that the use of calibrated collection drapes dramatically increased the PPH detection rate, from 51% to 93%, and the use of the WHO-recommended bundle of treatments, from 19% to 91%. Moreover, implementing the E-MOTIVE approach to treat PPH resulted in a 60% reduction in severe PPH. The median blood loss, the need for postpartum blood transfusion, and the number of maternal deaths were also reduced. The E-MOTIVE trial trained a pool of PPH champions across the intervention facilities, including nurses, midwives, medical officers, and obstetrics and gynecology specialists. Their roles were to coordinate the training and practice activities of all relevant labor ward staff in their hospitals, observe labor ward staff practices, and provide specific feedback for targeted improvements in implementing the E-MOTIVE bundle correctly by reviewing regular performance indicators and outcome data from their hospitals to assess if improvements were needed. Methods: After the study findings, the Kenyan hub team continued tracking the performance of the facilities after the trial, without any active support. The PPH champions collected, discussed at the facility level, and shared data with the Kenyan hub team monthly. The data shared were included in the hub Project Management Information System and triangulated with data from DHIS, where it was analyzed by the Kenyan study team, and feedback was shared at the facility level. Results: Data analyzed from the last quarter (September-November) showed that seven E-MOTIVE implementing facilities maintained 5% PPH rates (blood loss &gt;500 mls) and 2% severe PPH rates on moving averages. All components of the E-MOTIVE bundle were provided 100% to all PPH cases detected. During the same period, three maternal deaths were reported that had causes other than bleeding from PPH. Conclusion: Having PPH champions community of practice can help sustain best practices in the early detection and treatment of PPH beyond any project lifeline. It is a simple and cost-effective method that can prevent severe PPH and prevent maternal mortality arising from PPH.

HAYMAN COMPRESSION SUTURES : AN UNDERUTILIZED TOOL FOR MANAGEMENT OF UTERINE ATONY AND POSTPARTUM HAEMORRHAGE.

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in low- andmiddle-income countries. Uterine atony accounts for 70–80% of PPH cases. Management of PPH isusually based on a cascade beginning with the use of uterotonics and eventually hysterectomy in casesof refractory PPH. Different compression suture techniques have been described and used for themanagement of uterine atony where medical management is insufficient and preservation of fertility isdesired.Case presentation: This is a series of four patients who presented to our facility and consequentlydeveloped uterine atony that was unresponsive to medical management during cesarean delivery despitethe use of multiple uterotonics. All four patients had established risk factors for uterine atony, includinginduction of labor, augmentation of labor, chorioamnionitis, or fetal macrosomia. Hayman compressionsutures were performed in all four patients with success. Estimated blood loss in the series ranged from400 to 1200 mls. All patients recovered well with no complications reported during the postpartum period.Conclusion: Hayman compression sutures offer an alternative to the more ubiquitous B-Lynch suturewith several advantages, including ease of placement and no need for a hysterotomy in PPH post vaginalbirth or placement post repair of hysterotomy in cesarean cases. Thus, the may be easier to perform forjunior health care professionals as well as in stressful situations.

Risk factors for early postpartum hemorrhage: A retrospective, population-based, cohort analysis.

To identify risk factors for developing early postpartum hemorrhage (PPH) and to examine whether risk factors vary according to severity and mode of delivery. A population-based cohort study was conducted in which all deliveries at a tertiary medical center were included. Risk factors for developing early PPH were compared based on the severity of bleeding as well as the mode of delivery. Multiple logistic regression models were used to control for confounders. Among 322 497 deliveries included in the analysis, early PPH complicated 1811 (0.56%) of all deliveries. Among all cases of early PPH, 505 deliveries (28%) were complicated with severe PPH. Using a logistic regression model, invitro fertilization (IVF) pregnancy, previous cesarean delivery (CD), pre-eclampsia, placental abruption, and uterine rupture were independently associated only with severe early PPH, while non-progressive second stage of labor, induction of labor, and large for gestational age were independently associated with both severe and mild early PPH. When applying an additional logistic regression model, whereas IVF pregnancy, pre-eclampsia, and large for gestational age were independently associated with early PPH among vaginal deliveries only, placenta previa was independently associated with early PPH among CD only. Independent risk factors for developing severe PPH solely include IVF pregnancy, previous CD, pre-eclampsia, placental abruption, and uterine rupture. IVF pregnancy, pre-eclampsia, and large for gestational age are independent risk factors for early PPH following vaginal delivery, while placenta previa is independently associated with early PPH after CD only. Due to the recognition of the importance of both the provider and institutional planning and preparation for PPH, the study's results should be viewed within the scope of its retrospective cohort design.

Economic effects of treating postpartum hemorrhage with vacuum-induced hemorrhage control devices – A budget impact analysis of the Jada® System in the German obstetrics setting

ObjectiveThis study aimed to assess the budget impact of vacuum-induced hemorrhage control (VHC) devices for treating postpartum hemorrhage (PPH) from the perspective of the German statutory health insurance (SHI). Study DesignEvidence shows that treating PPH with VHC instead of uterine balloon tamponade (UBT) can reduce resource consumption (e.g., reduced number of blood transfusions and length of stay). A budget impact model combining aggregated German real-world reimbursement data of PPH cases with the assumption of resource reduction due to VHC usage was developed. Diagnosis-related groups (DRG) of PPH cases and their frequencies were collected using a publicly available database. A “downgrading mechanism” was performed, leading to a less resource-intensive DRG, i.e., resulting in a lower flat fee to be paid by SHI. Four subgroups were differentiated based on coded diagnoses and procedures: 1) PPH (O72.-) as main diagnosis, 2) PPH as secondary diagnosis, 3) UBT procedure coded, and 4) UBT or standard tamponade coded. Weighted averages of cost savings per case were calculated. ResultsData from 7,129 (subgroup 1), 49,523 (subgroup 2), 1,668 (subgroup 3), and 3,406 (subgroup 4) cases were retrieved. After applying the downgrading mechanism, cost savings (weighted average) resulted in 184.09 €, 210.50 €, 921.33 €, and 633.74 € for subgroups 1–4, respectively, ConclusionThis is the first German budget impact analysis of VHC for the treatment of PPH. Results showed the highest cost-saving potential for cases currently treated with UBT. Demonstrating not only clinical but also financial consequences of innovative treatments is crucial for the adoption into clinical practice.

Instructional and didactic support tool for teaching-learning Post-Partum Haemorrhage care in simulated settings: Creation and validation

ObjectiveTo describe the creation and validation process of an instructional, didactic and self-applied support tool for teaching-learning Post-Partum Haemorrhage care in simulated settings. BackgroundStudents frequently face difficulties performing the actions in the proper sequence in Post-Partum Haemorrhage simulated cases. Even in a controlled environment, anxiety, nervousness and fear of making mistakes are evident, which render the simulated experience highly stressful. Having a tool with a guideline can help students perform these actions more assertively. DesignA methodological study to develop a didactic tool. MethodsThe creation process of the didactic tool, called Instructional Disk for the Management of Post-Partum Haemorrhage, was divided into five phases: Analysis, Design, Development, Implementation and Evaluation. Nine experts specialised in Obstetrics and Midwifery validated the tool by answering a questionnaire with nine items; in turn, 32 undergraduate Midwifery program students carried out the evaluation using a questionnaire on applicability, functionality, clarity, coherence and usability of the tool in Post-Partum Haemorrhage simulated stations. The data were analysed descriptively, considering absolute agreement when the answers to all questions in the five-point Likert scale corresponded to 5 (I totally agree). The Content Validity Index was calculated for the experts' questionnaires. ResultsIn the validation stage, the experts agreed or totally agreed with all nine items, reaching a Content Validity Index = 1. In the total scores assigned by the experts, there was a variation between 80.0% and 100% absolute agreement, with a mean of 95.6%. In the students' assessment, the variation was between 87.5% and 100% absolute agreement, with a mean of 97.7%, in the eight items evaluated. The agreement level above 90% among experts and students was considered high. ConclusionsThe Instructional Disk for the Management of Post-Partum Haemorrhage was validated by experts with extensive experience in Obstetrics and Midwifery care and teaching, ensuring that the content included in the guidelines for the management of Post-Partum Haemorrhage adopted in Brazil is covered. The students positively evaluated this support tool for learning the care to be provided in Post-Partum Haemorrhage cases in the simulated stations.

Pregnancy and Delivery Outcome Among Ladies with Glanzmann Thrombasthenia: A Report from Glanzmann Thrombasthenia Registry of Al-Madinah, Saudi Arabia

Introduction Glanzmann's thrombasthenia (GT) is an autosomal recessive bleeding disorder due to functional platelet defects impairing platelet aggregation. AlMadinah has reported the highest prevalence of GT globally, with a prevalence of 1:10,000. Pregnancy had been reported among ladies with GT with different outcomes. As a bleeding disorder, Pregnancy among ladies with GT carries a higher risk for bleeding either during pregnancy or intra and postpartum. Neonates have an increased risk for hemorrhage, either due to alloimmunization or they may carry the gene of GT. Many GT ladies got pregnant earlier when GT diagnosis was difficult, and they did not know their diagnosis; even after the diagnosis was possible, ceasing the menstrual cycle was not culturally acceptable. In this study, we are describing the pregnancies among GT ladies and their outcomes. Methods This is a report from the AlMadinah GT registry in the Madinah Hemophilia Comprehensive Care Center. The registry covers a period of 20 years and includes all patients with a confirmed diagnosis of GT. 136 GT patients were identified. 11 patients had no data available. A spreadsheet designed to collect detailed data about pregnancy, delivery, and neonates. Electronic and hard copy medical records have been accessed to collect data. Data was analyzed by the statistical package of social sciences (SPSS) version 23. The research and ethical committee approved the study. Results Twenty-eight pregnancies have been identified. The median age of mothers at the time of pregnancy was 30 ± 5.7 years (20 - 42 years). Mothers' Gravidity was 1-7 (median 2.5 ± 1.6), and parity was 1-6 (median 2 ±1.4). Five miscarriages (18%) identified occurred at the 17 th, 11 th, 13 th and 15 th gestational weeks. In contrast, 5 th one is not on record. Three miscarriages took place after moderate to severe vaginal bleeding. Mild to severe post-abortion bleeding was controlled with platelets transfusion, activated human recombinant factor 7 (rFVIIa), and tranexamic acid. Thirty-two bleeding episodes occurred during 16 pregnancies, with 1-5 bleeding episodes per pregnancy (Median of 2 episodes). Seven (22%) bleeding episodes were vaginal bleeds, while 25 (78%) were GT-related bleeds such as gum bleeding or epistaxis. Two patients must undergo plasma exchange and be on steroids due to alloimmunization development during pregnancy. Delivery occurred at the gestational age of 34-40 weeks (median 38 ± 2 weeks). Sixteen (70%) deliveries were vaginal, and 7(30%) were cesarean sections. The indications for cesarean sections were family request in 4 cases, fetal distress in two instances, and precautional section in one case. Prophylactic platelets transfusion had given pre-delivery on four occasions, rFVIIa on 4, and a combination of rFVIIa and platelets transfusion on six occasions. Tranexamic acid was used in all cases. Ten deliveries were conducted with no prophylaxis. Post-partum hemorrhage (PPH) occurred in 18 (64%) cases, 13 (72%) cases of primary PPH, and 5 (28%) cases of secondary PPH. We could not find a correlation between pre-delivery prophylaxes and PPH (P=0.2). PPH had controlled successfully with platelets transfusion and rFVIIa though red blood cell transfusion was needed on eight occasions. Twenty-eight pregnancies produced 24 babies (13 girls and 11 boys). Four babies had bleeding (2 intracranial hemorrhages, one subdural hematoma, and one gum oozing), and 9 had alloimmunization with mild to severe thrombocytopenia. Of all babies tested for GT, 6 of them were GT. Conclusions Pregnancy among ladies with GT carries a higher risk of bleeding. Management of pregnancy in women with GT has to be in a Multidisciplinary approach. The high rate of PPH among GT ladies makes it essential to treat it promptly. Pregnancy among ladies with GT should be studied in multi-centers sitting to learn more about clinical courses and management.

Fetal Macrosomia and Postpartum Hemorrhage in Latin American and Caribbean Region: Systematic Review and Meta-analysis.

To determine the association between fetal macrosomia (FM) and postpartum hemorrhage (PPH) in Latin American and Caribbean (LAC) women. 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. 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 extraction was performed independently by two authors, and discrepancies were resolved with a third author. Data regarding FM and PPH cases were retrieved. 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. 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.

Maternal outcomes of a cohort of pregnancies affected by non-immune hydrops fetalis.

To describe the maternal outcomes of a prospective cohort of non-immune hydrops fetalis (NIHF) pregnancies with negative standard-of-care evaluations. This study was a secondary analysis of a prospective cohort study of NIHF pregnancies with negative work-ups (infection, alloimmune anemia, fetomaternal hemorrhage, and chromosomal disorders). Outcomes were obstetric complications, including pre-eclampsia, mirror syndrome, preterm birth, polyhydramnios, postpartum hemorrhage, and maternal mental health. Forty pregnancies were included. Four patients developed pre-eclampsia (4/40, 10.0%); three occurred postpartum. None was diagnosed with mirror syndrome. Of the 31 continued pregnancies, 16 (51.6%) resulted in early fetal death or stillbirth and 15 (48.4%) resulted in live births. Of the 15 live births, 8 (53.3%) were delivered by primary cesarean delivery; 5 (62.5%) were for hydrops fetalis. Eleven live births (73.3%) were delivered preterm; 9 (81.8%) were indicated, most commonly for fetal indications (7/9, 77.8%). Polyhydramnios occurred in 14/40 (35.0%) cases. Where EBL was recorded (n=37), there were 5(13.5%) cases of postpartum hemorrhage and an additional 3(8.1%) had uterine atony without hemorrhage. Eighteen patients (18/40, 45.0%) had new-onset or exacerbated depression or anxiety symptoms. Our study identified several important adverse outcomes of pregnancies complicated by NIHF with negative standard-of-care evaluations, including a high rate of postpartum pre-eclampsia and worsened mental health. We identified a higher rate of cesarean delivery and preterm birth, both primarily for fetal indications. We also observed the known relationship between polyhydramnios, hemorrhage, and atony, but noted that this risk included pregnancies concluding in dilation and evacuation. Counseling after a diagnosis of NIHF should include these adverse outcomes.

Awareness and use of tranexamic acid in the management of postpartum hemorrhage among health care professionals in Enugu, Nigeria.

This study was conducted to determine the knowledge, practice, and barriers regarding the use of tranexamic acid (TXA) for the prevention and treatment of postpartum hemorrhage (PPH) among health care providers in Enugu, Nigeria. A cross-sectional study was conducted among health professionals (doctors, pharmacists, and nurses) in two Nigerian tertiary teaching hospitals (one federal and one state). A total of 220 questionnaires were distributed and 207 were returned (response rate: 94%) and analyzed using SPSS for inferential statistics with a level of significance of P < 0.05. Only 23.7% of the respondents had good knowledge of TXA use in PPH (P < 0.001), and awareness of the recent World Health Organization (WHO) recommendation on the use of TXA for PPH was low (19.8%, P < 0.001). The majority of the respondents had neither prescribed nor dispensed TXA (30%, P < 0.001). Very few respondents used TXA for all cases of PPH (16.4%, P < 0.001). Barriers against its use include nonawareness of the latest WHO recommendation, preference for other uterotonics, and cost of the drug. There was poor knowledge of TXA, poor awareness of its recommendation, and low use for PPH among different cadres of health care providers.

Postpartum Hemorrhage et causa Atonia Uteri and Ruptured Portion with Complications of Shock Hemorrhagic and Anemia: A Case Report from Southwest Sumba, East Nusa Tenggara

Postpartum hemorrhage is one of the most common obstetric emergencies, and it is the most significant contributor to maternal mortality in the world. The most common cause is uterine atony, followed by laceration in the perineum or portion. P4A0 spontaneous postpartum at the primary health care facility (Puskesmas), a baby boy with a birth weight of 3000 grams cries spontaneously. After delivering the baby, the placenta was born 15 minutes later, with active bleeding afterwards of more than 1500 cc without uterine contractions. The patient was then diagnosed with spontaneous postpartum P4A0 with uterine atony, and the management of uterine atony was performed by massaging the fundus with external and internal bimanual compression, accompanied by fluid resuscitation by inserting a 2-line IV line. She was then given vaginal misoprostol, but contractions were still absent. She was then given a uterotonic drip of oxytocin (30 iu/30 dpm), and the contractions are getting better and stronger. Bleeding was evaluated, but still active then exploratorium on the birth canal and the source of the bleeding was found to be a portion of the tear from front to back, towards 5 o'clock. Then stitching was performed on the portion, and 1 hour after suturing, the bleeding was no longer active. The patient was treated at Puskesmas, with a final HB of 7.5 g/dL. To improve diagnosis accuracy and speed in handling emergency obstetric cases. Atonia uteri is caused by many factors, one of which is parturition as experienced by the patient. After active management of stage 3, bleeding continues, so that treatment is given, including the administration of crystalloid fluid, uterotonics, uterine massage, bimanual compression, and catheter condom placement. If the steps that have been taken have not stopped the bleeding, then the next intervention must be immediately taken, namely surgery. In cases of postpartum hemorrhage caused not by uterine atony but by a wound or tear in the portion, prompt actions must be taken to immediately eliminate bleeding by exploring and sewing the torn part and then re-evaluating to ensure that the bleeding stops. Establishing the right diagnosis in emergency cases of postpartum hemorrhage and providing prompt and appropriate treatment can prevent complications ranging from shock to death.

Intrauterine Vacuum-Induced Haemorrhage-Control Device: A Novel Approach For Pph.

Madam, Postpartum haemorrhage (PPH), defined as postpartum blood loss of &gt; 1000 mL, is a life-threatening emergency and the leading cause of maternal mortality accounting for 25% of maternal deaths worldwide (1). PPH can lead to significant morbidity, including shock, ARDS, coagulopathy, infertility due to hysterectomy, and even mortality (4). Uterine atony is the most common cause, accounting for 80% of all cases of PPH (1) (2). Active management of the third stage of labour consisting of a triad of oxytocin, controlled cord traction, and uterine massage can reduce the incidence of PPH by 60% (5). If abnormal uterine bleeding ensues, PPH protocols are activated, including uterine balloon tamponade, uterine packing, uterine artery embolization, or hysterectomy (1, 2). The Jada System (novel intrauterine vacuum-induced haemorrhage-control device) approved by the U.S. FDA in August 2020, utilizes a low-level vacuum to induce negative pressure in the uterine cavity that facilitates uterine contraction to constrict myometrial blood vessels that can help with uterine atony (1). The device is used in patients with PPH where standard PPH treatments have failed or are contraindicated (1). It is a soft medical-grade silicone that attenuates the risk of tissue trauma and can be placed trans-vaginally after 3 cm of cervical dilation after vaginal birth and C-section (1,2). Ultrasound is used to check correct device placement, along with real-time quantification of the expelled blood from the uterine cavity into the graduated canister. The device can be placed for 1.5 hours to 24 hours inside the uterus. The device can be removed after evaluation of evacuated blood and palpation for a firm uterus, both signifying control of the hemorrhage (2). A First-in-Human (FIH) feasibility study conducted in Indonesia on 10 participants with atony-related PPH showed that the device was placed effectively, and bleeding was controlled in under 2 minutes with no unfavorable outcome in any participants (1) (3). The study was conducted with 107 participants of which two-thirds had atony-related PPH with failed medical treatment (1). The Per Protocol showed a 99% success rate in effectively controlling PPH (2). Bleeding halted in a minimum of 3 minutes, the treatment duration was around 3.2 hours and 98% of users regarded it as convenient to use (1). Adverse events included endometritis and vaginal infections all of which were resolved with adequate treatment (2). ---Continue

Knowledge, Attitude and Practices on the Use of Uterine Tamponade in the Management of Severe Postpartum Hemorrhage in Public Health Facilities of Niger State

Background: Obstetric hemorrhage is a contributor to worldwide maternal morbidity and mortality in low-resource countries. The aim of this study was to assess knowledge, attitude and practices on the use of uterine tamponade in managing severe postpartum hemorrhage (PPH) by healthcare personnel.&#x0D; Method: The study was descriptive and cross-sectional. A self-administered, structured questionnaire was used to collect data on uterine tamponade from untrained and trained health workers who take deliveries in labour wards of selected health facilities. Respondents were selected by cluster sampling technique. Data was analyzed using SPSS version 20. Frequencies were determined and chi-square was used to test the hypothesis. A p-value of &lt;0.05 was considered statistically significant.&#x0D; Results: The mean age of the respondents was 35 years ± 11.7. Slightly less than half of the respondents 62 (42.5%) had poor knowledge of uterine tamponade. The majority of respondents 120 (82.2%) had positive attitudes about uterine tamponade. This was associated with point of service, professional group, and previous training on uterine tamponade insertion (p&lt;0.05). About 70% (46; 69.7%) of respondents who had managed cases of refractory postpartum hemorrhage, had never conducted uterine tamponade. Reasons include inadequate knowledge (29; 63.0%) and unavailability of the commodities (9; 19.6%)&#x0D; Conclusion: Though knowledge about uterine tamponade was poor, attitude towards uterine tamponade in managing severe post- partum hemorrhage was good. However, this did not translate to good practices on the use of uterine tamponade in managing severe PPH. Training and re-training on the application of uterine tamponade should be conducted and commodities made available in every health facility.

Women with severe postpartum hemorrhage have a decreased endogenous thrombin potential before delivery

BackgroundSevere postpartum hemorrhage (PPH), defined as a blood loss ≥1000 mL, is associated with maternal morbidity and mortality. ObjectivesWe aimed at characterizing coagulation properties of predelivery plasmas from pregnant women with thrombin generation assay and hemostatic biomarkers (plasminogen activator inhibitor-1, tissue factor [TF], and thrombomodulin). MethodsA nested case-control study was conducted within the “Study of Biological Determinants of Bleeding Postpartum,” a French prospective cohort study, in order to compare women with severe PPH (cases) and controls matched for age, body mass index, term, and mode of delivery. Plasma was collected at entry in the delivery room, and blood loss was measured objectively. The predelivery endogenous thrombin generation potential (ETP) was measured in plasma using calibrated automated thrombinography and low TF concentration. Hemostatic biomarkers were measured using ELISA kits. ResultsA total of 142 women (71 cases and 71 controls) were investigated. There was no difference in the median lag phase, thrombin peak, and time to peak between cases and controls. However, median predelivery ETP was lower in cases than in controls (2170 vs 2408 nM.min, P < .0001), independently of mode of delivery and PPH etiology. Median plasminogen activator inhibitor-1 and TF levels were higher in cases compared with controls (107.4 vs 68.1 ng/mL, P = .0003; 34.4 vs 27.4 pg/mL, P = .007), whereas thrombomodulin levels did not differ between the 2 groups. ConclusionAmong thrombin generation assay parameters, predelivery ETP levels may have a predictive value for severe PPH.

Incidence of postpartum hemorrhage based on the improved combined method in evaluating blood loss: A retrospective cohort study.

In view of the current clinical inaccuracies and underestimations of postpartum hemorrhage amount, this study aims to investigate the incidence, etiology, clinical characteristics of postpartum hemorrhage in different modes of delivery based on the combination of volumetric method, gravimetric method and area method in evaluating blood loss. This retrospective cohort study was conducted in Hangzhou Women's Hospital from January 2020 to June 2021, including 725 cases of postpartum hemorrhage among 18,977 parturients. Based on different modes of delivery, the participants were divided into three groups: vaginal delivery, forceps delivery, and cesarean section, for comparison. Using an improved combined assessment method for blood loss, we retrospectively analyzed a cohort of parturients with postpartum hemorrhage who underwent vaginal delivery, forceps delivery, or cesarean section and were hospitalized in Hangzhou Women's Hospital from January 2020 to June 2021. (1) Among the 18,977 parturients, 725 cases of postpartum hemorrhage occurred, with an incidence rate of 3.8%, and severe postpartum hemorrhage accounted for 0.4% of the cases. (2) The incidence of postpartum hemorrhage was significantly higher in the forceps delivery group than in the vaginal delivery group (χ2 = 19.27, P<0.001), while the incidence of severe postpartum hemorrhage was significantly higher in the cesarean section group than in the vaginal delivery group (χ2 = 8.71, P = 0.003). (3) The causes of postpartum hemorrhage were statistically different among the different delivery modes, with varying underlying factors (P<0.001). (4) Patients with postpartum hemorrhage in different delivery modes showed statistically significant differences in age, body mass index (BMI), birth weight, gestational age, gravidity, parity, the decline of postpartum peripheral blood hemoglobin concentration, and estimated blood loss (P<0.05). (5) The proportion of blood transfusion was significantly higher in the cesarean section group than in the vaginal delivery and forceps delivery groups (χ2 = 231.03, P<0.001). This study is a single-center retrospective study, which may have led to selection bias in case selection. Additionally, the implementation of the combined three blood loss assessment methods may not have been strictly followed in all cases. Moreover, due to the mixing of bleeding with amniotic and irrigation fluids, the accuracy of evaluation may have been affected, leading to the possibility of inaccuracy of blood loss. Forceps delivery and cesarean section increase the risk of postpartum hemorrhage, but forceps delivery does not significantly increase the incidence of severe postpartum hemorrhage. Uterine atony remains the leading cause of postpartum hemorrhage, while birth canal laceration and placental factors are the second most common causes of postpartum hemorrhage in forceps delivery and cesarean section, respectively. In this study, the volumetric method, gravimetric method and area method were combined to quantitatively assess postpartum hemorrhage amount. The combined method has strong clinical practicability and is less affected by subjective factors, although it also has limitations. In the future, we still need to focus on the early prediction and identification of postpartum hemorrhage, and further improve the quantitative assessment of postpartum blood loss.