Diagnosis Of Postpartum Hemorrhage Research Articles

Tranexamic acid for postpartum bleeding: a systematic review and individual patient data meta-analysis of randomised controlled trials

Tranexamic acid is a recommended treatment for women with a clinical diagnosis of postpartum haemorrhage, but whether it can prevent bleeding is unclear. We conducted a systematic review and individual patient data (IPD) meta-analysis of randomised controlled trials to assess the effects of tranexamic acid in women giving birth. In this systematic review and IPD meta-analysis, we searched the WHO International Clinical Trials Registry Platform from database inception to Aug 4, 2024 for randomised trials that assessed the effects of tranexamic acid in women giving birth. Trials were eligible if they were prospectively registered, placebo-controlled, included more than 500 women, and had a low risk of bias for random sequence generation and allocation concealment. IPD were requested from the trial investigators. The primary outcomes were the numbers of women with life-threatening bleeding and thromboembolic events. We used a one-stage model to analyse the data and explored whether the effect of tranexamic acid varied by the underlying risk of life-threatening bleeding, type of birth, presence of moderate or severe anaemia, or timing of administration (before or after a diagnosis of postpartum haemorrhage). This study is registered with PROSPERO, CRD42022345775. We analysed data on 54 404 women from five trials. We obtained IPD for 43 409 women from four trials and aggregate data on 10 995 women from one trial. All trials had a low risk of bias. Life-threatening bleeding occurred in 178 (0·65%) of 27 300 women in the tranexamic acid group versus 230 (0·85%) of 27 093 women in the placebo group (pooled odds ratio [OR] 0·77 [95% CI 0·63-0·93]; p=0·008). There was no evidence that the effect of tranexamic acid varied by the underlying risk of life-threatening bleeding, type of birth, presence of moderate or severe anaemia or timing of administration. No significant difference was identified between tranexamic acid and placebo groups with regard to thromboembolic events: 50 (0·2%) of 26 571 women in the tranexamic acid group had fatal or non-fatal thromboembolic events versus 52 (0·2%) of 26 373 women in the placebo group (pooled OR 0·96 [0·65-1·41]; p=0·82) with no significant heterogeneity identified in the subgroup analyses. Tranexamic acid reduces the risk of life-threatening postpartum bleeding. We found no evidence that tranexamic acid increases the risk of thrombosis. Although we do not recommend the use of tranexamic acid in all women giving birth, consideration should be given to its use before a diagnosis of postpartum haemorrhage in women at high risk of death. The Bill & Melinda Gates Foundation.

Postpartum Hemorrhage in Humanitarian Settings: Implementation Insights from Using Heat-Stable Carbetocin and Tranexamic Acid

Background and Objective Maternal mortality, largely due to postpartum hemorrhage (PPH), remains high in resource-limited and crisis-affected settings, where heat-stable carbetocin (HSC) and tranexamic acid (TXA) offer promise for PPH prevention and treatment but lack evidence. This study, implemented in basic maternity facilities within humanitarian settings, explores healthcare providers’ perspectives on an HSC and TXA-inclusive PPH intervention package and related operational challenges and facilitators. Methods Based on semi-structured interview guides and using thematic analysis, this qualitative research, through 13 focus group discussions and individual interviews, investigated the perspectives of 64 healthcare staff (mostly midwives) from eight basic emergency obstetric care facilities in South Sudanese and Ugandan settings hosting large numbers of forcibly displaced populations. The PPH intervention package comprised refresher training, an online provider community, PPH readiness kits, alarm bells, and displayed algorithms. Results Findings from both countries converged, highlighting providers’ positive views on HSC and TXA. HSC effectiveness in preventing bleeding was acknowledged, bolstering staff’s confidence in its use. TXA was perceived as effective although providers reported having less experience with it due to the limited number of PPH cases. Enabling factors included the ease of administration, practical training, endorsement by national and local authorities, and the absence of a cold chain requirement. Appreciation was given to the WhatsApp community of practice as it facilitated knowledge exchange, quality improvement projects that enhanced PPH diagnosis, and innovative tools like wall clocks to record the timing of clinical actions and bells to call for assistance. Challenges included confusion between new and existing medications and record systems that inadequately capture HSC, TXA, and other PPH indicators. Conclusion and Global Health Implications HSC and TXA integrated into a PPH intervention package were overall positively valued by providers in humanitarian settings. Continued education and support are crucial. Addressing challenges like medication confusion underscores the need for ongoing education and clear guidelines for the use of HSC, TXA, oxytocin, and other drugs for PPH prevention and treatment. Our findings stress the importance of a comprehensive strategy to overcome health system barriers in PPH management, potentially improving maternal health outcomes in resource-limited and fragile contexts, with broader global implications.

The cost-effectiveness of preventing, diagnosing, and treating postpartum haemorrhage: A systematic review of economic evaluations.

Postpartum haemorrhage (PPH) is an obstetric emergency. While PPH-related deaths are relatively rare in high-resource settings, PPH continues to be the leading cause of maternal mortality in limited-resource settings. We undertook a systematic review to identify, assess, and synthesise cost-effectiveness evidence on postpartum interventions to prevent, diagnose, or treat PPH. This systematic review was prospectively registered on PROSPERO (CRD42023438424). We searched Medline, Embase, NHS Economic Evaluation Database (NHS EED), EconLit, CINAHL, Emcare, Web of Science, and Global Index Medicus between 22 June 2023 and 11 July 2024 with no date or language limitations. Full economic evaluations of any postpartum intervention for prevention, detection, or management of PPH were eligible. Study screening, data extraction, and quality assessments (using the CHEC-E tool) were undertaken independently by at least 2 reviewers. We developed narrative syntheses of available evidence for each intervention. From 3,993 citations, 56 studies were included: 33 studies of preventative interventions, 1 study assessed a diagnostic method, 17 studies of treatment interventions, 1 study comparing prevention and treatment, and 4 studies assessed care bundles. Twenty-four studies were conducted in high-income countries, 22 in upper or lower middle-income countries, 3 in low-income countries, and 7 studies involved countries of multiple income levels. Study settings, methods, and findings varied considerably. Interventions with the most consistent findings were the use of tranexamic acid for PPH treatment and using care bundles. In both cases, multiple studies predicted these interventions would either result in better health outcomes and cost savings, or better health outcomes at acceptable costs. Limitations for this review include that no ideal setting was chosen, and therefore, a transferability assessment was not undertaken. In addition, some sources of study uncertainty, such as effectiveness parameters, were interrogated to a greater degree than other sources of uncertainty. In this systematic review, we extracted, critically appraised, and summarised the cost-effectiveness evidence from 56 studies across 16 different interventions for the prevention, diagnosis, and treatment of PPH. Both the use of tranexamic acid as part of PPH treatment, and the use of comprehensive PPH bundles for prevention, diagnosis, and treatment have supportive cost-effectiveness evidence across a range of settings. More studies utilizing best practice principles are required to make stronger conclusions on which interventions provide the best value. Several high-priority interventions recommended by World Health Organization (WHO) such as administering additional uterotonics, non-pneumatic anti-shock garment, or uterine balloon tamponade (UBT) for PPH management require robust economic evaluations across high-, middle-, and low-resource settings.

Modern methods for assessing blood loss in childbirth and diagnosing postpartum hemorrhage: A review

Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality in Russia and worldwide. Accurate calculation of circulating blood volume (CBV) and personalized estimation of the extent of blood loss (EBL) play vital roles in the early diagnosis of PPH. Visual assessment of BL in childbirth is an available diagnostic method, but it has a high error rate compared to the gravimetric method. A dynamic assessment of the shock index (SI) as an indicator that reflects hemodynamic disorders early enough can be used as an additional diagnostic method for PPH and a test that allows predicting the need for transfusion of blood products. Aim. To review current literature on the assessment of BL in childbirth and the diagnosis of PPH. Materials and methods. The search for publications by Russian and foreign authors was carried out in the information electronic databases PubMed, PubMed Central, Scopus, MEDLINE, ScienceDirect, Cochrane Library, and eLibrary from 2016 to January 2024 using the keywords "obstetric blood loss," "PPH," and "SI." Results. When assessing the CBV, its correlation with the body mass index was revealed. Subjective methods for the PPH assessment have a large margin of error, which does not depend on the experience and seniority of the healthcare provider. The gravimetric method is more accurate, but it can underestimate the clinical situation when physiological blood loss is exceeded. Dynamic assessment of SI is an early marker of hemodynamic disorders and makes it possible to identify patients with a high risk of adverse outcomes more reliably than other parameters. Conclusion. In order to provide timely and adequate emergency medical care for excessive obstetric blood loss, a personalized approach should be used to calculate the EBL, taking into account the woman's body mass index, as well as a systematic assessment of the BL, including at least the extent of blood loss and monitoring of the SI.

A cost-effectiveness analysis of early detection and bundled treatment of postpartum hemorrhage alongside the E-MOTIVE trial

Timely detection and treatment of postpartum hemorrhage (PPH) are crucial to prevent complications or death. A calibrated blood-collection drape can help provide objective, accurate and early diagnosis of PPH, and a treatment bundle can address delays or inconsistencies in the use of effective interventions. Here we conducted an economic evaluation alongside the E-MOTIVE trial, an international, parallel cluster-randomized trial with a baseline control phase involving 210,132 women undergoing vaginal delivery across 78 secondary-level hospitals in Kenya, Nigeria, South Africa and Tanzania. We aimed to assess the cost-effectiveness of the E-MOTIVE intervention, which included a calibrated blood-collection drape for early detection of PPH and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination and escalation), compared with usual care. We used multilevel modeling to estimate incremental cost-effectiveness ratios from the perspective of the public healthcare system for outcomes of cost per severe PPH (blood loss ≥1,000 ml) avoided and cost per disability-adjusted life-year averted. Our findings suggest that the use of a calibrated blood-collection drape for early detection of PPH and bundled first-response treatment is cost-effective and should be perceived by decision-makers as a worthwhile use of healthcare budgets. ClinicalTrials.gov identifier: NCT04341662.

Roles and challenges encountered by midwives in the management of postpartum haemorrhage following normal vaginal delivery: A scoping review

AbstractAimsTo establish a comprehensive understanding of the roles of midwives and the challenges they encounter in the prevention, diagnosis and management of postpartum haemorrhage (PPH) following normal vaginal delivery.DesignWe conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis for Scoping Reviews (PRISMA‐ScR) recommendations.MethodsWe considered studies related to the roles of midwives and the challenges they encounter in the prevention, diagnosis and management of PPH during vaginal delivery. We excluded guidelines, consensuses, abstracts of meetings and non‐English language studies. Databases, including the Cochrane Library, PubMed, Web of Science, Ovid, Medline, Embase, JBI EBP and BIOSIS Previews, were searched on January 1, 2023, with no time limitations.ResultsWe included 28 publications. Midwives play important roles in the prevention, diagnosis and management of postpartum haemorrhage during vaginal delivery. In the prevention of PPH, midwives' roles include identifying and managing high‐risk factors, managing labour and implementing skin‐to‐skin contact. In the diagnosis of PPH, midwives' roles include early recognition and blood loss estimation. In the management of PPH, midwives are involved in mobilizing other professional team members, emergency management, investigating causes, enhancing uterine contractions, the repair of perineal tears, arranging transfers and preparation for surgical intervention. However, midwives face substantial challenges, including insufficient knowledge and skills, poor teamwork skills, insufficient resources and the need to deal with their negative emotions. Midwives must improve their knowledge, skills and teamwork abilities. Health care system managers and the government should give full support to midwives. Future research should focus on developing clinical practice guidelines for midwives for preventing, diagnosing and managing postpartum haemorrhage.

Comparing visual estimation and hematocrit change in the assessment of blood loss among women undergoing cesarean delivery in a tertiary facility in northern Uganda.

Cesarean section poses a fourfold risk for postpartum hemorrhage (PPH), necessitating accurate blood loss estimation to enable timely interventions. However, the conventional visual estimation method often leads to underestimation, resulting in undiagnosed PPH even in our setting, Uganda. Yet, the quantitative standard techniques remain underutilized. We compared visual and calculated blood loss among women undergoing cesarean delivery at Gulu Regional Referral Hospital in northern Uganda. We employed a cross-sectional study design. We enrolled pregnant women scheduled for cesarean section and determined both calculated and visually estimated blood loss. Data analysis involved using Pearson's moment correlation coefficient to compare the two methods and logistic regression to determine the factors associated with PPH. We included 105 participants, most were primigravida (n = 100, 43%), aged 15-24 years (n = 100, 52%), with term gestation (n = 100, 75%). The mean visual estimated blood loss (vEBL) was 235.3 ± 123.7 ml (interquartile range (IQR) 50-600 ml), while the calculated estimated blood loss (cEBL) was 435.0 ± 1328.2 ml (IQR -11,182.1-2226.7 ml). Visual estimation underestimated blood loss in 90% of cases (n = 100), and 21% (n = 21) had undiagnosed PPH (>1000 ml blood loss). None of the respondents had PPH (>1000 ml blood loss) following vEBL. There was a small positive correlation between both methods (vEBL and cEBL; r = 0.1165; p = 0.2482). Women aged >35 years were 1.60 times more likely to experience PPH than their counterparts aged 25-34 years (adjusted odds ratio (AOR): 1.60; 95% CI: 1.11-2.30, p < 0.011). Chorioamnionitis increased the risk of PPH by 2.2 times (AOR: 2.20; 95% CI: 1.20-4.05, p < 0.012). The visual estimation technique significantly underestimated blood loss in up to 90% of cases, particularly during emergency cesarean sections. Among the 21% of cases diagnosed with PPH based on calculated blood loss, advanced maternal age and chorioamnionitis were notable contributing factors. Routine hemoglobin and hematocrit testing in obstetric care can be effectively utilized to objectively assess blood loss, aiding in the accurate diagnosis and management of PPH. Implementing these measures, even in resource-constrained settings, can significantly reduce the morbidity and mortality associated with PPH. Not applicable.

Postpartum Hemorrhage

Postpartum hemorrhage (PPH) affects about 4% of all deliveries in high-income countries and continues to rise, a trend attributable to the increase in caesarean section rates and maternal morbidity. Preventive measures such as the precautionary administration of uterotonics effectively reduce the risk of severe bleeding irrespective of birth mode. As a time-critical condition and a significant contributor to adverse maternal outcomes, PPH needs to be diagnosed early by measuring, not estimating, blood losses. Institutional treatment algorithms should be available to guide stage-based interdisciplinary management without delay. The main therapy goals are to identify the etiology and stop the bleeding by using uterotonics and mechanical and surgical interventions, to restore hemodynamic stability by volume and transfusion therapy and to optimize hemostasis by laboratory- and viscoelastic assay-guided factor replacement. This review highlights current recommendations for prevention, diagnosis and treatment of PPH.

Évolution du Shock Index obstétrical lors d’une hémorragie du post-partum selon le recours à la sulprostone

ObjectivesThe Shock Index (SI) is used in emergency medicine to assess the severity of active bleeding and in the postpartum context for postpartum haemorrhage (PPH). We investigated the diagnostic value of haemodynamic parameters (SI, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP)) in predicting subsequent use of uterotonic sulprostone treatment. MethodsThis was a retrospective study including parturients with PPH ≥ 500mL between January 2017 and December 2018. Hemodynamic parameters at the diagnosis of PPH were compared according to whether the patient required subsequent sulprostone treatment (sulprostone(+) group) or not (sulprostone(–) group). ResultsWe included in the analysis 147 patients. The SI was significantly higher in the sulprostone(+) group (0.92±0.28 vs. 0.83±0.22; p=0.04). The SBP (107.2±17.5 vs. 113.8±17.7mmHg; p=0.03), DBP (56.8±12,2 vs. 61.5±13,2mmHg; p=0.04), MAP (73.6±12.6 vs. 78.5±13.4mmHg; p=0.03) were significantly lower in the same group. No difference between AUC of these parameters to predict the use of sulprostone was found (AUC between 0.59 and 0.61). No significant difference was found for the HR between the two groups. ConclusionThe diagnostic value of SI appeared to be low and similar to other haemodynamic parameters in predicting the use of sulprostone.

Tranexamic acid for the prevention of postpartum bleeding in women with anaemia: Statistical analysis plan for the WOMAN-2 trial: an international, randomised, placebo-controlled trial.

Background: Postpartum haemorrhage (PPH) is responsible for over 50,000 maternal deaths every year. Most of these deaths are in low- and middle-income countries. Tranexamic acid (TXA) reduces bleeding by inhibiting the enzymatic breakdown of fibrin blood clots. TXA decreases surgical bleeding and reduces deaths from bleeding after traumatic injury. When given within three hours of birth, TXA reduces deaths from bleeding in women with PPH. However, for many women, treatment of PPH is too late to prevent death. World-wide, over one-third of pregnant women are anaemic and many are severely anaemic. These women have an increased risk of PPH and are more likely to die if PPH occurs. There is an urgent need to identify ways to prevent severe postpartum bleeding in anaemic women. The WOMAN-2 trial will quantify the effects of TXA on postpartum bleeding in women with anaemia. Results: This statistical analysis plan (version 1.0; dated 22 February 2023) has been written based on information in the WOMAN-2 Trial protocol version 2.0, dated 30 June 2022. The primary outcome of the WOMAN-2 trial is the proportion of women with a clinical diagnosis of primary PPH. Secondary outcomes are maternal blood loss and its consequences (estimated blood loss, haemoglobin, haemodynamic instability, blood transfusion, signs of shock, use of interventions to control bleeding); maternal health and wellbeing (fatigue, headache, dizziness, palpitations, breathlessness, exercise tolerance, ability to care for her baby, health related quality of life, breastfeeding); and other health outcomes (deaths, vascular occlusive events, organ dysfunction, sepsis, side effects, time spent in higher level facility, length of hospital stay, and status of the baby). Conclusions: WOMAN-2 will provide reliable evidence about the effects of TXA in women with anaemia. Registration: WOMAN-2 was prospectively registered at the International Standard Randomised Controlled Trials registry ( ISRCTN62396133) on 07/12/2017 and ClinicalTrials.gov on 23/03/2018 ( NCT03475342).

Tranexamic acid for the prevention of postpartum bleeding in women with anaemia: Statistical analysis plan for the WOMAN-2 trial: an international, randomised, placebo-controlled trial

Background: Postpartum haemorrhage (PPH) is responsible for over 50,000 maternal deaths every year. Most of these deaths are in low- and middle-income countries. Tranexamic acid (TXA) reduces bleeding by inhibiting the enzymatic breakdown of fibrin blood clots. TXA decreases surgical bleeding and reduces deaths from bleeding after traumatic injury. When given within three hours of birth, TXA reduces deaths from bleeding in women with PPH. However, for many women, treatment of PPH is too late to prevent death. World-wide, over one-third of pregnant women are anaemic and many are severely anaemic. These women have an increased risk of PPH and are more likely to die if PPH occurs. There is an urgent need to identify ways to prevent severe postpartum bleeding in anaemic women. The WOMAN-2 trial will quantify the effects of TXA on postpartum bleeding in women with anaemia. Results: This statistical analysis plan (version 1.0; dated 22 February 2023) has been written based on information in the WOMAN-2 Trial protocol version 2.0, dated 30 June 2022. The primary outcome of the WOMAN-2 trial is the proportion of women with a clinical diagnosis of primary PPH. Secondary outcomes are maternal blood loss and its consequences (estimated blood loss, haemoglobin, haemodynamic instability, blood transfusion, signs of shock, use of interventions to control bleeding); maternal health and wellbeing (fatigue, headache, dizziness, palpitations, breathlessness, exercise tolerance, ability to care for her baby, health related quality of life, breastfeeding); and other health outcomes (deaths, vascular occlusive events, organ dysfunction, sepsis, side effects, time spent in higher level facility, length of hospital stay, and status of the baby). Conclusions: WOMAN-2 will provide reliable evidence about the effects of TXA in women with anaemia. Registration: WOMAN-2 was prospectively registered at the International Standard Randomised Controlled Trials registry (ISRCTN62396133) on 07/12/2017 and ClinicalTrials.gov on 23/03/2018 (NCT03475342).

Change in Hemoglobin Was Not a Reliable Diagnostic Screening Test for Postpartum Hemorrhage: A French Prospective Multicenter Cohort Study (HERA Study).

Changes between pre- and postpartum hemoglobin might be useful for optimizing the postpartum diagnosis of postpartum hemorrhage (PPH), defined as a blood loss exceeding 500 mL. This study's principal objective was to estimate the mean change in hemoglobin (between pre/post-delivery hemoglobin) among women with vaginal deliveries and PPH. The secondary objectives were to analyze: hemoglobin changes according to blood volume loss, the appropriateness of standard thresholds for assessing hemoglobin loss, and the intrinsic and extrinsic performances of these threshold values for identifying PPH. French maternity units (n = 182) participated in the prospective HERA cohort study. Women with a vaginal delivery at or after a gestation of 22 weeks with a PPH (n = 2964) were eligible. The principal outcome was hemoglobin loss in g/L. The mean hemoglobin change was 30 ± 14 g/L among women with a PPH. Overall, hemoglobin decreased by at least 10% in 90.4% of women with PPH. Decreases ≥ 20 g/L and ≥40 g/L were found, respectively, in 73.9% and 23.7% of cases. Sensitivity and specificity values for identifying PPH were always <65%, the positive predictive values were between 35% and 94%, and the negative predictive values were between 14% and 84%. Hemoglobin decrease from before to after delivery should not be used as a PPH diagnostic screening test for PPH diagnosis for all vaginal deliveries.

Postoperative Care in the Caesarean Intensive Care Unit: Experience from a Tertiary Maternity Hospital

We aimed to determine whether follow-up in the intensive care unit for the postoperative first 8 hours is beneficial for early intervention in postpartum hemorrhage. In our hospital, all patients are admitted to the intensive care unit for the first 8 hours after cesarean section. Patients with postpartum hemorrhage after cesarean delivery who received medical and/or surgical treatment between 2016 and 2020 were reviewed in the presented study retrospectively. 36,396 cases who underwent cesarean delivery were reviewed. Three hundred fifty nine patients with postpartum hemorrhage were included in the study. The time between cesarean section and diagnosis of postpartum hemorrhage was 10.1 ± 19.1 hours, and the time between cesarean section and re- laparotomy was 9.26 ± 23.1 hours in the study group. A total of 3 maternal deaths occurred after cesarean section in our hospital. In the last five years, the mortality rate in patients delivered by cesarean section was calculated to be 3.9 per 100,000. The incidence of postpartum hemorrhage in cesarean deliveries at our hospital was calculated to be 1.0%, and the rate of obstetric near-miss events was calculated to be 0.6 per 1000 live births. Follow-up of patients in the intensive care unit in the first postoperative 8 hours after cesarean section may result in a lower number of re-laparotomies due to postpartum hemorrhage, a shortened interval between cesarean section and re-laparotomy, and a lower maternal mortality rate.

The role of ultrasound in the diagnosis and management of postpartum hemorrhage

Postpartum hemorrhage (PPH) is the leading cause of death or severe morbidity for the mother after delivery. As a consequence healthcare staff working in the delivery room should be trained to perform a prompt diagnosis and adequate management of PPH. Uneventful outcome is induced correct identification of the underlying cause of hemorrhage. Ultrasound is a promising technique for the prompt diagnosis of PPH etiology. Indeed, it is easily available, with relatively low cost, not using ionizing radiation, and can be used in different settings including the labor room, the operating theater and at the bedside of an affected women. In order to be effective Obstetricians should have an adequate knowledge of postpartum ultrasonography. In this article, we will review the sonographic findings occurring in PPH, in the differential diagnosis of the underlying cause of hemorrhage, that include retained placenta, morbidly adherent placenta, rupture of the uterus uterine, vascular anomalies of the uterine arteries and uterine inversion. We will also provide an algorithm to manage PPH according to the ultrasonographic findings.

The infection, cervical and perineal lacerations in relation to postpartum hemorrhage following vaginal delivery induced by Cook balloon catheter.

To identify whether infection, cervical laceration and perineal laceration are associated with postpartum hemorrhage in the setting of vaginal delivery induced by Cook balloon catheter. The retrospective study included 362 women who gave birth vaginally at or beyond 37weeks of gestation with a diagnosis of postpartum hemorrhage between February 2021 to May 2022, of which including 216 women with induction of labor (Cook balloon catheter followed by oxytocin or oxytocin) and 146 women with spontaneous delivery. Risk factors for postpartum hemorrhage were collected and compared. 362 women were divided into three groups, group 1 with spontaneous delivery, group 2 with oxytocin, group 3 with Cook balloon catheter followed by oxytocin. There was no significant difference in incidence of infection within three groups (P > 0.05). The rate of cervical laceration and perineal laceration was significantly higher in group 3 compared with groups 2 and 1 (P < 0.05); Multivariate logistic regression analysis found that compared with group 1, either group 3 or group 2 was associated with increased risks of cervical laceration and perineal laceration (P < 0.05), and compared with group 2, group 3 was not associated with increased risks of cervical laceration and perineal laceration (P > 0.05). Infection, cervical laceration and perineal laceration are identified not to be independent risk factors for postpartum hemorrhage for women undergoing labor with Cook balloon catheter; Cervical laceration and perineal laceration increase the risk of postpartum hemorrhage in women with labor induction.

Success Rate and Long-Term Effects of Embolization of Pelvic Arteries for the Treatment of Postpartum Hemorrhage

Introduction: Postpartum hemorrhage (PPH) is the leading cause of peripartal maternal mortality and accounts for 25% of all maternal deaths worldwide. The most common reasons of PPH are uterine atony, retained placenta, or placenta accreta spectrum. Treatment of PPH depends on the etiology and corresponds to a stepwise approach, which follows the German, Austrian and Swiss guideline for the diagnosis and therapy of PPH in Switzerland. In severe ongoing PPH, hysterectomy has been the ultima ratio for many decades. Nowadays, interventional embolization of the pelvic arteries (PAE) has become a popular alternative. Besides being a highly effective minimally invasive method, PAE avoids hysterectomy with consecutively reduced morbidity and mortality. However, data on the long-term effects of PAE on fertility and menstrual cycle are scarce. Methods: We performed a monocentric study consisting of a retro- and a prospective part including all women who had undergone a PAE between 2012 and 2016 at University Hospital Zurich. Descriptive characteristics of patients and efficacy of PAE defined as cessation of bleeding were analyzed retrospectively. In the prospective part, all patients were contacted for a follow-up questionnaire regarding menstruation and fertility after embolization. Results: Twenty patients with PAE were evaluated. Our data showed a success rate of PAE in 95% of patients with PPH; only 1 patient needed a second, then successful, PAE. No patient needed a hysterectomy or any other surgical intervention. In our study, an association between mode of delivery and identified etiology of PPH is observed. After spontaneous delivery (n = 6), the main reason of severe PPH was retained placenta (n = 4), while after cesarean section (n = 14), uterine atony was identified in most cases (n = 8). Regarding menstruation after embolization, all women reported regular menstruation after the breastfeeding period (100%). The majority reported a regular pattern with a shorter or similar duration (73%) and lower or similar intensity (64%). Dysmenorrhea decreased in 67% of patients. Four patients planned another pregnancy, of whom only one had become pregnant with assisted reproductive technology and ended up in a miscarriage. Discussion: Our study confirms the efficacy of PAE in PPH, thus obviating complex surgical interventions and associated morbidity. The success of PAE does not depend on the primary cause of PPH. Our results may encourage the prompt decision to perform PAE in the management of severe PPH in case of failure of conservative management and help physicians in the post-interventional counseling regarding menstruation patterns and fertility.

Beyond uterine atony: characterizing postpartum hemorrhage coagulopathy

Postpartum hemorrhage is a leading cause of morbidity and mortality worldwide, yet the associated early coagulopathy is not well defined. We hypothesized that women who develop postpartum hemorrhage have a distinct derangement of thrombin generation and coagulation factors compared with postpartum women without postpartum hemorrhage. This prospective study of pregnant patients with postpartum hemorrhage was completed at a single urban hospital. Blood was drawn on postpartum hemorrhage diagnosis and 2 and 4 hours later. Assays of patients with postpartum hemorrhage included thrombelastography, whole blood thrombin generation, coagulation factor activity, tissue factor levels and activity, and tissue factor pathway inhibitor levels, which were compared with that of patients without postpartum hemorrhage. A total of 81 patients were included in this study. Of those patients, 66 had postpartum hemorrhage, and 15 served as controls. Compared with patients without PPH, patients with postpartum hemorrhage had lower fibrinogen levels (469.0 mg/dL vs 411.0 mg/dL; P=.02), increased tissue plasminogen activator resistance (fibrinolysis 30 minutes after maximal clot strength: 8.7% vs 4.2%; P=.02), decreased peak thrombin concentration (150.2 nM vs 40.7 nM; P=.01), and decreased maximal rate of thrombin generation (60.1 nM/minute vs 2.8 nM/minute; P=.02). Furthermore, compared with patients without postpartum hemorrhage, patients with postpartum hemorrhage had decreased tissue factor levels (444.3 pg/mL vs 267.1 pg/mL; P=.02) and increased tissue factor pathway inhibitor levels (0.6 U/mL vs 0.8 U/mL; P=.04), with decreased tissue factor pathway inhibitor ratios (624 vs 299; P=.01). PPH is not only an issue of uterine tone and mechanical bleeding but also a distinct coagulopathy that is characterized by decreased fibrinogen level, clot breakdown resistance, and markedly low thrombin generation. This pathology seemed to be driven by low tissue factor and high tissue factor pathway inhibitor levels.

ENSEMBLE LEARNING BASED POSTPARTUM HEMORRHAGE DIAGNOSIS FOR 5G REMOTE HEALTH CARE

The fifth-generation (5G) communications enables various promising applications that were once impossible, e.g. remote healthcare with the help of fast and reliably delivery of medical data. Post-partum hemorrhage (PPH) refers to the massive blood loss after the birthing stage (within 24 hours), i.e.&gt;500ml for the vaginal delivery, and &gt;1000ml for the cesarean section. PPH is by far the most common cause of the mortality rate of pregnant women, as well as a primary cause of current pregnant mortality in China. Despite the great potential of prediction of PPH, there is currently no effective tool based on the limited raw data from the clinical trials. In the study, we retrospectively study the 3842 vaginal delivery cases in 2017 collected from Beijing Obstetrics and Gynecology Hospital, Capital Medical University. In particular, we obtain the prediction based diagnostic model relying on machine learning, and we adopt the ensemble learning to accomplish this task, by combining the results of various candidate methods. According to the experimental results, the accuracy of correct PPH diagnosis would approach 96.7%; the total disseminated intravascular coagulation (DIC) prediction accuracy approaches 90.3%. In this regard, we may conclude the proposed model based on machine learning would allow us to predict successfully the risk of PPH, and assess the critical level of PPH patient. We anticipate our study results would contribute to the reduction the mortality of pregnant women. According to the 2013 World Health Statistics, the maternal mortality rate in low-income countries were 410/100,000 live births. The majority of maternal deaths occurred mainly in Asian and African countries. Major causes of maternal deaths are similar across low-income countries, often obstetric in origin including hemorrhage, hypertensive diseases and maternal infections. 94% of births in Ethiopia are estimated to occur at home and 10% of maternal deaths are attributed to PPH. Uterine atony, or lack of effective contraction of the uterus, is the most common cause of PPH followed by infection, sub involution of the placental site, and inherited coagulation deficits. The majority of these fatal obstetric complications occur during labor and immediately after birth. In the low-income countries, more than three-quarters of maternal deaths due to the direct obstetric causes occur during and after birth. Organized diagnosis and management of PPH, including administration of uterotonic agents, controlled cord traction, and uterine massage after delivery of the placenta, are required to avoid maternal death.

Major obstetric hemorrhage management

Postpartum hemorrhage (PPH) is to this day one of the leading causes of maternal death and its diagnosis is still highly subjective, as it relies on unprecise estimates of the amount of blood loss. There are three areas in which PPH outcomes can be improved: prevention, treatment and rescue. PPH can escalate to a graver clinical picture of Severe Acute Maternal Morbidity (SAMM) due to an inaccurate estimate of the blood loss, inability to identify an at-risk patient, delays in testing and availability of hemoderivatives, and lack of clear guidelines and interdisciplinary communication. Many factors can predispose to PPH and in clinical practice the many causes of its insurgence are summarized with the 4T formula: Tone (uterine atony), Trauma (laceration/hematoma), Tissue (retained tissue/invasive placenta), Thrombin (coagulation). Some precautions can be taken in preventing PPH such as the use of uterotonics, the administration of oxytocin, the timing of umbilical cord clamping, and the monitoring of anemia and the platelet to fibrinogen concentration ratio. In recent years studies have been published with the goal of leading PPH diagnosis and management through universal guidelines, point-of-care testing and interdisciplinary approaches. The proposed algorithms, albeit not yet validated, are useful in the clinical practice; similarly beneficial is the use of reliable predictive panels such as the Modified Early Obstetric Warning System.

A novel oppositional binary crow search algorithm with optimal machine learning based postpartum hemorrhage prediction model

Postpartum hemorrhage (PPH) is an obstetric emergency instigated by excessive blood loss which occurs frequently after the delivery. The PPH can result in volume depletion, hypovolemic shock, and anemia. This is particular condition is considered a major cause of maternal deaths around the globe. Presently, physicians utilize visual examination for calculating blood and fluid loss during delivery. Since the classical methods depend on expert knowledge and are inaccurate, automated machine learning based PPH diagnosis models are essential. In regard to this aspect, this study introduces an efficient oppositional binary crow search algorithm (OBCSA) with an optimal stacked auto encoder (OSAE) model, called OBCSA-OSAE for PPH prediction. The goal of the proposed OBCSA-OSAE technique is to detect and classify the presence or absence of PPH. The OBCSA-OSAE technique involves the design of OBCSA based feature selection (FS) methods to elect an optimum feature subset. Additionally, the OSAE based classification model is developed to include an effective parameter adjustment process utilizing Equilibrium Optimizer (EO). The performance validation of the OBCSA-OSAE technique is performed using the benchmark dataset. The experimental values pointed out the benefits of the OBCSA-OSAE approach in recent methods.