High Risk Of Postpartum Hemorrhage Research Articles

Machine learning approaches for predicting postpartum hemorrhage: a comprehensive systematic literature review

Postpartum hemorrhage (PPH) represents a significant threat to maternal health, particularly in developing countries, where it remains a leading cause of maternal mortality. Unfortunately, only 60% of pregnant women at high risk for PPH are identified, leaving 40% undetected until they experience PPH. To address this critical issue and ensure timely intervention, leveraging rapidly advancing technology with machine learning (ML) methodologies for maternal health prediction is imperative. This review synthesizes findings from 43 selected research articles, highlighting the predominant ML techniques employed in PPH prediction. Among these, logistic regression (LR), extreme gradient boosting (XGB), random forest (RF), and decision tree (DT) emerge as the most frequently utilized methods. By harnessing the power of ML, we aim to foster technological advancements in the healthcare sector, with a particular focus on maternal health and ultimately contribute to the reduction of maternal mortality rates worldwide.

Aspirin for preeclampsia prevention in low- and middle-income countries: mind the gaps

Preeclampsia is a syndrome that continues to be a major contributor to maternal and neonatal mortality, especially in low-income countries. Low-dose aspirin reduces the risk of preeclampsia, but the mechanism is still unknown. Risk factors to identify women at risk of preeclampsia are based on clinical characteristics. Women identified as high-risk would benefit from aspirin treatment initiated preferably at the end of the first trimester. Current efforts have largely focused on developing screening algorithms that incorporate clinical risk factors, maternal biomarkers, and uterine artery Doppler evaluated in the first trimester. However, most studies on preeclampsia are conducted in high-income settings, raising uncertainties about whether the information gained can be totally applied in low-resource settings. In low- and middle-income countries, lack of adequate antenatal care and late commencement of antenatal care visits pose significant challenges for both screening for preeclampsia and initiating aspirin treatment. Further, the preventive effect of first-trimester screening based on algorithms and subsequent aspirin treatment is primarily seen for preterm preeclampsia, and reviews indicate minimal or no impact on reducing the risk of term preeclampsia. The lack of evidence regarding the effectiveness of aspirin in preventing term preeclampsia is a crucial concern, as 75% of women will develop this subtype of the syndrome. Regarding adverse outcomes, low-dose aspirin has been linked to a possible higher risk of postpartum hemorrhage, a condition as deadly as preeclampsia in many low- and middle-income countries. The increased risk of postpartum hemorrhage among women in low-income settings should be taken into consideration when discussing which pregnant women would benefit from the use of aspirin and the ideal aspirin dosage for preventing preeclampsia. Additionally, women's adherence to aspirin during pregnancy is crucial for determining its effectiveness and complications, an aspect often overlooked in trials. In this review, we analyze the knowledge gaps that must be addressed to safely increase low-dose aspirin use in low- and middle-income countries and we propose directions for future research.

Postpartum hemorrhage in electronic health records: risk factors at admission and in-hospital occurrence.

Postpartum hemorrhage (PPH) is the leading cause of maternal death globally. Therefore, prevention strategies have been created. The study aimed to evaluate the occurrence of PPH and its risk factors after implementing a risk stratification at admission in a teaching hospital. A retrospective cohort involving a database of SISMATER® electronic medical record. Classification in low, medium, or high risk for PPH was performed through data filled out by the obstetrician-assistant. PPH frequency was calculated, compared among these groups and associated with the risk factors. The prevalence of PPH was 6.8%, 131 among 1,936 women. Sixty-eight (51.9%) of them occurred in the high-risk group, 30 (22.9%) in the medium-risk and 33 (25.2%) in the low-risk group. The adjusted-odds ratio (OR) for PPH were analyzed using a confidence interval (95% CI) and was significantly higher in who presented multiple pregnancy (OR 2.88, 95% CI 1.28 to 6.49), active bleeding on admission (OR 6.12, 95% CI 1.20 to 4.65), non-cephalic presentation (OR 2.36, 95% CI 1.20 to 4.65), retained placenta (OR 9.39, 95% CI 2.90 to 30.46) and placental abruption (OR 6.95, 95% CI 2.06 to 23.48). Vaginal delivery figured out as a protective factor (OR 0.58, 95% CI 0.34 to 0.98). Prediction of PPH is still a challenge since its unpredictable factor arrangements. The fact that the analysis did not demonstrate a relationship between risk category and frequency of PPH could be attributable to the efficacy of the strategy: Women classified as "high-risk" received adequate medical care, consequently.

Tranexamic acid to reduce blood loss in women at high risk of postpartum hemorrhage undergoing cesarean delivery—a randomized controlled trial

BACKGROUNDPostpartum hemorrhage is a leading cause of maternal morbidity and mortality. Tranexamic acid has proven to be useful in treating hemorrhage from acute blood loss. However, its role in preventing blood loss in women at high risk of postpartum hemorrhage undergoing cesarean delivery is not well studied. OBJECTIVEThis study aimed to assess the role of tranexamic acid in reducing blood loss during elective and unscheduled cesarean deliveries in women at high risk of postpartum hemorrhage. STUDY DESIGNThis was a prospective, placebo-controlled, randomized controlled trial from March 2021 to February 2022 at the Karnatak Lingayat Education Society Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, India. Women at a high risk of postpartum hemorrhage undergoing cesarean delivery were recruited and randomized to receive either tranexamic acid or placebo (1:1) at least 10 minutes before skin incision. High-risk factors for postpartum hemorrhage included obesity, hypertension, multiparity, previous cesarean delivery, multiple pregnancy, abnormally implanted placenta, placenta previa, abruption, uterine leiomyomas, polyhydramnios, and fetal macrosomia. The primary outcome was blood loss, calculated by a formula using pre- and postoperative hematocrit levels. In addition, gravimetrically measured blood loss was measured and compared between the 2 groups. RESULTSA total of 212 women met the inclusion criteria and were randomized (tranexamic acid [n=106] and placebo [n=106]). The mean blood loss estimates were 400.9 mL in the tranexamic acid group and 597.9 mL in the placebo group (P<.001). The mean gravimetrically measured blood loss estimates were 379.2 mL in the tranexamic acid group and 431.1 mL in the placebo group (P<.001). In addition, there was a significant difference in the fall in hemoglobin levels (1.04 vs 1.61 g/dL) and change in hematocrit levels (3.20% vs 4.95%) from the pre- to postoperative period between the 2 groups (P<.001). No difference in the need for additional uterotonics (P=.26) or the need for postoperative parental iron (P=.18) was noted. No woman was transfused in either group. CONCLUSIONHigh-risk women receiving tranexamic acid had significantly less blood loss than women receiving placebo during cesarean delivery.

Impact of adenomyosis on pregnancy outcomes: a retrospective consecutive cohort study.

This retrospective study explored the potential connection between adenomyosis and pregnancy outcomes. A study included data from a total of 1,208 pregnancies. The adenomyosis group included 334 pregnant women with adenomyosis, and women in the control group (n=874) had uncomplicated pregnancies. Data on pregnancy complications and maternal and neonatal outcomes were compared. The incidence of gestational hypertension, gestational diabetes, and placenta previa was higher in the adenomyosis group compared to the control group (p<0.05). Adenomyosis was linked to a higher risk of postpartum hemorrhage (1,000-1,500 ml) but a lower risk of premature rupture of membranes (PROM) (p<0.05). Diagnosis of adenomyosis correlated with increased incidence of low fetal weight (20.3% vs. 21.3%, p<0.05) and a low APGAR score at 1 min (p<0.05). Adenomyosis correlated with a higher incidence of gestational hypertension, placenta previa, and gestational diabetes. At the same time, adenomyosis correlated with a significantly lower incidence of PROM compared to uncomplicated pregnancy. There was a significant increase in the incidence of postpartum hemorrhage and a higher risk of low fetal weight and lower APGAR score at 1 min in pregnancies with adenomyosis.

Comparison of tranexamic acid plus intramuscular oxytocin with intramuscular oxytocin alone for prophylaxis of primary postpartum haemorrhage in vaginal delivery

In contemporary obstetrics, postpartum hemorrhage is one of the primary causes of maternal mortality. Postpartum hemorrhage is defined as blood loss of more than 500 mL within the first 24 hours of birth. The term, late postpartum hemorrhage is used when the bleeding lasts more than 24 hours. Due to the physiological changes that occur during pregnancy, the body may sustain a 500 mL blood loss without experiencing any severe negative consequences. However, even a modest amount of blood loss might be harmful in cases of comorbidities like anemia. However, even a modest amount of blood loss might be harmful in cases of comorbidities like anemia. Postpartum hemorrhage poses a double threat because it decreases the mother's strength and immunity, leaving her more vulnerable to puerperal illnesses. Second, the loss of blood could be fatal. Maternal death occurs gradually as a result of constant trickle-like blood loss. There are predictors which may help us in scrutinizing patients to be labeled as high risk for postpartum hemorrhage, however, there are no formulized criteria for postpartum hemorrhage. The active management of the third stage of labor is a management protocol made to prevent as well as manage this potentially life-threatening condition. It has significantly led to a reduction in maternal mortality rates. However, with more permutation - combinations of medical management and using different pharmacological agents we can devise a better algorithm for further deduction in the mortality rates. Here we propose to randomly allocate and administer an additional drug, tranexamic acid, in addition to uterotonics prophylactically given during the active management of the third stage of labor in vaginal deliveries. In doing so we compare the differences between groups in which only oxytocin was given and in which oxytocin plus tranexamic acid was given.

Incidence of Postpartum Hemorrhage in Induced Versus Normal Labour

Aim: Postpartum hemorrhage (PPH), defined as blood loss exceeding 500 mL within 24 hours of childbirth, remains a major cause of maternal morbidity and mortality worldwide. PPH can result in severe complications, including anemia, transfusion requirements, organ dysfunction, and even maternal death. Prompt recognition, effective management, and risk reduction strategies are essential for improving maternal outcomes. Objective: To examine the cause and frequency of Postpartum Hemorrhage (“PPH”) in induced versus normal labour. Methods: This research was conducted in the Obstetrics and Gynecology Department, Unit no.2 at the Central Park Teaching Hospital. The research was conducted on three hundred and ten (310) patients, who were classified into two equal groups for the purposes of fair comparison. Group 1 consisted of one hundred and fifty-five (155) women who were either induced or had a cesarian section whereas Group 2 had one hundred and fifty-five (155) women who underwent a normal labour. The study was conducted in a six (6) month time duration from May 2023 to July 2023, the reason for PPH was observed and recorded in both groups. The patients and the hospital were informed beforehand of the research and written, and at times oral, consents were taken from both for recording the information below. Results: After examining both Group 1 and Group 2, it was observed that induced labour was associated with 5.8% higher risk of PPH as compared to normal labour. It was further observed that frequency of PPH was highest in women induced by oxytocin as compared to women induced by prostaglandin. Practical Implications: It will help in early and prompt management of labour and it also suggest that labour shouldn’t be induced until unless it’s indicated otherwise it can lead to post-partum hemorrhage. Conclusions: The risk of PPH increases with inducing the labour as compared to normal labour which is why a patient should only be induced in case of utmost emergency. Moreover, if such an emergency does arise, one should use prostaglandin as they are safer than oxytocin. Keywords: Postpartum Hemorrhage, Induction, Induced Labour, Labour, Spontaneous Labour, Normal Labour

Tranexamic Acid for the Prevention of Blood Loss After Cesarean Among Women With Twins: A Secondary Analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery Randomized Clinical Trial

(Am J Obstet Gynecol 2022;227:889e1–17) Tranexamic acid (TXA) has been proposed as a preventive medication in obstetrics to reduce the risk of postpartum hemorrhage (PPH). However, previous research has not shown TXA to be clinically beneficial for vaginal or cesarean delivery among a general obstetric population. Information is lacking on whether TXA might be more effective for women who are at increased risk of PPH. This study aimed to evaluate the effectiveness of prophylactic TXA in one group of women at high risk for PPH—those with multiple gestation. The purpose of this study was to examine the effect of TXA and a uterotonic agent compared with the uterotonic agent alone on the risk of PPH. The primary outcome was the incidence of calculated estimated blood loss of more than 1000 mL or a red blood cell transfusion by day 2 after delivery. Secondary outcomes included clinical and laboratory measurements of postpartum blood loss, adverse effects related to TXA, and maternal satisfaction.

Tranexamic Acid Administered During Cesarean Delivery in High-risk Patients: Maternal Pharmacokinetics, Pharmacodynamics, and Coagulation Status

(Am J Obstet Gynecol. 2022;S0002-9378(22)00441-0) Tranexamic acid (TXA) is often used to prevent or reduce postpartum hemorrhage (PPH), reducing the risk of maternal mortality and decreasing the blood transfusion rate. TXA is widely used in clinical practice, but dosing and covariates that affect the effectiveness of the drug have yet to be studied in the obstetric population. The purpose of this study was to evaluate the pharmacokinetics and pharmacodynamics of the current recommended 1 g intravenous dosage of TXA typically administered during cesarean delivery, and in conjunction use rotational thromboelastometry to assess clot formation and fibrinolysis in patients with high risk of PPH. The primary aim was to evaluate the central tendency and variability of TXA plasma concentrations in high-risk patients after the standard dose up to 5 hours after delivery. Secondary aims were to estimate the correlation between TXA plasma concentrations and body mass index, assess coagulation measurements using rotational thromboelastometry, and other outcomes related to PPH, such as changes in hemoglobin and the requirement of blood transfusions.

Analysis of risk factors associated with different degrees of postpartum hemorrhage in patients with pregnancy-induced hypertension and construction of a prediction model using line graph

Objective This study aims to analyze the risk factors associated with different degrees of postpartum hemorrhage in patients with pregnancy-induced hypertension and construct a prediction model using line graph. Methods The patients who were treated in our hospital for pregnancy-induced hypertension from January 2021 to December 2022 were enrolled as the study subjects. Their clinical data were collected, and the risk factors associated with postpartum hemorrhage in patients with pregnancy-induced hypertension were analyzed by single-factor and multi-factor logistic regression. The nomogram prediction model was constructed and validated internally, and the discrimination and consistency of the model were verified by the ROC curve and calibration graph. Results In this experiment, 125 out of the 482 patients with hypertensive disorder complicating pregnancy experienced different degrees of postpartum hemorrhage, with an incidence of 25.93%. Multivariate Logistic regression analysis showed that patients with severe disease (OR = 2.454), the degree of proteinuria +++ or ++++ (OR = 6.754, 7.206), fetal body mass ≥4000 g (OR = 5.972), uterine atony (OR = 11.789), abnormal HDL-C (OR = 3.174), abnormal LDL-C (OR = 8.812), and abnormal VEGF (OR = 7.702) had a higher risk of postpartum hemorrhage (p < .05). The risk of postpartum hemorrhage was lower in patients with onset gestational week ≥28 weeks (OR = 0.158, 0.025) and delivery gestational week ≥28 weeks (OR = 0.085, 0.152) (p < .05). Columnar line graph models for postpartum hemorrhage in patients with gestational hypertension were constructed based on nine independent risk factors, and the model differentiation (AUC 0.912 and 0.919, respectively) and precision (goodness of fit HL χ 2 = 8.441, p = .392, χ 2 = 7.741, p = .459) were better in the modeling and validation groups. Conclusion The severity of disease, the gestational week upon onset, the gestational week upon delivery, the degree of proteinuria, systolic blood pressure, diastolic blood pressure, uterine atony, HDL-C, LDL-C, VEGF are factors affecting the incidence of postpartum hemorrhage in patients with hypertensive disorder complicating pregnancy. The prediction model based on the above factors can accurately evaluate the risk of different degrees of postpartum hemorrhage in patients with hypertensive disorder complicating pregnancy.

Tranexamic Acid Versus Etamsylate in Reducing Blood Loss During Normal Vaginal Delivery in Patients with High Risk of Postpartum Hemorrhage: Randomized Controlled Trial

Tranexamic Acid Versus Etamsylate in Reducing Blood Loss During Normal Vaginal Delivery in Patients with High Risk of Postpartum Hemorrhage: Randomized Controlled Trial

British Society for Haematology guideline for anticoagulantmanagement of pregnant individuals with mechanical heart valves.

British Society for Haematology guideline for anticoagulantmanagement of pregnant individuals with mechanical heart valves.

Blood salvage at the time of vaginal delivery in patients at high risk for hemorrhage

Maternal hemorrhage is the leading cause of maternal morbidity worldwide (1). Autologous transfusion of filtered blood collected at the time of vaginal postpartum hemorrhage (PPH) is safe and eliminates the risk of donor blood transfusion (2). This pilot study assesses the feasibility and potential benefit of salvaging blood at the time of vaginal delivery in patients at high risk for PPH. 30 subjects were recruited. Patients with history of PPH, grand multiparity, multiple gestation, Large for Gestational Age fetus, polyhydramnios, prolonged labor ( >18 hours of Pitocin), or known fibroid uterus were approached. Waiver of consent was obtained from the IRB. HEMAsavR (TM) suction canister was used to collect blood loss. Gem 5000 blood gas analyzer was used to determine the hematocrit (Hct) of the blood collected. Using the Hct and the total volume in the canister, we calculated the estimated percentage of a unit of blood that could be auto transfused. All patients were multiparous, with a median parity of 5. Mean age was 34 (25-42). Mean gestational age was 39w3d. Mean quantitative blood loss (QBL) was 199cc (25 - 550). There were no cases of peripartum hemorrhage. QBL could not be calculated in four cases. Reasons included suction malfunction, arrest of dilation resulting in cesarean, precipitous delivery and insufficient blood loss. The sample Hct could not be calculated in an additional five cases due to insufficient blood loss. Mean Hct of a cell salvage unit (pRBC) is ∼55% (3) and the volume of a pRBC unit is 250cc. Use of HEMAsavR resulted in salvage of 39% (4-90) of a unit that would be available for autologous transfusion. In our high risk cohort of pregnant persons, the use of the Hemasavr device allowed for salvage of > 1/3 of a unit of pRBC. Future use of autologous transfusion of vaginal blood may provide a safe and effective way to manage peripartum hemorrhage.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

High prevalence of postpartum hemorrhage in women with rare bleeding disorders in the Netherlands: retrospective data from the RBiN study

BackgroundWomen with rare bleeding disorders (RBDs), including coagulation factor deficiencies and fibrinolytic disorders, may have a higher risk of postpartum hemorrhage (PPH). Information on this patient category is lacking in the existing PPH guidelines because data on PPH in patients with RBDs are scarce. ObjectiveTo describe the prevalence of PPH in women with an RBD and evaluate the use of peripartum hemostatic prophylaxis. MethodsIn the Rare Bleeding Disorders in the Netherlands (RBiN) study, patients with RBDs (n = 263) were included from all 6 Dutch hemophilia treatment centers. Patient–reported information on delivery, peripartum hemostatic prophylaxis, and occurrence of PPH was collected retrospectively. If available, information about the precise volume of postpartum blood loss was extracted from electronic patient files. PPH was defined as blood loss ≥500 mL (World Health Organization guideline). ResultsA total of 244 pregnancies, including 193 livebirths, were reported by 85 women. A considerable proportion of these women experienced PPH, ranging from 30% in factor V deficiency to 100% in hyperfibrinolysis. Overall, PPH was reported in 44% of deliveries performed with and 53% of deliveries performed without administration of peripartum hemostatic prophylaxis. Blood loss was significantly higher in deliveries without administration of hemostatic prophylaxis (median 1000 mL) compared to deliveries with administration of prophylaxis (median 400 mL) (p = 0.011). Patients with relatively mild deficiencies also frequently experienced PPH when peripartum hemostatic prophylaxis was omitted. ConclusionPPH is common in rare coagulation factor deficiencies, both severe and mild, and fibrinolytic disorders, especially when peripartum prophylactic hemostatic treatment was not administered. The use of prophylactic hemostatic treatment was associated with less postpartum blood loss.

The Effect of Anemia in Pregnancy on Postpartum Hemorrhage

Eighty percent of maternal deaths are caused by complications during pregnancy and childbirth. Furthermore, twenty-five percent of maternal deaths is affected by postpartum hemorrhage which is estimated 100,000 deaths annually. Indonesia places at the second ranks of the highest maternal deaths country after Laos. The cause of death in Indonesia is 28% by hemorrhage. The hemorrhage in maternity is due to anemia in pregnancy. It occurs because when the mother gives birth, there will be adequate uterine contractions so that the hemorrhage is inevitable. The objective of the study is to identify the effect of anemia in pregnancy on the incidence of postpartum hemorrhage. The type of research employed is an analytic survey with a retrospective design. The research location was at Juata Tarakan Health Center. The population in this study were all pregnant women who visited the obstetrics and gynecology polyclinic in 2020 which was obtained from secondary data, the patient's medical record book at the Juata Public Health Center with a sample of 271 on June 23 to August 31, 2021. Sampling employed a non-probability sampling technique, total sampling, and the data analysis was administered univariately, and bivariate with chi-square test. The incidence of postpartum hemorrhage in women giving birth in the working area of the Juata Tarakan Health Center is 12.9%. Anemia in pregnancy possesses a significant effect on the risk of postpartum hemorrhage with p value (OR=11,253, 95%CI 5,120-24,732). Meanwhile, parity, age, type of delivery did not possess significant effect on postpartum hemorrhage. Mothers with anemia in pregnancy own a higher risk of postpartum hemorrhage which was 11.253 times greater than mothers who were not anemic in pregnancy. Therefore, it is necessary to perform proper handling of anemia in pregnant women to prevent postpartum hemorrhage.

The indicators for early blood transfusion in patients with placental abruption with intrauterine fetal death: a retrospective review

BackgroundPlacental abruption (PA) with intrauterine fetal death (IUFD) is associated with a high risk of postpartum hemorrhage (PPH) resulting from severe disseminated intravascular coagulation (DIC). Therefore, blood products that are sufficient for coagulation factor replacement must be prepared, and delivery should occur at referral medical institutions that are equipped with sufficient blood products and emergency transfusion protocols. We retrospectively reviewed the records of patients with PA and IUFD (PA-IUFD) to identify possible factors that may indicate the need for early blood transfusion and investigated whether the Japanese scoring system for PPH can be applied in such cases.MethodsWe used a database of 16,058 pregnant patients who delivered at Yokohama City University Medical Center between January 2000 and February 2016. Thirty-three patients were diagnosed with PA-IUFD before delivery and categorized into two groups–blood transfusion and non-transfusion–to compare the maternal characteristics and pregnancy outcomes.ResultsIn patients with PA-IUFD, the transfusion group exhibited significantly more blood loss; lower fibrinogen levels and platelet counts; higher levels of fibrin degradation products (FDP), D-dimer, and prothrombin time; and a tendency for tachycardia on admission, compared to the non-transfusion group. Many patients in the transfusion group had normal fibrinogen levels on admission but later displayed markedly decreased fibrinogen levels. The Japan Society of Obstetrics and Gynecology (JSOG) DIC score was significantly higher in the transfusion than in the non-transfusion group.ConclusionsIn PA-IUFD, the fibrinogen level, platelet count, D-dimer, FDP, heart rate, and JSOG DIC score on admission may indicate the need for blood transfusion. However, even with normal fibrinogen levels on admission, continuous monitoring is indispensable for identifying progressive fibrinogen reductions in patients with PA-IUFD.

Intravenous Carbetocin Versus Rectal Misoprostol for the Active Management of the Third Stage of Labor: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Globally, postpartum hemorrhage (PPH) is the top cause of maternal death. Multiple uterotonic medications are available to prevent PPH; however, it is still unclear whether one is the most effective. The current study compared the efficacy and safety of intravenous carbetocin with rectal misoprostol for the active management of the third stage of labor in order to prevent PPH. Eligible studies were found utilizing digital medical sources, including the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science (WOS), PubMed, Scopus, and Google Scholar, from inception until September 2022. Only randomized controlled trials (RCTs) that matched the inclusion requirements were chosen. We used the Cochrane Risk of Bias scale (version 2) to assess the quality of the included studies. The Review Manager (version 5.4 for Windows) was used to conduct the meta-analysis. The results were summarized as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI) in fixed- or random-effects models according to the degree of between-study heterogeneity. Collectively, we screened 621 articles after omitting duplicates and eventually included three RCTs for analysis. Overall, 404 patients were included in these studies; 202 patients were allocated to the intravenous carbetocin group whereas 202 patients were allocated to the rectal misoprostol group. Two RCTs were judged as “low” risk of bias, whereas one RCT was judged as having “some concerns” regarding the quality assessment. Regarding efficacy endpoints, the intravenous carbetocin group had significantly lower blood loss (n=3 RCTs, MD=-117.74 mL, 95% CI [-185.41, -50.07], p<0.001), need for additional uterotonics (n=2 RCTs, RR=0.06, 95% CI [0.01, 0.46], p=0.007), need for uterine massage (n=2 RCTs, RR=0.40, 95% CI [0.20, 0.80], p=0.009), and need for blood transfusion (n=2 RCTs, RR=0.38, 95% CI [0.15, 0.95], p=0.04) compared with the rectal misoprostol group. Regarding safety endpoints, the rates of diarrhea (n=3 RCTs, RR=0.18, 95% CI [0.06, 0.55], p=0.003) and chills (n=2 RCTs, RR=0.31, 95% CI [0.12, 0.83], p=0.02) were significantly lower in the intravenous carbetocin group compared with the rectal misoprostol group. However, there was no significant difference between both groups regarding the rates of headache (n=3 RCTs, RR=1.23, 95% CI [0.06, 1.91], p=0.35) and facial flushing (n=2 RCTs, RR=0.88, 95% CI [0.46, 1.68], p=0.70). In conclusion, it was discovered that intravenous carbetocin was a superior substitute for rectal misoprostol for the active management of the third stage of labor. With far fewer side effects, intravenous carbetocin decreased postpartum blood loss and further uterotonic use. For women who have a high risk of PPH, intravenous carbetocin is advised.

Influence of previous laparoscopic surgical and pathological diagnosis of endometriosis on pregnancy outcomes in women with adenomyosis

ObjectivesPrevious studies demonstrated that endometriosis and adenomyosis are closely linked to lots of adverse pregnancy outcomes while the role of endometriosis in pregnant women with adenomyosis has not been explored yet. The present study aimed to evaluate the influence of previous laparoscopic surgical and pathological diagnosis of endometriosis on pregnancy outcomes in women with adenomyosis. MethodsA total of 60 pregnant women who were diagnosed with adenomyosis before or during pregnancy were included in this study. Among them, 8 were also diagnosed with endometriosis by previous laparoscopic surgery. The demographic characteristics and pregnancy outcomes were compared between women with adenomyosis only and those with the surgical history of endometriosis. ResultsCompared with women with adenomyosis only, those concomitant with the surgical history of endometriosis had significantly higher age at delivery [37.5(36.25–39.75) vs. 35(33.25–37), P ​= ​0.016] and an increased risk of postpartum hemorrhage (PPH) (adjusted OR: 5.992, 95% CI: 1.03–34.857, P ​= ​0.046) while no significant differences were found in other adverse pregnancy outcomes between these two groups. Then we further detected the risk factor of PPH in women with adenomyosis and found that the surgical history of endometriosis (OR: 6.995, 95% CI: 1.16–42.171, P ​= ​0.034) and assisted reproductive technology (ART) (OR: 5.062, 95% CI: 1.494–17.146, P ​= ​0.009) were the parameters closely associated with the occurrence of PPH. ConclusionsThe history of previous laparoscopic surgical and pathological diagnosis of endometriosis in pregnant women with adenomyosis may increase the risk of PPH, which still needs to be verified by future studies with a large sample size. Besides, pregnancy through ART is also an increased risk factor for PPH in women with adenomyosis. Pregnant women with adenomyosis who conceived with the surgical history of endometriosis or by ART should be closely monitored for the reason of being at high risk of PPH.

JTH in Clinic ‐ Obstetric bleeding: VWD and other inherited bleeding disorders

Individuals with inherited bleeding disorders (IBDs) have higher bleeding risk during pregnancy, childbirth, and the postpartum period. Clinical management requires recognition of the IBD as high risk for postpartum hemorrhage and a personalized multidisciplinary approach that includes the patient in decision making. When the fetus is known or at risk to inherit a bleeding disorder, fetal and neonatal bleeding risk also need to be considered. In pregnant IBD patients, it is common for providers to need to make decisions in the absence of high level of certainty evidence. We here present the case of a pregnant von Willebrand disease patient that reached multiple decision points where there is currently clinical ambiguity due to a lack of high level of certainty evidence. For each stage of her care, from diagnosis to the postpartum period, we discuss current literature and describe our approach. This is followed by a brief overview of considerations in other IBDs and pregnancy.

The MRI estimations of placental thickness and cervical length correlate with postpartum hemorrhage (PPH) in patients with risk for placenta accreta spectrum (PAS) disorders

IntroductionThis study aims to identify whether placental thickness and cervical length measured by MRI correlate with postpartum hemorrhage (PPH) in patients at high risk for placenta accreta spectrum (PAS) disorders. MethodsThe placental thickness and cervical length of 200 patients from October 2017 to October 2021 were retrospectively measured. The mid-sagittal plane of the placentas was measured by 2 independent radiologists using MRI. Partial correlation analysis was used to characterize the correlation between placental thickness, cervical length and estimated blood loss during surgery. The correlation between clinical features, placental thickness, cervical length and PPH was evaluated with univariate and multivariate analyses. A nomogram was constructed based on the logistic regression. ResultsPlacental thickness was positively correlated with the estimated blood loss during delivery, while cervical length had a negative correlation with it, based on the adjustment for gestational age. Multivariate analyses revealed that prior cesarean section, placenta previa, increased placental thickness(≧4.35 cm) and short cervical length（< 3.05 cm） were independent risk factors for PPH. When the 4 risk factors were combined together, the AUC was the highest, 0.773 (95%CI 0.707–0.840). DiscussionPlacental thickness and cervical length correlated with PPH. The nomogram constructed based on prior cesarean section, placenta previa, placental thickness and cervical length can be used to recognize patients with a higher risk of PPH.