High Risk Of Postpartum Hemorrhage Research Articles

Carbetocin versus oxytocin after caesarean section: similar efficacy but reduced pain perception in women with high risk of postpartum haemorrhage

Objective: To compare the effectiveness of carbetocin with oxytocin with respect to maintain adequate uterine tone and to reduce the incidence and severity of postpartum haemorrhage. Moreover safety, adverse effects and the need of additional medications were evaluated. Methods: Prospective controlled clinical trial. We compared the effect of a single dose of carbetocin (n = 55) with oxytocin infusion (n = 55) in a women population undergoing to elective caesarean section with regional subarachnoid anaesthesia with at least one risk factor for postpartum haemorrhage. Results: The mean ± SD of postoperative pain in the day of surgery in carbetocin group was significantly lower than in oxytocin group and remained significant till the third day after caesarean section. In the day of surgery and the first day after surgery, women of carbetocin group who needed analgesic drugs were significantly lower than women of oxytocin group. The differences of diuresis and of diuretic drugs need were not statistically significant between the two groups. Conclusions: A single carbetocin injection is efficacious and safe on the maintenance of uterine tone and on the limitation of blood losses, in peri- and in postoperative period. In addition, carbetocin was able to reduce pain perception during postoperative days improving quality life of women.

Postpartum haemorrhage: a focus on haematological management

Postpartum haemorrhage (PPH) results from the failure of normal obstetrical, surgical and/or systemic haemostasis. On a global scale, PPH is responsible for 25% of the estimated 358 000 maternal deaths each year. Primary prevention of PPH begins with an assessment of risk factors, acknowledging that the majority of women who develop PPH have no identifiable risk factors. All pregnant women must therefore be considered to be at risk of major hemorrhage. Women identified to be at high risk of PPH should be delivered in a centre with access to adequately trained staff and an onsite blood bank. A critical feature of massive haemorrhage in obstetrics is the development of disseminated intravascular coagulation (DIC). This is frequently an early feature, in contrast to DIC that develops with haemorrhage from surgery or trauma. There are likely to be similarities in management of transfusion in severe PPH to that of major bleeding in other clinical situations but the pathophysiological processes that contribute to massive PPH may necessitate different transfusion strategies; however, data from clinical trial are lacking. Early recognition and response to severe PPH by a multidisciplinary team has the potential to reduce morbidity and mortality of this common obstetric emergency.

Umbilical Vein Oxytocin for the Treatment of Retained Placenta (Release Study): A Double-Blind, Randomized Controlled Trial

Women who have a retained placenta are at high risk of postpartum hemorrhage without prompt treatment. The facilities and skilled personnel needed to perform manual removal of the placenta, the current treatment, are often unavailable to women in rural resource-poor settings, and the case fatality rate is nearly 10% in such settings. Some investigators have suggested that administration of oxytocin via the umbilical vein and placenta is a low-cost low technology method that could increase placental expulsion. A number of small studies reported that umbilical injection of oxytocin was an effective intervention, while a meta-analysis (Cochrane review) suggested that this intervention was effective but the results were of borderline significance Two large, high quality studies found no reduction in the rates of retained placenta compared with expectant management. This double-blind, placebo-controlled multicenter trial investigated the effectiveness of treatment with high-dose umbilical vein oxytocin in women with retained placenta. The study was conducted at teaching hospitals in the United Kingdom, Uganda, and Pakistan between 2004 and 2008. The participants were hemodynamically stable women who had a retained placenta for more than 30 minutes. A total of 577 women were randomly assigned to receive 30 ml saline containing either 50 IU oxytocin (n = 292) or 5 mL water (n = 285) via injection into the placenta through an umbilical vein catheter. The need for manual removal of the placenta was the primary outcome measure. No difference between the groups was found in the need for manual placental removal (oxytocin: 61.3% 179/292 vs. placebo: 62.1% 177/285; Relative Risk = 0.98, 95% confidence interval: 0.87-1.12; P = 0.84). There was a difference between the countries in the need for manual removal; the need was higher in the United Kingdom (69% 250/361) than in Uganda (47% 90/190); or Pakistan (62% 16/26). There was no difference in adverse events between the oxytocin and placebo groups. These findings are consistent with the results of other studies showing that umbilical injection of oxytocin has no clinically significant effect on the need for manual removal of the placenta in women with retained placenta, and suggest that other treatment approaches are necessary.

Haemorrhagia post partum; an implementation study on the evidence-based guideline of the Dutch Society of Obstetrics and Gynaecology (NVOG) and the MOET (Managing Obstetric Emergencies and Trauma-course) instructions; the Fluxim study

BackgroundOne of the most important causes of maternal mortality and severe morbidity worldwide is post partum haemorrhage (PPH). Factors as substandard care are frequently reported in the international literature and there are similar reports in the Netherlands. The incidence of PPH in the Dutch population is 5% containing 10.000 women a year. The introduction of an evidence-based guideline on PPH by the Dutch society of Obstetrics and Gynaecology (NVOG) and the initiation of the MOET course (Managing Obstetrics Emergencies and Trauma) did not lead to a reduction of PPH. This implies the possibility of an incomplete implementation of both the NVOG guideline and MOET-instructions. Therefore, the aim of this study is to develop and test a tailored strategy to implement both the NVOG guideline and MOET-instructionsMethods/DesignOne step in the development procedure is to evaluate the implementation of the guideline and MOET-instructions in the current care. Therefore measurement of the actual care will be performed in a representative sample of 20 hospitals. This will be done by prospective observation of the third stage of labour of 320 women with a high risk of PPH using quality indicators extracted from the NVOG guideline and MOET instructions. In the next step barriers and facilitators for guideline adherence will be analyzed by performance of semi structured interviews with 30 professionals and 10 patients, followed by a questionnaire study among all Dutch gynaecologists and midwives to quantify the barriers mentioned. Based on the outcomes, a tailored strategy to implement the NVOG guideline and MOET-instructions will be developed and tested in a feasibility study in 4 hospitals, including effect-, process- and cost evaluation.DiscussionThis study will provide insight into current Dutch practice, in particular to what extent the PPH guidelines of the NVOG and the MOET-instructions have been implemented in the actual care, and into the barriers and facilitators regarding guideline adherence. The knowledge of the feasibility study regarding the effects and costs of the tailored strategy and the experiences of the users can be used in countries with a relatively high incidence of PPH.Trial RegistrationClinicTrials.gov NCT00928863

Third Stage of Labour Care for Women at Low Risk of Postpartum Haemorrhage

In normal birth there should be a valid reason to interfere with normal processes. Yet, active management of third stage labor is being imposed on women who have no known risks of postpartum hemorrhage. This article examines the evidence from existing randomised trials comparing active and physiological third stage care for its relevance and validity to the effectiveness of physiological third stage care for women who are at low risk of postpartum hemorrhage. Consideration is given to midwifery and medical perspectives of the following definitions: 'postpartum hemorrhage'; 'low-risk status'; 'active'; 'expectant' and 'physiological' third stage care. A systematic search of the research literature regarding the third stage of labour is described. Four randomised trials and a meta-analysis by Cochrane were considered. These studies are examined in terms of their potential generalisability to women who are at low risk of postpartum hemorrhage. All trials included women who were at high risk of postpartum hemorrhage. The existing research does not provide relevant and valid evidence about the effectiveness of physiological third stage care, as defined by midwives, for women who are at low risk of postpartum hemorrhage.

Postpartum Hemorrhage After Cesarean Delivery: An Analysis of Risk Factors

To determine the incidence and risk factors for postpartum hemorrhage (PPH) associated with cesarean delivery. Blood loss at cesarean delivery was measured and defined as 1,000 to 1,499 mL or greater than 1,500 mL and/or the need for a blood transfusion. Variables were identified and evaluated to determine the factors associated with PPH. There were 1,844 elective and 2,993 nonelective cesarean deliveries over 4 years. The PPH rate in nonelective cesarean (6.75%) was greater than after elective cesarean (4.84%, P = 0.007). Risk factors for PPH after an elective operation included leiomyomata, blood disorders, placenta previa, antepartum bleeding, preterm birth, and general anesthesia. Nonelective cesarean PPH risk factors included blood disorders, retained placenta, antepartum transfusion, antepartum/intrapartum hemorrhage, placenta previa, general anesthesia, and macrosomia (odds ratio > 1.5, confidence interval > 1.5). Nonelective cesarean deliveries have a higher risk of PPH than women delivered electively. Risk factor identification and prevention should be a priority.

Acute Uterine Inversion: A Review of 40 Cases

Objective: To determine the incidence, complications, and risk of recurrence of acute uterine inversion.Methods: A retrospective chart review was conducted of all cases of acute uterine inversion recorded at the Grace Maternity Hospital in Halifax, Nova Scotia, from 1977 to 2000.Results: During the 24-year period studied, 40 cases of acute uterine inversion occurred following 125,081 births. The incidence of acute uterine inversion following vaginal birth was 1 in 3737, and following Caesarean section, 1 in 1860. Postpartum hemorrhage complicated 65% of cases of acute uterine inversion, and 47.5% required blood transfusion. There was no recurrence in 26 subsequent deliveries. Following the institution of active management of the third stage of labour in 1988, the incidence of acute uterine inversion following vaginal delivery fell 4.4-fold.Conclusion: Acute uterine inversion is rare but accompanied by high risk of postpartum hemorrhage and the need for blood transfusion. Active management of the third stage of labour may reduce the incidence of uterine inversion.

Higher risk of post-partum hemorrhage in malarious than in non-malarious areas of Papua New Guinea

Higher risk of post-partum hemorrhage in malarious than in non-malarious areas of Papua New Guinea

Application of anus misoprostol to decrease the volum of post partum hemorrhage

为观察米索前列醇塞肛对减少产后出血量的防治效果,将102例具有产后出血高危因素的病例随机分成米索前列醇塞肛组与催产素组,比较两者的效果及副反应.结果发现在产后不同时间段米索前列醇组产后出血量均少于催产素组,且副反应少见.结果提示,米索前列醇塞肛为一种安全、有效、简便的减少产后出血量的新途径.