Higher Rate Of Postpartum Hemorrhage Research Articles

Early vs delayed amniotomy following transcervical Foley balloon in the induction of labor: a randomized clinical trial

The optimal timing of amniotomy during labor induction is a topic of ongoing debate due to the potential risks associated with both amniotomy and prolonged labor. As such, individuals in the field of obstetrics and gynecology must carefully evaluate the associated benefits and drawbacks of this procedure. While amniotomy can expedite the labor process, it may also lead to complications such as umbilical cord prolapse, fetal distress, and infection. Therefore, a careful and thorough examination of the risks and benefits of amniotomy during labor induction is essential in making an informed decision regarding the optimal timing of this procedure. This study aimed to determine if an amniotomy within 2 hours after Foley balloon removal reduced the duration of active labor and time taken to achieve vaginal delivery when compared with an amniotomy ≥4 hours after balloon removal among term pregnant women who underwent labor induction. This was an open-label, randomized controlled trial that was conducted at a single academic center from October 2020 to March 2023. Term participants who were eligible for preinduction cervical ripening with a Foley balloon were randomized into 2 groups, namely the early amniotomy (rupture of membranes within 2 hours after Foley balloon removal) and delayed amniotomy (rupture of membranes performed more than 4 hours after Foley balloon removal) groups. Randomization was stratified by parity. The primary outcome was time from Foley balloon insertion to active phase of labor. Secondary outcomes, including time to delivery, cesarean delivery rates, and maternal and neonatal complications, were analyzed using intention-to-treat and per-protocol analyses. Of the 150 participants who consented and were enrolled, 149 were included in the analysis. In the intention-to-treat population, an early amniotomy did not significantly shorten the time between Foley balloon insertion and active labor when compared with a delayed amniotomy (885 vs 975 minutes; P=.08). An early amniotomy was associated with a significantly shorter time from Foley balloon placement to active labor in nulliparous individuals (1211; 584-2340 vs 1585; 683-2760; P=.02). When evaluating the secondary outcomes, an early amniotomy was associated with a significantly shorter time to active labor onset (312.5 vs 442.5 minutes; P=.02) and delivery (484 vs 587 minutes; P=.03) from Foley balloon removal with a higher rate of delivery within 36 hours (96% vs 85%; P=.03). Individuals in the early amniotomy group reached active labor 1.5 times faster after Foley balloon insertion than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1.1-2.2; P=.02). Those with an early amniotomy also reached vaginal delivery 1.5 times faster after Foley balloon removal than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1-2.2; P=.03). A delayed amniotomy was associated with a higher rate of postpartum hemorrhage (0% vs 9.5%; P=.01). No significant differences were observed in the cesarean delivery rates, length of hospital stay, maternal infection, or neonatal outcomes. Although an early amniotomy does not shorten the time from Foley balloon insertion to active labor, it shortens time from Foley balloon removal to active labor and delivery without increasing complications. The increased postpartum hemorrhage rate in the delayed amniotomy group suggests increased risks with delayed amniotomy.

Resolved but Not Forgotten: The Effect of Resolved Placenta Previa on Labor Management.

Placenta previa is diagnosed in up to 15% of pregnancies at the anatomy ultrasound and 0.5% persist to term. There is limited data regarding pregnancy outcomes with resolved previa. We aimed to examine patients with resolved placenta previa to determine if abnormal placentation at any time during pregnancy is associated with adverse events during labor. Patients with placenta previa were identified after second trimester ultrasound, included if placenta previa resolved with the placental edge greater than 2 cm from the internal cervical os, and excluded if placenta previa persisted to term, resolution occurred prior to 20 weeks, patients underwent a prior cesarean delivery, or delivered at an outside institution. Time-matched controls were identified among patients with normal placental location. Demographic data and outcomes were collected. Student's t-test, Wilcoxon's rank-sum test, Chi-square, Fisher's exact test, and univariable and multivariable logistic regression were used as appropriate RESULTS: Overall, 560 patients had placenta previa, 275 had resolved placenta previa, 285 were excluded. Resolved placenta previa patients were significantly older with lower prepregnancy body mass index (BMI), were significantly more likely to be a current smoker, have used assisted reproductive technology, and have had previous uterine surgeries. Overall, 10.2% of patients with resolved placenta previa experienced postpartum hemorrhage, compared with 2.1% in the normal placentation group. Patients with resolved placenta previa were 5.2 times more likely to have a postpartum hemorrhage (odds ratio [OR] = 5.2, 95% confidence interval [CI]: 2.1-12.7; p < 0.01) and 3.4 times more likely to require extra uterotonic medications (OR = 3.4, 95% CI: 1.9-6.2; p < 0.01). There is no difference with regard to rates of operative delivery for fetal distress (OR = 1.2, 95% CI: 0.7-1.9; p = 0.48), or category-II or-III fetal heart tracing around the time of delivery. Patients with resolved placenta previa had a higher rate of postpartum hemorrhage and use of uterotonic agents. This information might have important clinical implications and could be incorporated into the hemorrhage risk assessment during labor. · This study aimed to determine if patients with resolved placenta previa had an increased risk of expedited delivery due to fetal distress during labor.. · Patients age with resolved placenta previa have similar risk factors to those with persistent placenta previa, including older maternal, lower prepregnancy BMI, current smoking status, use of assisted reproductive technology (ART) and history of previous uterine surgeries. They were not at increased risk for operative vaginal delivery or cesarean section due to fetal distress. They did require increased uterotonic use and were at an increased risk for postpartum hemorrhage. · Patients with resolved placenta previa should undergo hemorrhage precautions at the time of admission..

Discontinuation of Oxytocin in the Second Stage of Labor and its Association with Postpartum Hemorrhage.

The objective of the study was to evaluate whether patients with oxytocin discontinued during the second stage of labor (≥30 minutes prior to delivery) had a lower rate of postpartum hemorrhage (PPH) compared with those with oxytocin continued until delivery or discontinued <30 minutes prior to delivery. Retrospective cohort study was performed from August 1, 2014 to July 31, 2019. Singleton pregnancies of 24 to 42 weeks gestation were included if they reached the second stage of labor and received oxytocin during labor. Patients on anticoagulants were excluded. Patients with oxytocin discontinued ≥30 minutes prior to delivery represented STOPPED and those with oxytocin continued until delivery or discontinued <30 minutes prior to delivery represented CONTINUED. Patient data were abstracted from the electronic medical record. The primary outcome was PPH (≥1,000 mL blood loss). Univariable analyses were performed to compare groups. Multi-variable logistic regression was performed to adjust for prespecified confounders. Planned sub-group analyses by the route of delivery were performed. Of 10,421 total patients, 1,288 had oxytocin STOPPED and 9,133 had oxytocin CONTINUED. There were no significant differences in age, race, or ethnicity, body mass index, public insurance, gestational diabetes, or pregnancy-induced hypertension between STOPPED and CONTINUED. The PPH rate was 15.2 and 5.7% in STOPPED and CONTINUED, respectively (p < 0.001). After adjusting for confounders, STOPPED remained at higher odds for PPH (adjusted odds ratio 2.859, 95% confidence interval 2.394, 3.414, p < 0.001). Among cesarean deliveries only, there was no significant difference in the rate of PPH between STOPPED and CONTINUED (38.0 vs. 36.4%, respectively, p = 0.730). However, among vaginal deliveries, the rate of PPH was actually lower in STOPPED than CONTINUED (3.4 vs. 5.2%, respectively, p = 0.024). The rate of PPH was higher in patients with oxytocin STOPPED compared with CONTINUED. However, among vaginal deliveries, there was a significantly lower rate of PPH in STOPPED. These disparate findings may be explained by the variable impact of second-stage oxytocin on PPH as a function of delivery type. · It is unclear if oxytocin use in the second stage of labor may independently increase the risk of hemorrhage.. · Patients with oxytocin discontinued during the second stage of labor had a higher rate of PPH.. · PPH was significantly lower among vaginal deliveries in patients with oxytocin discontinued..

Association between Endometriosis and Delivery Outcomes: A Systematic Review and Meta-Analysis.

Endometriosis is a common benign gynecological disorder; however, delivery outcomes concerning pregnancies with endometriosis remain understudied. This study aimed to assess the effect of endometriosis on delivery outcomes, including the rate of instrumental delivery, cesarean delivery (CD), postpartum hemorrhage (PPH), and perioperative complications during CD. A systematic literature review was conducted using multiple computerized databases, and 28 studies met the inclusion criteria. Pooled analysis showed that histologically diagnosed endometriosis was associated with an increased rate of instrumental delivery (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.02–1.56) and an increased risk of CD (adjusted OR 2.59, 95%CI 1.32–5.07). In our analysis, histologically diagnosed endometriosis was not associated with an increased rate of PPH; however, one retrospective study reported that endometriosis increased the rate of PPH during CD (adjusted OR 1.7, 95%CI 1.5–2.0). Two studies examined perioperative complications during CD, and women with deep endometriosis had a higher rate of bowel resection or bladder injury than those without endometriosis. Our findings suggest that endometriosis is a significant risk factor for instrumental delivery and CD and may be associated with a higher rate of PPH and intraoperative complications during CD.

933 Maternal and infant outcomes in those undergoing TOLAC by hospital volume

This study assessed whether maternal and neonatal outcomes in those undergoing trial of labor after cesarean (TOLAC) differ significantly between hospitals of different volumes. We conducted a retrospective cohort study of singleton, non-anomalous, term deliveries in California between 2007 and 2011. We studied outcomes stratified by low, medium, and high hospital volume based on previous literature. Chi-square and multivariable logistic regression analyses were employed for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance 45,763 women-infant dyads met our inclusion criteria. The odds of operative vaginal delivery in women undergoing TOLAC were significantly higher at high volume hospitals compared to low and medium volume hospitals (aOR: 1.65 vs 0.94 and 1.00, respectively). Rates of post-partum hemorrhage were significantly different, with highest rates in high volume hospitals (3.24%) compared with medium and low volume centers (2.68% and 2.46%, respectively). Transfusion rates were also significantly different. Rates of severe maternal morbidity, endometritis, and placental abruption were not significantly different. For neonates, rates of neonatal intensive care unit (NICU) admission was highest in medium volume centers (7.8%) compared to low and high (6.56% and 6.91%, respectively). APGAR scores <7 at 5 minutes were significantly different between groups, and highest at medium volume centers (0.63%) when compared to low and high (0.60% and 0.40%, respectively). There was no significant difference in brachial plexus injuries, HIE, neonatal or infant death between groups. In women undergoing TOLAC, most outcomes were not different. However, there was a significantly higher rate of post-partum hemorrhage and maternal blood transfusion between hospital volume categorizations. Of the outcomes studied, NICU admission and low APGAR scores were the only outcomes that were significantly different. Whether or not VBAC success rate is contributing to the lack of complications seen needs to be studied further.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

556 Resolved but not forgotten: does a diagnosis of resolved placenta previa affect labor and delivery?

Placenta previa (PP) is diagnosed in up to 15% of pregnancies at the anatomy ultrasound (US) and 0.5% persist to term. There is limited data regarding pregnancy outcomes with resolved previa (RPP). We aim to examine patients with RPP to determine if abnormal placentation at any time during pregnancy is associated with adverse events during labor. Anatomy US done at the Mount Sinai West Fetal Evaluation Unit between Mar 2018 - June 2020 were reviewed. Patients with PP were identified, included if PP resolved with placental edge >2cm from os, excluded if PP persisted to term, resolution occurred prior to 20 weeks, prior cesarean delivery or missing outcomes. Time matched controls identified among patients with normal placentation. Demographic data and outcomes collected. Student t-test, Wilcoxon rank-sum test, Chi-square, Fisher exact test, Univariable and multivariable logistic regression were used as appropriate A total of 8,881 US were performed, 560 with PP, 275 identified as RPP, 285 excluded. RPP patients were significantly older with lower pre pregnancy BMI. Patients with RPP were significantly more likely to be a current smoker, have used assisted reproductive technology, have had previous uterine surgeries (Table 1). Patients with RPP were 5.2 times more likely to have a post partum hemorrhage (PPH) (OR 5.2, 95% CI 2.1-12.7; p<0.01) and 3.4 times more likely to require extra uterotonic medications (OR 3.4, 95% CI 1.9-6.2; p<0.01). As the placental edge gets farther away from the os at resolution, the risk of PPH decreases (OR 0.9, 95% CI 0.9-1.0; p=0.03). There is no difference with regards to rates of operative delivery or cesarean delivery for fetal distress (OR 1.2, 95% CI 0.7-1.9; p=0.48), or Cat II/III fetal heart tracing at delivery. Patients with RPP had a higher rate of PPH and use of uterotonic agents. They were also more likely to have similar underlying risk factors of patients with persistent PP. This information might have important clinical implications and could be incorporated into the hemorrhage risk assessment during labor.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Gynecological, reproductive and sexual outcomes after uterine artery embolization for post-partum haemorrage

In this case control study, long-term gynecological, reproductive and sexual outcomes after uterine artery embolization (UAE) for postpartum hemorrhage (PPH) were evaluated. The study was performed in a single referral hospital for PPH in Lausanne from 2003 to 2013. Each woman whose delivery was complicated by PPH and treated by UAE was included, and compared to a control group of women whose delivery was uncomplicated. Cases were matched by maternal age, parity, ethnicity, year and mode of delivery, birth weight and gestational age in a 1–3 ratio. A total of 77 patients treated by UAE for PPH were identified in our obstetrical database. Among them, 63 were included and compared to 189 matched patients (no PPH). The mean interval time between UAE and this study was 8.1 years. Time to menstrual cycle recovery after delivery (3.9 vs 5.6 months, p = 0.66), spotting (7.9% vs 7.2%, p = 0.49), dysmenorrhea (25.4% vs 22.2%, p = 0.60) and amenorrhea (14.3% vs 12.2%, p = 0.66) were similar between the two groups. There was no difference in the FSFI score between the groups (23.2 ± 0.6 vs 23.8 ± 0.4; p = 0.41). However, the interval time to subsequent pregnancy was longer for patients after UAE than the control group (35 vs 18 months, p = 0.002). In case of pregnancy desire, the success rate was lower after UAE compared to controls (55% vs 93.5%, p < 0.001). The rate of PPH was higher in those with previous PPH (6.6% vs 36.4%, p = 0.010). Patients treated by UAE for PPH did not report higher rates of gynecological symptoms or sexual dysfunction compared to patients with uneventful deliveries. The inter-pregnancy interval was increased and the success rate was reduced. In subsequent pregnancies, a higher rate of PPH was observed in those that underwent UAE.

Blood type and postpartum hemorrhage by mode of delivery: A retrospective cohort study

ObjectiveTo assess the relationship between postpartum hemorrhage and ABO blood type for vaginal delivery and cesarean delivery. Study designThis is a retrospective cohort study of data abstracted from the PeriBank database regarding demographics and delivery outcomes. All live singleton deliveries from January 2011 until March 2018 were included in this study. Exclusion criteria were sickle cell disease and multiple gestations. Analyses were conducted separately for cesarean delivery and vaginal delivery. Quantitative variables were analyzed with analysis of variance testing and categorical variables with chi square testing. Significant demographic differences between groups were controlled for using multivariate logistical regression. The primary outcome was the rate of postpartum hemorrhage by blood type (A, B, AB, and O), defined as blood loss >500 mL in vaginal delivery and >1000 mL in cesarean delivery. 43,437 patients were screened and 32,023 women met inclusion criteria (22,484 vaginal deliveries (70.2%) and 9539 cesarean deliveries (29.8%)). ResultsIn the vaginal delivery group there were differences in age, parity, race, use of regional anesthesia, rate of induction of labor, and thrombocytopenia between blood types. In the cesarean delivery group, age, parity, and race were significantly different between blood types. There was no observed difference in the rate of postpartum hemorrhage by blood type for those who delivered via vaginal delivery when controlling for demographic differences (p = 0.2). In the cesarean delivery group, there was a significantly higher rate of postpartum hemorrhage in women with type O blood (5.2% type O vs 3.8% type A vs 4.4% type B vs 4.2% type AB, p = 0.035), including when controlling for demographic differences (p = 0.02). In both vaginal and cesarean delivery groups, there was no difference in rates of any of the secondary outcomes, including blood transfusion, hysterectomy, intrapartum dilation and curettage, and intensive care unit admission. ConclusionAlthough this study found no statistically significant difference in clinical outcomes between blood types, type O blood may be an additional risk factor to consider for postpartum hemorrhage at the time of cesarean delivery.

The role of mediolateral episiotomy during vacuum-assisted vaginal delivery with soft cup devices.

This study evaluated whether episiotomy during vacuum-assisted delivery leads to fewer third- and fourth-degree tears. This was a retrospective cohort study of all nulliparas who underwent a singleton, soft cup, vacuum-assisted vaginal delivery in one institution, from January 2014 to August 2019. Failed vacuum deliveries were excluded. Based on power analysis calculation, a sample size of 500 women in each group was sufficient to detect an advantage of episiotomy, if present. Primary outcome was third- or fourth-degree perineal tear. Secondary outcomes were other maternal complications, and low neonatal cord pH and Apgar scores. Outcomes were compared between women with and without episiotomy. During the study period, 2370 nulliparas had a vacuum-assisted vaginal delivery using soft vacuum cup and met the study inclusion criteria. Episiotomy was performed in 1868 (79%) women, and 502 (21%) delivered without episiotomy. Background characteristics were similar in both groups. There were no significant differences in the rates of third and fourth grade perineal lacerations between the two groups. Episiotomy was associated with higher rate of postpartum hemorrhage (p < 0.01) CONCLUSIONS: Using selective episiotomy for patients delivering vaginally with the assistance of soft cap vacuum does not increase third- or fourth-degree perineal tears.

Trial of labor after cesarean delivery in grand multiparous women: maternal and neonatal outcomes

Objective To evaluate success rates of vaginal birth after cesarean (VBAC) and maternal and neonatal outcomes associated with trial of labor after cesarean in grand multiparous women. Study design A retrospective computerized data base study was conducted at a single tertiary center, between 2005 and 2019. The study compared the maternal and neonatal outcomes of trial of labor after cesarean delivery in grand multiparous women (parity ≥ 6) as compared to multiparous women (parity: 3–5). Comparison analysis was performed by univariate analysis and followed by adjusted multiple logistic regression models. Results During the study period we identified 2749 and 4294 cases of trial of labor after cesarean in grand multiparous and multiparas, respectively. VBAC was observed in 94.6% of the grand multiparous as compared to 96.5% in the multiparous group, p < .01. The grand multiparous group had a higher rate of postpartum hemorrhage (3 vs. 2.2%, p = .03) and prolonged postpartum hospitalization (1.4 vs. 0.7%, p < .01). The rates of uterine rupture (0.3 vs. 0.2%, p=.50), peripartum hysterectomy (0.1 vs. 0%, p = .33) and adverse neonatal outcomes were comparable between the groups. Conclusion Trial of labor after cesarean in grand multiparous women is associated with favorable maternal and neonatal outcomes. Consideration and awareness should be given for the increased risk for postpartum hemorrhage, not associated with uterine rupture.

Mild Thrombocytopenia and Postpartum Hemorrhage in Nulliparous Women With Term, Singleton, Vertex Deliveries.

To assess whether mild thrombocytopenia (platelet count 100-149 k/microliter) is associated with an increased risk of postpartum hemorrhage. Nulliparous women with term, singleton, vertex pregnancies undergoing labor at our institution between August 2016 and September 2017 were included. The primary exposure was mild thrombocytopenia, defined as platelet count 100-149 k/microliter, and the comparator was normal platelet count (150 k/microliter or greater). Those with severe thrombocytopenia (platelet count less than 100 k/microliter) were excluded from analysis. The primary outcome was postpartum hemorrhage, determined by International Classification of Diseases, Tenth Revision codes and the hospital discharge problem list. Secondary outcomes included use of uterotonic agents (methylergonovine maleate or carboprost tromethamine), total blood loss 1,000 mL or greater, and blood transfusion. Data were analyzed by t test, χ or Fisher exact test, and multivariable logistic regression, with significance at α <0.05. We evaluated 2,845 eligible women, of whom 2,579 (90.2%) had normal platelet count 150 k/microliter or greater, 266 (9.3%) had platelet count 100-149 k/microliter (mild thrombocytopenia), and 13 (0.5%) had platelet count less than 100 k/microliter (severe thrombocytopenia). Compared with women with normal platelet count, those with mild thrombocytopenia had a higher rate of postpartum hemorrhage (16.9% vs 8.5%, P<.001) and were more likely to have total blood loss 1,000 mL or greater (4.5% vs 1.7%, P=.002) and receive methylergonovine maleate (10.5% vs 5.9%, P=.003) or carboprost tromethamine (6.0% vs 1.6%, P<.001) or both (3.8% vs 1.0%, P<.001), but rates of blood transfusion were no different (1.9% vs 1.5%, P=.59). The association between mild thrombocytopenia and postpartum hemorrhage persisted after multivariable adjustment for potential confounders (adjusted odds ratio 2.2, 95% CI 1.5-3.2, P<.001). Among nulliparous women with term, singleton, vertex pregnancies undergoing labor, those with mild thrombocytopenia (platelet count 100-149 k/microliter) had a twofold greater likelihood of postpartum hemorrhage compared with those with normal platelet count.

Incidence of postpartum haemorrhage defined by quantitative blood loss measurement: a national cohort

BackgroundVisual estimation of blood loss following delivery often under-reports actual bleed volume. To improve accuracy, quantitative blood loss measurement was introduced for all births in the 12 hospitals providing maternity care in Wales. This intervention was incorporated into a quality improvement programme (Obstetric Bleeding Strategy for Wales, OBS Cymru). We report the incidence of postpartum haemorrhage in Wales over a 1-year period using quantitative measurement.MethodsThis prospective, consecutive cohort included all 31,341 women giving birth in Wales in 2017. Standardised training was cascaded to maternity staff in all 12 hospitals in Wales. The training comprised mock-scenarios, a video and team drills. Uptake of quantitative blood loss measurement was audited at each centre. Data on postpartum haemorrhage of > 1000 mL were collected and analysed according to mode of delivery. Data on blood loss for all maternities was from the NHS Wales Informatics Service.ResultsBiannual audit data demonstrated an increase in quantitative measurement from 52.1 to 87.8% (P < 0.001). The incidence (95% confidence intervals, CI) of postpartum haemorrhage of > 1000 mL, > 1500 mL and > 2000 mL was 8.6% (8.3 to 8.9), 3.3% (3.1 to 3.5) and 1.3% (1.2 to 1.4), respectively compared to 5%, 2% and 0.8% in the year before OBS Cymru. The incidence (95% CI) of bleeds of > 1000 mL was similar across the 12 hospitals despite widely varied size, staffing levels and case mix, median (25th to 75th centile) 8.6% (7.8–9.6). The incidence of PPH varied with mode of delivery and was mean (95% CI) 4.9% (4.6–5.2) for unassisted vaginal deliveries, 18.4 (17.1–19.8) for instrumental vaginal deliveries, 8.5 (7.7–9.4) for elective caesarean section and 19.8 (18.6–21.0) for non-elective caesarean sections.ConclusionsQuantitative measurement of blood loss is feasible in all hospitals providing maternity care and is associated with detection of higher rates of postpartum haemorrhage. These results have implications for the definition of abnormal blood loss after childbirth and for management and research of postpartum haemorrhage.

Complications of the third stage of labor are more prevalent in IVF pregnancies

Background Pregnancies conceived by in vitro fertilization (IVF) are associated with a higher prevalence of perinatal complications than pregnancies conceived spontaneously, even after correction of confounding factors. Little is known about the prevalence of complications of the third stage of labor in IVF pregnancies. Objective To compare the prevalence and types of complications of the third stage of labor following vaginal delivery of singleton infants born to matched groups of women who conceived through IVF or spontaneously. Study design A retrospective case-control study design was used. The electronic delivery files of a tertiary medical center were reviewed for all women with a singleton IVF pregnancy who gave birth by vaginal delivery from August 2011 to March 2014. The women were matched 1:2 for age, gravidity, parity, and week of delivery to women with a singleton spontaneously conceived pregnancy who gave birth by vaginal delivery during the same period at the same hospital. The impact of mode of conception on the length and complications of the third stage of labor was evaluated. Results The study group consisted of 242 women with IVF pregnancies (cases), and 484 matched controls with spontaneously conceived pregnancies (controls). The length of the third stage was similar in the cases and controls (14.23 ± 8.89 and 13.69 ± 9.19 min, respectively). IVF pregnancy was associated with a significantly higher rate of postpartum hemorrhage (PPH) (5.79 versus 1.45%, p = .001), manual removal of retained placenta (11.98 versus 7.02%, p = .025), and blood transfusion (2.07 versus 0.41%, p = .032). On multivariate analysis, pregnancy conceived by IVF was an independent risk factor for an adverse outcome of the third stage of labor (OR 2.86, 95% CI 1.53–5.33). Conclusion After correction for confounders, IVF conception proved to be a significant independent risk factor for PPH, manual removal of the placenta, and blood transfusion in the third stage of labor. Therefore, the management of women who give birth vaginally following IVF pregnancy should be designed to anticipate complications in the third stage even in the absence of other risk factors.

Pushing the limits: perinatal outcomes beyond prolonged second stage

Objective: To evaluate whether extremely prolonged second stage of labor in nulliparous women affects mode of delivery and perinatal outcomes.Methods: We performed a retrospective cohort study of nulliparous women with singleton gestations and cephalic presentation who reached 10 cm of cervical dilation at gestational age 36 0/7–41 6/7. Women were stratified by epidural status. Deliveries were compared by length of second stage: 0–179 min (normal second stage, NSS), 180–299 min (prolonged second stage, PSS), and ≥300 min (extremely prolonged second stage, EPSS). Primary outcome was incidence of vaginal delivery. Secondary outcomes were maternal and neonatal morbidities.Results: Six hundred sixty-one women were evaluated; overall, 92.7% (613/661) of the patients delivered vaginally, with 84.6% (559/661) of women undergoing spontaneous vaginal delivery. In women with epidural anesthesia, 90.6% (446/492) delivered vaginally (97.2% of NSS, 95.1% of PSS, and 69.2% of EPSS). In women without epidural anesthesia, 98.8% (167/169) delivered vaginally (99.3% of NSS, 100.0% of PSS, and 87.5% of EPSS). Women with epidural anesthesia and EPSS had a higher rate of postpartum hemorrhage (aOR: 8.52; 95% CI: 3.99–18.19) and third-degree laceration when compared to NSS (aOR: 5.87; 95% CI: 1.71–20.17). EPSS neonates had a higher rate of CPAP use (OR: 3.99; 95% CI: 1.82–8.74) and significantly higher birth weight (p < .0001) and composite neonatal outcomes (OR: 4.98; 95% CI: 2.34–10.59) compared to NSS.Conclusion: In nulliparous women at term with singleton gestations who reached second stage, the chance of vaginal delivery was 92.7%; even after 5 h of second stage, most women delivered via vaginal delivery (70.4%, 81/115). In those with epidural anesthesia, the PSS group had similar perinatal outcomes as the NSS group, whereas the EPSS group had significantly worse perinatal outcomes. Second stage ≥5 h is a potential tipping point for hazardous perinatal outcomes.

A comparison of maternal and neonatal outcomes with forceps delivery versus cesarean delivery

Objective: To compare maternal and neonatal outcomes by forceps vaginal delivery versus cesarean delivery during the second stage of labor. Methods: We conducted a retrospective cohort study in a large tertiary maternity center in Shanghai, China through 2007–2016. A total of 7046 women carrying a singleton term nonanomalous fetus with vertex presentation who underwent forceps vaginal delivery, or cesarean delivery from a low station in the second stage of labor were included. Results: Of the 7046 women, 6265 underwent forceps and 781 underwent second stage cesarean delivery. Forceps were associated with lower frequency of maternal infection (2.2 versus 4.7%), but higher incidence of mild postpartum hemorrhage (PPH) (4.3 versus 0.6%). When the procedures were performed for fetal indication, forceps were associated with lower frequency of the composite of perinatal mortality and/or hypoxic ischemic encephalopathy (HIE) (0.5 versus 1.9%; adjusted odds ratio (aOR), 0.24; 95% CI: 0.08–0.75), and also shorter decision to delivery interval (12.3 ± 3.5 versus 19.1 ± 5.0 min). The neonatal infection rate was higher in the forceps group (3.9 versus 2.0%). There were no differences in other neonatal outcomes including birth trauma. Conclusions: In women who had a need for intervention during the second stage with a station of +2 or below, forceps were associated with a lower frequency of maternal infection but a higher rate of PPH. Deliveries performed for nonreassuring status were accomplished faster by forceps and were associated with a lower frequency of the composite of perinatal mortality and HIE.

The effects of severe iron-deficiency anaemia on maternal and neonatal outcomes: A case–control study in an inner-city London hospital

This case–control study investigates the effects of severe iron-deficiency anaemia in pregnancy on maternal and neonatal outcomes in a relatively deprived inner-city population in a North London hospital. The study group comprised of 106 women with haemoglobin (Hb) < 8 g/dl at any point during pregnancy, while controls were 106 women with Hb > 11 g/dl throughout pregnancy. The study group lost an average of 80 ml more blood at delivery (p = 0.032) and had higher rates of postpartum haemorrhage than the control group (27 vs 12 patients, p = 0.012). However, anaemia did not appear to influence other maternal or neonatal outcomes; these may have been confounded by antenatal intervention with oral haematinics or blood transfusion.

Can drug effects explain the recent temporal increase in atonic postpartum haemorrhage?

BackgroundRates of postpartum haemorrhage and atonic postpartum haemorrhage have increased in several high‐income countries. We carried out a study to examine if drug use in pregnancy, or drug and other interactions, explained this increase in postpartum haemorrhage.MethodsThe linked administrative and hospital databases of the Québec Pregnancy Cohort were used to define a cohort of pregnant women in Québec, Canada, from 1998 to 2009 (n = 138 704). Case–control studies on any postpartum haemorrhage and atonic postpartum haemorrhage were carried out within this population, with up to five controls randomly selected for each case after matching on index date and hospital of delivery (incidence density sampling). Conditional logistic regression was used to estimate the effects of drug use on postpartum haemorrhage and atonic postpartum haemorrhage.ResultsThere was an unexpected non‐linear, declining temporal pattern in postpartum haemorrhage and atonic postpartum haemorrhage between 1998 and 2009. Use of antidepressants (mainly selective serotonin reuptake inhibitors) was associated with higher rates of postpartum haemorrhage [adjusted rate ratio (aRR) 1.48, 95% confidence interval (CI) 1.23, 1.77] and atonic postpartum haemorrhage [aRR 1.40, 95% CI 1.13, 1.74]. Thrombocytopenia was also associated with higher rates of postpartum haemorrhage [aRR 1.52, 95% CI 1.16, 2.00]. There were no statistically significant drug interactions. Adjustment for maternal factors and drug use had little effect on temporal trends in postpartum haemorrhage and atonic postpartum haemorrhage.ConclusionsAlthough antidepressant use and thrombocytopenia were associated with higher rates of atonic postpartum haemorrhage, antidepressant and other drug use did not explain temporal trends in postpartum haemorrhage.

Participation of the endocannabinoid system (ECS) in the weight-gain and sensitization to LPS exposure in a maternal obesity model

The aim of the study is to evaluate whether placental location at term is associated with delivery outcome.A prospective study including 2354 patients with singleton pregnancy at term admitted for vaginal delivery was conducted. Placental position was determined before delivery by ultrasonographic examination performed transabdominally with women in the supine position. Maternal characteristics and delivery outcome such as premature rupture of membranes, induction of labor, mode and gestational age at delivery, indication for cesarean section, duration of the third stage, postpartum hemorrhage (PPH) and manual removal of placenta were correlated with anterior, posterior or fundal placental locations.Among women enrolled: i) 1164 had an anterior placenta, ii) 1087 a posterior placenta, iii) 103 a fundal placenta. Women with anterior placenta showed: i) a higher incidence of induction of labor (p = 0.0001), especially for postdate pregnancies and prolonged prelabor rupture of membranes (p < 0.0001), ii) a higher rate of cesarean section rate for failure to progress in labor (p = 0.02), iii) a prolonged third stage (p = 0.01), iv) a higher incidence of manual removal of placenta (p = 0.003) and a higher rate of PPH in vaginal deliveries (p = 0.02).The present study showed the influence of anterior placental location on the course of labor, with a later onset of labor, a higher rate of induction and cesarean section and postpartum complications. The reason for this influence on labor and delivery complications remains to be elucidated.

Feto-placental endothelium in pregnancy disease

The aim of the study is to evaluate whether placental location at term is associated with delivery outcome.A prospective study including 2354 patients with singleton pregnancy at term admitted for vaginal delivery was conducted. Placental position was determined before delivery by ultrasonographic examination performed transabdominally with women in the supine position. Maternal characteristics and delivery outcome such as premature rupture of membranes, induction of labor, mode and gestational age at delivery, indication for cesarean section, duration of the third stage, postpartum hemorrhage (PPH) and manual removal of placenta were correlated with anterior, posterior or fundal placental locations.Among women enrolled: i) 1164 had an anterior placenta, ii) 1087 a posterior placenta, iii) 103 a fundal placenta. Women with anterior placenta showed: i) a higher incidence of induction of labor (p = 0.0001), especially for postdate pregnancies and prolonged prelabor rupture of membranes (p < 0.0001), ii) a higher rate of cesarean section rate for failure to progress in labor (p = 0.02), iii) a prolonged third stage (p = 0.01), iv) a higher incidence of manual removal of placenta (p = 0.003) and a higher rate of PPH in vaginal deliveries (p = 0.02).The present study showed the influence of anterior placental location on the course of labor, with a later onset of labor, a higher rate of induction and cesarean section and postpartum complications. The reason for this influence on labor and delivery complications remains to be elucidated.

Anterior placental location influences onset and progress of labor and postpartum outcome

IntroductionThe aim of the study is to evaluate whether placental location at term is associated with delivery outcome. MethodsA prospective study including 2354 patients with singleton pregnancy at term admitted for vaginal delivery was conducted. Placental position was determined before delivery by ultrasonographic examination performed transabdominally with women in the supine position. Maternal characteristics and delivery outcome such as premature rupture of membranes, induction of labor, mode and gestational age at delivery, indication for cesarean section, duration of the third stage, postpartum hemorrhage (PPH) and manual removal of placenta were correlated with anterior, posterior or fundal placental locations. ResultsAmong women enrolled: i) 1164 had an anterior placenta, ii) 1087 a posterior placenta, iii) 103 a fundal placenta. Women with anterior placenta showed: i) a higher incidence of induction of labor (p = 0.0001), especially for postdate pregnancies and prolonged prelabor rupture of membranes (p < 0.0001), ii) a higher rate of cesarean section rate for failure to progress in labor (p = 0.02), iii) a prolonged third stage (p = 0.01), iv) a higher incidence of manual removal of placenta (p = 0.003) and a higher rate of PPH in vaginal deliveries (p = 0.02). DiscussionThe present study showed the influence of anterior placental location on the course of labor, with a later onset of labor, a higher rate of induction and cesarean section and postpartum complications. The reason for this influence on labor and delivery complications remains to be elucidated.