History Of Postpartum Hemorrhage Research Articles

Clinical, Endocrine, Metabolic Profile, and Bone Health in Sheehan's Syndrome.

Background:Sheehan's syndrome (SS) occurs due to ischemic pituitary necrosis resulting from severe postpartum hemorrhage (PPH). SS is characterized by varying degrees of pituitary insufficiency involving mostly the anterior lobe. Comprehensive data on SS apart from endocrine dysfunction is scarcely available.Materials and Methods:Thirty-eight subjects previously diagnosed with SS were enrolled in this observational study. Their clinical, biochemical, hormonal, radiological data at presentation were recorded from past records and bone density was measured in all.Results:Mean (±SD) age was 39 (±8.7) years and diagnostic delay was 9.3 (±5.5) years. All had history of PPH and lactation failure. About 47% were referred from emergency, and rest 53% were diagnosed from outpatient's department. Mean free T4, TSH, prolactin, morning cortisol, FSH, LH, and IGF-1 were mostly low. Panhypopituitarism was present in 97%. Hyponatremia was most common electrolyte imbalance found in about 53%. More than 40% had elevated transaminases. Dyslipidemia especially low HDL was found in 31 (81.5%) subjects. MRI of hypothalamus–pituitary region showed empty sella in 53% and partial empty sella in 47%. About 13% subjects had diabetes mellitus. Low bone mass (BMD Z-Score ≤-1) was seen in 80% and it was more severe (BMD Z-Score ≤-2) in 44% subjects, affecting predominantly lumbar spine. Bone loss at femoral neck was less prominent.Conclusion:Apart from variable spectrum of clinical presentation, subjects with SS have significant abnormalities in serum electrolytes, metabolic parameters. Low bone mass is also a frequent accompaniment.

Von Willebrand Disease and other hereditary haemostatic factor deficiencies in women with a history of postpartum haemorrhage.

Postpartum haemorrhage (PPH) is the main cause of maternal morbidity and mortality globally, but it is far more important in non-developed countries. PPH represents 25% of all maternal deaths worldwide. Women with von Willebrand disease (VWD) and other inherited haemorrhagic disorders are at increased risk of PPH. Our aim was to establish a probable association of severe PPH in women with a history of haemostatic abnormalities. An observational, controlled study of adult women with a one or more episodes of severe PPH requiring treatment in an intensive care unit or >10 units of blood products during the 24-hour period after diagnosis and their controls. The tests performed were blood cell count, blood group, renal, viral, liver function and haemostatic tests, fibrinogen, activity of the plasma factors and specific test to diagnose and classify VWD. We included 124 women with 133 PPH events and their controls. The median age at the first event was 25.5years old. Results were significantly different between the groups in terms of fibrinogen concentration, VWF:Ag, VWF:RCo and FVIII. A specific diagnosis was established in 69 (55.6) and 4 (3.2%) patients in the PPH group and controls, respectively. Of 61 patients with VWD, 57 had type 1, two had type 2A, and another two had type 2B. Our results show a relationship between PPH and inherited haemostatic disorders. VWD was the most frequent diagnosis. Appropriate and opportune diagnosis before pregnancy of inherited haemostatic disorders may be important to effectively prevent and treat PPH.

Postpartum Haemorrhage Occurrence Seen from Influencing Factors

The biggest cause of maternal mortality rates in developing countries, one of which is bleeding after childbirth or commonly called postpartum hemorrhage (PPP). This study was conducted to determine factors that influence the incidence of postpartum hemorrhage. Observational research design with a case control approach. held on 1 - 31 August 2018 with a population of 109 people and a sample of 90 mothers giving birth, sample random sampling technique. Data collection is independent and dependent variable by observation and questionnaire. Data analysis uses logistic regression test. Based on the results of logistic regression test obtained variable bleeding history postpartum p value value of 0.019, preeclampsia p value of 0.012, anemia p value of 0.009 at α = 0.05, the effect of the incidence of postpartum hemorrhage was influenced by a history of postpartum hemorrhage, preeclampsia and anemia significantly. Anemia is a dominant risk factor contributing to the incidence of postpartum hemorrhage. It is recommended that pregnant women take precautions as early as possible with regular pregnancy checks, knowing the factors preventing the occurrence of postpartum hemorrhage, be more careful to prevent complications at the time of delivery.

Post-partum Hemorrhage and Anemia as its Modifiable Risk Factor: A Literature Review

<p>Maternal mortality is an indicator of a country’s health status. Postpartum hemorrhage is the main cause of maternal mortality. Understanding the postpartum hemorrhage risk factors useful to develop strategy in order to reduce maternal mortality. The aim of this study was to find modifiable postpartum hemorrhage's risk factors. This study used 6 steps which include formulating the research questions and objectives, searching the extant literature, screening for inclusion, assessing the quality of primary studies, extracting data, and analyzing data. The article was searched from Google Scholar and NCBI databases using bilingual keywords: "faktor-faktor, perdarahan postpartum, risk factors, and postpartum hemorrhage". There were 1736 papers founded and only 14 articles met the inclusion criteria and included in the analysis. The review revealed that anemia, age, parity, birth passage laceration, obstetric history, multiple pregnancy, placental retention, prolonged labor, atonia uteri, pre-eclampsia, pregnancy induced hypertension, section caesarian, placental complication, history of post-partum hemorrhage, episiotomy, high neonatal birth weight. Anemia is the only modifiable risk factor which may be prevented by nurses. </p>

A case of Sheehan Syndrome with chronic diffuse muscle pain and weakness

Objective: Sheehan’s syndrome is pituitary deficiency induced by intrapartum and postpartum hemorrhage and hypovolemia. It is still frequent in underdeveloped and developing countries. Sheehan’s syndrome is one of the reason of empty sella. The symptoms of the syndrome can be seen months to years later depend on the degree of pituitary damage. History of postpartum hemorrhage, failure to lactate and cessation of menses are important clues to the diagnosis. Early diagnosis and appropriate treatment are very important to reduce morbidity and mortality of the patients.
 Case: In this study sheehan’s syndrome which led to auto pan-hypopituitarism and developed gradually in a patient with sheehan‘s syndrome which in this case, delivered a baby at home 27 years ago and had severe postpartum hemorrhage will be presented. And this 63-year-old female patient was diagnosed as Sjogren’s syndrome and sheehan syndrome by clinical and laboratory findings for the purpose of further investigation and treatment because of symptoms of fever and anemia

Prevalence, Morphological Classification, And Factors Associated With Anemia Among Pregnant Women Accessing Antenatal Clinic At Itojo Hospital, South Western Uganda.

PurposeThe study aimed to determine the prevalence, morphological classification, and risk factors of anemia among pregnant mothers attending antenatal clinic at Itojo hospital, Ntungamo district, southwestern Uganda.Patients and methodsAfter obtaining an informed consent, 5mL of blood was collected from the vein of each participant for complete blood count (CBC) and peripheral film report. The CBC was performed using HumaCount 80 hematology analyzer (HUMAN Gesellschaft für Biochemica und Diagnostica mbH Max-Planck-Ring 21 65,205 Wiesbaden Germany). Peripheral blood smears were made and stained using Wright’s Romanowsky stain and examined under ×1000 magnification for morphological classification of anemia. Structured questionnaires were administered to each participant to collect information on patients’ demography and risk factors of anaemia in pregnancy. The data generated were prepared in EXCEL and later transferred to SPSS version 20 for analysis. Univariate logistic regression and multivariate logistic regression were used to evaluate the association of socio-demographic characteristics of the participants with anemia. A 95% confidence level was used and statistical significance was reached at p<0.05.ResultsOne hundred and sixty-three participants (n=163) were recruited for the study with the median age of 25 years and range of (17 to 40 years). The overall prevalence of anemia was 12 (7.4%), the morphological classification was 1 (8.3%) normocytic normochromic anemia, 6 (50%) microcytic hypochromic anemia, and 5 (41.7%) macrocytic anemia. Spouse occupation (p=0.03), household income (p=0.04), use of insecticide-treated mosquito nets (p=0.001), history of urinary tract infection (p=0.002), use of haematinics (p≤0.001), and history of postpartum hemorrhage (p=0.03) were significantly associated with anemia in pregnancy.ConclusionDespite the reported high prevalence of anemia in pregnancy in other areas within the country, anemia prevalence was low in this study. Routine screening for anemia at all antenatal care clinics countrywide is recommended.

Von Willebrand Disease and Other Hemostatic Abnormalities in Women with a History of Postpartum Haemorrhage

Background: Postpartum haemorrhage (PPH), is the main cause of maternal morbidity and mortality globally but it is far more important in non-developed countries. PPH represents 25% of all maternal deaths worldwide. von Willebrand disease (VWD) is a disease caused by quantitative or qualitative deficiency of the von Willebrand factor (VWF) and women with VWD are at increased risk of PPH. Our aim was to establish a probable association of severe PPH in women with a history of haemostatic abnormalities. Methods: An observational, controlled study of adult women with a history of one or more episodes of life-threatening severe PPH requiring treatment in an intensive care unit or >10 units of blood products during the 24-hour period after diagnosis and their controls. The following tests were performed: blood cell count, blood group, renal, viral, liver function and haemostatic tests, fibrinogen, activity of the plasma factors and specific test to diagnose and classify VWD. Findings: We included 124 women with PPH and their controls. A total of 133 PPH events were recorded. The median age at the first event was 25.5 years old. Results were significantly different between the groups in terms of fibrinogen concentration, VWF:Ag, VWF:RCo, and FVIII. A specific diagnosis was established in 69 (55.6) and 4 (3.2%) patients in the PPH group and controls, respectively. Of 61 patients with VWD, 57 had type 1, two had type 2A, and another two had type 2B. Other non-significant haemostatic deficiencies were found between the groups. Interpretation: Our results show a relationship between PPH and inherited haemostatic disorders. VWD was the most frequent diagnosis but it was unknown at the time of delivery in all patients. Appropriate and opportune diagnosis before pregnancy of inherited haemostatic disorders, particularly VWD, may be important to effectively prevent and treat PPH. Funding: None. Declaration of Interest: Karim Majluf-Cruz: no conflict of interest to declare. Liliana Anguiano-Robledo: no conflict of interest to declare. Claudia C. Calzada-Mendoza: no conflict of interest to declare. Jesus Hernandez-Juarez: no conflict of interest to declare. Manuel Moreno-Hernandez: no conflict of interest to declare. Victor Manuel Dominguez-Reyes: no conflict of interest to declare. Anahi Guadalupe Figueroa-Torres: no conflict of interest to declare. Patricia Gomez-Rosas: no conflict of interest to declare. Rodrigo Arreola-Diaz: no conflict of interest to declare. Maria Teresa Garcia-Lee: no conflict of interest to declare. Maria Tania Ricardo-Moreno: no conflict of interest to declare. Rosa Elena Sosa-Camas: no conflict of interest to declare. Jaime Garcia-Chavez: no conflict of interest to declare. Irma Isordia-Salas: no conflict of interest to declare. Abraham Majluf-Cruz: no conflict of interest to declare. Ethical Approval: The study protocol was approved by the Human Ethics Committees and the Medical Research Councils of our institutions. Informed written consent was obtained from all patients before enrollment in the study. All women received complete information about the aim of the study and explained that their participation was voluntary. Data obtained was made anonymous immediately after blood drawing.

Renal Cortical Necrosis; Five Consecutive Cases within Short Span of Time.

Renal cortical necrosis (RCN) is characterized by patchy or diffuse destruction of all the elements of renal cortex resulting from significantly diminished renal arterial perfusion due to vascular spasm and microvascular injury. It is a rare cause of acute kidney injury (AKI) in developed countries with frequency of 1.9%-2% of all patients of AKI. In contrast, the incidence of RCN is higher in developing countries ranging from 6%-7%. Obstetric complication is the main cause of RCN, earlier it was about 20%-30% which has been declining to 5% in the Indian subcontinent during the past two decades. The aim of this study is to review five consecutive cases of RCN diagnosed within very short span of time. Histopathologically, diagnosed five cases of RCN during one-month span in September 2016 at Armed Forces Institute of Pathology, Dhaka were included in this study. All the cases were referred cases from a tertiary level obstetric center of Dhaka city; the mean age was 24.2 ± 3.4 years. All the cases had the history of postpartum hemorrhage followed by septicemia. They all presented with acute renal failure dependent on hemodialysis for >21 days. On histological examination, three (60%) had patchy RCN and two (40%) had diffuse RCN. Two (40%) showed coagulative necrosis of all the glomeruli, two (40%) showed coagulative necrosis of >50% of glomeruli, and in one (20%) case necrosis of about 25% of glomeruli. One of the glomeruli showed global sclerotic change of most of the glomeruli. In all the cases, interstitium showed moderate focal lymphocytic infiltration and mild edema. Among all, one (20%) was found with immunoglobulin A nephropathy as an associated diagnosis. RCN is still encountered as an obstetric complication in our setting and this type of grave consequences should be prevented by better monitoring of pregnancies.

Sheehan’s Syndrome: A Rare but Potentially Life-Threatening Complication of Postpartum Haemorrhage

Sheehan’s syndrome (SS), also known as postpartum pituitary gland necrosis, is a rare but potentially life-threatening complication of postpartum haemorrhage. The diagnosis of Sheehan’s syndrome is based on the features of hormone deficiency, a suggestive obstetric history and decreased levels of basal hormones. Diagnosis of pan-hypopituitarism is straightforward, but partial deficiencies are often difficult to elicit. SS is a frequent cause of hypopituitarism in underdeveloped countries. The clinical features of hypopituitarism are often subtle, and years may pass before the diagnosis is made following the inciting delivery. History of postpartum haemorrhage, failure to lactate and cessation of menses are important clues to the diagnosis.

Increased postpartum haemorrhage, the possible relation with serotonergic and other psychopharmacological drugs: a matched cohort study

BackgroundPostpartum haemorrhage is a major obstetric risk worldwide. Therefore risk factors need to be investigated to control for this serious complication. A recent systematic review and meta-analysis revealed that the use of both serotonergic and non-serotonergic antidepressants in pregnancy are associated with a higher risk of postpartum haemorrhage. However, use of antidepressants in pregnancy is often necessary because untreated depression in pregnancy is associated with adverse maternal and neonatal outcome, such as postpartum depression, preterm birth and dysmaturity. Therefore it is of utmost importance to unravel the possible association between postpartum haemorrhage and the use of serotonergic and other psychopharmacological medication during pregnancy.MethodsWe performed a matched cohort observational study consecutively including all pregnant women using serotonergic medication (n = 578) or other psychopharmacological medication (n = 50) visiting two teaching hospitals in Amsterdam between 2010 and 2014. The incidence of postpartum haemorrhage in women using serotonergic medication or other psychopharmacological medication was compared with the incidence of postpartum haemorrhage in 641,364 pregnant women not using psychiatric medication selected from the database of the Netherlands Perinatal Registry foundation (Perined). Matching took place 1:5 for nine factors, i.e., parity, maternal age, ethnicity, socioeconomic status, macrosomia, gestational duration, history of postpartum haemorrhage, labour induction and hypertensive disorder.ResultsPostpartum haemorrhage occurred in 9.7% of the women using serotonergic medication. In the matched controls this was 6.6% (p = 0.01). The adjusted odds ratio (aOR) before matching was 1.6 (95% CI 1.2–2.1) and after matching 1.5 (95% CI 1.1–2.1). Among the women using other psychopharmacological medication, the incidence of postpartum haemorrhage before matching was 12.0% versus 6.1% (p = 0.08) with OR 2.1 (95% CI 0.9–4.9), and after matching 12.1% versus 4.4% (p = 0.03) with aOR of 3.3 (95% CI 1.1–9.8).ConclusionsPregnant women using serotonergic medication have an increased risk of postpartum haemorrhage, but this high risk is also seen in pregnant women using other psychopharmacological medication. We suggest that this higher risk of postpartum haemorrhage could not only be explained by serotonin, but also by other mechanisms. An additional explanation could be the underlying psychiatric disorder.

The effect of parity, birth weight babies, pregnancy interval and a history of hemorrhage with the incidence of postpartum hemorrhage (Case Study in the RSUD Ngudi Waluyo Wlingi Blitar on 2014)

Postpartum hemorrhage is one of the problems was the cause of maternal deaths in Indonesia. The maternal mortality rate is one indicator for the degree of health specially of a woman. Postpartum hemorrhage is bleeding or blood loss of 500 cc or more that occurred after the child is born. The research objective was to analyze the effect of parity, birth weight babies, pregnancy interval and a history of postpartum hemorrhage in the mother after giving birth to the incidence of postpartum hemorrhage in Ngudi Waluyo Hospital Wlingi Blitar 2014. This study used a case-control design. The populations in this study are all mothers who gave birth in Ngudi Waluyo Hospital Wlingi Blitar 2014. The sampling technique was simple random sampling. The results were obtained no effect of parity on the incidence of postpartum hemorrhage (OR=0,810, CI 95% 0,329&lt;OR&lt;1,995 , OR=0,895, CI 95% 0,260&lt;OR&lt;3,077), there was no effect of birth weight babies on the incidence of postpartum hemorrhage (OR=0,651, CI 95% 0,104&lt;OR&lt;4,096), there was effect of pregnancy interval on the incidence of postpartum hemorrhage (OR = 17.953, 95% CI 3.550 &lt;OR &lt;90.785) and there was effect of a history of bleeding on the incidence of postpartum hemorrhage postpartum (OR = 18.104, 95% CI 3.559 &lt;OR &lt;92.097). Health workers are expected to provide advice to the mother who gave birth to not be pregnant again during the next 2 years, and then advise the mother to join the family planning program in order to distance the pregnancy can be arranged. Examination of the precision of pregnant women visit each semester will make health care workers, pregnant women and families more aware of the possibility of postpartum hemorrhage after childbirth.Key words: parity, birth weight babies, pregnancy interval, a history of postpartum hemorrhage, the incidence of postpartum hemorrhage

The effect of parity, birth weight babies, pregnancy interval and a history of hemorrhage with the incidence of postpartum hemorrhage (Case Study in the RSUD Ngudi Waluyo Wlingi Blitar on 2014)

Postpartum hemorrhage is one of the problems was the cause of maternal deaths in Indonesia. The maternal mortality rate is one indicator for the degree of health specially of a woman. Postpartum hemorrhage is bleeding or blood loss of 500 cc or more that occurred after the child is born. The research objective was to analyze the effect of parity, birth weight babies, pregnancy interval and a history of postpartum hemorrhage in the mother after giving birth to the incidence of postpartum hemorrhage in Ngudi Waluyo Hospital Wlingi Blitar 2014. This study used a case-control design. The populations in this study are all mothers who gave birth in Ngudi Waluyo Hospital Wlingi Blitar 2014. The sampling technique was simple random sampling. The results were obtained no effect of parity on the incidence of postpartum hemorrhage (OR=0,810, CI 95% 0,329&lt;OR&lt;1,995 , OR=0,895, CI 95% 0,260&lt;OR&lt;3,077), there was no effect of birth weight babies on the incidence of postpartum hemorrhage (OR=0,651, CI 95% 0,104&lt;OR&lt;4,096), there was effect of pregnancy interval on the incidence of postpartum hemorrhage (OR = 17.953, 95% CI 3.550 &lt;OR &lt;90.785) and there was effect of a history of bleeding on the incidence of postpartum hemorrhage postpartum (OR = 18.104, 95% CI 3.559 &lt;OR &lt;92.097). Health workers are expected to provide advice to the mother who gave birth to not be pregnant again during the next 2 years, and then advise the mother to join the family planning program in order to distance the pregnancy can be arranged. Examination of the precision of pregnant women visit each semester will make health care workers, pregnant women and families more aware of the possibility of postpartum hemorrhage after childbirth.Key words: parity, birth weight babies, pregnancy interval, a history of postpartum hemorrhage, the incidence of postpartum hemorrhage

Reported Knowledge, Attitude and Practice of Antenatal Care Services among Women in Dodoma Municipal, Tanzania

Antenatal care service is an important goal concerning in the health status of the pregnant women during their reproductive period and its health beneficial accounting for nearly one quarter of all pregnant worldwide. Early booking has an advantage for proper pregnancy information sharing and pregnancy monitoring. Unfortunately, adverse pregnancy outcome can occur even in women without identifiable risk factors. The objective of this study was to describe knowledge, attitudes and practices towards women seeking antenatal care from their previous pregnancy in Dodoma Municipal Tanzania. This was a cross sectional community based descriptive survey study. A pre-tested structured questionnaire was applied. . Among the 500 women included, 299(59.8%) was from the age group of 19 to 25 years. A total of 477(95.4%) were at the level of primary education. About 341(68.2%) of them were housewives while 155(31%) of them worked as Petty business and only 4(0.8%) worked at the public work. 101(20.2%) of women having more than three children and categorized as multipara. A total of 104 women (20.8%) had history of home delivery and only 4 women (0.8%) had history of assisted by traditional birth attendance, however highest interviewed women 257(51.4%) had the hospital delivery and 117(23.4) had delivery at the health centre. Regarding of the reproduction history, 78(15.6%) of them had experienced episode of eclampsia, 235(47%) had episode of involved with perineal tear. Only 1(0.2%) of them had history of one stillbirth before while 186(37.2%) of the interviewed women had history of postpartum haemorrhage. The highest first antenatal clinic attendance of pregnancy were 28weeks of gestation age 169(33.8%) with the few of the women had attended at 36weeks of gestation age 20(4%).Only 62(12.4%) of the women admitted that they did come for antenatal visit during the first three months and others had the late visit. However, only 92(18.4%) admitted that they had delivery by caesarian section on their previous pregnancy while 408(81.6%) of them had spontaneous vaginal delivery. Only 60(12.0%) of women had one visit of antenatal clinic and 270(54.0%) were the highest which had two visit, three were 93(18.6) and four visit were 77(12.4%). In Conclusion, ANC services, awareness and the use of supplements therapy are promising in the pregnancy women. To achieve maximum ANC services and practices among pregnancy women with high and low risk groups, there is a need to integrate public and private sector concerning ANC services planned and conducted in order to improve their maternal health and eventually improve the health status of newborn child.

Patterns of recurrence of postpartum hemorrhage in a large population-based cohort

Although a history of postpartum hemorrhage (PPH) is a recognized risk factor for PPH in subsequent pregnancies, little is known about how the risk accumulates over multiple pregnancies, how recurrence varies by PPH subtype, and whether recurrence can be explained by chronic maternal conditions. Risks of PPH were assessed according to a history of PPH, severity, and subtype (atony, retained placenta, or lacerations) in 538,332 primiparous women whose data were included in the Swedish Medical Birth Register from 1997-2009. The role of stable maternal risk factors was evaluated in regression models that predicted probability of recurrent PPH in second and third pregnancy. Women with a history of PPH had a 3-fold increased risk of PPH in their second pregnancy compared with unaffected women (15.0% vs 5.0%, respectively). Adjustment for stable maternal risk factors did not attenuate this risk significantly (adjusted relative risk, 3.0; 95% confidence interval, 2.9-3.1). In a third pregnancy, the risk of PPH was 26.6% after 2 previously affected pregnancies, compared with 4.4% in women with no previous PPH. A history of a specific type of PPH predicted recurrence of PPH in the second pregnancy, not only of the same type but other causes as well. PPH risk is highest among women with >1 previously affected delivery and in those with a previous severe PPH. Chronic conditions that are known to be risk factors for PPH do not explain the recurrence risks. The recurrence patterns across PPH subtypes may point to shared pathologic mechanisms underlying the varying PPH causes.

162: Evaluation of the efficacy of the intrauterine balloon tamponade as a second-line procedure in the management of severe postpartum hemorrhage within a perinatal network

tamponade as a second-line procedure in the management of severe postpartum hemorrhage within a perinatal network Thomas Popowski, Pierre Raynal, Patrick Rozenberg Poissy Saint-Germain Hospital, Versailles Saint-Quentin-en-Yvelines University, research unit EA 7285, Department of Obstetrics and Gynecology, Poissy, France, Mignot Hospital, Department of Obstetrics and Gynecology, Le Chesnay, France OBJECTIVE: To evaluate the efficacy of the intrauterine balloon tamponade (IUBT) as the initial second-line procedure when medical management fails in the management of severe postpartum hemorrhage (PPH). STUDY DESIGN: We carried out a prospective cohort study within a perinatal network comprising 10 perinatal units managing around 20,000 deliveries per annum. The protocol for management of PPH followed the French national guidelines. In April 2008, the IUBT using Bakri balloon was introduce in the tertiary referral university hospital and the protocol was modified to require that an IUBT test be used before any invasive procedure in PPH unresponsive to prostaglandin. The modified protocol was progressively extended to the 9 other maternities. The tamponade test was considered successful if control was achieved following inflation of the balloon. RESULTS: Between April 2008 and June 2012, 166 IUBT tests were performed. The mean maternal age was 30.4 (SD 5.2) years, the mean gestational age 39.1 (SD 2.5) WG, and the mean parity 1.1 (SD 1.2). Nineteen (11.5%) patients had a previous history of cesarean section (CS), 25 (15.1%) a previous history of PPH, 14 (8.4%) were multiple pregnancies, and 8 (4.8%) presented a placenta previa. Among the 166 patients, the mean blood loss was 1484 (SD 602) mL, 105 (63.3%) patients had blood transfusion with a mean of 3.9 (SD 2.8) units of packed red blood cells. Among the 122 patients delivered vaginally, the IUBT failed in 17 (13.9%) patients leading to 11 embolizations, 2 conservative surgical procedures, and 4 hysterectomies. Among the 44 patients delivered by CS, the IUBT failed in 10 (22.7%) patients leading to 5 embolizations, 3 conservative surgical procedures, and 2 hysterectomies. The global success rate of the IUBT was 83.7%. CONCLUSION: In the setting of PPH unresponsive to medical management, IUBT should be used as the initial second-line procedure.

Varied presentations of Sheehan's syndrome at diagnosis: A review of 18 patients.

Introduction:Sheehan's syndrome (SS) occurs due to ischemic pituitary necrosis as a result of severe postpartum hemorrhage (PPH).Aims and Objectives:The aim of the present study was to review the presenting features of SS at diagnosis.Materials and Methods:We retrospectively reviewed 18 cases of SS at diagnosis. Presenting clinical features, laboratory data, pituitary hormone deficiencies, and magnetic resonance imaging (MRI) of the sella were analyzed.Results:Age ranged from 28-71 years with a mean age of 47 ± 14.44 years. Time to diagnosis of SS was 6-33 years with a mean of 15.35 ± 6.74 years. Four (22.2%) patients were referred from emergency for hyponatremia, one each (5.6%) for hypotension, hypoglycemia, and vomiting. Three (16.7%) patients presented with asthenia and weight loss, two (11.1%) with slightly raised thyroid stimulating hormone (TSH). Only six (33.3%) presented with classic features of amenorrhea. None presented with isolated lactational failure or apoplexy after PPH. Seventeen (94.4%) patients had lactational failure; thirteen (72.2%) did not menstruate following last delivery. Lactotroph and gonadotroph failure were present in all at diagnosis but corticotrophs preservation was documented in three (16.7%) and thyrotroph in two (11.1%) patients. Twelve (66.7%) patients had empty sella while six (33.3%) had partial empty sella on MRI.Conclusion:SS has variable features at diagnosis and may present to different specialties. The clinical features of hypopituitarism are often subtle, leading to delay in diagnosis. History of PPH, lactational failure and cessation of menses are important clues. Thyrotroph, corticotroph axis may be preserved in some SS patients.

Hospital Data Reporting on Postpartum Hemorrhage: Under-Estimates Recurrence and Over-Estimates the Contribution of Uterine Atony

This study aimed to explore whether recording of a prior adverse pregnancy outcome (postpartum hemorrhage) in a medical record increases the likelihood that recurrence of the same event is reported in hospital data. Using a sample of 588 pregnancies [2 consecutive pregnancies for 294 randomly selected women with at least one postpartum hemorrhage (PPH)], we compared 'coded' recurrence rates in hospital data with those obtained from medical record audit. 'Coded' recurrence in a second pregnancy was also compared for women with or without a documented history of prior PPH. We found a 'coded' recurrence rate of 18.5% and an 'audited' recurrence rate of 28.4%. The 'coded' rate of recurrence among women who had a documented history of PPH was 27.4% compared to 19.1% when the previous PPH was not noted in the second pregnancy medical record. Medical record reporting of uterine atony as the cause for postpartum hemorrhages in first and second births was 37.9 and 34.0% while 'coded' hospital data reporting attributed 79.8 and 73.9% respectively to atony. Our study results indicate that a history of postpartum hemorrhage may be a stronger risk factor for subsequent PPH than previously demonstrated. A recorded history of PPH was associated with an increased likelihood of reporting a subsequent PPH, and in such cases recurrence rates approximate true recurrence. The contribution of uterine atony as a cause of postpartum hemorrhage is over-estimated using hospital data.

Sheehan's syndrome: Newer advances.

Sheehan's syndrome (SS) is postpartum hypopituitarism caused by necrosis of the pituitary gland. It is usually the result of severe hypotension or shock caused by massive hemorrhage during or after delivery. Patients with SS have varying degrees of anterior pituitary hormone deficiency. Its frequency is decreasing worldwide and it is a rare cause of hypopituitarism in developed countries owing to advances in obstetric care. However, it is still frequent in underdeveloped and developing countries. SS often evolves slowly and hence is diagnosed late. History of postpartum hemorrhage, failure to lactate and cessation of menses are important clues to the diagnosis. Early diagnosis and appropriate treatment are important to reduce morbidity and mortality of the patients.

Expectant and medical management of placenta increta in a primiparous woman presenting with postpartum haemorrhage: The role of Imaging

We report a case of postpartum hemorrhage due to adherent placenta. A 28 year old primiparous woman who underwent manual removal of placenta for primary postpartum haemorrhage soon after delivery was referred to our Institute on her third postnatal day because of persistent tachycardia and low grade fever. Placenta accreta was suspected on initial ultrasonographic examination. MRI examination confirmed the diagnosis of placenta accreta in few areas and revealed increta in other areas. On expectant management she developed genital tract sepsis and hence she was treated with intravenous Methotrexate after controlling infection with appropriate antibiotics. Doppler Imaging showed decreased blood flow to the placental mass and increased echogenecity on gray scale USG after Methotrexate administration. She expelled the whole placental mass on 35th postnatal day and MRI performed the next day showed empty uterine cavity. Morbid adhesion of placenta should be suspected even in primiparous women without any risk factors when there is history of post-partum hemorrhage. MRI is the best modality for evaluation of adherent placenta.

Introduction of cell salvage to a large obstetric unit: the first six months

Background We introduced red-cell salvage to our obstetric unit following a two-month period of training and education. We report a service evaluation of the first six months of activity from May to October 2007. Methods The indications for using cell salvage were: placenta praevia, suspected placental abruption, multiple pregnancy, multiple repeat caesarean, previous history of post partum haemorrhage, refusal of blood transfusion, caesarean section at full dilatation, low preoperative haemoglobin and at the discretion of the theatre team. Results The cell saver was used for 46 patients with a blood loss (median; range) of 800 (200–2000) mL and a heterologous transfusion rate of 22% (10 cases). Blood was processed and returned in 19 cases of which nine were emergency and 10 elective. The median volume (range) of blood returned was 390 (200–800) mL. For the unit as a whole the percentage of all theatre cases who received a heterologous transfusion fell from 10.2% for the equivalent time period in the preceding year to 7.9% during the six month period that cell salvage was in use ( P = 0.126, χ 2). There were no adverse reactions following the administration of processed blood. Conclusion We have successfully introduced cell salvage to our unit in a relatively short period of time and have used it for the largest series of patients reported in the UK.