Incidence Of Severe Postpartum Hemorrhage Research Articles

Cephalad-caudad vs transverse blunt expansion of low transverse hysterotomy during caesarean section and risk of severe postpartum haemorrhage: A prospective comparative study

BackgroundThe global prevalence of caesarean section as a delivery method is increasing worldwide. However, there is notable divergence among countries in their national guidelines regarding the optimal technique for blunt expansion hysterotomy of the low transverse uterine incision during caesarean section (cephalad-caudad or transverse). AimTo compare the risk of severe postpartum haemorrhage (PPH) between cephalad-caudad and transverse blunt expansion hysterotomy during caesarean section. MethodsThis prospective comparative observational study was conducted in a university maternity hospital. All women who gave birth to one infant by caesarean section after 30 weeks of gestation between November 2020 and November 2021 were included in this study. The exclusion criteria were a coagulation disorder, the presence of placenta previa, multiple pregnancies, or enlargement of the hysterotomy with scissors. The choice between cephalad-caudad or transverse blunt expansion of the low transverse hysterotomy was left to the surgeon’s discretion. The primary outcome measure was severe PPH, defined as estimated blood loss ≥ 1000 ml. Univariate and multivariate analyses were employed to assess the risk of severe PPH associated with the two methods of enlarging the low transverse hysterotomy. ResultsThe study included 850 women, of whom 404 underwent transverse blunt expansion and 446 underwent cephalad-caudad blunt expansion. The overall incidence of severe PPH was 13.3 %. Univariate analysis revealed no significant difference in the frequency of severe PPH between the cephalad-caudad and transverse blunt expansion groups (13.9 % vs 12.6 %; p = 0.61). However, the use of additional surgical sutures (mainly additional haemostatic stitches) was less common with cephalad-caudad blunt expansion (26.7 % vs 36.9 %; p < 0.05). Multivariate analysis showed no significant difference in risk between the two techniques (odds ratio 1.17, 95 % confidence interval 0.77–1.78). ConclusionNo significant difference in the risk of severe PPH was found between cephalad-caudad and transverse blunt expansion of the low transverse hysterotomy during caesarean section.

Trends in severe postpartum haemorrhage among nulliparous women with spontaneous onset of labour: A population-based cohort study.

To investigate the incidence of severe postpartum haemorrhage among nulliparous women with a spontaneous onset of labour at term from 2000 to 2020. Population-based cohort study. National, using the Medical Birth Registry of Norway. Women (n = 330 244) who gave birth to their first singleton child in a cephalic presentation after a spontaneous onset of labour at term. Cross-tabulations and regression analysis with generalised linear models were used to assess time trends and adjust for potential confounding factors. We also stratified the analyses by maternal age groups, obstetric interventions, mode of delivery and institution size. Time trends were analysed using periods of 5 or 6 years as a unit, and the period from 2000 to 2004 was used as the reference. Severe postpartum haemorrhage (PPH) was defined as blood loss of >1500 mL within 24 h and/or in combination with blood transfusion. Severe PPH occurred in 7601/330 244 (2.30%) women. The incidence increased from 1.24% in 2000-2004 to 3.83% in 2015-2020 (adjusted relative risk, aRR 2.90; 95% CI 2.70-3.12). Changes in maternal characteristics or obstetric interventions did not explain the increase, and we found similar increases across institutions of all sizes. The incidence of severe PPH among nulliparous women increased almost threefold over 21 years. The current high incidence warrants urgent efforts to assess unknown risk factors, the health care provided and health system factors that may contribute to the increase, to inform improvements in care.

Clinical analysis of 102 cases of labor induction in the third trimester on twin pregnancy

Objective: To investigate the clinical characteristics of induced labor in twin pregnancy and the related factors of induced labor failure. Methods: The clinical data of twin pregnant women who underwent induced labor in Peking University Third Hospital from January 2016 to December 2022 were retrospectively analyzed. According to whether they had labor or not after induction, pregnant women were divided into the success group (pregnant women who had labor after induction, 72 cases) and the failure group (pregnant women who did not have labor after induction, 30 cases). Logistic regression was used to analyze the related factors of induction failure in twin pregnant women. Results: The parity and cervical Bishop score in the failure group were significantly lower than those in the success group, while the proportion of dichorionic diamniotic twins, assisted reproductive technology pregnancy and cervical Bishop score <6, postpartum hospital stay and total hospital stay in the failure group were significantly higher than those in the success group (all P<0.05). The proportion of induced labor by artificial rupture of membranes ± oxytocin intravenous infusion in the success group was 72.2% (52/72), which was significantly higher than that in the failure group (46.7%, 14/30; P=0.030). There were no significant differences between the two groups in the gestational age at delivery, the incidence of severe postpartum hemorrhage and blood transfusion, the amount of postpartum hemorrhage, the neonatal weight of two fetuses, the incidence of neonatal asphyxia, and the proportion of neonates admitted to the neonatal intensive care unit (all P>0.05). There were no severe perineal laceration and hysterectomy in all pregnant women. Multivariate logistic regression analysis showed that primipara (OR=3.064, 95%CI: 1.112-8.443; P=0.030) and cervical Bishop score <6 (OR=5.208, 95%CI: 2.008-13.508; P=0.001) were the independent risk factors for induction failure in twin pregnancy. Conclusions: Elective induction of labor in twin pregnancy is safe and feasible. It is helpful to improve the success rate of induction of labor by strictly grasping the timing and indications of termination of pregnancy, choosing the appropriate method of induction according to the condition of the cervix, and actively promoting cervical ripening.

Incidence of postpartum hemorrhage based on the improved combined method in evaluating blood loss: A retrospective cohort study.

In view of the current clinical inaccuracies and underestimations of postpartum hemorrhage amount, this study aims to investigate the incidence, etiology, clinical characteristics of postpartum hemorrhage in different modes of delivery based on the combination of volumetric method, gravimetric method and area method in evaluating blood loss. This retrospective cohort study was conducted in Hangzhou Women's Hospital from January 2020 to June 2021, including 725 cases of postpartum hemorrhage among 18,977 parturients. Based on different modes of delivery, the participants were divided into three groups: vaginal delivery, forceps delivery, and cesarean section, for comparison. Using an improved combined assessment method for blood loss, we retrospectively analyzed a cohort of parturients with postpartum hemorrhage who underwent vaginal delivery, forceps delivery, or cesarean section and were hospitalized in Hangzhou Women's Hospital from January 2020 to June 2021. (1) Among the 18,977 parturients, 725 cases of postpartum hemorrhage occurred, with an incidence rate of 3.8%, and severe postpartum hemorrhage accounted for 0.4% of the cases. (2) The incidence of postpartum hemorrhage was significantly higher in the forceps delivery group than in the vaginal delivery group (χ2 = 19.27, P<0.001), while the incidence of severe postpartum hemorrhage was significantly higher in the cesarean section group than in the vaginal delivery group (χ2 = 8.71, P = 0.003). (3) The causes of postpartum hemorrhage were statistically different among the different delivery modes, with varying underlying factors (P<0.001). (4) Patients with postpartum hemorrhage in different delivery modes showed statistically significant differences in age, body mass index (BMI), birth weight, gestational age, gravidity, parity, the decline of postpartum peripheral blood hemoglobin concentration, and estimated blood loss (P<0.05). (5) The proportion of blood transfusion was significantly higher in the cesarean section group than in the vaginal delivery and forceps delivery groups (χ2 = 231.03, P<0.001). This study is a single-center retrospective study, which may have led to selection bias in case selection. Additionally, the implementation of the combined three blood loss assessment methods may not have been strictly followed in all cases. Moreover, due to the mixing of bleeding with amniotic and irrigation fluids, the accuracy of evaluation may have been affected, leading to the possibility of inaccuracy of blood loss. Forceps delivery and cesarean section increase the risk of postpartum hemorrhage, but forceps delivery does not significantly increase the incidence of severe postpartum hemorrhage. Uterine atony remains the leading cause of postpartum hemorrhage, while birth canal laceration and placental factors are the second most common causes of postpartum hemorrhage in forceps delivery and cesarean section, respectively. In this study, the volumetric method, gravimetric method and area method were combined to quantitatively assess postpartum hemorrhage amount. The combined method has strong clinical practicability and is less affected by subjective factors, although it also has limitations. In the future, we still need to focus on the early prediction and identification of postpartum hemorrhage, and further improve the quantitative assessment of postpartum blood loss.

Efficacy of early intrauterine balloon tamponade for immediate postpartum hemorrhage after vaginal delivery: a randomized clinical trial

Many questions remain about the appropriate use of intrauterine balloon devices in postpartum hemorrhage after vaginal delivery refractory to first-line uterotonics. Available data suggest that early use of intrauterine balloon tamponade might be beneficial. This study aimed to compare the effect of intrauterine balloon tamponade used in combination with second-line uterotonics vs intrauterine balloon tamponade used after the failure of second-line uterotonic treatment on the rate of severe postpartum hemorrhage in women with postpartum hemorrhage after vaginal delivery refractory to first-line uterotonics. This multicenter, randomized, controlled, parallel-group, nonblinded trial was conducted at 18 hospitals and enrolled 403 women who had just given birth vaginally at 35 to 42 weeks of gestation. The inclusion criteria were a postpartum hemorrhage refractory to first-line uterotonics (oxytocin) and requiring a second-line uterotonic treatment with sulprostone (E1 prostaglandin). In the study group, the sulprostone infusion was combined with intrauterine tamponade by an ebb balloon performed within 15 minutes of randomization. In the control group, the sulprostone infusion was started alone within 15 minutes of randomization, and if bleeding persisted 30 minutes after the start of sulprostone infusion, intrauterine tamponade using the ebb balloon was performed. In both groups, if the bleeding persisted 30 minutes after the insertion of the balloon, an emergency radiological or surgical invasive procedure was performed. The primary outcome was the proportion of women who either received ≥3 units of packed red blood cells or had a calculated peripartum blood loss of >1000 mL. The prespecified secondary outcomes were the proportions of women who had a calculated blood loss of ≥1500 mL, any transfusion, an invasive procedure and women who were transferred to the intensive care unit. The analysis of the primary outcome with the triangular test was performed sequentially throughout the trial period. At the eighth interim analysis, the independent data monitoring committee concluded that the incidence of the primary outcome did not differ between the 2 groups and stopped inclusions. After 11 women were excluded because they met an exclusion criterion or withdrew their consent, 199 and 193 women remained in the study and control groups, respectively, for the intention-to-treat analysis. The women's baseline characteristics were similar in both groups. Peripartum hematocrit level change, which was needed for the calculation of the primary outcome, was missing for 4 women in the study group and 2 women in the control group. The primary outcome occurred in 131 of 195 women (67.2%) in the study group and 142 of 191 women (74.3%) in the control group (risk ratio, 0.90; 95% confidence interval, 0.79-1.03). The groups did not differ substantially for rates of calculated peripartum blood loss pf ≥1500 mL, any transfusion, invasive procedure, and admission to an intensive care unit. Endometritis occurred in 5 women (2.7%) in the study group and none in the control group (P=.06). The early use of intrauterine balloon tamponade did not reduce the incidence of severe postpartum hemorrhage compared with its use after the failure of second-line uterotonic treatment and before recourse to invasive procedures.

Incidence and predictors of severe postpartum hemorrhage after cesarean delivery in South Central Ethiopia: a retrospective cohort study

Severe postpartum hemorrhage is an obstetric emergency that needs immediate intervention and is a leading cause of maternal death. Despite its significant health burden, little is known, about its magnitude and risk factors, especially after cesarean delivery in Ethiopia. This study aimed to evaluate the incidence and predictors of severe postpartum hemorrhage following cesarean section. This study was conducted on 728 women who underwent cesarean section. We retrospectively collected data from the medical records, including baseline characteristics, obstetrics, and perioperative data. Potential predictors were investigated using multivariate logistic regression analyses, adjusted odd ratios, and a 95% confidence interval to see associations. A p-value < 0.05 is considered statistically significant. The incidence of severe postpartum hemorrhage was 26 (3.6%). The independently associated factors were previous CS scar ≥ 2 (AOR 4.08: 95% CI 1.20–13.86), antepartum hemorrhage (AOR 2.89: 95% CI 1.01–8.16), severe preeclampsia (AOR 4.52: 95% CI 1.24–16.46), maternal age ≥ 35 years (AOR 2.77: 95% CI 1.02–7.52), general anesthesia (AOR 4.05: 95% CI 1.37–11.95) and classic incision (AOR 6.01: 95% CI 1.51–23.98). One in 25 women who gave birth during cesarean section experienced severe postpartum hemorrhage. Considering appropriate uterotonic agents and less invasive hemostatic interventions for high-risk mothers would help to decrease its overall rate and related morbidity.

Literature Review: Perbedaan Pemberian Oksitosin Profilaksis Secara Intravena dan Intramuskular Terhadap Kejadian Perdarahan Postpartum

Postpartum Haemorrhage is a condition of blood loss of more than 500 cc that occurs within 24 hours after delivery. Postpartum hemorrhage is a significant cause of morbidity and mortality in childbirth. Postpartum Haemorrhage occurs in about 1% to 6% of all deliveries. Uterine atony, the leading cause of primary postpartum hemorrhage, accounts for 70% to 80% of all bleeding. Early prevention in postpartum hemorrhage cases is the usage of uterotonics in the third stage of labor which has become the standard of intervention worldwide. The choice of uterotonic in managing postpartum hemorrhage should be adjusted to the administration and dosage. This Study aims to analyze the difference in prophylactic administration of oxytocin injected in intramuscular and intravenous during postpartum hemorrhage. Data were searched using PICO, articles were selected using PRISMA, and critical appraisal. There is decreased postpartum hemorrhage compared to IM oxytocin administration. Intra Vena oxytocin administration could reduce the incidence of severe postpartum hemorrhage and prevent blood transfusions compared to IM oxytocin administration in the third stage of labor in postpartum hemorrhage. However, there was no significant difference in hemoglobin changes. The side effects caused by intravenous administration are still manageable compared to intramuscular administration. Intravenous oxytocin prevented postpartum hemorrhage in stage III more effectively than intramuscular administration. The side effects that emerged in the two groups of intravenous and intramuscular administration were not significantly different and were still within mild limits. The administration of oxytocin in preventing postpartum hemorrhage in the third stage of labor has become a procedure and recommendation of health organizations.

Effect of induction of labor on maternal and perinatal outcomes in low-risk singleton pregnancies: a retrospective case-control study.

The aim of the study was to investigate the effect of induction of labor on maternal and fetal outcomes. This retrospective case-control study included 4386 pregnant women with low-risk singleton pregnancies who underwent regular prenatal examination and successful vaginal delivery at ≥41 weeks and 0 days of gestation in Fujian Maternal and Child Health Hospital between January 2014 and December 2018. Clinical data of women were retrospectively divided into the induction of labor group (2007 cases) and spontaneous onset of labor group (2361 cases) based on the mode of labor initiation. Two-sample independent t-test and χ2 tests were used to analyze the differences in clinical characteristics, such as maternal age and parity between the two groups. The induction of the labor group had a significantly longer total duration of labor (9.37±5.37 vs. 8.82±5.13 h; p<0.001), more postpartum blood loss (219.18±188.32 vs. 199.95±124.69 mL; p=0.01) and a significantly higher incidence of severe postpartum hemorrhage (PPH) comparing to the spontaneous onset of labor group [0.8% (16/2007) vs. 0.33% (8/2361); p=0.041]. However, no significant difference was found in the neonatal outcomes. After adjusting for age, induction of labor in nulliparous women was more likely to lead to PPH than the spontaneous onset of labor [2.74% (55/2007) vs. 1.65% (39/2361); odds ratio=1.557; 95% confidence interval: 1.039-2.332; p<0.05]. Induction of labor increases the duration of labor and postpartum blood loss, especially in primary parturient, leading to an increased risk of PPH. This increase may be related to the overall higher duration of labor, associated with IOL. Therefore, low-risk nulliparous women should try to avoid induction of labor without medical indications.

Perinatal outcome of pregnant women with adenomyosis

Objective: To analyze the effect of pregnancy with adenomyosis on perinatal outcome. Methods: From April 2014 to April 2019, singleton pregnant women complicated with adenomyosis in Peking University Third Hospital was selected and the perinatal outcomes were analyzed retrospectively. Results: The age of patients in the pregnancy with adenomyosis group (study group) was not different from that of the control group (median: 35 vs 34 years old, P>0.05); the body mass index was higher than that of the control group (median: 23.9 vs 21.8 kg/m2, P<0.01); the rate of assisted reproductive technology was significantly higher than that of the control group [25.3% (64/253) vs 3.1% (8/257), P<0.01]. Compared with the control group, the gestational age at delivery was significantly lower in the study group (median: 38.0 vs 39.2 weeks, P<0.01); the rates of preterm birth [17.1% (44/257) vs 4.7% (12/257), P<0.01] and preeclampsia [13.7% (35/255) vs 5.8% (15/257), P=0.003] were significantly higher in the study group. The incidence of severe postpartum hemorrhage in the study group was significantly higher than that in the control group [5.8% (14/241) vs 1.2% (3/257), P=0.004]. The incidence of cesarean section was higher in the study group [(57.0% (146/256) vs 31.5% (81/257), P<0.01]. Neonatal weight was lower in the study group than that in the control group (median: 3 140 vs 3 440 g, P<0.01); the incidence of small for gestational age (SGA) was higher in the study group [21.5% (55/256) vs 4.7% (12/257), P<0.01]. There were no significant differences in umbilical artery pH and 1-minute Apgar score between the study group and the control group (all P>0.05). Conclusions: Pregnant women complicated with adenomyosis has low fertility, and most of them need assisted reproductive technology to conceive. The pregnant women with adenomyosis has the poor perinatal outcome, including an increased incedence of preterm birth, preeclampsia, postpartum hemorrhage, cesarean section and SGA, and low newborn weight.

Relation of meconium-stained amniotic fluid and postpartum hemorrhage: a retrospective cohort study.

Postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. The purpose of this study was to evaluate if meconium-stained amniotic fluid (MSAF) is a risk factor for PPH after vaginal delivery. We retrospectively analyzed medical records of all patients who had a vaginal delivery at Fujian Provincial Maternity and Children's Hospital, between 1st January 2013 to 31st December 2018. Women with cesarean deliveries, multiple pregnancies, abnormal coagulation profile, and those with concomitant liver or kidney disorders were excluded. Patients were classified into MSAF (n=13686) and clear amniotic fluid (AF) (n=41511) groups. The incidence of PPH was significantly higher at 2.7% (370/13686) in the MSAF group as compared to 2.18% (904/41511) in the clear AF group (p=0.0004). There was no difference in the incidence of severe PPH between the two groups. Statistically significant difference in the incidence of PPH between MSAF and clear AF was seen in the maternal age groups of 30-34 and 35-39 years, gestational age>40weeks and >3 gravidity (p<0.05). Our study demonstrates that MSAF is a significant risk factor for minor and moderate PPH. Presence of meconium could therefore alert clinicians to expect PPH and make arrangements for further patient management. Further basic research is required to evaluate the mechanism by which meconium influences the incidence of PPH.

Different management for women in the third stage of labour

Active management of the third stage of labour involves giving a prophylactic uterotonic, early cord clamping, controlled cord traction and uterine massage. Active management of the third stage, as the main package of procedure to prevent postpartum hemorrhage, can effectively shorten the third stage of labor and reduce the incidence of severe postpartum hemorrhage, this is a major cause of women dying in developing countries. In developed countries, severe bleeding occurs much less often, yet active management has become standard practice in many countries for several decades. The most common complications of active management of the third stage of labor are pain and side effects of oxytocin, in addition to serious complications such as inversion of uterus and retained placental. Therefore, in recent years, a variety of interventions have been adopted in the third stage of labour, especially for low-risk pregnant women, which have been questioned and the evidence for using active management for all women is insufficient. The purpose of this article is to compare the effectiveness and variations of different management of the third stage of labour, and provide the basis for reasonable and individualized management of the third stage of labour, ultimately promote the natural labour. Key words: The third stage of labour; Active management; Expectant management; Mixed management

Prophylactic management of postpartum haemorrhage in the third stage of labour: an overview of systematic reviews

BackgroundPostpartum haemorrhage is a direct cause of maternal death worldwide and usually occurs during the third stage of labour. Most women receive some type of prophylactic management, which may include pharmacological or non-pharmacological interventions. The objective of this study was to summarize systematic reviews that assessed the effects of postpartum haemorrhage prophylactic management during the third stage of labour.MethodsWe applied the guidelines for conducting an overview of reviews from the Cochrane Handbook for Systematic Reviews of Interventions. We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews to identify all relevant systematic reviews of randomized controlled trials of prophylactic management of postpartum haemorrhage in the third stage of labour compared with no treatment, placebo, or another management technique. Two review authors independently extracted data and assessed methodological quality using a measurement tool to assess reviews and quality of evidence using the Grades of Recommendation, Assessment, Development, and Evaluation for primary outcomes, summarizing results narratively.ResultsWe identified 29 systematic reviews: 18 Cochrane and 11 non-Cochrane. Cochrane systematic reviews were high quality, while the quality of non-Cochrane systematic reviews varied. The following techniques suggested effective, third-stage interventions to reduce the incidence of severe postpartum haemorrhage: active management of the third stage of labour compared to physiological management, active management compared to expectant management, administration of oxytocin compared to placebo, and use of tranexamic acid compared to placebo. The following third-stage management approaches reduced the need for blood transfusion: active management compared to physiological management, active management compared to expectant management, oral misoprostol compared to placebo, and tranexamic acid compared to placebo.ConclusionsNo effective prophylactic management techniques were identified for maternal mortality. Most methods of effective prophylactic management of postpartum haemorrhage were supported by evidence; however, they were limited to low- or moderate-quality evidence, and high-quality studies are therefore needed. Outcome measures of the included systematic reviews varied. It is recommended that outcome measures in preventive postpartum haemorrhage intervention trials align with the World Health Organization guidelines.Systematic review registrationPROSPERO: CRD42016049220.

Effect of twin pregnancy chorionic properties on maternal and fetal outcomes

ObjectiveThis study aimed to determine the effect of twin pregnancy chorionic properties on pregnancy complications and fetal outcomes. Materials and methodsA total of 559 subjects with gemellary pregnancy were included in the retrospective analysis, and clinical data, such as monitoring data during pregnancy and maternal and fetal outcomes, were recorded in detail. Based on the ultrasound results and methods of the postpartum pathologic examination of the placental membranes, the subjects were divided into the twin group with monochorionic diamnion (MCDA group, n = 198) and twin group with dichorionic diamnion (DCDA group, n = 361). The relationships of different chorionic properties and maternal and fetal outcomes were determined by comparing the maternal complications and fetal outcomes. ResultsThe occurrence rate of gemellary pregnancy was 2.97% and that of monochorionic twin pregnancy was 34.8%. The MCDA group showed a higher incidence of pregnancy-induced hypertension, gestational diabetes mellitus, polyhydramnios, premature rupture of membranes, and abruptio placenta and a lower incidence of severe postpartum hemorrhage than the DCDA group. However, the incidence of preterm birth was significantly different (57.6% vs. 45.7%, P < 0.05). Significant differences were also detected in the incidence of fetal loss, complicated twins, neonatal asphyxia, and perinatal death between the two groups (P < 0.05). ConclusionThe incidence of maternal complication (such as pregnancy-induced hypertension, gestational diabetes mellitus, polyhydramnios, premature rupture of membranes, and abruptio placenta and severe postpartum hemorrhage) in the two groups was not significantly different; however, the fetal outcomes in the MCDA group were inferior to those in the DCDA group. The fetal outcomes may be improved by determining the chorionic properties in early pregnancy by using ultrasound and consequently planning for pregnancy monitoring and intervention.

Nationwide survey of severe postpartum hemorrhage in Japan: an exploratory study using the national database of health insurance claims

Aim: The aim of this study was to investigate epidemiological and clinical aspects of severe postpartum hemorrhage (PPH) in Japan.Methods: We used national health insurance claims from 2011 to 2014 provided by the Ministry of Health, Labour and Welfare. The data included randomly selected claims that covered 10% of all inpatients in October, a so-called sampling dataset (covering 1/120 inpatients per year). We extracted claims for transfused blood, and further narrowed down the claims by names of diseases linked to PPH. As most referral obstetric facilities have adopted the diagnosis procedure combination (DPC)-based payment system while small-scale obstetric facilities have not (non-DPC facilities), the claims were also analyzed separately for DPC and non-DPC facilities. We assessed the incidence and causes of PPH, transfusion volume of red blood cells (RBC) and fresh frozen plasma (FFP), and surgical hemostatic management.Results: The number of PPH cases that required blood transfusion in the sampling dataset was 29, 29, 32, and 36 in 2011, 2012, 2013, and 2014, respectively. The leading cause of PPH was uterine atony followed by placental abruption. Although no specific trends were observed for the volume of transfused RBC (1467 ± 234 ml in 2014), there was a steady increase in the rate of FFP utilization in non-DPC facilities from 37% to 79% over the 4-year sampling period. Intrauterine balloon tamponade emerged in 2014.Conclusion: This nationwide survey indicates that the annual incidence of severe PPH is increasing. Furthermore, FFP has become more prevalent in small-scale obstetric facilities.

Cezarean Hysterectomy, A lifesaving Procedure that Albanian Obstetricans Must Be Familiar With

Cesarean Hysterectomy refers to emergency peripartum hysterectomy - EPH, which is performed as a life-saving procedure in cases of continual obstetric hemorrhage secondary to uterine atony, uterine rupture, placental disorders, fibroids, and lacerations during cesarean section - CS or vaginal parturition. Emergency peripartum hysterectomy - EPH, although rare in modern obstetrics, remains a life- saving procedure in cases of severe hemorrhage. In contemporary obstetrics, the overall incidence of severe postpartum hemorrhage was reported to occur in 6.7/1,000 deliveries worldwide. It is one of the leading causes of maternal mortality and morbidity and represents the most challenging complication that an obstetrician will face. The incidence of peripartum hysterectomy in the literature is reported as 0.24, 0.77, 2.3, and 5.09 per 1,000 deliveries by many authors mentioning a few; Sakse et al., White- man et al., Bai et al., and Zeteroglu et al., respectively. Nevertheless, there is a lack of Albanian data on EPH. To our knowledge, there is no Portuguese information on postpartum hemorrhage and EPH, which does not mean that we do not have such obstetrical complications and therefore such emergency intervention. This paper’s intention is to bring awareness of such catastrophic obstetrical complications especially in young primigravida and primipara women.

Place of Tranexamic Acid and Fibrinogen Association in the Management of Severe Postpartum Haemorrhage

Introduction: Severe postpartum hemorrhage (PPH) is the main cause of death in Tunisia. Its management is multidisciplinary and requires perfect knowledge of a regularly updated protocol and consistent with available resources. We propose an evaluation of the impact of different therapeutic attitudes, in particular the combination of tranexamic acid and fibrinogen concentrates in the management of this hemorrhage. Material and Methods: This was a retrospective, descriptive and analytical study, conducted in the departments of Gynecology-Obstetrics and Surgical Resuscitation anesthesia of the Farhat Hached University Hospital, Sousse, Tunisia. The study was conducted over six years (2009-2014), and included all parturients who were treated for severe PPH that occurred on a term greater than 24 weeks of amenorrhea. Patients were divided into two groups according to the study period: 1) Group 1 (G1): from 1 January 2009 to 31 December 2011, 2) Group 2 (G2): from January 1, 2012 to December 31, 2014, a group that benefited particularly from the combination of tranexamic acid and fibrinogen concentrates for the management of their PPH. Results: 166 patients were included: 57 in G1 and 109 in G2. The overall incidence of severe PPH was 3.15/1000 deliveries. We noted a significant decrease in the fall of hemoglobin in per and post haemorrhagic manifestations in favor of G2 with a p value of 0.003 and p = 0.025, respectively. The use of blood transfusion decreased significantly, in frequency and in number of packed red cells per patient, between the two groups; transfusion ratio was 1/1.7/1.5 for G1, and 1/2/1.8 for G2. Fluid therapy, use of macromolecules and catecholamines were less important in G2. The use of tranexamic acid, fibrinogen and the association of both increased significantly between the two groups (p 10-4). Haemostasis hysterectomies were less performed (p 10-3) in G2. Conclusion: The management of PPH has evolved over the years. The use of tranexamic acid in association with fibrinogen concentrates had proved his interest.

Trends in conservative procedures and peripartum hysterectomy rates in severe postpartum haemorrhage

Objective: The objective of this study is to explore whether increase in use of second-line conservative surgical procedures will alter the rate of peripartum hysterectomies in management of severe postpartum haemorrhage (PPH).Methods: This is a retrospective cohort. All pregnant patients with gestation > = 28 weeks with severe PPH (> = 1.5 L) within 72 h of delivery from year 2000 to 2015 (16-year period) in an obstetric training unit was recruited. Basic patient anthropometric characteristics and the main causes for PPH were calculated. The incidence of any second-line conservative surgical procedures and peripartum hysterectomies were evaluated. The total number of patients in each category was then stratified into four 4 years-intervals (4 quadrennium) to compare trends.Results: The incidence of severe PPH gradually increased over the study period (lowest 0.21% in 2002 to 0.76% in 2015) (p < .001). There is an obvious increasing trend in the overall use of second-line surgical procedures from nil to 82% (p < .001), with balloon tamponade constituting up to 48%. The incidence of successful second-line procedures increased gradually from 72.2% in the second quadrennium to 89% in the fourth quadrennium. The total peripartum hysterectomy rate among cases of severe PPH could be seen to drop from 40.2% in the first to 10.9% in the fourth quadrennium (p = .04).Conclusions: Despite the increasing trends in PPH, the increasing utilisation of second-line conservative surgical procedures in severe PPH should be able to reduce the need for peripartum hysterectomy.

Risk factors for severe postpartum hemorrhage: a case-control study

BackgroundIn high-income countries, the incidence of severe postpartum hemorrhage (PPH) has increased. This has important public health relevance because severe PPH is a leading cause of major maternal morbidity. However, few studies have identified risk factors for severe PPH within a contemporary obstetric cohort.MethodsWe performed a case-control study to identify risk factors for severe PPH among a cohort of women who delivered at one of three hospitals in Norway between 2008 and 2011. A case (severe PPH) was classified by an estimated blood loss ≥1500 mL or the need for blood transfusion for excessive postpartum bleeding. Using logistic regression, we applied a pragmatic strategy to identify independent risk factors for severe PPH.ResultsAmong a total of 43,105 deliveries occurring between 2008 and 2011, we identified 1064 cases and 2059 random controls. The frequency of severe PPH was 2.5% (95% confidence interval (CI): 2.32–2.62). The most common etiologies for severe PPH were uterine atony (60%) and placental complications (36%). The strongest risk factors were a history of severe PPH (adjusted OR (aOR) = 8.97, 95% CI: 5.25–15.33), anticoagulant medication (aOR = 4.79, 95% CI: 2.72–8.41), anemia at booking (aOR = 4.27, 95% CI: 2.79–6.54), severe pre-eclampsia or HELLP syndrome (aOR = 3.03, 95% CI: 1.74–5.27), uterine fibromas (aOR = 2.71, 95% CI: 1.69–4.35), multiple pregnancy (aOR = 2.11, 95% CI: 1.39–3.22) and assisted reproductive technologies (aOR = 1.88, 95% CI: 1.33–2.65).ConclusionsBased on our findings, women with a history of severe PPH are at highest risk of severe PPH. As well as other established clinical risk factors for PPH, a history of severe PPH should be included as a risk factor in the development and validation of prediction models for PPH.

Incidence of immediate postpartum hemorrhages in French maternity units: a prospective observational study (HERA study).

BackgroundMost estimates of postpartum hemorrhage (PPH) are calculated from studies that use administrative or medical birth databases, and only a few from prospective observational studies.Our principal objective was to estimate the incidence of PPH according to their severity (mild or severe) in vaginal deliveries (>500 mL, ≥1000 mL) and cesareans (>1000 mL and ≥1500 mL). The secondary objectives were to describe the incidence of PPH according to maternity unit characteristics, causes, and types of PPH management.MethodsThis prospective observational study took place in French maternity wards. Women who gave birth at a term ≥ 22 weeks were eligible for the study. 182 maternity units participated in a study with prospective data collection from 1 February, 2011, to 31 July, 2011. The main outcome measure was PPH incidence.ResultsPPH incidence after vaginal delivery was 3.36 % [95 % CI: 3.25–3.47 %] and after cesareans 2.83 % [95 % CI: 2.63–3.04 %]. The incidence of severe PPH after vaginal delivery was 1.11 % [95 % CI: 1.05–1.18 %] and after cesareans 1.00 % [95 % CI: 0.88–1.13 %]. This incidence rate varied according to maternity unit characteristics. The principal cause of PPH for both modes of delivery was uterine atony (57.7 % for vaginal births and 66.3 % for cesareans). Vascular embolization was more frequent among women with cesareans (10.0 vs. 2.9 %), who also required transfusions more often (44.4 vs 12.7 %).ConclusionsThe incidence of PPH was lower than the rate expected from the literature. Effective treatment of uterine atony and optimizing the identification of blood loss remain important priorities.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-1008-7) contains supplementary material, which is available to authorized users.

A double centre retrospective study into rates of postpartum haemorrhage in women on low molecular weight heparin

A double centre retrospective study into rates of postpartum haemorrhage in women on low molecular weight heparin