Major Obstetric Haemorrhage Research Articles

Pregnancy and birth complications associations with long-term adverse maternal mental health outcomes: a systematic review and meta-analysis protocol

Background: Existing studies have established an association between pregnancy, birth complications, and mental health in the first few weeks postpartum. However, there is no clear understanding of whether pregnancy and birth complications increase the risk of adverse maternal mental outcomes in the longer term. Research on maternal adverse mental health outcomes following pregnancy and birth complications beyond 12 months postpartum is scarce, and findings are inconsistent. Objective: This systematic review and meta-analysis will examine the available evidence on the association between pregnancy and birth complications and long-term adverse maternal mental health outcomes. Methods and analysis: We will include cohort, cross-sectional, and case-control studies in which a diagnosis of pregnancy and/or birth complication (preeclampsia, pregnancy loss, caesarean section, preterm birth, perineal laceration, neonatal intensive care unit admission, major obstetric haemorrhage, and birth injury/trauma) was reported and maternal mental disorders (depression, anxiety disorders, bipolar disorders, psychosis, and schizophrenia) after 12 months postpartum were the outcomes. A systematic search of PubMed, Embase, CINAHL, PsycINFO, and Web of Science will be conducted following a detailed search strategy until August 2022. Three authors will independently review titles and abstracts of all eligible studies, extract data using pre-defined standardised data extraction and assess the quality of each study using the Newcastle-Ottawa Scale. We will use random-effects meta-analysis for each exposure and outcome variable to calculate overall pooled estimates using the generic inverse variance method. This systematic review will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Ethical consideration: The proposed systematic review and meta-analysis is based on published data; ethics approval is not required. The results will be presented at scientific meetings and publish in a peer-reviewed journal. PROSPERO registration: CRD42022359017

Vascular clamps in perimortem caesarean delivery in parturients with placenta accreta spectrum: Case report and literature review

The increasing incidence of caesarean section (CS) increases the risk for placenta accrete spectrum (PAS) conditions in pregnancy. The aortic vascular clamps can be used in low resource settings to minimise major obstetric haemorrhage in a parturient with PAS. We report one case of major obstetric haemorrhage attributable to PAS and other cases that had the potential to bleed post-return of spontaneous circulation (ROSC). The first case had torrential bleed following classical CS done for percreta leading to severe haemodynamic instability and a near arrest situation despite standard protocolised management. As a last resort to control catastrophic bleeding, the aortic vascular clamp was used to avert an imminent cardiac arrest, which successfully lead to effective resuscitation and later uneventful recovery. The second case was a perimortem caesarean delivery in a diagnosed case of placenta percreta where we contemplated to use this clamp during resuscitative hysterotomy [Perimortem caesarean delivery (PMCD)] as its usage is likely to confer haemodynamic stability post-ROSC bleeding. However, the patient could not be revived. We have found that in addition to anaesthetic and major haemorrhage management skills in tackling a massive obstetric haemorrhage, the availability of trained surgical teams for controlling ongoing haemorrhage is crucial for effective resuscitation. Using aortic and common iliac vascular clamps as a damage control measure also plays a very important role in controlling catastrophic maternal haemorrhage. With the growing incidence of PAS and uncontrolled bleeding in these parturients, the skilled anaesthetic and resuscitative skills of anaesthesiologists are futile if haemorrhage is not controlled. We found that the availability and use of the vascular clamps at the time of PMCD are very useful to control bleeding and help in effective resuscitation. Its use has a short learning curve and the personnel can be trained easily.

Prevalence, Outcome, and Predictors of Placenta Migration among Pregnant Women with Placenta Praevia in Enugu Nigeria

Abstract Background: Placenta praevia is one of the leading causes of obstetric haemorrhages and a major contributor to maternal and fetal morbidity and mortality. Although low-lying placentae are common during routine midtrimester anomaly scans, the incidence of placenta praevia at term remains low, probably due to placenta migration. It is important to follow-up pregnant women with low-lying placentae to identify the few whose placenta will remain in the lower segment and hence at risk of major obstetric haemorrhage. Aim: The objectives of this study were to determine the prevalence, predictors, and pregnancy outcome of low-lying placenta diagnosed in the midtrimester. Materials and Methods: The study was a cohort study with longitudinal follow-up of 416 pregnant women from the University of Nigeria Teaching Hospital, Enugu State University Teaching Hospital, and Mother of Christ Specialist Hospital who had an ultrasound diagnosis of low-lying placentae between 16 weeks and 20 weeks of gestation. Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 22. P < 0.05 was considered statistically significant. Results: The prevalence of low-lying placenta at 20, 24, 28, 32, and 36 weeks of gestation was 51%, 41.3%, 22.3%, 12.7%, and 10.5%, respectively. 87.3% of those with low-lying placenta had normally situated placenta at term. Previous caesarean section and male gender were significant predictors of placenta praevia at delivery (P < 0.001 and P = 0.03, respectively). Conclusion: Despite the high prevalence of low-lying placenta before 20 weeks of gestation, only a few of these placentas remain low-lying at term. Previous caesarean section and male gender were significant predictors of placenta praevia at delivery. This study recommends a routine ultrasound scan in the second or third trimester for placenta localisation.

Medical termination of pregnancy for fetal anomaly at or beyond 20weeks' gestation-What are the maternal risks?

To evaluate the common and severe maternal morbidities associated with medical termination of pregnancy (MTOP) for fetal anomaly ≥20weeks' gestation. A 10-year retrospective cohort study (January 2010-December 2019) analyzing 407 consecutive singleton pregnancies MTOP for fetal anomaly ≥20weeks' gestation, at a quaternary maternity centre in Australia (Royal Women's Hospital, Melbourne). The cohort comprised of 191 primiparous and 216 multiparous women, of whom 75 (34.7%) had at least one prior Cesarean; 13 women had a low-lying placenta or placenta praevia. The average gestation was 23weeks (interquartile range 22-26weeks). A spontaneous unassisted vaginal delivery was achieved by the majority (n=403, 99.0%). The most common maternal morbidities were transferred to the theater for manual removal of retained placental tissue (n=65, 16.0%) and postpartum haemorrhage (PPH) (n=45, 11.1%). Severe maternal morbidity occurred in six cases (1.3%) and included amniotic fluid embolism, cardiac arrest, major obstetric haemorrhage, uterine rupture and intensive care unit admission. There were no maternal deaths. The most common complications of MTOP for fetal anomaly ≥20weeks' gestation were manual removal of placenta and PPH. Severe maternal morbidity affected 1 in 81 women.

Major obstetric hemorrhage management

Postpartum hemorrhage (PPH) is to this day one of the leading causes of maternal death and its diagnosis is still highly subjective, as it relies on unprecise estimates of the amount of blood loss. There are three areas in which PPH outcomes can be improved: prevention, treatment and rescue. PPH can escalate to a graver clinical picture of Severe Acute Maternal Morbidity (SAMM) due to an inaccurate estimate of the blood loss, inability to identify an at-risk patient, delays in testing and availability of hemoderivatives, and lack of clear guidelines and interdisciplinary communication. Many factors can predispose to PPH and in clinical practice the many causes of its insurgence are summarized with the 4T formula: Tone (uterine atony), Trauma (laceration/hematoma), Tissue (retained tissue/invasive placenta), Thrombin (coagulation). Some precautions can be taken in preventing PPH such as the use of uterotonics, the administration of oxytocin, the timing of umbilical cord clamping, and the monitoring of anemia and the platelet to fibrinogen concentration ratio. In recent years studies have been published with the goal of leading PPH diagnosis and management through universal guidelines, point-of-care testing and interdisciplinary approaches. The proposed algorithms, albeit not yet validated, are useful in the clinical practice; similarly beneficial is the use of reliable predictive panels such as the Modified Early Obstetric Warning System.

Author reply: Interventions in low/middle‐income countries to reduce severe maternal morbidity due to placenta accreta spectrum and major obstetric haemorrhage

Author reply: Interventions in low/middle‐income countries to reduce severe maternal morbidity due to placenta accreta spectrum and major obstetric haemorrhage

Placenta Accreta Spectrum Disorder: Updates on Anesthetic and Surgical Management Strategies

(Int J Obstet Anesth. 2021;46:102975) Placenta accreta spectrum (PAS) is a leading cause of major obstetric hemorrhage [postpartum hemorrhage (PPH)], severe maternal morbidity and peripartum hysterectomy, and has become more prevalent over the last 70 years. This review aims to report updated information on PAS for obstetric anesthesiologists.

P.117 Improving communication during major obstetric haemorrhage

P.117 Improving communication during major obstetric haemorrhage

P.118 Survey evaluation of major obstetric haemorrhage protocols across the UK

P.118 Survey evaluation of major obstetric haemorrhage protocols across the UK

P.114 Major obstetric haemorrhage - how did we get away with not transfusing blood products?

P.114 Major obstetric haemorrhage - how did we get away with not transfusing blood products?

384 Great grand-multiparity

Introduction and aims of the study: Great grand multiparity (GGM) (a woman delivering for the 10thtime or more) has mostly disappeared in Western countries. Are great grand-multiparous women at increased risk of maternal/neonatal complications? Methods: Retrospective analysis from computerised patient records. All women with deliveries ≥ 10 between 1stJanuary 2014 and 31stDecember 2020. The incidence of diabetes mellitus, preterm birth, stillbirth, multiple pregnancies, malpresentation, Caesarean and vaginal births, uterine rupture, major obstetric haemorrhage were calculated and compared to the reported in the literature ones.

Anesthetic management of complicated placenta percreta

BackgroundPlacenta percreta is a severe form of placenta accreta in which the placenta penetrates the entire uterine wall and attaches to another organ such as the bladder and bowel. It gives rise to a major obstetric hemorrhage, peripartum hysterectomy, and maternal and fetal morbidity and mortality.Case presentationI present a 34-year-old female of 24 week gestation a case of placenta percreta with a history of bleeding per vagina for the last 1 month for that she received 11 units of blood transfusion. Placenta percreta with fetal demise was diagnosed in magnetic resonance imaging on admission. Uterine artery embolization was done to reduce perioperative bleeding. Hysterectomy was done successfully with the multidisciplinary team approach under general anesthesia.ConclusionsSo, proper preoperative planning and good communication with the multidisciplinary approach will make a better outcome in these types of cases.

Comparison of Efficacy of Refrigerated Oxytocin with Oxytocin Kept at Room Temperature for the Prevention of Post-Partum Haemorrhage in Vaginal Deliveries in a Tertiary Care Setting

Introduction: Postpartum haemorrhage is one of the leading causes of maternal death worldwide and it accounts for nearly one-quarter of all maternal deaths and almost half of all postpartum deaths in low-income countries. Primary postpartum haemorrhage (PPH) is the most common form of major obstetric haemorrhage. Materials and Methods: The study protocol was comprised of Consent, Measurement of Pre-delivery Hemoglobin, Administration of the Intervention, Measurement of postpartum blood loss and Measurement of Post-delivery (24-48 hours) Hemoglobin. Blood loss was measured using a calibrated drape. The drape was placed beneath the parturient buttocks and secured around her abdomen with ties. Blood loss was monitored for a minimum of one hour and was continued in the second hour in case of persistent bleeding. The drape with the collected blood was weighed on a scale. The weight of the drape and the container in which it is placed was deducted from the total recorded weight in order to obtain the weight of the blood collected in the drape. Blood loss weight in grams was converted to milliliters by dividing the figure in grams by 1.06 (blood density in grams per milliliter). Results: The cross tabulations were used to study the demographic, obstetrical and medical factors in women with obstetrical haemorrhage. Table 1 shows the selected sociodemographic characteristics of the study population. The mean age of cases and controls are 26.333.559 and 26.853.873 respectively. On comparison, they are statistically insignificant. (p=0.324). The educational, occupational and socioeconomic status was comparable between cases and controls (p >0.05). Table 2 shows Antenatal, intra-partum and post-partum data in cases and controls. Discussion & Conclusion: It is a study done in North India comparing the Oxytocin kept at room temperature with failure of maintenance of cold chain during transport and storage and the refrigerated Oxytocin. It is the common understanding and general training that Oxytocin must be stored in the refrigerator, failing which its efficacy reduces i.e. it, will not be effective in controlling PPH. During the study we compared the mean blood loss and change in hemoglobin levels in cases and control and despite the fact that major risk factor for PPH for example past history of PPH, past history of D&C, prolonged third stage labour duration, manual removal of placenta were comparable in both cases and controls, still the mean blood loss and change in hemoglobin values was more in cases than controls. This could be attributed to usage of market oxytocin which had failed cold chain maintenance resulted in less effective oxytocin in prevention of PPH, Hence causing more blood loss and drop in hemoglobin values. This shows the need of room temperature stable uterotonic drug in LMIC’s like ours. Recently room temperature stable carbetocin shows the potential as an effective uterotonic drug for the prevention of PPH. However according to various studies carbetocin cannot be used for induction or augmentation of labour so it cannot replace oxytocin fully, rather it acts as a part of collective PPH reduction strategy

Resurgence of classical caesarean section in current obstetric practice- A case series

Although, the incidence of placenta accreta spectrum (PAS) and large fibroids is rare but still these cases contributes to a large number of maternal morbidity and mortality. Major obstetric hemorrhage is one the dreadful complication of these types of cases and thus early diagnosis and intervention in such cases helps the physician to minimize the risk to mother and the fetus. Also, current widespread use of ultrasound has helped us to manage these cases judiciously, predict and prevent life threatening obstetric hemorrhage. Here we present three complicated obstetric cases of placenta accreta, large lower segment uterine fibroid and large cervical fibroid which necessitated classical cesarean sections (CCS) thus emphasizing prowess in CCS in modern obstetric era. High index of suspicion, Multidisciplinary approach alongwith expert surgical personnel should be available in high risks cases like placenta accreta syndrome and large fibroids in pregnancy.

Maternal morbidity and mortality: an iceberg phenomenon

To apply the iceberg model, quantifying absolute and relative incidence, to the four main causes of maternal morbidity and mortality in Ireland: haemorrhage, hypertension, sepsis and thrombosis. Secondary analysis of national data on maternal morbidity and mortality. Republic of Ireland. Approximately 715 000 maternities, 1 200 000 maternal hospitalisations, 2138 cases of severe maternal morbidity (SMM) and 54 maternal deaths. Incidence rates and case-fatality ratios were calculated. Maternal death, SMM and hospitalisation. At the 'tip of the iceberg', the incidence of maternal death per 10 000 maternities was 0.09 (95% CI 0.03-0.20) due to thrombosis and 0.03 (95% CI 0-0.11) due to haemorrhage, hypertension disorders or sepsis. For one death due to thrombosis there were 35 cases of pulmonary embolism and 257 thrombosis hospitalisations. For one death due to eclampsia, there were 58 eclampsia cases, 13 040 hospitalisations with pre-existing hypertension and 40 781 hospitalisations with gestational hypertension. For one death due to pregnancy-related sepsis, there were 92 cases of septicaemic shock and 9005 hospitalisations with obstetric sepsis. For one maternal death due to haemorrhage, there were 1029 cases of major obstetric haemorrhage and 53 715 maternal hospitalisations with haemorrhage. For every 100 maternities, there were approximately 16 hospitalisations associated with haemorrhage, 12 associated with hypertension disorders, three with sepsis and 0.2 with thrombosis. Haemorrhage and hypertension disorders are leading causes of maternal morbidity in Ireland but they have very low case fatality. This indicates that these morbidities are managed effectively but their prevention requires more focus. Study shows that haemorrhage and hypertension are main causes of #maternalmorbidity in Ireland. Timely interventions for #maternalhealth and focus on prevention of severe and non-severe morbidities are needed. @NPEC #maternityservices #clinicalaudit #qualityimprovement.

Clinical Results of a Massive Blood Transfusion Protocol for Postpartum Hemorrhage in a University Hospital in Japan: A Retrospective Study.

Background and objectives: Massive postpartum hemorrhage (PPH) is the most common cause of maternal death worldwide. A massive transfusion protocol (MTP) may be used to provide significant benefits in the management of PPH; however, only a limited number of hospitals use MTP protocol to manage massive obstetric hemorrhages, especially in Japan. This study aimed to assess the clinical outcomes in patients in whom MTP was activated in our hospital. Materials and Methods: We retrospectively reviewed the etiology of PPH, transfusion outcomes, and laboratory findings among the patients treated with MTP after delivery in our hospital. Results: MTP was applied in 24 cases (0.7% of deliveries). Among them, MTP was activated within 2 h of delivery in 15 patients (62.5%). The median estimated blood loss was 5017 mL. Additional procedures to control bleeding were performed in 19 cases, including transarterial embolization (18 cases, 75%) and hysterectomy (1 case, 4.2%). The mean number of units of red blood cells, fresh frozen plasma, and platelets were 17.9, 20.2, and 20.4 units, respectively. The correlation coefficients of any two items among red blood cells, fresh frozen plasma, platelets, blood loss, and obstetrical disseminated intravascular coagulation score ranged from 0.757 to 0.892, indicating high levels of correlation coefficients. Although prothrombin time and activated partial thromboplastin time levels were significantly higher in the <150 mg/dL fibrinogen group than in the ≥150 mg/dL fibrinogen group at the onset of PPH, the amount of blood loss and blood transfusion were comparable between the two groups. Conclusions: Our MTP provides early access to blood products for patients experiencing severe PPH and could contribute to improving maternal outcomes after resuscitation in our hospital. Our study suggests the implementation of a hospital-specific MTP protocol to improve the supply and utilization of blood products to physicians managing major obstetric hemorrhage.

COMPARATIVE STUDY BETWEEN CARBETOCIN VERSUS OXYTOCIN FOR THE PREVENTION OF ATONIC POSTPARTUM HEMORRHAGE AFTER REPEATED ELECTIVE CESAREAN SECTIONS

Background: Postpartum hemorrhage (PPH) is a serious condition remaining the single main cause of maternal morbidity and mortality. Objective: To compare the prophylactic effects of carbetocin with those of oxytocin in the prevention of atonic PPH in patients undergoing repeated elective cesarean section (CS) under spinal anesthesia. Patients and Methods: This comparative study was conducted on 100 pregnant women after 38 weeks underwent elective cesarean section under spinal anesthesia at Al- Azhar University Hospitals (Al- Hussein and Bab Al- Shaaria Hospitals) from April 2019 to October 2020, 50 patients received a single dose of 100 microgram intravenous carbetocin, the other 50 patients received 5 IU of oxytocin IV followed by 20-40 IU of oxytocin infusion on 1000 ml saline with a rate of 150 ml per hour. Results: Patients who received carbetocin developed less major obstetric hemorrhage, required less intervention in the form of uterine massage and less additional uterotonic agents than those received oxytocin. The estimated blood loss was significantly lower in the carbetocin group than the oxytocin group. Also, the carbetocin group showed less incidence of severe anemia and the need for blood transfusion than oxytocin but that was statistically insignificant. Conclusion: Carbetocin appeared to be effective or more as oxytocin for prevention of atonic postpartum hemorrhage in patients undergoing elective cesarean section. Carbetocin reduced the use of additional oxytocics following cesarean section when compared with the licensed dose of oxytocin (5 IU). Also, carbetocin improved the hemodynamic states of the patients, decreased the need for blood transfusion and incidence of severe anemia.

P.27 Anaesthesia at the extremes of obstetric haemorrhage

Introduction: Major obstetric haemorrhage may be defined as blood loss > 1.5 L. A subgroup of women suffer more extreme haemorrhage, with associated morbidity and mortality. Placenta accreta spectrum (PAS) may result in catastrophic haemorrhage and/or caesarean hysterectomy, posing a significant challenge for surgical and anaesthetic teams. With the UK rate of caesarean section now 30%, [1] Sultan P, Sultan E, Carvalho B. Regional anaesthesia for labour, operative vaginal delivery and caesarean delivery:a narrative review. Anaesthesia 2021. 76:136-47. Google Scholar the incidence of PAS is rising. Following several cases of massive haemorrhage associated with PAS in our tertiary unit, a multidisciplinary evaluation of the management of women with haemorrhage > 3 L and/or PAS over 3 years was undertaken.

P.85 Re-audit of the management of blood product administration for major obstetric haemorrhage

Introduction: Major obstetric haemorrhage (MOH) is a leading cause of morbidity and mortality worldwide accounting for 12.6% of direct maternal deaths in the 2015-17 MBRRACE-UK report. [1] Knight M, Bunch K, Tuffnell D et al. (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care-Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015–17. Oxford: The National Perinatal Epidemiology Unit, University of Oxford 2020. Google Scholar Point-of-care (POC) testing (ROTEM/TEG) has been recommended by the RCOA, OAA and Association of Anaesthetists, to improve patient care, allowing cost-effective, real-time haemostatic resuscitation. Local hospital policy for MOH recommends 1:1 transfusion of RBC:FFP or as directed by TEG. Following a 2016 audit, [2] Niewiarowski J, Russell R. Management of blood product administration for major obstetric haemorrhage. OAA Obstetric Anaesthesia 2017. https://www.epostersonline.com/oaa2017/node/690?view=true Google Scholar a visual aid using TEG traces was designed to guide blood product replacement. Re-audit in 2018, [3] Niewiarowski J, Smith A, Russell R. Improving the management of blood product administration for major obstetric haemorrhage. Int J Obstet Anesth 2019;39/S1:S50. Google Scholar showed significant improvement in protocol adherence and led to the purchase of two TEG6 machines. This audit aimed to re-evaluate adherence to hospital guidelines and use of TEG6 to streamline transfusion of blood products.

P.61 Evaluation of major obstetric haemorrhage management in a tertiary unit

Introduction: Major obstetric haemorrhage (MOH) is a leading cause maternal morbidity/mortality. [1] Knight M, Bunch K, Tuffnell D et al. (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care- Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015 –17. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2019. Google Scholar Optimal blood and blood product transfusion is pivotal to preventing coagulopathy, and complements pharmacological/surgical treatments. We reviewed management of MOH in our unit.