Management Of Postpartum Hemorrhage Research Articles

Code Crimson: A Postpartum Hemorrhage Bundled Intervention Quality Improvement Project.

Postpartum hemorrhage (PPH) is a leading cause of maternity mortality in the United States. The Code Crimson project aimed to enhance PPH management by implementing a standardized intervention bundle to mitigate morbidity and mortality associated with PPH. At a large Philadelphia tertiary hospital, health disparities existed for severe maternal morbidity and mortality, and PPH was a significant factor. A quality improvement design, using Plan-Do-Study-Act cycles and interrupted time series analysis, was undertaken. The Code Crimson project implemented a standardized bundle to manage PPH, including blood product administration and massive transfusion protocol activation. After implementing the Code Crimson bundle, there was a significant decrease in blood product use (P <.001), with minor reductions in packed red blood cell administration over 4 units and mean blood loss. The Code Crimson bundle effectively reduced blood product utilization for PPH treatment.

Uterine Artery Embolization Versus Hysterectomy in Postpartum Hemorrhage: A Systematic Review With Meta-Analysis.

The objective of this study is to perform a meta-analysis comparing the effectiveness of uterine artery embolization (UAE) versus peripartum hysterectomy for acute refractory postpartum hemorrhage (PPH) control. We systematically searched 6 medical databases for studies comparing UAE and hysterectomy in PPH. Outcomes examined were mortality, hospitalization duration (HD) in days, and red blood cells (RBC) units utilization. Statistical analysis used RevMan 5.1.7 and random-effects models. Odds ratios (OR) and mean differences (MDs) with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively. We included 833 patients from 4 cohort studies, with 583 (70%) undergoing UAE. The UAE population required fewer RBC units (MD: -7.39; 95% CI: -14.73 to -0.04; p=0.05) and had shorter HD (MD: -3.22; 95% CI: -5.42 to -1.02; p=0.004). Lower mortality rates were noted for UAE in the pooled analysis, but no statistical significance. Uterine artery embolization demonstrated lower procedural complications (16.45% vs. 28.8%), in which UAE had less ureter and bladder lesions (OR: 0.05; 95% CI: 0.01-0.38; p=0.004 and OR: 0.02; 95% CI: 0.00-0.15; p<0.001, respectively). Only 35 (6%) required conversion to hysterectomy, while 27 (4.6%) underwent re-embolization with 100% bleeding control. Uterine artery embolization did not hinder fertility, with normal menstruation restored in 19 patients with postoligomenorrhea. Uterine artery embolization for the control of PPH is associated with lower use of RBC units and HD, but similar rates of mortality are noted when compared to hysterectomy. These results associated with uterine preservation could support its importance for refractory PPH management. Uterine Artery Embolization is associated with a shorter hospitalization duration and reduced use of red blood cell units when compared with hysterectomy in refractory postpartum hemorrhage. Although demonstrating similar mortality rates, these findings, together with fertility preservation, support the method incorporation as a valuable option in obstetric services.

Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus

ObjectiveThere are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international...

Rotational thromboelastometry for the transfusion management of postpartum hemorrhage

Rotational thromboelastometry for the transfusion management of postpartum hemorrhage

Evaluating the Quality of Postpartum Hemorrhage Nursing Care Plans Generated by Artificial Intelligence Models.

With the rapidly advancing technological landscape of health care, evaluating the potential use of artificial intelligence (AI) models to prepare nursing care plans is of great importance. The purpose of this study was to evaluate the quality of nursing care plans created by AI for the management of postpartum hemorrhage (PPH). This cross-sectional exploratory study involved creating a scenario for an imaginary patient with PPH. Information was put into 3 AI platforms (GPT-4, LaMDA, Med-PaLM) on consecutive days without prior conversation. Care plans were evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scale. Med-PaLM exhibited superior quality in developing the care plan compared with LaMDA ( Z = 4.354; P = .000) and GPT-4 ( Z = 3.126; P = .029). Our findings suggest that despite the strong performance of Med-PaLM, AI, in its current state, is unsuitable for use with real patients.

Clinical and biological factors associated with red blood cell transfusion during severe postpartum haemorrhage – A single-center retrospective cohort study

IntroductionRed blood cell (RBC) transfusions are of utmost importance in the management of severe post-partum haemorrhage. Although the recommendations for blood transfusion protocols are regularly issued, there are significant differences in management depending on the context and the medical teams involved. ObjectiveTo determine during the first 24 h, the clinical and biological factors associated with the decision for RBC transfusion during severe PPH (≥1000 mL) for vaginal and caesarean deliveries. Study designMonocentric retrospective study conducted in a tertiary care university maternity unit (CHI-Creteil) including all parturients from November 23th 2018 to 31th December 2020 with severe PPH (≥1000 mL). ResultsOver the study period, we reported 7103 deliveries, out of which 682 were complicated by PPH (9.6 %) with 200 cases of PPH ≥1000 mL (2.8 %). In our study, 40 % of patients (80/200) required a RBC transfusion”. After multivariate analysis, severe PPH caused by placental abruption, uterine rupture or placental implantation disorders (aOR = 3.48 IC95 [1.27–9.52], p < 0.001), estimated blood loss ≥1500 mL (aOR = 9.60 IC95 [3.69–24.95], p < 0. 001), invasive measures such as uterine balloon tamponade, arterial ligation and uterine packing (aOR = 4.15 IC95 [1.80–9.61], p < 0.001), pre-labor hemoglobin <10 g/dL (aOR =4.88 IC95 [1.57–15.15], p < 0.001) or abnormal biological results in the acute phase (including hemoglobin <7.0 g/dL and/or fibrinogen <2 g/L and/or platelets <100 G/L) (aOR =356 IC95 [1,05–12,10], p < 0.001) were significantly and independently associated with the decision to initiate RBC transfusions. ConclusionsIn a monocentric retrospective study including 200 consecutive cases of severe PPH (≥1000 mL) we identified groups of clinical and biological factors directly accessible to clinicians, significantly and independently associated with RBC transfusion in the first 24 h of management.

Tranexamic acid versus oxytocin for primary postpartum Haemorrhage in the out-of-hospital setting: A systematic review with implications for rural practice.

Primary postpartum haemorrhage causes approximately 25% of global maternal deaths and accounts for significant maternal morbidity. While high certainty evidence demonstrates that tranexamic acid reduces comparative blood loss in postpartum haemorrhage in hospital settings, limited data exist on the specific pharmacological management of this condition in out-of-hospital settings, and the implications for rural communities. To determine the efficacy of oxytocin compared to tranexamic acid in women suffering postpartum haemorrhage in the out-of-hospital environment. A systematic review comparing evidence containing patients with postpartum haemorrhage in the out-of-hospital and/or rural setting, in which oxytocin/tranexamic acid were used. Outcome measures were comparative blood loss/haemorrhagic shock, the need for further interventions and maternal/neonatal morbidity/mortality. No randomised control trials have been conducted in an out-of-hospital environment in relation to oxytocin/tranexamic acid. In this setting, there is no difference in outcome measures when using oxytocin compared to no intervention, or oxytocin compared to standard care. Data are lacking on the effect of tranexamic acid on the same outcome measures. Rural and out-of-hospital management of postpartum haemorrhage is limited by resource availability and practitioner availability, capacity and experience. In-hospital evidence may lack transferability, therefore direct evidence on the efficacy of pharmacological management in these contexts is scant and requires redress. There is no difference in blood loss, neonatal or maternal mortality or morbidity, or need for further interventions, when using oxytocin or TXA compared to no intervention, or compared to standard care, for PPH. Further studies are needed on the efficacy of these drugs, and alternate or co-drug therapies, for PPH in the out-of-hospital environment and rural clinical practice.

Use of Fibrinogen in Prevention and Management of Postpartum Haemorrhage in High Risk Patient

Use of Fibrinogen in Prevention and Management of Postpartum Haemorrhage in High Risk Patient

How to choose and apply a uterine compression suture for the management of postpartum hemorrhage?

SynopsisB‐Lynch 1 uterine compression suture is useful for bleeding from the uterine body and “B‐Lynch 2” (transverse B‐Lynch) for bleeding from the lower uterine segment.

Maternal mortality review in a major tertiary referral hospital in Liberia, 2018–2021

ObjectivesAnecdotal evidence showed increased maternal deaths at the major tertiary hospital over the past two years (2020–2021). We reviewed the maternal death audit data, identified the main causes of maternal death, and associated risk factors. Findings were shared with policymakers to help reduce maternal mortality. Study designWe conducted a secondary data review and descriptive analysis of maternal death at the tertiary hospital located in Monrovia. MethodThe maternal death data were extracted from patient medical records, including death certificates and maternal audit records. The record of live births was obtained from the delivery register. Data were analyzed using Epi Info version 7.2 Maternal mortality ratio (MMR) was estimated, the leading direct and indirect causes of maternal death were identified, and the factors associated with maternal death were explored using logistic regression at a 5% level of significance. ResultsThere are a total of 233 maternal deaths and 14, 879 live births giving a maternal mortality ratio (MMR) of 1565 per 100,000 live births during the period under review. The median age of the mothers at death was 29 (14–45) years. About 40.3% (94/233) of cases died within <1 day of admission, referrals accounted for 59% (137/233) of the cases. Direct causes of death accounted for 66% (147/223). Hemorrhage [30.6% (45/147)], Eclampsia [(30/147) 20.6%] and Sepsis [(30/147) 20.6%] were the main direct causes of death while cardiovascular-related [18.4% (14/76)] and HIV/AIDS [16% (12/76)] were the leading indirect cause of death. Patients from referred other facilities were 7.9 times more likely to die as compared to non-referral (pOR:7.9, 95%CI: 5.9–10.6, p < 0.001). ConclusionThe maternal mortality ratio remained high. Referrals were done late. The Liberia Ministry of Health should equip more secondary-level health facilities and tertiary hospitals to handle maternal emergencies and sensitize the populace and healthcare workers on prompt identification and referral of obstetric emergencies. The MoH also needs to improve the blood transfusion services to help in the management of postpartum hemorrhage.

Reducing trainee mistakes. Better performance with changing to a high-fidelity simulation system?

Postpartum hemorrhage is a significant cause of both maternal morbidity and mortality worldwide and is increasing in incidence. This study aimed to assess improvement and identify shortcomings in trainee performance in different simulation systems in the management of postpartum hemorrhage. To perform a pilot study evaluating and comparing high- and low-fidelity simulation models, assessing improvement in repeated performance with high-fidelity mode and identifying mistakes made assessed using Objective Structured Assessment of Technical Skills and thereby exploring what aspects of emergency management of postpartum hemorrhage should be prioritized in teaching settings and assessing what simulation setup is most effective in achieving competence. This was a prospective randomized, single-blinded, single-institution trial in a population of 17 junior obstetrical trainees at the Charité University Hospital Obstetric Simulation Center in Berlin. Trainees were randomized into 2 groups, with either initial low-fidelity simulation or high-fidelity simulation, followed by repeated assessment of performance, using the high-fidelity model simulation system. Individual simulation sessions were video-recorded and transcribed, and the timing of interventions was documented. Strandardized Objective Structured Assessment of Technical Skills forms were used as a checklist for performance. There was a statistically significant general improvement in performance (P=.02; 24.7-27.2 of 31.0 points; average of 8.7%) in the second cycle of simulation assessment and a statistically significant training effect (P=.043; 24.4-28.4 of 31.0 points; average of 12.9%) in the group that underwent repeat simulation assessment from the initial low-fidelity system to the high-fidelity system compared with the group using the same high-fidelity setup (P=.276; 25.0-25.8 of 31.0; average of 2.4%). There was an improvement in the performance when trainees underwent a repeated cycle of simulation assessment changing from a low-fidelity system to a high-fidelity system. Simulation assessment can identify mistakes and learning gaps that are important for obstetrical trainees. This study found that trainees make the same mistakes, regardless of which simulation model was initially used.

Role of intensive care in management of post-partum hemorrhage (PPH)

The management of obstetric emergencies is a challenge and in most hospital setting the management in intensive care is ill-defined. A multidisciplinary approach to the management of obstetric emergency helps to give favorable outcome. In low resource setting, maternal care can be challenging as it faces lack of infrastructure facilities, specialist trained in intensive care, availability of drugs and equipment. Though early intervention is the need of hour there are delays in seeking healthcare due to lack of awareness, financial constraints, culture and beliefs. This article describes the approach to management of PPH in intensive care, defining clear transition from labor care to intensive care should occur.

Perception of health care providers on the quality of oxytocin across six E-MOTIVE Trial sites in Kenya

Background: According to the WHO, in 2020, almost 800 women died daily from preventable causes related to pregnancy and childbirth. An estimated 95% of these deaths were in low- and middle-income countries (LMICs). Postpartum hemorrhage (PPH), excessive bleeding after childbirth, is a leading cause of maternal death globally. Of the estimated 95% of maternal deaths in LMIC, an unacceptable 95% were due to PPH. A significant barrier to women receiving PPH treatment is access to quality PPH medicines, which is the basis for reducing maternal mortality. The E-MOTIVE Trial Kenyan hub conducted an online survey on September after the E-MOTIVE trial findings were released. This survey assessed the perception of health care providers’ (HCPs) of the quality of oxytocin in Augmentation of Labour, Active Management of third Third Stage of Labor (AMSTL), including PPH management.  Methods: An online survey was conducted using the Survey Monkey platform in Gatundu level 4 hospital, Makindu subcounty hospital, and Vihiga, Embu, Nyeri, and Kakamega county referral hospitals. The survey targeted HCPs working within the respective maternity units. The results were analyzed in Excel.  Results: 56 HCPs across the 6 health facilities participated in the survey. On augmentation of labor, Oxymed Medisel and Oxytocin Umedical were perceived to be more effective, while a score of 100% with Curtocin and Oxyt Kilitch were perceived to be very ineffective. On AMSTL, Oxymed Medisel, Syntocinin Norvatis, and Oxytocin Laborate were perceived to be very effective, whereas Curtocin and Oxyt Kilitch were perceived to be very ineffective. On PPH management, Oxytocin Umedical, Syntocinon Norvatis, and Oxytocin Laborate were perceived to be very effective, whereas Curtocin and Oxyt Kilitch were perceived to be very ineffective. Oxytocin Laborate was available across the health facilities, with other brands lacking in some facilities. Conclusion: Access to and availability of quality PPH medicines are key to effectively managing PPH and reducing maternal mortality.

HAYMAN COMPRESSION SUTURES : AN UNDERUTILIZED TOOL FOR MANAGEMENT OF UTERINE ATONY AND POSTPARTUM HAEMORRHAGE.

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in low- andmiddle-income countries. Uterine atony accounts for 70–80% of PPH cases. Management of PPH isusually based on a cascade beginning with the use of uterotonics and eventually hysterectomy in casesof refractory PPH. Different compression suture techniques have been described and used for themanagement of uterine atony where medical management is insufficient and preservation of fertility isdesired.Case presentation: This is a series of four patients who presented to our facility and consequentlydeveloped uterine atony that was unresponsive to medical management during cesarean delivery despitethe use of multiple uterotonics. All four patients had established risk factors for uterine atony, includinginduction of labor, augmentation of labor, chorioamnionitis, or fetal macrosomia. Hayman compressionsutures were performed in all four patients with success. Estimated blood loss in the series ranged from400 to 1200 mls. All patients recovered well with no complications reported during the postpartum period.Conclusion: Hayman compression sutures offer an alternative to the more ubiquitous B-Lynch suturewith several advantages, including ease of placement and no need for a hysterotomy in PPH post vaginalbirth or placement post repair of hysterotomy in cesarean cases. Thus, the may be easier to perform forjunior health care professionals as well as in stressful situations.

Hepatitis B virus infection during pregnancy and the risk of postpartum hemorrhage: a protocol for systematic review and meta-analysis

Background: Hepatitis B virus (HBV) infection is a significant public health issue worldwide, with a hepatitis B surface antigen (HBsAg) seroprevalence of 3.5%. Maternal HBV infection during pregnancy, a common comorbidity, is associated with an increase in the risk of adverse obstetric and perinatal outcomes. However, the relationship between maternal HBV infection and postpartum hemorrhage (PPH), a leading contributor to maternal morbidity and mortality, is currently uncertain. The aim of this study is to comprehensively clarify the potential impact of maternal HBV on PPH risk. Methods and Analysis: The authors initially searched five English databases and three Chinese databases from their inception to 26th June 2023. Two reviewers will independently conduct study selection, data extraction, and quality assessment. Cohort and case–control studies investigating the effect of maternal HBV infection on PPH will be included, with study quality assessed using the Newcastle–Ottawa Scale (NOS). Meta-analyses will be performed using a fixed-effects model for I 2≤50% or a random-effects model otherwise. Several categories of subgroup analyses (e.g. sample size more than 1000 vs. less than 1000) and sensitivity analyses (e.g. omit NOS scores less than 7) will be conducted, and publication bias will be assessed through funnel plots, Begg’s and Egger’s tests using STATA 18.0. Ethics and Dissemination: This systematic review and meta-analysis do not require ethics approval and the results will be published in peer-reviewed journals. The findings of this systematic review will provide evidence on the impact of maternal HBV infection on PPH, which will contribute to better prevention and management of PPH in clinical practice and a better understanding of the disease burden of HBV infection. PROSPERO registration number: CRD42023442626

Clinical Prediction of Retained Products of Conception: Combining Obstetric History and Ultrasound for Improved Accuracy in Severe Postpartum Hemorrhage.

Background The current challenge is how to improve the management of postpartum hemorrhage (PPH) to reduce the maternal mortality rate further. This study aimed to investigate whether a combined specific obstetric history and ultrasonographic findings can improve the predictive accuracy of retained products of conception (RPOC) with severe PPH. Methods This retrospective study included 56 patients who were diagnosed with RPOC. We extracted the following clinical data: obstetric history of second-trimester miscarriage, the time at which there was clinical suspicion of RPOC after the previous pregnancy (TIME), grayscale ultrasonographic finding (RPOC long-axis length [SIZE]), and color Doppler ultrasonographic finding based on the Gutenberg classification (RPOC hypervascularity). In this study, we defined cases requiring blood transfusion therapy or transcatheter arterial embolization as severe PPH. The patients were divided into two groups according to the presence or absence of severe PPH. The predictors of severe PPH were evaluated using logistic regression models. Model A comprised a combination of second-trimester miscarriage and TIME, Model B comprised a combination of Model A and long-axis SIZE, and Model C comprised a combination of Model B and RPOC hypervascularity. Results The multivariable analysis showed that long-axis SIZE was the only significant predictor of severe PPH (odds ratio [OR], 10.38; 95% confidence interval [CI], 2.06-63.86) independent of second-trimester miscarriage, TIME, and RPOC hypervascularity. The c-statistic was higher in Model C (OR, 0.863; 95% CI, 0.731-0.936) than in Model A (OR, 0.723; 95% CI, 0.551-0.847) and Model B (OR, 0.834; 95% CI, 0.677-0.923). Conclusion Combining a specific obstetric history (second-trimester miscarriage and TIME) and ultrasonographic findings (long-axis SIZE and RPOC hypervascularity) improves the predictive accuracy of RPOC with severe PPH. This prediction model may be a useful clinical screening tool for RPOC with severe PPH.

Uterotonic Management of Postpartum Hemorrhage in Pregnancies Affected by Intra-amniotic Infection

Uterotonic Management of Postpartum Hemorrhage in Pregnancies Affected by Intra-amniotic Infection

A Multilobulated Intramural Fibroid in Pregnancy: A Clinical Case Report

Leiomyoma is the most common benign tumor of the female reproductive tract. It is prevalent among women in the age group 30 to 50 years. Other than placental estrogens and progesterone, a range of endocrine and paracrine factors have their impact on fibroid blood supply, growth rate, and risk of degeneration during the gestational and puerperal periods. The current case report is about a 30-year-old primigravida with pregnancy and a large fibroid presenting with complications such as malpresentation and pressure symptoms, ending up in a cesarean section at 36 weeks delivering a live baby with a birth weight of 2.5 kgs and a large fibroid weighing 6.4 kg. During the pregnancy, there was adequate fetal development, without major maternal complications. There were four crucial issues: tailored pregnancy surveillance, the decision of time and route of delivery, postpartum hemorrhage management, the decision to perform an interval myomectomy, and the management of decreasing blood loss perioperatively.

Uterine Balloon Tamponade: An Effective Tool for Managing Postpartum Haemorrhage

This article explores the crucial subject of Uterine Balloon Tamponade (UBT) as a very efficient method for controlling postpartum haemorrhage (PPH). Maternal mortality continues to be a pressing issue in global health, with postpartum haemorrhage playing a prominent role in this troubling pattern. This study investigates the versatile operational processes of UBT devices, with a particular focus on their capacity to stimulate uterine receptors, initiate contractions, and exert hydrostatic pressure to halt bleeding sinuses. The research highlights the crucial importance of healthcare workers, namely nurses, in promptly identifying and skillfully implementing UBT to achieve hemostasis. This resource offers a comprehensive examination of the many factors that contribute to postpartum haemorrhage (PPH), including uterine atony and retained placental fragments. It emphasises the need of implementing focused therapies to address these causes. The article highlights the worldwide inequalities in maternal healthcare and proposes comprehensive measures to tackle shortcomings in healthcare facilities, improve accessibility, and invest in highly qualified healthcare professionals. Evidence-based procedures, including UBT, are promoted for wider application, needing intensive instructional programs for healthcare practitioners. It is recommended that policymakers give high importance to maternal health on the international agenda, promoting cooperation across different fields of study and involving the community. In conclusion, the abstract highlights the need of taking proactive steps and working together to include UBT as a primary intervention in the management of PPH, with the main objective of decreasing global maternal death rates.

Efficacy of Bakri Intrauterine Balloon in Managing Postpartum Hemorrhage: A Comparative Analysis of Vaginal and Cesarean Deliveries with Placenta Accreta Spectrum Disorders.

BACKGROUND The incidence of placenta accreta spectrum disorder (PAS) has been increasing in past decades, and women with PAS are a high-risk maternal population. This study aimed to explore the performance of Bakri intrauterine balloon tamponade (IUBT) in the treatment of postpartum hemorrhage (PPH), among those with and without PAS. MATERIAL AND METHODS The outcomes of 198 women who underwent treatment for PPH using IUBT were retrospectively analyzed. The demographics and maternal outcomes were analyzed for vaginal and cesarean births, with PAS and without PAS. RESULTS Compared to women with vaginal births (n=130), women who underwent cesarean births (n=68) showed a higher proportion of age ≥35 years (χ²=6.85, P=0.013), multiple births (χ²=13.60, P<0.001), preeclampsia (χ²=9.81, P=0.002), use of transabdominal IUBT (χ²=84.12, P<0.001) and pre-IUBT interventions (χ²=41.61, P<0.001), but had less infused volume of physiological saline (t=6.41, P<0.001). Women with PAS (n=105) showed a higher rate of pre-IUBT intervention (χ²=4.96, P=0.029) and transabdominal IUBT placement (χ²=9.37, P=0.002) than non-PAS women (n=93). The 36 women with PAS (n=36) showed a higher rate of preeclampsia (χ²=4.80, P=0.029), pre-IUBT intervention (χ²=5.90, P=0.015), and transabdominal IUBT placement (χ²=14.94, P<0.001) and a shorter duration from delivery to Bakri insertion (χ²=3.31, P=0.002), than non-PAS women (n=32). CONCLUSIONS PAS was a major cause of PPH at 198 vaginal and cesarean births. An accurate and timely pre-IUBT intervention and Bakri IUBT placement was critical for controlling PPH in cesarean births, especially in women with PAS.