Massive Obstetric Haemorrhage Research Articles

Tranexamic acid for the prevention and treatment of postpartum hemorrhage in resource-limited settings: a literature review.

Postpartum haemorrhage is a major cause of maternal morbidity and mortality worldwide. Early recognition and appropriate treatment are crucial for managing postpartum haemorrhage. This literature review aimed to evaluate the efficacy of tranexamic acid in the prevention and treatment of postpartum haemorrhage in resource-limited settings. This literature review was conducted based on the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. A computerized systematic search of the MEDLINE (PubMed), Google Scholar, and Cochrane databases using a combination of the following Medical Subject Headings (MeSH) terms for PubMed: [(obstetric haemorrhage OR postpartum haemorrhage OR massive obstetric haemorrhage) AND (tranexamic acid OR antifibrinolytic drugs) AND (prophylaxis OR prevention) AND (management OR treatment) AND (resource-limited settings OR resource-limited area OR developing countries)] to find articles published in English since 2010. Studies on the obstetric population who underwent vaginal or caesarean delivery, comparing the use of tranexamic acid versus placebo (or no treatment) for treatment (or prevention) of postpartum haemorrhage with the outcome of postpartum haemorrhage rate, blood transfusion requirements, uterotonics requirements, hysterectomy, or mortality were included. In total, 5315 articles were identified. Following the elimination of duplicates, the methodological quality of 15 studies was evaluated independently, with eligibility determined based on the inclusion and exclusion criteria, as well as outcome variables. Finally, eight articles were included in the review. This review provides evidence that the administration of tranexamic acid has the potential to decrease the need for blood transfusion, incidence of postpartum haemorrhage, demand for supplementary uterotonics, and maternal morbidity and mortality with marginal adverse effects. Healthcare systems must develop and implement interventions that involve the use of tranexamic acid for the treatment of postpartum haemorrhage in resource-limited settings.

The Association between Placenta Previa in Pregnant Women with Previous Caesarian Section at Combined Military Hospital

Background: Placenta praevia is defined as a placenta implanted partially or completely over the lower uterine segment. Placenta praevia is a major cause of massive obstetric bleeding that leads to significant maternal morbidity and mortality. In the present day, the hypothesis is that previous cesarean section is the risk of development of placenta praevia.
 Objective: To assess the relationship between placenta praevia and previous cesarean section.
 Material and Methods: It was a descriptive cross-sectional study carried out in the Department of Obstetrics and Gynaecology, Combined Military Hospital, Dhaka, from July 2021 to July 2022. Total 35 patients with placenta praevia were included in this study. Informed verbal and written consent were taken from the study participants. A detailed history was taken, general physical and per abdominal examination and previous records were reviewed properly. Placenta praevia was diagnosed by patient clinical presentation, ultrasonogram, and incidentally during cesarean section.
 Results: The study shows the incidence of placenta praevia was 1.75% and incidence of placenta praevia in woman with previous caesarean section was 1% compared with 0.75% without previous caesarean section. The commonest age group was 26-30 years, which included 44%, and 32% belonged to 31-35 years age group. The mean age was 29.28± 10 years. Most of the patients were multigravida (62%). In maximum number of cases, (52%) were admitted at the gestational period between 35-38 weeks. Common clinical presentations were per vaginal bleeding 84% and 16% of patients were symptomatic. Regarding preoperative findings, 30(62.5%) patients had average preoperative bleeding. Postpartum hemorrhages corrected conservatively were 14(29.1%), and postpartum hemorrhage needed hysterectomy were 4(8.3%). In patients with no history of previous cesarean section 90% were delivered by cesarean section and 10% were delivered vaginally. Among patients with a history of the previous cesarean section all patients underwent cesarean section.
 Conclusion: There is a strong association between having a previous caesarean delivery and the subsequent development of placenta praevia. The risk increases with the number of cesarean sections. So, pregnant women with a history of caesarean section must be regarded as high risk for placenta praevia and must be monitored carefully.

Placenta Previa, Percreta – A Case Report of Successful Management

Background: Placenta percreta is a rare complication of pregnancy and is associated with significant postpartum hemorrhage. Incidence of morbidadherant placenta has dramatically increased due to increasing caesarean section rate all over the world. Placenta percreta is the most severe form of morbid adherent placenta. It frequently results in maternal morbidity and mortality which is mainly caused by massive obstetric hemorrhage emergency hysterectomy. Majority of these cases are seen in patient with history of previous LSCS with anterior low lying placenta. Here we present a case of placenta in lower segment with percreta in a women with H/O previous 2 C/S with large fibroid in fundus. J Com Med Col Teachers Asso Jan 2023; 27(1): 34-37

A comprehensive approach to the prevention and treatment of massive obstetric hemorrhage

In the case of progression of obstetric haemorrhage (OH) and non-effective preventive and therapeutic measures during childbirth and after delivery, the volume of blood loss can increase and exceed > 1.5% of body weight (25–30% of circulating blood volume – CBV). In such cases that we are talking about massive obstetric haemorrhage (MOH), which leads to an increase in the frequency of maternal morbidity and mortality.The objective: determine the effectiveness of various approaches to the restoration of blood loss in the cases of MOH development, which occurred to various etiological factors, with the introduction of the modern concept of damage control resuscitation (DCR) and innovative methods of surgical hemostasis.Materials and methods. During 2015–2023 years at five clinical bases of the Department of Obstetrics and Gynecology N1 of Shupyk National Healthcare University of Ukraine we analyzed 165 cases of MOH. In all MOH cases, an integrated approach was used to stop haemorrhage using both drug therapy and modern methods of surgical hemostasis in accordance with the regulatory documents of the Ukrainian Ministry of Healthcare.In main group of 59 women in labor with the MOH (2020–2023 years) an integrated approach to stop haemorrhage and restore the blood loss according to DCR concept with the priority of high-quality and rapid CBV restoration with blood products and minimization of infusion therapy was used. The comparison group consisted of 106 women in labor with MOH (2015–2019 years) and similar methods of haemorrhage termination to restore blood loss in accordance with the order N 205 of the Ukrainian Ministry of Healthcare «Obstetric haemorrhage» with the priority of rapid restoration of blood loss by crystalloids (during 2015–2019 years).Results. The mean blood loss, time till haemorrhage is stopped, and the duration of surgery in the main group were significantly lower than in the comparison group (p<0.05). In the postpartum period the number of cases with severe anemia was significantly more often in the comparison group – 47.2% versus 11.9% in the main group (OR 6.6 CI 2.7–15.9; p<0.01), as well as the frequency of hysterectomy – 50.9% versus 28.8% (OR 2.6 CI 1.3–5.1; p<0.01).An early onset and a significantly higher rate of transfusions of fresh frozen plasma and erythrocyte mass were found in the main group – respectively 88.1% versus 38.7% in the comparison group (OR 11.7, CI: 4.8–28.4; p<0.001). This resulted in a significantly lower volume of blood loss, duration of surgical intervention, and average time for haemorrhage stop in the main group compared to the comparison group (p<0.05).Conclusions. The use of modern uterotonic agents (carbetocin), tranexamic acid preparations, innovative surgical technologies and early initiation of transfusion therapy with blood preparations with minimization of crystalloid infusion and according to the DCR concept for the development of MOH allows to reduce the volume of blood loss, the frequency of severe postpartum complications, and to prevent maternal morbidity and death.

Role of pelvic packing in massive obstetric haemorrhage with severe coagulopathy: a case report

Role of pelvic packing in massive obstetric haemorrhage with severe coagulopathy: a case report

Health status of children born from pregnant women with placenta accreta

One of the frequent causes of massive obstetric bleeding is placenta accreta, an unpredictable and iatrogenic pathology, where maternal mortality varies from 7 to 52%. The purpose of the study: to assess the condition of newborns from pregnant women with placenta accreta.Material and methods. Seventy pregnant women and their 70 newborns were examined, of which: 40 with placenta accreta and their 40 newborns who made up the 1st group; 30 healthy pregnant women and their 30 newborns who made up the 2nd control group. A retrospective analysis of the course of gestation and perinatal outcomes was carried out. Questionnaire charts were compiled to collect obstetric, gynecological and somatic history. The assessment of newborns was carried out on the Apgar score at the 1st and 5th minutes. Ultrasound and neurosonography of newborns were used.Results. Analyzing the results of the study, it was found that women with placenta accreta often have a violation of utero-placental-fetal circulation, childbirth ends prematurely, while premature babies are often born in a state of asphyxia. These children have a high incidence of neurological disorders, more complex postnatal adaptation is observed, and concomitant pathology is more often detected.Conclusion. It is possible that the high frequency of asphyxia and neurological diseases in children born to women with placenta accreta is associated with a violation of utero-placental-fetal circulation during pregnancy and a prematurity. These data are very important not only for obstetricians making it possible to develop tactics for the management and delivery of a pregnant woman with placenta accreta, but also for neonatologists to correctly assess the condition of the fetus, determine the tactics of management and treatment of newborns, as well as including them from an early stage in a high-risk group for neurological disorders.

Anesthetic implications in managing a case of placenta percreta: A case report

Placenta percreta is the extreme end of the placenta accreta spectrum. It involves the placenta which invades through out the wall of the myometrium, crossing the uterus and getting adherent to other pelvic or abdominal organs. Surgical and anaesthetic management of placenta percreta can be challenging in such scenarios, especially in the cases where placenta percreta is getting a direct feed from aorta. It carries a high risk of maternal and fetal mortality and morbidity. I present a case of placenta percreta, G5P4, with a history of previous 3 Caesarean sections and placenta previa. Admitted with severe abdominal pain at 23 weeks. Imaging was suggestive of placenta percreta with placenta extending beyond the uterus, getting adherent to the urinary bladder, and getting direct feed from the aorta along with neovascularisation in the pelvis. She was managed by a multidisciplinary approach, caesarean delivery followed by a hysterectomy, and urinary bladder dome repair was carried out. The intraoperative course was complicated by severe obstetric haemorrhage which was successfully managed with fluids and blood products.
 Keywords: Placenta Accreta Spectrum; Placenta Percreta; Massive Obstetric Hemorrhage; Massive Transfusion Protocol
 Citation: Rubab UI. Anesthetic implications in managing a case of placenta percreta: A case report. Anaesth. pain intensive care 2023;27(5):614−618; DOI: 10.35975/apic.v27i5.2240
 Received: April 07, 2023; Reviewed & Accepted: July 01, 2023

ОПЫТ ОРГАНОСОХРАНЯЮЩЕЙ ТАКТИКИ ВЕДЕНИЯ ПРИ ВРАСТАНИИ ПЛАЦЕНТЫ

The purpose of this study is to substantiate the possibility of successful organ-preserving management tactics for placenta accretion based on the study of a clinical case. We studied the results of examination and treatment of a pregnant woman, a woman in labor and a maternity ward, 32 years old, who received medical care in inpatient conditions at the Perinatal Center of the V.D. Seredavin State Medical University. It can be assumed that the cause of the abnormal attachment of the placenta in this patient could be an infection, in particular, chronic endometritis. This is evidenced by the premature rupture of the fetal membranes, the cause of which is most often an infectious factor. Diagnosis of anomalies of placental attachment is based on the data of instrumental studies. It should be detected in the antenatal period with ultrasound. Despite the presence of placenta accretion, this pathology, unfortunately, was not detected at the stage of pregnancy, which would make it possible to draw up a plan for pregnancy and childbirth in accordance with the tactics recommended for this pathology. In this clinical case, an additional placental lobule isolated from the main part of the placental tissue apparently grew in, which made it possible to avoid massive bleeding in the postpartum period before attempting to separate this part. Careful observation of the patient in the postpartum period with dynamic ultrasound control allowed the diagnosis of placental ingrowth. With diagnostic hysteroscopy, the diagnosis was confirmed, an organ-preserving operation was performed: hysteroesectoscopy with electrosurgical resection of placenta increta. During the control examination, no pathology of the myometrium was detected. It is necessary to take into account the presence of all causes that can lead to abnormalities of placental attachment, in particular, an infectious factor. Active identification of risk factors and early diagnosis of placental abnormalities are the main conditions in the prevention of massive obstetric bleeding and reduction of maternal mortality rates. It is necessary to strive to perform organ-preserving surgical interventions, if there are conditions that ensure their implementation. In this clinical case, despite the presence of a difficult-to-diagnose variant of placental ingrowth, it was possible to perform an organ-preserving operation and preserve the patient's ability to realize reproductive function in the future.

Ultrasound discrimination between placenta accreta spectrum and urinary bladder varices.

Distinguishing between urinary bladder varices and retroplacental neovascularization in placenta accreta spectrum in high-risk patients with placental previa is a diagnostic challenge since they have similar appearances on prenatal ultrasound. Placenta accreta spectrum is associated with massive obstetric haemorrhage while the presence of urinary bladder varices in pregnancy poses a lower surgical risk. Since the clinical implications and management approach for both conditions are entirely different, false positive diagnoses have iatrogenic consequences. In this article, we share our experiences in differentiating these two phenomena on prenatal ultrasound supported by ultrasound and intraoperative images.

Placenta Accreta Spectrum—Variations in Clinical Practice and Maternal Morbidity Between the UK and France: A Population-based Comparative Study

(BJOG. 2022;129:1676–1685) Placenta accreta spectrum (PAS) carries significant maternal risk following birth when the placenta does not spontaneously detach from the uterus. Risks include massive obstetric hemorrhage (PPH), further maternal morbidity, and possible death. Three subtypes characterize the spectrum (placenta accreta, placenta increta, and placenta percreta) and all are managed by either cesarean hysterectomy or a conservative approach that preserves the uterus in situ in full or part. Practice guidelines in France encourage a uterine-conserving approach when possible, while the standard of care in the UK recommends cesarean hysterectomy as the default. This country level variation in practice allows for comparison of maternal outcomes for a large number of women with PAS receiving different interventions. The aim of this study was to compare management and outcomes in patients with PAS in the United Kingdom and France.

Hemostasis restoring in postpartum hemorrhage — algorithm 2023

Postpartum hemorrhage (PPH) is still the leading cause of perinatal death in women of reproductive age. It is characterized by high dynamics, and most women die within the first day of puerperium and as many as 88% of them within the first 4 hours from the onset of hemorrhage. Management of each massive obstetric hemorrhage requires interdisciplinary, team-based and multidirectional action. The need for simultaneous application of uterotonic agents, surgical and/or endovascular methods as well as procedures aimed at restoring volume and hemostasis should be emphasized. The protocol for the management of severe PPH should be individualized and take into account hemorrhage etiology. Each time the volume of circulating blood as well as the degree of blood loss have to be determined, and the adequate procedures, the starting points for implementing aggressive treatment and the satisfactory end points must be defined. The most common cause of severe, life-threatening PPH is uterine atony. Restoration of hemostasis in massive PPH consists in transfusion of blood components, administration of antifibrinolytic drugs and coagulation factor concentrates, rFVIIa included. Patient survival is often determined by the very risk assessment for hemorrhage, early diagnosis and rapid implementation of PPH management algorithms.

Progressive detachment of the normally located placenta: the clinical case of failed maternal death in massive blood loss

Introduction. Despite the global achievements of obstetric science and practice, massive bleeding with premature progressive detachment of the normally located placenta, as well as in placenta previa and ingrowth, hypotonic bleeding, occupy one of the leading positions in the structure of obstetric bleeding and are associated with high rates of nearly dead women (near miss), with maternal and perinatal morbidity and mortality. The purpose of the study was to demonstrate the effectiveness of organizational methodology of emergency care in a 24-hour hospital using the clinical example of PPCR with atypical clinical picture, massive obstetric hemorrhage, and favorable outcome for the patient. Materials and methods. Material for the analysis of the clinical case was an exchange and notification card of a pregnant woman and a parturient and a labor history. Methods: anamnestic data analysis based on the study of official documentation of pregnancy and its outcome, peculiarities of delivery and labor outcome. Results. The analysis demonstrates the possibility of a rapid diagnosis of PPDNLP, which proceeded without the classical triad of symptoms, with a severe course, massive obstetric hemorrhage and timely specialized care, which led to a favorable outcome for the patient. Discussion. The speed of care on admission to the hospital, the timeliness of the correct diagnosis even in the absence of the classical clinical picture of PPDNLP, the equipment of the maternity hospital, the timely and adequate obstetric tactics allowed to avoid maternal mortality in massive blood loss and the presence of the disseminated internal coagulation (DIC) syndrome, complicating PPDNLP. Further study of mechanisms of formation, determination of the most significant predictors and triggers of PPDNLP, improvement of organization of care and planned trainings should make a certain contribution to the improvement of maternal and perinatal morbidity and mortality. Conclusion. In the maternal mortality rate reduction vector, an effective organizational technology of care is demonstrated in a case of PPONR with an atypical clinical picture, the presence of massive obstetric hemorrhage, which ended favorably for the patient.

Prevention of postpartum haemorrhage: Economic evaluation of the novel butterfly device in a UK setting

ObjectivesTo explore the cost-effectiveness of a novel PPH device as compared with usual care. DesignA decision analytical model was used to explore the cost-effectiveness of the PPH Butterfly device compared with usual care. This was part of a United Kingdom, UK, clinical trial ISRCTN15452399 using a matched historical cohort who had standard PPH management without the use of the PPH Butterfly device. The economic evaluation was conducted from a UK National Health Service (NHS) perspective. SettingLiverpool Women’s Hospital, UK. Participants57 women with 113 matched controls. InterventionThe PPH Butterfly is a novel device that has been invented and developed in the UK to facilitate bimanual compression of the uterus in the treatment of PPH. Main outcome measuresMain outcome measures included healthcare costs, blood loss, and maternal morbidity events. ResultsMean treatment costs in the Butterfly cohort were £3,459.66 as compared with standard care £3,223.93. Treatment with the Butterfly device resulted in decreased total blood loss in comparison with standard care. The Butterfly device had an incremental cost-effectiveness ratio of £3,795.78 per PPH progression avoided (defined as ≤ 1000 ml additional blood loss from device insertion point). If the NHS is prepared to pay £8,500 per PPH progression avoided, then the Butterfly device is cost-effective with a probability of 87 percent. In the PPH Butterfly treatment arm there were 9% fewer cases of massive obstetric haemorrhage (severe PPH of more than 2000mls or more than 4 units of blood transfusion required) recorded as compared with the standard care historical cohort. As a low-cost device, the PPH Butterfly device is cost-effective but can be cost-saving to the NHS. ConclusionThe PPH pathway can result in high-cost resource use such as blood transfusion or high dependence unit hospital stays. The Butterfly device is a relative low-cost device in a UK NHS setting with a high probability of being cost-effective. The National Institute for Health and Care Excellence (NICE) can use this evidence in considering the adoption of innovative technologies such as the Butterfly device in the NHS. Extrapolation on an international scale to lower and middle-income countries could prevent mortality associated with PPH.

Pregnancy characteristics of patients with placenta acreta spectrum at Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar, Bali-Indonesia during January 2020 - January 2022

Introduction: Placenta accreta spectrum is a problem during delivery when the placenta is not completely separated from the uterus and is followed by massive obstetric bleeding and can cause postnatal morbidity and mortality. The purpose of this study was to describe the pregnancy characteristics of patients with placenta accreta spectrum at Prof. Dr. I.G.N.G. Ngoerah Hospital Denpasar, Bali-Indonesia during period 1 January 2020 - 1 January 2022. Methods: This study is a descriptive study that describes the basic sociodemographic characteristics, ligation procedures, ultrasonographic findings, and histopathology. Results: A total of 48 patients were sampled in this study, the highest proportion of pregnant women with placenta accreta spectrum with lacuna grade II (39.6%), loss of basal hypoechoic zone (64.6%), myometrial thickness <1 mm (39.6%), anterior placenta location (81.3%), regular vesicouterine border (75%), no exophytic mass (97.9%), bridging vessels (68.8%), no feeding vessels (85.4%), loss of placental basal Doppler image (97.9%), no hypervascularity of the vesicouterine area (66.7%), no lacunae vascular turbulence (83.3%) and the highest PAI score with a value of less than 5.37 (56.3%). Conclusion: The spectrum of placenta accreta was found with grade II lacunae, loss of basal hypoechoic zone, myometrial thickness <1 mm, anterior placenta location, regular vesicouterine border, no exophytic mass, no bridging vessels, no feeding vessels, loss of placental basal Doppler image, there was no hypervascularity in the vesicouterine area, no vascular lacunae turbulence and the highest PAI score with a value of less than 5.37.

Blood component therapy in patients having massive obstetric hemorrhage in a tertiary care center in Puducherry.

A proper transfusion protocol must be followed for every patient with massive obstetric hemorrhage (MOH), as each patient may need a different pattern of transfusion support. In this background, it is prudent to understand the current prevalent practices and devise preparatory strategies for managing blood requirements during such scenarios. This study helps us know the pattern and type of blood components given to patients with MOHs. This prospective cross-sectional study was conducted on patients with a MOH admitted to a single center at a tertiary care teaching hospital in Puducherry between January 2020 and October 2021. During the hospital stay, patient parameters such as diagnosis, obstetric history, blood loss, transfusion of blood products, transfusion reaction, blood group, length of hospital stay, laboratory parameters, and patient vitals and comorbidities were recorded in a predesigned pro forma and tabulated into Excel sheet and analyzed using SPSS software version 19.0. Fifty-four patients with MOH were included in our study. The median blood loss was 2.15 L, with a range of 2 L. The mean difference between the baseline and posthemorrhage hemoglobin is 1.7 g/dl. No correlation was observed between the number of packed red blood cell (PRBC) transfused and baseline hemoglobin or between random donor platelets (RDP) transfusion and baseline platelet count. The median number of hospital stays was 10 days, ranging from 7 to 14.5 days. Eleven (20.38%) patients had a hysterectomy done to control bleeding. The remaining 43 patients were managed successfully by other measures such as medical management, compressive surgical suturing, and arterial ligation. Forty-eight (88.9%) patients survived, and 6 (11.1%) patients expired. The percentage of RDP and cryoprecipitate transfused to the patients was less than PRBC and fresh frozen plasma (FFP). The FFP-to-PRBC ratio was 2. Regular transfusion audits must be conducted to assess the flaws and improve current strategies.

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.

Ренальна дисфункція у пацієнток із післяпологовими кровотечами

The purpose of the study was to assess the influence of the hematocrit level on the frequency of development of renal dysfunction in massive obstetric bleeding. Materials and methods. For the study, we selected 33 women in labor in whom low hematocrit values were determined as a result of blood loss. The examined group had no risk factors and signs of renal dysfunction in the prenatal period. The average age of the women in labor was 32.5 ± 6.4 years, the average weight was 76.5 ± 12.4, and the average gestational age was 39.5 ± 1.5 weeks. Postpartum blood loss averaged 1830.5 ± 622.7 ml (from 1200 to 2500 ml). All bleeding was stopped according to current protocols. Results and discussion. Despite improvements in prenatal and delivery care, postpartum acute kidney injury, associated with massive postpartum blood loss and blood transfusions, currently remains a serious problem. A lot of factors play a role in kidney damage and the development of postpartum acute kidney injury, but it is largely related to hemodilution and low values of hematocrit and hemoglobin. At the same time, there are currently no reliable data on hematocrit threshold values in patients undergoing infusion therapy against the background of postpartum blood loss. Acute kidney injury was defined according to the Kidney Disease: Improving Global Outcomes 2012 recommendations as the presence of at least one of the following criteria: an increase in serum creatinine concentration ≥0.3 mg/dl (≥26.5 μmol/l) within 48 hours, or an increase in serum creatinine concentration ≥1.5 times from the baseline, which is known or assumed to have occurred within 7 days, or a diuresis rate <0.5 ml/kg/h within 6 hours. Conclusion. As a result of the research, it was established that the following pathological conditions and nosologies were the most frequent causes of postpartum acute kidney injury: HELLP syndrome (75% of cases), preeclampsia (70.8% of cases), postpartum hemorrhage (58.3% of cases) and gestational hypertension (45.8% of cases). At the same time, the most frequent clinical manifestation of acute kidney injury occurred with the development of oliguria/anuria (45.8%), hypertension more than 140/90 mm Hg (37.5%) and eclampsia (29.2%). The functional state of the kidneys (namely, the glomerular filtration rate) depended on the hematocrit level, and when its values decreased, the glomerular filtration rate decreased significantly. The obtained dependence was statistically reliable, which was indicated by the value of p=0.0000132 and corresponded to a strong positive correlation, which was indicated by the value r = 0.9449 and r2 = 0.8928. Hematocrit values in the range of 19.57 ± 2.18% and below are a risk factor for the development of postpartum renal dysfunction

Comparative retrospective study on the validity of point-of-care testing device for massive obstetrical hemorrhage: dry hematology vs thromboelastography

Early recognition of hypofibrinogenemia and prompt initiation of transfusion therapy in patients with massive obstetrical hemorrhage can improve prognosis. There are reports on the usefulness of point-of-care testing, which provides quicker test results compared with fibrinogen measurements using the conventional Clauss method. This study aimed to compare and investigate the diagnostic accuracy of dry hematology and thromboelastography in point-of-care testing for the diagnosis of hypofibrinogenemia. A single-center, retrospective study of 126 massive obstetrical hemorrhage cases with point-of-care testing before treatment was initiated. The correlation of fibrinogen values with the Clauss method and the diagnostic accuracy for hypofibrinogenemia were compared between dry hematology and thromboelastography. Fibrinogen value in dry hematology showed a strong positive correlation with values measured by the Clauss method, and the diagnostic accuracy for hypofibrinogenemia was high, but there were many residuals above 100 mg/dL, and the distribution of these residuals was not uniform. Although thromboelastography cannot be used to directly measure fibrinogen values, maximum amplitude citrated functional fibrinogen, amplitude-10 citrated rapid thromboelastography, and amplitude-10 citrated functional fibrinogen showed a strong positive correlation with fibrinogen values using the Clauss method, and no significant difference in correlation or diagnostic accuracy was observed relative to dry hematology. Dry hematology and thromboelastography were equally accurate in diagnosing hypofibrinogenemia, with results correlating well with fibrinogen values measured by the Clauss method.

INTRAUTERINE BALLOON TAMPONADE AS AN EFFECTIVE METHOD OF CONSERVATIVE TREATMENT OF POSTPARTUM BLEEDING

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide and accounts for approximately a quarter of all maternal deaths today. In May 2021, the World Health Organization (WHO) published updated recommendations that intrauterine balloon tamponade is an effective treatment for postpartum hemorrhage when first-line treatment is ineffective. The implementation of balloon intrauterine tamponade during postpartum hemorrhage after cesarean section appears to be safe and effective, which contributes to the reduction of both invasive procedures and the frequency of transfusions. Objective of the study To evaluate the effectiveness of the complex treatment of hypotonic postpartum hemorrhage and bleeding with placental abruption or placentaaccreta during cesarean section by using intrauterine balloon tamponade to prevent periportal hysterectomy. Methods An analysis of 30 cases of postpartum bleeding, which were treated with intrauterine balloon tamponade (IBT), and ended with effective conservative treatment without hysterectomy, was conducted. Research results and their discussion Parity of childbirth is important as a risk factor for the occurrence of hypotonic bleeding. A stretched uterus due to a large fetus was present in 4 (13.3%), twins - in 3 (10%), polyhydramnios - in 2 (6.6%), that is, every third woman had such a risk factor for bleeding. The course of childbirth plays an important role in the exhaustion of the contractile activity of the uterus and the occurrence of postpartum bleeding. Massive obstetric bleeding was more than 1.5% of the weight in 3 (13.6%) women, up to 1.5% in 17 (77.2%), up to 1% in 2 (9.2%). Intrauterine balloon tamponade was performed for the treatment of PPK after ineffective first-line measures. According to our data, finding an intrauterine balloon gradually stopped the bleeding. 1 hour after UBT of the uterus, the amount of blood loss decreased to 400 ml per hour, gradually decreasing to 4-6 hours. After 6 hours of VBT being in the uterus, the bleeding was stopped and the volume of circulating blood was restored. Conclusions Thus, women who have a history of massive postpartum bleeding, multiparous women, pregnant women with a stretched uterus due to a large fetus, multiple pregnancy, women who give birth with a violation of the contractile activity of the uterus are a risk group for the occurrence of postpartum bleeding. Intrauterine balloon tamponade is an effective method of conservative treatment of postpartum bleeding, which should be widely used in obstetric practice.

Emergencies in obstetric anaesthesia: a narrative review.

We conducted a narrative review in six areas of obstetric emergencies: category-1 caesarean section; difficult and failed airway; massive obstetric haemorrhage; hypertensive crisis; emergencies related to neuraxial anaesthesia; and maternal cardiac arrest. These areas represent significant research published within the last five years, with emphasis on large multicentre randomised trials, national or international practice guidelines and recommendations from major professional societies. Key topics discussed: prevention and management of failed neuraxial technique; role of high-flow nasal oxygenation and choice of neuromuscular drug in obstetric patients; prevention of accidental awareness during general anaesthesia; management of the difficult and failed obstetric airway; current perspectives on the use of tranexamic acid, fibrinogen concentrate and cell salvage; guidance on neuraxial placement in a thrombocytopenic obstetric patient; management of neuraxial drug errors, local anaesthetic systemic toxicity and unusually prolonged neuraxial block regression; and extracorporeal membrane oxygenation use in maternal cardiac arrest.