Obstetric Hemorrhage Research Articles

Profile and outcomes of management of patients admitted to obstetric high care unit in a tertiary academic hospital in Gauteng Province, South Africa.

The aim of this study was to describe maternal characteristics and pregnancy outcomes of women admitted in a dedicated obstetric high care unit (OHCU) in a tertiary hospital in Gauteng province, South Africa. The study involved review of clinical records of women admitted to OHCU between January and June 2016. Data collected included maternal demographic data, indication for admission, management and outcomes. A total of 4 637 of women gave birth and 114 (2.5%) were admitted to the OHCU during this period. Majority (90, 78.9%) were younger than 35 (mean 29.6) years with 32(28.1%), in their first pregnancy. Obstetric related indications for OHCU admission were mainly, pre-eclampsia and related complications (89, 78.1%), followed by obstetric haemorrhage (32, 28.1%). Cardiac disease, 14(12.3%) and pneumonia 6(5.3%) were the most common non-obstetrics indications for admission. Majority of patients stayed in OHCU for an average of 24-48 hours and were discharged alive (99.86.8%). Only 11(9.6%) were transferred to ICU and complications related to cardiac diseases were the most common reason for the transfer. Preeclampsia, obstetric hemorrhage and cardiac related complications are the most common reasons for OHCU and ICU admissions however most of these condition can be successfully managed in OHCU.

A Comprehensive Review of Causes and Determinants of Maternal and Infant Mortality in Uttarakhand

India is trying to achieve the target of sustainable development goals of reducing maternal mortality ratio to 70/1,00,000 live births by the year 2030. The maternal mortality in Uttarakhand is 89/100,000 live birth (2015–2017), against the national average of 122. Daley in the care during the labour process, poor transport system, and inadequate health care facilities for maternal care leading to maternal and infant mortality are not well understood, including other contributing factors. In Uttarakhand, maternal haemorrhage (22.9%), eclampsia (14.6%), sepsis (10.6%), rupture of the uterus (6.2%), ectopic pregnancy (2.1%), and pulmonary embolism (2.1%) were the direct causes for maternal mortality; the indirect causes were anaemia (16.6%), jaundice (12.5%), heart diseases during pregnancy (6.2%), and other communicable diseases (6.3%). Age at pregnancy, not having health schemes, health care accessibility, presence of complications, and residing in a rural area were additional risk factors. Being multigravida adds to a higher risk for women to die (66.7%). Common causes of neonatal mortality were birth asphyxia (20.4%) and preterm birth (15.4%), whereas pneumonia (26.1%), septicaemia (12.5%), diarrhoeal and acute gastroenteritis (19%) were common causes for post-neonatal deaths. It was also reported that prematurity with respiratory distress syndrome (37.7%), septicaemia (16.8%), and perinatal asphyxia (13.9%) were the leading causes in Uttarakhand, while neonatal seizures (3.54%), congenital anomalies (3.23%), intrauterine growth restriction (IUGR) (2.6%), and neonatal jaundice (2.3%) were fewer common causes reported. Multidirectional contributing factors had been reported for maternal and infant mortality, so it needs a multidimensional approach to address the issue.

Facility-based maternal deaths: Their prevalence, causes and underlying circumstances. A mixed method study from the national referral hospital of Somaliland

ObjectiveSomaliland has one of the highest rates of maternal deaths in the world. An estimated 732 women die for every 100,000 live births. This study aims to identify the prevalence of facility-based maternal deaths, the causes and their underlying circumstances by interviewing relatives and health care providers at the main referral hospital. MethodA hospital-based mixed method study. The prospective cross-sectional design of the WHO Maternal Near Miss tool was combined with narrative interviews with 28 relatives and 28 health care providers in direct contact with maternal deaths. The quantitative data was analysed with descriptive statistics using SPSS and the qualitative part of the study was analysed with content analysis using NVivo. ResultsFrom the 6658 women included 28 women died. The highest direct cause of maternal death was severe obstetric haemorrhage (46.4%), followed by hypertensive disorders (25%) and severe sepsis (10.7%). An indirect obstetric cause of death was medical complications (17.9%). Twenty-five per cent of these cases were admitted to ICU and 89% had referred themselves to the hospital for treatment. The qualitative data identifies two categories of missed opportunities that could have prevented these maternal mortalities: poor risk awareness in the community and inadequate interprofessional collaboration at the hospital. ConclusionThe referral system needs to be strengthened utilizing Traditional Birth Attendants as community resource supporting the community facilities. The communication skills and interprofessional collaboration of the health care providers at the hospital needs to be addressed and a national maternal death surveillance system needs to be commenced.

Maternal complications associated with second trimester medical abortion using mifepristone priming and subsequent misoprostol

ObjectivesTo assess the frequency of maternal adverse events associated with second trimester medical abortion using sequential mifepristone and misoprostol. Study designRetrospective analysis of medical abortions 13 to 28 weeks gestation using sequential mifepristone and misoprostol in a single center from January 2008 to December 2018. The main outcomes evaluated were the nature and incidence of adverse procedural events and the impact of gestation upon these outcomes. ResultsDuring the study period, 1393 people underwent a medical abortion with sequential mifepristone and misoprostol. The median maternal age was 31 years (IQR 27–36 years) and 21.8% had at least one prior cesarean delivery. The median gestational age at abortion commencement was 19 weeks (IQR 17–21).The main adverse maternal events were complete or partial placental retention greater than 60 minutes triggering removal in the operating room (19%), maternal hemorrhage>1000 cc (4.3%), blood transfusion (1.7%), hospital readmission (1.4%), uterine rupture (0.29%) and hysterectomy (0.07%). There were significant reductions in placental retention rates with increasing gestational age (23.3% at 13–16 weeks gestation declining to 10.1% at>23 weeks gestation, p < 0.001). ConclusionsSerious adverse maternal events associated with second trimester medical abortion with sequential mifepristone-misoprostol are uncommon. ImplicationsSecond trimester medical abortion with mifepristone and misoprostol is generally safe, however, on occasions serious complications may occur. All health care units providing a medical abortion service require the facilities and expertise to deal with these adverse events in a timely manner.

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.

The AccuFlow sensor: a novel digital health tool to assess intrapartum blood loss at cesarean delivery.

During obstetric hemorrhage, peripheral vasoconstriction maintains heart rate and blood pressure until compensatory mechanisms are overwhelmed and patients deteriorate rapidly. Real-time perfusion measurements could quantify vasoconstriction, improving early recognition of hemorrhage and facilitating early intervention to reduce morbidity and mortality. The AccuFlow device makes rapid, non-invasive, quantitative measurements of perfusion, but has not been studied for hemorrhage detection or used in surgical settings. This study evaluated feasibility, tolerability, and preliminary efficacy of the AccuFlow for assessment of blood loss at cesarean delivery (CD). In this pilot study, sensors were applied to the wrist, forearm, bicep, and chest wall of 25 patients undergoing scheduled CD. Postoperatively, sensors were removed and patients rated the AccuFlow and the standard anesthesia monitoring equipment on a validated comfort rating scale for wearable computers (CRS). Blood loss was estimated by the surgical team (EBL) and calculated from change in hematocrit, weight, and height (CBL). CRS scores were compared via Wilcoxon signed ranks tests. Coefficients of correlation between sensor readings and CBL, and between EBL and CBL, were compared using Fisher's R-to-z transformation. There were no safety events; no participants requested device removal. CRS ratings of the AccuFlow andthe standard monitoring equipment were similar (7.2vs. 8.8, p=0.25). Change in wrist perfusion from delivery to dressing placement was more strongly correlated with CBL than was EBL (R=-0.48 vs. R=0.087, p=0.03). The AccuFlow sensor is well-tolerated and shows promise in detecting intrapartum hemorrhage, though larger studies are needed.

Postpartum Hemorrhage and Tranexamic Acid: A Literature Review.

This review aims to explore the postpartum hemorrhage (PPH) burden and the efficacy of prophylactic tranexamic acid (TXA) in PPH and recent indications of TXA. A comprehensive review of the literature was conducted using a combination of Medical Subject Headings keywords including "Postpartum haemorrhage," "Tranexamic acid," and "Cesarean section." PPH has been explored for epidemiology, risk factors, and pathophysiology in the first part of the article. Recent indications of TXA, obstetric indications, and the role of TXA as prophylaxis for PPH are discussed in the second part of this article. TXA has many indications apart from obstetric indications and shows a significant effect in controlling bleeding. Furthermore, TXA is more efficient in preventing PPH if administered during the final stage of laborand is a valuable option for managing obstetric bleeding.

Role of Recombinant Activated FVII in Severe Post‐Partum Haemorrhage

In Pakistan, improvement of health care structure and evolution of perinatal care, have led to momentous drop in pregnancy related deaths, however obstetrical haemorrhage maintains to be the principal cause of maternal motility. The aim of this study was to probe the utilization of activated, and recombinant, Factor VII (rFVIIa) in cases of severe postpartum haemorrhage (PPH). This study was carried out at Unit 2 of Obstetrics &amp; Gynaecology Department of Sir Ganga Ram Hospital (Fatima Jinnah Medical University), Lahore, over a period of 10 weeks, from 15/01/2023, to 31/03/2023. Fifteen females with severe PPH who were treated with rFVIIa were included in this study. The overall observed median and mean blood loss were 8639 mL and 11835 mL respectively. The management prior to rFVIIa involved trans-arterial embolization in five patients, while three of them had hysterectomy. One patient had one single dose, two of them had two doses, three of those patients had four doses, two patients had five plus doses, and a single patient had twenty plus doses of rFVIIa. The mean (± SD) of single dose was at 81.60 ± 16.25 µg/kg. Fourteen of those females could survive, however one of them died due to complication. The cause of that death was uterine rupture, and the quantum of haemorrhage in that case of death, was 6428–43 810 mL. This may, therefore, lead us to conclude that, irrespective of the fact whether a patient would survive or otherwise, much dependents upon her general health and proceeding rFVIIa infusion, rather than haemorrhage. Four of those females presented thromboembolic events post rFVIIa management deep vein thrombosis (DVT), DVT plus pulmonary embolism (PE), PE and acute myocardial infarction (MI). This study revealed that rFVIIa infusion had promising effects for severe PPH and markedly reduced the maternal motility. Keywords: Post-Partum Haemorrhage, Hystectomy, rFVIIa, thromboembolism

Improving Health Care Responses to Obstetric Hemorrhage.

Obstetric hemorrhage is one of the most commonly encountered obstetrical complications. Decreases in maternal mortality and severe maternal morbidity have continued to be achieved despite the increasing incidence of obstetric hemorrhage over time through the diligent efforts of quality improvement initiatives. Approaches currently advocated to optimize the management of obstetrical hemorrhage are presented and discussed in this chapter focusing on readiness, recognition and prevention, clinical response, patient support, and tracking and monitoring outcome and performance measures over time. Readers are encouraged to access publicly available programs from state-based perinatal quality collaboratives and national programs designed to support and structure such efforts.

Maternal near miss at Kathmandu Medical College: An analysis of severe maternal morbidity at a Nepalese tertiary care facility.

The World Health Organization (WHO) 'near miss' tool has been extensively used to audit maternal morbidity in low- and middle-income countries. Analysis of the cases of 'near miss' enables a better understanding of the associated factors, identifies deficiencies in the provision of maternity services and lays a foundation for better preventive measures in the future. To understand the epidemiology, aetiology and determine the aspects of preventability of maternal 'near miss' (MNM) at Kathmandu Medical College. A prospective audit of MNM and maternal deaths (MD) was undertaken at Kathmandu Medical College over a period of 12 months. The cases were identified using WHO 'near miss' criteria and areas of preventability in the provision of care determined using the modified Geller's criteria. The total number of deliveries and live births in the study period were 2747 and 2698 respectively. A total of 34 'near misses' and two MDs were identified. The common direct aetiologies of MNM and MDs identified were obstetric haemorrhage followed by hypertensive disorders with one-third of cases being of indirect aetiology. Fifty-five percent of cases had some aspects of provider- or system-related preventability with the leading delays being lack of diagnosis and recognition of high-risk status among patients and lack of interdepartmental communication. The WHO near miss rate at Kathmandu Medical College was 12.5/100 live births. Significant aspects of preventability, especially at the level of the provider, were noted among cases of MNM and MDs.

Clear and present danger: Mechanical heart valves in pregnancy.

Specialists in Obstetric Haematology continue to be challenged by pregnant women with mechanical heart valves, who are at high risk of death or severe morbidity. Effective anticoagulation to reduce valve thrombosis inevitably increases risk of obstetric haemorrhage and fetal loss or harm, and difficult decisions need to be made. Lester and mulitdisciplinary colleagues on behalf of the British Society for Haematology review available evidence and provide comprehensive recommendations to guide management in this difficult area. Commentary on: Lester et al. British Society for Haematology guideline for anticoagulant management of pregnant individuals with mechanical heart valves. Br J Haematol 2023;202:465-478.

Promoting Best Practice in Obstetrics: Findings From a State-Based Perinatal Quality Collaborative Implementing the Obstetric Hemorrhage Maternal Safety Bundle [ID: 1377611

INTRODUCTION: The Perinatal Neonatal Quality Improvement Network (PNQIN) of Massachusetts engaged hospital teams in a statewide improvement initiative to address maternal morbidity from obstetric hemorrhage (OB HEM) through support of implementation and adherence to best practices in screening for and diagnosis of OB HEM. METHODS: The Alliance for Innovation on Maternal Health (AIM) OB HEM bundle was adapted and implemented across hospitals in Massachusetts from June to December 2021. Each month, participating hospital teams joined educational webinars, learned quality improvement strategies, received access to resources for the intervention, and submitted data on six structure and five process measures. Severe maternal morbidity rates were provided using state hospital discharge data. Reliability of implementation was monitored by structure and process measure submission. Aggregate data were shared statewide. RESULTS: Fifty-three percent of birthing hospitals in the state (21 of 40) voluntarily participated. Baseline risk screening for OB HEM was 93% and quantitative blood loss measurement (QBL) was 60% in aggregate for all teams. Six participating hospitals reported all 11 measures monthly across the 6-month period. Half of these sites had all six structure measures in place at baseline and 83% reported completion of structure measures by the end of the study period. Among these six sites, the cumulative proportion QBL utilization increased 178% from 28% to 78% and documented OB HEM risk assessment during labor admission increased 8.4% from 83% to 90%. CONCLUSION: Implementation of the OB HEM bundle was effective in increasing adherence to evidence-based care among participating birth hospitals through a collaborative, quality improvement approach.

Maternal Coagulation Disorders and Postpartum Hemorrhage.

Coagulation disorders are rare causes of postpartum hemorrhage. Disturbances in coagulation should be suspected in patients with a family history of coagulopathy, those with a personal history of heavy menstrual bleeding, and those with persistent bleeding despite correction of other causes. The coagulopathic conditions discussed include disseminated intravascular coagulation, platelet disorders, and disturbances of coagulation factors. These should not be overlooked in the evaluation of obstetric hemorrhage, as diagnosis and appropriate treatment may prevent severe maternal morbidity and mortality.

Effect of Tranexamic Acid in a Cohort of Placenta Accreta Spectrum Patients [ID: 1380346

INTRODUCTION: Use of tranexamic acid (TXA) is beneficial in the setting of obstetric hemorrhage. We sought to understand whether patients with placenta accreta spectrum disorder benefit from TXA administration during cesarean hysterectomy. METHODS: This is an IRB-approved retrospective cohort study of participants with suspected placenta accreta spectrum undergoing cesarean hysterectomy in a single hospital system. Those who received TXA were compared to those who did not. The primary outcome was the rate of blood transfusion. Secondary outcomes included maternal intensive care unit (ICU) admission, massive transfusion, length of postoperative stay, operative time, and a composite of adverse maternal outcomes. Chi-square, t tests, and Fisher’s exact test were used to compare baseline characteristics, and a logistic regression was performed with possible confounders. RESULTS: A total of 87 participants met criteria for the study; among those were 35 (40.2%) who received TXA. Baseline characteristics between groups were similar. Although not statistically significant in univariable analysis, there was a trend for those who received TXA to have lower blood loss overall (∼2,000 mL versus ∼2,300 mL, P=.483) and be less likely to require transfusion (48.6% versus 69.2%, P=.053). Further, they were statistically less likely to undergo ICU admission (22.9% versus 60.4%, P=.001). There was no difference in the other secondary outcomes including the combined adverse maternal outcome (40.0% versus 44.2%, P=.695). After controlling for confounders, TXA administration was independently associated with decreased rates of blood transfusion (adjusted odds ratio [aOR] 0.23, 95% CI 0.08–0.68) and ICU admission (aOR 0.16, 95% CI 0.05–0.48). CONCLUSION: Tranexamic acid use in the setting of cesarean hysterectomy for PAS was associated with decreased risks of transfusion and ICU admission.

P23 The role of TEG6s in managing major obstetric haemorrhage

P23 The role of TEG6s in managing major obstetric haemorrhage

P117 Audit of the use of ROTEM in major obstetric haemorrhage in The National Maternity Hospital

P117 Audit of the use of ROTEM in major obstetric haemorrhage in The National Maternity Hospital

Descriptive statistical study of the most important possible causes of obstetric and postpartum hemorrhage in Thi-Qar province

The aim of the study is to describe and analyze the most important causes that lead to postpartum hemorrhage. This research was carried out at The Bent al-Huda Hospital for Maternity and Children's Hospital in Nasiriyah, where the study included (63) cases of women with postpartum hemorrhage from the reviews of the hospital for the period from February 2020 to December 2020 as shown in the hospital records, and collected information for the study through a simple questionnaire, including information: age of women, place of residence, place of birth, type of birth and causes of hemorrhage. Age groups between (40-44) accounted for (22?), (35-39), which are the highest age groups at risk of postpartum hemorrhage. The most frequent deliveries take place in the hospital, because natural or cesarean deliveries increase in this percentage. The results of the current study also show that there is no difference between natural childbirth and caesarean section with the occurrence of postpartum hemorrhage , that the condition of non-constriction of the uterus (inertia of uterus) constitutes (30%) and is considered the highest percentage among the causes of hemorrhage after birth, and then the causes such as the remnants of part of the placenta and the frequency of caesarean section by (16%), the use of accelerated medicines for childbirth and by percentage (14%) while the other causes came in low rates of cases postpartum hemorrhage.

Utilization of non-pneumatic anti-shock garment for the management of obstetric hemorrhage among healthcare providers in north Shewa zone, Ethiopia.

Global maternal deaths have either increased or stagnated tragically. Obstetric hemorrhage (OH) remains the major cause of maternal deaths. Non-Pneumatic Anti-Shock Garment (NASG) has several positive results in the management of obstetric hemorrhage in resource-limited settings where getting definitive treatments are difficult and limited. Therefore, this study aimed to assess the proportion and factors associated with the utilization of NASG for the management of obstetric hemorrhage among healthcare providers in the North Shewa zone, Ethiopia. A cross-sectional study was conducted at health facilities of the north Shewa zone, Ethiopia from June 10th-30th/2021. A simple random sampling (SRS) technique was employed among 360 healthcare providers. Data were collected using a pretested self-administered questionnaire. EpiData version 4.6 and SPSS 25 were used for data entry and analysis, respectively. Binary logistic regression analyses were undertaken to identify associated factors with the outcome variable. The level of significance was decided at a value of p of <0.05. The utilization of NASG for the management of obstetric hemorrhage among healthcare providers was 39% (95%CI: 34-45). Healthcare providers who received training on NASG (AOR = 3.3; 95%CI: 1.46-7.48), availability of NASG in the health facility (AOR = 9.17; 95%CI: 5.10-16.46), diploma (AOR = 2.63; 95%CI: 1.39-3.68), bachelor degree (AOR = 7.89; 95%CI: 3.1-16.29) and those healthcare providers who have a positive attitude toward utilization of NASG (AOR = 1.63; 95%CI: 1.14-2.82) were variables positively associated with the utilization of NASG. In this study, almost two-fifths of healthcare providers used NASG for the management of obstetrics hemorrhage. Arranging educational opportunities and continuous professional development training for healthcare providers, providing in-service and refresher training, and making it available at health facilities may help healthcare providers to effectively use the device, thereby reducing maternal morbidity and mortality.

Delayed versus immediate cord clamping in dichorionic twins

Objectives Strong evidence imply that delayed cord clamping (DCC) provides significant benefits for singleton neonates. However, there is little information about the safety or efficacy of DCC in twins to recommend for or against DCC in twins in guidelines. We aimed to determine the effect of DCC on dichorionic twins born at <32 weeks of gestation. Study design This is a retrospective cohort study comparing the neonatal and maternal outcomes of immediate cord clamping (ICC) [<15 second (s)] versus DCC (at 60 s). Generalized estimating equations models were performed accounting for twin correlation. Results A total of 82 pairs of twins (DCC: 41; ICC: 41) were included in analysis. The primary outcome of death before discharge occurred in 3.66% of twins in the DCC group and 7.32% in the ICC group, without a significant difference between the groups. Compared to ICC group, DCC was associated with increased hemoglobin levels [β1 coefficient 6.51; 95% confidence interval (CI) 0.69–12.32. β2 coefficient 5.80; 95% CI 0.07–11.54] at 12–24 h of life. There were no significant differences between the groups in neonatal death, neonatal major morbidities and maternal bleeding complications, although DCC was associated with higher estimated maternal blood loss in the cesarean section group (p = .005). Conclusions DCC for 60 s in dichorionic twins born at <32 weeks of gestation was associated with increased neonatal hemoglobin levels, when compared with ICC. The finding of a higher estimated maternal blood loss by cesarean section in the DCC group calls for further trials to assess maternal safety of this procedure in this patient population.