Obstetric Hemorrhage Research Articles

Prophylactic resuscitative endovascular balloon occlusion of the aorta use during cesarean hysterectomy for placenta accreta spectrum: a retrospective cohort study

Objective Resuscitative endovascular balloon occlusion of the aorta for placenta accreta spectrum is used to control maternal hemorrhage during cesarean hysterectomy. This study aimed to assess the efficacy of resuscitative endovascular balloon occlusion of the aorta for placenta accreta spectrum by examines the change in the quantitative blood loss after applying resuscitative endovascular balloon occlusion of the aorta. Methods This retrospective cohort study included patients with placenta accreta spectrum who required cesarean hysterectomy (n = 37) between 2003 and 2022 at a tertiary care center. Patients were divided into two groups (with resuscitative endovascular balloon occlusion of the aorta, n = 13; without resuscitative endovascular balloon occlusion of the aorta, n = 24). The quantitative blood loss was compared between the groups. Generalized linear mixed models were used to examine changes in quantitative blood loss during cesarean hysterectomy after resuscitative endovascular balloon occlusion of the aorta was applied. The operating surgeon was set as the random effect. Results Operation time did not differ significantly between the groups (p = .09). The quantitative blood loss was significantly higher in patients who did not undergo resuscitative endovascular balloon occlusion of the aorta (2160 g) than in patients who did (1110 g; p < .01). Resuscitative endovascular balloon occlusion of the aorta significantly decreased the quantitative blood loss during cesarean hysterectomy (partial regression coefficient, 2312; 95% confidence interval, 49–4577; p < .05). Conclusion Resuscitative endovascular balloon occlusion of the aorta decreased the quantitative blood loss during cesarean hysterectomy in patients with placenta accreta spectrum without significantly increasing the operation time. This suggests that resuscitative endovascular balloon occlusion of the aorta is effective in patients with placenta accreta spectrum.

Quantification of blood loss in obstetric haemorrhage: implications on intervention and transfusion

Key content Postpartum haemorrhage accounts for 27% of all maternal deaths. Incorrect quantification of blood loss can lead to unnecessary interventions, such as the transfusion of blood products, which is not without risk. During pregnancy, cardiovascular changes may explain how blood loss can occur rapidly, with pregnant women tolerating large volumes of blood loss before a change in clinical signs is seen. Several methods are used to quantify blood loss, such as visual estimation, volumetric, gravimetric, colorimetric and photometric. The Obstetric Bleeding Strategy for Wales (OBS Cymru) project, which standardised management of obstetric haemorrhage in Wales using a four‐stage approach, showed a statistically significant improvement in outcomes. Different definitions of postpartum haemorrhage make it difficult to compare available evidence. Further studies are required combining the use of point‐of‐care tests and quantitative techniques to help improve morbidity and mortality associated with obstetric haemorrhage. Learning objectives To understand the physiological changes in pregnancy and how they affect postpartum haemorrhage. To know the different available methods of quantifying blood loss. To review the point‐of‐care tests used to guide transfusion and management of postpartum haemorrhage. Ethical issues Understanding the advantages and disadvantages of different methods of quantifying blood loss is essential to providing appropriate and safe care. Inaccuracy in measurement increases the risk of morbidity and mortality, in addition to complications of unnecessary treatments.

Patterns and Causes of Hospital Maternal Mortality in a Tertiary Center in Nigeria

Background: Maternal mortality is a preventable public health challenge in sub-Saharan Africa including Nigeria. Reporting of its trend and causes is important in auditing of care. Objectives: The study is aimed at evaluating the trends, causes, and maternal mortality rate in Alex Ekwueme Federal University Teaching Hospital Abakaliki (AEFUTHA), Ebonyi State, Nigeria. Materials and Methods: This is a 9-year retrospective review of case note of maternal deaths (MDs) in AEFUTHA. All pregnancy-related deaths of patients managed at the hospital were included in the study. Data obtained were analyzed using IBM SPSS Statistics version 20. Results: The maternal mortality ratio (MMR) was 1,114 per 100,000 live births. The MMR remained high at above 1,100 per 100,000 live births between 2012 and 2016; and a sharp decline was seen between 2017 and 2020. The lowest MMR was in 2018 (512 per 100,000 live births). Most of the MDs occurred in unbooked (85.4%) and grand multiparous (43.4%) women. Obstetric hemorrhage was the leading cause of death (28.0%), followed by hypertensive disorders of pregnancy. Less than 3% of MD was caused by Lassa fever. Women with low socioeconomic status, lower level of education, and rural place of abode were major contributors to MD. Conclusion: Our study shows that MD is unacceptably high in the hospital. The burden of MD is borne by unbooked and grand multiparous women. Obstetric population should be educated on the importance of antenatal care and the need for family size reduction via the use of modern method of contraception.

UNVEILING THE NEXUS BETWEEN PREECLAMPSIA AND NUTRITION: A COMPREHENSIVE LITERATURE REVIEW ON MATERNAL HEALTH

Preeclampsia, a pregnancy-related syndrome impacting multiple organ systems, is a leading cause of maternal mortality, bleeding, and infection. The World Health Organization estimates that preeclampsia contributes to 70,000 maternal and 500,000 infant deaths annually worldwide. Recent research highlights the importance of optimal nutrition from preconception through childhood and adolescence. The novelty of this research is that it examines the relationship between preeclampsia and food: a comprehensive literature review of maternal health. This literature review collected and analyzed articles from online databases to explore the role of micronutrient supplementation in preventing preeclampsia. Findings emphasize the potential benefits of micronutrient supplementation, including L-arginine, vitamin D, and folic acid. Recommendations include daily vitamin D supplementation of 10-25 µg for pregnant women, oral administration of 3g per day of L-arginine for 3 weeks, and high-dose folic acid (4 mg/day) during the first trimester of pregnancy along with multivitamin supplementation. Micronutrient supplements and consuming nutrient-rich foods during pregnancy have been proposed to reduce the likelihood of developing preeclampsia. These approaches can potentially impact the formation of the placenta, oxidative stress levels, and the expression of angiogenic factors. This review underscores the importance of optimal nutrition throughout preconception, pregnancy, birth, and beyond for maternal and infant health. It highlights the need for further research and policy attention in this area. Implementing recommended micronutrient supplementation strategies during pregnancy may contribute to improved maternal and infant outcomes and should be considered as part of a comprehensive prenatal care program.

Emergency postpartum hysterectomy as a consequence of cervical varix during pregnancy; a case report and literature review

Vaginal bleeding might accrue during pregnancy and it has different causes due to the pregnancy trimester and the diagnosis and management would be crucial to prevent maternal-fetal life-threatening situations. In uncommon cases, varicose veins can emerge in the neck of the uterus, leading to a severe maternal hemorrhage. We presented a pregnant woman with vaginal bleeding and spotting during pregnancy with the diagnosis of cervical varix at 22 weeks of gestation. Close monitoring and proper patient education led to a term delivery at 37 weeks of gestation. Otherwise, an emergency postpartum hysterectomy after a cesarean section was performed due to uncontrolled bleeding from cervical varix. Although rare, cervical varix should be included in the differential diagnosis in a pregnant patient who appears with extensive vaginal bleeding to reduce maternal and/or neonatal morbidity or fatality. The approved diagnosis for that is not clear. This case report showed that Doppler and transvaginal sonography could be suitable diagnostic tools. The best management for cervical varix needs further research.

To study the Transfusion Practice with respect to Component Therapy in Major Obstetric Hemorrhage

Introduction: Peripartum hemorrhage is a major complicationrequiring emergency transfusion of packed blood or itscomponents with quick decision-making. We describeour experience of transfusion practices in major obstetrichemorrhage.Materials and Methods: Retrospective observational dataof all the deliveries (n = 1837) over period of one year.All cases were assessed for obstetric hemorrhage andsubsequent transfusion practices done. Demographic details,obstetric history, indications for transfusion, gestational ageat transfusion, pre- and post-transfusion hemoglobin levels,nature and type of transfusion, units of transfusion, adverseevents following transfusion and outcome in terms of morbidityand mortality were noted. Data was analyzed using SPSS 21.0software. Chi-square test was used for analysis.Results: Transfusion was required in 776 (42.2%) pregnantwomen. Obstetric hemorrhage was the indication in 432 (55.7%)of the women receiving a transfusion. Other indications wereanemia during pregnancy (39.7%) and traumatic pph (10.5%),respectively. Among major obstetric hemorrhage cases (n =432), the majority (n = 224; 51.9%) had antepartum hemorrhage(abruptio placentae/placenta previa) and the remaining 208(48.1%) had postpartum hemorrhage change no significantchange seen. A total of 138/432 (31.9%) cases had pretransfusionhemoglobin level &lt;8 g/dl in cases of moderateanemia. PRBC was transfused to 319 (73.8%) followed byplatelets (212; 49.1%) and FFP (n = 29; 6.7%), respectively.The majority of cases required only 2 units of transfusion.There were 21 (4.9%) cases requiring more than 3 units.Post-transfusion hemoglobin levels were &gt;10 g/dl in 319/432(73.8%) cases, thus showing a significant change (p &lt; 0.05).Most common adverse reactions (fever/shivering) were notedin 32 (7.4%) cases. There were 6 (1.4%) mortalities (all havingpre-transfusion Hb &lt;6 g/dl).Conclusion: The study highlighted the significance of packedblood cells and component transfusion in reducing obstetricmorbidity and mortality

Literature Study: Analysis of the Relationship Between Age and the Incidence of Postpartum Hemorrhage in Maternity Mothers

Postpartum hemorrhage is the leading cause of maternal death worldwide with an incidence of 5 – 10 percent of all deliveries. Data shows a downward trend in maternal mortality in Indonesia in 1991 from 390 to 230 in 2020 per 100,000 live births. Maternal mortality is an important concern because being one of the indicators of health status and the success of health development, the reduction in maternal mortality rate is also a target in the Sustainable Development Goals (SDGs). In the SDGs, the target of reducing the maternal mortality rate is 70 per 100,000 live births by 2030. The preliminary study found cases of postpartum hemorrhage with risk age less than 20 years as many as 90 people (6.2 percent), bleeding with age more than 35 years as many as 40 people (2.7 percent). The purpose of this study was to conduct a literature study on the relationship between maternal age and postpartum hemorrhage. This study used 13 national journals obtained through Google scholar and Garuda (Digital Referral Guard). Based on the results of the study, 10 journals stated that there was a significant relationship between maternal age and postpartum hemorrhage, while 3 other journals showed that there was no significant relationship between maternal age and postpartum hemorrhage.

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.

Activities of the Japan Council for Implementation of the Maternal Emergency Life Support System reduced direct causes of maternal deaths in Japan.

Here, we aimed to provide an overview of Japan Council for the Implementation of the Maternal Emergency Life-Saving System (J-CIMELS) and its simulation program, which has reduced maternal mortality due to direct causes in Japan. The Japan Association of Obstetricians and Gynecologists (JAOG), Japan Association of Obstetricians and Gynecologists, and Maternal Death Exploratory Committee (JMDEC) launched the Maternal Death Reporting Project in 2010. The project analyzed obstetricians' tendency to delay their initial response to sudden maternal deterioration. Obstetricians can predict small changes before deterioration by monitoring vital signs. In 2015, the J-CIMELS was established to provide practical education. J-CIMELS developed a simulation program (J-MELS; Japan Maternal Emergency Life Support) to ensure that the obstetricians acquire the latest knowledge of emergency physicians, anesthesiologists, and other general practitioners and apply it in clinical situations. In the last 7 years, the J-MELS basic course has been conducted 1000 times with a total attendance of 19 890 people. As a result, the incidence of obstetric hemorrhage progressively decreased from 29% in 2010 to 7% in 2020. We believe that the activities of J-CIMELS are improving obstetric care providers' medical practices in Japan.

Implications for assessing the association between maternal anaemia and postpartum haemorrhage

Implications for assessing the association between maternal anaemia and postpartum haemorrhage

Transfusion and hematologic indices in cases of stillbirth due to placental abruption

Stillbirth because of placental abruption is often associated with maternal hemorrhage and coagulopathy. This study aimed to describe blood product requirements, hematologic indices, and the overall clinical picture of patients experiencing abruption demise. This retrospective cohort included patients with abruption demise at an urban hospital from 2010 to 2020. Outcome data from patients who delivered stillborn infants ≥500 g or with gestational age of ≥24 weeks were included. Abruption was a clinical diagnosis made by a multidisciplinary stillbirth review committee. The overall number and type of blood products given were analyzed. Patients with a stillbirth who required blood transfusion were compared with those that did not. In addition, the hematologic indices of these 2 populations were analyzed and compared with one another. Finally, the overall clinical characteristics of the 2 populations were analyzed. The analysis of data included chi-square, t test, and logistic and negative binomial regression models. Of 128,252 deliveries, 615 patients (0.48%) experienced a stillbirth, with 76 cases (12%) caused by abruption. Of note, 42 patients (55.2%) required blood transfusion; all received either packed red blood cells or whole blood with a median 3.5 units (2.0-5.5) received. The total units ranged from 1 to 59, with 12 of 42 patients (29%) requiring ≥10 units. Maternal age, gestational age, and mode of delivery were not different, with most (61/76 [80%]) delivering vaginally. Hematocrit level on arrival (odds ratio, 0.80; 95% confidence interval, 0.68-0.91; P=.002) and vaginal bleeding on arrival (odds ratio, 3.73; 95% confidence interval, 1.15-13.40; P=.033) were associated with blood transfusion, as was a diagnosis of preeclampsia (odds ratio, 8.40; 95% confidence interval, 2.49-33.41; P=.001). Those that required a blood transfusion often presented with lower hematologic indices and were more likely to develop disseminated intravascular coagulation (28% vs 0%; P<.001). Most patients experiencing stillbirth because of abruption required blood transfusion, with almost 1 in 3 of those patients consuming ≥10 units of blood products. Hematocrit level on arrival, vaginal bleeding, and preeclampsia were all predictors of the need for blood transfusion. Those requiring blood transfusion were more likely to develop disseminated intravascular coagulation. Blood transfusion should be prioritized when abruption demise is suspected.

Effects of misoprostol as a drug to induce abortion in the second trimester: a forensic case report

Link of Video Abstract: https://youtu.be/rMasD6pMero Introduction: Induced abortion with misoprostol in the second trimester can be harmful to both mother and fetus, especially when the abortion is self-administered with telemedicine. Considering the effects that might occur in misoprostol usage to induce abortion, we ought to present our experience through this article regarding the effect of misoprostol as a drug to induce abortion in the second trimester. Case Description: In the first case, a 30-year-old woman engaged in a self-induced abortion at her residence subsequent to consulting with medical personnel at a local community health centre, where she received oral and vaginal administration of misoprostol. Unfortunately, complications arose as the mother experienced post-abortion bleeding, which necessitated a curative procedure. Tragically, the fetus perished in utero due to asphyxia. In the second case, a 20-year-old woman opted to undergo a self-induced abortion at home following consultation and the acquisition of misoprostol from an online source. In cases where fetuses experience asphyxia within the womb, they are unable to exit the uterus spontaneously. Consequently, the mother experienced post-abortion bleeding as an aftermath of the procedure. Conclusions: Misoprostol-induced abortion in the second trimester causes maternal bleeding and intrauterine fetal mortality. Medical staff should handle abortions professionally, considering into account both the patient's health and the legal considerations.

Caring for two in the ICU: Pharmacologic management of pregnancy-related complications.

Maternal mortality continues to be an issue globally despite advances in technology and pharmacotherapy. Pregnancy can lead to complications that necessitate immediate action to prevent severe morbidity and mortality. Patients may need escalation to the ICU setting for close monitoring and administration of advanced therapies not available elsewhere. Obstetric emergencies are rare but high-stakes events that require clinicians to have prompt identification and management. The purpose of this review is to describe complications of pregnancy and provide a focused resource of pharmacotherapy considerations that clinicians may encounter. For each disease state, the epidemiology, pathophysiology, and management are summarized. Brief descriptions of non-pharmacological (e.g., cesarean or vaginal delivery of the baby) interventions are provided. Mainstays of pharmacotherapy highlighted include oxytocin for obstetric hemorrhage, methotrexate for ectopic pregnancy, magnesium and antihypertensive agents for preeclampsia and eclampsia, eculizumab for atypical hemolytic uremic syndrome, corticosteroids, and immunosuppressive agents for thrombotic thrombocytopenic purpura, diuretics, metoprolol, and anticoagulation for peripartum cardiomyopathy, and pulmonary vasodilators for amniotic fluid embolism.

Determinants of Maternal Near Miss at a Tertiary Care Hospital in Ahmedabad, Western India

Abstract Background: The aim is to study the various demographic characters, etiologies and outcomes of Maternal Near Miss (MNM) in antenatal and postnatal women coming to a Tertiary Care Hospital in Ahmedabad, Gujarat (Western India). Material and Methods: This is a retrospective observational study conducted between June 2021 and July 2022at SVPIMSR, Ahmedabad. 78 pregnant women based on WHO near-miss criteria were included.Details were recorded by studying the case sheets of the patients and asking relevant focused questions to the patients themselves or their relatives regarding the patient’s condition at the time of admission.Detailed history, clinical examination, treatment given, causes of referral in case the patient was referred from outside were noted. Results: In this study, Obstetric Haemorrhage (69.2%) and hypertensive disorders of pregnancy (30.7%) were the leading causes of MNM cases. Majority of the women(56.4%) belonged to the age group of 18-25 years, were multiparous (83.3%). 74.4% cases were emergency cases and 66.7% were referred cases. The maternal near-miss to maternal death ratio in our study is 8.9:1. 66.5% cases were referred due to various causes like lack of HDU facility, blood and blood products, NICU facilities etc from the peripheral centres. 18 near-miss cases (23.1%) were identified to have a delay; maximum was level 1 delay(12.8%). 31.5% of MNM cases required blood and blood product transfusion. 25% were admitted to the intensive care unit.Conclusion: Timely recognition, prompt treatment of MNM cases with availability of essential services like blood banks and obstetric ICUs at the primary level of treatment can help in preventing adverse outcomes. Reviewing near miss cases gives significant information about the three delays in health seeking so that appropriate action is taken. Delay in referral to tertiary care centres can be avoided by proper education to identify warning signs and symptoms and training to give primary treatment amongst primary care doctors. Keywords: - Maternal Near Miss (MNM), Pregnancy, Obstetric Haemorrhage, Hypertensive disorder of pregnancy, Tertiary care

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.