Moderate Postpartum Hemorrhage Research Articles

Clinical benefit of MKANDA SALAMA KIT in a real-world population with Postpartum Hemorrhage. A prospective observational study

Based on Tanzania administrative data and policy Implication report of 2018, revealed that Postpartum hemorrhage contributed to about 29% of all maternal deaths in Tanzania. MKANDA SALAMA KIT (MSK) is the new innovated technological device designed to stop Postpartum hemorrhage (PPH). To determine the effects of MSK on the clinical symptoms improvement, hemodynamic restoration, and bleeding stoppage in post- delivery mothers with PPH. The primary outcome was the composite of Postpartum hemorrhage maternal death and PPH rehospitalization within 42 days follow-up time; secondary outcomes were all causes of maternal death and the occurrence of rehospitalization for worsening PPH -data from 120 women with PPH aged from 13 to 39 years from December 2020 to May 2021 (6 months) at St. Francis referral hospital labor ward were included. Patients were grouped into mild PPH, moderate PPH, and severe PPH. A multinomial regression model was used to determine the associations between risk and outcomes using Statistical Package for Social Sciences software version 21.0". 23% had a previous history of PPH, 36% had maternal hypertension, 45% had anemia, and 12% had maternal diabetes. Mild PPH was 20%, moderate PPH was 37%, and severe PPH was 43%. MSK significantly improved clinical symptoms and signs of all PPH categories by 84%. A significant restoration to normal all hemodynamic parameters was observed to all patients by 79% MSK significantly stopped mild PPH by 100% within 10-20 minutes, while stopped moderate PPH by 70.3% within 10-20 minutes and stopped severe PPH by 63.5% within 10-20 minutes. There was no rehospitalization during follow-up time and no death was reported. MSK significantly improved clinical symptoms, hemodynamic parameters and stopped bleeding in PPH patients, timely application of MSK can significantly prevent PPH maternal death and PPH rehospitalization.

The impact of breastfeeding during the third stage of labor on postpartum haemorrhage according to Higham Chart among women Attending Maternity Teaching Hospital in Sulaimani City

One of the most important factor influencing the maternal health is postpartum haemorrhage. Immediate breastfeeding after birth is beneficial for releasing natural oxytocin that led to contracting uterus and reducing hemorrhage. To identify the impacts of breastfeeding on postpartum haemorrhage based on Higham chart. The design, a quasi-experimental study, post-test, only control was applied. Non- probability purposive was as sampling technique. Data collection was continued from 26th of February 2020 to 30th of July 2020. Three hundred women were selected from labor word, in the labor ward; these parturient women were equally divided into experimental group, applying early initiation of breastfeeding and control group, following the routine hospital care. In addition to a questionnaire, Pictorial Blood Assessment Cart (PBAC) was used to investigate the postpartum bleeding pattern of women in the labor's third stage. The chart of pictorial blood assessment is according to the presence of clots and the visual appearance of stained pads. According to Higham chart, in the experimental group, within 300 mothers 130 (86.7%) had a mild postpartum haemorrhage, 18 (12.0%) had a moderate postpartum haemorrhage and only 2 (1.3%) had severe postpartum haemorrhage; where in the control group, 32.7% and 30.7% of the women developed severe and moderate postpartum hemorrhage respectively. It is revealed that the extent of postpartum hemorrhage of the experimental group was greatly lower than the control group. Breastfeeding immediately after the birth is effective for decreasing the postpartum hemorrhage.

Blood management in post-partum haemorrhage, including point of care coagulation tests

Postpartum haemorrhage (PPH) is the leading global cause of maternal mortality, and an important cause of morbidity and mortality in the UK. Management of PPH requires a patient centred team approach to ensure effective management. Early recognition is crucial, hence quantitative measurement of blood loss should be started as soon as bleeding is identified and continue throughout an evolving haemorrhage. Pregnancy is associated with haematological changes resulting in a pro-coagulant state. Blood management in PPH has moved away from the use of shock packs and fixed transfusion ratios. Most women are not initially coagulopathic and coagulopathy is uncommon in mild to moderate PPH, Practice has therefore moved towards goal directed transfusion of blood products informed by haematological investigations alongside clinical assessment. Fibrinogen tends to be the first coagulation factor to fall and Clauss fibrinogen is an important predictor of PPH severity. Transfusion of fibrinogen rich blood products such as cryoprecipitate and fibrinogen complex are more effective at rapidly increasing fibrinogen levels compared to FFP. Point of care (POC) coagulation tests such as rotational thromboelastometry (ROTEM) and thromboeslastography (TEG) allow rapid bedside assessment compared to traditional laboratory tests. Surrogate markers of fibrinogen from POC tests can be used to both predict severity of PPH and inform blood transfusion. There is growing evidence that POC coagulation tests can be used to safely guide blood management in PPH, with its use associated with lower transfusion rates and possibly improved clinical outcomes. Further multi-centre studies are required to clarify debate surrounding their use. In this review we discuss blood management in PPH, with a focus on recent evidence regarding assessment of coagulopathy and the use of blood products.

Cesarean section complications according to degree of emergency during labour

ObjectiveEvaluate the complications rate of cesarean section delivery based on degree of labour emergency. Study designMonocentric (Lille, France), retrospective study of all term, singleton, and cesarean deliveries during labour. Three groups were categorized based on the degree of emergency according to a color code: green (no time limit between surgical decision and birth), orange (birth within 30 min), and red (birth within 20 min). Scheduled cesareans were excluded. Complications were defined as minor/major and intra-/post-operative. ResultsA total of 881 patients were included. Among these, 303 (34.5 %) were in the green group, 353 (40.1 %) in the orange group, and 225 (25.4 %) in the red group. Major intra-operative complications, mainly postpartum hemorrhage, were more frequent in the red group compared with the green group (16.9 % vs. 9.9 %, p = 0.05; OR 1.9; 95 % CI [1.1–3.1]). Among the minor complications, there was no difference on moderate postpartum hemorrhage and four times uterine artery wounds in the red group (1.7 % vs. 7.1 %, respectively; p = 0.007; OR 4.6; 95 % CI [1.6–12.6]). The overall major post-operative complication rate, mainly infectious morbidity, was 6.1 % and this was more frequent in the red group compared with the green group (12.4 % vs. 1.7 %, respectively; p < 0.0001; OR 8.5; 95 % CI [3.2–22.3]). ConclusionPre- and post-operative complications of cesarean section delivery during labour (i.e., emergency cesarean) increase with the degree of labour emergency. It would be ideal to identify women in labour who are at increased risk of emergency cesarean earlier, so that the situation does not escalate to a red code cesarean.

Relation of meconium-stained amniotic fluid and postpartum hemorrhage: a retrospective cohort study.

Postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. The purpose of this study was to evaluate if meconium-stained amniotic fluid (MSAF) is a risk factor for PPH after vaginal delivery. We retrospectively analyzed medical records of all patients who had a vaginal delivery at Fujian Provincial Maternity and Children's Hospital, between 1st January 2013 to 31st December 2018. Women with cesarean deliveries, multiple pregnancies, abnormal coagulation profile, and those with concomitant liver or kidney disorders were excluded. Patients were classified into MSAF (n=13686) and clear amniotic fluid (AF) (n=41511) groups. The incidence of PPH was significantly higher at 2.7% (370/13686) in the MSAF group as compared to 2.18% (904/41511) in the clear AF group (p=0.0004). There was no difference in the incidence of severe PPH between the two groups. Statistically significant difference in the incidence of PPH between MSAF and clear AF was seen in the maternal age groups of 30-34 and 35-39 years, gestational age>40weeks and >3 gravidity (p<0.05). Our study demonstrates that MSAF is a significant risk factor for minor and moderate PPH. Presence of meconium could therefore alert clinicians to expect PPH and make arrangements for further patient management. Further basic research is required to evaluate the mechanism by which meconium influences the incidence of PPH.

Point-of-care coagulation testing in obstetrics: more evidence, please?

Severe postpartum haemorrhage (PPH), defined as ≥2500ml, occurs in approximately 0.5% of maternities in the UK (Green et al, BJOG 2016;123:2164-70). It may be complicated by coagulopathy, which can develop rapidly. In moderate PPH, however, coagulopathy is uncommon and routine administration of fresh frozen plasma (FFP) may result in overtreatment. Coagulation testing should therefore be performed and should focus on fibrinogen, which falls earlier than other factors.

The impact of antenatal factor XIII levels on postpartum haemorrhage: a prospective observational study.

Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and morbidity. Our aim was to investigate the relationships between antenatal factor XIII (FXIII), fibrinogen levels, and blood loss at childbirth. This prospective observational study evaluated an unselected cohort of pregnant women admitted for intended vaginal deliveries of singletons at term. To determine clotting factor levels, we obtained blood samples at a maximum of three days prior to vaginal delivery. A calibrated collecting drape was used to quantify blood loss in the third stage of labour. Moderate and severe PPH were diagnosed as blood losses ≥500mL and ≥1000mL, respectively. In a multiple logistic regression analysis, we determined whether coagulation factors and their interactions could independently predict (severe) PPH. We analysed 548 vaginal deliveries that occurred during the study period. Of those, 78 (14.2%) lost ≥500mL and 18 (3.3%) lost ≥1000mL of blood. The mean pre-delivery FXIII activity in women with PPH (79.33% ± 15.5) was significantly (p < 0.001) lower than in women without PPH (86.45% ± 14.6). A receiver operating characteristic curve analysis detected antenatal FXIII cutoff levels of 83.5% and 75.5% for PPH and severe PPH, respectively. The multiple logistic regression analysis showed that FXIII alone (p < 0.001) and its interaction with fibrinogen (p = 0.03) significantly predicted PPH. FXIII was not significantly correlated with blood loss among patients with severe PPH. Our results suggested that antenatal FXIII levels may have a significant influence on PPH. The interaction between FXIII and fibrinogen might also provide slight advantages in forecasting PPH.

Meconium-stained amniotic fluid: a risk factor for postpartum hemorrhage.

Background/aimClinical data with respect to the impact of meconium on the risk of maternal hemorrhage are scarce. Therefore, in this study, we aimed to determine whether meconium-stained amniotic fluid (MSAF) represents a risk factor for postpartum hemorrhage (PPH) after vaginal delivery in a large unselected population.Patients and methodsA retrospective cohort study evaluated 78,542 consecutive women who had a vaginal delivery between 24th and 44th weeks of gestation. The women who had undergone cesarean section were excluded to avoid possible bias. Postpartum blood loss was measured with graduated blood sack. Postpartum blood loss between 1,000 and 2,000 mL and >2,000 mL were classified as moderate and severe PPH, respectively.ResultsA total of 74,144 patients were available for analysis. According to the color of amniotic fluid (AF), two groups of patients were identified: MSAF (n=10,997) and clear AF (n=63,147). The rates of severe and massive PPH were found to be significantly higher in the MSAF group than that of clear AF group (OR=1.3, 95% CI: 1.2–1.5, p<0.001 and OR=2.5, 95% CI: 1.5–4.2, p<0.001). Operative vaginal delivery rate was found to be higher in the MSAF group than that of clear AF group, but the difference was only borderline significant (OR=1.5, 95% CI: 1.0–2.2, p=0.05). There were no significant differences between the MSAF and the clear AF groups with respect to episiotomies, second- or third-degree perineal tears, vaginal–perineal thrombus, cervical lacerations, vaginal births after cesarean section, twin deliveries, and placental retention rates.ConclusionTo the best of our knowledge, this is the first clinical study that has investigated the role of MSAF as a risk factor for PPH after vaginal delivery in an unselected population. Our results suggest that MSAF is significantly associated with higher risk of moderate and severe PPH than clear AF.

Exercise during pregnancy on maternal lipids: a secondary analysis of randomized controlled trial

Today, scientific evidence has supported the popular belief that physical activity is associated with biological health in pregnant women. A randomized controlled trial was used to assess the benefits of physical exercise during pregnancy on maternal lipids in low-income Latina women. The study included 67 nulliparous low-income Latina women in gestational weeks 16–20, randomly assigned into one of two groups: 1) The exercise group, which took part in aerobic and resistance exercise for 60 min, three times a week for 12 weeks, 2) The control group, which undertook their usual physical activity and prenatal care. The primary outcomes were changes in maternal blood lipids after intervention. Obstetrical and neonatal outcomes measured were type of delivery, postpartum hemorrhage, newborn and/or maternal complications’, gestational age, weight gain, birth weight, foetal growth, and Apgar score. Fifty women completed the study. At the end of the intervention, there were differences between groups in low-density lipoprotein levels (mean change: −8 mg/dL, 95%CI -3 to −29; P < 0.001) and triglycerides (mean change: −6 mg/dL, 95%CI -1 to −11; P = 0.03). Also, compared with women who remained in the control group, active women showed lower complications during delivery (moderate postpartum haemorrhage) (58% compared with 75%; P < 0.05) and lower complications in newborns (e.g. cyanosis or respiratory distress) (21% compared with 46%; P < 0.001). An exercise programme during the second and third trimester favours less gain in low-density lipoprotein cholesterol and triglycerides fewer delivery and neonatal complications. NCT00741312 (August 22, 2008).

Systematic prophylactic oxytocin injection and the incidence of postpartum hemorrhage: A before-and-after study

Assess the impact of routine injection of 5units of oxytocin as soon as the anterior shoulder is delivered on the incidence of postpartum haemorrhage (PPH) in a context of daily practice. Single-centre before-and-after study evaluating the effect of a change in the protocol for PPH prevention as applied in our obstetrical unit. During the first period, oxytocin (5units) was to be injected only in case of PPH risk factors. During the second period, the injection was systematic. In the "before" study period, there were 1953patients vaginal deliveries and 843 (43%) oxytocin injections, with a protocol compliance of 85%. In the "after" study period, 2018women had vaginal deliveries and 1911 (95%) had an oxytocin injection (protocol compliance: 95%). The whole study period was associated with a reduced risk of moderate haemorrhage (13.4% vs. 9.2%, P<0.001), but no significant reduced risk of severe haemorrhage was observed (2.1% vs. 2.0%, P=0.79). After logistic regression, the study period remained associated with a significant reduction in the risk of moderate PPH (OR=0.72 [0.58-0.89]). Routine injection of 5units of oxytocin makes it possible to reduce the risk of moderate PPH, but it does not affect the risk of severe PPH.

A randomized trial of sublingual misoprostol to augment routine third-stage management among women at risk of postpartum hemorrhage.

To assess whether a combination of misoprostol and oxytocin is more beneficial than oxytocin alone in reducing blood loss after vaginal delivery among women with known risk factors for postpartum hemorrhage (PPH). A randomized, double-blind trial was conducted in a medical college in eastern India among women aged at least 18 years who had known high-risk factors for PPH. Using a computer-generated random number sequence (block size 6-8), participants were randomly assigned to receive 400 μg misoprostol or matched placebo tablets sublingually, in addition to 10 units of oxytocin, after vaginal delivery. The primary outcomes were postpartum blood loss at 1 hour and frequency of PPH. Analyses were by intention to treat. Both groups contained 144 participants. Postpartum blood loss at 1 hour after delivery was significantly lower among women who received misoprostol than among those who received placebo (225.8±156.7 mL vs 302.4±230.3 mL; P<0.001). The frequency of moderate PPH (500-999 mL) was significantly lower in the group receiving misoprostol than in the placebo group (5 [3.5%] vs 15 [10.4%] participants; P=0.03). As compared with oxytocin alone, misoprostol with oxytocin more effectively reduced blood loss after vaginal delivery among women at risk of PPH. Clinical Trial Registry India:CTRI/2014/03/004491.

Postpartum haemorrhage: are we following the guidelines on coagulation monitoring and transfusion support?

Background Postpartum haemorrhage (PPH) may be associated with early hypofibrinogenaemia and disseminated intravascular coagulation (DIC), and therapy with fresh frozen plasma (FFP), cryoprecipitate (for fibrinogen replacement) and platelets may be required in addition to red blood cell (RBC) transfusion. National patient blood management (PBM) on critical bleeding guidelines recommend early and frequent coagulation testing to guide therapy. Aim/Method A retrospective audit of PPH transfusion support was undertaken during two 6-month periods (2011 and 2013) at a major metropolitan obstetric service. Results In 157 PPH episodes, 154 (98%) patients had >1 risk factor (RF) for bleeding and 59 (38%) had >4 RF. Median estimated blood loss (EBL) was 1000 mL (300 mL to >9000mL). Correlation between EBL, haemoglobin (Hb) fall and Hb nadir was very poor. Ninety-five percent of patients received RBC, with 47% receiving 1000mL, 46% had no coagulation testing (2011, 42%; 2013, 50%). Of 31 who received >4 units RBC, 26% had no coagulation testing. Only 10% received FFP, 8% platelets and 3% cryoprecipitate. Conclusion Although most patients were young and had minor/ moderate PPH, nearly all received RBC. Conversely, coagulation testing was not performed in nearly half the patients with major bleeding. Very few received non-RBC components, even when hypofibrinogenaemia was documented. More work is required to align our practice with current national guidelines on management of critical bleeding.

Vaginal delivery through annular placenta – case report

Annular placenta is an extremely rare morphological type of human placenta. It is commonly related to placental vessel abnormalities frequently causing antenatal and postnatal hemorrhage and operative delivery. Gravida 4 para 1 had an uneventful course of pregnancy and normal vaginal delivery followed by moderate postpartum hemorrhage. Hemorrhage was found to be local in origin but the placenta was annular in shape and the newborn was delivered through one of the openings. Annular placenta was not recognized before delivery. Its implantation site was in the lower uterine segment but high enough to allow the passage of the fetus through its annular defect and vaginal birth. To our knowledge, this is a first report of annular placenta ending in normal vaginal delivery.

The management of moderate pph: an audit from the royal infirmary Edinburgh

BackgroundPrimary post-partum haemorrhage (PPH) is defined as a blood loss of more than 500mls following delivery. Emergency measures are required to be initiated when a blood loss exceeds 1000mls, as...

Use of oxytocin during early stages of labor and its effect on active management of third stage of labor

The purpose of this study was to evaluate whether the use of oxytocin during the first and second stages of labor is associated with a higher incidence of postpartum hemorrhage (PPH) in pregnant women who received active management of third stage of labor (AMTSL). A secondary data analysis from vaginal deliveries in a hospital-based cohort study from 24 maternity hospitals in South America. The primary outcomes that were analyzed were moderate PPH (≥500 mL of blood loss), severe PPH (≥1000 mL of blood loss), and need of blood transfusion. A total of 11,323 vaginal deliveries were included. The incidence of moderate and severe PPH was 10.8% and 1.86%, respectively. Overall, 36% of deliveries received AMTSL. There was no association between induced/augmented labor and moderate PPH (P = .753), severe PPH (P = .273), and blood transfusion (P = .603) in the population that received AMTSL. AMTSL should be recommended, regardless of whether pregnant women received oxytocin during the first and second stages of labor.

Risk Factors for Postpartum Hemorrhage in Vaginal Deliveries in a Latin-American Population

To identify risk factors for immediate postpartum hemorrhage after vaginal delivery in a South American population. This was a prospective cohort study including all vaginal births (N=11,323) between October and December 2003 and October and December 2005 from 24 maternity units in two South American countries (Argentina and Uruguay). Blood loss was measured in all births using a calibrated receptacle. Moderate postpartum hemorrhage and severe postpartum hemorrhage were defined as blood loss of at least 500 mL and at least 1,000 mL, respectively. Moderate and severe postpartum hemorrhage occurred in 10.8% and 1.9% of deliveries, respectively. The risk factors more strongly associated and the incidence of moderate postpartum hemorrhage in women with each of these factors were: retained placenta (33.3%) (adjusted odds ratio [OR] 6.02, 95% confidence interval [CI] 3.50-10.36), multiple pregnancy (20.9%) (adjusted OR 4.67, CI 2.41-9.05), macrosomia (18.6%) (adjusted OR 2.36, CI 1.93-2.88), episiotomy (16.2%) (adjusted OR 1.70, CI 1.15-2.50), and need for perineal suture (15.0%) (adjusted OR 1.66, CI 1.11-2.49). Active management of the third stage of labor, multiparity, and low birth weight were found to be protective factors. Severe postpartum hemorrhage was associated with retained placenta (17.1%) (adjusted OR 16.04, CI 7.15-35.99), multiple pregnancy (4.7%) (adjusted OR 4.34, CI 1.46-12.87), macrosomia (4.9%) (adjusted OR 3.48, CI 2.27-5.36), induced labor (3.5%) (adjusted OR 2.00, CI 1.30-3.09), and need for perineal suture (2.5%) (adjusted OR 2.50, CI 1.87-3.36). Many of the risk factors for immediate postpartum hemorrhage in this South American population are related to complications of the second and third stage of labor. II.

Aspects génétiques de la maladie de Creutzfeldt-Jakob : intérêt de l'étude moléculaire du gène PrP

Postpartum haemorrhage (PPH) is caused by obstetric complications but may be exacerbated by haemostatic impairment. In a 10-year programme of research we have established that haemostatic impairment is uncommon in moderate PPH and that fibrinogen falls earlier than other coagulation factors. Laboratory Clauss fibrinogen and the point-of-care surrogate measure of fibrinogen (FIBTEM A5 measured on the ROTEM® machine) are predictive biomarkers for progression from early to severe PPH, the need for blood transfusion and invasive procedures to control haemorrhage. Fibrinogen replacement is not required in PPH unless the plasma level falls below 2 g/L or the FIBTEM A5 is below 12 mm. Deficiencies of coagulation factors other than fibrinogen are uncommon even during severe PPH, and ROTEM® monitoring can inform withholding FFP safely in most women. In the absence of placental abruption, clinically significant thrombocytopenia is uncommon unless the platelet count is low before the bleed started, or very large bleeds (>5000 mL) occur. Measuring blood loss is feasible in routine practice during PPH and is more accurate than estimation. These research findings have been collated to design an ongoing quality improvement programme for all maternity units in Wales called OBS Cymru (Wales) (The Obstetric Bleeding Strategy for Wales).

Les thérapeutiques pharmacologiques dans la maladie d'Alzheimer : situation en 1994 et perspectives

Postpartum haemorrhage (PPH) is caused by obstetric complications but may be exacerbated by haemostatic impairment. In a 10-year programme of research we have established that haemostatic impairment is uncommon in moderate PPH and that fibrinogen falls earlier than other coagulation factors. Laboratory Clauss fibrinogen and the point-of-care surrogate measure of fibrinogen (FIBTEM A5 measured on the ROTEM® machine) are predictive biomarkers for progression from early to severe PPH, the need for blood transfusion and invasive procedures to control haemorrhage. Fibrinogen replacement is not required in PPH unless the plasma level falls below 2 g/L or the FIBTEM A5 is below 12 mm. Deficiencies of coagulation factors other than fibrinogen are uncommon even during severe PPH, and ROTEM® monitoring can inform withholding FFP safely in most women. In the absence of placental abruption, clinically significant thrombocytopenia is uncommon unless the platelet count is low before the bleed started, or very large bleeds (>5000 mL) occur. Measuring blood loss is feasible in routine practice during PPH and is more accurate than estimation. These research findings have been collated to design an ongoing quality improvement programme for all maternity units in Wales called OBS Cymru (Wales) (The Obstetric Bleeding Strategy for Wales).

Combination of local and general anesthesia in obstetrics

Combined infiltration and general anesthesia was employed in a series of eightyfive cases. There were complications in two cases. One patient had a moderate postpartum hemorrhage. Another patient developed bronchopneumonia which probably originated in the usual manner before admission to the hospital, or might possibly have been due to aspiration. There were four fetal deaths none of which could be ascribed to the anesthetic.