Obstetric Hemorrhage Research Articles

Using the SEIPS Model to Assess a Maternal Hemorrhage Risk Alert Tool

Deaths resulting from maternal hemorrhage (MH), for example, excessive blood loss related to childbirth, are preventable if the hemorrhage is identified in a timely manner. One approach to support timely identification is the use of alerts. However, alerts with low utility have negative, unanticipated consequences for both clinician and patient outcomes. This study has two objectives: (1) use the Systems Engineering Initiative for Patient Safety model to describe how the MH risk alert tool is used in the care process, and (2) evaluate the utility of the MH risk alert tool from the perspective of the care team. We performed observations to understand the care process and fielded a survey to evaluate the alarm utility. Our results showed that the MH risk alert tool is used throughout the care process, both antepartum and postpartum. Additionally, our results showed that workflow integration, usefulness, and trustworthiness of the alert need to be improved.

An Integral Assessment of Patient’s Condition in Postpartum Women with Critic Obstetric Complications

Introduction. Septic complications after critical obstetric conditions (COC) are a pressing problem in obstetrics. The aim of the study is to conduct an integral assessment of the severity of postpartum women with septic complications after COC.Materials and methods. We examined 39 postpartum women after COC (massive obstetric hemorrhage, severe preeclampsia). All patients were divided into 2 groups: the main group (n = 18) — with associated septic complications, the comparison group (n = 21) — without septic complications. The average age of the subjects was (29.80±6.48) years.Results. Obstetric bleeding was complicated by hemorrhagic shock in more than 75 % of patients in both groups. Premature detachment of a normally located placenta (PDNLP) was statistically significantly more often recorded in the main group (p = 0.04). All patients underwent total hysterectomy during childbirth or in the early postpartum period. Multiple organ failure syndrome (MODS) occurred in all women of the main group and in 17/21 (80.95 %) in the comparison group (p = 0.05). When assessing the condition of maternity hospitals using integral scales, a higher number of points were noted in the main group on the APACHE II scale (p = 0.02), SOFA (p = 0.001), NEWS2 (p < 0.001). In the main group, septic complications developed on the 9 [4; 9] day after delivery.Conclusion. Risk factors for septic complications after COC are: MODS, renal failure, acute kidney injury, heart failure, respiratory distress syndrome, pneumonia. Maternity hospitals at risk of septic complications after COC initially show an increase in the number of points according to APACHE II, SOFA, NEWS2.

Risks Associated with Prolonged Latent Phase of Labor.

We sought to assess the impact of a prolonged latent phase (PLP) on maternal and neonatal morbidity. This is a secondary analysis of a prospective cohort study conducted 2010 to 2015 that included all term gravidas who reached active labor (6 cm). Primary outcomes were composite maternal morbidity (maternal fever, postpartum hemorrhage, transfusion, endometritis, and severe perineal lacerations) and composite neonatal morbidity (respiratory distress syndrome, mechanical ventilation, birth injury, seizures, hypoxic ischemic encephalopathy, therapeutic hypothermia, or umbilical artery pH ≤ 7.1). Outcomes were compared between patients with and without PLP, defined as ≥90th percentile of labor duration between admission and active phase. Results were stratified by induction of labor (IOL) versus spontaneous labor. A stratified analysis was performed by mode of delivery. Multivariable logistic regression was used to adjust for confounders. In this cohort of 6,509 patients, 51% underwent IOL. A total of 650 patients had a PLP with a median length of 8.5 hours in spontaneous labor and 18.8 hours in IOL. Among patients with PLP, there was a significant increase in composite maternal morbidity with both IOL (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [CI]: 1.01, 1.84) and spontaneous labor (aOR: 1.49, 95% CI: 1.09, 2.04) and an increase in composite neonatal morbidity with spontaneous labor only (aOR: 1.57, 95% CI: 1.01, 2.45). Cesarean delivery occurred more often in PLP group (14.0 vs. 25.1%). Among patients who underwent cesarean delivery, PLP remained associated with increased odds of maternal morbidity compared with those with normal latent phase. PLP at or above the 90th percentile in patients who reach active labor is associated with increased risk of maternal morbidity that is not mediated by cesarean delivery. PLP in spontaneous labor is associated with increased neonatal morbidity. These data suggest that further research is needed to establish latent phase cutoffs that may be incorporated into labor management guidelines. · Latent labor ≥90th percentile is associated with increased maternal morbidity in induced and spontaneous labor.. · Latent labor ≥90th percentile in spontaneous but not induced labor is associated with increased neonatal morbidity.. · Cesarean delivery alone does not explain this increased maternal morbidity..

Prevalence, underlying causes, and determinants of maternal near miss in Ethiopia: a systematic review and meta-analysis.

Maternal near miss (MNM) is one of the newly adopted assessment parameters to gauge the quality of maternity care. In Ethiopia, several studies have been conducted to investigate the incidence, underlying causes, and determinants of MNM. However, the findings from those studies vary greatly and are largely inconsistent. Thus, this review aims to more robustly estimate the pooled prevalence, identify underlying causes, and single out determinants of MNM in Ethiopia. Studies were searched from international databases (PubMed/ Medline, Cochrane Library, and Embase databases) and other potential sites. All observational studies were included. Heterogeneity between studies was checked using Cochrane Q test statistics and I2 test statistics and small study effects were checked using Egger's statistical test at a 5% significance level. Outcome measures were overall and specific underlying causes (obstetrics hemorrhage, hypertensive disorder pregnancy, pregnancy-related infection) rates of MNMs per 10,000 live births. The meta-analysis included 43 studies consisting of 77240 MNM cases. The pooled prevalence MNM per 1000 live births in Ethiopia was 54.33 (95% CI: 33.93 to 85.89). Between-study heterogeneity was high (I2 = 100%, P < 0.0001), with the highest rate observed in Amhara region (384.54 per 1000). The prevalence of obstetrics hemorrhage (14.56 per 1000) was higher than that of hypertensive disorder pregnancy (12.67 per 1000) and pregnancy-related infections (3.55 per 1000) were identified as underlying causes. Various factors, including socio demographic characteristics, previous medical and obstetrics history as well as access to and quality of care obtained, were associated with MNM. Almost six women encounter near miss among a hundred live births in Ethiopia. Obstetric hemorrhage and hypertensive disorder pregnancy were the most common underlying causes of MNM. Both individual and facility level determinants were found to be associated with MNM. Considering the magnitude and identified factors, tailored measures should be taken at every stage of the continuum of care. https://www.crd.york.ac.uk/prospero/, identifier CRD42023395259.

Perioperative mortality of caesarean section in North-West Ethiopia: a prospective cohort study

ObjectiveThis study aimed to assess 7-day perioperative maternal mortality and risk factors at Tibebe Ghion Specialized Hospital.DesignA single-centre prospective cohort study.SettingA tertiary hospital in North-West Ethiopia, 01 June 2019 to...

Impact of introduction of point-of-care viscoelastic testing on transfusion practice in major obstetric haemorrhage

Impact of introduction of point-of-care viscoelastic testing on transfusion practice in major obstetric haemorrhage

Predicting Intra- and Postpartum Hemorrhage through Artificial Intelligence.

Background and Objectives: Intra/postpartum hemorrhage stands as a significant obstetric emergency, ranking among the top five leading causes of maternal mortality. The aim of this study was to assess the predictive performance of four machine learning algorithms for the prediction of postpartum and intrapartum hemorrhage. Materials and Methods: A prospective multicenter study was conducted, involving 203 patients with or without intra/postpartum hemorrhage within the initial 24 h postpartum. The participants were categorized into two groups: those with intra/postpartum hemorrhage (PPH) and those without PPH (control group). The PPH group was further stratified into four classes following the Advanced Trauma Life Support guidelines. Clinical data collected from these patients was included in four machine learning-based algorithms whose predictive performance was assessed. Results: The Naïve Bayes (NB) algorithm exhibited the highest accuracy in predicting PPH, boasting a sensitivity of 96.3% and an accuracy of 98.6%, with a false negative rate of 3.7%. Following closely were the Decision Tree (DT) and Random Forest (RF) algorithms, each achieving sensitivities exceeding 94% with a false negative rate of 5.9%. Regarding severity classification I, the NB and Support Vector Machine (SVM) algorithms demonstrated superior predictive capabilities, achieving a sensitivity of 96.4%, an accuracy of 92.1%, and a false negative rate of 3.6%. The most severe manifestations of HPP were most accurately predicted by the NB algorithm, with a sensitivity of 89.3%, an accuracy of 82.4%, and a false negative rate of 10.7%. Conclusions: The NB algorithm demonstrated the highest accuracy in predicting PPH. A notable discrepancy in algorithm performance was observed between mild and severe forms, with the NB and SVM algorithms displaying superior sensitivity and lower rates of false negatives, particularly for mild forms.

Fluid resuscitation strategy in patients with placenta previa accreta: a retrospective study.

Obstetric hemorrhage is the leading cause of maternal death worldwide. Placenta previa accreta is one of the major direct causes of postpartum hemorrhage, accounting for two-thirds of obstetric hemorrhage cases. Fluid resuscitation is a life-saving procedure for patients suffering from massive hemorrhage. This study aims at evaluating the risk factors of massive hemorrhage and appropriate fluid resuscitation strategy in patients with placenta previa accreta. This study retrospectively analyzed the risk factors for massive hemorrhage, clinical characteristics, and perinatal outcomes of patients with placenta previa accreta. Maternal noninvasively evaluated hemodynamic indicators, including maternal heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and shock index, were collected and analyzed at nine time points, from the administration of anesthesia until the end of procedures, in patients diagnosed with placenta previa accreta and receiving different fluid supply volumes. Complicated with placenta increta/percreta and gestational age of delivery later than 37 weeks are two independent risk factors of massive hemorrhage in patients with placenta previa accreta. A total of 62.27% (170/273) patients diagnosed with placenta increta/percreta had massive hemorrhage, significantly higher than those diagnosed with placenta previa accreta (5.88%, 6/102). Patients delivered after 37 weeks of gestation had significantly higher ratios (86.84%, 99/114) of massive hemorrhage compared with those delivered between 36 and 36+6 weeks of gestation (35.39%, 63/178). Maternal SBP, DBP, and MAP started to decrease immediately after the baby was delivered and reached a relatively stable trough state at 15-30 min after delivery. No statistical differences were found in hemodynamic indicators, the occurrence of hypotension, or in-hospital days after the procedure among the transfusion volumes < 30 ml/kg, 30-80 ml/kg, and ≥ 80 ml/kg groups. Patients with a suspected diagnosis of placenta previa accreta should plan to deliver before 37 weeks of gestation. The ability to identify concurrent placenta increta/percreta should be improved to schedule a reasonably rapid perioperative plan. Restrictive fluid resuscitation could achieve good effects in maintaining hemodynamic stability in patients with placenta previa accreta. A time period of 15-30 min after delivery is the critical stage for fluid resuscitation.

Cell salvage techniques and obstetric haemorrhage

Over the last decade, the incidence of postpartum haemorrhage has risen because of increasing maternal age at time of delivery, multiple births, obesity and increased obstetric interventions, resulting in most of these women requiring blood transfusions. While lifesaving, blood transfusion is not without risk. Recipients may rarely develop transfusion-transmitted infections or suffer immunological sequelae. Intraoperative cell salvage is recommended by several national policy making organisations as a safe cost-effective alternative to autologous blood transfusion in both emergency and elective settings. Moreover, emerging data has also revealed that autotransfusion of vaginally shed blood is both feasible and safe. These techniques are useful in patients who decline blood transfusions for both personal and religious reasons and should therefore be taken into consideration when planning place of birth.

Feasibility, Acceptability, and Appropriate Use of Novel and Lesser-Used Medicines for Prevention and Treatment of Postpartum Hemorrhage: Evidence from Implementation Research

Maternal mortality remains one of the primary global health challenges of the 21st century, despite major medical advances in the field. Although solutions are available, inequities determine where mothers die, with the majority of maternal deaths occurring in low- and middle-income countries (LMICs). More than one-third of maternal deaths are related to obstetric hemorrhage and most commonly postpartum hemorrhage (PPH). Effective, quality-assured uterotonics significantly reduce PPH-related morbidity and mortality. Updated World Health Organization (WHO) recommendations on uterotonics used for PPH prevention include the addition of heat-stable carbetocin (HSC) to the suite of prophylactic uterotonic agents as well as the use of tranexamic acid (TXA) for PPH treatment. Both medicines are promising interventions in obstetric care. However, the introduction of these medicines faces numerous challenges to end-user access, such as decentralized procurement, time-consuming policy updates, market access barriers, lack of demand for quality-assured products, and inadequate systematic training and information provision, impeding access in many LMICs. Assessing the feasibility and acceptability of implementing these medicines in different resource settings can help bridge the gap between research and development to policy and practice, in an effort to reduce the significant health inequities facing women accessing the public health sector for quality care during labor and delivery. In this Special Collection, we explore the findings from mixed-methods implementation research studies in nine LMICs which support the acceptability and feasibility of HSC and TXA administration by healthcare providers, generating evidence to help inform the introduction and scale-up of these new and lesser-utilized PPH medicines.

Incidence, Causes and Outcomes of Postpartum Hemorrhage in Eastern Ethiopia: A Multicenter Surveillance Study

Abstract Objectives Maternal mortality remains an unfinished global agenda and postpartum hemorrhage (PPH) remains one of the leading causes. The aims of this study were to describe the incidence, underlying causes, and case fatality rate of PPH in public hospitals in eastern Ethiopia. Methods This study was part of a larger Ethiopian Obstetric Surveillance System (EthOSS) project — a multicenter surveillance of women admitted to 13 public hospitals in eastern Ethiopia due to any of the five major obstetric conditions: obstetric hemorrhage, eclampsia, uterine rupture, sepsis, and severe anemia – conducted from April 1, 2021 to March 31, 2022. All registers in maternity units of those hospitals were reviewed to identify eligible women and collect data on sociodemographic and obstetric characteristics, management and maternal outcomes at discharge or death. Findings were reported using descriptive statistics. Results Among 38,782 births registered during the study period, 2043 women were admitted with at least one of the five major obstetric conditions. Of these 2043, 306 women (15%) had PPH corresponding with an incidence rate of 8 (95% CI: 7–9) per 1000 births. Uterine atony was the main underlying cause in 77%; 81% of women with PPH received at least one uterotonic drug, and 72% of women for whom blood was requested received at least one unit. Of the 70 hospital based maternal deaths, 19 (27%) died from PPH, making a case fatality rate of 6 per 100. Conclusions Although the overall incidence of PPH appeared low, it was still the underlying cause of death in one out of four women who died. The contributing factors might be that one in five women with PPH did not receive any uterotonic drug and the low blood transfusion. Ongoing audit, followed by targeted action, is essential to improve care quality and reduce adverse maternal outcome. The relatively low incidence may reflect under-recording in paper-based records, implying that further research into methods to optimize the surveillance is needed.

Socio-medical Factors Associated with Neurodevelopmental Disorders on the Kenyan Coast.

Neurodevelopmental disorders (NDDs) are a group of conditions with their onset during the early developmental period and include conditions such as autism, intellectual disability and attention deficit hyperactivity disorder (ADHD). Occurrence of NDDs is thought to be determined by both genetic and environmental factors, but data on the role of environmental risk factors for NDD in Africa is limited. This study investigates environmental influences on NDDs in children from Kenya. This case-control study compared children with NDDs and typically developing children from two studies on the Kenyan coast that did not overlap. We included 172 of the study participants from the Kilifi Autism Study and 151 from the NeuroDev Study who had a diagnosis of at least one NDD and 112 and 73 with no NDD diagnosis from each study, respectively. Potential risk factors were identified using unadjusted univariable analysis and adjusted multivariable logistic regression analysis. Univariable analysis in the Kilifi Autism Study sample revealed hypoxic-ischaemic encephalopathy conferred the largest odds ratio (OR) 10.52 (95%CI 4.04 - 27.41) for NDDs, followed by medical complications during pregnancy (gestational hypertension & diabetes, eclampsia, and maternal bleeding) OR: 3.17 (95%CI 1.61 - 6.23). In the NeuroDev study sample, labour and birth complications (OR: 7.30 (2.17 - 24.61)), neonatal jaundice (OR: 5.49 (95%CI 1.61 - 18.72)) and infection during pregnancy (OR: 5.31 (1.56 - 18.11)) conferred the largest risk associated with NDDs. In the adjusted analysis, seizures before age 3 years in the Kilifi Autism study and labour and birth complications in the NeuroDev study conferred the largest increased risk. Higher parity, the child being older and delivery at home were associated with a reduced risk for NDDs. Recognition of important risk factors such as labour and birth complications could guide preventative interventions, developmental screening of at-risk children and monitoring progress. Further studies examining the aetiology of NDDs in population-based samples, including investigating the interaction between genetic and environmental factors, are needed.

Cornual Ectopic Pregnancy Rupture Early Diagnosis and Treatment: A Case Report

Cornual pregnancy is a severe form of ectopic pregnancy, comprising 2-4% of such cases and presenting a mortality rate 6-7 times higher than typical ectopic pregnancies. It is often confused with interstitial pregnancy which arises from the implantation of the gestational sac in the myometrium’s proximal part. Diagnosis and treatment are challenging and considered medical emergencies due to potential for significant maternal haemorrhage. This is a case report of a 26-year-old woman in hypovolemic shock due to a ruptured ectopic pregnancy, confirmed via ultrasound and treated with emergency laparotomy, revealing a left corneal ectopic pregnancy, which was successfully repaired.

Values and preferences towards the use of prophylactic low-molecular-weight heparin during pregnancy: a convergent mixed-methods secondary analysis of data from the decision analysis in shared decision making for thromboprophylaxis during pregnancy (DASH-TOP) study

BackgroundVenous thromboembolism (VTE) in pregnancy is a major cause of maternal morbidity and mortality, and the use of preventive low-molecular-weight heparin (LMWH) can be challenging. Clinical guidelines recommend eliciting pregnant individuals’ preferences towards the use of daily injections of LMWH and discussing the best option through a shared decision-making (SDM) approach. Our aim was to identify individuals’ preferences concerning each of the main clinical outcomes, and categorize attributes influencing the use of LMWH during pregnancy.MethodsDesign: Convergent mixed-methods.Participants: Pregnant women or those planning a pregnancy with VTE recurrence risk.Intervention: A SDM intervention about thromboprophylaxis with LMWH in pregnancy.Analysis: Quantitatively, we report preference scores assigned to each of the health states. Qualitatively, we categorized preference attributes using Burke’s pentad of motives framework: act (what needs to be done), scene (patient’s context), agent (perspectives and influence of people involved in the decision), agency (aspects of the medication), and purpose (patient’s goals). We use mixed-method convergent analysis to report findings using side-by-side comparison of concordance/discordance.ResultsWe comprehensively determined preferences for using LMWH by pregnant individuals at risk of VTE: through value elicitation exercises we found that the least valued health state was to experience a pulmonary embolism (PE), followed by major obstetrical bleeding (MOB), deep vein thrombosis (DVT), and using daily injections of LMWH (valued as closest to a ‘healthy pregnancy’); through interviews we found that: previous experiences, access to care (scene) and shared decision-making (agent) affected preferences. LMWH's benefits were noted, but substantial drawbacks were described (agency). For participants, the main goal of using LMWH was avoiding any risks in pregnancy (purpose). Side-by-side comparisons revealed concordance and discordance between health states and motives.ConclusionsMixed-methods provide a nuanced understanding of LMWH preferences, by quantifying health states preferences and exploring attributes qualitatively. Incorporating both methods may improve patient-centered care around preference-sensitive decisions in thromboprophylaxis during pregnancy.

Maternal mortality due to obstetric hemorrhage by surgical injury during cesarean section: A nationwide study.

Obstetric hemorrhage remains a largely preventable cause of maternal mortality globally. The contribution of uterine atony to hemorrhage-related maternal mortality has decreased in France, while the contribution of other causes of obstetric hemorrhage such as surgical injury during cesarean has been reported to increase. However, little evidence exists regarding the risk factors and care processes of women who died from this cause of hemorrhage. Therefore, we aimed to describe the clinical profile, underlying mechanisms, and preventability factors among women who died from obstetric hemorrhage by surgical injury during cesarean section. Nationwide analysis of all hemorrhage-related maternal deaths by surgical injury during cesarean in France identified by the nationwide permanent enhanced maternal mortality surveillance system (ENCMM) between 2007 and 2018. We described the characteristics of the women, delivery hospitals, circumstances of hemorrhage, features of obstetric and resuscitation/transfusion care, and main preventability factors. Between 2007 and 2018, hemorrhage-related maternal mortality in France decreased from 1.6/100 000 live births (95% CI 1.1-2.2) (39/2 472 650) in 2007-2009 to 0.8/100 000 live births (95% CI 0.5-1.3) (19/2 311 783) in 2016-2018. Hemorrhage-related maternal mortality ratio due to surgical injury during cesarean increased from 0.08 (95% CI 0.01-0.3) (2/2 472 650) to 0.2 (95% CI 0.07-0.5) (5/2 311 783) per 100 000 live births. Among the 18 women who died from surgical injury during cesarean over the 12-year study period, we report a high prevalence of obesity (67%, 12/18), previous cesarean (72%, 13/18), and second-stage cesareans (56%, 10/18). In 22% (4/18), cesarean section was performed in a hospital providing <1000 births annually, with no blood bank (39%, 7/18) or no adult intensive care (44%, 8/18) on-site. Overall preventability of deaths was 94% (17/18). Main preventability factors were related to delay in hemorrhage diagnosis (77%, 14/18) due to late recognition of abnormal parameters (33%, 6/18) and late bedside ultrasound (56%, 10/18), and delay in management due to insufficient surgical skills (56%, 10/18). In France, surgical injury during cesarean section is an increasing, largely preventable contributor to hemorrhage-related maternal mortality, as other causes of fatal hemorrhage have become less frequent. The profile of these women showed a high prevalence of obesity, previous cesarean, second-stage cesarean, and delivery in hospitals with limited medical and surgical resources, which suggests explanatory mechanisms for the fatal outcome and opportunities for prevention.

Maternal and Fetal Outcomes in Disseminated Intravascular Coagulation Cases Associated with Pregnancy Complications.

The relationship between the pregnancy modified DIC score, which is applied in obstetric conditions where the risk of disseminated intravascular coagulation is high, and underlying disease, as well as its effect on the prognosis, was investigated. Those with a DIC score ≥ 26 from obstetric conditions, such as obstetric bleeding, placental abruption, or preeclampsia/HELLP syndrome, which are at high risk of developing DIC, were included in the study. These patients were compared in terms of laboratory results, maternal morbidity/mortality, and neonatal outcomes, according to the underlying disease. The DIC score was ≥ 26 in 224 of 154,233 deliveries in our center, and the incidence was 0.14%. In the preeclampsia/HELLP syndrome group, the platelet count and prothrombin time were lower, and the fibrinogen level was higher than those of the obstetric hemorrhage and placental abruption groups. In addition, the rates of blood transfusion and hysterectomy were lower in women who developed DIC due to pre-eclampsia/HELLP syndrome than in those with obstetric hemorrhage. Considering the underlying disease is an important factor in predicting prognosis, when using the new pregnancy modified diagnostic scores for DIC diagnosis.

External aortic compression: buying time to save lives in obstetric hemorrhage

External aortic compression: buying time to save lives in obstetric hemorrhage

Impact of the 2017 revised Japanese obstetric hemorrhage management guidelines on tranexamic acid use in patients undergoing cesarean delivery: an interrupted time series analysis

BackgroundTranexamic acid is one component of a complex management algorithm for postpartum hemorrhage. In Japan, the 2010 obstetric hemorrhage management guidelines was revised in 2017, adding the recommendation for the administration of tranexamic acid for postpartum hemorrhage. This research aims to delineate the temporal trends in tranexamic acid administration in patients undergoing cesarean deliveries and to examine the impact of the obstetric hemorrhage management guidelines implementation. MethodsAn interrupted time series analysis was conducted on data from patients who underwent cesarean deliveries from April 2012 to August 2021, sourced from Japan’s nationwide health insurance claims database. We examined the trends of tranexamic acid usage and blood transfusion use before and after the implementation of the revised guidelines in 2017. ResultsThe study cohort comprised 91 166 cesarean deliveries. Prior to the guideline implementation, the rate of tranexamic acid usage decreased. Post-guidelines implementation, there was a statistically significant increase in the rate of tranexamic acid use, with a quarterly percentage change of 0.48% (95% confidence interval: 0.36 to 0.60; P < 0.001). The guidelines implementation in 2017 was not significantly associated with a change in the rate of transfusions. ConclusionsThis interrupted time series analysis demonstrated a significant increase in the rate of tranexamic acid administration following the implementation of the revised guidelines, reversing the previously observed downward trend. Our findings could reflect the impact of the revised guideline on the use of tranexamic acid for postpartum hemorrhage, but this did not translate to fewer blood transfusions.

Evolution of the Use of Therapeutic Fibrinogen Concentrate in the Massive Bleeding Guidelines

Fibrinogen concentrate was approved for the first time in the European Union by the German Federal Ministry of Health on January 4th, 1966. Since then, its use has been shown to be effective and well-tolerated in numerous clinical studies with congenital or acquired fibrinogen deficiency. In this review, we analyze the evolution of the indications for the use of fibrinogen concentrate in massive bleeding guidelines in three main clinical scenarios of acquired hypofibrinogenemia, such as cardiac, obstetric, and polytrauma patients. In cardiac surgery, the administration of fibrinogen has become a noteworthy tool in the management of perioperative haemostasis. The implementation of therapeutic algorithms, together with the use of viscoelastic coagulation tests, has allowed a faster and more personalized diagnosis and treatment of perioperative bleeding. In obstetrics, fibrinogen administration has evolved significantly over the years to a part of the management of massive obstetric haemorrhage, with early administration of fibrinogen now considered important in cases of hypofibrinogenemia during haemorrhage, helping to effectively correct coagulopathy and improve maternal outcomes. Currently, the implementation of protocols based on point-of-care viscoelastic testing has proven to be useful in the management of obstetric haemorrhage. In polytrauma patients with severe bleeding, fibrinogen administration is recommended based on clinical criteria and prior to laboratory test outcomes. After this first approach, guidelines recommend goal-directed coagulation management based on the results of viscoelastic tests and, in their absence, classical laboratory tests are recommended.

The Impact of Adenomyosis on Pregnancy.

Adenomyosis is characterized by ectopic proliferation of endometrial tissue within the myometrium. Histologically, this condition is marked by the presence of islands of benign endometrial glands surrounded by stromal cells. The myometrium appears thinner, and cross-sectional analysis often reveals signs of recent or chronic hemorrhage. The ectopic endometrial tissue may respond to ovarian hormonal stimulation, exhibiting proliferative or secretory changes during the menstrual cycle, potentially leading to bleeding, uterine swelling, and pain. Adenomyosis can appear as either a diffuse or focal condition. It is crucial to understand that adenomyosis involves the infiltration of the endometrium into the myometrium, rather than its displacement. The surgical management of adenomyosis is contingent upon its anatomical extent. The high incidence of the disease and the myths that develop around it increase the need to study its characteristics and its association with pregnancy and potential obstetric complications. These complications often require quick decisions, appropriate diagnosis, and proper counseling. Therefore, knowing the possible risks associated with adenomyosis is key to decision making. Pregnancy has a positive effect on adenomyosis and its painful symptoms. This improvement is not only due to the inhibition of ovulation, which inhibits the bleeding of adenomyotic tissue, but also to the metabolic, hormonal, immunological, and angiogenic changes associated with pregnancy. Adenomyosis affects pregnancy through disturbances of the endocrine system and the body's immune response at both local and systemic levels. It leads to bleeding from the adenomyotic tissue, molecular and functional abnormalities of the ectopic endometrium, abnormal placentation, and destruction of the adenomyotic tissue due to changes in the hormonal environment that characterizes pregnancy. Some of the obstetric complications that occur in women with adenomyosis in pregnancy include miscarriage, preterm delivery, placenta previa, low birth weight for gestational age, obstetric hemorrhage, and the need for cesarean section. These complications are an understudied field and remain unknown to the majority of obstetricians. These pathological conditions pose challenges to both the typical progression of pregnancy and the smooth conduct of labor in affected women. Further multicenter studies are imperative to validate the most suitable method for concluding labor following surgical intervention for adenomyosis.