Persistent Postpartum Hemorrhage Research Articles

Rotational thromboelastometry during Cesarean section as a predictive evaluation for the progression of persistent postpartum hemorrhage in parturients with placenta previa: A prospective observational study

BackgroundThe rotational thromboelastogram (ROTEM) has been used in the management of massive bleeding and transfusion strategy. This study investigated ROTEM parameters measured during Cesarean section as predictors for the progression of persistent postpartum hemorrhage (PPH) in parturients with placenta previa. MethodsThis prospective observational study recruited 100 women scheduled for elective Cesarean section after being diagnosed with placenta previa. Recruited women were divided into two groups according to the amount of estimated blood loss: the PPH group (PPH > 1500 ml) vs. the non-PPH group. ROTEM with laboratory tests was performed three times, preoperative, intraoperative, and postoperative time, which were compared between the two groups. ResultsThe PPH and non-PPH groups included 57 and 41 women, respectively. The area under the receiver-operating characteristic curve of postoperative FIBTEM A5 to detect PPH was 0.76 (95% CI = 0.64 to 0.87; P < 0.001). When postoperative FIBTEM A5 was 9.5, the sensitivity and specificity were 0.74 (95% CI = 0.55 to 0.88) and 0.73 (95% CI = 0.57 to 0.86), respectively. When subgrouping the PPH group based on the postoperative FIBTEM A5 value of 9.5, intraoperative cEBL was similar between the two subgroups; however, postoperative RBC was transfused more in the subgroup with FIBTEM A5 < 9.5 than the subgroup with FIBTEM A5 ≥ 9.5 (7.4 ± 3.0 vs 5.1 ± 2.3 units, respectively; P = 0.003). ConclusionPostoperative FIBTEM A5, with appropriate selection of the cut-off value, can be a biomarker for more prolonged PPH and massive transfusion following Cesarean section by placenta previa.

Risk Factors of Bakri Balloon Tamponade Failure for Persistent Postpartum Hemorrhage

Background: The aim of this study was to identify risk factors of Bakri balloon tamponade (BBT) failure for postpartum hemorrhage (PPH) and to evaluate the efficacy of BBT for PPH caused by different etiologies. Methods: All women who underwent BBT for PPH at International Peace Maternity &amp; Child Healthcare Hospital, Shanghai, China were included. Univariate analysis and logistic multivariate models were used to identify prognostic factors for BBT failure. Results: Of 48,511 deliveries during the study period, 487 (1.0%) women underwent BBT for persistent PPH. The overall success rate was 91.8% (447/487). The individual success rates of BBT for PPH caused by uterine atony, placenta previa, placenta accreta spectrum (PAS), and coagulopathy were 95.9%, 90.6%, 50.0%, and 25.0%, respectively. Blood loss before BBT was remarkably higher in the failure group than in the success group. In addition, estimated blood loss (EBL) before BBT insertion, disseminated intravascular coagulation (DIC) development, in vitro fertilization (IVF) pregnancy, and PAS were considered to be independent risk factors of BBT failure. Conclusions: BBT is an effective method in the management of PPH resulting from uterine atony and placenta previa. Risk factors of BBT failure primarily include the EBL before BBT insertion, DIC development, IVF pregnancy and PAS.

Risk Factors for Carbetocin Failure after a Cesarean Section: Is Obesity One of Them?

Obese pregnant women have increased rates of fetal macrosomia, long labor, and cesarean sections, which lead to an increased risk of postpartum hemorrhage (PPH). Carbetocin is useful for the prevention of PPH after a cesarean section. Our study aimed to investigate predictors of carbetocin failure after a cesarean section, and specifically whether obesity is associated with carbetocin failure. We retrospectively analyzed all women who received carbetocin after a cesarean section. Carbetocin failure was defined as changes in hematocrit and hemoglobin, blood loss ≥ 1000 mL, and the need for an additional uterotonic agent or second-line therapies for persistent PPH. Univariate and multivariate analyses were performed to investigate predictors of carbetocin failure. The study included 600 women, with 131 (21.8%) obese women. Overall, 44 (7.3%) carbetocin failures were reported, and rates of obese women were similar between groups (carbetocin failure, 11.4% vs. 22.9%; p = 0.08). Previous PPH (p < 0.001), a cesarean section during labor (p = 0.01), cervical ripening (p = 0.02), and birthweight (p = 0.01) were significantly different between groups. In the multivariable logistic regression analysis adjusted for potential confounders, cervical ripening (adjusted odds ratio (OR) 2.23, 95% confidence interval (CI) 1.01–4.80), compared with spontaneous labor, was significantly associated with carbetocin failure. Obesity was not associated with carbetocin failure after cesarean sections.

The Effect of Tranexamic Acid on Blood Loss and Maternal Outcome in the Treatment of Persistent Postpartum Hemorrhage: A Nationwide Retrospective Cohort Study

Background: Recent results show a protective effect of tranexamic acid on death due to bleeding in patients with postpartum hemorrhage in low- and middle-resource countries. We set out toquantify the association between early administration of tranexamic acid compared to late or no administration and severe acute maternal morbidity and blood loss among women suffering from persistent severe postpartum hemorrhage in a high-income country.Methods and Findings: We performed a nationwide retrospective cohort study in 61 hospitals in the Netherlands.The study population consisted of 1260 women with persistent postpartum hemorrhage who had received at least four units of red cells, or fresh frozen plasma or platelets in addition to red cells. A review of medical records was performed and cross-referenced with blood bank data. The composite endpoint comprised maternal morbidity (hysterectomy, ligation of the uterine arteries, emergency B-Lynch suture, arterial embolization or admission into an intensive care unit) and mortality.Results: 247 women received early tranexamic acid treatment. After adjustment for confounding, odds ratio for the composite endpoint for early tranexamic acid (n= 247) versus no/late tranexamic acid (n= 984) was 0.92 (95% confidence interval (CI) 0.66 to 1.27). Propensity matched analysis confirmed the absence of a difference between women with and without tranexamic acid. Blood loss after administration of first line therapy did not differ significantly between the two groups (adjusted difference -177 mL, CI -509.4 to +155.0).Conclusions: Our findings suggest that in a high-resource country the effect of tranexamic acid on both blood loss and the combined endpoint of maternal mortality and morbidity may be disappointing.Keywords: postpartum hemorrhage, treatment, tranexamic acid, severe acute maternal morbidity, maternal mortality, blood transfusion DisclosuresNo relevant conflicts of interest to declare.

Early and systematic administration of fibrinogen concentrate in postpartum haemorrhage following vaginal delivery: the FIDEL randomised controlled trial.

To assess the benefits and safety of early human fibrinogen concentrate in postpartum haemorrhage (PPH) management. Multicentre, double-blind, randomised placebo-controlled trial. 30 French hospitals. Patients with persistent PPH after vaginal delivery requiring a switch from oxytocin to prostaglandins. Within 30minutes after introduction of prostaglandins, patients received either 3g fibrinogen concentrate or placebo. Failure as composite primary efficacy endpoint: at least 4g/dl of haemoglobin decrease and/or transfusion of at least two units of packed red blood cells within 48hours following investigational medicinal product administration. Secondary endpoints: PPH evolution, need for haemostatic procedures and maternal morbidity-mortality within 6±2weeks after delivery. 437 patients were included: 224 received FC and 213 placebo. At inclusion, blood loss (877±346ml) and plasma fibrinogen (4.1±0.9g/l) were similar in both groups (mean±SD). Failure rates were 40.0% and 42.4% in the fibrinogen and placebo groups, respectively (odds ratio [OR]=0.99) after adjustment for centre and baseline plasma fibrinogen; (95%CI 0.66-1.47; P=0.96). No significant differences in secondary efficacy outcomes were observed. The mean plasma FG was unchanged in the Fibrinogen group and decreased by 0.56g/l in the placebo group. No thromboembolic or other relevant adverse effects were reported in the Fibrinogen group versus two in the placebo group. As previous placebo-controlled studies findings, early and systematic administration of 3g fibrinogen concentrate did not reduce blood loss, transfusion needs or postpartum anaemia, but did prevent plasma fibrinogen decrease without any subsequent thromboembolic events. Early systematic blind 3g fibrinogen infusion in PPH did not reduce anaemia or transfusion rate, reduced hypofibrinogenaemia and was safe.

Comparison of Outcome Between Intrauterine Balloon Tamponade and Uterine Artery Embolization in the Management of Persistent Postpartum Hemorrhage: A Propensity Score–matched Cohort Study

(Acta Obstet Gynecol Scand. 2019;98:1473–1482) Peripartum hysterectomy can be life-saving in the setting of postpartum hemorrhage (PPH). However, it produces infertility and is therefore considered a treatment of last resort. Many other procedures are first attempted to control PPH in an effort to avoid peripartum hysterectomy, such as intrauterine balloon tamponade, uterine compression sutures, and uterine artery ligation or embolization. Uterine artery embolization and intrauterine balloon tamponade have not previously been compared in terms of their effectiveness in preventing maternal death or near miss in women experiencing PPH. Uterine artery embolization is costly and may lead to thromboembolic events and other complications. Intrauterine balloon tamponade has more recently emerged as a more inexpensive strategy for managing PPH. This study aimed to compare the effectiveness of these 2 techniques for the management of persistent PPH.

Effectiveness of Intrauterine Bakri Balloon® Tamponade for Placenta Previa and Placenta Accreta Spectrum.

To investigate the effectiveness and success rate of Bakri balloon tamponade (BBT) for postpartum haemorrhage (PPH) in patients with placenta previa and placenta accreta spectrum (PAS). Descriptive study. Department of Obstetrics and Gynaecology, Bursa Yüksek Ihtisas Education and Research Hospital, Bursa, Turkey, from June 2016 to June 2019. Patients treated with BBT for severe PPH and uncontrollable bleeding due to treatment failure with uterotonic agents were retrospectively analysed. Exclusion criteria were age <18 years and >46 years, having multiple pregnancies, less amount of bleeding than indicated in the definition of PPH and requiring no BBT and those with hemodynamic instability before BBT requiring emergency postpartum hysterectomy, and having missing obstetric and laboratory data. The main outcome was the rate of surgical exploration and peripartum hysterectomy following the use of BBT as an adjunct treatment for refractory PPH. Secondary outcome was the need for blood transfusion. The BBT was considered to fail, if the bleeding from drainage catheter was continued and more than 100 mL during failure was 10 minutes. In case of BBT failure, C-section hysterectomy was performed. Of the 128 patients, 14 (10.9%) had vaginal birth and 109 (85.2%) had Cesarean section delivery. Of patients with cesarean section delivery, 84 (65.6%) had multiple repeat cesarean deliveries and 22 (17.2%) were previous cesarean cases. Ninety-one patients (71.1%) had placental site abnormality. Twenty patients (15.6%) underwent hypogastric and uterine artery ligation. Eleven patients (8.7%) with persistent uterine bleeding and hemodynamic instability underwent hysterectomy. Success rate of BBT was found to be 91.3% in PPH. No mortality was observed. BBT is an effective tool for management of postpartum uterine atony and prevention of persistent PPH in patients with placenta previa and placenta accreta spectrum due to increased cesarean section and uterine surgeries in recent years. Key Words: Placenta previa, Placenta accreta spectrum, Postpartum haemorrhage, Balloon tamponade, Bakri balloon.

The Effect of Maternal Position on Maternal, Fetal and Neonatal Outcomes: A Systematic Review

Background & aim: Maternal care during the different stages of labor should be targeted towards the promotion of maternal, fetal, and neonatal health status. Maternal position is very important in labour and delivery Care. Nevertheless, there is controversial results regarding the effect of maternal position in labor. The present study reviewed the effect of maternal position on maternal, fetal, and neonatal outcomes. Methods: In this systematic review, databases including PubMed, Web of Science, Scopus, Google Scholar as well as Persian databases of Magiran and SID, were searched and all related articles between 2005 to 2018 were retrieved. The quality of the studies was examined using the Joanna Briggs Institute tool. Results: 17 clinical trials performed on 4,848 subjects were reviewed. Maternal position during the labour were the upright and lying positions. The outcome measures included duration of the different stages of labor, persistent posterior position, postpartum hemorrhage, maternal pain, anxiety and fatigue. The fetal and neonatal outcomes entailed Apgar score, umbilical venous blood pH, need for neonatal resuscitation, and need for hospitalization in NICU. The results revealed that different maternal positions during the first- and second-stage of labor did not affect maternal, fetal, and neonatal outcomes. However, all studies stated that low-risk mothers should have the chance for choosing a comfortable position in the different stages of labor. Conclusion: In order to propose an evidence-based care plan concerning maternal position in labor, it is required to perform further studies with higher quality regarding the effect of maternal position on maternal, fetal, and neonatal outcomes.

Association of Timing of Plasma Transfusion With Adverse Maternal Outcomes in Women With Persistent Postpartum Hemorrhage

Early plasma transfusion for women with severe postpartum hemorrhage (PPH) is recommended to prevent coagulopathy. However, there is no comparative, quantitative evidence on the association of early plasma transfusion with maternal outcomes. To compare the incidence of adverse maternal outcomes among women who received plasma during the first 60 minutes of persistent PPH vs women who did not receive plasma for similarly severe persistent PPH. This multicenter cohort study used a consecutive sample of women with persistent PPH, defined as PPH refractory to first-line measures to control bleeding, between January 1, 2011, and January 1, 2013. Time-dependent propensity score matching was used to select women who received plasma during the first 60 minutes of persistent PPH and match each of them with a woman who had shown the same severity and received the same treatment of PPH but who had not received plasma at the moment of matching. Transfusions were not guided by coagulation tests. Statistical analysis was performed from June 2018 to June 2019. Transfusion of plasma during the first 60 minutes of persistent PPH vs no or later plasma transfusion. Incidence of adverse maternal outcomes, defined as a composite of death, hysterectomy, or arterial embolization. This study included 1216 women (mean [SD] age, 31.6 [5.0] years) with persistent PPH, of whom 932 (76.6%) delivered vaginally and 780 (64.1%) had PPH caused by uterine atony. Seven women (0.6%) died because of PPH, 62 women (5.1%) had a hysterectomy, and 159 women (13.1%) had arterial embolizations. Among women who received plasma during the first 60 minutes of persistent PPH, 114 women could be matched with a comparable woman who had not received plasma at the moment of matching. The incidence of adverse maternal outcomes was similar between the women, with adverse outcomes recorded in 24 women (21.2%) who received early plasma transfusion and 23 women (19.9%) who did not receive early plasma transfusion (odds ratio, 1.09; 95% CI, 0.57-2.09). Results of sensitivity analyses were comparable to the primary results. In this cohort study, initiation of plasma transfusion during the first 60 minutes of persistent PPH was not associated with adverse maternal outcomes compared with no or later plasma transfusion, independent of severity of PPH.

Clinical characteristics of women captured by extending the definition of severe postpartum haemorrhage with \u2018refractoriness to treatment\u2019: a cohort study

BackgroundThe absence of a uniform and clinically relevant definition of severe postpartum haemorrhage hampers comparative studies and optimization of clinical management. The concept of persistent postpartum haemorrhage, based on refractoriness to initial first-line treatment, was proposed as an alternative to common definitions that are either based on estimations of blood loss or transfused units of packed red blood cells (RBC). We compared characteristics and outcomes of women with severe postpartum haemorrhage captured by these three types of definitions.MethodsIn this large retrospective cohort study in 61 hospitals in the Netherlands we included 1391 consecutive women with postpartum haemorrhage who received either ≥4 units of RBC or a multicomponent transfusion. Clinical characteristics and outcomes of women with severe postpartum haemorrhage defined as persistent postpartum haemorrhage were compared to definitions based on estimated blood loss or transfused units of RBC within 24 h following birth. Adverse maternal outcome was a composite of maternal mortality, hysterectomy, arterial embolisation and intensive care unit admission.ResultsOne thousand two hundred sixty out of 1391 women (90.6%) with postpartum haemorrhage fulfilled the definition of persistent postpartum haemorrhage. The majority, 820/1260 (65.1%), fulfilled this definition within 1 h following birth, compared to 819/1391 (58.7%) applying the definition of ≥1 L blood loss and 37/845 (4.4%) applying the definition of ≥4 units of RBC. The definition persistent postpartum haemorrhage captured 430/471 adverse maternal outcomes (91.3%), compared to 471/471 (100%) for ≥1 L blood loss and 383/471 (81.3%) for ≥4 units of RBC. Persistent postpartum haemorrhage did not capture all adverse outcomes because of missing data on timing of initial, first-line treatment.ConclusionThe definition persistent postpartum haemorrhage identified women with severe postpartum haemorrhage at an early stage of haemorrhage, unlike definitions based on blood transfusion. It also captured a large majority of adverse maternal outcomes, almost as large as the definition of ≥1 L blood loss, which is commonly applied as a definition of postpartum haemorrhage rather than severe haemorrhage.

Inferior mesenteric artery embolization for persistent postpartum hemorrhage after sufficient bilateral iliac arteries embolization: safety and efficacy in eight patients.

To assess the safety and efficacy of transcatheter arterial embolization (TAE) of the inferior mesenteric artery (IMA) for the management of post-partum hemorrhage (PPH). A retrospective analysis was performed regarding eight patients (mean age, 34.4 y; age range, 31 - 40 y) who underwent TAE of the IMA for PPH between March 2001 and September 2018. Obstetric records, including maternal characteristics, clinical manifestations, complications, and clinical outcomes, as well as TAE details were obtained. All eight patients had primary PPH and the vaginal delivery mode. CT scans of two patients showed active bleeding from the lower uterus or hematoma and with the origin of contrast extravasation abutting the adjacent rectum. In seven patients, an aortogram or IMA arteriogram following persistent vaginal bleeding after sufficient embolization of the bleeding focus from the bilateral iliac arteries, found the bleeding focus of the IMA, while in one patient, the IMA bleeding focus was found at the second session 4 h after the first session. TAE of the IMA was technically successful in all eight patients and cessation of bleeding without repeated TAE or additional hemostatic surgery was achieved in all patients after TAE of the IMA. There were neither procedure-related complications nor bowel ischemia during follow-up. TAE of the IMA for PPH was safe and effective with successful hemostasis. Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries. Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries.

Predictors of failed intrauterine balloon tamponade for persistent primary postpartum hemorrhage after vaginal delivery

Predictors of failed intrauterine balloon tamponade for persistent primary postpartum hemorrhage after vaginal delivery

Treatment of persistent post-partum haemorrhage: A case report

Introduction: Postpartum hemorrhage (PPH) is an obstetrical emergency and a major cause of maternal morbidity worldwide. Uterine atony, delivery-related trauma, retained placenta and coagulopathies present the main causes of PPH.

Fluid resuscitation during persistent postpartum haemorrhage and maternal outcome: A nationwide cohort study

ObjectiveTo determine the association between increasing volumes of crystalloids and colloids administered before transfusion of packed red blood cells in women with persistent postpartum haemorrhage and adverse maternal outcomes. Study designRetrospective cohort study in the Netherlands. Women with persistent postpartum haemorrhage and known clear fluids volume for resuscitation were included. Women who received ≤2 L of clear fluids were the reference group. We determined the effect of every additional litre of clear fluids on total blood loss, severe maternal morbidity and mortality. Results were adjusted for patient and bleeding characteristics. ResultsOf the 883 included women, 199 received ≤2 L of clear fluids. Median blood loss for the reference group was 2.9 L (interquartile range 2.2–3.4). Adjusted mean difference in blood loss compared with the reference group was 0.2 L (95% confidence interval −0.1 to 0.5) for women in the >2 to ≤3 L, 0.4 L (0.1–0.7) for the >3 to ≤4 L category, 0.6 L (0.5–0.7) for the >4 to ≤5 L category, and 1.9 L (1.5–2.3) for the >5 to ≤7 L category. Adjusted odds ratios for adverse maternal outcomes were 1.0 (0.7–1.6), 1.2 (0.8–1.9), 1.8 (1.1–3.1) and 4.4 (2.6–7.5) for women in the 2 to ≤3 L category, >3 to ≤4 L, >4 to ≤5 L, and >5 to ≤7 L volume categories respectively. Results were similar in strata of different severities of bleeding. ConclusionClear fluids volume >4 L was independently associated with adverse maternal outcome in women with persistent postpartum haemorrhage.

Predictors of failed intrauterine balloon tamponade for persistent postpartum hemorrhage after vaginal delivery.

ObjectiveTo identify the predictors of intrauterine balloon tamponade (IUBT) failure for persistent postpartum hemorrhage (PPH) after vaginal delivery.DesignRetrospective case-series in five maternity units in a perinatal network.SettingAll women who underwent IUBT for persistent PPH after vaginal delivery from January 2011 to December 2015 in these hospitals.MethodsAll maternity apply the same management policy for PPH. IUBT, using a Bakri balloon, was used as a second line therapy for persistent PPH after failure of bimanual uterine massage and uterotonics to stop bleeding after vaginal delivery. Women who required another second line therapy (embolization or surgical procedures) to stop bleeding after IUBT were defined as cases, and women whom IUBT stopped bleeding were defined as control group. We determined independent predictors for failed IUBT using multiple regression and adjusting for demographics with adjusted odds ratios (aORs) and 95% confidence intervals (95% CI).ResultsDuring the study period, there were 91,880 deliveries in the five hospitals and IUBT was used in 108 women to control bleeding. The success rate was 74.1% (80/108). In 28 women, invasive procedures were required (19 embolization and 9 surgical procedures with 5 peripartum hysterectomies). Women with failed IUBT were more often obese (25.9% vs. 8.1%; p = 0.03), duration of labor was shorter (363.9 min vs. 549.7min; p = 0.04), and major PPH (≥1,500 mL) before IUBT was more frequent (64% vs. 40%; p = 0.04). Obesity was a predictive factor of failed IUBT (aOR 4.40, 95% CI 1.06–18.31). Major PPH before IUBT seemed to be another predictor of failure (aOR 1.001, 95% CI 1.000–1.002), but our result did not reach statistical significativity.ConclusionIntrauterine balloon tamponade is an effective second line therapy for persistent primary PPH after vaginal delivery. Pre-pregnancy obesity is a risk factor of IUBT failure.

158: Predictors of failed intrauterine balloon tamponade for persistent primary postpartum hemorrhage after vaginal delivery

To determine predictors of failed intrauterine balloon tamponade (IUBT) for persistent primary postpartum hemorrhage (PPH) after vaginal delivery. This was a retrospective survey in five hospitals in a French perinatal network. All women who underwent IUBT for persistent PPH after vaginal delivery in these hospitals from 2011-2015 were included. All maternity belong to the same perinatal network and apply the same management policy for PPH. IUBT, using a Bakri balloon (Cook Medical, Bloomington, IN, USA), was used as a second line therapy for persistent PPH after failure of uterine massage and uterotonic agents to stop bleeding. Women were identified in the hospital discharge database. Women in the case group were defined as women who had IUBT but required another second line therapy (embolization or surgical procedures) to stop bleeding, and women whom IUBT stopped bleeding were defined as control group. Univariate and logistic regression analyses were performed to determine independent predictors for failed IUBT. The study was approved by the French Ethics Review Committee (No. CEROG OBS 2016-03-28) and we obtained informed consent from the women. During the study period, there were 91,880 deliveries in the 5 hospitals, and 1,367 persistent PPH after vaginal delivery (1.5%) were registered. IUBT was used in 108 women (7.9%) to control PPH. Bleeding stopped after IUBT in 80 women (74.1%). In 28 women, invasive procedures were required, including 19 embolization and 9 surgical procedures with 5 peripartum hysterectomies. Women with failed IUBT were more often obese (BMI ≥ 30 kg/m2) (25.9% vs. 8.1%; P=.03), duration of labor was shorter (363.9 min vs. 549.7min, P=.04), and severe PPH (blood loss>1,500 mL) before IUBT was more frequent (64% vs. 40%; P=.04). In the multivariable logistic regression analysis (adjusted for maternal age, BMI before pregnancy, and blood loss), maternal obesity was a predictive factor of failed IUBT (aOR 4.40, CI95% 1.06-18.31). Severe PPH before IUBT seemed to be another predictor of failure (aOR 1.001, CI95% 1.000-1.002; P=.055), but our result did not reach statistical significativity. Intrauterine balloon tamponade is an effective second line therapy for persistent PPH after vaginal delivery. Maternal obesity and delayed use of the device are the main risk factors of failure.

The effect of tranexamic acid on blood loss and maternal outcome in the treatment of persistent postpartum hemorrhage: A nationwide retrospective cohort study.

BackgroundRecent results show a protective effect of tranexamic acid on death due to bleeding in patients with postpartum hemorrhage in low- and middle-resource countries. We quantify the association between early administration of tranexamic acid compared to late or no administration and severe acute maternal morbidity and blood loss among women suffering from persistent severe postpartum hemorrhage in a high-income country.Methods and findingsWe performed a nationwide retrospective cohort study in 61 hospitals in the Netherlands. The study population consisted of 1260 women with persistent postpartum hemorrhage who had received at least four units of red cells, or fresh frozen plasma or platelets in addition to red cells. A review of medical records was performed and cross-referenced with blood bank data. The composite endpoint comprised maternal morbidity (hysterectomy, ligation of the uterine arteries, emergency B-Lynch suture, arterial embolization or admission into an intensive care unit) and mortality.Results247 women received early tranexamic acid treatment. After adjustment for confounding, odds ratio for the composite endpoint for early tranexamic acid (n = 247) versus no/late tranexamic acid (n = 984) was 0.92 (95% confidence interval (CI) 0.66 to 1.27). Propensity matched analysis confirmed the absence of a difference between women with and without tranexamic acid. Blood loss after administration of first line therapy did not differ significantly between the two groups (adjusted difference -177 mL, CI -509.4 to +155.0).ConclusionsOur findings suggest that in a high-resource country the effect of tranexamic acid on both blood loss and the combined endpoint of maternal mortality and morbidity may be disappointing.

Maternal outcome after abdominal packing for uncontrolled postpartum hemorrhage despite peripartum hysterectomy.

BackgroundIntra-abdominal packing is a possible option for persistent bleeding following hysterectomy for postpartum hemorrhage. However, to date, only very limited data about maternal outcome after intra-abdominal packing for surgically uncontrolled hemorrhage following hysterectomy are available. The objective of the current study was to estimate maternal outcome after intra-abdominal packing following unsuccessful peripartum hysterectomy for postpartum hemorrhage.MethodsA questionnaire was mailed to all maternity units performing more than 850 deliveries per year. Inclusion criteria were: all cases of abdominal packing performed following unsuccessful peripartum hysterectomy for postpartum hemorrhage between 2003 and 2013. The primary outcome was success of intra-abdominal packing, defined as the arrest of hemorrhage with no need of additional procedure.ResultsThe total number of deliveries during the study period that occurred in the 51 participating centers was 1,430,142. The centers reported a total of 718 (1 per 2000 deliveries) peripartum hysterectomies for PPH and 53 abdominal packings performed after unsuccessful peripartum hysterectomy (about 1 per 14 hysterectomies). A median of 5 [IQR 3–7] pads were used for packing. Abdominal packing was removed after a median of 39.5 hours [IQR 24–48]. The success rate of abdominal packing was 62% (33/53). Among the 20 (38%) women in whom bleeding did not stop following the use of abdominal packing, 6 required a second surgical intervention, 6 a pelvic artery embolization and the 8 other women had “only” further intensive resuscitation and pharmacological treatments. Finally, mortality rate was 24% (13/53).ConclusionOur results suggest that abdominal packing, used for duration of 24 to 48 hours, seems to be an option as an ultimate procedure to control persistent life-threatening postpartum hemorrhage following peripartum hysterectomy.

Choriocarcinoma, A Rare Cause of Antepartum and Postpartum Haemorrhage, Report of A Case and Review of Literature

Objective: To present a case of choriocarcinoma as a cause of antepartum haemorrhage and of severe and fatal postpartum haemorrhage in a patient carrying her pregnancy to term. Method: Detailed clinical, postmortem gross and histopathological analysis of a patient who presented with severe persistent postpartum haemorrhage after a caesarian hysterectomy was carried out and histopathological findings correlated with clinical findings. Results: showed disseminated gestational choriocarcinoma at term, resulting in a massive intracerebral haemorrhage culminating in the death of the patient. Conclusion: choriocarcinoma is an uncommon cause of antepartum haemorrhage, severe primary and secondary postpartum haemorrhage and intracerebral haemorrhage, when clinically suspected the diagnosis should be pursued aggressively and patients vigorously treated.

Novel pathophysiological cause for post-partum hemorrhage: Case report of post-partum hemorrhage with occult abnormal artery diagnosed on pelvic angiography

To the best of our knowledge, this is the first report of post-partum hemorrhage (PPH) caused by an occult abnormal artery detected shortly after delivery on pelvic angiography (PAG). Initially, a diagnosis of uterine atony was made because the apparent cause of hemorrhage was not detected via the usual obstetrical examination. An abnormal artery, however, was suspected on PAG and confirmed on pathology. This case suggests a novel cause of persistent PPH resistant to obstetric management. Obstetricians should be aware that an abnormal artery may cause PPH, and that radiology may be required for diagnosis.