Placental Delivery Research Articles

Comparison of Blood Loss in Induced vs. Spontaneous Vaginal Delivery Using Specialized Blood Collection Bag.

To compare third stage blood loss in induced vs. spontaneous vaginal deliveries and to correlate the amount of blood loss with the decrease in haemoglobin following deliveries. Department of Obstetrics and Gynaecology, Kasturba Hospital Manipal, Karnataka, India. Blood loss following placental deliveries was measured by using special collection bags in 150 pregnant ladies who delivered vaginally by labour induction and it was compared with that of another 50 women who had spontaneous vaginal deliveries. Haemoglobin values were recorded for each patient prior to labour and after delivery of child. The mean blood loss in induced group was 30 mL more than that in spontaneous group (202 ± 117 mL vs. 172 ± 114 mL), but this was not statistically significant (p=0.12). However, when different methods of induction were compared, oxytocin group was found to have significantly higher blood loss (327 ± 140 mL) as compared to that in other types of labour inductions as well as spontaneous deliveries. Labour induction using prostaglandins did not produce more blood loss as compared that produced by spontaneous deliveries. Both induced and spontaneous delivery groups showed statistically significant drops in post-delivery haemoglobin values, but the drop was relatively more in induced group as compared to that in spontaneous vaginal delivery group (0.96gm/dL vs. 0.56gm/dL), which appeared to be statistically significant (p=0.002). Labour induction using prostaglandins is safe as compared to oxytocin usage. Accurate estimation of blood loss is important in all types of deliveries, in order to detect postpartum haemorrhage early, so that appropriate measures can be undertaken.

New Multidisciplinary Approach of Conservative Surgical Management of Placenta Percreta Antenatally Diagnosed

Background: Placenta percreta, accreta, increta and transcreta are abnormal placentation adherence (APA), significantly associated with high maternal morbidity and mortality. When APA is suspected antenatally there are two current recommended alternatives: a radical treatment by planned cesarean-hysterectomy or a conservative management leaving the placenta in place with secondary uterine devascularization by embolisation, in aim to preserve fertility but at the cost of heavy monitoring and possibly severe complications and secondary hysterectomy. A third option could be considered when APA is antenatally diagnosed. This is a multidisciplinary planned management, consisting in per operative placental localization and delivery of the fetus via transverse uterine incision above the upper edge of the placenta. Then pelvic devascularization by inflation of internal iliac artery balloons preoperatively inserted is established and excision of the accreta part of the placenta followed by reconstruction of the uterine wall defect with healthy myometrium is performed. Principe of the work: We evaluated the management and outcome of all APA diagnosed between January 1st 2012 and 31 July 2013, in a Reunion Island tertiary care center, and describe our first case of placenta percreta managed according to this new multidisciplinary conservative alternative technique. Statement of main conclusion: 7 cases of APA occurred during the study period, and have been systematically complicated of severe Post-Partum Hemorrhage (PPH) and hysterectomy in four cases. Train finding: This first case report of multidisciplinary planned CS and conservative management of a placenta percreta was also the first one uncomplicated to PPH, transfusion or hysterectomy, in our service since 2 years. This new alternative seems very encouraging, must be available as soon as possible and should be evaluated prospectively.

Incidence of Post-Cesarean Uterine Infection in relation to Methods of Placental Management

Objectives: To study the rate of uterine infection following cesarean delivery with respect to mode of placental delivery and the practice of removal of residual membranes. Material and Methods: In 318 women undergoing elective cesarean delivery grouped based on placental management into four groups, viz., those with manual removal with uterine wiping (n=102), manual removal without uterine wiping (n=65), spontaneous extraction with uterine wiping (n=79), and spontaneous extraction without uterine wiping (n=72; taken as control group)were prospectively studied. The cases were monitored for 7 post-cesarean days for evidence of uterine infection. Uterine infection was considered to be present if at least two of the parameters with one of them being laboratory evidence, were positive. Results: Incidence of uterine infection was (65/ 318 cases, 20.4%).Occurrence of uterine infection did not differ when placenta was managed either manually or not (p=1). Uterine infection was apparently higher when residual membranes were not removed after placental delivery (p=0.4). Proportion of cases with uterine infection appeared to be lower in the group who had manual placental delivery and removal of residual membranes (17.7%) than in manual manual placental removal with no uterine wiping groups (24.6%). And there was no influence of post-placental removal of residual membranes in the cohort with unaided placental delivery (p=0.854). Conclusion: The practices of either manual removal of placenta or uterine wiping to clear the residual placental membranes do not increase the rate of post cesarean uterine infection rate after elective surgeries.

Bakri balloon during cesarean delivery for placenta previa

ObjectiveTo determine if the use of a Bakri balloon at cesarean delivery (CD) for placenta previa is associated with a reduced need for additional surgical or pharmacologic measures and less blood loss than usual practices. MethodsIn a randomized controlled trial, 52 women undergoing CD for placenta previa were randomly allocated 1:1 into an intervention arm (prophylactic Bakri balloon immediately following placental delivery) or a control arm (use of any usual surgical/pharmacologic measures to achieve hemostasis). The primary outcomes were a clinician’s decision to undertake further intervention to control bleeding, and the difference between preoperative and postoperative hemoglobin levels. ResultsAlthough fewer women in the intervention group required additional measures to achieve hemostasis during CD, the difference between the groups was not significant (relative risk 0.54; 95% confidence interval, 0.19–1.57). The change in hemoglobin level among women in the intervention arm was also similar to that among controls (2.3g/dL; 95% confidence interval, –4.4 to 8.9). ConclusionThe prophylactic use of a Bakri balloon at CD for placenta previa tended to be of benefit, with no evidence of harm or patient dissatisfaction, but the need for additional medical/surgical measures to control blood loss was not significantly reduced.Australian New Zealand Clinical Trials Registry:ACTRN12613000348752.

Gene Expression Analysis of the Microdissected Trophoblast Layer of Human Placenta after the Spontaneous Onset of Labor

BackgroundDespite increasing evidence that human parturition is associated with alteration in gene expression in the uteroplacental unit, the precise mechanisms that elicit spontaneous term labor in humans remain unknown. Our goal in this study was to compare the mRNA expression pattern of the trophoblast layer of normal term placenta between women who had given natural birth (labor group) and those who had undergone an elective cesarean section without labor (non-labor group).MethodsWe collected placental tissue samples from six pregnant women after term vaginal deliveries (labor group) and from six pregnant women after scheduled Cesarean sections (non-labor group). Frozen sections were made immediately after placental delivery. Because the placenta is a heterogeneous tissue composed of several cell types, we used laser capture microdissection to separate the trophoblast layer from the rest of the placental tissues.ResultsA number of genes were differentially expressed in the trophoblast layer when the labor and non-labor groups were compared. The expression of SIRT1, KAP1, and CRH was significantly lower in the trophoblast layer of the labor group than of the non-labor group. The expression of IL-1b, NF-kB1 and TLR 8 in the labor group was significantly higher than that in the non-labor group.ConclusionsHuman term labor may be closely associated with inflammatory response. We suggest that downregulation of SIRT1, KAP1, and CRH gene expression in the trophoblast may play a key role in parturition and initiation of labor in pregnant human females.

Dietary selenium and nutritional plane alter specific aspects of maternal endocrine status during pregnancy and lactation

Objectives were to examine effects of selenium (Se) supply and maternal nutritional plane during gestation on placental size at term and maternal endocrine profiles throughout gestation and early lactation. Ewe lambs (n = 84) were allocated to treatments that included Se supply of adequate Se (ASe; 11.5 μg/kg BW) or high Se (HSe; 77 μg/kg BW) initiated at breeding and nutritional plane of 60% (RES), 100% (CON), or 140% (EXC) of requirements beginning on day 40 of gestation. At parturition, lambs were removed from their dams, and ewes were transitioned to a common diet that met requirements of lactation. Blood samples were taken from a subset of ewes (n = 42) throughout gestation, during parturition, and throughout lactation to determine hormone concentrations. Cotyledon number was reduced (P = 0.03) in RES and EXC ewes compared with CON ewes. Placental delivery time tended (P = 0.08) to be shorter in HSe ewes than in ASe ewes, whereas placental delivery time was longer (P = 0.02) in RES ewes than in CON and EXC ewes. During gestation, maternal progesterone, estradiol-17β, and GH were increased (P < 0.05) in RES ewes and decreased (P < 0.05) in EXC ewes compared with CON ewes. In contrast, maternal cortisol, IGF-I, prolactin, triiodothyronine, and thyroxine were decreased in RES ewes and increased in EXC ewes compared with CON ewes during gestation. Selenium supply did not alter maternal hormone profiles during gestation. During parturition and lactation, maternal hormone concentrations were influenced by both Se and maternal nutritional plane. During the parturient process, HSe ewes tended to have greater (P = 0.06) concentrations of estradiol-17β than ASe ewes. Three hours after parturition a surge of GH was observed in ASe-RES ewes that was muted in HSe-RES ewes and not apparent in other ewes. Growth hormone area under the curve during the parturient process was increased (P < 0.05) in ASe-RES vs HSe-RES ewes. Ewes that were overfed during gestation had reduced (P < 0.05) estradiol-17β but greater IGF-I, triiodothyronine, and thyroxine (P < 0.05) compared with RES ewes. Even though ewes were transitioned to a common diet after parturition, endocrine status continued to be affected into lactation. Moreover, it appears that gestational diet may partially affect lactational performance through altered endocrine status.

Carbetocin vs. Syntometrine in Prevention of Postpartum Hemorrhage: a Double Blind Randomized Control Trial

BackgroundPostpartum hemorrhage is a significant cause of maternal mortality and morbidity, worldwide.ObjectivesThe aim of this study was to compare the efficacy between carbetocin and syntometrine in prevention of postpartum hemorrhage.Materials and MethodsThis study was a double blind randomized clinical trial that carried out on 200 pregnant women referred to Shabiehkhani maternity center of Kashan, during 2011. The first group received intramuscular syntometrine and the second group received intramuscular carbetocin after placental delivery. All of the participants were followed for 24 hours and blood pressure, pulse rate, uterine tone, hemoglobin concentration at first and 24 hours after delivery, and the need for additional uterotonic drugs and drug side effects were evaluated. Finally all data were analyzed using t-test, chi square tests and logistic regression.ResultsThe mean fall in hemoglobin level in the carbetocin group was significantly lower than the syntometrine group (P < 0.001). Also there were significant differences between the two groups, regarding additional uterotonic drug requirements (P = 0.002). Moreover systolic blood pressure and uterine tone immediately and 30 minutes after drug administration were significantly different (P < 0.001). Incidence rate of tachycardia in the carbetocin group was 13%, in contrast to 5% in the syntometrine group (P = 0.04).ConclusionsThis study revealed that carbetocin is more effective than syntometrine in prevention of postpartum hemorrhages. Thus it can be used as a good alternative of syntometrine for low-risk women.

Uterine massage for preventing postpartum haemorrhage.

Postpartum haemorrhage (PPH) (bleeding from the genital tract after childbirth) is a major cause of maternal mortality and disability, particularly in under-resourced areas. In these settings, uterotonics are often not accessible. There is a need for simple, inexpensive techniques which can be applied in low-resourced settings to prevent and treat PPH. Uterine massage is recommended as part of the routine active management of the third stage of labour. However, it is not known whether it is effective. If shown to be effective, uterine massage would represent a simple intervention with the potential to have a major effect on PPH and maternal mortality in under-resourced settings. To determine the effectiveness of uterine massage after birth and before or after delivery of the placenta, or both, to reduce postpartum blood loss and associated morbidity and mortality. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2013). All published, unpublished and ongoing randomised controlled trials comparing uterine massage alone or in addition to uterotonics before or after delivery of the placenta, or both, with non-massage. Two researchers independently considered trials for eligibility, assessed risk of bias and extracted the data using the agreed form. Data were checked for accuracy. The effect of uterine massage commenced before or after placental delivery were first assessed separately, and then the combined for an overall result. This review included two randomised controlled trials. The first trial included 200 women who were randomised to receive uterine massage or no massage following delivery of the placenta, after active management of the third stage of labour including use of oxytocin. The numbers of women with blood loss more than 500 mL was small, with no statistically significant difference (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.16 to 1.67). There were no cases of retained placenta in either group. The mean blood loss was significantly less in the uterine massage group at 30 minutes (mean difference (MD) -41.60 mL, 95% CI -75.16 to -8.04) and 60 minutes after trial entry (MD -77.40 mL, 95% CI -118.71 to -36.09). The need for additional uterotonics was significantly reduced in the uterine massage group (RR 0.20, 95% CI 0.08 to 0.50).For use of uterine massage before and after delivery of the placenta, one trial recruited 1964 women in Egypt and South Africa. Women were assigned to receive oxytocin, uterine massage or both after delivery of the baby but before delivery of the placenta. There was no added benefit for uterine massage plus oxytocin over oxytocin alone as regards blood loss greater than or equal to 500 mL (average RR 1.56, 95% CI 0.44, 5.49; random-effects) or need for additional use of uterotonics (RR 1.02, 95% CI 0.56 to 1.85).The two trials were combined to examine the effect of uterine massage commenced either before or after delivery of the placenta. There was substantial heterogeneity with respect to the blood loss 500 mL or more after trial entry. The average effect using a random-effects model found no statistically significant differences between groups (average RR 1.14, 95% CI 0.39 to 3.32; random-effects). The results of this review are inconclusive, and should not be interpreted as a reason to change current practice. Due to the limitations of the included trials, more trials with sufficient numbers of women are needed in order to estimate the effects of sustained uterine massage. All the women compared in this review received oxytocin as part of the active management of labour. Recent research suggests that once an oxytocic has been given, there is limited scope for further reduction in postpartum blood loss. Trials of uterine massage in settings where uterotonics are not available, and which measure women's experience of the procedure, are needed.

Tranexamic acid in decreasing blood loss during and after caesarean section.

To determine the effectiveness of tranexamic acid (TXA) in reducing blood loss during and after caesarean section (CS), as well as its safety. A randomized double-blind placebo controlled study. The Lyari General Hospital, Karachi, from March 2009 till April 2011. Women undergoing lower segment caesarean section (LSCS) were enrolled. The patients were randomized to receive either injection TXA or distilled water just before the surgery. Blood loss was collected and measured. First from the time of placental delivery to the end of LSCS and later from the end of LSCS to two hours postpartum. Haemoglobin, urine analysis, liver and renal functions were tested in both the groups. Mean values blood loss were compared using t-test with significance at p < 0.05. Tranexamic acid significantly reduced the quantity of blood loss from placental delivery to the end of LSCS which was 356.44 ± 143.2 ml in the TXA group versus 710.22 ± 216.72 ml in the placebo group (p < 0.001). It also reduced the quantity of blood loss from the end of LSCS to 2 hours postpartum which was 35.68 ± 23.29 ml in the TXA group versus 43.63 ± 28.04 ml in the placebo group (p = 0.188), was not significant. No complications or side effects were reported in either group. Tranexamic acid significantly reduced the amount of blood loss during the LSCS, but it did not reduce the blood loss significantly after the caesarean section. Its use was not associated with any side effects or complication like thrombosis. TXA can be used safely and effectively in women undergoing LSCS to reduce intraoperative blood loss.

Enhancing Contraceptive Usage by Post-placental Intrauterine Contraceptive Devices (IUCD) Insertion: Safety, Efficacy, and Expulsion

More than 100 million women in developing countries would prefer to avoid a pregnancy; but they may not be using any form of contraception. Objective: The study was conducted to assess the safety incidence of perforation/pain/bleeding/foul discharge and expulsion rates at 6 week follow-up and willingness to continue when Copper T 380A (Cu T 380A) inserted within 10 minutes of placental expulsion both in vaginal and C-section deliveries. Methods: This was an open label, prospective, and multicentric longitudinal study. The study was approved by the Ethics Committee of FOGSI. Results: The insertion of Intrauterine Contraceptive Devices (IUCD) was easy in 98.76 per cent of subjects after normal delivery, and 100 per cent in all subjects after assisted vaginal and c-section deliveries. The position of the Cu T was in situ in 97.61 per cent of subjects, ultra sonogram was used in 1 per cent to confirm location of IUCD and in 1 per cent of subjects the IUCD was in the cervix. There was no case of perforation in this series and no other major complications. Conclusion: Inserting Cu T 380A at 10 minutes after placental delivery is safe leading to the expanding of the usage of IUCD meeting the unmet needs. The expulsion rates would be minimal if it was inserted by a trained provider and placed at the fundus.

SNAT2 expression and regulation in human growth-restricted placentas

Amino acid placental delivery is reduced in human intrauterine growth-restricted (IUGR) fetuses, and the activity of placental amino transporters has been consistently shown to be decreased in in vitro studies. We hypothesized lower placental expression and localization of sodium-coupled neutral amino acid transporter 2 (SNAT2 (also known as SLC38A2)), altered levels of intron-1 methylation, and altered distribution of single-nucleotide polymorphisms in human IUGR vs. normal pregnancies. We studied 88 IUGR and 84 control placentas from singleton pregnancies at elective caesarean section. SNAT2 expression was investigated by real-time PCR and immunohistochemistry. Intron-1 methylation levels were analyzed by pyrosequencing, and single-nucleotide polymorphism distribution was analyzed by allelic discrimination. mRNA levels were significantly decreased in IUGR placentas with reduced umbilical blood flows. Syncytiotrophoblast immunostaining was lower in IUGR placentas than in control placentas. Methylation levels were steadily low in both IUGR and control placentas. SNP genotype and allele frequencies did not differ between the two groups. This is the first study investigating SNAT2 expression and regulation mechanisms in human IUGR placentas. We confirm previous results obtained in rats and cell cultures that support the fundamental role of SNAT2 in fetal growth and well-being, as well as a possible role of oxygen levels in regulating SNAT2 expression, indicating the relevance of hypoxia in IUGR.

Review: Potential druggable targets for the treatment of early onset preeclampsia.

Placental delivery is the only known cure for early onset preeclampsia, a major cause of maternal and neonatal morbidity and mortality worldwide. Prolonging pregnancy beyond 25weeks without undue maternal risk favors fetal survival, improves neonatal outcome and saves money. In vitro experiments using human placental tissue and in vivo studies employing "preeclamptic" animal models reveal the presence of likely druggable targets, especially within the maladapted intracellular nucleotide transduction pathways of preeclampsia. This review focuses on some novel pharmacological treatment options targeting early onset severe preeclampsia. Human and animal derived experimental data support the possible roles of nitric oxide donors (glyceryltrinitrate), aspirin, dietary supplements (calcium, l-Arginine, anti-oxidant vitamins), phosphodiesterase-5 inhibitors, statins, carbon monoxide and most recently, hydrogen sulfide. Extension of pregnancy or improvement of the disorder using means applicable in under resourced areas of the world would have a major positive impact on women's health globally. We therefore advocate the immediate launch of clinical trials testing simple innovative therapies in large obstetric units of developing countries such as South Africa or Brazil where preeclampsia is endemic and a regular killer of both mothers and offspring.

Reformulation of standardised neonatal parenteral nutrition to improve nutrient delivery

Postnatal growth failure is common in preterm infants and one reason for this is that nutritional care is often variable and suboptimal. Achieving targets for nutrient intakes in this group...

Abnormally Invasive Placenta – AIP. Awareness and pro‐active management is necessary

Abnormally Invasive Placenta – <scp>AIP</scp>. Awareness and pro‐active management is necessary

Risk Factors for a Prolonged Third Stage of Labor and Postpartum Hemorrhage

To determine the effect of a third stage of labor ≥15 minutes on bleeding after delivery and other risk factors for a postpartum hemorrhage (PPH). This was a case-control study of women undergoing vaginal delivery with placental delivery ≥15 minutes matched by gestational age to the next delivery with placental delivery <15 minutes. Multiple risk factors were evaluated for association with delayed placenta and with PPH. There were 226 pregnancies ≥15 minutes (cases) versus 226 whose placental time was <15 minutes (controls). The best-fit model identified placental delivery ≥15 minutes, history of retained placenta, nulliparity, and increased length of first stage of labor as significant factors for PPH. The best risk model for PPH includes placental delivery ≥15 minutes, history of retained placenta, nulliparity, and longer first stage of labor.

2011 AND 2012 EARLY CAREERS ACHIEVEMENT AWARDS: Placental programming: How the maternal environment can impact placental function1,2

Proper establishment of the placenta is important for fetal survival; however, placental adaptations to inadequate maternal nutrition or other stressors are imperative for fetal growth to be optimal. The effects of maternal nutritional status and activity level on placental vascular function and uteroplacental blood flows are important to understand as improper placental function leads to reduced growth of the fetus. In environments where fetal growth can be compromised, potential therapeutics may augment placental function and delivery of nutrients to improve offspring performance during postnatal life. Factors that could enhance placental function include supplementation of specific nutrients, such as protein, hormone supplements, such as indolamines, and increased activity levels of the dam. To understand the mechanism of how the maternal environment can impact uterine or umbilical blood flows, assessment of placental vascular reactivity has been studied in several large animal models. As we begin to understand how the maternal environment impacts uterine and umbilical blood flows and other uteroplacental hemodynamic parameters, development of management methods and therapeutics for proper fetal growth can be achieved.

Comparative evaluation of two doses of tranexamic acid used prophylactically in anemic parturients for lower segment cesarean section: A double-blind randomized case control prospective trial

Background:Postpartum hemorrhage (PPH) and anemia thereafter can be a life threatening condition in parturients undergoing lower segment cesarean section (LSCS), especially when anemia is present.Aim:The objective of this study was to assess two doses of Tranexamic acid (TXA) in reducing intra operative blood loss and incidence of PPH, in terms of both efficacy and safety profiles, when used prophylactically.Methods:A monocenter prospective case control double blind randomized study was carried out on a consecutive series of 90 anemic patients undergoing LSCS, with hemoglobin between 7-10 g percent. Three random groups were formed. Group T1 (n=30) received 10mg/kg TXA in 20 ml of 5% dextrose intravenously, while T2 group (n=30) received 15mg/kg. Group C (n=30) received a placebo. Drug was administered prophylactically 20 min before skin incision. Blood loss was measured from placental delivery up to 24 hours by method of weight and volume.Staistical Analysis:To compare quantitative data between two groups, t-test, and for more than two groups ANOVA was used. To compare the mean for non- parametric data between two groups Mann – Whitney test was used, while in case of more than two groups Kruskal – Wallis test was employed. Probability (p) value was considered significant when it was 0.05 or less.Results:TXA significantly reduced blood loss in both the study groups. Mean total blood loss was 527.17±88.666 ml, 376.83±31.961ml and 261.17±56.777 ml in group C, T1, and T2 respectively. While reduction of blood loss in T1 group compared to control group was 146.34±56.32ml, it was 262±31.51ml in T2 group. Difference between T1 and T2 was 115.66±24.81ml, which was statistically significant (P<0.05). Postoperative blood loss was insignificant in all three groups. Pre- and post-operative hemoglobin levels differed significantly when compared to control group. Blood transfusion was needed in two patients in the control group, whereas no patient in groups T1 and T2 needed transfusion (P=0.02). No significant adverse effect was seen in all the three groups.Conclusion:Hence, TXA was found to be effective in reducing blood loss and transfusion in anemic parturients undergoing LSCS. 15mg/kg dose of TXA was more efficacious than the 10mg/kg dose and without any undue increase in adverse events. Postpartum anemia is a public health problem worldwide and TXA could prove to be a very useful drug to prevent blood loss and transfusions in patients undergoing LSCS, especially in the anemic subgroup.

Case Scenario

P ERIPARTUM hemorrhage is responsible for 150,000 maternal deaths worldwide each year. Although the risk of maternal death has decreased over the preceding century, there has recently been a concerning suggestion of an increase in the overall incidence of hemorrhage. Despite multiple advances in medical and surgical care, a steady rise in hemorrhage has been noted within the developed world. Statistically significant increases in the incidence of maternal hemorrhage have been reported in retrospective studies in Canada (from 4.1% to 5.1%) and Australia (from 4.9% to 6.3%). Similarly, there was an increase in maternal deaths secondary to hemorrhage in the United Kingdom during the years 2000– 2002. This new uptick in the rate of peripartum hemorrhage has been attributed to increasing maternal age, multiple gestations, and the rise in the rate of cesarean sections. The most common cause of postpartum hemorrhage remains uterine atony. Disorders of placentation can be associated with either uterine atony or retained placenta. Importantly, in the developed world abnormal placentation is commonly diagnosed before delivery; with proper medical management and multidisciplinary planning, the associated morbidity and mortality can be minimized. During the past decade the rate of cesarean section has increased for multiple reasons, including an increase in maternal age, in vitro fertilization, multiple gestation, a decrease in vaginal breech delivery, and less frequent vaginal birth after cesarean section. A systematic review of 30 studies from 1997–2002 showed that nearly 90% of women chose to have a cesarean section after a previous cesarean section despite recent evidence for increased neonatal mortality. Repeated cesarean sections are a risk factor for abnormal placentation. Diagnosis of placenta previa is an indication of abnormal placentation. It is associated with an increased risk of postpartum hemorrhage due to inability of the lower uterine segment site of placental implantation to contract after placental delivery. In patients with placenta previa who have had previous cesarean delivery, each surgery is associated with an increased risk of placenta accreta. Placenta accreta, an abnormally deep attachment of the placenta into the endometrium and myometrium (the middle layer of the uterine wall), complicates 3% of primary, 11% of secondary, 40% of tertiary, 61% of quaternary, and 67% of higher-order cesarean sections for placenta previa. In this case scenario, a patient with suspected placenta accreta who required cesarean hysterectomy is presented. The risks and benefits of various anesthetic treatments and transfusion strategies are discussed with a multidisciplinary approach to delivery.

Tranexamic acid for the prevention of postpartum hemorrhage after cesarean section: a double-blind randomization trial

Our purpose in conducting this study was to determine the efficacy of tranexamic acid (TXA) in reducing blood loss in patients after cesarean section (CS). A randomized, double-blind, case-controlled study was conducted on 174 primipara undergoing CS. 88 of them given 10 mg/kg TXA immediately before CS were compared with 86 others to whom TXA was not given. Blood loss was calculated from blood collected and measured during two periods: the first period was from placental delivery to end of CS and the second from the end of CS to 2 h postpartum. Vital signs such as BP, HR, RP, hemoglobin, platelet count, postoperative PT and PPT were tested in the two groups. Blood loss in the period between the end of CS and 2 h postpartum was significantly lower (p < 0.01) in the TXA group (46.6 ± 42.7) than in the control group (84.7 ± 80.2). The quantity of total blood from placental delivery to 2 h postpartum was also significantly reduced (p = 0.02) in the TXA group (379.2 ± 160.1) than in the control group (441.7 ± 189.5). However, the amount of blood loss in the period from placental delivery to the end of CS did not differ between the TXA and control groups (p = 0.17). PPH stopped in 65 women (75.6 %) in the control group and in 81 (92.0 %) in the TXA group (p < 0.01). No significant abnormal vital signs were observed after TXA administration. Mild, transient side effects occurred more often in the TXA group than in the control group. Treatment with TXA is effective in reducing blood loss in patients undergoing CS. Although the study was not adequately powered to address safety issues, the observed side effects were mild and transient.

Active Management of the Third Stage of Labour With and Without Controlled Cord Traction

Summary Background Active management of the third stage of labour reduces the risk of post-partum haemorrhage. We aimed to assess whether controlled cord traction can be omitted from active management of this stage without increasing the risk of severe haemorrhage. Methods We did a multicentre, non-inferiority, randomised controlled trial in 16 hospitals and two primary health-care centres in Argentina, Egypt, India, Kenya, the Philippines, South Africa, Thailand, and Uganda. Women expecting to deliver singleton babies vaginally (ie, not planned caesarean section) were randomly assigned (in a 1:1 ratio) with a centrally generated allocation sequence, stratified by country, to placental delivery with gravity and maternal effort (simplified package) or controlled cord traction applied immediately after uterine contraction and cord clamping (full package). After randomisation, allocation could not be concealed from investigators, participants, or assessors. Oxytocin 10 IU was administered immediately after birth with cord clamping after 1–3 min. Uterine massage was done after placental delivery according to local policy. The primary (non-inferiority) outcome was blood loss of 1000 mL or more (severe haemorrhage). The non-inferiority margin for the risk ratio was 1·3. Analysis was by modified intention-to-treat, excluding women who had emergency caesarean sections. This trial is registered with the Australian and New Zealand Clinical Trials Registry, ACTRN 12608000434392. Findings Between June 1, 2009, and Oct 30, 2010, 12 227 women were randomly assigned to the simplified package group and 12 163 to the full package group. After exclusion of women who had emergency caesarean sections, 11 861 were in the simplified package group and 11 820 were in the full package group. The primary outcome of blood loss of 1000 mL or more had a risk ratio of 1·09 (95% CI 0·91–1·31) and the upper 95% CI limit crossed the pre-stated non-inferiority margin. One case of uterine inversion occurred in the full package group. Other adverse events were haemorrhage-related. Interpretation Although the hypothesis of non-inferiority was not met, omission of controlled cord traction has very little effect on the risk of severe haemorrhage. Scaling up of haemorrhage prevention programmes for non-hospital settings can safely focus on use of oxytocin. Funding United States Agency for International Development and UN Development Programme/UN Population Fund/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research.