Placental Delivery Research Articles

Placenta accreta spectrum in subsequent pregnancy following myomectomy

Purpose To compare the prevalence of placental abnormalities in pregnancy following different modes of operative myomectomy. Methods A retrospective cohort study, including all women after myomectomy that gave birth in a single tertiary care center from February 2011 to January 2019. Data was collected from the patients' medical files and completed by telephone questionnaire. Patients were stratified to 3 groups, according to the mode of operative myomectomy (laparotomy, laparoscopy, hysteroscopy). Groups were compared for women demographics, fibroid's characteristics, operative management, post-operative placental evaluation and delivery characteristics. Primary outcome was defined as the need for any intervention for placental separation during the third phase of the delivery. Results Two hundred forty one women met inclusion criteria. Complete follow-up was achieved in 199 (82.57%) women, of whom 82, 89, and 28 underwent laparoscopic, laparotomy and hysteroscopic myomectomy, respectively. There were no in-between groups differences in women's age, BMI, and gravidity. Disruption of the endometrial cavity during laparoscopy and laparotomy was reported in 3 (3.6%) and 7 (7.8%) cases, respectively (p = .21). During the subsequent pregnancy following myomectomy, placenta accreta spectrum disorder was suspected in only one woman in each of the study groups (p = .63). Placenta previa was low and comparable between groups. Vaginal delivery rate was significantly higher in the hysteroscopy group, as compared to the laparoscopy or the laparotomy groups [11 (36.3%) vs. 5 (6.1%) vs. 4 (4.5%); p = .001], with significantly lower need for manual lysis of the placenta [11(39.0%) vs. 51 (62.1%) vs. 62 (69.7%); p = .01] and further interventions for blood loss control. Conclusions Subsequent pregnancy following surgical myomectomy was not found to be associated with higher prevalence placental abnormality. Furthermore, other than manual lysis, the different modes of myomectomy did not necessitate any further intervention for complications associated with abnormal placentation requiring intervention. Key Message Subsequent pregnancy following surgical myomectomy is not associated with higher prevalence of placental abnormality

The Impact of Breastfeeding on the Total Duration of the Third Stage of Labour among Women Attending Maternity Teaching Hospital in Sulaimani City

Background: Quick breastfeeding during the third stage of labour is considered the safest and most effectiveintervention to reduce the blood loss associated with labour, as it can naturally release the oxytocin tostimulate the uterine contraction. These contractions make it easier to dislodge the placenta and help reducethe total duration of the third stage of labour.Aim of the Study: To evaluate the impacts of breastfeeding immediately after birth for the total duration ofthe third stage of labour.Study Design: A quasi-experimental study, post-test only control design.Material and Method: 300 pregnant women from the labour ward in their third stage of labour participatedin this study, carried out between 26th of February 2020 and 30th of July 2020. Samples were selectedby using a convenient sampling technique through the structured observation record sheet, onto whichthe beginning of breastfeeding time and placental delivery was recorded. The data were analyzed usingdescriptive and inferential statistics.Results: Among the 300 mothers (34%) had delivered the placenta within 5 minutes, (46%) within 8-10minutes, (13.3%) within 11-13 minutes and (6.7%) had 14-16 minutes in the experimental groups. While,in the control group the duration was longer (46.7%) between 11 and 13 minutes, (20%) within 14 and 16minutes.Conclusion: The study results show that early initiation of breastfeeding is an effective intervention toreduce the total duration of the third stage among the mothers during the third stage of labour.

Cord Traction Versus Manual Removal for Placental Delivery during Cesarean Section

Background: Cesarean section is the most common major surgery performed on pregnant women around the world. It is necessary to apply the practical skills training and current knowledge, especially in the procedure that would need to help keep mothers alive and the fetus safe. Objective: To study the efficacy of the umbilical cord traction versus manual removal for placenta delivery in the third stage of labor during the cesarean section. Materials and Methods: The present study was a retrospective comparative study conducted in Srisangwornsukhothai Hospital between January 2017 and January 2020. The purposive sample size was calculated by using a power of 80%, with a significant level of 5%. One hundred twenty pregnant women were divided into two groups, sixty pregnant women each, the cord traction as the first group and the manual removal as the second group for placental delivery during the cesarean section. The significance of the two groups were compared by using the independent t-test (p<0.05), 95% confidence interval (CI), and the Mann-Whitney U test. Results: Several outcomes of the umbilical cord traction were better than the manual removal, such as decrease time of the operation and a statistically significant decrease in hemoglobin (p<0.001, 0.049, respectively). However, there was not a statistically significant decrease of blood loss, fever after surgery, or the length of stays (p=0.839, 0.056, 0.175, respectively). Only one outcome, the time of the third stage of labor, was slightly more than the manual removal group for placental delivery during the cesarean section with statistically significance (p=0.003). Conclusion: The umbilical cord traction maneuver for the delivery of the placenta had more advantages than the manual removal maneuver. This technique should be a recommendation during the cesarean section. Keywords: Cesarean section, Umbilical cord traction, Placental delivery

Unusual and delayed presentation of chronic uterine inversion in a young woman as a result of negligence by an\xa0untrained birth attendant: a case report

BackgroundUterine inversion is a rare but known complication following parturition and may prove fatal due to neurogenic shock or postpartum hemorrhage if not corrected immediately. The incidence is variable, occurring in 1 in 2000 to 1 in 50,000 deliveries, as reported in the past. Nowadays, the incidence is declining due to better antenatal care and increasing institutional deliveries. However, in a developing country such as India, due to cultural and financial reasons, most of the deliveries are still being conducted by untrained birth attendants (“dais”) who have sparse knowledge of oxytocic drugs. Hence, proper education and training should be imparted to the traditional birth attendants and local village health practitioners about the management of labor, placental delivery, timely diagnosis, and proper management of uterine inversion to avoid this grave complication. We report this case because only a limited number of such cases have been reported so far with delayed presentation of chronic uterine inversion 8 months after delivery as a result of the negligence of an untrained birth attendant.Case presentationWe report a case of a patient with chronic uterine inversion presenting 8 months after childbirth as a result of ignorance at the time of delivery. A 22-year-old P1L1 (Para 1 Live 1) Asian woman of Punjabi ethnicity presented to our institute with a progressively increasing painless vaginal mass along with blood-stained vaginal discharge for the last 6 months and progressive dyspareunia (pain during intercourse) for the last 5 months that had worsened with time. She had experienced a full-term normal vaginal delivery at home 8 months earlier with the assistance of an untrained birth attendant (dai). Her history revealed that she had an unduly prolonged second stage of labor and was given aggressive fundal pressure due to inadequate bearing-down efforts and had collapsed after delivery but was managed conservatively by an untrained birth attendant. A provisional diagnosis of chronic uterine inversion was made on the basis of vaginal findings of a globular mass protruding from the cervix and approaching the vagina with thinning of the cervix around the mass, forming a tight constriction ring, in addition to ultrasound findings. The patient’s condition was corrected surgically using Haultain’s approach. She had a satisfactory outcome and was discharged symptom-free.ConclusionAwareness of this complication with timely diagnosis and prompt management can significantly minimize maternal morbidity and mortality, especially in a low- and middle-income country such as India, where 70–80% of deliveries still occur in a rural setting with untrained birth attendants.

Comparative Evaluation to Assess the Effect of SRP With or Without Human Placental Extracts as Local Drug Delivery in Treatment of Localized Periodontal Pocket- A Randomized Controlled Clinical Trial

Background: Periodontal disease is one of the most prevalent global chronic disorder. Pathology affecting the structure surrounding teeth results in inflammation initiated by bacterial aggregation & alteration in their profile. Conventional periodontal therapeutics has focused on the control of etiologic agents, thereby promoting healing & repair of tissues. Delivery of therapeutic agents into the local milieu act as drug reservoirs which could alter pathogenic flora & promote its repair & wound healing. Aim & Objective: In an effort to develop a novel therapy, the present study aims to compare clinical soft tissue parameters around periodontal pockets treated with & without human placental extracts delivered locally. Materials & Method: In 10 patients of chronic periodontitis, bilateral localized periodontal pockets of 4-6 mm depth were included. Each site was randomly allocated to group 1 & group 2,where in group 1, scaling & root planing( SRP) was done while in group 2,Placentrex Gel (Human placental extracts) adsorbed on absorbable gelatin matrix (Abgel) used as a vehicle was delivered as an adjunct to SRP . Clinical parameters were recorded & re- evaluated after one month for both the treatment groups . Statistical analysis was carried out to evaluate the effect of Placentrex gel as an adjunct to SRP in treatment of periodontal pockets, Mann Whitney & Paired t test were done. Results: There was a statistically significant improvement in clinical parameters with notable difference in probing depth reduction & gain of clinical attachment level in the treatment group subjected to SRP & Placental extract delivery. Conclusion: Clinical variables showed a greater efficacy of SRP & adjunctive use of placental extracts as compared to conventional treatment by SRP thereby underlying placental extracts usage in the management of periodontal disease condition

The effect of baricity of intrathecal bupivacaine for elective cesarean delivery on maternal cardiac output: a randomized study

BackgroundHemodynamic instability during spinal anesthesia for cesarean delivery is associated with adverse maternal and fetal outcomes. Plain and hyperbaric bupivacaine are commonly used for cesarean delivery, however, their distinctive pharmacologic properties may affect maternal hemodynamic profiles differently. The aim of this study was to compare hemodynamic profiles using a suprasternal Doppler cardiac output (CO) monitor in healthy term parturients randomized to receive plain or hyperbaric bupivacaine for cesarean delivery. MethodsOne hundred-and-sixty-eight healthy parturients scheduled for elective cesarean delivery were randomly assigned to receive 10.9 mg of intrathecal 0.5% plain or hyperbaric bupivacaine, both with 0.2 mg morphine. The primary outcome was CO change after spinal anesthesia. Secondary outcomes were the incidence of hypotension, vasopressor use, and conversion to general anesthesia. ResultsThe mean (±SD) CO at baseline, 1 min and 5 min after spinal anesthesia, and after placental delivery was 4.6 ± 1.2, 5.4 ± 1.3, 5.1 ± 1.4, and 6.4 ± 1.7 L/min in the plain bupivacaine, and 4.5 ± 1.1, 5.2 ± 1.3, 4.9 ± 1.3, and 6.2 ± 1.9 L/min in the hyperbaric bupivacaine group. There were no significant differences in CO, mean arterial pressure, or systemic vascular resistance. Incidences of hypotension, vasopressor and supplemental analgesic use, and conversion to general anesthesia, were not different between groups. ConclusionsCardiac output changes after plain or hyperbaric bupivacaine were not different in term parturients undergoing spinal anesthesia for cesarean delivery. Further studies comparing block quality and the rate of conversion to general anesthesia are required.

Comparison of Labor and Delivery Complications and Delivery Methods Between Physicians and White-Collar Workers.

To evaluate labor and delivery complications and delivery modes between physicians and white-collar workers in Taiwan, this retrospective population-based study used data from Taiwan’s National Health Insurance Research Database. We compared 1530 physicians aged 25 to 50 years old who worked and had singleton births between 2007 and 2013 with 3060 white-collar workers matched by age groups, groups of monthly insured payroll-related premiums, previous cesarean delivery, perinatal history anemia, and gestational diabetes mellitus. The logistic regression models were used to assess the labor and delivery complications between the two groups. Multivariate analysis revealed that physicians had a significantly higher risk of placenta previa (odds ratio (OR) 1.35, 95% confidence interval (CI) 1.08–1.69) and other malpresentation (OR 1.86, 95% CI 1.45–2.39) than white-collar workers, whereas they had a significantly lower risk of placental abruption (OR 0.53, 95% CI 0.40–0.71), preterm delivery (OR 0.75, 95% CI 0.61–0.92), and premature rupture of membranes (OR 0.72, 95% CI 0.59–0.88). Increased risks of some adverse labor and delivery complications were observed among physicians, when compared to white-collar workers. These findings suggest that working women should take preventative action to manage occupational risks during pregnancy.

Megalin-targeting liposomes for placental drug delivery

Every year, complications during pregnancy affect more than 26 million women. Some of those diseases are associated with significant morbidity and mortality, as is the case of preeclampsia, the main cause of maternal deaths globally. The ability to improve the delivery of drugs to the placenta upon administration to the mother may offer new opportunities in the treatment of diseases of pregnancy. The objective of this study was to develop megalin-targeting liposome nanocarriers for placental drug delivery. Megalin is a transmembrane protein involved in clathrin-mediated endocytic processes, and is expressed in the syncytiotrophoblast (SynT), an epithelial layer at maternal-fetal interface. Targeting megalin thus offers an opportunity for the liposomes to hitchhike into the SynT, thus enriching the concentration of any associated therapeutic cargo in the placental tissue. PEGylated (2 KDa) lipids were modified with gentamicin (GM), a substrate to megalin receptors as we have shown in earlier studies, and used to prepare placental-targeting liposomes. The ability of the targeting liposomes to enhance accumulation of a fluorescence probe was assessed in an in vivo placental model - timed-pregnant Balb/c mice at gestational day (GD) 18.5. The targeting liposomes containing 10 mol% GM-modified lipids increased the accumulation of the conjugated fluorescence probe in the placenta with a total accumulation of 2.8% of the initial dose, which corresponds to a 94 fold increase in accumulation compared to the free probe (p < .0001), and 2–4 fold accumulation compared to the non-targeting control liposomes (p < .0001), as measured by both tissue extraction assay and ex vivo imaging. Furthermore, confocal images of placental SynT cross-sections show a 3-fold increase of the targeting liposomes compared with the non-targeting liposomes. The rate and extent of uptake of a fluorescent probe encapsulated within targeting liposomes was also probed in an in vitro model of the human placental barrier (polarized BeWo monolayers) using flow cytometry. Targeting liposomes containing 5 mol% GM-modified lipids enhanced the uptake of the probe by 1.5 fold compared to the non-targeting control. An increase to 10 mol% of the modified lipid resulted in further enhancement in uptake, which was 2 fold greater compared to control. In a competition assay, inhibition of the megalin receptors resulted in a significant reduction in uptake of the fluorescence probe encapsulated in GM-modified liposomes compared to the uptake without free inhibitor (p < .0001), implicating the involvement of megalin receptor in the internalization of the liposomes. Taken together, these results demonstrate that megalin-targeted liposomes may offer an opportunity to enhance the delivery of therapeutics to the placenta for the treatment of diseases of pregnancy.

Intravenous Administration of Carbetocin Versus Oxytocin for Preventing Postpartum Hemorrhage After Vaginal Delivery in High Risk Women: A Double-blind, Randomized Controlled Trial

Abstract Objective: To compare the effects between carbetocin and oxytocin on reducing postpartum hemorrhage (PPH) after vaginal delivery in high risk pregnant women. Methods: A prospective double-blinded randomized study was conducted in the Nanjing Drum Tower Hospital from March to May 2018. Women at or beyond 28 gestational weeks, cephalic presentation, 18–45 years old, and with at least one risk factor for PPH, were enrolled. Using a computer-generated randomization sequence, women were randomized to carbetocin group or oxytocin group which receive 100 μg intravenous infusion carbetocin or 10 IU intravenous infusion of oxytocin after anterior shoulder and before placental delivery. The primary outcome was the incidence of blood loss ≥500 mL within 24 hours postpartum. The secondary outcomes were amount of total blood loss, blood loss within 2 hours after delivery, the rate of blood loss ≥ 1 000 mL postpartum, need for a second-line uterotonics and interventions, blood transfusion, difference between hemoglobin before and 48 hours after delivery, adverse maternal events attributed to the trial medication. Hemodynamic status (blood pressure and pulse) was measured at 0 minutes, 30 minutes, 60 minutes, and 120 minutes after delivery. Results: A total of 314 and 310 participants constituted the carbetocin and oxytocin groups, respectively. The baseline characteristics were comparable between the groups. The carbetocin group had similar rates of PPH (blood loss ≥500 mL) and rates of ≥1 000 mL PPH, (29.6% vs. 26.8%, P = 0.48) and (3.2% vs. 3.5%, P = 0.83), to the oxytocin group. The average amount of bleeding was (422.9 ± 241.4) mL in carbetocin group and (406.0 ± 257.5) mL in oxytocin group, which was no statistically significant difference (P = 0.40). Either the amount of blood loss within 2 hours ((55.5 ± 33.9) mL vs. (59.9 ± 48.7) mL) was no statistically significant difference (P = 0.19). The need for therapeutic uterotonics was 23.9% in carbetocin group and 23.5% in oxytocin group, which was also no statistically difference (P = 0.93). The rate of blood transfusion (P = 0.62) and hemoglobin change (P = 0.07) were not differ between the carbetocin and oxytocin groups. However, the rate of manually removing placenta was significantly different between two groups regarding the need for manually remove of placenta because of uterine bleeding in the third stage of labor (4 cases in carbetocin group vs. 13 cases in oxygen group), especially in those after oxytocin-induced or augmented labor (relative risk:3.39, 95% confidence interval: 1.09–10.52). After delivery, the blood pressure in the carbetocin group tend to be lower than that in the oxytocin group (P &gt; 0.05), especially at 30 minutes postpartum (P &lt; 0.05), while pulse tend to be simultaneously higher (P &gt; 0.05). Conclusion: Among women with high risk of PPH, intravenous carbetocin infusion did not better than oxytocin in the prevention of blood loss ≥500 mL after vaginal delivery.

Comparison of Blood Loss in Manual and Spontaneous Removal of Placenta in Caesarean Section

Background: Efforts should be made to minimize the blood loss at the time of cesarean section. The techniques used to reduce the blood loss include finger splitting versus scissor cutting of incision, in situ stitching versus exteriorization and stitching of uterus and finally spontaneous or manual removal of the placenta. Objective: The main objective of this study is to correlate the frequency of loss of blood between the placenta removed manually and spontaneously during cesarean section. Methods: Randomized controlled trial in the department of Obstetrics and Gynecology, Fauji Foundation Hospital, Rawalpindi. The sample is collected through Consecutive (non- probability) sampling. The study was conducted after approval from the hospital ethical and research committee. Informed written consent was taken from all the patients. The patients were divided into two groups, group A and group B randomly by using random table numbers. Group A had spontaneous placental delivery. Group B had manual placental delivery. Each patient was examined thoroughly and detailed history was taken. Data Analysis: Data was analyzed using SPSS 20 for windows. The frequency and percentage of blood loss were measured. A chi-square test was applied to correlate the blood loss between the two groups. p values &lt;0.05 were considered statistically significant. Effect modifiers like age, gestational age, parity were controlled by stratification. Results: The blood loss was compared between both groups using the chi-square test not assuming null-hypothesis. The blood loss was comparatively high in-group in which the placenta was removed manually (p=0.007). Keywords: Caesarean Section, Placenta removal, Spontaneous, Manual, Blood loss.

Umbilical vein injection of 400 versus 800 μg misoprostol for the treatment of retained placenta: A multicenter, randomized double-blind controlled trial.

This trial was conducted to determine the efficacy of umbilical vein injection of 400 versus 800 μg misoprostol to deliver retained placenta and to compare both regimens regarding the time of placental delivery and amount of vaginal blood loss. A double-blind, multicenter randomized clinical trial was undertaken in four teaching hospitals in the North of Iraq and Al-Azhar University Hospital in Egypt, from March 2016 to May 2019. Group I (274 women) received 400 μg misoprostol and group II (249 women) received 800 μg misoprostol. Data regarding the time of placental separation and amount of vaginal blood loss were analyzed and proportions were compared between groups using Chi-squared test. Mean values were compared using the Student's t-test. The Mann-Whitney test was used to determine the median of vaginal blood loss. The proportion of placental separation was 84.3% among women in group I and 86.7% of women in group II. The mean time of placental separation was 18.86 ± 234.2 and 17.86 ± 213.09 min in groups I and II, respectively (P < 0.05).The mean hemoglobin levels on admission and 24 h after placental deliveries were significantly higher in group I than group II. Intra-umbilical injection of 400 and 800 μg misoprostol were both safe and effective methods for delivery of retained placenta.

Reappraisal of the relationship between 24-hour proteinuria and preeclampsia in terms of the maternal and perinatal outcomes

ABSTRACT Objective This study evaluated the association between proteinuria levels and maternal, and perinatal outcomes of preeclampsia patients and determined the cutoff values for predicting severe complications. Methods We retrospectively evaluated the records of 412 patients with proteinuric preeclampsia. Results Median proteinuria levels were significantly higher in patients with severe maternal and adverse perinatal outcomes than in those without such outcomes, except in cases of placental abruption and late preterm delivery. Conclusion Proteinuria levels may aid in diagnosing preeclampsia and indicating early intervention. The revised guidelines do not suggest that proteinuria encountered during pregnancy is clinically insignificant.

Evaluation of Safety and Efficacy of Postpartum Intrauterine Contraceptive Devices (PPIUCD) in Vaginal and Caesarean Section Deliveries: A Hospital Based Study

Background: Immediate postpartum intrauterine contraceptive device (PPIUCD) is a lucrative postpartum family planning method which provide an effective reversible contraception for women in delivery settings. PPIUCD can be inserted post-placental, intra-caesarean and within 48 hours postpartum. We conducted this study to determine the outcome, satisfaction rate and continuation rate of PPIUCD. Materials and Method: This was a prospective observational study conducted in a tertiary care teaching institute. CuT 380A was inserted within 10 minutes of placental delivery in accepters who fulfilled the Medical Eligibility Criteria and had no contraindications for PPIUCD. They were then followed up for 3 months. A Cohort of 260 vaginal and caesarean deliveries with PPIUCD in situ were studied over seven months period and follow-up results were compared between Vaginal and Caesarean groups. Result: Overall expulsion rate was 8.47%, removal rate was 14.83% and continuation rate was 76.7%. There was no significant difference in removal rate of two groups. Spontaneous expulsion occurred in 8.47% cases and were significantly higher in vaginal insertion group (p value 0.0017). Overall complication rate was low. No case of perforation or accidental pregnancy was reported. Conclusion: PPIUCD is a safe, highly effective, long acting, cost effective method of postpartum contraception, which can be used during institutional delivery visit and eliminates the need for a return visit to start contraception. PPIUCD is a strong weapon in the family planning armory and should be encouraged in both vaginal and caesarean deliveries.

Factors associated with blood cord unit bankability: an analysis of a 15-year-long case series.

Blood banking is a long and complex process requiring an accurate screening of potential donors and high-quality control systems. Previous studies in literature investigated factors potentially determining a higher cell levels with the aim of optimizing donors' selection and improving banking process. This study aims to identify factors associated with the concentration of stem cells in umbilical cord blood, so increasing the probability of bankability, focusing on the possible implications in terms of obstetric and resources management. This is a retrospective study conducted in the Obstetric Units of two Italian Hospitals in Montebelluna and Castelfranco Veneto. Study has been conducted on cord blood units banked between 1999 and 2015. Data on medical histories and clinical characteristics of mother and baby have been retrieved via a retrospective examination of medical records. A total of 869 cord blood units were studied. At multivariable analysis, in agreement with literature, birthweight and placental weight have been found to be associated with higher concentration of total nucleated cells. As additional factor, amount of fluid infused was associated with cord blood units' count. This study is the first one to clearly identify the role of fluid infusion on cord blood units' counts in addition to placental weight and delivery. Some non-modifiable features can help in predicting bankability from pre-natal aspects to factors more related with obstetric management is suggested.

Randomized controlled trial of the effect of bilateral uterine artery ligation during cesarean among women at risk of uterine atony.

To assess the effectiveness of prophylactic bilateral uterine artery ligation (BUAL) in reducing the incidence of postpartum hemorrhage (PPH) during cesarean delivery among women at risk of uterine atony. A randomized clinical trial at Cairo University Maternity Hospital, Egypt, from December 2017 to December 2018. Women at risk of uterine atony undergoing scheduled or emergency cesarean were randomized to two groups. In the BUAL group, women underwent BUAL before placental delivery; in the control group, women had cesarean delivery without BUAL. The primary outcome was the estimated blood loss during cesarean. Intraoperative blood loss during cesarean was significantly lower in the BUAL group than in the control group (523.4±41.0 vs 619.6±36.1mL; P=0.003). Blood loss in the first 6hours after cesarean was also significantly lower in the BUAL group than in the control group (246.1±21.4 vs 326.1±18.5mL; P=0.006). There was no difference in operative time between the two groups (52.1±6.1 vs 52.2±6.8, P=0.880). BUAL during cesarean was found to be an effective method for decreasing blood loss during and after cesarean delivery among women at risk of uterine atony and subsequent PPH. CLINICALTRIALS.GOV: NCT03591679.

2561 Should Placental Abnormality be Expected in Subsequent Pregnancy after Myomectomy?

Study Objective To compare the incidence of placental abnormalities in subsequent pregnancy after myomectomy performed by laparoscopy, laparotomy and hysteroscopy. Design A retrospective cohort study, conducted from February 2011 to November 2018. Setting A single tertiary care center. Patients or Participants All women after myomectomy that gave birth. Interventions Data was collected from patients' medical files. Groups were compared for women demographics, fibroids characteristics, operative management, post-operative placental evaluation and delivery characteristics. Primary outcome was defined as the need for any intervention for placental separation during the third phase of the delivery. Non-parametric statistics were used for analysis. Measurements and Main Results 241 women met inclusion criteria. Complete follow-up was achieved in 199 (82.57%) women, of them 82, 89 and 28 underwent laparoscopic, laparotomy and hysteroscopic myomectomy, respectively. There were no significant differences between the groups in women's age, BMI, gravidity and history of cesarean deliveries. Endometrial damage during laparoscopy and laparotomy was reported in 3 (3.6%) and 7 (7.8%) of the women, respectively (p=0.21), and in all women undergoing hysteroscopic myomectomy (p=0.001). During subsequent pregnancy, morbidly adherent placenta was suspected in only one woman in each of the groups (p=0.63), a rate that is considered lower than the reported rate after one cesarean delivery. Placenta previa was not seen in any of the women included in the study. Normal vaginal delivery was significantly higher in the hysteroscopy group compared to laparoscopy and laparotomy groups [11 (36.3%) vs. 5 (6.1%) vs. 4 (4.5%); p=0.001], with significantly lower need for manual lysis of the placenta [11(39.0%) vs. 51 (62.1%) vs. 62 (69.7%); p=0.01] and no need for any further interventions to control blood loss. Conclusion Subsequent pregnancy after myomectomy was not found to be associated with high placental abnormality rate. Furthermore, other than manual lysis, no difference in abnormal placentation requiring intervention was seen between the different techniques.

No evidence of attenuation of placental insulin-stimulated Akt phosphorylation and amino acid transport in maternal obesity and gestational diabetes mellitus.

Pregnancies complicated by obesity and/or gestational diabetes (GDM) are associated with peripheral insulin resistance; however, the insulin responsiveness of the placenta in these pregnancy complications remains largely unknown. We tested the hypothesis that primary human trophoblast cells and placental villous explants will be insulin responsive, characterized by amino acid transport, Akt and Erk activity with maternal obesity, and/or GDM. We evaluated term placentas from women with normal body mass index (BMI) (normal; n = 15), obesity (OB; n = 11), normal BMI with GDM (N-GDM; n = 11), and obesity with GDM (OB-GDM; n = 11). In a subgroup, primary human trophoblast cells (PHT) were isolated, and in an independent subgroup placental villous explants were exposed to varying concentrations of insulin. Amino acid transport capacity and insulin signaling activity were determined. Insulin significantly increased amino acid transport activity to a similar degree in PHT cells isolated from normal (+21%), N-GDM (+38%), OB (+37%), and OB-GDM (+35%) pregnancies. Insulin increased Akt and Erk phosphorylation in PHT cells (3-fold) and in villous explants (2-fold) in all groups to a similar degree. In contrast to the peripheral maternal insulin resistance commonly associated with obesity and/or GDM, we found that the placenta is insulin sensitive in these pregnancy complications. We suggest that elevated maternal insulin levels in pregnancies complicated by obesity and/or GDM promote critical placental functions, including amino acid transport. Insulin-stimulated placental nutrient delivery may contribute to the increased risk of fetal overgrowth and adiposity in these pregnancies. Moreover, our findings may inform efforts to optimize insulin regimens for women with GDM.

Uterine artery ligation before placental delivery during caesarean in patients with placenta previa accreta.

To investigate the influence of uterine artery ligation before placental delivery during cesarean section on postpartum hemorrhage (PPH) and related complications in patients with placenta previa accreta.A retrospective study was conducted of data from 78 patients with pernicious placenta previa, treated at Fujian Provincial Maternal and Child Health Hospital (Fuzhou, China) between January 2014 and June 2018. Twenty-nine patients underwent uterine arterial ligation before placental delivery (UALBPD), and the other 49 patients in the control group did not undergo peri-paracentesis before the delivery of the placenta. The statistical analysis and data management were performed with SPSS 19.0.The intraoperative and postoperative complications after uterine artery ligation were compared between the 2 groups: in the UALBPD group, no woman (0.0%) underwent a subtotal cesarean hysterectomy, whereas four (8.2%) did so in the control group (P = .24). The mean number of packed red blood cell (RBC) units transfused was 3.7 ± 1.2 in the UALBPD group and 5.7 ± 3.4 units in the control group (P = .0002). The estimated blood loss was 734.2 ± 317.5 mL in the UALBPD group and 1101.6 ± 442.7 mL in the control group (P < .0001). Nine (31.0%) women in the UALBPD group underwent transfusion compared with 38 (77.6%) in the control group (P = .003). The reduction in hemoglobin was 2.63 ± 1.85 g/L in the UALBPD group and 5.41 ± 2.38 g/L in the control group (P < .0001). The reduction in hematocrit was 2.96 ± 4.07 in the UALBPD group and 6.77 ± 8.74 (%) in the control group (P = .009).Bilateral uterine artery ligation before the delivery of the placenta in women with placenta accreta can effectively reduce the amount of intraoperative blood loss, the incidence of PPH, and the risk of complications, such as hysterectomy.

The duration of the third stage in relation to postpartum hemorrhage.

In this study, we describe the distribution of placenta delivery and the incidence of postpartum hemorrhage in both spontaneous placental delivery and manual removal of the placenta. A retrospective study was performed of 7603 singleton vaginal deliveries of a gestational age over 32weeks, registered between September 2011 and 2016. We calculated the incidence of postpartum hemorrhage (≥1000mL blood loss) per 10-minute duration of the third stage. The odds ratio for developing postpartum hemorrhage was assessed, adjusted for risk factors. The incidence of postpartum hemorrhage was compared between women that did and did not receive manual removal of placenta. The median duration of the third stage was 10minutes (interquartile range 7-16minutes). The median amount of blood loss was 300mL (200-400mL). The overall incidence of postpartum hemorrhage was 8.5%. With every additional 10minutes of third-stage duration, the risk of developing postpartum hemorrhage significantly increased. In a third stage longer than 60minutes, the incidence of postpartum hemorrhage was 21.2% without manual removal of the placenta and 70.3% with manual removal. The incidence of postpartum hemorrhage increases significantly from 10 to 19minutes into the third stage. Women with the removal of the placenta had a significantly higher percentage of postpartum hemorrhage. The optimal timing for manual removal of the placenta should be investigated in a carefully designed randomized controlled trial to examine whether earlier manual removal of placenta lowers the incidence and limits the severity of postpartum hemorrhage.

The Link Between Human Menstruation and Placental Delivery: A Novel Evolutionary Interpretation: Menstruation and fetal placental detachment share common evolved physiological processes dependent on progesterone withdrawal.

A new interpretation of human menstruation is presented, resulting from a cross-disciplinary investigation of evolution, developmental biology, and physiology. A process evolutionarily associated with childbirth expresses itself as menstruation in women for whom frequent and continual failure to conceive has become the default situation. In humans and Old World primates, contractile uterine spiral arterioles evolved as the complement of the highly invasive hemochorionic placenta and is the selected phenotype. Placental progesterone withdrawal during the last stage of birth leads to arrested blood flow through maternal spiral arterioles, allowing detachment of the deciduous placenta with minimal maternal hemorrhage. In nonpregnant females, progesterone withdrawal from a degenerating corpus luteum initiates menstruation and stops blood flow through uterine spiral arterioles. Both events share similar physiological mechanisms and sequences. This explanation may improve our understanding of a recurrent event experienced by half of the human population and for a quarter of their adult reproductive life.