Placental Delivery Research Articles

Utilization of carbetocin for prevention of postpartum hemorrhage after cesarean section: a randomized clinical trial

A randomized study involving pregnant women was conducted to compare the effectiveness of a single intravenous (IV) injection of carbetocin with that of a standard 2-h oxytocin IV infusion with respect to intraoperative blood loss in the prevention of uterine atony after cesarean section (CS). The two treatments also were compared for safety and ability to maintain adequate uterine tone and to reduce the incidence and severity of postpartum hemorrhage (PPH) in women at risk for this condition. Between 1 September 2007 and 5 January 2008, we enrolled 104 patients with at least one risk factor for PPH undergoing CS in a randomized, controlled clinical trial. We compared the effect of a single 100 microg IV dose of carbetocin with that of a standard 2-h ten international units (IU) IV infusion of oxytocin. The primary outcome was the proportion of patients requiring additional oxytocic intervention for uterine atony. Fiftytwo women received 100 microg carbetocin IV immediately after placental delivery, while 52 women received 10 IU oxytocin IV infusion. Complete blood count was collected at entry and 24 h postpartum. All outcome measures, including the need for additional uterotonic agents or uterine massage, and blood loss, were analyzed using chi-square, Fisher exact, and Student's t tests. A single 100 microg IV injection of carbetocin was as effective as a continuous 2-h infusion of oxytocin in controlling intraoperative blood loss after placental delivery. Mean blood loss after carbetocin administration was 30 ml less than after oxytocin administration (P = 0.5). The percentage of patients with blood loss < or =500 ml was greater with carbetocin (81 vs. 55%; P = 0.05). Carbetocin enhanced early postpartum uterine involution. The fundus was below the umbilicus in more patients who received carbetocin at 0, 2, 6, and 24 h on the ward (P < 0.05). The main additional uterotonic agent used was a further administration of oxytocin (20 IU in physiological solution 500 ml at an infusion rate of 200 ml/h). In the carbetocin group, 20 of the 52 women (38.4%) required at least one uterine massage compared to 30 of the 52 women (57.7%) in the oxytocin group (P < 0.01). Overall, uterotonic intervention was clinically indicated in two of the women (3.8%) receiving carbetocin compared to five of the women (9.6%) given an IV oxytocin infusion (P < 0.01). The odds ratio of treatment failure requiring oxytocic intervention was 1.83 (95% confidence interval, CI, 0.9-2.6) times higher in the oxytocin group compared with the carbetocin group. Carbetocin makes possible to obtain, with a single IV injection, results equivalent to those of oxytocin on the maintenance of uterine tonicity and the limitation of blood losses, in the peri- and in the post-operative period, during a delivery by CS. It has in addition a comparable tolerance. Even in our series adverse events are practically of the same type and similar frequency in both study groups. Thus, the effectiveness of carbetocin consists, thanks to its long half-life, on an unique injection, whereas oxytocin requires repeated injections or a perfusion of several hours, with a variability of the administered doses.

Maternal Circulating Levels of Activin A, Inhibin A, sFlt-1 and Endoglin at Parturition in Normal Pregnancy and Pre-Eclampsia

BackgroundMaternal circulating levels of anti-angiogenic factors such as soluble fms-like tyrosine kinase-1 (sFlt-1), endoglin (sEng) and placental proteins like activin A and inhibin A are increased before the onset of pre-eclampsia. There is evidence for oxidative stress in pre eclampsia. Recently it was shown that placental oxygen concentration is related to sFlt-1 and inhibin A. In addition it is reported that oxidative stress markers are increased in placental tissue delivered after labour. Therefore, the objective of this study is to investigate if these proteins are altered in maternal circulation of labouring pre-eclampsia and normal pregnancies.MethodologyTo assess the effects of labour, samples were taken from 10 normal pregnant (NP) and 10 pre-eclamptic (PE) women pre-labour, full dilation, placental delivery and 24 h. To assess the effects of placental delivery, plasma samples were taken from 10NP and 10PE women undergoing elective Caesarean section, pre-delivery, placental delivery and 10 min, 60 min and 24 h post delivery. SFlt-1 and sEng and activin A and inhibin A were measured using commercial and in house ELISA's respectively.ResultsThe levels of sFlt-1 and sEng were significantly higher in PE compared to NP women in both groups. In labour, sFlt-1 levels increased significantly at full dilatation in PE women, before declining by 24 hr. However there was no significant rise in sEng levels in labour. Activin A and inhibin A levels declined rapidly with placental delivery in NP and PE pregnancies. There was a significant rise in activin A levels during labour in PE compared to pre labour, but inhibin levels did not increase.ConclusionLabour in pre-eclamptic women increases the levels of sFlt-1 and activin A. This pilot data suggests that increase in the maternal levels of these factors in labour could predict and/or contribute to the maternal syndrome postpartum.

Maternal use of antihypertensive drugs in early pregnancy and delivery outcome, notably the presence of congenital heart defects in the infants

To investigate the association between maternal use of antihypertensives in early pregnancy and delivery outcome, notably infant congenital malformations. A cohort study of 1,418 women who had used antihypertensive drugs in early pregnancy but had no diabetes diagnosis were identified from the Swedish Medical Birth Register. There was an excess risk for placental abruption, caesarean section, delivery induction, and post-delivery hemorrhage in women taking hypertensives. Infants were more often than expected born preterm, were small for gestational age, and had an excess of various neonatal symptoms. Cardiovascular defects occurred with an adjusted odds ratio of 2.59 (95% CI 1.92-3.51). The results were similar when the woman had used ACE inhibitors or other antihypertensives, notably beta blockers. Stillbirth rate was increased (risk ratio 1.87, 95% CI 1.02-3.02), again without any clear drug specificity. There seems to be little drug specificity in the association between maternal use of antihypertensives and an increased risk for infant cardiovascular defects.

Use of Luprostiol and Cloprostenol for Induction of Parturition in Pregnant Goats

Pregnant goats were induced to parturition on day 145 of pregnancy, with three different protocols: group Cl (n = 19) was injected intramuscularly (IM) with 75 microg of the prostaglandin analogue R-Cloprostenol; group L (n = 20) was treated IM with 7.5 mg of the prostaglandin analogue Luprostiol; group L(50) (n = 18) was injected IM with 3.75 mg of Luprostiol (IM); in addition, Group S (Control, n = 15) was injected IM with 1 ml of saline solution. Thereafter, goats were continuously observed to record the following parameters: parturition, dystocia incidence, placental delivery and kid and maternal survival. Moreover, blood sampling was performed around kidding and plasma progesterone concentrations were analyzed. The interval from injection to parturition (mean +/- SEM) was not significantly different among the experimental groups: 35.1 +/- 1.5 h, 33.3 +/- 0.9 h and 34.1 +/- 1.8 h (groups Cl, L and L(50), respectively). In the control group, time to parturition was 99.4 +/- 12.1 h (range: 34-166 h). All the goats expelled the foetal membranes within the first 2 h after the induction. The incidence of dystocia due to foetal posture was not significantly different between induced and control goats (21.1%, 20.0%, 22.0% and 20%, for groups Cl, L, L(50) and S, respectively). The percentage of live kids was practically similar between induced goats (93.9%, 94.9% and 92.1%, for groups Cl, L and L(50), respectively); in addition, there was a case of maternal mortality in control group (6.7%; 1/15), whereas there was no mortality in induced goats (0%; 0/57). Plasma concentrations of progesterone showed an intense drop (<2 ng/ml) at 24 h after induction. This study confirms the effectiveness of the luprostiol to induce the parturition in goats, within a narrow range (30-40 h) in most of the induced females (80.0%, 7.5 mg; 77.8%, 3.75 mg).

Rectal misoprostol vs 15-methyl prostaglandin F 2α for retained placenta after second-trimester delivery

The purpose of this study was to compare rectal misoprostol (RM) with 15-methyl prostaglandin F2alpha (PGF(2alpha)) for the management of retained placenta after second-trimester deliveries. A retrospective study of all second-trimester deliveries between the years 2000 and 2005 was performed. Women were divided into 2 groups, depending on whether they received RM or PGF(2alpha) after the delivery. Three hundred three second-trimester deliveries were analyzed. The time from the administration of medications to the placental delivery was significantly shorter in women who received PGF(2alpha), compared with the RM group (49.5 vs 89 minutes; P < .01). Women who received PGF(2alpha) had lower rates of retained placenta (4.9% vs 12.4%; P = .02). The use of PGF(2alpha) after second-trimester deliveries results in shorter third stage of labor and lower rates of retained placenta compared with RM.

Red blood cell n-3 polyunsaturated fatty acids in first trimester of pregnancy are inversely associated with placental weight

To investigate pregnancy outcome in relation to red blood cell (RBC) level of long-chain n-3 polyunsaturated fatty acids (PUFA) in the first trimester of pregnancy and the influence of lifestyle factors on the RBC level of long-chain n-3 PUFA. Observational study in a community with traditional fish and cod liver oil consumption. Seventy-seven healthy pregnant women. The PUFA composition of RBC was measured in the 11th to 15th week of pregnancy. The women answered food frequency and lifestyle questionnaires. Information on pregnancy outcome was collected from birth records. Placental weight, long-chain n-3 PUFA in diet and RBC, smoking. Of all the pregnancy outcome variables tested, placental weight was the only one associated with long-chain n-3 PUFA in RBC. Inverse association was found between the proportion of long-chain n-3 PUFA in RBC and placental weight, adjusted for birthweight (p=0.035). The proportion of long-chain n-3 PUFA in RBC was positively related to long-chain n-3 PUFA intake (p<0.001) and negatively related to smoking (p=0.011). The human fetus relies on maternal supply and placental delivery of long-chain n-3 PUFA for optimal development and function, particularly of the central nervous system. Given the importance of dietary n-3 PUFA during pregnancy, further studies are warranted to investigate the relationship between placental weight, maternal long-chain n-3 PUFA status and smoking.

The Effect of Labour and Placental Separation on the Shedding of Syncytiotrophoblast Microparticles, Cell-free DNA and mRNA in Normal Pregnancy and Pre-eclampsia

The clinical features of the maternal syndrome of pre-eclampsia can be explained by generalised maternal endothelial cell dysfunction, which is a part of a more global maternal systemic inflammatory response. There is growing evidence that these effects are associated with the shedding of cellular debris, including syncytiotrophoblast microparticles (STBM), cell-free DNA and mRNA, from the surface of the placenta (syncytiotrophoblast) into the maternal circulation. The increased shedding of this debris seen in pre-eclampsia is believed to be caused by placental ischaemia, reperfusion and oxidative stress. This study was carried out to determine whether uterine contractions during labour and subsequent placental separation lead to an acute increase in the release of placental debris into the maternal circulation. To assess the effects of labour, samples were taken from 10 normal pregnant (NP) and 10 pre-eclamptic (PE) women at varied time points. Similarly to assess the effects of placental delivery, plasma samples were taken from 10 NP and 10 PE women undergoing elective caesarean section. There was a significant increase in the shedding of STBM in pre-eclampsia which was not seen in normal pregnancy and there was a small rise in STBM levels at placental separation in both normal pregnant and pre-eclamptic women undergoing caesarean section, but the differences were not significant. However, levels of placental cell-free corticotrophin releasing hormone mRNA were significantly increased in labour in both normal pregnancy and pre-eclampsia and were still high 24 h after delivery in the pre-eclamptic women. There was no significant increase in fetal or total DNA in labour, but the overall levels of total DNA (maternal and fetal) was increased in labour in pre-eclampsia compared to normal labour. The enhanced shedding of STBM and CRH mRNA in pre-eclampsia labour may have a role in cases of postpartum worsening of pre-eclampsia.

Uterine rupture at scar of prior laparoscopic cornuostomy after vaginal delivery of a full‐term healthy infant

A 30-year-old, gravida 2, para 0 woman who had a history of a laparoscopic cornuostomy for a left interstitial pregnancy was admitted for a vaginal delivery due to labor pains at 40 weeks gestation. A prolonged placental delivery, persistent abdominal pain, and hemorrhagic shock were noted after the delivery of the infant. An emergency laparotomy was carried out, and the diagnosis of a uterine rupture at the scar of a prior cornuostomy was confirmed. The entire placenta extruded through the rupture wound into the abdominal cavity. A Medline computer search revealed that a similar case of a uterine rupture after full-term vaginal delivery has yet to be reported. In order to prevent a uterine rupture, we suggest that a planned cesarean delivery, before the onset of labor in a subsequent pregnancy, may be safer for a patient with a scarred uterus from a prior cornuostomy for an interstitial pregnancy.

Prediction and Prevention of Recurrent Stillbirth

Stillbirth is one of the most common adverse pregnancy outcomes in the United States, occurring in one out of every 200 pregnancies. There is a paucity of information on the outcome of pregnancies after stillbirth. Prior stillbirth is associated with a twofold to 10-fold increased risk of stillbirth in the future pregnancy. The risk depends on the etiology of the prior stillbirth, presence of fetal growth restriction, gestational age of the prior stillbirth, and race. Categorization of the cause of the initial stillbirth will allow better estimates of individual recurrence risk and guide management. A history of stillbirth also increases the risk of other adverse pregnancy outcomes in the subsequent pregnancy such as placental abruption, cesarean delivery, preterm delivery, and low birth weight infants. Prospective studies have revealed an increased risk of stillbirth with low pregnancy-associated plasma protein A, elevated maternal serum alpha fetoprotein, abnormal uterine artery Doppler studies, and antiphospholipid antibodies. However, the positive predictive value of these factors individually is poor. Because fetal growth restriction is associated with almost half of all stillbirths, the correct diagnosis of fetal growth restriction is essential. The use of individualized or customized growth standards will improve prediction of adverse pregnancy outcome by distinguishing growth-restricted fetuses from constitutionally small, healthy fetuses. Antepartum fetal surveillance and fetal movement counting are also mainstays of poststillbirth pregnancy management.

An Essential Ligand-binding Domain in the Membrane Receptor for Retinol-binding Protein Revealed by Large-scale Mutagenesis and a Human Polymorphism

Plasma retinol-binding protein (RBP), the principal carrier of vitamin A in the blood, delivers vitamin A from liver, the site of storage, to distant organs that need vitamin A, such as the eye, brain, placenta, and testis. STRA6 is a high-affinity membrane receptor for RBP and mediates vitamin A uptake in these target organs. STRA6 is a 74-kDa multi-transmembrane domain protein that represents a new class of membrane transport protein. In this study, we used an unbiased strategy by analyzing >900 random mutants of STRA6 to study its structure and function, and we identified an essential RBP-binding domain in STRA6. Mutations in any of the three essential residues in this domain can almost completely abolish binding of STRA6 to RBP and its vitamin A uptake activity from holo-RBP without affecting its cell surface expression. We have also functionally characterized the mutations in human STRA6 that cause severe birth defects as well as several human polymorphisms. All STRA6 mutants associated with severe birth defects have largely abolished vitamin A uptake activity, consistent with the severe clinical phenotypes. In addition, we have identified a human polymorphism that significantly reduces the vitamin A uptake activity of STRA6. Interestingly, the residue affected by this polymorphism is located in the RBP-binding domain we identified, and the polymorphism causes decreased vitamin A uptake by reducing RBP binding. This study identifies an essential functional domain in STRA6 and a human polymorphism in this domain that leads to reduced vitamin A uptake activity.

Maternal Insulin-like Growth Factor-II Promotes Placental Functional Development Via the Type 2 IGF Receptor in the Guinea Pig

In guinea pigs, maternal insulin-like growth factor (IGF) infusion in early-pregnancy enhances placental transport near-term, increasing fetal growth and survival. The effects of IGF-II, but not IGF-I, appear due to enhanced placental labyrinthine (exchange) development. To determine if the type-2 IGF receptor (IGF2R) mediates these distinct actions of exogenous IGF-II in the mother, we compared the impact of IGF-II with an IGF-II analogue, Leu 27-IGF-II, which only binds the IGF2R. IGF-II, Leu 27-IGF-II (1 mg/kg per day.sc) or vehicle were infused from days 20–38 of pregnancy (term = 67 days) and placental structure and uptake and transfer of [ 3H]-methyl- d-glucose (MG) and [ 14C]-amino-isobutyric acid (AIB) and fetal growth and plasma metabolites, were measured on day 62. Both IGF-II and Leu 27-IGF-II increased the volume of placental labyrinth, trophoblast and maternal blood space within the labyrinth and total surface area of trophoblast for exchange, compared to vehicle. Leu 27-IGF-II also reduced the barrier to diffusion (trophoblast thickness) compared to vehicle and IGF-II. Both IGF-II and Leu 27-IGF-II increased fetal plasma amino acid concentrations and placental transfer of MG to the fetus compared to vehicle, with Leu 27-IGF-II also increasing AIB transport compared with vehicle and IGF-II. In addition, Leu 27-IGF-II increased fetal weight compared to vehicle. In conclusion, maternal treatment with IGF-II or Leu 27-IGF-II in early gestation, induce similar placental and fetal outcomes near term. This suggests that maternal IGF-II in early gestation acts in part via the IGF2R to persistently enhance placental functional development and nutrient delivery and promote fetal growth.

RETRACTED: Cell Recovery Sufficient for Adult Transplantation by Additional Cord Blood Collection From Placenta

The amount of newborn blood that can be collected from a single cord donor is limited, but a significant amount remains in the placenta. We used a simplified perfusion method to collect this additional blood. Umbilical cord blood from 15 newborns was collected before placental delivery by umbilical vein puncture. After delivery, the placenta was placed on sterile gauze and 63 mL of citrate-phosphate-dextrose-adenine anticoagulant were injected into the umbilical vein that was then clamped near the placenta. The placenta was gently massaged, hung over a sterile vessel, and the umbilical cord cut sterilely near the embryonic surface. Additional blood was collected into the sterile vessel by pressuring a gauze bag around the placenta. We assessed the contribution of this second fraction to the total volume, total nucleated cell (NC), CD34+, hematopoietic progenitors cell, and colony forming unit count and bacterial contamination risk. The total collected volume was 127.3 mL (range 92-170) and the NC content was 1.6+/-0.73x10(9). The mean second fraction contribution from 15 units to the total nucleated and mononuclear cell content was 54+/-9.87% and 54+/-9.52%, respectively. The added percentage of CD34+ and hematopoietic progenitor cells was 54.3+/-10.35% and 46.7+/-11.5%, respectively, while the additional percentages of colony forming-granulocyte macrophage and colony forming-erythroid in the second fraction were 43.2+/-5.5% and 39.8+/-4.3%, respectively, indicating that the cells collected after placental perfusion (second fraction) had similar HPC content and in vitro hematopoietic potential. The method did not increase the risk of bacterial contamination.

Selección de donantes y recogida de las unidades en un banco de sangre de cordón umbilical

Umbilical cord blood (UCB) contains hematopoietic stem cells that can be used as an alternative to bone marrow transplantation in certain cases. This study was designed to investigate the influence of obstetric, neonatal and collection factors on the hematopoietic content of UCB donations.A total of 391 consecutive maternal-neonatal pairs were evaluated during the prepartum period in the maternity ward at La Fe University Hospital. Maternal, neonatal and collection factors influencing cord blood quality measured as volume, total nucleated cells count, CD34+ cells and colony forming units were analyzed in 2,000 UCB collections.32.5% of UCB potential donors were excluded, mainly due to obstetrical reasons. Among the collected units, 56% were discarded before cryopreservation, mainly due to low cell counts. In the multivariate analysis, placental weight was a predictor variable for total nucleated cells, CD34+ cells and colony forming units, while the mode of collection influenced the total nucleated cells and CD34+ cell counts.The collection of UCB units before placental delivery (using the birth weight as an estimation of the placental weight) could be added to standard cord blood donors criteria in order to improve the bank efficiency.

Placental Drainage of Fetal Blood at Cesarean Delivery and Feto–Maternal Transfusion

To assess the efficacy of placental drainage of fetal blood at the time of cesarean delivery on the incidence of feto-maternal transfusion. This randomized trial includes 86 gravid women who underwent cesarean delivery. Forty-four women were assigned to the placental drainage group and 42 to the no-drainage group. Placental drainage was accomplished by cutting and milking the umbilical cord until no further blood flow occurred. All placentas were spontaneously expelled. The primary outcome variable, as assessed by preoperative and postoperative Kleihauer-Betke tests, was the amount of fetal blood (greater than or equal to 0.5 mL) in the maternal circulation. The group having placental drainage of fetal blood before placental delivery showed a significantly lower incidence (3 of 44, 6.8%) of feto-maternal transfusion (P=.003) as compared with the undrained group (14 of 42, 33%; relative risk 0.20, 95% confidence interval 0.065-0.65; number needed to treat=4). Placental drainage of fetal blood before spontaneous placental delivery at the time of cesarean delivery significantly reduces the incidence of feto-maternal transfusion. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00470899 I.

A pilot clinical trial of ultrasound-guided postplacental insertion of a levonorgestrel intrauterine device

Background Postplacental intrauterine device (IUD) insertion is a safe, convenient and effective option for postpartum contraception. Few studies involve ultrasound-guided insertion, and none involve the levonorgestrel IUD or take place in the United States. Study Design The study was conducted to assess the safety and feasibility of ultrasound-guided postplacental insertion of the levonorgestrel IUD following vaginal delivery in a U.S. residency program. Levonorgestrel IUDs were inserted under ultrasound guidance within 10 min of placental delivery by hand or using ring forceps. Subjects were examined at 4 and 10 weeks postpartum for evidence of expulsion or infection. Results Thirty-four subjects were enrolled and 20 received an IUD. Follow-up data are available for 19 subjects over the 10-week follow-up period; 16 subjects returned for the 4-week follow-up, and 14 returned at 10 weeks. Two additional subjects could be contacted by telephone only. At 4 and 10 weeks postpartum, no subjects had evidence of infection. There were two expulsions (2/19, 10.5%) by 10 weeks postpartum. None of the subjects examined had a partial expulsion (intracervical location of the IUD). Conclusions In this pilot study, ultrasound-guided postplacental insertion of the levonorgestrel IUD was feasible and not associated with infection. The risk of expulsion was acceptable. Ultrasound-guided postplacental insertion of the levonorgestrel IUD may be an alternative to delayed insertion but warrants further study.

Importância clínica da dosagem de lactato e contagem de eritroblastos no sangue colhido no segmento placentário da veia umbilical para o diagnóstico de hipóxia-isquemia em prematuros

OBJETIVO: Determinar a validade clínica das dosagens de lactato e contagem de eritroblastos quando comparados com o excesso de bases (EB) em sangue do segmento placentário da veia umbilical de prematuros. MÉTODOS: foram colhidas amostras de 25 prematuros, após ligadura e dequitação. Os prematuros foram seguidos até a alta. Estatística incluiu regressão linear, correlação de Spearman, curvas ROC, Teste de Fisher. RESULTADOS: Lactato mostrou boa correlação com pH e EB (p < 0,0001). Níveis de lactato de 4,04 mmol/L mostraram sensibilidade de 62,5% e especificidade de 91,1% em discriminar pH < 7,2 e EB < -10 mmol/L. Contagens de eritroblastos mostraram boa correlação com o EB (p = 0,0095), mas sensibilidade de 37,5% e especificidade 82,4% em discriminar EB < 10 mmol/L. CONCLUSÕES: Lactato é um marcador válido para hipóxia fetal, em amostras do segmento placentário das veias umbilicais. Contagens de eritroblastos apresentaram baixa sensibilidade na discriminação da acidose.

Clinical value of lactate measurement and nucleated red blood cell counts in the placental segment of the umbilical vein of premature newborns for diagnosis of hypoxia-ischemia

To evaluate the clinical value of lactate measurement and nucleated red blood cell (NRBC) counts when compared to base excess (BE) in the blood collected from the placental segment of the umbilical vein. 25 umbilical cords from premature babies were sampled after placental delivery and cord clamping. Babies were followed until discharge. Statistics involved linear regression, Spearman's correlation, ROC curves, and Fisher's exact test. The relationship between lactate in the umbilical vein blood and pH and BE was significant (p < 0.0001). A 4.04 mmol/L lactate level showed a sensitivity of 62.5% and a specificity of 94.1% in detecting pH < 7.2 and BE < -10 mmol/L. NRBC counts were related to BE (p = 0.0095), but with a sensitivity of 37.5% and specificity of 82.4% in detecting BE < -10 mmol/L. Lactate is a valuable marker of fetal hypoxia when sampled from placental segment veins. NRBC counts demonstrated low sensitivity for the detection of acidosis.

Prise en charge du placenta accreta

Placenta accreta occurs when a defect of the decidua basalis results in abnormally invasive placental implantation. Main risk factors include placenta previa and previous caesarean section. The conventional sonographic criteria for abnormally adherent placenta have a good diagnostic value that has to be assessed. MRI should improve the diagnosis when sonography is inconclusive. The choice of the treatment results of medical staff and the women's choice. It implies centers with adequate equipment and resources. Radical strategy consists in caesarean hysterectomy according to American recommendations or in an attempt of complete placental delivery associated with trial haemostasis and hysterectomy if this fails. A conservative approach whereby the placenta is left in place may however be proposed in selected cases if the woman wishes to continue to be fertile. This strategy needs a rigorous follow-up until complete resorption of the placenta. In case of major hemorrhage, hysterectomy should not be delayed to prevent major maternal complications or even maternal death.

Increased postpartum blood loss in pregnancies associated with placental malaria

Objective To determine the relationship of placental malaria and parity with postpartum blood loss in a malarious area of Tanzania. Methods A total of 706 uncomplicated vaginal deliveries were studied at Muhimbili University Hospital, Dar es Salaam, Tanzania. Maternal age, parity, date of delivery, birth weight, presence of placental malaria, stillbirths, and delivery complications were noted. Collection and measurement of vaginal blood loss commenced immediately following birth using a plastic vinyl sheet placed underneath the mother. The bed was divided in the middle to allow the blood to drain into a bucket. Blood loss was measured for a period of 2 h following delivery. Results In singleton births the mean postpartum blood loss was 170 mL in nulliparas and 187 mL in multiparas ( p = 0.017). Blood loss was 400 mL or greater in 23 women (3.4%) and 500 mL or greater in 10 women (1.5%). Mean postpartum bleeding tended to increase with maternal age, parity, and birth weight. In logistic regression the odds ratio for a blood loss of 400 mL or greater was significantly increased for women with placental malaria (3.2; 95% confidence interval, 1.1–9.0; p = 0.028), after adjusting for a birth weight greater than 4000 g. Placental malaria showed a marked seasonal pattern, which corresponded to the months of peak prevalence for a postpartum blood loss of 400 mL or greater ( p = 0.007). Conclusion A postpartum blood loss of 400 mL or greater should be considered a possible complication of placental malaria.

Grossesse des patientes obèses: quels risques faut-il craindre?

To evaluate the deleterious effects of maternal obesity on obstetrical complications and neonatal outcomes. Historical cohort study including all patients delivered in our maternity between 1st January 2002 and 31st December 2004. Intra uterine death and fetal loss before 22 weeks were excluded. Women were categorized by the Body Mass Index: less than 25, between 25 and 30, and more than 30. Maternal data, obstetrical complications, labor and its complications, and neonatal outcomes were studied. During these 3 years, 23.5% (1336/5686) of patients were overweight and 7.5% (425/5686) were obese. Obstetrical pathologies (gestational diabetes mellitus, hypertension, preeclampsia and fetal macrosomia) and labour induction were more significantly frequent in obese patients (P < 0.01). We noted twice more caesarean sections during labour in obese patients. The rate of artificial placental delivery was significantly higher in obese patients (P < 0.01). Obese patients with prior caesarean sections had a rate of vaginal delivery significantly lower than non obese patients with prior C-sections (23.6 vs 43.8%; P < 0.01). Mean children birth weight was significantly higher in obese patients (3305 vs 3181 g; P < 0.01) with no impact on Apgar score. Our study confirms that obesity is responsible for major obstetrical complications, for what should no doubt be considered as high risk pregnancies. Our practices must take these complications into account by ensuring an adapted and early management in order to improve maternal and neonatal issues.