Cases Of Postpartum Hemorrhage Research Articles

SURGICAL INTERVENTION IN SEVERE POSTPARTUM HAEMORRHAGE

Postpartum haemorrhage (PPH) is one of the major causes of maternal mortality and morbidity, defined as haemorrhage occurring within 24 h of childbirth. Postpartum haemorrhage can be categorized into primary, which takes place within the first one day after childbirth, and secondary, which happens anytime from 24 hours after birth up to six weeks after delivery. Among the cases of PPH, some are severe and fatal and hence need to be treated effectively and on time. Conservative methods are to some extent useful in controlling PPH but surgical management involves the use of special operations to address the problem. Objective: This proposed study aims to finally summarize the evidence about surgical interventions in the management of postpartum haemorrhage, including the effectiveness and side effect profile of various surgical techniques. Methods: This study type used a retrospective cohort design and the sample consisted of patients with severe PPH that needed surgical management. This paper used quantitative data and the data was gathered from the records of hospitals for five years. Some of the surgical management activities considered in the study were uterine artery ligation, B-Lynch suture, and hysterectomy. The variables measured were success rates, early clinical outcomes, late clinical recovery and early complications. Quantitative methods of data analysis used in this study include survival analysis tests and chi-square tests. Results: The study enrolled 150 patients with severe manifested PPH; 60% of the patients underwent uterine artery ligation; 25% of the patients required a B-Lynch suture performed; and 15% of the patients required a hysterectomy. Short-term effects revealed that both techniques provided effective control of bleeding, in 85% of cases did not require additional surgery in the form of a B-Lynch suture. It was also shown that 70% of the cases with uterine artery ligation were associated with long-term preservation of fertility. Hysterectomy had the highest complication rates; infection, organ damage, and higher maternal mortality of 5%. Conclusion: Uterine artery ligation as well as B-Lynch suture should be used in cases of severe PPH because during this procedure no tubal sterilization occurs and fertility can be preserved when selecting the right cases. Although hysterectomy remains the surgical option of choice, the procedure is fraught with some significant risks. The study confirms the necessity for early surgical management and the collaboration of multiple specialists to optimise maternal results in grave cases of PPH. More clinical research is required to optimize surgical approaches and to define the role of non-operative interventions to improve the patient’s prognosis.

Cesarean section with operation on placental support as an adapted EXIT procedure for fetal thyroid goiter: A case report and literature review.

The ex-utero intrapartum treatment (EXIT) procedure is a specialized delivery strategy that extends utero-placental-fetal circulation to convert a potential neonatal emergency condition into a condition that is compatible with postnatal life. Cesarean section with operation on placental support is an EXIT technique that requires a relatively short duration of placental support and few skilled medical personnel and specialized instruments; it can successfully treat selected fetal indications. In the present study, we report a case of fetal thyroid goiter as an example of a fetal anomaly requiring the procedure. We then review all cases published in the medical literature that were similar to our procedure (15 cases including our new case). Twelve (80%) cases of fetal anomalies and three prophylactic cases of extremely low birth weight were delivered using a procedure adapted from the standard EXIT procedure. All 12 cases of fetal anomalies were treated by airway intervention. In 12 of the 15 cases (80%), direct laryngoscopy and endotracheal intubation were attempted; intubation was successful in seven of these 12 cases (58%). There was only one case of postpartum hemorrhage caused by uterine incisional bleeding, with a consequence of delayed hysterotomy closure. In summary, cesarean section with operation on placental support is a promising alternative delivery technique for neonates with airway obstructive lesions, especially in resource-limited settings.

Analysis of Risk Factors and Establishment of a Risk Prediction Model for Severe Postpartum Haemorrhage.

Aims/Background Severe postpartum haemorrhage (PPH) is a dangerous condition, characterized by rapid progression and poor prognosis. It remains the leading preventable cause of maternal death worldwide. This study aimed to investigate the risk factors for severe PPH and establish a prediction model to identify severe PPH early, allowing for early intervention reduce maternal death. Methods Clinical data were collected from 784 patients diagnosed with PPH and delivered at the Second Affiliated Hospital of Anhui Medical University between December 2018 and December 2023. These cases were categorized into the training cohort. Severe PPH was diagnosed in 234 patients based on the criterion of the volume of vaginal bleeding volume exceeding 1000 mL within 24 hours after delivery; these patients were assigned to the experimental group. The remaining 550 patients with nonsevere PPH were assigned to the control group. Data from an additional 338 postpartum women from the same period were selected and classified into the validation cohort. Univariate and multivariate logistic regression analyses were performed to pinpoint the determinants associated with severe PPH. Additionally, these analyses were instrumental for developing and assessing a prediction model to forecast the risk of such complications. Results Most of the PPH cases in this study stemmed from uterine atony, the leading aetiology. The second most common factor was soft birth canal lacerations and haematoma formation, accounting for 7.26% of the subjects in experimental group and 6.55% of those in the control group. Uterine rupture, uterine inversion, and amniotic fluid embolism were exclusively observed in the experimental group. In the univariate analysis, notable disparities were identified across various parameters, including maternal age, gravidity, parity, abortion frequency, gestational week at delivery, prothrombin time (PT), activated partial thromboplastin time (APTT), in vitro fertilisation, foetal position, caesarean delivery, pregnancy with anaemia, and hypertensive disorders of pregnancy (p < 0.05). A multivariate logistic regression model revealed that a parity of two or more, two or more abortions, in vitro fertilisation, gestational weeks at delivery, foetal position, caesarean delivery, pregnancy with anaemia, and hypertensive disorders of pregnancy were independent predictors of severe PPH (p < 0.05). The predictive model demonstrated excellent calibration for the training and validation datasets, with the areas under the curve (AUC) for receiver operating characteristic (ROC) curves measuring 0.799 and 0.759, respectively. Clinical decision curve analysis (DCA) confirmed a significant threshold exceeding 0.9, signifying a substantial net benefit and model precision. Conclusion Parity ≥2 times, abortion ≥2 times, in vitro fertilisation, gestational week at delivery, abnormal foetal position, caesarean delivery, pregnancy with anaemia, and hypertensive disorders of pregnancy are independent risk factors for severe PPH. The predictive model established in this study accurately predicts the occurrence of severe PPH and has significant value for clinical application.

Prevention of intrauterine balloon displacement in patients with postpartum hemorrhage: A narrative review.

Postpartum hemorrhage (PPH) remains a significant complication of pregnancy globally, with uterine atony accounting for the great majority of cases. Second-line hemostatic strategies such as uterine balloon tamponade play a crucial role in managing refractory hemorrhage. Despite its effectiveness, the phenomenon of balloon displacement poses a challenge to PPH management, often leading to treatment failure. Various techniques have been proposed to address this issue, including vaginal packing, cervical cerclage, fixation to the abdominal wall, holding the cervix with ring forceps, and suspending the balloon with cervical sutures. Each method has its advantages and limitations, influencing its suitability in different clinical scenarios. Understanding these techniques may be useful to optimize and improve the management of PPH and maternal outcomes. This review provides a comprehensive summary of these strategies, their mechanisms, and their clinical implications, aiming to guide healthcare providers in choosing the most appropriate approach for individual cases of PPH.

The effect of B-Lynch uterine compression suture performed for uterine atony on future menstrual pattern and reproductive outcome.

The effects of B-Lynch (UCS) compression sutures applied in postpartum hemorrhage cases due to uterine atony on menstrual pattern, fertility, obstetric outcomes, dysmenorrhea and dyspareunia were evaluated. Between January 2012 and March 2017, 77 patients (study group 37, control group 40) diagnosed postpartum hemorrhage in our clinic were included in the study. The long-term results of the patients were evaluated comparatively. In the B-Lynch UCS group, an increase in the postoperative menstrual cycle length and the intensity of dyspareunia measured by the VAS score, and a statistically significant decrease in the duration of menstrual bleeding were observed. In the control group, a decrease in the self-estimated time of postpartum menstrual bleeding and a statistically significant increase in dyspareunia VAS values ​​were observed. There was a statistically significant difference between the groups in terms of menstrual cycle length only after treatment. B-Lynch UCS can be used effectively and safely in PPH due to uterine atony without causing any additional pathology in menstrual pattern, fertility, dysmenorrhea and dyspareunia complaints other than the length of the menstrual cycle.

Relationship between Antenatal Care and Pregnancy Outcome among Participants of a Rural Upazilla Health Complex in Bangladesh

Background: Antenatal care (ANC) is crucial for monitoring pregnancy and improving maternal and neonatal health outcomes. This study aimed to examine the relationship between ANC and pregnancy outcomes among participants at rural upazilla health complex, like Sariakandi Upazilla of Bangladesh. Methods: This retrospective study was conducted at the Upazilla Health Complex in Saniakandi, Bangladesh included 45 pregnant women selected through simple random sampling. Data were collected from medical records and structured interviews to gather information on demographics, obstetric history, clinical history, and specifics of ANC. Maternal outcomes of interest included preeclampsia and postpartum hemorrhage, while neonatal outcomes included gestational age at birth, birth weight, Apgar scores, and NICU admissions. Data were analyzed using SPSS version 26, and Pearson correlation coefficients were calculated to explore the relationship between the number of antenatal visits and pregnancy outcomes. Results: Most participants were aged 21-30 (55.6%) with secondary education (80.0%) and were predominantly housewives (97.8%). Preeclampsia was diagnosed in 6.7% of participants, and postpartum hemorrhage occurred in 2.2%. All cases of preeclampsia and postpartum hemorrhage occurred in women with fewer than 4 antenatal visits, indicating a strong negative correlation (Pearson correlation coefficient of 0.82). Neonatal outcomes showed that 2.2% of newborns were preterm, and 17.8% had low birth weight. Higher frequency of ANC visits correlated positively with better Apgar scores at 1 minute (Pearson correlation coefficient of 0.71) and 5 minutes (Pearson correlation coefficient of 0.61). Conclusion: The study highlights the critical role of frequent and timely ANC in improving maternal and neonatal outcomes. Enhanced ANC accessibility and early initiation are essential for reducing the risks of adverse outcomes, particularly in resource-limited settings.

Predictive model for postpartum hemorrhage requiring hysterectomy in a minority ethnic region.

Postpartum hemorrhage (PPH) is a leading cause of maternal mortality, and hysterectomy is an important intervention for managing intractable PPH. Accurately predicting the need for hysterectomy and taking proactive emergency measures is crucial for reducing mortality rates. To develop a risk prediction model for PPH requiring hysterectomy in the ethnic minority regions of Qiandongnan, China, to help guide clinical decision-making. The study included 23490 patients, with 1050 having experienced PPH and 74 who underwent hysterectomies. The independent risk factors closely associated with the necessity for hysterectomy were analyzed to construct a risk prediction model, and its predictive efficacy was subsequently evaluated. The proportion of hysterectomies among the included patients was 0.32% (74/23490), representing 7.05% (74/1050) of PPH cases. The number of deliveries, history of cesarean section, placenta previa, uterine atony, and placenta accreta were identified in this population as independent risk factors for requiring a hysterectomy. Receiver operating characteristic curve analysis of the prediction model showed an area under the curve of 0.953 (95% confidence interval: 0.928-0.978) with a sensitivity of 90.50% and a specificity of 90.70%. The model demonstrates excellent predictive power and is effective in guiding clinical decisions regarding PPH in the ethnic minority regions of Qiandongnan, China.

A study of critically ill obstetric patients admitted to intensive care unit of a tertiary care hospital.

To evaluate characteristics, indications, complications and outcome of obstetric patients admitted to ICU of tertiary care hospital in KPK, Pakistan. This descriptive study was conducted in department of OBGYN of Lady Reading Hospital, Peshawar from January 2021 till December 2021. A total of 62 patients were enrolled into the study using nonprobability consecutive sampling technique. Their data were collected on a proforma. All patients were followed till their death or discharge home from hospital. The mean duration of ICU stay of patients, was 6.85 ± 4.82 days. Out of 62 patients 17 (27.41%) expired in ICU, while 45 (72.58%) patients survived and were discharged. Pre-eclampsia and Eclampsia was the commonest primary diagnosis, accounting for 28 cases (45.2%) with a case fatality rate of 25%, followed by 13 cases (21%) of primary postpartum hemorrhage (PPH) as the second commonest reason for ICU admission and a case fatality rate of 38%. The underlying primary diagnosis had no statistically significant association with outcome of the patient. Acute Renal failure had statistically significant association with outcome of the patient with adjusted OR 4.79, CI:1.17-19.66, p-0.02. Similar positive association with mortality existed for patients having DIC (aOR:6.59; CI:1.34-32.34, p-0.02). Pre-eclampsia/Eclampsia is the commonest reason for intensive care admission, however PPH has the highest case fatality rate. The outcome of critically ill obstetric patients is dependent on complications and not primary underlying diagnosis.

Predelivery Haemostatic Biomarkers in Women with Non-Severe Postpartum Haemorrhage.

Background: Postpartum haemorrhage (PPH) is a frequent complication of childbirth that is difficult to predict. Predelivery coagulation biomarkers may help to guide preventive strategies. Our objective was to evaluate the association of predelivery haemostatic biomarkers with non-severe PPH. Methods: A nested case-control study was conducted within the « Study of Biological Determinants of Bleeding Postpartum » in order to compare different haemostatic biomarkers in plasma from pregnant women with non-severe PPH (cases) and controls without PPH matched for age, body mass index, term, and mode of delivery. Blood was collected at entry in the delivery room. Global haemostatic assays (thrombin generation assay (TGA) and plasmin generation assay (PGA)) were then performed on freshly thawed aliquots of platelet-poor plasma. Results: A total of 370 pregnant women (185 cases and 185 controls) were included. Median [interquartile range] predelivery platelet count was lower in PPH cases than in controls (217 [181-259] versus 242 [196-280] G/L). TGA and PGA parameters were similar between cases and controls. In a subset analysis of vaginal deliveries (n = 144), median predelivery TGA thrombin peak was lower, and median predelivery PGA lag phase was longer in cases compared to controls. In multivariable analysis, only predelivery platelet count was independently associated with non-severe PPH. Conclusions: Predelivery platelet count is associated with non-severe PPH. Differences in other haemostatic parameters are tenuous, questioning their usefulness in predicting non-severe PPH.

A Retrospective Study of Cases of Postpartum Hemorrhage at Secondary Health Care Center

A Retrospective Study of Cases of Postpartum Hemorrhage at Secondary Health Care Center

Impact of the Early COVID-19 Pandemic on the Quality of Obstetric Care in a Tertiary Care Center in Karachi, Pakistan.

Objective This study aimed to assess the indirect impactof the COVID-19 pandemic on obstetric quality measures. Materials and methods This cross-sectional study was conducted at a private-sector tertiary care hospital in Karachi, Pakistan. Data were collected for specific antenatal, intrapartum, and postpartum care indicators during the initial six months of the COVID-19 phase (March to August 2020) and compared with baseline measures from the preceding six months before the COVID-19 phase (September 2019 to February 2020) using frequencies and percentages. Results During COVID-19, there was a 10% reduction (pre-COVID: 1041 and during COVID: 946)in outpatient obstetric volumes and a 65% increase(pre-COVID: 240 and during COVID: 396) in clinic cancellations, indicating a decreased influx of antenatal patients. Teleclinics served 8.3% (1429/18279) of the total obstetric patients during this period. Marginal decreases were observed in spontaneous vaginal deliveries 1358 (44%)vs 1049 (42.4%) and labor inductionrates 818 (26.6%)vs 606 (24.2%). Additionally, there was a slight increase in instrumental deliveries, 121 (3.9%) vs 114 (4.6%) during the COVID phase. However, these changes were not statistically significant. Similarly, no substantial impact was observed on elective and emergency C-sections. Notably, there were more cases of primary postpartum hemorrhage (PPH) during the COVID-19 phase 36 (1.17%) vs46 (1.86%), and these changes were statistically significant (p= 0.035). Similar trends were observed for eclampsia (p =0.05) and preeclampsia cases (p-value 0.074). However, other maternal morbidity indicators and intrauterine fetal deaths remained relatively unchanged. NICU admissions increased significantly (p=0.001), while early neonatal deaths remained unaffected. Patient satisfaction rates remained steady for inpatients and improved for outpatients during COVID-19. Conclusion The COVID-19 pandemic primarily affected antenatal volumes, neonatal admissions, and maternal morbidity indicators such as PPH, preeclampsia, and eclampsia. Despite the challenges, patient satisfaction and quality care standards were maintained during COVID-19 through new strategies and revised patient care processes.

Comparison of Carbetocin and Oxytocin Efficacy in Preventing Postpartum Hemorrhage after C-Section

Introduction: Postpartum hemorrhage (PPH) is defined as a blood loss of more than 0.5 liters within 24 hours of birth, and a blood loss of more than 1 liter is considered a significant PPH. In low- and middle-income countries, PPH is a major factor causing maternal morbidity and mortality, whereas in high-income countries, the mortality is comparatively lower, but still PPH poses a major risk for postpregnancy complications. Uterine atony is the most frequent cause of the PPH, and it accounts for up to 80% of PPH cases. Aim: The aim of this study is to examine the prophylactic effects of oxytocin and carbetocin in preventing atonic PPH in individuals receiving recurrent elective CS under spinal anesthesia. Materials and Methods: A computerized, randomized, cross-sectional prospective comparative study was conducted on 100 pregnant women at Konaseema Institute of Medical Sciences and Research Foundation for the time period of an year, from October 2020 to October 2021. Inclusion Criteria: This study includes patients with singleton pregnancy, gestational age &gt;38 weeks, spinal anesthesia and repeated C.S with cephalic, breech, or any malpresentations. Exclusion Criteria: Patients with placenta previa and placental abruption, uterine myomata, congenital uterine anomalies, gestational age before 38 weeks, women having emergency cesarean section for fetal or maternal distress, and patients with hepatic or pre-existing bleeding disorder were excluded from the study. The patients included based on the above criteria were split into two equal groups. Group I received carbetocin as a single dose of 100 microgram slow intravenous, and Group II received oxytocin as 5 IU intravenous drip followed by 20 IU of oxytocin infusion on 500 ml saline or lactated ringer with a rate of 150 ml per hour. Results: When compared to the oxytocin group, the blood loss was considerably reduced in the carbetocin group. The levels of Hb and hematocrit [HCT] were evaluated pre- and postoperative in both the groups. The levels of preoperative Hb and HCT showed nonsignificant difference between the two groups, while the levels of postoperative Hb and HCT were significantly higher in carbetocin group than oxytocin group concluding that carbetocin showed the better results in controlling the blood loss and maintaining the levels of Hb and HCT volume and the carbetocin group showed less need for administration of uterotonic agents (20%) in comparison with (32%) in oxytocin group but with no statistically significant difference. Only 8 (16%) patients showed PPH in carbetocin treatment, whereas 14 (28%) showed PPH in patients on oxytocin treatment.

Interpretable machine learning predicts postpartum hemorrhage with severe maternal morbidity in a lower-risk laboring obstetric population

BackgroundEarly identification of patients at increased risk for postpartum hemorrhage (PPH) associated with severe maternal morbidity (SMM) is critical for preparation and preventative intervention. However, prediction is challenging in patients without obvious risk factors for postpartum hemorrhage with severe maternal morbidity. Current tools for hemorrhage risk assessment use lists of risk factors rather than predictive models. ObjectiveTo develop, validate (internally and externally), and compare a machine learning model for predicting PPH associated with SMM against a standard hemorrhage risk assessment tool in a lower risk laboring obstetric population. Study DesignThis retrospective cross-sectional study included clinical data from singleton, term births (>=37 weeks’ gestation) at 19 US hospitals (2016–2021) using data from 58,023 births at 11 hospitals to train a generalized additive model (GAM) and 27,743 births at 8 held-out hospitals to externally validate the model. The outcome of interest was PPH with severe maternal morbidity (blood transfusion, hysterectomy, vascular embolization, intrauterine balloon tamponade, uterine artery ligation suture, uterine compression suture, or admission to intensive care). Cesarean birth without a trial of vaginal birth and patients with a history of cesarean were excluded. We compared the model performance to that of the California Maternal Quality Care Collaborative (CMQCC) Obstetric Hemorrhage Risk Factor Assessment Screen. ResultsThe GAM predicted PPH with an area under the receiver-operating characteristic curve (AUROC) of 0.67 (95% CI 0.64–0.68) on external validation, significantly outperforming the CMQCC risk screen AUROC of 0.52 (95% CI 0.50–0.53). Additionally, the GAM had better sensitivity of 36.9% (95% CI 33.01–41.02) than the CMQCC screen sensitivity of 20.30% (95% CI 17.40–22.52) at the CMQCC screen positive rate of 16.8%. The GAM identified in-vitro fertilization as a risk factor (adjusted OR 1.5; 95% CI 1.2–1.8) and nulliparous births as the highest PPH risk factor (adjusted OR 1.5; 95% CI 1.4–1.6). ConclusionOur model identified almost twice as many cases of PPH as the CMQCC rules-based approach for the same screen positive rate and identified in-vitro fertilization and first-time births as risk factors for PPH. Adopting predictive models over traditional screens can enhance PPH prediction.

Agnostic identification of plasma biomarkers for postpartum hemorrhage risk

Postpartum hemorrhage is difficult to predict, is associated with significant maternal morbidity, and is the leading cause of maternal mortality worldwide. The identification of maternal biomarkers that can predict increased postpartum hemorrhage risk would enhance clinical care and may uncover mechanisms that lead to postpartum hemorrhage. This retrospective case-control study employed agnostic proteomic profiling of maternal plasma samples to identify differentially abundant proteins in controls and postpartum hemorrhage cases. Maternal plasma samples were procured from a cohort of >60,000 participants in a single institution's perinatal repository. Postpartum hemorrhage was defined as a decrease in hematocrit of ≥10% or receipt of transfusion within 24 hours after delivery. Postpartum hemorrhage cases (n=30) were matched by maternal age and delivery mode (vaginal or cesarean) with controls (n=56). Mass spectrometry was used to identify differentially abundant proteins using integrated peptide peak areas. Statistically significant differences between groups were defined as P<.05 after controlling for multiple comparisons. By study design, cases and controls did not differ in race, ethnicity, gestational age at delivery, blood type, or predelivery platelet count. Cases had slightly but significantly lower predelivery and postdelivery hematocrit and hemoglobin. Mass spectrometry detected 1140 proteins, including 77 proteins for which relative abundance differed significantly between cases and controls (fold change >1.15, P<.05). Of these differentially abundant plasma proteins, most had likely liver or placental origins. Gene ontology term analysis mapped to protein clusters involved in responses to wound healing, stress response, and host immune defense. Significantly differentially abundant proteins with the highest fold change (prostaglandin D2 synthase, periostin, and several serine protease inhibitors) did not correlate with predelivery hematocrit or hemoglobin but identified postpartum hemorrhage cases with logistic regression modeling revealing good-to-excellent area under the operator receiver characteristic curves (0.802-0.874). Incorporating predelivery hemoglobin with these candidate proteins further improved the identification of postpartum hemorrhage cases. Agnostic analysis of maternal plasma samples identified differentially abundant proteins in controls and postpartum hemorrhage cases. Several of these proteins are known to participate in biologically plausible pathways for postpartum hemorrhage risk and have potential value for predicting postpartum hemorrhage. These findings identify candidate protein biomarkers for future validation and mechanistic studies.

Use of Postpartum Hemorrhage Checklist during Vaginal Deliveries: A Quality Improvement Study.

Postpartum hemorrhage (PPH) protocols improve patient safety and reduce utilization of blood products; however, few data exist on sustainability of PPH checklist use, how use affects care delivery, and variation of use among patient subgroups. This study aimed to (1) examine compliance with PPH checklist use during vaginal deliveries, (2) evaluate whether checklist use varied by patient and/or care team characteristics, and (3) evaluate whether checklist use was associated with increased use of recommended medications/interventions. This was a quality improvement study performed from April 2021 through June 2023. A multidisciplinary team developed a revised PPH checklist and used quality improvement methodology to increase checklist use following vaginal birth. Data were collected from medical records and clinician survey. Control charts were generated to track checklist use and evaluate special cause variation. Chi-square tests and logistic regression were used to evaluate variation in medications/interventions and across subgroups. During the study period, there were 342 cases of PPH at the time of vaginal birth. The checklist was used in 67% of PPH cases during the 20-month period after implementation in a setting where no checklist was previously being used. We found no statistically significant differences in checklist use by patient or health care team characteristics. Use of tranexamic acid, carboprost, and misoprostol were significantly associated with checklist use. This study demonstrated successful implementation of a checklist protocol where no checklist was previously being used, with sustained use in an average of 67% of PPH cases over 20 months. Checklist use was consistent across subgroups and was associated with higher use of interventions shown to lower blood loss. · Our study showed sustainability of PPH checklist use over a 20-month period.. · PPH checklist use was associated with increased use of interventions known to reduce blood loss.. · Checklist was used consistently across patient subgroups; may help address inequities in obstetric outcomes..

E-MOTIVE Trial: Sustaining capacity building of healthcare providers in the early detection and treatment of postpartum hemorrhage in 11 facilities in Kenya

Background: Training healthcare providers on early detection and use of the first response bundle for postpartum hemorrhage (PPH) cases was one of the key strategies used in the intervention facilities during the E-MOTIVE trial. Results published from the E-MOTIVE trial revealed a marked reduction of 60% in the severity of PPH, idicating the need to implement the same approaches in the 11 control arm facilities. Methods: Healthcare providers (HCPs) from the 11 sites were trained on the E-MOTIVE bundle and issued with PPH emergency trollies, mannequins, and blood pressure machines. The staff was also mentored on self-PPH audits and feedback mechanisms from the data generated monthly from the labor ward. Two days of on-site training were conducted for the staff, which included knowledge tests (before and after) and skills assessment (objective skilled clinical examinations (OSCES)). EMOTIVE champions were identified from the training to promote ongoing skills practice sessions at the facility level. Monthly follow-ups were cpnducted to track individual progress using the training tracking sheet. Results: The HCPs cited confidence in detecting and treating PPH after the training with the hospitals demonstrating readiness in managing PPH through the presence of PPH emergency trollies. There was increased teamwork among the HCPs with improved documentation practices in the labor wards. Conclusion: Adoption of a sustainable training approach for healthcare providers in the prevention, early detection, and treatment of PPH that incorporates evidence-based strategies is key to improving maternal outcomes. National and county ministries of health have demonstrated a commitment to leverage the E-MOTIVE bundle approach after remarkable findings.

Postpartum hemorrhage champions: Sustaining gains beyond the E-MOTIVE Trial

Background: Results published from the E-MOTIVE trial concluded that for women undergoing vaginal delivery, early detection of postpartum hemorrhage (PPH), combined with bundled treatment of PPH, reduced severe PPH and associated adverse outcomes. Eighty hospitals across Nigeria, Kenya, Tanzania, and South Africa and over 210,000 women participated in the randomized trial, which was designed to assess the effect of implementing the E-MOTIVE intervention to detect and treat PPH. The results showed that the use of calibrated collection drapes dramatically increased the PPH detection rate, from 51% to 93%, and the use of the WHO-recommended bundle of treatments, from 19% to 91%. Moreover, implementing the E-MOTIVE approach to treat PPH resulted in a 60% reduction in severe PPH. The median blood loss, the need for postpartum blood transfusion, and the number of maternal deaths were also reduced. The E-MOTIVE trial trained a pool of PPH champions across the intervention facilities, including nurses, midwives, medical officers, and obstetrics and gynecology specialists. Their roles were to coordinate the training and practice activities of all relevant labor ward staff in their hospitals, observe labor ward staff practices, and provide specific feedback for targeted improvements in implementing the E-MOTIVE bundle correctly by reviewing regular performance indicators and outcome data from their hospitals to assess if improvements were needed. Methods: After the study findings, the Kenyan hub team continued tracking the performance of the facilities after the trial, without any active support. The PPH champions collected, discussed at the facility level, and shared data with the Kenyan hub team monthly. The data shared were included in the hub Project Management Information System and triangulated with data from DHIS, where it was analyzed by the Kenyan study team, and feedback was shared at the facility level. Results: Data analyzed from the last quarter (September-November) showed that seven E-MOTIVE implementing facilities maintained 5% PPH rates (blood loss &gt;500 mls) and 2% severe PPH rates on moving averages. All components of the E-MOTIVE bundle were provided 100% to all PPH cases detected. During the same period, three maternal deaths were reported that had causes other than bleeding from PPH. Conclusion: Having PPH champions community of practice can help sustain best practices in the early detection and treatment of PPH beyond any project lifeline. It is a simple and cost-effective method that can prevent severe PPH and prevent maternal mortality arising from PPH.

HAYMAN COMPRESSION SUTURES : AN UNDERUTILIZED TOOL FOR MANAGEMENT OF UTERINE ATONY AND POSTPARTUM HAEMORRHAGE.

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in low- andmiddle-income countries. Uterine atony accounts for 70–80% of PPH cases. Management of PPH isusually based on a cascade beginning with the use of uterotonics and eventually hysterectomy in casesof refractory PPH. Different compression suture techniques have been described and used for themanagement of uterine atony where medical management is insufficient and preservation of fertility isdesired.Case presentation: This is a series of four patients who presented to our facility and consequentlydeveloped uterine atony that was unresponsive to medical management during cesarean delivery despitethe use of multiple uterotonics. All four patients had established risk factors for uterine atony, includinginduction of labor, augmentation of labor, chorioamnionitis, or fetal macrosomia. Hayman compressionsutures were performed in all four patients with success. Estimated blood loss in the series ranged from400 to 1200 mls. All patients recovered well with no complications reported during the postpartum period.Conclusion: Hayman compression sutures offer an alternative to the more ubiquitous B-Lynch suturewith several advantages, including ease of placement and no need for a hysterotomy in PPH post vaginalbirth or placement post repair of hysterotomy in cesarean cases. Thus, the may be easier to perform forjunior health care professionals as well as in stressful situations.

Risk factors for early postpartum hemorrhage: A retrospective, population-based, cohort analysis.

To identify risk factors for developing early postpartum hemorrhage (PPH) and to examine whether risk factors vary according to severity and mode of delivery. A population-based cohort study was conducted in which all deliveries at a tertiary medical center were included. Risk factors for developing early PPH were compared based on the severity of bleeding as well as the mode of delivery. Multiple logistic regression models were used to control for confounders. Among 322 497 deliveries included in the analysis, early PPH complicated 1811 (0.56%) of all deliveries. Among all cases of early PPH, 505 deliveries (28%) were complicated with severe PPH. Using a logistic regression model, invitro fertilization (IVF) pregnancy, previous cesarean delivery (CD), pre-eclampsia, placental abruption, and uterine rupture were independently associated only with severe early PPH, while non-progressive second stage of labor, induction of labor, and large for gestational age were independently associated with both severe and mild early PPH. When applying an additional logistic regression model, whereas IVF pregnancy, pre-eclampsia, and large for gestational age were independently associated with early PPH among vaginal deliveries only, placenta previa was independently associated with early PPH among CD only. Independent risk factors for developing severe PPH solely include IVF pregnancy, previous CD, pre-eclampsia, placental abruption, and uterine rupture. IVF pregnancy, pre-eclampsia, and large for gestational age are independent risk factors for early PPH following vaginal delivery, while placenta previa is independently associated with early PPH after CD only. Due to the recognition of the importance of both the provider and institutional planning and preparation for PPH, the study's results should be viewed within the scope of its retrospective cohort design.

Economic effects of treating postpartum hemorrhage with vacuum-induced hemorrhage control devices – A budget impact analysis of the Jada® System in the German obstetrics setting

ObjectiveThis study aimed to assess the budget impact of vacuum-induced hemorrhage control (VHC) devices for treating postpartum hemorrhage (PPH) from the perspective of the German statutory health insurance (SHI). Study DesignEvidence shows that treating PPH with VHC instead of uterine balloon tamponade (UBT) can reduce resource consumption (e.g., reduced number of blood transfusions and length of stay). A budget impact model combining aggregated German real-world reimbursement data of PPH cases with the assumption of resource reduction due to VHC usage was developed. Diagnosis-related groups (DRG) of PPH cases and their frequencies were collected using a publicly available database. A “downgrading mechanism” was performed, leading to a less resource-intensive DRG, i.e., resulting in a lower flat fee to be paid by SHI. Four subgroups were differentiated based on coded diagnoses and procedures: 1) PPH (O72.-) as main diagnosis, 2) PPH as secondary diagnosis, 3) UBT procedure coded, and 4) UBT or standard tamponade coded. Weighted averages of cost savings per case were calculated. ResultsData from 7,129 (subgroup 1), 49,523 (subgroup 2), 1,668 (subgroup 3), and 3,406 (subgroup 4) cases were retrieved. After applying the downgrading mechanism, cost savings (weighted average) resulted in 184.09 €, 210.50 €, 921.33 €, and 633.74 € for subgroups 1–4, respectively, ConclusionThis is the first German budget impact analysis of VHC for the treatment of PPH. Results showed the highest cost-saving potential for cases currently treated with UBT. Demonstrating not only clinical but also financial consequences of innovative treatments is crucial for the adoption into clinical practice.