Rate Of Postpartum Hemorrhage Research Articles

Step forward: implementation and evaluation of STEPS program to optimize postpartum hemorrhage management in vaginal deliveries.

Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide, particularly in resource-limited settings. Enhancing maternal safety in relation to PPH requires optimizing care protocols, continuous monitoring, and timely interventions. However, integrating these methodologies into vaginal delivery practices remains underexplored. To assess the impact and sustainability of a recently implemented Strategies and Tools to Enhance Parturient Safety (STEPS) program on PPH management. This before-and-after study included women who delivered vaginally between January 2020 and November 2023. Clinical practices and PPH-related outcomes were compared for 2-year periods before and after STEPS implementation, initiated in January 2022. The program involved enhanced perinatal care bundles, interdisciplinary team training, and continuous monitoring using statistical process control (SPC) tools. The primary outcome was PPH incidence (≥500 mL blood loss within 24 hours). During the 4-year observation period, 24,235 women underwent vaginal deliveries. The incidence of PPH was 11.1% (1,473/13272) before STEPS and 11.8% (1,293/10963) after STEPS (aRR, 1.09; 95% CI, 1.00-1.18; P=.042). Severe PPH rates remained unchanged (aRR, 1.09; 95% CI, 0.90-1.33; P=.391). However, the proportion requiring blood transfusion significantly decreased (aRR, 0.77; 95% CI, 0.61-0.98; P=.035). Compared to preintervention period, a higher proportion of women experiencing PPH were identified as being at elevated risk prior to delivery in the postintervention period (P<.001). Notably, blood transfusion rates (P=.047) and hospital stay durations for women with PPH (P<.001) significantly declined. The STEPS program effectively improved PPH management by enhancing risk identification, increasing targeted interventions, and reducing blood transfusion rates and hospital stays. These findings highlight the importance of a comprehensive approach that integrates risk assessment, monitoring, and tailored interventions for managing PPH in vaginal deliveries, particularly in resource-limited settings.

Association of assisted reproductive technology with adverse maternal outcome: A cohort study

Background &amp; Objective: To assess the association of assisted reproductive technologies (ART) conception with postpartum hemorrhage (PPH) during the peripartum and postpartum periods. Methods: Clinical records of 11,497 patients enrolled in Fujian Maternity and Child Health Hospital between March 2013 and December 2018 were retrospectively analyzed and divided into the ART group and the natural conception group based on the mode of conception. The incidence of PPH and blood loss at 30, 60, 90, and 120 minutes after delivery were compared. Results: Clinical records of 2527 patients with ART-derived and 78,970 patients with spontaneous pregnancies, who delivered at Fujian Maternity and Child Health Hospital between March 2013 and December 2018, were included. The incidence of PPH (2.53%vs 1.58%, P &lt; 0.001) was greater in the ART group than in the natural conception group. ART was associated with significantly higher rates of PPH both in women who delivered vaginally and by cesarean section (P &lt; 0.001). Similarly, blood loss during the delivery stage was greater in the ART group than in the naturally conceived group, regardless of the mode of delivery (P&lt;0.001). Among women who delivered vaginally, blood loss was greater in the ART group at 30 minutes and 60 minutes after the delivery. However, blood loss at 90 and 120 minutes after the delivery was comparable in all groups, regardless of the mode of delivery. Conclusion: The use of ART was associated with poorer maternal outcomes, including increased incidence of PPH and higher blood loss at 30 and 60 minutes after the delivery. doi: https://doi.org/10.12669/pjms.41.1.10845 How to cite this: Liu Z, Yu L, Kang X, Zhang Y, Yan J. Association of assisted reproductive technology with adverse maternal outcome: A cohort study. Pak J Med Sci. 2025;41(1):15-21. doi: https://doi.org/10.12669/pjms.41.1.10845 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Assessing the timing of amniotomy after Foley balloon catheter removal in women with labor induction: The role of Bishop score: An observational study.

The timing of amniotomy after the Foley balloon catheter removal is crucial for successful labor induction. This study aimed to assess the effects of the Bishop score on the timing of amniotomy in patients undergoing labor induction after the Foley balloon catheter removal. This was a retrospective cohort study based on electronic medical records. We performed a Chester sampling in patients with singleton-term pregnancies who initially underwent cervical ripening using a Foley balloon catheter at the Obstetrical Department of Taixing People's Hospital from January 2023 to July 2023. A total of 889 patients were admitted to the study. After excluding 330 patients according to the exclusion criteria, 103 patients were included. Following the Foley balloon removal, an amniotomy with a Bishop score < 6 was defined as an amniotomy with an unfavorable Bishop score (n = 62), and an amniotomy with a Bishop score ≥ 6 was defined as an amniotomy with a favorable Bishop score (n = 41). The primary outcome was the incidence of cesarean delivery and the interval from induction to delivery. The secondary outcomes included the incidence of operative vaginal delivery, intrapartum hemorrhage, postpartum hemorrhage, infection, thrombosis, and neonatal outcomes. All statistical comparisons were analyzed by GraphPad Prism 9. All data were presented as the mean ± SD or percentage. Statistical analysis comparing both groups was performed using the t test, chi-square test, or Fisher exact test where appropriate. The baseline data, operative vaginal delivery rate, postpartum hemorrhage rate, infection rate, thrombosis rate, intrapartum and postpartum hemorrhage volume, and neonatal outcomes showed no significant differences between the 2 groups. However, the cesarean delivery rate, interval from induction to delivery, and hemoglobin postdelivery decline were significantly decreased in the favorable Bishop score group. Amniotomy with a favorable Bishop score after Foley balloon catheter removal is linked to lower cesarean delivery rates, shorter induction-to-delivery intervals, and less postdelivery hemoglobin decline without increasing adverse maternal or neonatal outcomes.

Evaluation of Labor Mirror Use During the Active Pushing Phase of the Second Stage of Labor.

To evaluate whether the use of a labor mirror during the active pushing phase of the second stage of labor is associated with a shorter duration of pushing. Additionally, we examined maternal and neonatal outcomes secondary to mirror use versus non-mirror use. Retrospective observational cohort study. Community hospital in the midwestern United States with a Level 3 maternity center and approximately 2,000 births annually. Four hundred fifty-three women≥18 years old who had a singleton pregnancy at term (37-41weeks' gestation) with a spontaneous vaginal birth. The use of a ceiling-mounted labor mirror offered before or at the beginning of the active pushing phase of the second stage of labor. Use was determined by patient choice. One hundred seventy-seven (39.1%) women elected use of the labor mirror. Mirror users and nonusers were similar in terms of clinical and demographic characteristics except for epidural use (93.2%vs. 86.6%, respectively; p= .0298). Among nulliparous women who used the mirror, second stage labor duration was shortened by an average of 19.4 minutes (p=.0198). This effect was not seen in multiparous women (p=.2208). Mirror users and nonusers did not differ on rates of postpartum hemorrhage (p= .5498) or chorioamnionitis (p=.6528). Among nulliparous and multiparous women, Apgar scores and NICU admission rates did not differ between mirror users and nonusers. The labor mirror represents a simple, noninvasive tool for labor and delivery units. Use of the labor mirror during the active pushing phase of the second stage of labor may be associated with decreased pushing duration for nulliparous women.

Analysis of the outcomes and factors influencing vaginal trial labor in primiparas at term.

To explore the outcomes and factors influencing vaginal trial labor in primiparas with term singleton fetuses. A retrospective analysis of 9174 first-time mothers who opted for a vaginal trial of labor at Peking University First Hospital from October 2019 to September 2022 was performed. The primary outcomes included the outcome of the trial of labor and influencing factors. Of the total population, the success rate of attempted vaginal delivery was 74.3% (6818/9174). Logistic regression analysis revealed that increasing maternal age (OR = 1.054; 95% CI = 1.239-2.316; p < 0.001), gestational weight gain (OR = 1.033; 95% CI = 1.022-1.045; p < 0.001), neonatal weight (OR = 1.971; 95% CI = 1.724-2.253; p < 0.001), prepregnancy body mass index (BMI) ≥ 24kg/m2 (OR = 1.605; 95% CI = 1.411-1.825; p < 0.001), prenatal BMI ≥ 24kg/m2 (OR = 1.326; 95% CI = 1.137-1.546; p < 0.001), and induced labor (OR = 2.434; 95% CI = 2.187-2.708; p < 0.001) increased the risk of failed vaginal delivery attempts, and labor analgesia reduced the risk of failed vaginal delivery attempts (OR = 0.356; 95% CI = 0.320-0.397; p < 0.001). However, the use of assisted reproductive technology had no significant effect on the outcome of attempted vaginal delivery (p = 0.137). According to the partial regression coefficient, the area under the ROC curve was 0.710 (95% CI = 0.698-0.723), and the model passed the Hosmer-Lemeshow test and had good discrimination and calibration (χ2 = 12.833, p = 0.118). The postpartum hemorrhage (PPH) rate and overall neonatal asphyxia rate differed significantly between women who had different outcomes of vaginal trial labor. There are many factors affecting the occurrence of abnormal delivery in primiparas. These independent factors can be used for prenatal evaluation.

Broad-Spectrum Micronutrients or Antidepressants for Antenatal Depression: Effect on Maternal and Infant Birth Outcomes in an Observational Secondary Analysis of NUTRIMUM.

One-fifth of women experience antenatal depression. Untreated antenatal depression is associated with increased risk of adverse birth outcomes. This study investigated the effect of broad-spectrum micronutrients (BSM; vitamins and minerals), used to treat antenatal depression (NUTRIMUM trial), on birth outcomes. Birth outcomes of 129 mother-infant pairs were obtained from hospital medical records or personal health records for home births. Pairs from NUTRIMUM exposed to ≥8 weeks of BSM antenatally (MN; n = 55) were compared to pairs exposed to antidepressants antenatally (MED; n = 20) and a reference group (REF; n = 54) of pairs not exposed to trial BSM or antidepressants. Groups were comparable on demographic variables. At study entry, MN and MED had depression scores in the moderate range, statistically higher than REF (nonclinical range). MN and REF did not differ significantly for gestational age, preterm births, infant size, or infant resuscitation. There were significantly lower rates of postpartum hemorrhage in MN relative to REF (7.7% vs 30%; RR = 0.26, 95% CI [0.08-0.84]). Gestational age at birth was higher for MN (39.5 weeks) than MED (38.5 weeks; d = 0.67, 95% CI [0.15-1.20], P = 0.03) as well as infant birth length (52.2 vs 50.0 cm; d = 0.77, 95% CI [0.21-1.33], P = 0.02), and rates of infant resuscitation were lower (14.5% vs 45%; RR = 0.33, 95% CI [0.15-0.73]). Days of BSM exposure was positively associated with birth weight ( r = 0.32, P = 0.008) and length ( r = 0.25, P = 0.04). Micronutrients used to alleviate antenatal depression may mitigate negative effects of depression on birth outcomes and showed more favorable birth outcomes compared with antidepressants.

Use of the WHO partograph and Zhang’s guideline for labor and delivery in China: implications for clinical practice

BackgroundThere is an unmet need for a large comprehensive population-based dataset documenting national birthing trends in China and a partograph specifically tailored to Chinese women. This study assessed the impact of using the World Health Organization (WHO) partograph or Zhang’s guideline to manage labor and delivery in China and inform the development of a partograph that specifically aligns with the progression of labor in Chinese women.MethodsThis retrospective analysis included low-risk nulliparous women with a singleton, full-term fetus in cephalic presentation entering spontaneous labor at a specialized obstetric hospital in China between January 2010 and June 2022. Pregnant women were managed according to the WHO partograph (January 2010-August 2014, n = 31,286) or Zhang’s guideline (September 2014-June 2022, n = 49,821).ResultsRates of assisted reproduction (4.57% vs. 1.05%; p < 0.0001) and hypertension (7.44% vs. 6.71%; p < 0.0001) were significantly higher for pregnant women managed according to Zhang’s guideline compared to the WHO partograph. Rates of labor intervention (35.31% vs. 13.95%; p < 0.0001), including induction of labor by oxytocin, artificial rupture of membranes, lateral episiotomy and conversion to cesarean section (all, p < 0.0001), were significantly higher for pregnant women managed according to the WHO partograph. Rates of forceps assisted vaginal deliveries (12.67% vs. 6.42%; p < 0.0001) and postpartum hemorrhage (10.9% vs. 6.2%; p < 0.0001) were significantly higher, and birth asphyxia (0.15% vs. 0.09%; p = 0.02) was significantly lower, for pregnant women managed according to Zhang’s guideline.ConclusionsThis study provides valuable insights into the utilization of the WHO partograph and Zhang’s guideline in managing labor and delivery among Chinese women. Findings indicate that women managed according to Zhang’s guideline had higher rates of assisted reproduction and hypertension, suggesting a potentially different demographic profile or underlying health conditions compared to women managed according to the WHO partograph. Notably, the use of the WHO partograph was linked to a significant increase in labor interventions, while Zhang’s guideline resulted in higher rates of forceps-assisted vaginal deliveries and postpartum hemorrhage, yet interestingly, a lower incidence of birth asphyxia. These contrasting outcomes underscore the importance of aligning labor management tools with the specific needs and progression of labor in Chinese women. The results advocate for a tailored partograph that could better reflect the unique characteristics of Chinese women and optimize decision making and maternal and neonatal outcomes.

A History of Cesarean Birth as a Risk Factor for Postpartum Hemorrhage Even After Successful Planned Vaginal Birth.

It is unclear if a history of cesarean birth (CB) is a risk factor for postpartum hemorrhage (PPH) even after a successful planned vaginal birth. A historical retrospective cohort study from all deliveries (42,456) between 2004 and 2019. Inclusion criteria were as follows: (i) women with only one previous CB; (ii) liveborn cephalic singleton pregnancy and term spontaneous labor; (iii) successful planned vaginal birth; (iv) no operative vaginal delivery; and (v) no history of PPH. Women who experienced intrapartum uterine rupture leading to CB were excluded. Those who experienced uterine rupture diagnosed after vaginal birth were not excluded. The labor after cesarean (LAC) group (109 women with previous CB and current vaginal birth) were compared with 2 control groups to consider the parity: control group 1 (1633 nulliparous women) and control group 2 (4197 parous women). The main outcome was the rate of PPH (> 500 mL). Multivariate analysis was performed to investigate whether previous CB was an independent risk factor for PPH. Bivariate analysis and causal framework was used to determine the relation between variables of clinical interest. The PPH rates in the LAC group, control group 1, and control group 2 were 12.8%, 5.3%, and 6.4%, respectively. Irrespective of the group control (1 or 2), a history of CB was associated with an increased risk of PPH: adjusted odds ratio (aOR) 2.38 [95% confidence interval (CI) 1.28-4.44] (adjusted with maternal age, overweight, hyperthermia, and use of oxytocin) and aOR 2.16 [95% CI 1.20-3.87] (adjusted with maternal age and overweight) for Groups 1 (parous) and 2 (nulliparous), respectively. A history of cesarean birthcould be a risk factor for PPH even after successful planned vaginal delivery.

Effectiveness of Telemedicine and Remote Monitoring in Reducing Postpartum Hemorrhage Rates: A Meta-Analysis

Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide, particularly in low- and middle-income countries (LMICs) with limited access to healthcare. Telemedicine and remote monitoring technologies offer potential solutions for early detection and management of PPH. This meta-analysis aimed to evaluate the effectiveness of these technologies in reducing PPH rates. A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was conducted for studies published between 2013 and 2024 investigating the impact of telemedicine and remote monitoring interventions on PPH rates. Randomized controlled trials (RCTs) and observational studies with a control group were included. The primary outcome was the incidence of PPH (blood loss ≥500 ml after vaginal delivery or ≥1000 ml after cesarean delivery). Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model. Publication bias was assessed using funnel plot asymmetry and Egger's test. Six studies involving 4200 women met the inclusion criteria. The pooled analysis demonstrated a statistically significant reduction in PPH rates in the intervention groups compared to the control groups (RR 0.56; 95% CI 0.47-0.67; p&lt;0.00001). The funnel plot was symmetrical, and Egger's test was not statistically significant (p=0.45), suggesting no evidence of publication bias. Telemedicine and remote monitoring interventions are associated with a significant reduction in PPH rates. These findings support the integration of these technologies into postpartum care to improve maternal outcomes, particularly in resource-constrained settings.

Nondiabetic Fetal Macrosomia: Causes, Outcomes, and Clinical Management.

Fetal macrosomia (FM) is common in clinical practice and carries increased risk of adverse maternal and neonatal health outcomes. Maternal diabetes mellitus (DM) is a well-known cause of macrosomia with significant research and guidelines focusing on macrosomia in this population. Less is known about causes, prevention, and clinical management for suspected FM in individuals without diabetes. The objective of this review is to describe the risk factors associated with nondiabetic FM, review risks associated with macrosomia in pregnancy, and potential treatment considerations for this condition. Original research articles, review articles, and guidelines on macrosomia were reviewed. Risk factors for macrosomia in patients without DM include previous delivery of an infant with macrosomia, excessive pregnancy weight gain, and obesity. Maternal complications of FM include higher rates of cesarean delivery, postpartum hemorrhage, and vaginal laceration. Fetal complications include shoulder dystocia, decreased Apgar scores, and increased risk of childhood obesity. Exercise during pregnancy has been shown to reduce the risk of FM. Induction of labor prior to 39 weeks is not recommended in the setting of suspected macrosomia as there is a lack of adequate evidence to support that this decreases adverse neonatal or maternal outcomes. In addition, elective cesarean delivery for suspected macrosomia is not recommended to be considered unless estimated fetal weight is greater than 5000 g in the absence of DM. Delivery of an infant with macrosomia in patients without DM has increased maternal and fetal risks. Predicting infants who will meet criteria for macrosomia is challenging. More research is needed to identify ways to accurately estimate fetal weight, interventions to prevent macrosomia, and additional ways to mitigate risk in patients without DM who have suspected FM.

Impact of vaginism on mode of delivery and obstetrical outcomes

IntroductionAccording to ICD 10, vaginism is defined as the presence of spasm of the pelvic floor muscles surrounding the vagina, causing occlusion of the vaginal opening. Intromission is impossible or painful. Vaginism, whose prevalence is estimated at 1%, is often diagnosed during pregnancy follow-up, when clinical examination is difficult or impossible. However, few studies report obstetrical complications and pregnancy outcomes associated with this pathology. ObjectiveEvaluate the impact of vaginism on mode of delivery and obstetrical complications. Materials and methodsComparative, monocentric, retrospective study at the Montreuil maternity hospital between January 2019 and January 2024 that included all singleton deliveries in cephalic presentation at term. Vaginism was defined as an involuntary contraction of the pelvic muscles that made clinical examination during pregnancy impossible. Mode of delivery (caesarean section during labour, operative delivery, spontaneous vaginal delivery) and obstetric complications (episiotomy, OASIS, complex tear, Postpartum haemorrhage (PPH) due to tear) were compared between patients with vaginism and a control group, in univariate analysis and multivariate logistic regression with adjustment for maternal age, BMI, maternal origin, gestational age, high obstetrical and medical risk level, diabetes with or without insulin use, pregnancy complications, Robson group and birthweight. A propensity score adjustment with matching 1 case to 3 controls was conducted. ResultsDuring the study period, 13,469 patients were included, among which 440 patients had vaginism. In univariate analysis, patients with vaginism had a higher rate of caesarean section (16,8% versus 9,4%, p < 0.001), operative delivery (29,3% versus 13,3%, p < 0.001), episiotomy (12,5% versus 5.3 %, p < 0.001), OASIS (3.4 % versus 1.0 %, p < 0.001), complex tear (17,5% versus 7,7%) and PPH due to tear (2,5% versus 1,1%, p = 0,009).After adjustment, vaginism appeared to be an independant risk factor for cesarean section with a psaOR of 1.38 [1.02–1.85], operative delivery psaOR 2.39 [1.83–3,10], OASIS psaOR 2,19 [1.10–4,27], and complex tear psaOR 1,39 [1,02–1,87] ConclusionVaginism appears to be an independent risk factor for cesarean section, operative delivery, OASIS, and complex tear. Further studies should evaluate the impact of early and appropriate follow-up during pregnancy on adverse obstetrical outcomes.

Postpartum Hemorrhage Management in Canadian Emergency Nursing Practice

Background: Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality globally, claiming approximately 70,000 lives annually. Despite preventive efforts, high-income countries, including Canada, have reported increasing rates of PPH. The rising incidence and associated complications indicate improved emergency nursing practices in managing PPH are needed. Methods: PPH guidelines from the Society of Obstetricians and Gynecologists of Canada, Federation of International Gynecologists and Obstetricians, and the Canadian Association of Perinatal, and Women’s Health Nurses were compared to National Emergency Nurses Association guidelines. The competencies, medications, and obstetric maneuvers for PPH that may be relevant to emergency nurses were extracted and categorized for the emergency nursing HIRAID (History &amp; Red flags, Assessment, Interventions, &amp; Diagnosis) framework. Findings/Results: We found 13 discrete skills across the PPH guideline recommendations that are applicable to emergency nurses. There is near perfect overlap in medical recommendations, but gaps exist between FIGO and SOGC guidelines and NENA and CAPWHN guidelines. There are SOGC and FIGO guidelines that apply to emergency nurses that are not addressed in NENA guidelines, Discussion: There was significant overlap on treatment recommendations from maternal health bodies such as uterotonic drugs, hemorrhage control, and hemostatic resuscitation. There were significant gaps in NENA recommendations. Conclusion: The comparison of PPH guidelines highlights where NENA guidelines need further detail. These skills are particularly significant for providing nursing care in rural and remote areas. Standardized protocols for PPH management, interprofessional collaboration, and regular competency assessments are included in most guidelines but are conspicuously absent for emergency nurses. To address the gap, NENA could integrate national emergency nursing PPH competencies standards or develop recommendations for the care of maternal emergencies.

Analysis of perinatal outcomes in pregnant women with the resolution of placenta previa in the second trimester

Objective: To investigate perinatal outcomes of pregnant women with the resolution of placenta previa in the second trimester. Methods: This study was a retrospective cohort study, which included singleton pregnant women who received prenatal care and delivered at Peking University Third Hospital from January 1st 2019 to December 31st 2020. A total of 403 pregnant women diagnosed with placenta previa by ultrasound at 20-24 weeks of gestation and the placental position returned to normal before delivery were included in the study group, and 403 pregnant women with normal placental position matched 1∶1 were the control group. The primary outcome was postpartum hemorrhage rate, and secondary outcomes included postpartum bleeding volume, severe hemorrhage complications, blood transfusion, drug application, the application of instrument or surgical hemostasis measures, gestational week of delivery, and neonatal outcomes. The perinatal outcomes were analyzed by univariate and multivariate logistic regression methods. Results: (1) Compared with the control group, the incidence of postpartum hemorrhage [10.4% (42/403) vs 17.6% (71/403)], postpartum hemorrhage volume (median: 375 vs 400 ml), the proportion of postpartum hemorrhage≥500 ml [18.6% (75/403) vs 30.5% (123/403)], and the proportion of application of instrument or surgical hemostasis measures [1.7% (7/403) vs 4.5% (18/403)] in the study group were increased, and the differences were statistically significant (all P<0.05). Neonatal outcomes, including birth weight, small for gestational age, hospitalization in neonatal intensive care unit and incidence of neonatal asphyxia, were compared between the two groups, and there were no statistically significant differences (all P>0.05). (2) In pregnant women with vaginal delivery, the postpartum hemorrhage rate [31.7% (66/208) vs 17.5% (39/223)], postpartum hemorrhage volume (median: 390 vs 380 ml), the proportion of instrument or surgical hemostasis measures [3.8% (8/208) vs 0.4% (1/223)] of the study group were higher than those of the control group, and the differences were statistically significant (all P<0.05). There was no significant difference in the rate of postpartum hemorrhage between the study group and the control group who gave birth by cesarean setion (P=0.545), but the proportion of postpartum hemorrhage≥500 ml in the study group and the control group were 29.2% (57/195) and 20.0% (36/180), and the difference was statistically significant (P=0.039). (3) The results of multivariate analysis showed that compared with the control group, the risk of postpartum hemorrhage (aOR=2.042, 95%CI: 1.313-3.175), the application of drugs (aOR=1.684, 95%CI: 1.142-2.484) and the application of instruments or surgical hemostasis measures (aOR=2.696, 95%CI: 1.089-6.675) were significantly increased in the study group (all P<0.05). Among women who delivered vaginally, the risk of postpartum hemorrhage in the study group was 2.021 times greater than that in the control group (95%CI: 1.269-3.220; P=0.003). Conclusion: In women with placental previa in the second trimester of pregnancy, even if the placental position returns to normal before delivery, it is still a high risk factor for postpartum hemorrhage, especially in vaginal delivery.

Diagnostic value of prenatal ultrasound screening and analysis of pregnancy outcomes in velamentous umbilical cord insertion

Objective: To explore diagnostic value of prenatal ultrasound screening in velamentous umbilical cord insertion (VCI) and its influence on perinatal outcomes, and to provide theoretical basis for clinical practice. Methods: Fifty-eight pregnant women diagnosed with VCI before or after delivery admitted to the First Affiliated Hospital of Xi'an Jiaotong University were selected from January 2012 to December 2022. The clinical features and perinatal outcomes of 45 women finally with VCI after delivery (VCI group) were retrospectively analyzed, and 225 women with normal umbilical cord attachment were selected as the control group during the same period. Results: (1) Among 58 women, 54 (93.1%, 54/58) were diagnosed with VCI by prenatal ultrasound screening, 4 patients (6.9%, 4/58) were missed; and 13 (22.4%, 13/58) were misdiagnosed. Finally, a total of 45 women were confirmed by postpartum placental examination, and 11 (24.4%,11/45) were combined with vasa previa. (2) There were no differences in age, number of pregnancies, and number of induced abortions between the two groups (all P>0.05). Compared with the control group, the rate of assisted reproductive technology [13.3% (6/45) vs 0.4% (1/225); P<0.01], and twin pregnancy rate [8.9% (4/45) vs 0.4% (1/225); P<0.01] in the VCI group were significant higher. (3) Compared with the control group, the rate of placenta previa, succenturiate placenta, vasa previa, postpartum hemorrhage, prenatal hemorrhage and postpartum intrauterine remainder in the VCI group were significant higher (all P<0.05); there was no significant difference in the incidence of placental abruption, premature rupture of membranes, fetal distress and single umbilical artery between the two groups (all P>0.05). The incidence of fetal structural abnormalities in the VCI group (4.4%, 2/45) was higher than that in the control group (1.3%, 3/225), but there was no significant difference between the two groups (P=0.195). (4) The cesarean section rate [75.0% (33/44) vs 45.1% (101/224); P<0.01], preterm birth rate [29.5% (13/44) vs 5.4% (12/224); P<0.01], rate of small for gestational age [20.5% (9/44) vs 5.4% (12/224); P<0.01] in the VCI group were significant higher. However, neonatal birth weight [(2 928±552) vs (3 353±498) g; P<0.01], and 1-minute Apgar score (median: 10 vs 10; P<0.01) in the VCI group were lower than those in the control group. Conclusions: Prenatal ultrasound screening is an important method to diagnose VCI. VCI is more prone to adverse pregnancy outcomes, such as postpartum hemorrhage, premature delivery, small for gestational age, et al. Its risk factors include twin pregnancy, assisted reproductive technology, placenta previa, and para-placenta.

A double-blind, randomized, placebo-controlled trial of melatonin as an adjuvant agent for induction of labor: TheMILO trial.

Melatonin has been suggested to have a biological role in the onset and progress of labor. We tested the hypothesis that the addition of melatonin during an induction of labor will reduce the need for a cesarean birth. This trial underwent protocol amendments that are detailed in the main text of the article. This trial is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12616000311459). At a multi-center health service including secondary and tertiary obstetric hospitals, we performed a randomized, double-blind, placebo-controlled trial in women with a singleton cephalic pregnancy, free of significant maternal or perinatal complications who were undergoing induction of labor (with or without cervical ripening). Women were randomized to 10 mg melatonin vs placebo, with cervical ripening as required, and then 6-h during their induction of labor to a maximum of four doses or until birth. The primary outcome was cesarean birth. Secondary outcomes included labor, maternal, and neonatal outcomes. Data were analyzed using intention to treat. Sub-group analyses based on mode of ripening and parity were also performed. Between 2019 and 2021 we randomized 189 women (103 to melatonin and 86 to placebo). The study was prematurely terminated due to logistical complications resulting from the COVID-19 pandemic. Cesarean rates were 28/103 (27.2%) in the melatonin group vs 20/84 (23.3%) in the placebo group (RR 1.17 95% CI 0.71-1.92). There were no significant differences in rate of cesarean birth between the melatonin and placebo groups for failure to progress (13.4% and 9.3%, respectively, RR 1.46; 95% CI 0.64-3.32) or suspected fetal distress (10.7% and 10.5%, respectively, RR 1.02; 95% CI 0.44-2.34). The melatonin group had significantly lower rates of spontaneous vaginal birth within 24 h (35.0% vs. 50.0%; RR 0.70 95% CI 0.50-0.98). The rates of secondary outcomes such as total length of labor, rate of postpartum hemorrhage, and instrumental birth were comparable. Babies born in the melatonin group were more likely to need admission to the special care nursery, namely for hypoglycemic monitoring (18.5% vs. 8.1% RR 2.26; 95% CI 1.00-5.10). In women undergoing induction of labor, melatonin does not reduce the cesarean section rate. Melatonin use intrapartum may also be associated with neonatal hypoglycemia.

Multidisciplinary care to optimise pregnancy outcomes among Jehovah’s Witness: Case series over fifteen years in a tertiary teaching hospital

ObjectiveTo assess the obstetric and neonatal outcomes of Jehovah’s Witness (JW) mothers and the willingness to accept blood products after multidisciplinary management. Study DesignA retrospective case-control study was conducted at Queen Mary Hospital from 2005 to 2020. Delivery records of pregnant women who identified themselves as JW were reviewed. The immediate next age-matched non-JW patient in the booking register was assigned as control. ResultsA total of 96 subjects were identified within the study period (48 JW and 48 non-JW age-matched patients). The haemoglobin levels of JW and non-JW were similar at booking, 28 weeks of gestation, pre-delivery and postnatal day 2. JW mothers were more likely to receive iron supplements in the antenatal period than the control group (27.1 % vs. 6.3 %, p = 0.01) despite the similar rate of antenatal anemia in both groups (4.2 % vs. 4.2 %, p = 1.00). There were no differences in mode of delivery, total blood loss at delivery, rate of primary postpartum haemorrhage, gestational age at delivery, birth weight, and Apgar score at 1 and 5 min between JW and non-JW. There were no maternal deaths, hysterectomy or admissions to the adult intensive care unit in either group. Six JW women accepted packed cell transfusion at the initial consultation and did not receive multidisciplinary care. The remaining 42 JW women had consultant obstetric and anesthesiologist review before delivery. After multidisciplinary consultation, two (4.8 %, 2/42) accepted blood transmission and 11 (26.2 %, 11/42) accepted some components of blood. The remaining 29 (69 %, 29/42) women refused all blood products. ConclusionJW patients who received multidisciplinary care achieved comparable pregnancy and neonatal outcomes to the normal population. Antenatal iron supplement was more common among pregnant JW despite the similar rate of antenatal anemia compared with the non-JW women. 12.5% of JW women agreed packed cell transfusion at the initial consultation and a further 27.1% of JW women agreed to some forms of blood products after multidisciplinary counseling.

Association between psychopharmacotherapy and postpartum hemorrhage

BackgroundPrior studies evaluating the relationship between psychopharmacotherapy (PPT), and postpartum hemorrhage (PPH) have yielded inconsistent findings. Clarifying this potential relationship is important for effective counseling and risk stratification. ObjectivesOur primary objective was to evaluate the association between prenatal exposure to PPT (any drug class) and the occurrence of PPH requiring transfusion of packed red blood cells (PPH+pRBC) after systematically adjusting for known hemorrhage risk factors at the time of admission for delivery. Secondary objectives were to evaluate the association between individual PPT drug classes and PPH+pRBC, and the association between treatment intensity of mental health condition and PPH+pRBC. Finally, we evaluated the association between PPT and a broader definition of PPH that included deliveries requiring multiple uterotonic drugs. Study designThis is a retrospective cross-sectional study of all pregnancies delivered at 23 weeks of gestational age or greater at seven hospitals within a large academic health system in New York between January 2019 and December 2022. There were no exclusion criteria, as postpartum hemorrhage risk assessment is necessary for all patients admitted for delivery. We assessed exposure to prenatal PPT, including selective serotonin reuptake inhibitors (SSRIs: escitalopram, fluoxetine, sertraline), serotonin-norepinephrine reuptake inhibitors (SNRIs: duloxetine, venlafaxine), dopamine-norepinephrine reuptake inhibitors (DNRIs: buproprion), benzodiazepines (alprazolam, diazepam, lorazepam), and others (buspirone, trazodone, zolpidem). Multivariable logistic regression was performed to evaluate the relationship between PPT and PPH+pRBC, while systematically adjusting for known hemorrhage risk factors at the time of hospital admission. Similar regression analyses were performed to address the secondary objectives. ResultsA total of 107,425 deliveries were included. Non-Hispanic White patients constituted the largest race and ethnicity group (43.4%), followed by Hispanic patients (18.7%), Asian or Pacific Islander patients (13.2%), and non-Hispanic Black patients (12.3%). Prenatal exposure to PPT occurred in 3.6% of pregnancies (n=3,834). The overall rate of PPH+pRBC was 2.9% (n=3,162). PPH+pRBC occurred more frequently in pregnancies exposed to PPT than in pregnancies which were not exposed (5.5% vs. 2.8%, respectively; aOR 2.10, 95% CI: 1.79–2.44). SSRIs and benzodiazepine monotherapy were each associated with higher odds of PPH+pRBC than nonexposure. Compared to patients without a mental health condition, monotherapy was associated with nearly 2-fold increased odds and combination PPT was associated with nearly 4-fold greater odds of PPH+pRBC after adjustment for confounding variables (monotherapy: aOR 1.94, 95% CI: 1.64–2.28; combination PPT: aOR 3.96, 95% CI: 2.61–5.79). Patients with untreated mental health conditions (no PTT) had no increased odds of PPH+pRBC compared to those without mental health conditions. Finally, after adjusting for covariates, a positive association was found between PPT and PPH requiring pRBC transfusion and/or the use of two additional uterotonic agents beyond routine postpartum oxytocin (aOR 1.53, 95% CI: 1.35–1.73). ConclusionsPrenatal PPT exposure is associated with increased odds of clinically significant PPH+pRBC after adjusting for other hemorrhage risk factors. Combination PPT was associated with greater odds of PPH+pRBC than monotherapy.

Fetomaternal Outcome in Pregnancy with Gestational Thrombocytopenia

Introduction: Gestational thrombocytopenia, a common hematological disorder in pregnancy, poses risks to both maternal and neonatal health. This study aims to evaluate the fetomaternal outcomes in pregnancies complicated by gestational thrombocytopenia compared to those with normal platelet counts. Methods: This prospective cohort study was conducted over 12 months at Jalalabad Ragib-Rabeya Medical college hospital sylhet Bangladesh. It included 100 pregnant women diagnosed with gestational thrombocytopenia (platelet count &lt;150,000/µL after 20 weeks of gestation) and 100 matched controls with normal platelet counts. Maternal data included demographic information, obstetric and medical history, mode of delivery, incidence of pre-eclampsia, postpartum hemorrhage, and need for platelet transfusions. Fetal outcomes assessed were birth weight, Apgar scores, preterm birth rates, NICU admissions, and neonatal thrombocytopenia. Data were analyzed using t-tests for continuous variables and chi-square tests for categorical variables, with multivariate logistic regression to identify predictors of adverse outcomes. Result: The gestational thrombocytopenia group showed higher, though not statistically significant, rates of cesarean delivery (30% vs. 25%, p=0.453), pre-eclampsia (15% vs. 12%, p=0.540), and postpartum hemorrhage (18% vs. 10%, p=0.110). Platelet transfusions were required more frequently in the gestational thrombocytopenia group (8% vs. 2%, p=0.052). Fetal outcomes revealed lower mean birth weight (2950g vs. 3050g, p=0.145), higher preterm birth rates (14% vs. 10%, p=0.371), and more NICU admissions (20% vs. 12%, p=0.132) in the gestational thrombocytopenia group. Notably, neonatal thrombocytopenia was significantly more prevalent in the gestational thrombocytopenia group (10% vs. 2%, p=0.017). Conclusion: Gestational thrombocytopenia is associated with increased risks of certain maternal and neonatal complications. Vigilant monitoring and management are essential to improve outcomes in affected pregnancies. Further research is needed to develop targeted interventions and improve antenatal care practices.

MATERNAL AND PERINATAL OUTCOMES OF EARLY TRIMESTER BLEEDING

Bleeding per vagina is one of the most everyday presentations in the first trimester, with an incidence of 15- 25%. These pregnancies end up in pregnancy loss and multiple poor feto-maternal outcomes requiring early registration and treatment. Objectives: To evaluate for maternal perinatal outcomes in normal intrauterine pregnancies complicated by first-trimester vaginal bleeding Methods: This cohort study was conducted at the Gynecology and Obstetrics department of Lady Reading Hospital Peshawar from January 2024 till the required sample size is obtained in May 2024. Data were collected from 195 pregnant females. Women were divided into two groups. All pregnant women with singleton pregnancy and with or without vaginal bleeding during the first trimester, defined as up to the first 12 weeks of pregnancy, both delivering at our institute, were selected. Results: Miscarriage rates were notably higher in the exposed group (20.4% vs. 10.3%, OR 3.5, p=0.02), as were preterm births (22.4% vs. 15.5%, OR 2.8, p=0.01) and placental complications (12.2% vs. 5.2%, OR 4.2, p=0.03). The exposed group also had higher rates of postpartum hemorrhage (14.3% vs. 10.3%, OR 2.2, p=0.01), though cesarean section rates were similar between groups (30.6% vs. 30.9%, OR 2.0, p=0.15). Conclusion: It is concluded that early trimester bleeding is associated with an increased risk of adverse maternal and perinatal outcomes, including miscarriage, preterm birth, placental complications, and low birth weight.

The impact of indication for cesarean on blood loss

BackgroundPostpartum hemorrhage is the leading cause of maternal mortality worldwide. Quantitative blood loss assessment at the time of cesarean delivery is a more accurate measure of blood loss than is simple estimation. Risk factors for postpartum hemorrhage are well described; however, contemporary, systematic investigations into the impact of the indication for cesarean delivery on quantitative blood loss are lacking. ObjectiveTo investigate whether there are clinically significant differences in quantitative blood loss and postpartum hemorrhage risk based on the indication for cesarean delivery. Study DesignA cohort of 4,881 cesarean deliveries performed at a large academic hospital between 2020 and 2022 was identified. Primary and repeat cesarean deliveries were analyzed separately and further subdivided into seven indications: elective, labor arrest, fetal heart rate abnormalities, placenta previa, placenta accreta, malpresentation, and other. Quantitative blood loss and rates of postpartum hemorrhage ( > 1000 cc and >1500cc) were compared among the different indications. ResultsMean quantitative blood loss for primary, repeat and total cesarean deliveries was 886 cc, 697 cc and 792 cc, respectively. Excluding cases of placenta accreta, the greatest blood loss in both primary and repeat groups was seen in cesareans performed for labor arrest, with blood loss exceeding 1500 cc in 18% and 13% of all cases. Blood loss exceeding 1500cc was seen in 1% and 2% of elective cesarean deliveries. The mean blood loss for planned repeat cesarean/hysterectomies for placenta accreta was < 400cc greater than primary cesareans performed for labor arrest (1442 cc vs. 1065 cc), despite the addition of an often-complex hysterectomy to the procedure. ConclusionsClinically and statistically significant differences in blood loss exist based on the indication for cesarean delivery. Large differences in rates of serious postpartum hemorrhage (>1500cc) with negligible differences in mean quantitative blood loss suggests the presence of frequent, large clinical outliers not reflected in a statistical mean. The indication for cesarean and the possibility of such outliers, rather than the predicted “average blood loss for cesarean delivery” should be considered in determining risk and the degree of necessary pre-operative blood preparation. These data raise questions about whether current, traditional techniques of non-accreta related cesarean delivery can be justified in non-emergent cases when such procedures could be performed with significantly less blood loss using accreta-specific techniques.