Postpartum Hemorrhage Research Articles

Abnormal AFI and Its Implications on Fetomaternal Outcome

Background: The AFI is directly associated with adverse outcomes for both the mother and the foetus; oligohydramnios (AFI ≤8 cm) and polyhydramnios (AFI ≥25 cm) are considered ‘abnormal’. The aim of this study was to compare the maternal and foetal complications in full-term pregnancies with abnormal AFI, as well as to assess the effectiveness of ultrasound and Doppler in identifying possible threats that may affect delivery plans. Methods: The current observational study was conducted in a hospital context at Paropakar Maternity and Women’s Hospital located in Kathmandu, Nepal between October 2019 and February 2020. This study investigates the maternal and fetal outcomes associated with polyhydramnios and oligohydramnios in 60 cases of pregnancy. Data on maternal and foetal results, including the type of birth, problems, and neonatal APGAR ratings, were collected and evaluated. Continuous variables were described as mean ± SD, while categorical data were expressed in percentage. Results: The prevalence of polyhydramnios was 2% and oligohydramnios was 5.33%. Common maternal complications included preeclampsia, postpartum hemorrhage, and gestational hypertension, while fetal outcomes included low APGAR scores, low birth weight, and NICU admissions. Oligohydramnios was found to be predominantly associated with post-term pregnancies (36.36%) and preterm premature rupture of membranes (13.63%), which led to a higher frequency of caesarean sections (70.46%) when compared to polyhydramnios cases. Conclusion: Our findings suggest that ultrasound and Doppler assessments are crucial in identifying high-risk pregnancies and making appropriate delivery decisions to improve maternal and fetal outcomes."

Five-year retrospective analysis of Bakri balloon tamponade for obstetric haemorrhage and patient survey at a single tertiary centre.

Intrauterine balloon tamponade (IUBT), specifically the usage of Bakri balloon tamponade (BBT), is an effective conservative management technique for postpartum haemorrhage (PPH). The primary objective was to evaluate local guidelines and contribute to evidence regarding ideal duration for BBT. The secondary objectives were to consider impacts on maternal-foetal wellbeing, and optimise healthcare efficiency by reducing length of ICU admissions. This five-year retrospective case series analysed 132 cases of obstetric ICU admissions requiring Bakri balloon insertion for PPH within our centre. Additionally, a prospective patient experience survey was conducted over six-month period, involving 22 obstetric patients who required unplanned ICU admissions. Bakri balloon insertion was successful in 95%, whilst 5% experienced failure, necessitating further interventions (uterine artery embolisation) or return to theatre (hysterectomy). The success group demonstrated significant reductions in median blood loss (1.8 L vs. 2.5 L, p = 0.016) and difference in median duration of BBT (18.3 vs. 3.92 hours, p = 0.001). The prospective patient survey revealed a high level of satisfaction of care. Approximately 50% breastfed prior to discharge, on average commencing 23.4 hours post-delivery. This study demonstrates a high success rate of BBT, with failures typically occurring within median duration 3.9 hours. Considering the separation of mother from baby during the Bakri balloon's presence in ICU, we propose timely removal at around six hours, as failures are unlikely post this timeframe, or nursing these women in a neonatal care setting to facilitate earlier mother-baby bonding.

SAFETY AND MATERNAL-FETAL OUTCOMES OF ISOSORBIDE MONONITRATE AND MISOPROSTOL COMBINATION VERSUS MISOPROSTOL ALONE FOR LABOR INDUCTION: A RANDOMIZED DOUBLE-BLIND STUDY

Objective: The induction of labor is essential in managing pregnancies where early delivery benefits outweigh the risks. Misoprostol is a common agent for labor induction but has side effects like uterine hyperstimulation. Isosorbide mononitrate (ISMN), a nitric oxide donor, may enhance cervical ripening and reduce complications when used with misoprostol. This study evaluates the safety and maternal-fetal outcomes of ISMN combined with misoprostol versus misoprostol alone. Methods: A randomized, double-blind study was conducted at Dr. R. P. G. M. C. Kangra. Patients meeting the inclusion criteria were randomly assigned to receive either ISMN with misoprostol or misoprostol with a placebo. Primary outcomes measured were maternal complications (e. g., uterine hyperstimulation, headache, postpartum hemorrhage) and neonatal outcomes (e. g., birth weight, APGAR scores, NICU admission). Secondary outcomes included the need for oxytocin augmentation and the duration of labor stages. Results: The study included 100 patients divided into two groups of 50 each. The ISMN and misoprostol group had significantly fewer headaches and dizziness but showed no significant difference in uterine hyperstimulation or postpartum hemorrhage compared to the misoprostol alone group. The ISMN group required less oxytocin augmentation, and their total labor duration was shorter, though not significantly. Neonatal outcomes were similar across both groups. Conclusion: The combination of ISMN and misoprostol appears to be a safer and potentially more effective alternative to misoprostol alone for labor induction, with fewer maternal complications and similar neonatal outcomes. Further large-scale studies are recommended to confirm these findings and inform clinical practice.

The Correlation between Occupation and Birth Interval in Primary Postpartum Hemorrhage

ntroduction: Postpartum hemorrhage stands as one of the major contributors to maternal mortality globally. Postpartum hemorrhage is a rapid heavy vaginal bleeding that can cause signs and symptoms of hypovolemic shock. Many factors cause postpartum hemorrhage classified into indirect causes, namely type of delivery, age, parity, birth spacing, family income, education, and occupation. Objective: This study aims to determine the correlation between occupation and birth spacing with primary postpartum hemorrhage. Method: This study uses a case-control approach with a purposive sampling technique. The sample for this study included multigravida mothers and mothers diagnosed with primary postpartum hemorrhage at Ananda Maternity and Child Hospital, Makassar, in 2021. The total sample was 174 consisting of 84 cases and 84 control samples. The research instrument data is in the form of secondary data, namely medical records. Data analysis employed the chi-square test for bivariate analysis and multiple logistic regression for multivariate analysis, with a significance level of 0.05 Result: The results of the bivariate analysis showed a relationship between occupation (p-value: 0.000) and delivery distance (p-value: 0.000). Working mothers are 6 times at risk for experiencing primary postpartum hemorrhage (OR= 5.833) while mothers whose delivery interval is < 2 years or > 5 years have 4 times the risk (OR= 3.719). The results of the multivariate analysis show that the work and pregnancy distance is significantly related to the risk of postpartum hemorrhage (value P: 0,000) where the odds ratio for work (OR = 6,178) is higher than the distance of pregnancy (OR = 4.008). Conclusion: Occupational factors and birth spacing are significantly associated with primary postpartum hemorrhage, working mothers have a higher risk of experiencing primary postpartum hemorrhage. Pregnant women and women of childbearing age should receive more education about postpartum hemorrhage and its influencing factors to help prevent and identify it early.

Cell salvage in obstetrics-Background and practical implementation

Postpartum hemorrhage (PPH) remains aleading cause of maternal mortality worldwide, with an increasing incidence in western countries over the past decades. During this period the numbers of PPH-related allogeneic red blood cell (RBC) transfusions have also significantly increased. Given the increasing scarcity and risks of allogeneic RBC transfusions, which are also associated with adverse maternal outcomes, optimized blood management strategies are urgently needed in obstetrics. In recent years, patient blood management (PBM) has been increasingly integrated into medical care, resulting in asignificant improvement in patient outcomes. Cell salvage (CS) is one of the PBM blood-sparing techniques that enables the collection, processing and retransfusion of the patient's own blood during major bleeding events. Although recent evidence indicates that CS can significantly reduce the demand for allogeneic RBC transfusions and improve patient outcomes, the utilization in obstetrics in German hospitals remains low, with ausage rate of only 0.07% of births with peripartum hemorrhage. It must be assumed that concerns about patient-related complications, such as amniotic fluid embolism and maternal alloimmunization contribute to this hesitancy, alongside alack of familiarity with the technique. This article provides an overview of the current evidence on the use and safety of CS in obstetrics. To facilitate a practical implementation, fundamental considerations and organizational precautions were prepared based on the experiences of the University Hospitals in Würzburg and Frankfurt and presented in the form of graphics and checklists for the perioperative use of CS during cesarean sections.

Case Report: Allelic and biallelic variants in coagulation factor XI cause factor XI deficiency

Factor XI deficiency is a rare inherited coagulation disorder with an estimated prevalence of affecting 1 in 1 million. It is characterized by mild and variable bleeding phenotypes, including bruises, nosebleeds, hematuria, and postpartum hemorrhage. It can be caused by either allelic or biallelic variants in coagulation factor XI (F11). Coagulation factor XI is a glycoprotein that circulates in plasma as a non-covalent complex with high-molecular-weight kininogen. It is converted to an active protease, coagulation factor XIa, which participates in blood coagulation as a catalyst. In this study, we recruited a family with Factor XI deficiency and identified two F11 variants using whole-exome sequencing. One (NM_000128.4: c.841C>T, p.Q281X) was a known variant, and the other (NM_000128.4: c.1832T>G, p.V611G) had not been reported. In addition, we compiled the characteristics of known missense variants in coagulation factor XI. Our findings enriched the variant spectrum of Factor XI deficiency and contributed to the genetic counseling and molecular diagnostics of Factor XI deficiency.

Case Report of Placenta Accreta Spectrum and Arteriovenous Malformations with Successful Preservation of Fertility After Birth

Uterine arteriovenous malformations (UAVMs) that occur after birth are a rare cause of late postpartum hemorrhage. Acquired UAVMs usually occur in conjunction with pathology of the placenta. In the spectrum of placenta accreta (PAS), subinvolution of the placental bed plays an important role in its pathophysiology. We present a case of UAVM in a pregnant woman with PAS who presented with marked metrorrhagia after delivery, which was treated with classical management. Then, 35 days later, she presented to the emergency room with severe metrorrhagia. As it was suspected that she had placental remnants, an instrumental uterine control was performed, but the bleeding persisted, requiring further uterine packing and blood administration. Later, uterine artery embolization was performed with good results. Color Doppler ultrasound, magnetic resonance imaging, and angiography were the methods with the greatest diagnostic value. The differential diagnosis was as complex as the treatment. We hypothesize that UAVM may develop from minimal residual PAS in this late postpartum period. Moreover, they may recover rapidly after local surgical ablation. Considering the clinical condition, hemodynamic status, and desire to preserve fertility, we were able to avoid a hysterectomy, which is often chosen in such cases of severe, life-threatening bleeding complications.

Retraction: Multicenter Randomized Controlled Trial Assessing the Impact of a Cervical Traction Maneuver (Amr's Maneuver) on the Incidence of Postpartum Hemorrhage.

Retraction: A. Hamdy, O. Azmy, R. Lotfy, A. A. Attia, M. M. Elsherbini, A. Al Sawaf, M. M. Soliman, M. F. Sharaf, A. Kamel, M. N. A. El-Raouf, S. Salem, M. A. Rasheed, H. Torky, and E. R. Issak, "Multicenter Randomized Controlled Trial Assessing the Impact of a Cervical Traction Maneuver (Amr's Maneuver) on the Incidence of Postpartum Hemorrhage," International Journal of Gynecology & Obstetrics 144, no. 1 (2019): 56-61. https://doi.org/10.1002/ijgo.12687. A third party raised concerns regarding miscalculated data and discrepancies between the reported sample size and the sample size included in the clinical trial registry. The authors responded to an inquiry by the journal and publisher, and have stated that the prospectively-registered sample size for the trial had changed from 4866 to 804 following the trial start, due to an interim analysis by the IRB and DSMB. Neither this change nor the reason for it were reported in the article. Therefore, the authors' stated original sample size and calculations do not correspond to the number presented in the published article. In addition, an independent review of the available dataset found that the results of all three categorical variables in Table1 are not reproducible and the authors' argument of averaging the two-sided and one-sided Fisher's exact p values is not methodologically sound. The retraction has been agreed to because neither the data nor the results presented in the article can be considered reliable. Author M. M. Soliman disagrees with the retraction. All other authors did not respond to our notice regarding the retraction.

Perinatal and obstetric-neonatal outcomes following frozen embryo transfer cycles with a thinner endometrium: a retrospective study.

The purpose of this study was to evaluate the relationship of thin endometrial thickness (EMT) on the maternal and child health outcome of frozen-thawed embryo transfer (FET) cycles with singletons. The retrospective cohort study included 1,771 live singleton deliveries, with 273 in the thin endometrium group (EMT ≤ 7.5mm) and 1,498 in the control group (EMT > 7.5mm). Pregnancy, perinatal complications and neonatal outcomes were compared between the two groups. Women in the thinner endometrium group had higher rates of preeclampsia (7.69% vs. 7.00%), placenta previa (4.39% vs. 2.43%), postpartum haemorrhage (15.38% vs. 11.42%) than the control groups, although they were not significantly different. Significant difference was observed in the rates of placental abruption (1.09% vs. 0.07%, P = 0.001), abnormal placental cord insertion (3.66% vs. 1.74%, P = 0.011), placental adherence (15.38% vs. 7.14%, P < 0.001) between the two groups. No significant difference could be found regarding preterm labour, macrosomia, Apgar ≤ 7, large for gestational age (LGA) and appropriate for gestational age (AGA), and singletons from the thinner endometrium group had a significantly lower birthweight than those from the controls. Then after adjusting for confounders, thinner endometrium was still statistically significantly associated with placental adherence, postpartum haemorrhage and low birthweight (LBW). These findings highlight the important role of endometrial thickness in influencing perinatal and obstetric-neonatal outcomes in FET cycles. The study contributes to the growing body of evidence supporting the clinical relevance of endometrial thickness in FET cycles and underscores the need for close monitoring and management of pregnancies in women with a thin endometrium. Future research should focus on elucidating the underlying mechanisms and identifying effective interventions to improve endometrial thickness and pregnancy outcomes in this patient population.

Transabdominal sonographic sliding signs for preoperative prediction of dense intra-abdominal adhesions in women undergoing repeat Cesarean delivery.

To assess the accuracy and utility of transabdominal sonographic paraumbilical and suprapubic sliding signs in predicting intra-abdominal adhesions in women undergoing repeat Cesarean section (CS) and the association of repeat CS with short-term maternal and neonatal outcomes. This was a prospective observational study of pregnant women with a history of CS who were scheduled for third-trimester elective or emergency CS at a tertiary referral and teaching hospital between July 2021 and June 2022. In order to evaluate the role of transabdominal sonographic paraumbilical and suprapubic sliding signs in the prediction of intra-abdominal adhesions, participants underwent a high-resolution transabdominal ultrasound scan prior to repeat CS. Free cephalad and caudad gliding of the uterus under the abdominal wall during deep inhalation and exhalation in each area was considered a positive sliding sign, suggesting a low risk of intra-abdominal adhesions. The absence of such movement was considered a negative sliding sign, suggesting a high risk of intra-abdominal adhesions. The presence or absence of intra-abdominal adhesions was then confirmed during surgery by physicians who were blinded to the sonographic sliding-sign findings. The type of adhesion, structures involved, method of adhesiolysis, incision-to-delivery time, 1-min and 5-min Apgar scores, maternal and neonatal injury and other short-term complications were also reported. Of 419 women with a history of at least one previous CS who underwent repeat CS, the preoperative sonographic paraumbilical and suprapubic sliding signs were negative in 173 (41.3%) and 178 (42.5%) women, respectively. On repeat CS, 224 (53.5%) women had intra-abdominal adhesions, of which 165 (39.4%) had dense adhesions and 59 (14.1%) had only filmy adhesions. The sensitivity and specificity of a negative preoperative paraumbilical sliding sign in predicting the presence of dense intra-abdominal adhesions in women undergoing repeat CS were 94.6% (95% CI, 92.4-96.7%) and 93.3% (95% CI, 90.9-95.7%), respectively. A negative suprapubic sliding sign also showed high sensitivity (95.2% (95% CI, 93.1-97.2%)) and specificity (91.7% (95% CI, 89.1-94.4%)). Additionally, a negative sliding sign at both locations in the same patient had robust sensitivity (90.2% (95% CI, 87.3-93.0%)) and specificity (96.3% (95% CI, 94.5-98.1%)). We found that the risk of dense intra-abdominal adhesions increased with parity and the number of previous CS. Dense intra-abdominal adhesions were associated with increased incision-to-delivery time, higher risk of maternal bladder injury, intraoperative bleeding and postpartum hemorrhage. Dense intra-abdominal adhesions are common in women with a previous history of CS and are associated with delayed delivery of the neonate and increased risk of adverse maternal outcomes. The transabdominal sonographic paraumbilical and suprapubic sliding signs are robust methods for the accurate preoperative prediction of dense intra-abdominal adhesions in patients with a history of CS. As the techniques are easy to learn and perform, the sliding sign should be used more widely for triaging patients at high risk of dense intra-abdominal adhesions for appropriate preoperative planning. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

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.

May the indication for a previous cesarean section affect the outcome at trial of labor in women with induction of labor? Aretrospective cohort study.

Cesarean sections are increasing worldwide and are associated with altered risks of complications for both mother and child. Vaginal birth after cesarean section is associated with lower maternal and neonatal morbidity than in repeat cesarean section. Only a few studies have considered the indication for the previous cesarean section to be of importance for the outcome of subsequent labor. The aim of this study was to evaluate whether the indication for a previous cesarean section affects the outcomes at a subsequent delivery in women with induction of labor. This retrospective cohort study of the four largest delivery units in Stockholm during 2012-2015 included 1150 women with one previous cesarean section with induction of labor. women with induced labor and a previous cesarean section, singleton pregnancy, cephalic presentation, gestational age of ≥34 weeks. The women were grouped by indication for the previous cesarean section. mode of delivery (vaginal birth after previous cesarean section or repeat cesarean section). induction to delivery time, postpartum hemorrhage, uterine rupture. Neonatal outcomes: birth weight, Apgar score <7, arterial umbilical cord blood gas pH <7.0. Our study found that the indication of labor dystocia at the previous cesarean section, increased the risk of repeat cesarean section (aOR 5.35; 95% CI: 1.64-17.50) in women with induction of labor. Other risk factors for repeat cesarean section were birth weight >4000 g, maternal BMI ≥30 or if vaginal prostaglandin was used as the method for induction of labor. A previous vaginal delivery and use of oxytocin increased the chance of a vaginal delivery in this group of women. Our study showed that the indication for the previous cesarean section affects the outcome in the subsequent delivery in women with induction of labor. If the indication for the previous cesarean section was labor dystocia, the risk of repeat cesarean section was increased.

Maternal mortality in Panama from 1998 to 2022.

To examine maternal mortality in Panama, analyzing its direct obstetric deaths, indirect obstetric deaths, and contributory conditions. This cohort study used publicly available data from the National Institute of Statistics and Census to present a 25-year retrospective analysis of maternal deaths in the Republic of Panama from 1998 to 2022. Public data were sourced from the National Institute of Statistics and Census website of Panama. Relevant codes from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD) were used. The maternal mortality ratio (MMR) was defined as the number of maternal deaths per 100 000 live births. Trendline reliability with R 2 was performed to analyze the data. A total of 1 026 maternal deaths occurred in Panama from 1998 through 2022, of which 61.2% were attributed to direct obstetric causes; 23.9%, indirect obstetric causes; 13.6%, contributory conditions; and 1.4% were unknown or undetermined. The average MMR was 60.1. The trendline reliability resulted in R 2 = 0.1 (y = -0.5147x + 1094.7), which is not statistically significant but meets the 2030 Sustainable Development Goals. The specific primary causes of direct obstetric deaths were: 12.9% due to postpartum hemorrhage (ICD O72); 9.2%, eclampsia (ICD O15); 6.7%, puerperal sepsis (ICD O85); and 6.3%, pre-eclampsia (ICD O14). For indirect obstetric deaths, the primary causes were: 14.9% due to other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth, and the puerperium (ICD O99); and 7.3%, maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth, and the puerperium (ICD O98). The findings of this study confirmed that there were substantially more direct obstetric causes (61.2%) than indirect obstetric causes (23.9%), contributory causes (13.6%), or unknown/undetermined causes (1.4%) of maternal mortality, despite being highly preventable. Although Panama is right on track to fulfill the target of 70 MMR by 2030, these results highlight the lack of health care access due to the absence of obstetrician-gynecologists per 100 000 population in indigenous comarcas, where 30.8% of the maternal mortalities occur. Furthermore, the health system in Panama is not immune to pandemics and crises. From 1998 to 2022, there were 5 years when the MMR in Panama exceeded 70: 2001, 2002, 2006, 2011, and 2020. These findings also underscore the dichotomy between statistics and health policy. While the trendline reliability was insignificant (R 2 = 0.1), the MMR satisfies requirements for the 2030 Sustainable Development Goals. Future studies should consider factors related to indirect obstetrics and contributory causes of deaths, health care access, COVID-19, cesarean section and natural birth, age, economic income, prenatal and postpartum care, as well as the quality of private and public health facilities in the Americas.

Implementing a Labor and Delivery Cell Salvage Protocol in Patients at Increased Risk of Hemorrhage: A Pilot Study.

Postpartum hemorrhage (PPH) contributes significantly to maternal morbidity and mortality. The use of cell salvage has been implemented in operating rooms across the world, but only a limited number of institutions have protocols for use of cell salvage during vaginal hemorrhage at the time of vaginal delivery. Observations suggest that blood salvaged from vaginal delivery is comparable to blood salvaged during cesarean delivery. Using pre-validated protocols of cell salvage, we sought to assess the feasibility and potential benefit of implementing cell salvage in our Labor and Delivery unit in all patients at high risk of hemorrhage. This was a prospective pilot study conducted from April 2022 to December 2022 on the Labor and Delivery floor at Mount Sinai Hospital in New York City. A total of 50 participants were identified for cell salvage after vaginal delivery during the study period.The mean age of participants was 34.4 years (SD 5.5).We utilized acell salvage technique at the time of vaginal delivery in patients at high risk of PPH. We employed simple descriptive statistics and examined sums and percentages (and means and standard deviations, where appropriate). A simple equation was used to determine the average cell salvaged volume in each delivery and describe potential values. The HEMAsavR™device (Ecomed Solutions, Mundelein, IL, USA) was used as a standby system to be used at the time of the vaginal delivery. Fifty participants were identified for the cell salvage protocol as described. Despite a diversity of clinical risk factors, the sample consisted ofpredominately non-Hispanic White patients. The mean quantitative blood lossof cell salvaged samples was 157.2 mL(SD 153.0). We identified that, on average, >33% of vaginally shed blood could be used for cell salvage and improve patient blood management. The implementation of cell salvage in our Labor and Delivery unit was feasible and easy to perform. We identified that a significant volume of blood would be available for cell salvage. Further studies should be done to evaluate the benefit of cell salvage to improve postpartum recovery.

Combination of body mass index and body fat percentage in middle and late pregnancy to predict pregnancy outcomes in patients with gestational diabetes in Wenzhou, China: a single-centre retrospective cohort study

ObjectivesThe present study aimed to evaluate whether body mass index (BMI) and body fat percentage (BFP) could be used to predict pregnancy outcomes in patients with gestational diabetes mellitus (GDM).DesignRetrospective...

Does induction or augmentation of labor increase the risk of postpartum hemorrhage in pregnant women with anemia? A multicenter prospective cohort study in India.

To investigate whether induction/augmentation of labor in pregnant women with anemia increases the risk of postpartum hemorrhage (PPH) and whether this risk varied by indications for labor induction/augmentation and by anemia severity in pregnancy. In a prospective cohort study of 9420 pregnant women from 13 hospitals across India, we measured hemoglobin concentrations at recruitment (≥28 weeks of gestation) and blood loss after childbirth during follow-up and collected clinical information about PPH. Clinical obstetric and childbirth information at both visits were extracted from medical records. Anemia severity in the third trimester was categorized using hemoglobin concentrations (no/mild anemia: hemoglobin ≥10 g/dL; moderate: hemoglobin 7 to 9.9 g/dL; severe: hemoglobin <7 g/dL), while PPH was defined based on blood loss volume (vaginal births: ≥500 mL or cesarean sections: ≥1000 mL) and clinical diagnosis. Indications for labor induction/augmentation were classified as clinically indicated and elective as per guidelines. We performed multivariable modified Poisson regression analyses to investigate the associations of anemia severity and indications for labor induction/augmentation, including their interaction, with PPH, adjusted for potential confounders. PPH was associated with anemia but not with indications for labor induction/augmentation. However, there was a significant interaction between the two factors in relation to PPH (P = 0.003). Among pregnant women with severe anemia, a higher risk of PPH was associated with elective (adjusted risk ratio, 3.44 [95% confidence interval, 1.29-9.18]) but not with clinically indicated (adjusted risk ratio, 1.22 [95% confidence interval, 0.42-3.55]) labor induction/augmentation. No associations were observed among pregnant women with no/mild and moderate anemia. The risk of PPH is higher in women who have moderate-severe anemia in late pregnancy. Induction/augmentation of labor is generally safe for women with anemia, but it can increase the risk of PPH in women with severe anemia if performed electively.

Midwifery-led brief counseling on the severity of posttraumatic stress symptoms of postpartum hemorrhage: quasi-experimental study

BackgroundPostpartum hemorrhage is a preventable cause of maternal mortality all over the world and a significant contributor to post-traumatic stress among women.MethodsThis quasi-experimental study was conducted in 2023 on 60 primiparous women with postpartum hemorrhage in Zahedan, Iran. The participants were identified and randomly assigned to two groups. The intervention group received face-to-face individual counseling based on Gamble’s counseling model, conducted by a midwife. The counseling lasted from 40 to 60 min and took place over two sessions; one within the first 48 to 72 h in the ward, and a follow-up telephone session two weeks postpartum. Assessments were made using the Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) and the Perinatal Post-Traumatic Stress Disorder Questionnaire-II (PPQ-II) before the intervention and four weeks after the last post-test session for the two groups, either in person or by phone.ResultsFollowing the intervention, the post-traumatic stress score (PCL-5) in the intervention group significantly decreased compared to the control group (P < 0.001). Moreover, the perinatal post-traumatic stress disorder score (PPQ-II) after midwife-led brief counseling in the intervention group was significantly lower than in the control group, as determined by an analysis of covariance (ANCOVA), controlling for pre-test effects (p =0.05).ConclusionsMidwife-led brief counseling may be effectively implemented by developing a localized clinical guideline based on midwifery recommendations following traumatic births caused by postpartum hemorrhage.

Development and validation of a nomogram for predicting postpartum hemorrhage in women with preeclampsia: A retrospective case-control study.

This retrospective case-control study aimed to develop a nomogram for predicting postpartum hemorrhage in women with preeclampsia. This study was carried out at the Fujian Maternity and Child Health Hospital, involving 542 preeclampsia patients who underwent vaginal deliveries. The participants were split into 2 groups: a training cohort (85%, n = 460) and a validation cohort (15%, n = 82). Least absolute shrinkage and selection operator regression was applied to pinpoint relevant risk factors by selecting appropriate candidate variables. Subsequently, multivariate logistic regression analysis was conducted on the training set, leading to the creation of a nomogram as a visual risk prediction tool. The model's performance was tested and verified internally and externally by examining receiver operating characteristic curves and calibration curves. The correlation heatmap revealed collinearity among variables, necessitating the use of least absolute shrinkage and selection operator regression to select 4 candidate variables. Multivariate logistic regression analysis identified significant associations with the following outcomes: white blood cell count (odds ratio [OR]: 2.485, 95% confidence interval [CI]: 1.483-4.166), third stage of labor (OR: 1.382, 95% CI: 1.182-1.616), anemia (OR: 9.588, 95% CI: 4.022-22.854), and labor analgesia (OR: 0.187, 95% CI: 0.073-0.477). These variables were utilized to construct the nomogram. The receiver operating characteristic curves demonstrated good predictive performance (area under the curve train = 0.867, area under the curve test = 0.882), and the calibration curve yielded a C-index of 0.867. The nomogram created in this study has good sensitivity and specificity to assess risk and support clinical decision-making for postpartum hemorrhage in women with preeclampsia.

Comparison of the efficacy and safety of dinoprostone and double-balloon catheters in cervical ripening: a propensity score matching retrospective study.

The methods of prompting cervical ripening (CR) include mechanical and pharmacological approaches. The former seems safer. However, this superiority may change with the application of a new labor curve. Therefore, we aimed to compare the efficacy and safety of dinoprostone and double-balloon catheters (DBC) in promoting CR in induction of labor (IOL). A total of 877 primipara women with Bishop score ≤ 6 were divided into the dinoprostone group (n = 502) and DBC group (n = 375) according to the IOL way. The women in the dinoprostone group received dinoprostone to perform IOL, while those in the DBC group received DBC to perform IOL. The natural birth rate, time to labor onset and birth, and maternal and neonatal complications were compared between the two groups. A propensity score match (PSM) was used to eliminate the selection bias. A total of 516 cases were left after PSM (1:1) to Bishop score. The dinoprostone was associated with an improved Bishop score. However, there were no significant differences in the vaginal delivery rate, the stage of labor, and the time from ripening to labor onset and delivery between the two groups (p > 0.05). The incidence rates of puerperal infection and blood loss were notably higher in the DBC group than in the dinoprostone group (p < 0.05). However, there was no statistical difference in the incidence of postpartum hemorrhage between the two groups (p > 0.05). Dinoprostone is associated with a lower puerperal infection rate and improved Bishop score in IOL without an increased success rate of vaginal delivery.

Quantitative Validation of Hematocrit Percentage Drop Cutoff Points in Postpartum Hemorrhage: An Automated Gravimetric Approach

Quantitative Validation of Hematocrit Percentage Drop Cutoff Points in Postpartum Hemorrhage: An Automated Gravimetric Approach