Postpartum Hemorrhage In Group Research Articles

Risk factors for postpartum hemorrhage in twin pregnancies with cesarean section.

The rates of twin pregnancies and cesarean section have increased in recent years, and both of them are at high risks of postpartum hemorrhage (PPH). However, few studies have concentrated on the risks of PPH in twin pregnancies and cesarean deliveries. In this study, we aimed to identify the risk factors for PPH among twin-pregnant women with cesarean section. This was a retrospective observational study including 1,649 women with twin pregnancies delivered by cesarean section from 2016 to 2022 in the Second Affiliated Hospital of Wenzhou Medical University, China. The eligible women were divided into PPH group (n = 116) and non-PPH group (n = 1,533) according to the blood loss after delivery within 24 h. The baseline maternal and perinatal characteristics were compared between the two groups. Logistic regression analysis was conducted to identify the potential risk factors for PPH. We found nulliparity, assisted reproductive technology (ART) usage, preeclampsia or HELLP syndrome, placenta previa, placenta accreta and general anesthesia were more common in PPH group than non-PPH group (P < 0.05). Women in PPH group had higher maternal body mass index at delivery and higher combined birthweight of the twins than non-PPH group, but had lower parity (P < 0.05). Seven independent risk factors for PPH were identified after logistic regression analysis: ART usage (OR 2.354 95% CI 1.357-4.083, P = 0.002), preeclampsia or HELLP syndrome (OR 2.605, 95% CI 1.471-4.616, P = 0.001), placenta previa (OR 7.325, 95% CI 3.651-14.697, P < 0.001), placenta accreta (OR 6.296, 95% CI 1.316-30.12, P = 0.021), thrombocytopenia (OR 1.636, 95% CI 1.056-2.535, P = 0.027), general anesthesia (OR 2.394, 95% CI 1.223-4.686, P = 0.011), and combined birthweight (OR 1.00032, 95% CI 1.00005-1.00059, P = 0.020). Collectively, in women with twin pregnancies delivered by cesarean section, the use of ART, preeclampsia or HELLP syndrome, placenta previa, placenta accreta, thrombocytopenia, general anesthesia and the combined birthweight were identified as independent risk factors for PPH. More attention should be paid to women with these risk factors.

Establishment of Risk Nomogram Model of Postpartum Hemorrhage After Second Cesarean Section.

To establish and evaluate a nomogram model for predicting the risk of postpartum hemorrhage in second cesarean section. A total of 440 parturients who underwent the second cesarean section surgery and were registered in our hospital from August 2019 to July 2021 were selected as the study subjects. They were randomly divided into 220 modeling group and 220 validation group based on simple randomization. The two groups were divided into postpartum hemorrhage group and postpartum non bleeding group according to whether postpartum hemorrhage occurred. In the modeling group, the incidence of postpartum hemorrhage in the second cesarean section was 15.00%; the Logistic regression model showed that placenta previa, operation time, prenatal anemia, placenta accreta, uterine inertia were the independent risk factors of postpartum hemorrhage in the second cesarean section (P < 0.05). ROC results showed that AUC of predicting the risk of postpartum hemorrhage in the second cesarean section was 0.824. The slope of calibration curve is close to 1, Hosmer-Lemeshow goodness of fit test showed x2= 7.585, P = 0.250. The external verification results show that the AUC is 0.840, and the predicted probability of the calibration curve is close to the actual probability. Based on the five risk factors of postpartum hemorrhage in the second cesarean section, including placenta previa, operation time, prenatal anemia, placenta accreta and uterine inertia, the nomogram model for predicting the risk of postpartum hemorrhage in the second cesarean section has good accuracy and differentiation.

Risk factors for postpartum hemorrhage after elective cesarean deliveries for twin pregnancies.

To identify the high-risk factors associated with postpartum hemorrhage (PPH) after an elective cesarean delivery of twins. This retrospective cohort study included all women with twin gestations who chose to have an elective cesarean delivery after 28 weeks of gestation at at the Women's Hospital, School of Medicine, Zhejiang University between September 2014 and April 2019. Women with an intrauterine fetal demise of one or both twins were excluded. PPH was defined as an estimated blood loss of ≥ 1,000 mL within 24 h of birth. A total of 532 women were analyzed and classified into the PPH group (n = 70) and the no-PPH group (n = 462). Univariate and multivariate logistic regression analyses were performed to assess the independent risk factors. Among the 532 women pregnant with twins, PPH occurred in 13.2% women (n = 70). There were statistically significant differences in preeclampsia (p = 0.005), premature rupture of membrane (PROM, p < 0.001), placenta previa (p < 0.001), anemia [hemoglobin (Hb) < 100 g/L; p = 0.003], and antenatal magnesium sulfate (MgSO₄) use (p < 0.001) between the two groups. However, the following were the independent risk factors for PPH after an elective cesarean delivery for a twin pregnancy: preeclampsia [odds ratio (OR): 2.91; 95% confidence interval (CI): 1.33-6.36], PROM (OR: 8.57; 95% CI: 2.54-28.89), placenta previa (OR: 9.46; 95% CI: 3.59-24.89), antenatal MgSO₄ use (OR: 7.64; 95% CI; 3.18-18.41), and anemia (Hb < 100 g/L; OR: 2.68; 95% CI: 1.42-5.06). Preeclampsia, PROM, placenta previa,and antenatal MgSO₄ use were the risk factors for PPH after an elective cesarean delivery for twin pregnancies. Risk factor identification and prevention should be a priority.

Retrospective analysis of associated factors and adverse pregnancy outcomes of postpartum hemorrhage in the caesarean section of different types of placenta previa

Objective: To analyze associated factors and adverse pregnancy outcomes of postpartum hemorrhage in the caesarean section of puerperae with different types of placenta previa. Methods: This retrospective research was a case-control study. Puerperae with cesarean section of placenta previa from January 2019 to December 2020 in Women's Hospital, School of Medicine, Zhejiang University were collected and divided into the<1 000 ml control group or ≥1 000 ml postpartum hemorrhage group according to the amount of blood loss during cesarean section. Differences in continuous variables were analyzed by t-test and categorical variables were analyzed by χ2 test. The risk factors of postpartum hemorrhage were analyzed by logistic multivariate regression. Results: A total of 962 puerperae were enrolled with 773 cases in the control group and 189 cases in the postpartum hemorrhage group. The incidence of gestational weeks, gravidity, parity, induced abortion, placental accreta and preoperative hemoglobin<110 g/L was significantly different between two groups in different types of placenta previa (P<0.001). Logistic multivariate regression model analysis showed that the independent risk factors of postpartum hemorrhage in the caesarean section of low-lying placenta included placental accreta (OR=12.713, 95%CI: 4.296-37.625), preoperative hemoglobin<110 g/L (OR=2.377, 95%CI: 1.062-5.321), and prenatal vaginal bleeding (OR=4.244, 95%CI: 1.865-9.656). The independent risk factors of postpartum hemorrhage in the caesarean section of placenta previa included once induced abortion (OR=2.789, 95%CI:1.189-6.544), induced abortion≥2 (OR=2.843, 95%CI:1.101-7.339), placental accreta (OR=6.079, 95%CI:3.697-9.996), HBsAg positive (OR=3.891, 95%CI:1.385-10.929), and placental attachment to the anterior uterine wall (OR=2.307, 95%CI:1.285-4.142). The rate of postpartum hemorrhage and premature delivery in puerperae with placenta previa was higher than that in puerperae with low-lying placenta (P<0.001). Conclusions: The associated factors of postpartum hemorrhage in puerperae with different types of placenta previa are different. Placenta accreta is the common risk factor of postpartum hemorrhage in puerperae with low-lying placenta and placenta previa.

Analysis of Factors Affecting Postpartum Hemorrhage in Twin Pregnancy

Objective: To explore the factors affecting postpartum hemorrhage in twin pregnancy. Methods: The clinical data of 839 twin pregnancy patients who delivered at the Second Hospital of Shandong University from May 2010 to July 2020 were retrospectively analyzed. According to the amount of postpartum hemorrhage, patients were divided into postpartum hemorrhage group (PPH group) and non- PPH group. The basic population information and clinical data during pregnancy were compared between the two groups. Results: A total of 839 women with twin pregnancy were included in this study, and hemorrhage occurred in 11% (n=96). The Binary logistic regression model predicts the risk of factor of postpartum hemorrhage in twin pregnancy: gestation week of delivery, placenta previa, polyhydramnios, acute delivery, anemia, placental adhesions and DIC (disseminated intravascular coagulation). Conclusions: There are many factors that affect postpartum hemorrhage in twin pregnancy. Choosing the right gestational week for delivery, strengthening pregnancy management, and improving pregnancy complications can reduce the risk of postpartum hemorrhage in twin pregnancy.

Decreased inferior vena cava diameter as an early marker in postpartum hemorrhage.

To examine the association between inferior vena cava (IVC) diameter and postpartum blood loss and assess whether IVC diameter is a useful marker in the evaluation of intravascular volume status in women with postpartum hemorrhage (PPH). This was a prospective case-control study conducted in a university medical teaching center in Afula, Israel, between November 2018 and March 2020. The study cohort consisted of women with a singleton pregnancy who delivered vaginally at term. The PPH group included women diagnosed with PPH based on visually estimated blood loss of 1000 mL or more at the time of enrolment. Hemodynamically unstable women or women with major bleeding at the time of diagnosis were not included. The control group consisted of women with an uneventful fourth stage of labor. IVC diameter was measured using transabdominal ultrasonography during inspiration (IVCi diameter) and expiration (IVCe diameter), and the collapsibility index was calculated ((IVCe - IVCi)/IVCe × 100). The primary outcome was the percentage difference in IVC diameter and collapsibility index between the PPH group and controls. The performance of the IVC collapsibility index in the prediction of the need for blood transfusion in women with PPH was assessed. In order to demonstrate a difference of 20% with a power of 80% and alpha of 0.05, 108 women, at a ratio of 1:2 in the study and control groups, respectively, were needed. Overall, 36 and 72 women were included in the final analysis in the PPH and control groups, respectively. IVCi and IVCe diameters were significantly smaller in the PPH group (0.93 ± 0.30 cm and 1.26 ± 0.32 cm, respectively) than in controls (1.42 ± 0.31 cm and 1.75 ± 0.28 cm, respectively) (P = 0.001 for both). The percentage reductions in IVCi and IVCe diameters in the PPH group compared with controls were 35.0% and 28.0%, respectively. IVC collapsibility index was increased significantly, by 42.9% (26.04 ± 8.67% vs 18.15 ± 5.07%; P = 0.001) in the PPH group compared with controls. IVC collapsibility index was a significant predictor of the need for blood transfusion and correctly predicted 81% of cases. Logistic regression analysis demonstrated that IVC collapsibility index was also a significant predictor of a drop in hemoglobin level of ≥ 2 g/dL (P = 0.001). IVC diameter changes in response to postpartum blood loss. Measurement of IVC diameter using transabdominal ultrasonography is an objective and useful non-invasive method for the early evaluation of intravascular volume status in women with PPH and for the prediction of cases that might require blood transfusion. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

EVALUATION OF PERIPARTUM HYSTERECTOMY CASES: EXPERIENCES OF A TERTIARY HEALTH CENTER IN WESTERN REGION OF TURKEY

OBJECTIVE: We aimed to retrospectively examine the cases of peripartum hysterectomy performed in our clinic in the last three years and to evaluate the incidence, risk factors, indications, surgical methods, complications, and results of peripartum hysterectomy.MATERIAL AND METHODS: Patients who had undergone a peripartum hysterectomy in Pamukkale University Medical Faculty Hospital between January 2017 and January 2020 were included in the study. We excluded all patients with the massive peripartum hemorrhage who were treated with conservative approaches (such as suturing or segmental resection of the defective placenta insertion area, uterine compression sutures, intrauterine balloon applications, and uterine or internal iliac artery ligation) rather than hysterectomy. Data of the patients were obtained from patient files and hospital medical records. The demographic and clinical data of the patients were recorded and analyzed.RESULTS: During the three years, a total of 3220 births took place in our hospital. Peripartum hysterectomy was performed in twenty-one patients; the incidence was 6.5/1000. The most common indication for peripartum hysterectomy in the postpartum hemorrhage group was placental location and invasion anomalies (90.4%) and among these anomalies, the most common histopathological diagnosis was the association of placenta previa and placenta increta (33.33%). Massive transfusion, bladder damage, relaparotomy, and wound infection were the major causes of morbidity in patients with peripartum hysterectomy.CONCLUSIONS: Recently, placental location and invasion anomalies have become the most common cause of peripartum hemorrhages. Peripartum hysterectomy is the leading treatment method for patients with abnormal placentation.

Factors Associated with Primary Postpartum Hemorrhage in Elderly Women Undergoing Repeated Cesarean Deliveries.

PurposeThe aim of this study was to analyze the risk factors for primary postpartum hemorrhage in elderly parturients undergoing repeated cesarean delivery (PHEPWRCD).Participants and MethodsThe clinical data of 1675 elderly parturients who underwent repeated cesarean delivery in our hospital from May 2011 to March 2020 were retrospectively collected for analysis. The women were divided into a postpartum hemorrhage group (116 individuals) and a nonpostpartum hemorrhage group (1559 individuals). We analyzed the association of maternal age, maternal history, pregnancy complications, placenta and other factors with postpartum hemorrhage in elderly women who underwent repeated cesarean delivery and screened out independent risk factors by multivariate logistic regression analysis.ResultsThe incidence rate of PHEPWRCD was 6.92% (116/1675). Using single-factor analysis of variance, we found that maternal age (p=0.012), the number of pregnancies (p=0.007), the number of cesarean deliveries (p<0.001), fetal position (p<0.001), fetal macrosomiaren (p<0.001), placental attachment position (p<0.001), placenta previa (p<0.001), and placental implantation (p<0.001) were significantly associated with PHEPWRCD. Multivariate logistic regression analysis showed that the number of cesarean deliveries (OR=2.457, 95% CI=1.453–4.540, P=0.013), placenta previa (OR=11.741, 95% CI=5.874–26.078, P<0.001), placenta implantation (OR=6.844, 95% CI=3.514–14.873, P<0.001), placental attachment position (OR=2.421, 95% CI=1.275–3.917, P=0.009) and fetal position (OR=5.722, 95% CI=3.817–16.577, P<0.001) were independent risk factors for PHEPWRCD.ConclusionThis study found that the number of cesarean deliveries, placental attachment, placental previa, and placental implantation are independent risk factors for PHEPWRCD.

Risk factors for postpartum hemorrhage following cesarean delivery

Objective To identify risk factors for postpartum hemorrhage (PPH) following cesarean delivery (CD). Methods A retrospective study of all women who underwent CD in a university-affiliated tertiary hospital (2014–15). PPH was defined as any of the following: clinical PPH (≥1000 ml estimated blood loss), hemoglobin (Hb) drop ≥3 g/dl (the difference between pre-CD Hb level within a 24 h prior to the delivery) and post-CD (nadir level during the first 72 h after CD)) or the need for blood products transfusion. The characteristics of women with PPH following CD were compared to a control group of those with CD without PPH. Results Of the 15,564 deliveries during the study period, 3208 (20.6%) women met inclusion criteria, of them, 307 (9.6%) had PPH and 2901 (90.4%) served as controls. Women in the PPH group were younger (32.6 ± 5.3 vs. 33.5 ± 5.4, p = .006) and more often nulliparous (45.9% vs. 33.3%, p<.001) compared to the controls. However, there were no differences between the groups regarding the rate of multiple gestations, maternal diabetes mellitus, hypertensive disorders, polyhydramnios, and macrosomia. The rates of induction of labor (16.3% vs. 8.6%, p<.001) and urgent CD (47.9% vs. 32.0%, p<.001) were higher in the PPH group compared to the controls. In multivariate logistic regression, predictors for PPH following CD were (odds ratio, 95% confidence interval) urgent CS (1.57, 1.78–2.11, p = .002), CD duration (1.02, 1.01–1.03, p<.001), and the number of previous CDs (0.74, 0.62–0.90, p = .003). Conclusions In women undergoing cesarean section, urgent CD, the duration of the surgery, and the number of the previous CD are associated with the risk of PPH and should be taken into consideration during the postpartum assessment.

Hemoglobin drop following postpartum hemorrhage

Postpartum hemorrhage (PPH) is defined as blood loss of ≥ 500–1000 ml within 24 h after delivery. Yet, assessment of blood loss is imprecise. The present study aimed to profile the hemoglobin (Hb) drop after vaginal delivery with versus without PPH. This was a secondary analysis of a prospective cohort study of women who delivered vaginally. Women were included if complete blood counts (CBC) before and after delivery were taken until stabilization (N = 419). Women were categorized into the PPH group and controls, for whom post-delivery CBCs were performed due to indications unrelated to bleeding. The PPH patients were then classified as either overt or occult PPH (symptoms related to hypovolemia without overt bleeding) subgroups. The primary endpoint was mean Hb drop after delivery. One hundred and ten (26%) and 158 (38%) women presented with overt PPH or occult PPH, respectively; 151 (36%) women were included in the control group. Mean Hb decrease from baseline was 3.0 ± 1.6, 2.0 ± 1.4 and 0.9 ± 1.0 g/dl, respectively (p < 0.0001). In all groups, maximal rate of Hb decline was in the first 6–12 h postpartum and plateaued after 24–48 h. At 48 h post-delivery, 95% and 86% of women who had dropped to Hb ≤ 9.5 and < 7 g/dl, respectively, reached those thresholds. Taken together, an Hb decrease ≥ 2 g/dl was consistent with PPH diagnosis and should be followed for at least 48 h after delivery.

Can prepartum platelet indices be a parameter to predict postpartum hemorrhage?

Objective Postpartum hemorrhage (PPH) is the single largest contributor to maternal mortality worldwide. It has been demonstrated that certain platelet parameters are indicative of platelet reactivity. The aim of this study was to determine whether antenatal platelet indices can be used as risk factors in the prediction of primary PPH. Methods This comparative case-control study involved 3207 pregnant women at term who were recruited over one year period in İstanbul. Postpartum hemorrhage, defined as blood loss ≥1000 mL within 24 h after delivery. The study group consisted of 42 patients who developed primary PPH after vaginal delivery without defined risk factors. The patients in the control group were matched with age, parity, body mass index (BMI), and hemoglobin value. Platelet indices – platelet count, mean platelet volume (MPV), platelet distribution width, and plateletcrit were measured prior to delivery and evaluated for the prediction of PPH. Results Prepartum MPV and PDW values were determined to be lower in the patients with in the PPH group, when compared to the healthy group (respectively, p < .001 and p < .004). By receiver-operating characteristic analysis, MPV and PDW were able to distinguish between patients with and without any bleeding (respectively, AUC 0.823, 95% confidence interval (CI) 0.735–0.912, (AUC) 0.682, 95% CI 0.569–0.795). Prepartum MPV (cutoff = 10.95 fL) had a high AUC (>0.8) for predicting PPH, with a specificity of 81% and sensitivity of 69%. Conclusion Results suggest a novel hypothesis that pre-delivery lower MPV value may be used predicting PPH.

Arterial Embolization for Prophylaxis and Treatment in Severe Obstetric and Gynecologic Hemorrhage

Objective : To evaluate the efficacy and safety of arterial embolization for prophylaxis and treatment in severe obstetric and gynecologic hemorrhage. Methods : A retrospective study was conducted among 17 patients who undergone arterial embolization for prophylaxis and treatment in severe obstetric and gynecologic hemorrhage between 2008 and 2013 at Siriraj Hospital. Efficacy of embolization, embolization procedure details, clinical outcomes and complications were collected and analyzed. Results : The obstetric causes were abnormal placentation (n=6, 35.2%), postpartum hemorrhage (n=5, 29.4%), and intractable bleeding from gynecologic cause (n=6, 35.2%). The median age of the patients in prophylaxis for severe obstetric hemorrhage group, postpartum hemorrhage group and in the gynecologic group were 35 (range, 32-37 years), 31 (range 25-38 years), and 45 (range 28-61 years), respectively. Out of 17 patients, a total of 21 embolization procedures were performed. The technical success rate was 95.6%. Superselection into ovarian artery for embolization of arteriovenous shunting was unsuccessful in one patient. The clinical success rate was 82.6%. Second embolization was done in one patient. Major complication occurred in 3 patients which were microembolism of first dorsal metatarsal artery, pseudoaneurysm at the puncture site and lumbosacral plexopathy. Conclusion : Arterial embolization has an important role in management of obstetric and gynecologic hemorrhage which is safe, effective and has a low rate of complications.

Risk factors for post-partum hemorrhage following vacuum assisted vaginal delivery.

To identify risk factors for post-partum hemorrhage (PPH) following vacuum assisted vaginal delivery (VAVD). A retrospective study of all women with singleton pregnancies who underwent VAVD in a tertiary hospital (2012-2014). PPH was defined as any of the following: ≥500ml estimated blood loss, hemoglobin drop ≥3g/dl (difference between pre- and post-VAVD hemoglobin levels) or the need for blood products transfusion. Characteristics of women with PPH following VAVD were compared to those of women with no PPH following VAVD. Of 1,154 VAVDs, 295 (25.6%) had PPH. Women in the PPH group were more often nulliparous (83.1 vs. 70.5%, p=0.001) and had higher rate of hypertensive disorders (4.4 vs. 1.4%, p=0.001). The rate of episiotomy (87.8 vs. 81.6%, p=0.01) was higher in the PPH group. In multivariate analysis, risk factors for PPH were (Odds Ratio, 95% Confidence Interval) hypertensive disorders (2.40, 1.03-5.58, p=0.04), induction of labor (1.42, 1.01-2.10, p=0.04) and longer second (1.003, 1.001-1.006, p=0.03) and 3rd (1.02, 1.01-1.04, p=0.004) stages of labor. Risk factors for PPH following VAVD can be identified and should be taken into consideration at the immediate post-partum period.

Induction of labor in twin pregnancies with oral misoprostol versus vaginal dinoprostone – is it effective and safe?

Objective: To compare the effectiveness and safety of oral misoprostol versus vaginal dinoprostone for the induction of labor in twin pregnancies.Methods: All twin pregnancies ≥ 34 weeks 0 days that were induced with either misoprostol or dinoprostone in St. Hedwig Hospital between 2002 and 2013 were included in this retrospective study. Length of induction, mode of delivery, maternal and neonatal outcomes were compared between the two groups.Results: After identifying 186 twin mothers matching the inclusion criteria, 154 women were induced with misoprostol (group A) and 32 with dinoprostone (group B). There were no differences in demographic data between the groups. Rates of successful vaginal delivery (53.9% versus 56.3%) and length of induction to delivery (30.2 h versus 26.9 h) were also similar. There were slightly higher rates of postpartum hemorrhage in group B (16.6% versus 10.8%), but without reaching statistical significance. Neonatal outcomes regarding umbilical artery pH <7.20 and one minute Apgar also were without significant differences.Conclusions: Study data indicate that oral misoprostol and vaginal dinoprostone are similarly effective and safe for the induction of labor in twin gestations. Further trials with larger series are needed to confirm these results.

Diagnostic accuracy of insulin-like growth factor binding protein-1 for amniotic fluid embolism*

To test whether serum insulin-like growth factor binding protein-1 could be used as a biomarker of amniotic fluid passage into the maternal circulation. Case-control study. Thirteen centers in France. This case-control study included a group with amniotic fluid embolism (the amniotic fluid embolism group) and a group with symptoms unrelated to amniotic fluid embolism (the non-amniotic fluid embolism group). Serum insulin-like growth factor binding protein-1 level was measured within 6 hrs from onset of symptoms. We also determined serum insulin-like growth factor binding protein-1 in four additional groups of patients with 1) postpartum hemorrhage, 2) uncomplicated labor, 3) normal pregnancy, and 4) non-pregnant patients with acute pulmonary embolism. None. Serum insulin-like growth factor binding protein-1 levels were determined using an immuno-enzymatic assay. The amniotic fluid embolism group included 25 patients, the non-amniotic fluid embolism group had 20 patients, the postpartum hemorrhage group had 24 patients, and the uncomplicated labor group had 50 patients. The serum levels of insulin-like growth factor binding protein-1 were higher in the amniotic fluid embolism group (234 134-635 µmol/L) compared with the non-amniotic fluid embolism, postpartum hemorrhage, and uncomplicated labor groups, which had serum levels of 56 36-91 µmol/L, 65 39-91 µmol/L and 49 30-78 µmol/L, respectively (p < .001). Serum insulin-like growth factor binding protein-1 level was not different in women during normal pregnancy (57 37-85 µg/L) compared to the uncomplicated labor group. Patients with acute pulmonary embolism had the lowest insulin-like growth factor binding protein-1 level (5 2-14 µg/L). The area under the receiver-operating-characteristic curve for serum insulin-like growth factor binding protein-1 was 0.98 0.97-1.00 for the amniotic fluid embolism diagnostic. Insulin-like growth factor binding protein-1 rose from 56 43-90 µg/L before symptoms to 458 161-1514 µg/L after the onset of symptoms in ten patients with available measurements of baseline serum insulin-like growth factor binding protein-1. Increased serum levels of insulin-like growth factor binding protein-1 appear to be a valuable biomarker of amniotic fluid passage into the maternal circulation and may be used to diagnose amniotic fluid embolism.

Intrauterine adhesions (IUA): effect of different etiologies upon surgical outcome

The purpose of this study was to assess the efficacy of therapy for IUA of diffferent etiologies. Retrospective analysis of patients treated by the same surgeon. 1121 patients with IUA were treated over a 33 year period. The apparent causes, presenting menstrual patterns, methods of diagnosis, extent of disease, types and number of precedures performed, methods of follow-up, subsequent menstrual patterns, presence of other infertility factors, use of fertility promoting therapy and pregnancies were recorded. Antecedent factors were curettage for a voluntary or spontaneous abortion (AB), gynecologic surgery (GS) or curettage for a post-partum hemorrhage (PPH). Many in the GS group had used a gonadotropin-releasing hormone agonist (GnRHa) prior to surgery and most in the PPH group continued to lactate after curettage. All patients desired normal menses and most wished to conceive in the near future. If adhesiolysis by hysteroscopy (HSC) proved too difficult and/or if the patient had had a prior uterine perforation, simultaneous laparoscopy (LSC) was performed. Four patients required hysterotomy. After surgery a uterine stent was placed and high dose estrogen therapy was prescribed. Surgery was repeated if IUA persisted. Results were assessed by restoration of menses, by hysterosalpingogram (HSG), mid-cycle untrasound (U/S) and/or occurrence of pregnancy (PG). Significant differences were noted in the therapies required and outcome relative to the apparent cause: TableResults of therapy for IUA compared to apparent etiologyCause (N)HSC onlyHSC/LSC>One ProcedureNormal MensesNormal HSGNormal U/SPgAB (757)72235 (5%) ab53 (7%) ab654/682 (96%) ab706/750 (94%) ab207/225 (92%) ab531/755 (70%) abGS (113)7934 (30%) ac28 (25%) ac29 /113 (26%) ac27/105 (26%) ac7/34 (21%) ac17/111 (15%) acPPH (245)14798 (40%) bc98 (40%) bc118/244 (48%) bc117/225 (52%) bc40/91 (44%) bc78/243 (32%) bcValues in the same column followed by the same letter differ significantly (P<0.005; Chi2). Open table in a new tab Values in the same column followed by the same letter differ significantly (P<0.005; Chi2). IUA formation after either GS or PPH is usually more extensive and more difficult to treat. Prolonged estrogen deficiency may be an important contributing factor to the severity of disease. Current challenges are to anticipate these injuries, to reduce their frequency and severity and to develop techniques that facilitate early diagnosis.