Rate Of Postpartum Hemorrhage Research Articles

Effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries: a systematic review and meta-analysis

BackgroundMidwifery-led care is an evidence-based practice in which a qualified midwife provides comprehensive care for low-risk pregnant women and new-borns throughout pregnancy, birth, and the postnatal period. Evidence indicates that midwifery-led care has positive impacts on various outcomes, which include preventing preterm births, reducing the need for interventions, and improving clinical outcomes. This is, however, mainly based on studies from high-income countries. Therefore, this systematic review and meta-analysis aimed to assess the effectiveness of midwifery-led care on pregnancy outcomes in low- and middle-income countries.MethodsWe used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Three electronic databases (PubMed, CINAHL, and EMBASE) were searched. The search results were systematically screened by two independent researchers. Two authors independently extracted all relevant data using a structured data extraction format. Data analysis for the meta-analysis was done using STATA Version 16 software. A weighted inverse variance random-effects model was used to estimate the effectiveness of midwifery-led care on pregnancy outcomes. Odds ratio with a 95% confidence interval (CI) was presented using a forest plot.ResultsTen studies were eligible for inclusion in this systematic review, of which five studies were eligible for inclusion in the meta-analysis. Women receiving midwifery-led care had a significantly lower rate of postpartum haemorrhage and a reduced rate of birth asphyxia. The meta-analysis further showed a significantly reduced risk of emergency Caesarean section (OR = 0.49; 95% CI: 0.27–0.72), increased odds of vaginal birth (OR = 1.14; 95% CI: 1.04–1.23), decreased use of episiotomy (OR = 0.46; 95% CI: 0.10–0.82), and decreased average neonatal admission time in neonatal intensive care unit (OR = 0.59; 95% CI: 0.44–0.75).ConclusionsThis systematic review indicated that midwifery-led care has a significant positive impact on improving various maternal and neonatal outcomes in low- and middle-income countries. We therefore advise widespread implementation of midwifery-led care in low- and middle-income countries.

Pregnancy, childbirth and neonatal outcomes associated with adolescent pregnancy

ObjectiveTo assess the obstetric and neonatal outcomes associated with adolescent pregnancy in Iran. MethodsWe retrospectively assessed women who gave birth between January 1st, 2020, and January 1st, 2022. These pregnant women were separated into two groups: (1) women aged 19 and younger; (2) women aged 20–34 years. Main outcome measures include preterm birth, maternal comorbidities, preeclampsia, eclampsia, low birth weight (LBW), intrauterine growth restriction (IUGR), placenta abnormalities, placenta abruption, chorioamnionitis, meconium fluid, fetal distress, methods of delivery, rate of cesarean section (CS), perineal lacerations, postpartum hemorrhage, childbirth trauma, shoulder dystocia, congenital malformation, and unfavorable maternal and neonatal outcome. Logistic regression models were used to determine the influence of teenage pregnancy on adverse pregnancy and childbirth outcomes. ResultsOf 7033 deliveries, 92.4% of women were adults, and 7.6% were adolescents. Adolescents residing in rural districts were more common than adults (42.3% vs. 33.7%). However, access to prenatal facility care was the same as the majority of women had 6-10 prenatal care visits during their pregnancy. There was no difference in the risk of preeclampsia, placenta abruption, placenta previa, fetal distress, preterm labor, shoulder dystocia, perineal lacerations, childbirth trauma, congenital malformation, postpartum hemorrhage, intensive care unit admission, maternal death, and unfavorable neonatal outcome including stillbirth, neonatal intensive care unit admission, neonatal death in adolescent pregnancies compared to adults. Adolescents had a significantly higher risk of LBW (OR: 1.47, 95%CI: 1.01–2.73), IUGR (OR: 1.96, 95%CI: 1.31–2.45), and meconium fluid (OR: 1.74, 95%CI: 1.41–2.32), however, there was no statistically significant difference after adjusting the confounding factors. Compared with adults, adolescents had a significantly lower risk of CS (aRR: 0.67, 95%CI: 0.51–0.77) and a lower risk of gestational diabetes (aRR: 0.78, 95%CI: 0.51–0.95). ConclusionsAlthough we found no serious consequences of adolescent pregnancy, more research is needed to reach a more accurate conclusion about teenage pregnancy.

Incidence and risk factors for severe postpartum haemorrhage in women with anterior low-lying or praevia placenta and prior caesarean: prospective population-based study.

To assess the incidence and risk factors for severe postpartum haemorrhage (PPH) in women with an anterior low-lying or praevia placenta, prior caesarean and no prenatal suspicion of placenta accreta spectrum (PAS). Population-based study in 176 maternity units in France. All women with anterior low-lying (0-19 mm from the cervical internal os) or praevia placenta, diagnosed prospectively before birth, prior caesarean and no prenatal suspicion of PAS. Multivariable logistic regression to identify risk factors for severe PPH in the main population and after exclusion of women with PAS diagnosed only at birth. Severe PPH defined by a composite criterion either estimated blood loss of ≥1500 ml, transfusion of ≥4 or more units of packed red blood cells, embolisation or surgical treatment. Of the 520 114 women constituting the source population, 230 (0.44/1000 women; 95% confidence interval [CI] 0.38-0.50) met the inclusion criteria. Severe PPH rate was 24.8% (95% CI 19.2-30.4) overall, 27.5% (95% CI 21.8-33.3) in women with placenta praevia and 15.4% (95% CI 10.7-20.0) in women with low-lying placenta. PAS was diagnosed at birth in 22 women (9.9%; 95% CI 5.8-13.4), although previously unsuspected. After their exclusion, severe PPH incidence was 17.3% (95% CI 12.4-22.2). In multivariate analysis, the only factor associated with a higher severe PPH risk was placenta previa (aOR, 3.65; 95%CI, 1.20-15.8). Severe PPH is frequent among women with anterior low-lying or praevia placenta and prior caesarean, even after exclusion of women with PAS. The risk of severe PPH for those with praevia is nearly twice that with low-lying placenta.

Exploring trends of severe postpartum haemorrhage: a hospital-based study

BackgroundOver the past two decades several high-income countries have reported increased rates of postpartum haemorrhage (PPH). Many of the studies are registry studies with limited access to detailed information. We aimed to explore trends of severe PPH in the largest labour ward in Norway during a 10-year period with a hospital based study. Our population constituted all women who gave birth after week 22 at Oslo University Hospital between 2008 and 2017. The main outcome measure was severe PPH, defined as registered blood loss greater than 1500 ml, or transfusion of blood products due to PPH.MethodsWe estimated the incidence of severe PPH and blood transfusions, and performed temporal trend analysis. We performed Poisson regression analysis to investigate associations between pregnancy characteristics and severe PPH, presented using crude incidence rate ratios (IRR) with 95% confidence intervals (CI)s. We also estimated annual percentage change of the linear trends.ResultsAmong 96 313 deliveries during the 10-year study period, 2621 (2.7%) were diagnosed with severe PPH. The incidence rate doubled from 17.1/1000 to 2008 to 34.2/1000 in 2017. We also observed an increased rate of women receiving blood transfusion due to PPH, from 12.2/1000 to 2008 to 27.5/1000 in 2017. The rates of invasive procedures to manage severe PPH did not increase, and we did not observe a significant increase in the number of women defined with maternal near miss or massive transfusions. No women died due to PPH during the study period.ConclusionWe found a significant increasing trend of severe PPH and related blood transfusions during the 10-year study period. We did not find an increase in massive PPH, or in invasive management, and we suspect that the rise can be at least partly explained by increased awareness and early intervention contributing to improved registration of severe PPH.

Efficacy of early intrauterine balloon tamponade for immediate postpartum hemorrhage after vaginal delivery: a randomized clinical trial

Many questions remain about the appropriate use of intrauterine balloon devices in postpartum hemorrhage after vaginal delivery refractory to first-line uterotonics. Available data suggest that early use of intrauterine balloon tamponade might be beneficial. This study aimed to compare the effect of intrauterine balloon tamponade used in combination with second-line uterotonics vs intrauterine balloon tamponade used after the failure of second-line uterotonic treatment on the rate of severe postpartum hemorrhage in women with postpartum hemorrhage after vaginal delivery refractory to first-line uterotonics. This multicenter, randomized, controlled, parallel-group, nonblinded trial was conducted at 18 hospitals and enrolled 403 women who had just given birth vaginally at 35 to 42 weeks of gestation. The inclusion criteria were a postpartum hemorrhage refractory to first-line uterotonics (oxytocin) and requiring a second-line uterotonic treatment with sulprostone (E1 prostaglandin). In the study group, the sulprostone infusion was combined with intrauterine tamponade by an ebb balloon performed within 15 minutes of randomization. In the control group, the sulprostone infusion was started alone within 15 minutes of randomization, and if bleeding persisted 30 minutes after the start of sulprostone infusion, intrauterine tamponade using the ebb balloon was performed. In both groups, if the bleeding persisted 30 minutes after the insertion of the balloon, an emergency radiological or surgical invasive procedure was performed. The primary outcome was the proportion of women who either received ≥3 units of packed red blood cells or had a calculated peripartum blood loss of >1000 mL. The prespecified secondary outcomes were the proportions of women who had a calculated blood loss of ≥1500 mL, any transfusion, an invasive procedure and women who were transferred to the intensive care unit. The analysis of the primary outcome with the triangular test was performed sequentially throughout the trial period. At the eighth interim analysis, the independent data monitoring committee concluded that the incidence of the primary outcome did not differ between the 2 groups and stopped inclusions. After 11 women were excluded because they met an exclusion criterion or withdrew their consent, 199 and 193 women remained in the study and control groups, respectively, for the intention-to-treat analysis. The women's baseline characteristics were similar in both groups. Peripartum hematocrit level change, which was needed for the calculation of the primary outcome, was missing for 4 women in the study group and 2 women in the control group. The primary outcome occurred in 131 of 195 women (67.2%) in the study group and 142 of 191 women (74.3%) in the control group (risk ratio, 0.90; 95% confidence interval, 0.79-1.03). The groups did not differ substantially for rates of calculated peripartum blood loss pf ≥1500 mL, any transfusion, invasive procedure, and admission to an intensive care unit. Endometritis occurred in 5 women (2.7%) in the study group and none in the control group (P=.06). The early use of intrauterine balloon tamponade did not reduce the incidence of severe postpartum hemorrhage compared with its use after the failure of second-line uterotonic treatment and before recourse to invasive procedures.

The utility of inpatient anemia workup in hemoglobin < 10g/dL diagnosed randomly in the third trimester: a retrospective study.

About 40% of pregnant women are anemic and at an increased risk for complications. We examined the efficacy of inpatient anemia workup and treatment in pregnant women diagnosed with moderate-severe anemia (hemoglobin < 10mg/dL), during hospitalization in the late second-trimester and third-trimester. This retrospective study, conducted between March 2020 and November 2022, included women at ≥ 24 gestational weeks who were hospitalized due to various indications and diagnosed with anemia (hemoglobin < 10mg/dL). The study group comprised women who underwent an inpatient anemia workup and initiation of anemia treatment. The comparison group comprised women who did not undergo an inpatient anemia investigation. The primary outcome was the rate of pre-delivery hemoglobin > 11g/dL. The most frequent etiology of anemia in the study group (n = 188) was iron-deficiency anemia (30.2%), followed by mixed anemia of iron, folate and vitamin-B12 deficiencies (20.7%). In the study vs. the comparison group (n = 179), the rate of pre-delivery hemoglobin > 11g/dL was higher, and the increase in hemoglobin from intervention to delivery was greater. The ideal timing for anemia intervention for maximizing the increase in pre-delivery hemoglobin was 6-weeks or more prior to delivery. The rates of postpartum hemorrhage and blood transfusions were similar. The rate of postpartum hemoglobin < 10g/dL was lower in the study than the comparison group. Inpatient anemia investigation and treatment resulted in higher peri-delivery hemoglobin. In women randomly diagnosed with anemia at hospitalization, the rate of pre-delivery hemoglobin > 11g/dL was increased among those who underwent a simple anemia investigation and treatment initiation.

Application of the PDCA cycle for implementing the WHO Safe Childbirth Checklist in women with vaginal deliveries.

The World Health Organization Safe Childbirth Checklist (SCC) has been recommended globally. However, the results are inconsistent. The aim of this study was to investigate the effectiveness of implementing the SCC based on plan-do-check-act (PDCA) cycle management. From November 2019 to October 2020, women who were hospitalized and had vaginal deliveries were enrolled in this study. Before October 2020, the PDCA cycle was not applied for the SCC, and women who had vaginal deliveries were included in the pre-intervention group. From January 2021 to December 2021, the PDCA cycle was applied for the SCC, and women who had vaginal deliveries were included in the post-intervention group. The SCC utilization rate and the incidence of maternal and neonatal complications were compared between the 2 groups. The SCC utilization rate in the post-intervention group was higher than that in the pre-intervention group (P < .01). The postpartum infection rate in the post-intervention group was lower than that in the pre-intervention group, and the difference was statistically significant (P < .05). After the intervention, postpartum hemorrhage, neonatal mortality, and neonatal asphyxia rates were also reduced, although no significant differences were observed between the 2 groups. There was no significant difference in the third-degree perineal laceration or neonatal intensive care unit hospitalization rate between the 2 groups (P > .05). Application of the PDCA cycle can improve the SCC utilization rate, and the SCC combined with the PDCA cycle can effectively reduce the postpartum infection rate.

Implementation of glucose 5% supplementation protocol to reduce the duration of labor among women with cervical ripening by prostaglandins: The GLUCOSHORT before-and-after study.

Previous publications have shown that glucose supplementation could reduce labor duration in women with induction of labor with a favorable cervix but none have shown it for women with an unfavorable cervix. The purpose of our study was to assess the impact on labor duration of a protocol of glucose supplementation used for induction of labor in women with an unfavorable cervix. The protocol implemented in November 2017 added glucose supplementation by 5% dextrose at 125mL/h to Ringer lactate for women with an unfavorable cervix with labor induced with dinoprostone gel. The study included women who underwent this protocol with a singleton, term, cephalic fetus from June 2017 through April 2018. The primary outcome was the labor duration. The secondary outcomes were mode of delivery, postpartum hemorrhage rate, neonatal outcomes, and durations other stage of labor. These outcomes were compared between the pre-intervention (from June 1 to October 31, 2017) and post-intervention (from December 1, 2017 to April 30, 2018) periods. The pre-intervention period included 116 women, and the post-intervention period 123. The characteristics of women and the induction of labor were similar in the two periods. The median duration from induction to delivery was not significantly different between the two periods (13.2h, IQR 9.1-18.6 versus 13.6h IQR 9.3-18.3, P=.67). The secondary outcomes did not differ significantly between the two groups. Glucose supplementation administered to women with an unfavorable cervix undergoing induction does not appear to reduce the induction-delivery duration.

Understanding the Effect of Expectant Versus Expedited Delivery in the Periviable Period [ID: 1376738

INTRODUCTION: Periviable birth accounts for only 0.5% of births but contributes to a majority of neonatal deaths. There is no clear recommendation regarding expediting delivery in periviable patients with advanced cervical dilation (ACD). The objective of this study was to assess whether expectant management versus expedited delivery in patients with ACD affects perinatal outcomes. METHODS: This is a single-institution retrospective cohort study of singleton gestations at 20.0–25.6 weeks with ACD (4–6 cm) on admission from 2016 to 2018. Individuals were stratified into two groups: 1) those who progressed spontaneously to delivery (expectant management) and 2) those who underwent augmentation of labor or cesarean delivery at the time of ACD diagnosis (expedited delivery). The primary outcome was neonatal mortality. Secondary outcomes included differences in postpartum hemorrhage and infection rates. RESULTS: Forty-three of 199 preterm deliveries met eligibility criteria: 21 were expectantly managed and 22 underwent expedited delivery. There was no difference in demographic characteristics or gestational age between the expectant management and expedited delivery groups (23′1 [SD 1.65] versus 24′4 [SD 3.05] weeks, [P=.9]). There was no difference in neonatal mortality (n=13 [61.9%] versus n=10 [45.5%], P=.3), maternal infection (n=1 [4.76%] versus n=4 [18.2%], P=.3) or postpartum hemorrhage (n=2 [9.5%] versus n=1 [4.5%], P=1.0) between the expectant management and expedited delivery groups, respectively. CONCLUSION: In this cohort, there were no differences in neonatal mortality, maternal infection, or postpartum hemorrhage between expectant management and expedited delivery in singletons with ACD in the periviable period. Larger studies are needed to inform guidelines for management of these complex cases.

Recent Trends in Tranexamic Acid Use During Postpartum Hemorrhage in the United States [ID: 1380480

INTRODUCTION: The United States has one of the highest rates of maternal mortality among developed regions, and postpartum hemorrhage (PPH) accounted for 14% of all pregnancy-related deaths between 2017 and 2019. Several large studies have demonstrated decreased PPH rates with the use of tranexamic acid (TXA). Consensus has not yet been reached on the when to administer use of TXA. Little data exist regarding the prevalence of TXA use in obstetric patients with and without PPH. METHODS: Using a national database, we identified over 1.2 million pregnancies between January 1, 2015, and June 30, 2021. Pregnancy and delivery information was abstracted using ICD-10 codes. The GW Institutional Review Board approved the study protocol and waived the requirement for patient informed consent. RESULTS: Overall, TXA was used 1% of the time (12,394/1,262,574), and there was a fivefold increase in TXA use (0.5–2.5%) during the study period. Patients had similar demographic characteristics. Tranexamic acid use differed by geographic region. The use of TXA increased in both patients with PPH and those without. There was a greater increase in the number of patients who received TXA for prophylaxis of PPH than those who received it as treatment of PPH. CONCLUSION: This is the largest U.S. observational study to examine patterns of TXA use in obstetrics. Tranexamic acid was only administered in approximately 10% (4,586/43,928) of cases of PPH. This represents an opportunity to increase awareness for the role of TXA in management and prevention of PPH.

Descriptive statistical study of the most important possible causes of obstetric and postpartum hemorrhage in Thi-Qar province

The aim of the study is to describe and analyze the most important causes that lead to postpartum hemorrhage. This research was carried out at The Bent al-Huda Hospital for Maternity and Children's Hospital in Nasiriyah, where the study included (63) cases of women with postpartum hemorrhage from the reviews of the hospital for the period from February 2020 to December 2020 as shown in the hospital records, and collected information for the study through a simple questionnaire, including information: age of women, place of residence, place of birth, type of birth and causes of hemorrhage. Age groups between (40-44) accounted for (22?), (35-39), which are the highest age groups at risk of postpartum hemorrhage. The most frequent deliveries take place in the hospital, because natural or cesarean deliveries increase in this percentage. The results of the current study also show that there is no difference between natural childbirth and caesarean section with the occurrence of postpartum hemorrhage , that the condition of non-constriction of the uterus (inertia of uterus) constitutes (30%) and is considered the highest percentage among the causes of hemorrhage after birth, and then the causes such as the remnants of part of the placenta and the frequency of caesarean section by (16%), the use of accelerated medicines for childbirth and by percentage (14%) while the other causes came in low rates of cases postpartum hemorrhage.

Bleeding disorders and postpartum hemorrhage by mode of delivery: a retrospective cohort study

BackgroundPregnant persons with bleeding disorders and their potentially affected newborns are at a higher risk of peripartum bleeding complications. The safest mode of delivery for persons with bleeding disorders remains debated, leading to uncertainties in decision-making between the patient and her multidisciplinary team. ObjectivesThis study aimed to describe maternal outcomes for pregnant persons with bleeding disorders by mode of delivery and to examine whether postpartum hemorrhage (PPH) and neonatal hemorrhagic manifestations are associated with the mode of delivery. MethodsWe collected retrospective data on pregnant persons with bleeding disorders who delivered at a single center from 2010 to 2021. Descriptive statistics, Fisher exact test, and odds ratios were used for analysis. ResultsA total of 82 pregnancies in 56 subjects were included. Hemophilia A and von Willebrand disease represented the largest cohort, at 30% (17/56) each. Overall rates of primary and secondary PPH were 7.3% (6/82) and 17.4% (12/69), respectively. We did not find a statistically significant difference between mode of delivery and PPH. Upon comparing vaginal and cesarian deliveries, we found an odds ratio of 0.7 (95% CI, 0.1-3.4) for primary PPH and 2.6 (95% CI, 0.4-16.4) for secondary PPH. One male newborn with severe hemophilia A was treated for a suspected intracranial hemorrhage. ConclusionIn our cohort, high rates of PPH remained an important complication for pregnant persons with bleeding disorders. There was no significant difference in PPH based on modes of delivery. The small sample size likely limited the power of our study, and consequently, future larger studies are needed.

Increased maternal morbidity and mortality among Asian American and Pacific Islander women in the military health system

Rates of maternal morbidity and mortality experienced by women in the United States have been shown to vary significantly by race, most commonly attributed to differences in access to healthcare and socioeconomic status. Recent data showed that Asian Pacific Islanders have the highest rate of maternal morbidity despite having a higher socioeconomic status. In the military, women of all races are granted equal access to healthcare, irrespective of socioeconomic class. We hypothesized that within the military, there would be no racial disparities in maternal outcomes because of universal healthcare. This study aimed to evaluate if universal access to healthcare, as seen in the military healthcare system, leads to similar rates of maternal morbidity regardless of racial or ethnic background. This was a retrospective cohort study of data from the National Perinatal Information Center reports obtained from participating military treatment facilities from April 2019 to March 2020 and included 34,025 deliveries. We compared racial differences in the incidence of each of the following 3 outcomes: postpartum hemorrhage, severe maternal morbidity among women with postpartum hemorrhage including transfusion, and severe maternal morbidity among women with postpartum hemorrhage excluding transfusion. A total of 41 military treatment facilities (a list of participating military treatment facilities are provided in the Appendix) provided data that were included. There was an increased rate of postpartum hemorrhage (relative risk, 1.73; 95% confidence interval, 1.45-2.07), severe maternal morbidity including transfusion (relative risk, 1.22; 95% confidence interval, 0.93-1.61), and severe maternal morbidity excluding transfusion (relative risk, 1.97; 95% confidence interval, 1.02-3.8) among Asian Pacific Islander women when compared with Black or White women. Even with equal access to healthcare in the military, Asian Pacific Islander women experience statistically significant increased rates of postpartum hemorrhage and severe maternal morbidity excluding transfusion when compared with Black or White women. The increased rates of severe maternal morbidity including transfusion were not statistically significant.

Investigation of Intrapartum Parenteral Magnesium Sulfate as an Independent Risk Factor for Postpartum Hemorrhage Using Quantitative Blood Loss Assessment

Magnesium sulfate is used for seizure prophylaxis in preeclampsia and for fetal neuroprotection when delivery is anticipated before 32 weeks of gestation. Existing risk assessment tools for postpartum hemorrhage often identify the use of magnesium sulfate as an intrapartum risk factor. Previous studies examining the association between the use of magnesium sulfate and postpartum hemorrhage have relied largely on qualitative estimates of blood loss rather than quantitative estimates of blood loss. This study aimed to determine whether intrapartum administration of magnesium sulfate is associated with an increased risk of postpartum hemorrhage using a quantitative blood loss assessment via the use of graduated drapes and weight differences in surgical supplies. This case-control study was conducted to test the hypothesis that intrapartum parenteral administration of magnesium sulfate is not independently associated with postpartum hemorrhage. All deliveries at our tertiary-level academic medical center between July 2017 and June 2018 were reviewed. Of note, 2 categories of postpartum hemorrhage were defined: the traditional definition (>500 mL for vaginal delivery and >1000 mL for cesarean delivery) and the contemporary definition (>1000 mL regardless of delivery mode). Statistical analyses using the chi-square test, Fisher exact test, t test, or Wilcoxon rank-sum test were performed to compare the patients who did and did not receive magnesium sulfate concerning the rates of postpartum hemorrhage, pre- and postdelivery hemoglobin level, and rates of blood transfusion. A total of 1318 deliveries were included, with postpartum hemorrhage rates of 12.2% (traditional definition) and 6.2% (contemporary definition). Multivariate logistic regression did not find the use of magnesium sulfate as an independent risk factor by either definition (odds ratio, 1.44 [95% confidence interval, 0.87-2.38] and 1.34 [95% confidence interval, 0.71-2.54]). The only significant independent risk factor was cesarean delivery, by both definitions (odds ratio, 2.71 [95% confidence interval, 1.85-3.98] and 19.34 [95% confidence interval, 8.55-43.72]). In our study population, intrapartum administration of magnesium sulfate was not found to be an independent risk factor for postpartum hemorrhage. Cesarean delivery was determined as an independent risk factor, consistent with previous reports.

Low-dose asprin use during pregnancy may be a potential risk for postpartum hemorrhage and increased blood loss: a systematic review and meta-analysis.

The association between aspirin use during pregnancy and the risk of postpartum hemorrhage remains unclear. This study aimed to explore the incidence of postpartum hemorrhage and the amount of postpartum blood loss among women who used aspirin during pregnancy. From inception to October 2022, this study searched the following databases: MEDLINE, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials. Studies comparing pregnancy outcomes that covered the incidence of postpartum hemorrhage or the amount of postpartum blood loss in pregnancies with aspirin vs placebo (or no aspirin) were included. Reviewers separately ascertained studies, obtained data, and gauged study quality. The meta-analysis was conducted using a random effects model owing to the probable heterogeneity of the included studies. The rates of postpartum hemorrhage or the mean amounts of postpartum blood loss were compared, and the odds ratios or mean differences with 95% confidence intervals were estimated. Of note, 2 parts performed both a pooled analysis of randomized controlled trials and cohort studies and a separate analysis of randomized controlled trials. Overall, 21 studies with 373,926 women were included in the postpartum hemorrhage part, and 7 studies with 10,163 women were included in the postpartum blood loss part. The results suggested that aspirin (dose 60-150mg a day) use during pregnancy was associated with an increased incidence of postpartum hemorrhage (odds ratio, 1.20; 95% confidence interval, 1.07-1.34). When only randomized controlled trials were retained, the results remained significant (odds ratio, 1.12; 95% confidence interval, 1.00-1.25). In the second part, higher total blood loss after delivery was obtained (mean difference, 12.85 mL; 95% confidence interval, 3.28-22.42), and the result was unaltered when cohort studies were eliminated (mean difference, 13.72 mL; 95% confidence interval, 4.63-22.81). The conclusions are more likely to be obtained in developed countries. Low-dose aspirin use during pregnancy is a potential risk of postpartum hemorrhage and does slightly increase the amount of postpartum blood loss. Without denying the combined value of aspirin, our conclusions raised an alarm for clinicians about postpartum hemorrhage in women using aspirin during pregnancy.

Focal-occult placenta accreta: a clandestine source of maternal morbidity

Focal-occult placenta accreta spectrum is known to cause adverse obstetrical morbidity outcomes, however, direct comparisons with previa-associated placenta accreta spectrum morbidity are lacking. We sought to compare the baseline characteristics, surgical and obstetrical morbidity, and subsequent pregnancy outcomes of patients with focal-occult placenta accreta spectrum with those of patients with previa-associated accreta. A retrospective review was conducted of all pathologically confirmed placenta accreta spectrum cases from 2018 to 2022 at a tertiary care center. The baseline characteristics, surgical, obstetrical, and subsequent pregnancy outcomes were recorded. Cases of focal-occult placenta accreta spectrum was compared with cases of previa-associated placenta accreta spectrum across a range of morbidity characteristics including hemorrhagic factors, interventions, postdelivery reoperations, infections, and intensive care unit admission. Statistical comparison was performed using Kruskal-Wallis or chi-square tests, and a P value of <.05 was considered significant. A total of 74 cases were identified with 43 focal-occult and 31 previa-associated placenta accreta spectrum cases. Of those, 25.6% of the patients with focal-occult placenta accreta spectrum and 100% of the patients with previa-associated placenta accreta spectrum underwent a hysterectomy. One case of focal-occult placenta accreta spectrum and 29 cases of previa-associated placenta accreta spectrum were diagnosed antenatally. Patients with focal-occult placenta accreta spectrum did not differ from those with previa-associated placenta accreta spectrum in mean maternal age (33.0 vs 33.1 years), body mass index, or the incidence of previous dilation and curettage procedures (16.3% vs 25.8%). Patients with focal-occult placenta accreta spectrum were significantly more likely to have a lower mean parity (1.5 vs 3.6 gestations), higher gestational age at delivery (36.1 vs 33.9 weeks' gestation), and were less likely to have had a previous cesarean delivery (12/43, 27.9% vs 30/31, 96.8%). In addition, patients with focal-occult placenta accreta spectrum had less previous cesarean deliveries (mean, 0.5 vs 2.3), were more likely to have undergone in vitro fertilization (20.9% vs 3.2%), and less likely to have anterior placentation. When contrasting the clinical outcomes of patients with focal-occult placenta accreta spectrum with those with previa-associated placenta accreta spectrum, the postpartum hemorrhage rates (71.0% vs 67.4%), mean quantitative blood loss (2099 mL; range, 500-9516 mL vs 2119 mL; range 350-12,220 mL), mean units of red blood cells transfused (1.4 vs 1.7), massive transfusion rate (9.3% vs 3.2%), and intensive care unit admission rates (11.6% vs 6.5%) were not significantly different, but there was a nonsignificant trend toward higher morbidity among patients with focal-occult accreta. Patients with focal-occult accreta had a higher incidence of reoperations or return to the operating room (30.2 vs 6.5%; P=.01). When comparing focal-occult with previa-associated placenta accreta spectrum, the composite outcomes, including hemorrhagic morbidity (77.4% vs 74.4%), any maternal morbidity (83.9% vs 76.7%), and severe maternal morbidity (64.5% vs 65.1%), were not significantly different between the groups. Nine focal-occult placenta accreta spectrum patients had a subsequent pregnancy, and 3 of those had recurrent placenta accreta spectrum. Focal-occult placenta accreta spectrum presents with fewer identifiable risk factors than placenta previa-associated placenta accreta spectrum but may be associated with an in vitro fertilization pregnancy. Patients with focal-occult placenta accreta spectrum was observed to have a higher incidence of reoperation when compared with patients previa-associated placenta accreta spectrum, and no other statistically significant differences in morbidity outcomes were observed. The absence of differences in morbidity outcomes may be attributable to a lack of antenatal detection of focal-occult accreta and merits further investigation.

All Children Deserve to Be Safe, Mothers Too: Evidence and Rationale Supporting Continuous Glucose Monitoring Use in Gestational Diabetes Within the Medicaid Population.

Gestational diabetes mellitus (GDM) is a common metabolic disease of pregnancy that threatens the health of several million women and their offspring. The highest prevalence of GDM is seen in women of low socioeconomic status. Women with GDM are at increased risk of adverse maternal outcomes, including increased rates of Cesarean section delivery, preeclampsia, perineal tears, and postpartum hemorrhage. However, of even greater concern is the increased risk to the fetus and long-term health of the child due to elevated glycemia during pregnancy. Although the use of continuous glucose monitoring (CGM) has been shown to reduce the incidence of maternal and fetal complications in pregnant women with type 1 diabetes and type 2 diabetes, most state Medicaid programs do not cover CGM for women with GDM. This article reviews current statistics relevant to the incidence and costs of GDM among Medicaid beneficiaries, summarizes key findings from pregnancy studies using CGM, and presents a rationale for expanding and standardizing CGM coverage for GDM within state Medicaid populations.

High glucose induced HIF-1α/TREK1 expression and myometrium relaxation during pregnancy.

The incidence of gestational diabetes mellitus (GDM) is increasing worldwide. GDM patients have a significantly higher rate of cesarean section and postpartum hemorrhage, suggesting changes in uterine contractility. TWIK-1-related potassium channel (TREK1) expressed in the pregnant uterus and its role in uterine contraction. In this study, we examined the expression of HIF-1α and TREK1 proteins in GDM uterine and investigated whether high glucose levels are involved in the regulation of human uterine smooth muscle cells (HUSMCs) contraction through TREK1, and verified the role of HIF-1α in this process. Compared the uterine contractility between GDM and normal patients undergoing elective lower segment cesarean section. The HUSMCs were divided into normal glucose group, high glucose group, normal glucose with CoCl2 group, CoCl2 with echinomycin/L-Methionine group, and high glucose with echinomycin/L-Methionine group; Compare the cell contractility of each group. Compared the expression of hypoxia-inducible factor-1α (HIF-1α) and TREK1 protein in each group. The contractility of human uterine strips induced by both KCl and oxytocin was significantly lower in patients with GDM compared with that in normal individuals, with increased TREK1 and HIF-1α protein expression. The contractility of cultured HUSMCs was significantly decreased under high glucose levels, which was consistent with increased expression of HIF-1α and TREK1 proteins. The contractility of HUSMCs was decreased when hypoxia was induced by CoCl2 and increased when hypoxia was inhibited by echinomycin. The TREK1 inhibitor L-methionine also recovered the decreased contractility of HUSMCs under high glucose levels or hypoxia. The high glucose levels decreased the contractility of the myometrium, and increased expression of HIF-1a and TREK1 proteins play a role in changes in uterus contractility.

Recent trends in tranexamic acid use during postpartum hemorrhage in the United States.

Postpartum hemorrhage (PPH) was the second leading cause of maternal death, accounting for approximately 14% of all pregnancy-related deaths between 2017 and 2019 in the United States. Several large multi-center studies have demonstrated decreased PPH rates with the use of tranexamic acid (TXA). Little data exists regarding the prevalence of TXA use in obstetric patients. We identified over 1.2million US pregnancies between January 1, 2015 and June 30, 2021, with and without PPH by International Statistical Classification of Disease and Related Health Problems, Tenth Revision codes using Cerner Real-World Database™. TXA use and patient characteristics were abstracted from the electronic medical record. During delivery, TXA was used approximately 1% of the time (12,394 / 1,262,574). Pregnant patients who did and did not receive TXA during delivery had similar demographic characteristics. Pregnant patients who underwent cesarean delivery (4,356 / 12,394), had a term delivery (10,199 / 12,394), and had comorbid conditions were more likely to receive TXA during hospitalization for delivery. The majority of TXA was use was concentrated in Arizona, Colorado, Idaho, New Mexico, Nevada, Utah, and Wyoming. During the study period the use of TXA increased in both patients with PPH and those without. The data illustrate a rapid increase in the use of TXA after 2017 while the total number of pregnancies remained relatively constant. The observed increase in TXA use may reflect changing practicing patterns as the support for use of TXA in the setting of PPH prophylaxis increases.

Repeat uterine artery embolization (UAE) for recurrent postpartum hemorrhage in patients who underwent UAE after a previous delivery: a multicenter study.

To evaluate angiographic findings and outcomes of repeat uterine artery embolization (UAE) for recurrent postpartum hemorrhage (PPH) in patients who previously underwent UAE for PPH after a previous delivery. Among 1805 patients who underwent UAE for PPH from 2007 to 2020 at four participating hospitals, the data of 21 (1.16%) patients who underwent UAE for PPH after subsequent delivery were collected and analyzed retrospectively. The rate of placental abnormalities, causes of PPH, angiographic findings, and clinical success rate were evaluated. The technical success rates were 100% and 95.2%, and clinical success rates were 85.7% and 95.2% in association with first and second UAEs, respectively. The time intervals between first and second UAEs ranged from 15.6 to 103.3months (46.5 ± 25.0months). The rate of placental abnormalities was significantly higher in association with second UAEs than with first UAEs (71.4% vs. 42.8%, p = 0.034). The causes of PPH were different between first and second UAEs with borderline significance (p = 0.049); uterine atony (81.0%) and placenta accreta spectrum (57.1%) were most common in association with first and second UAEs, respectively. During second UAEs, obliterated arteries were observed in 27 uterine arteries (27/42, 64.3%) of 16 patients (16/21, 76.2%), with partial obliteration predominating over total obliteration. Collateral arteries were observed in 15 patients during second UAEs. Repeat UAE is safe and effective for recurrent PPH after subsequent delivery in patients with prior UAE. Obliteration of UAs and formation of collateral arteries are common at the second UAEs. • The rate of placental abnormalities was significantly higher in association with second UAEs than with first UAEs (71.4% vs. 42.8%, p = 0.034). • Obliteration of UAs and formation of collateral arteries are common at the second UAEs. • Repeat UAE is safe and effective for recurrent PPH after subsequent delivery in patients with prior UAE.