Previous Postpartum Hemorrhage Research Articles

Breastfeeding Update 2: Clinical Lactation Management

Breastfeeding Update 2: Clinical Lactation Management

Postpartum haemorrhage

Most cases of postpartum haemorrhage are caused by uterine atony, maternal soft-tissue trauma, retained placenta or its parts, and obstetric coagulopathy. The factors most significantly associated with haemorrhage include advanced maternal age, prolonged labour, pre-eclampsia, obesity of mother, multiple pregnancy, a birth weight of more than 4000g, and previous postpartum haemorrhage. It seems that multiparity itself is only a weakly associated factor. The prophylactic use of oxytocic drugs (oxytocin or its combination with ergometrine at the third stage of labour is always recommended for decreasing the bleeding. Prostaglandins should be used as a second line treatment if uterine atony cannot be abolished by uterine massage and oxytocin infusion. In the surgical management, the role of hypogastric artery ligation is decreasing. The stepwise uterine devascularization may be a reasonable method in the most severe uncontrollable postpartum bleeding. The uterine tamponade with gauze or specific tubes may also be a useful alternative in some cases. Selective arterial embolization is a promising new method that seems to have success in controlling the heavy postpartum bleeding unresponsive to more usual measures. However, the value of this method should be evaluated in bigger series.

Prediction of Hemorrhage at Cesarean Delivery

To identify and quantitate the risk factors that might be predictive of hemorrhage during abdominal delivery. Over a 2-year period, 1610 women underwent cesarean delivery and 127 (7.9%) had hemorrhage, defined as a decrease in hematocrit of 10% or greater, estimated blood loss greater than 1500 mL, or packed red blood cell administration. These women were compared through a case-control study design with the next abdominal birth without hemorrhage that could be matched for age, parity, indication for cesarean delivery, type of anesthesia, type of skin incision, and antepartum hematocrit. Preeclampsia (odds ratio 3.6, 95% confidence interval [CI] 1.8-7.4), disorders of active labor (odds ratio 4.4, 95% CI 1.4-13.7), Native American ethnicity (odds ratio 6.4, 95% CI 1.8-22.4), previous postpartum hemorrhage (odds ratio 8.4, 95% CI 1.9-37.4), and obesity of greater than 250 lb (odds ratio 13.1, 95% CI 1.7-102.7) were all statistically associated with significant bleeding during abdominal delivery. Combinations of two or more of these factors were associated with a markedly increased risk for hemorrhage, with odds ratios of 18.4 or greater. Patients undergoing cesarean delivery who have factors exposing them to increased risk of hemorrhage can be identified prospectively. These women will benefit greatly from extended preoperative counseling when possible, effective utilization of blood bank technology through type and cross-match requests, and preventive measures during abdominal delivery to minimize blood loss.

Hypopituitarism: a difficult diagnosis in elderly people but worth a search.

Hypopituitarism is uncommon in elderly people. We report 12 cases of hypopituitarism diagnosed after the age of 60 (range 63-89, mean 74.9) years over a 10-year period. Aetiology was evident in eight cases, viz. pituitary tumour in six and previous post-partum haemorrhage and giant aneurysm of carotid artery in one each. The presentation was often non-specific with symptoms such as lethargy, pallor, falls, urinary incontinence, confusion, fever and flexion contractures. Subtle clues to the condition were missed in four cases resulting in delayed diagnosis. Although levels of pituitary trophic hormones are generally low in this condition, the thyrotrophin (TSH) was normal in seven cases in the present series. Normal levels of serum sodium and potassium did not exclude cortisol deficiency. Hormone replacement therapy resulted in improved quality of life. Physicians dealing with elderly patients should bear this easily treated condition in mind.

Management of the third stage of labour in women at low risk of postpartum haemorrhage

Objective: To compare active management with physiological management of the third stage of labour in women at low risk of postpartum haemorrhage. Design: Randomised allocation of women in labour at low risk of postpartum haemorrhage to either physiological or active management of the third stage. Setting: Labour ward in a district general hospital. Patients: 193 Women with spontaneous vaginal delivery at term completed the study. Exclusion criteria were induction or augmentation of labour, antepartum or previous postpartum haemorrhage, premature rupture of membranes, previous caesarean section, raised blood pressure, cervical lacerations and third degree tears. Interventions: Active management with syntometrine and controlled cord traction; or physiological management, where the cord was not clamped and the placenta was delivered by maternal effort. Measurements: Blood loss was measured subjectively at delivery and estimated objectively by comparing the haemoglobin in labour with that on the third postpartum day. The duration of the third stage was also measured as was the incidence of retained placenta and blood transfusion. Results: There was no significant difference in the estimated blood loss or haemoglobin drop between the two groups ( P > 0.5). In addition the duration of the third stage was significantly longer in the physiological group ( P < 0.001). Out of 90 women having physiological management, 7 received oxytocics for presumed postpartum haemorrhage. Only one case in the active group required further oxytocics and one other case in this group required a manual removal of placenta. Conclusions: This preliminary study confirms that active management results in a reduction in the length of the third stage of labour. However, it suggests that active management does not reduce blood loss when compared to physiological management in the woman at low risk of postpartum haemorrhage.

Maternal health antecedents of infant and early childhood mortality and morbidity.

The article reviews the maternal demographic factors the availability and accessibility of health care services preconceptual care risk assessment breast feeding the training of traditional birth attendants (TBAs) adolescent health care and family planning (FP) as antecedents of infant and early childhood mortality and morbidity. The maternal demographic factors which affect infant outcome are the age of the mother the mothers age at marriage marital status education poverty and family size and use of FP. Many of the maternal demographic factors are closely associated with insufficient prenatal care. Prenatal care services need to be easily available and accessible to all and be culturally sensitive. Understanding of a womans nutritional needs and broader living conditions is also needed. Tetanus immunization is required. Low birth weight can be reduced with early and regular high quality prenatal care. Womens general health before pregnancy can be assured with good personal habits nutrition treatment for medical conditions and safe environmental conditions. Preconceptual care involves risk assessment health promotion immunization against tetanus and intervention and followup. Only low risk women should deliver at home. Criteria for high risk need to be identified and might include: cephalopelvic disproportion in short women hemorrhage in a high parity or a history of previous postpartum hemorrhage and previous history of complications in pregnancy labor and delivery. Breast feeding particularly through the hazardous period of infancy is recommended. Nutrition of lactating women is an important consideration TBAs should be trained in hand-washing and safe umbilical cord care as well as more comprehensive training in anemia screening recognition of twins and abnormal presentations by palpation application of prophylactic eye ointment and assessment of at-risk pregnancies. Women should be referred for prenatal care and FP services. Predisposing factors to infant mortality may be grand multiparity poor nutrition unwanted pregnancy and overwork. FP can help birth spacing of more than 2 years and provide protection for young and older women. Health education and family life education are also needed.

Anterior Pituitary Function in Women with Postpartum Hemorrhage

Thirteen asymptomatic women with postpartum blood loss of at least 500 cc were evaluated for anterior pituitary endocrine function. Insulin tolerance tests and TRH stimulation tests were done and determinations made for serum growth hormone, cortisol, thyrotropin, and prolactin. There was no laboratory evidence of pituitary dysfunction in this group of 13 patients. Subclinical hypopituitarism in women with previous postpartum hemorrhage would appear to be uncommon.

Anterior Pituitary Function in Women with Postpartum Hemorrhage

Thirteen asymptomatic women with postpartum blood loss of at least 500 cc were evaluated for anterior pituitary endocrine function. Insulin tolerance tests and TRH stimulation tests were done and determinations made for serum growth hormone, cortisol, thyrotropin, and prolactin. There was no laboratory evidence of pituitary dysfunction in this group of 13 patients. Subclinical hypopituitarism in women with previous postpartum hemorrhage would appear to be uncommon.