Rate Of Postpartum Hemorrhage Research Articles

Effects of COVID-19 Vaccination on Nebraska Maternal Health Outcomes [ID 2683619

INTRODUCTION: When the COVID-19 vaccine was developed, there were many concerns about the risk–benefit profile, especially in pregnancy. The purpose of this study was to elucidate the effect of COVID-19 vaccination on maternal health outcomes. METHODS: An IRB-approved, retrospective analysis was performed using data from CHI Nebraska's 2021 EPIC health records to determine whether maternal COVID-19 vaccination prior to delivery in previously healthy, primigravid women aged 18–35 affected maternal health outcomes. The outcomes studied included preterm delivery, eclampsia, gestational diabetes, preeclampsia, placental abruption, placenta previa, and postpartum hemorrhage. RESULTS: Of the 7,997 patients analyzed, 1,220 were vaccinated for COVID-19 prior to their delivery date. Compared to patients that were not vaccinated, vaccinated patients had statistically significant increased rates of gestational diabetes and preeclampsia (odds ratio [OR] 1.31; P=.02103; OR 1.47, P=.00589). Vaccinated patients were also found to have increased rates of eclampsia, placenta previa, preterm delivery, and postpartum hemorrhage, but these were not statistically significant. Clinically, these differences between vaccinated and nonvaccinated patients were small for all outcomes tested, all being less than 2%. CONCLUSION: Although our research was restricted by accessibility of the vaccine in early 2021, it illustrated that vaccinated individuals did not experience any significant increase in eclampsia, placenta previa, postpartum hemorrhage, or preterm delivery compared to the unvaccinated. We found that history of COVID-19 vaccination correlated with a small, yet significant increased rate of gestational diabetes and preeclampsia. Further research should be done to further elucidate how the vaccination affects health outcomes as they pertain to pregnancy.

Pregnancy Outcomes in Patients with Prosthetic Heart Valves in Saudi Arabia

Background: Pregnancies in women with heart prostheses are high-risk pregnancies with increased maternal and fetal adverse outcomes. Advances in prosthetic heart valve design and anticoagulation have improved these outcomes over the past decades. Objectives: To study the pregnancy outcomes in pregnancies with heart prostheses and to compare these outcomes between mechanical and biosynthetic heart prostheses in Saudi patients. Methods: In this single centered retrospective study conducted at King Saud Medical City (KSUMC) between January 2011 and February 2020, we have reviewed all pregnant women’s heart prostheses. Fetal and maternal data were obtained, and outcomes were compared between pregnancies with mechanical heart prostheses and bioprostheses. Results: A total of 111 pregnancies were reviewed. A total of 51.4% of pregnancies had bioprostheses, 48.6% had mechanical prostheses, and 64.0% of participants were obese. The majority of the participants had a parity in the range of 2-9 (N=107, 96.4%). The most frequent type of rheumatic heart disease was mitral regurgitation (N=49, 44.1%), followed by mitral stenosis (N=32, 28.8%). There was no maternal mortality and no structural valve failure. There was a high rate of hospital admission in both groups, up to 55% of pregnancies. The rates of abortion, postpartum hemorrhage and transfusions were higher than those in general pregnancies; however, there was no difference in maternal and fetal complications between the two types of prostheses, i.e., bioprostheses and mechanical. Conclusion: Although women with prosthetic heart valves have higher rates of adverse outcomes, they generally tolerate pregnancy well. There was no difference in adverse outcomes between bioprosthetic and mechanical prostheses

Effects of magnesium sulfate combined with labetalol on inflammatory stress and pregnancy outcome of patients with gestational hypertension.

Gestational hypertension (GH) is a common disorder during pregnancy that can cause adverse pregnancy outcomes. In the present study, magnesium sulfate (MgSO4) combined with labetalol was used for clinical treatment. Randomized controlled trial was conducted in 100 patients with GH, documented in the Department of Obstetrics and Gynecology (Taicang TCM Hospital) grouped into the experimental (Expt) and control (Ctrl) groups (n=50 cases/group). The Ctrl group was treated with MgSO4, whereas the Expt group was treated with MgSO4 + labetalol. The systolic blood pressure (SBP) and diastolic blood pressure (DBP) in the Expt group were not significantly different from those in the Ctrl group (P>0.05). By contrast, the SBP and DBP were significantly lower after treatment than those before treatment in both groups (P<0.05). Whole blood viscosity, plasma viscosity and hematocrit were significantly lower in the Expt group compared with those in the Ctrl group after treatment (P<0.05). High mobility group box-1 protein, homocysteine and serum cystatin C levels in the Expt group were also markedly lower than those in the Ctrl group after treatment (P<0.05). In the Expt group, the rate of spontaneous vaginal delivery was much higher, whereas the rates of cesarean section and postpartum hemorrhage were markedly lower than those in the Ctrl group (P<0.05). The occurrence of fetal intrauterine distress, placental abruption, neonatal asphyxia, premature birth and neonatal death were also significantly lower in the Expt group than those in the Ctrl group (P<0.05). In conclusion, MgSO4 + labetalol could improve inflammatory stress and the hemodynamics of patients with GH, and may have a marked antihypertensive effect. Thus, it may improve pregnancy outcome and reduce perinatal complications.

Decline in home births associated with faster increase in trend of postpartum haemorrhage and manual removal of the placenta

In this study we explored the relationship between home birth rates and increasing rates of postpartum haemorrhage (PPH) and manual removal of the placenta (MROP). Data were used from the Dutch national perinatal registry (2000–2014) of women in midwife-led care. Adjusting for place of birth flattened the increasing trends of PPH and MROP. By adjusting for place of birth, the rising trend of MROP among multiparous women disappeared. This suggests that if home birth rates had not declined, PPH and MROP rates might not have increased as much. This study supports policies of enabling women to choose home births.

Low-dose aspirin for the prevention of preterm birth in nulliparous women: systematic review and meta-analysis

ObjectiveThe objective was to assess the efficacy and safety of low-dose aspirin for the prevention of preterm birth in nulliparous women.Data sourcesWe searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to June 2022.Study eligibility criteriaRandomized controlled trials that compared aspirin to placebo in nulliparous women were eligible.MethodsThis study was reported in accordance with the PRISMA 2020 checklist. The primary outcomes of this study were the rates of preterm birth at less than 37 weeks and less than 34 weeks of gestation. The secondary outcomes included postpartum hemorrhage, placental abruption, cesarean section, any hypertensive disorder of pregnancy and small for gestational age. Relative risks with their 95% confidence intervals were calculated for analysis. Heterogeneity was assessed by Cochran’s Q test and Higgins’s I2. A random-effects model was used when I2 was > 50% to generate the RR and 95% CI; otherwise, a fixed-effects model was used. The risk of publication bias was assessed by funnel plots. We performed sensitivity analysis by sequentially omitting each included study to confirm the robustness of the analysis.ResultsSeven studies with a total of 29,029 participants were included in this review. Six studies were assessed as having a low risk of bias or an unclear risk of bias, and one study was judged as having a high risk of bias. In nulliparous women, low-dose aspirin was associated with a significant reduction in the rate of preterm birth at less than 34 weeks of gestational age (RR 0.84,95% CI: 0.71–0.99; I2 = 0%; P = 0.04), but we did not observe a significant difference in the rate of preterm birth at less than 37 weeks of gestation (RR 0.96,95% CI: 0.90–1.02; I2 = 31%; P = 0.18). Low-dose aspirin was associated with a significant increase in the rates of postpartum hemorrhage (RR 1.32,95% CI: 1.14–1.54; I2 = 0%; P = 0.0003), placental abruption (RR 2.18,95% CI: 1.10–4.32; I2 = 16%; P = 0.02) and cesarean section (RR 1.053, 95% CI: 1.001–1.108; I2 = 0%; P = 0.05) in nulliparous women. We also did not observe a significant effect of low-dose aspirin on the rates of any hypertensive disorder of pregnancy (RR 1.05, 95% CI: 0.96–1.14; I2 = 9%; P = 0.28) or small for gestational age (RR 0.96, 95% CI: 0.91–1.02; I2 = 0%; P = 0.16) in nulliparous women. Funnel plots indicated that no significant publication bias existed in this meta-analysis. Except for preterm birth at less than 34 weeks of gestation, placental abruption and cesarean section, the sensitivity analysis showed similar results, which confirmed the robustness of this meta-analysis.ConclusionsLow-dose aspirin might reduce the risk of preterm birth at less than 34 weeks of gestation in nulliparous women. The use of low-dose aspirin in nulliparous women increased the risk of postpartum hemorrhage and might increase the risk of placental abruption and cesarean section.

Face presentation at term: incidence, risk factors and influence on maternal and neonatal outcomes.

The incidence, diagnosis, management and outcome of face presentation at term were analysed. A retrospective, gestational age-matched case-control study including 27 singletons with face presentation at term was conducted between April 2006 and February 2021. For each case, four women who had the same gestational age and delivered in the same month with vertex position and singletons were selected as the controls (control group, n = 108). Conditional logistic regression was used to assess the risk factors of face presentation. The maternal and neonatal outcomes of the face presentation group were followed up. The incidence of face presentation at term was 0.14‰. After conditional logistic regression, the two factors associated with face presentation were high parity (adjusted odds ratio [aOR] 2.76, 95% CI 1.19-6.39)] and amniotic fluid index > 18cm (aOR 2.60, 95% CI 1.08-6.27). Among the 27 cases, the diagnosis was made before the onset of labor, during the latent phase of labor, during the active phase of labor, and during the cesarean section in 3.7% (1/27), 40.7% (11/27), 11.1% (3/27) and 44.4% (12/27) of cases, respectively. In one case of cervical dilation with a diameter of 5cm, we innovatively used a vaginal speculum for rapid diagnosis of face presentation. The rate of cesarean section and postpartum haemorrhage ≥ 500ml in the face presentation group was higher than that of the control group (88.9% vs. 13.9%, P < 0.001, and 14.8% vs. 2.8%, P = 0.024), but the Apgar scores were similar in both sets of newborns. Among the 27 cases of face presentation, there were three cases of adverse maternal and neonatal outcomes, including one case of neonatal right brachial plexus injury and two cases of severe laceration of the lower segment of the uterus with postpartum haemorrhage ≥ 1000ml. Face presentation was rare. Early diagnosis is difficult, and thus easily neglected. High parity and amniotic fluid index > 18cm are risk factors for face presentation. An early diagnosis and proper management of face presentation could lead to good maternal and neonatal outcomes.

Clinical analysis of complete uterine rupture during pregnancy

BackgroundUterine rupture in pregnant women can lead to serious adverse outcomes. This study aimed to explore the clinical characteristics, treatment, and prognosis of patients with complete uterine rupture.MethodsData from 33 cases of surgically confirmed complete uterine rupture at Chenzhou No.1 People’s Hospital between January 2015 and December 2022 were analyzed retrospectively.ResultsIn total, 31,555 pregnant women delivered in our hospital during the study period. Of these, approximately 1‰ (n = 33) had complete uterine rupture. The average gestational age at complete uterine rupture was 31+4 weeks (13+1–40+3 weeks), and the average bleeding volume was 1896.97 ml (200–6000 ml). Twenty-six patients (78.79%) had undergone more than two deliveries. Twenty-five women (75.76%) experienced uterine rupture after a cesarean section, two (6.06%) after fallopian tube surgery, one (3.03%) after laparoscopic cervical cerclage, and one (3.03%) after wedge resection of the uterine horn, and Fifteen women (45.45%) presented with uterine rupture at the original cesarean section incision scar. Thirteen patients (39.39%) were transferred to our hospital after their initial diagnosis. Seven patients (21.21%) had no obvious symptoms, and only four patients (12.12%) had typical persistent lower abdominal pain. There were 13 cases (39.39%, including eight cases ≥ 28 weeks old) of fetal death in utero and two cases (6.06%, both full term) of severe neonatal asphyxia. The rates of postpartum hemorrhage, blood transfusion, hysterectomy were 66.67%, 63.64%, and 21.21%. Maternal death occurred in one case (3.03%).ConclusionsThe site of the uterine rupture was random, and was often located at the weakest point of the uterus. There is no effective means for detecting or predicting the weakest point of the uterus. Rapid recognition is key to the treatment of uterine rupture.

Postpartum haemorrhage: latest developments in prediction, drug treatment and monitoring

With increasing global rates of postpartum haemorrhage, recent developments aim to ensure that birthing women are safe. This focused review will discuss developments in prediction of postpartum haemorrhage, blood loss measurement, uterotonic use and the thromboelastogram, aiming to improve prevention and treatment of postpartum haemorrhage. The unpredictable nature of postpartum haemorrhage is a significant hurdle, as all women must be considered at risk, imposing a heavy burden on healthcare services. Evidence-based tools have shown promise in improving prediction and management strategies. However, the lack of consensus and agreement on risk factors presents obstacles to developing accurate models. Ongoing research is exploring the development of an individual postpartum haemorrhage risk index, providing personalised care to pregnant women. Accurate blood loss quantification is essential for prompt postpartum haemorrhage diagnosis and appropriate interventions, but challenging in busy clinical settings. Recent advancements in prophylaxis and treatment using medication (uterotonics and tranexamic acid), as well as in monitoring using thromboelastograms, emphasise the need for effective prediction and management strategies. This critical review underscores the need for further research to enhance prediction tools, refine management protocols and address existing challenges to improve maternal outcomes.

Risk factors and management of perinatal genital hematoma: A single, tertiary medical center retrospective study in China.

The goal of this study was to identify the risk factors associated with puerperal genital hematoma (PGHA) and analyze the management strategies employed and the resulting maternal outcomes. This retrospective cohort study examined the pregnant women delivering vaginally with PGHA in Peking University Third Hospital during January 2002 to December 2021. Exploratory data analysis was performed to assess mean, standard deviation (SD), frequency, percentage and percentiles. Independent-samples t-test was performed for continuous variables. Chi-squared test was performed to compare categorical data. A total of 47 women with PGHA were included, and 94 matched controls were enrolled during the same study period. Compared with the control group, labor induction (34.0% vs. 9.6%, P = 0.000) and episiotomy (66.0% vs. 31.9%, P = 0.000) were more frequently performed in PGHA cases. There was a significantly higher incidence of postpartum hemorrhage (PPH) (53.2% vs. 6.4%, P = 0.000) in PGHA patients than in controls. Compared with the patients with <5 cm hematoma, the proportion of prenatal anemia (25.8% vs. 0.0%, P = 0.027) and the incidence of PPH (67.7% vs. 25.0%, P = 0.005) were significantly higher in patients with ≥5 cm hematoma. In comparison, the active period was significantly shorter (3.1 ± 1.9 vs. 5.1 ± 3.0, P = 0.031) in patients with ≥5 cm hematoma. There were significant differences in perineal pain and swelling (31.3% vs. 67.7%, P = 0.017), vulva hematoma (93.8% vs. 48.4%, P = 0.002) and surgical treatment (62.5% vs. 96.8%, P = 0.002). Nearly half of the patients in the ≥5 cm group underwent secondary suture (41.9% vs. 6.3%, P = 0.011). In patients with PGHA detected after more than 2 h, the body mass index was substantially higher (24.5 ± 4.3 vs. 21.4 ± 2.7, P = 0.011), and the weight gain during pregnancy (14.1 ± 4.3 vs. 11.4 ± 3.5, P = 0.021) was significantly lower. Compared with the patients in PGHA without PPH, age (31.7 ± 4.4 vs. 29.4 ± 2.6, P = 0.033) and newborn birth weight (3367 ± 390 g vs. 3110 ± 419 g, P = 0.045) were considerably higher in PGHA cases with PPH, and the platelet count ([182 ± 44] × 109/L vs. [219 ± 51] × 109/L, P = 0.015) was significantly lower. Pregnant women who underwent labor induction and episiotomy had a higher incidence of PGHA. The PGHA-related PPH rate is significantly increased. Active surgical treatment is recommended for patients with ≥5 cm hematoma.

THE STUDY OF MATERNAL OUTCOME FOLLOWING EARLY AND DELAYED CORD CLAMPING IN BIRTHS ASSOCIATED WITH ANEMIA IN PREGNANCY

Aim and Objectives: (The objectives of the study are as follows: 1) To compare the Blood loss in both early cord clamping (ECC) versus delayed cord clamping (DCC) (in the third stage of labor). (2) To compare the third-stage complications following ECC versus of DCC in anemic pregnant females. (3) To compare Maternal hemoglobin and hematocrit at 24 h of delivery in both ECC versus DCC. Methods: This prospective study was carried out in the Department of Obstetrics and Gynaecology in Lady Hardinge Medical College and Associated Hospitals, New Delhi pregnant women. A total of 120 anemic pregnant women between 32 and 40 weeks of gestation admitted in the labour room were enrolled in the study (hemoglobin between 7 and 10.9 g%). Twenty patients were lost to follow-up. Third-stage complications of 46 women who underwent ECC (&lt;60 s) were compared with 54 women who underwent DCC (more than 60 s to &lt;3 min). Maternal hemoglobin and hematocrit at 24 h of delivery were also compared between both groups. Results: The mean blood loss in both the groups was 325±89.287 and 326.85±66.384, comparable statistically with p=0.906. Out of 100 patients enrolled, only two patients had postpartum hemorrhage. Each one belonged to each group (p&lt;0.909). None of the groups had retained placenta showing no statistical significance between two groups (p&lt;1). DCC was not associated with increased risk of third-stage complications whether in cesarean section or vaginal delivery. There were no differences in operative time, post-delivery decrease in hematocrit, rates of postpartum hemorrhage, bleeding complications, maternal blood transfusions, and therapeutic hysterectomy between the two groups. Conclusions: DCC is safe for mother especially in anemic mothers also as it does not increase the mean blood loss and also it has beneficial effect on neonates. No difference in third-stage complications and maternal hemoglobin and hematocrit levels at 24 h in both groups. It should be recommended in routine practice where it is not contraindicated especially in resource-poor settings.

Dose-dependent increase in risk of bleeding and bleeding complications in relation to SSRI use at delivery

IntroductionDepression during pregnancy is a severe state that increases the risk of suicide, as well as adverse newborn outcomes. Selective serotonin re-uptake inhibitors (SSRIs) are effective for the treatment of depression, but increase the risk of bleeding complications at delivery. Knowledge on the dose dependency of this association is lacking. MethodsA hospital-based cohort study of all women who gave birth at Karolinska University Hospital in Stockholm over the 5-year period from 2007 to 2011, with or without SSRI use, was undertaken. In total, 334 women who delivered vaginally and were exposed to SSRIs at delivery were identified. All other women who delivered vaginally formed the control group (n = 31,929). The electronic maternal health records of the 334 SSRI users were scrutinized, and the women were categorized into two groups: moderate (n = 246) or high (n = 88) SSRI dose at delivery. The main outcome was bleeding complications at delivery in relation to SSRI dose. ResultsA dose-dependent increase in the rate of postpartum haemorrhage (≥1000 ml) was found, affecting 8.4 %, 14.6 % and 23.9 % (p ≤ 0.001) of women in the control group, the moderate-dose group and the high-dose group, respectively. In addition, a dose-dependent increase in the rate of postpartum anaemia was found, affecting 7.0 %, 9.3 % and 15.9 % (p = 0.001) of women in the control group, the moderate-dose group and the high-dose group, respectively. Mean blood loss of 406 ml, 483 ml and 482 ml (p ≤ 0.001) was found in the control group, the moderate-dose group and the high-dose group, respectively. Women exposed to SSRIs delivered earlier, but did not have higher prevalence of pre-eclampsia compared with the control group. ConclusionsThe dose-dependent relationship between SSRIs and bleeding complications may be clinically useful in the management of this vulnerable group of women.

Anaemia and red blood cell transfusion in women with placenta accreta spectrum: an analysis of 38,060 cases

Placenta accreta spectrum (PAS) has become a significant life-threatening issue due to its increased incidence and associated morbidity and mortality. Pregnancy is often associated with states of anaemia, and severe maternal haemorrhage represents a major risk factor for red blood cell (RBC) transfusion. The present study retrospectively analyzed the prevalence of anaemia, transfusion requirements and outcome in women with PAS. Using data from the German Statistical Office pregnant patients with deliveries hospitalized between January 2012 and December 2021 were included. Primary outcome was the prevalence of anemia and administration of RBCs. Secondary outcome were complications in women with PAS who received RBC transfusion. In total 6,493,606 pregnant women were analyzed, of which 38,060 (0.59%) were diagnosed with PAS. The rate of anaemia during pregnancy (60.36 vs. 23.25%; p < 0.0001), postpartum haemorrhage (47.08 vs. 4.41%; p < 0.0001) and RBC transfusion rate (14.68% vs. 0.72%; p < 0.0001) were higher in women with PAS compared to women without PAS. Women with PAS who had bleeding and transfusion experienced significantly more peripartum complications than those who did not. A multiple logistic regression revealed that the probability for RBC transfusion in all pregnant women was positively associated with anaemia (OR 21.96 (95% CI 21.36–22.58)). In women with PAS, RBC transfusion was positively associated with the presence of renal failure (OR 11.27 (95% CI 9.35–13.57)) and congestive heart failure (OR 6.02 (95% CI (5.2–7.07)). Early anaemia management prior to delivery as well as blood conservation strategies are crucial in women diagnosed with PAS.

Early vs delayed amniotomy following transcervical Foley balloon in the induction of labor: a randomized clinical trial

The optimal timing of amniotomy during labor induction is a topic of ongoing debate due to the potential risks associated with both amniotomy and prolonged labor. As such, individuals in the field of obstetrics and gynecology must carefully evaluate the associated benefits and drawbacks of this procedure. While amniotomy can expedite the labor process, it may also lead to complications such as umbilical cord prolapse, fetal distress, and infection. Therefore, a careful and thorough examination of the risks and benefits of amniotomy during labor induction is essential in making an informed decision regarding the optimal timing of this procedure. This study aimed to determine if an amniotomy within 2 hours after Foley balloon removal reduced the duration of active labor and time taken to achieve vaginal delivery when compared with an amniotomy ≥4 hours after balloon removal among term pregnant women who underwent labor induction. This was an open-label, randomized controlled trial that was conducted at a single academic center from October 2020 to March 2023. Term participants who were eligible for preinduction cervical ripening with a Foley balloon were randomized into 2 groups, namely the early amniotomy (rupture of membranes within 2 hours after Foley balloon removal) and delayed amniotomy (rupture of membranes performed more than 4 hours after Foley balloon removal) groups. Randomization was stratified by parity. The primary outcome was time from Foley balloon insertion to active phase of labor. Secondary outcomes, including time to delivery, cesarean delivery rates, and maternal and neonatal complications, were analyzed using intention-to-treat and per-protocol analyses. Of the 150 participants who consented and were enrolled, 149 were included in the analysis. In the intention-to-treat population, an early amniotomy did not significantly shorten the time between Foley balloon insertion and active labor when compared with a delayed amniotomy (885 vs 975 minutes; P=.08). An early amniotomy was associated with a significantly shorter time from Foley balloon placement to active labor in nulliparous individuals (1211; 584-2340 vs 1585; 683-2760; P=.02). When evaluating the secondary outcomes, an early amniotomy was associated with a significantly shorter time to active labor onset (312.5 vs 442.5 minutes; P=.02) and delivery (484 vs 587 minutes; P=.03) from Foley balloon removal with a higher rate of delivery within 36 hours (96% vs 85%; P=.03). Individuals in the early amniotomy group reached active labor 1.5 times faster after Foley balloon insertion than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1.1-2.2; P=.02). Those with an early amniotomy also reached vaginal delivery 1.5 times faster after Foley balloon removal than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1-2.2; P=.03). A delayed amniotomy was associated with a higher rate of postpartum hemorrhage (0% vs 9.5%; P=.01). No significant differences were observed in the cesarean delivery rates, length of hospital stay, maternal infection, or neonatal outcomes. Although an early amniotomy does not shorten the time from Foley balloon insertion to active labor, it shortens time from Foley balloon removal to active labor and delivery without increasing complications. The increased postpartum hemorrhage rate in the delayed amniotomy group suggests increased risks with delayed amniotomy.

Postpartum hemorrhage champions: Sustaining gains beyond the E-MOTIVE Trial

Background: Results published from the E-MOTIVE trial concluded that for women undergoing vaginal delivery, early detection of postpartum hemorrhage (PPH), combined with bundled treatment of PPH, reduced severe PPH and associated adverse outcomes. Eighty hospitals across Nigeria, Kenya, Tanzania, and South Africa and over 210,000 women participated in the randomized trial, which was designed to assess the effect of implementing the E-MOTIVE intervention to detect and treat PPH. The results showed that the use of calibrated collection drapes dramatically increased the PPH detection rate, from 51% to 93%, and the use of the WHO-recommended bundle of treatments, from 19% to 91%. Moreover, implementing the E-MOTIVE approach to treat PPH resulted in a 60% reduction in severe PPH. The median blood loss, the need for postpartum blood transfusion, and the number of maternal deaths were also reduced. The E-MOTIVE trial trained a pool of PPH champions across the intervention facilities, including nurses, midwives, medical officers, and obstetrics and gynecology specialists. Their roles were to coordinate the training and practice activities of all relevant labor ward staff in their hospitals, observe labor ward staff practices, and provide specific feedback for targeted improvements in implementing the E-MOTIVE bundle correctly by reviewing regular performance indicators and outcome data from their hospitals to assess if improvements were needed. Methods: After the study findings, the Kenyan hub team continued tracking the performance of the facilities after the trial, without any active support. The PPH champions collected, discussed at the facility level, and shared data with the Kenyan hub team monthly. The data shared were included in the hub Project Management Information System and triangulated with data from DHIS, where it was analyzed by the Kenyan study team, and feedback was shared at the facility level. Results: Data analyzed from the last quarter (September-November) showed that seven E-MOTIVE implementing facilities maintained 5% PPH rates (blood loss &gt;500 mls) and 2% severe PPH rates on moving averages. All components of the E-MOTIVE bundle were provided 100% to all PPH cases detected. During the same period, three maternal deaths were reported that had causes other than bleeding from PPH. Conclusion: Having PPH champions community of practice can help sustain best practices in the early detection and treatment of PPH beyond any project lifeline. It is a simple and cost-effective method that can prevent severe PPH and prevent maternal mortality arising from PPH.

Impact of inherited bleeding disorders on maternal bleeding and other pregnancy outcomes: A population-based cohort study.

Increasing rate of postpartum haemorrhage (PPH) has been observed between 2003 and 2010 in Canada. Inherited bleeding disorders contribute to the risk of PPH. To identify the trend in PPH in the last decade, assess the impact of bleeding disorders on pregnancy outcomes and evaluate their coagulation workup during pregnancy. We conducted a population-based retrospective cohort study using the Alberta Pregnancy Birth Cohort from 2010 to 2018. We included women with von Willebrand disease (VWD) and haemophilia, identified by previously validated algorithm and matched with controls. Logistic regression was used to compute odds of PPH and other pregnancy outcomes. We identified 311,330 women with a total of 454,400 pregnancies with live births. The rate of PPH did not change significantly from 10.13 per 100 deliveries (95% CI 10.10-10.16) in 2010-10.72 (95% CI 10.69-10.75) in 2018 (p for trend=.35). Women with bleeding disorders were significantly more likely to experience PPH (odds ratio [OR] 2.3; 95% CI 1.5-3.6), antepartum haemorrhage (OR 2.9; 95% CI 1.5-5.9) and red cell transfusion (OR 2.8; 95% CI 1.1-7.0). We observed a nonsignificant rise in the rate of PPH in women with VWD and haemophilia. Only 49.5% pregnancies with bleeding disorders had third trimester coagulation factor levels checked. Higher odds of PPH and antepartum haemorrhage were observed even with factor levels ≥0.50IU/mL in third trimester. Despite comprehensive care in women with bleeding disorders, they are still at higher risk of adverse pregnancy outcomes compared to population controls.

A Prospective Cohort Study Investigating Adverse Perinatal Outcomes in Mosul, Iraq, among Women with Grand Multiparity

Introduction: This prospective case-control study aimed to compare the incidence of fetomaternal complications between grand multiparous women under the age of 35 and pregnant women with low parity in the same age group. Methods: The study was conducted at Al-khansaa and Al-Batool Teaching Hospitals from October 1, 2020, to June 1, 2021. One hundred pregnant women with singleton pregnancies in all three trimesters, aged between 18 and 34 years, were selected from the outpatient clinic and the ward. The participants were divided into two groups: Group A consisted of 50 grand multiparous women (with five or more deliveries), and Group B comprised 50 pregnant women with low parity (2-4 pregnancies) in the same age group. Results: The study found that gestational diabetes, anemia, meconium-stained amniotic fluid, cesarean section rate, postpartum hemorrhage, and neonatal intensive care unit admissions were significantly higher in the grand multiparity group compared to the low parity group. The mean Apgar scores at 1 and 5 minutes were significantly lower in Group A compared to Group B. Conclusion: The findings suggest that grand multiparity among younger mothers poses additional risks to pregnancy outcomes, including increased rates of gestational diabetes, anemia, postpartum hemorrhage, cesarean section, and neonatal intensive care unit admissions, especially in cases with inadequate antenatal care. The findings of this study underscore the need for further research in this area. Understanding the underlying mechanisms and risk factors associated with grand multiparity among younger mothers can lead to more targeted interventions and improved outcomes.

Duration time of labor progression for pregnant women of vaginal birth after cesarean in Hubei, China.

There have been limited reports on the duration of labor progression in pregnant women undergoing vaginal birth after cesarean (VBAC). This study aimed to investigate the duration of labor progression during VBAC in Hubei, China. A total of 359 pregnant women undergoing VBAC were enrolled as the VBAC group, meeting the following criteria: singleton pregnancy, gestational age ≥ 37weeks, live birth, history of cesarean delivery, and a willingness to attempt a vaginal delivery. At the same time, 359 primiparas successfully undergoing vaginal delivery were randomly enrolled in the control group at a 1:1 ratio. Subsequently, the durations of the first, second, and third stages of labor were comparatively analyzed between the two groups. The duration of the first, second, and total stages of labor in the VBAC group was significantly shorter than that in the control group (p < 0.05). There was no significant difference in the duration of the third stage of labor between the two groups (p > 0.05). The amount of blood loss, the rate of postpartum hemorrhage (PPH), and episiotomy were higher in the VBAC group than in the control group (p < 0.05). The rate of labor analgesia and intrapartum fever in the VBAC group was significantly lower than that in the control group (p < 0.05). The duration of labor progression of the first, second, and total stages of VBAC is shorter than that in primiparous women in our observation in China.

Tranexamic acid for the prevention and treatment of postpartum hemorrhage in resource-limited settings: a literature review.

Postpartum haemorrhage is a major cause of maternal morbidity and mortality worldwide. Early recognition and appropriate treatment are crucial for managing postpartum haemorrhage. This literature review aimed to evaluate the efficacy of tranexamic acid in the prevention and treatment of postpartum haemorrhage in resource-limited settings. This literature review was conducted based on the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. A computerized systematic search of the MEDLINE (PubMed), Google Scholar, and Cochrane databases using a combination of the following Medical Subject Headings (MeSH) terms for PubMed: [(obstetric haemorrhage OR postpartum haemorrhage OR massive obstetric haemorrhage) AND (tranexamic acid OR antifibrinolytic drugs) AND (prophylaxis OR prevention) AND (management OR treatment) AND (resource-limited settings OR resource-limited area OR developing countries)] to find articles published in English since 2010. Studies on the obstetric population who underwent vaginal or caesarean delivery, comparing the use of tranexamic acid versus placebo (or no treatment) for treatment (or prevention) of postpartum haemorrhage with the outcome of postpartum haemorrhage rate, blood transfusion requirements, uterotonics requirements, hysterectomy, or mortality were included. In total, 5315 articles were identified. Following the elimination of duplicates, the methodological quality of 15 studies was evaluated independently, with eligibility determined based on the inclusion and exclusion criteria, as well as outcome variables. Finally, eight articles were included in the review. This review provides evidence that the administration of tranexamic acid has the potential to decrease the need for blood transfusion, incidence of postpartum haemorrhage, demand for supplementary uterotonics, and maternal morbidity and mortality with marginal adverse effects. Healthcare systems must develop and implement interventions that involve the use of tranexamic acid for the treatment of postpartum haemorrhage in resource-limited settings.

Evaluation of labor management practices during spontaneous labor

IntroductionIn 2017, the French national authority for health issued national guidelines to support physiologic labor and reduce medical interventions. This study's primary aim was to evaluate the association between the publication of these guidelines and the vaginal delivery rate in a type IIb perinatal center. The secondary objectives were to evaluate the implementation of these guidelines, their association with the duration of labor, and the rates of postpartum hemorrhage and adverse neonatal outcomes. Material and methodsA before-and-after, retrospective, single-center study comparing a "before" group (2016) and an "after" group (2018), one year after the recommendations were published. Women were eligible if they had no prior cesarean delivery and gave birth after 37 weeks of gestation to a singleton fetus in cephalic presentation after spontaneous labor. The analysis was stratified by parity. ResultsOxytocin administration decreased between the two periods (48% vs 35 %, P < 0.0001), as did the frequency of amniotomies (artificial rupture of membranes) (39.5 % vs 27.7 %, P < 0.0001). The duration of labor was significantly prolonged (360 vs 390 min, P < 0.0001), especially in nulliparous women (465 min vs 562 min, P<0.0001). The frequency of vaginal delivery rose between the two periods (94.6 % vs 96 %, P = 0.05), and the postpartum hemorrhage rate fell (6 % vs 4.5 %, P = 0.04). The numbers of neonates with an umbilical artery pH< 7.10 and of neonatal transfers also decreased. ConclusionsThe reduction of active interventions during labor is associated with a longer duration of labor and a decrease in the rates of cesarean births, postpartum hemorrhages, and neonatal transfers.

Association between first-trimester ultrasound imaging of eccentric implantation and retained placenta

Objectives To evaluate first-trimester ultrasound imaging of eccentric implantation in predicting the probability of retained placenta. Methods A total of 61 cases with gestational sac eccentrically implanted in first-trimester ultrasound imaging was selected. Demographic and obstetric data were collected through data extraction of the electronic medical record at the time of delivery admission. Baseline characteristics (including age, gestational age of first-trimester ultrasound, size of gestational sac, gestational age of delivery), delivery outcomes (mode of delivery, retained placenta or placental fragments, blood loss, postpartum hemorrhage and postpartum ultrasound imaging) were collected and analyzed. Results The risk difference for a woman with eccentric implantation to have a retained placenta was −0.18 (95% CI −0.28 to −0.08, p = 0.000) and the incidence of retained placenta in the study group was higher than in the control group (18% vs. 0%, p = 0.006). First-trimester ultrasound imaging of eccentric implantation was also found to be an independent risk factor for the incidence of inhomogeneous mass in postpartum ultrasound imaging (27.9% vs. 10.8%, adjusted OR 0.19, 95% CI 0.05 to 0.79, p = 0.012). Though 2 cases in the study group suffered postpartum hemorrhage, the risk difference for a woman with eccentric implantation to suffer postpartum hemorrhage was −0.03 (95% CI −0.08 to −0.01, not significant) and eccentric implantation did not increase postpartum hemorrhage rates (3.3% vs. 0%, not significant). Conclusions First-trimester ultrasound imaging of eccentric implantation was associated with an increased risk of retained placenta and inhomogeneous mass in postpartum ultrasound imaging.