Risk Factors For Postpartum Hemorrhage Research Articles

309 Resolved low-lying placenta and placenta previa is associated with increased risk of postpartum hemorrhage

Second trimester diagnosis of low placentation, defined as low-lying placenta and placenta previa, is a risk factor for postpartum hemorrhage (PPH), but it is unknown if resolved low placentation leads to higher rates of PPH. Initial implantation of the placenta in the lower uterine segment increases vascularity and may cause unsuccessful contraction of the vascular beds at delivery. We hypothesize despite resolution of low placentation, women are at increased risk of PPH at delivery. This retrospective cohort includes women who delivered at Mount Sinai Hospital from 2015-2019, diagnosed with low placentation at mid-trimester anatomy survey with resolution on subsequent ultrasound. Women with normal placentation at mid-trimester anatomy survey were randomly selected for comparison. Demographic and neonatal characteristics were compared. Primary outcome was PPH. Secondary outcomes included blood transfusion, use of additional uterotonic medication or procedures to control bleeding. Outcomes were assessed using a logistic regression model adjusting for age, BMI and race/ethnicity. Resolved low placentation was associated with older age, lower BMI, White race, IVF and a posterior placenta (p<0.01). Patients with resolved low vs. normal placentation had greater odds of PPH (aOR 3.3, 95% CI 1.9-5.7; p<0.01), additional uterotonic use (aOR 2.1, 95% CI 1.5-3.1; p<0.01) and a trend toward increased rates of additional procedures (aOR 3.6, 95% CI 1.2-11.0; p=0.02) and blood transfusion (aOR 2.0, 95% CI 0.9-4.2; p=0.07). Composite neonatal morbidity was increased in the resolved low placentation cohort (9.1% vs. 4.0%, p<0.01), likely driven by higher rates of hypoglycemia (p<0.01). Women with resolved low placentation are at increased risk of PPH compared to those with normal placentation throughout pregnancy. The trend toward higher rates of additional procedures and blood transfusion suggest women with resolved low placentation may be at increased risk of morbidity. This may alter counseling and delivery management and increase preparation for PPH in these patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Ethnic disparities in postpartum hemorrhage after cesarean delivery: a retrospective case\u2013control study

PurposeTo explore the relationship of ethnicity and postpartum hemorrhage (PPH) for women who underwent cesarean delivery (CD) and examine the risk factors for PPH in distinct ethnic groups in China.MethodsWe conducted case–control studies with the maternity data from the 11,778 CD cases, in Xinjiang Uygur Autonomous Region. Initially, multivariable logistic regression was used to estimate the disparity of race-ethnicity on the risk of PPH in ethnic Han, Uygur, Hui and Kazakh. Then, we performed case–control studies within two major ethnic groups, identifying the specific risk factors for PPH.ResultsEthnic Uygur were associated with a statistically significant increased odds [adjusted odds ratios (aOR) 2.05; 95% confidence interval (CI) 1.26–3.33] of PPH compared with ethnic Han. For subgroup analyses, in Uygur subgroup, general anesthesia (aOR 7.78; 95% CI 2.31–26.20); placenta previa (aOR 11.18; 95% CI 3.09–40.45); prenatal anemia (aOR 4.84; 95% CI 2.44–9.60); emergency surgery (aOR 4.22; 95% CI 1.95–9.13) were independently associated with PPH. In Han subgroup, general anesthesia (aOR 5.70; 95% CI 1.89–17.26); placenta previa (aOR 20.08; 95% CI 6.35–63.46); multiple pregnancy (aOR 7.21; 95% CI 1.61–32.37); body mass index (aOR 1.19; 95% CI 1.07–1.31) were the risk factors to PPH.ConclusionUygur have more tendency to PPH compared to Han, and risk factors for PPH in Uygur and Han groups may differ. Knowing these differences may be meaningful when planning interventions and resources for high-risk patients undergoing cesarean delivery, and we need more research aimed at risk factors for PPH.

Risk Factors for Postpartum Hemorrhage and its Severe Forms with Blood Loss Evaluated Objectively - A Prospective Cohort Study.

To identify risk factors related to postpartum hemorrhage (PPH) and severe PPH with blood loss quantified objectively. This is a complementary analysis of a prospective cohort study that included pregnant women delivering vaginally. The total blood loss was obtained through the sum of the volume collected from the drape with the weight of gauzes, compresses and pads used by women within 2 hours. Exploratory data analysis was performed to assess mean, standard deviation (SD), frequency, percentage and percentiles. The risk factors for postpartum bleeding were evaluated using linear and logistic regression. We included 270 women. The mean blood loss at 120 minutes was 427.49 mL (±335.57 mL). Thirty-one percent (84 women) bled > 500 mL and 8.2% (22 women) bled > 1,000 mL within 2 hours. Episiotomy, longer second stage of labor and forceps delivery were related to blood loss > 500 mL within 2 hours, in the univariate analysis. In the multivariate analysis, only forceps remained associated with bleeding > 500 mL within 2 hours (odds ratio [OR] = 9.5 [2.85-31.53]). Previous anemia and episiotomy were also related to blood loss > 1,000mL. Prolonged second stage of labor, forceps and episiotomy are related to increased incidence of PPH, and should be used as an alert for the delivery assistants for early recognition and prompt treatment for PPH.

Risk factors for postpartum hemorrhage following cesarean delivery

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

Frozen-thawed embryo transfer is an independent risk factor for third stage of labor complications.

Third stage of labor complications are more prevalent following singleton vaginal deliveries of gestations conceived through in vitro fertilization (IVF) and fresh embryo transfer. This study aimed to evaluate these complications in pregnancies conceived through frozen-thawed embryo transfer (FET), in which endometrial preparation differs from fresh cycles. A cohort study of all singleton pregnancies conceived through IVF-FET who delivered vaginally at a tertiary medical center during 2007-2017. The study group consisted of 88 IVF-FET gestations (cases) that were matched to 176 spontaneous pregnancies based on age, gravidity, parity and gestational week at delivery (controls). The association between mode of conception and third stage of labor complication rate was examined. Baseline characteristics were similar between groups, except for a lower prevalence of induction of labor in the control group (23.3% vs. 36.3%, p = 0.03). The rate of post-partum hemorrhage (PPH), manual lysis and revision of the uterine cavity were all higher in pregnancies conceived through IVF-FET versus spontaneously (13.6% vs. 5.7%, p = 0.018; 17% vs. 2.3%, p < 0.001; and 21.6% vs. 6.8%, p < 0.001, respectively). Multivariate analysis adjusting for age, previous cesarean section, induction of labor, neonatal weight and use of analgesia demonstrated that deliveries following IVF-FET were independently associated with an increased risk for third stage of labor complications (estimated OR = 3.45, p = 0.0002). IVF-FET is an independent risk factor for PPH, need for manual lysis and revision of the uterine cavity. Precautionary measures should be undertaken in the third stage in deliveries following IVF-FET, even if no other risk factors are present.

Postpartum hemorrhage in maternal mothers at Anutapura Public Hospital in Palu, 2017

ObjectivePostpartum hemorrhage is one of the factors causing maternal mortality in Indonesia. In Indonesia, at least 128.000 women suffer from hemorrhage, causing them to death. Data from the Anutapura Public Hospital in Palu showed that the rate of postpartum hemorrhage within 2015–2017 was fluctuated and still caused maternal mortality. This study aimed to determine the risk factors of the incidence of postpartum hemorrhage in maternal mothers at Anutapura Public Hospital, Palu. MethodThe type of study was observational with a case-control approach. The subject of the study was mothers having a postpartum hemorrhage. The total sample of this study was 50 people as the case group and 100 people as the control group by adjusting the types of labor. Sampling was done using a total sampling technique. The data were analyzed using an odds ratio test with α=5%. ResultThis study showed that anemia (OR=2.874 and CI=1.421–5.812), parity (OR=3.995 and CI=1.952–8.174), age (OR=2.874 and CI=1.421–5.812) were the risk factors of postpartum hemorrhage in women. ConclusionThe anemia, parity, and age are the risk factors of postpartum hemorrhage in women. The importance of increasing ANC (antenatal care) visits is to control maternal and fetal health and provide information through a medical consultation about the importance of planning a good pregnancy.

Эффективность и безопасность применения терлипрессина при кесаревом сечении у беременных с высоким риском кровотечения: многоцентровое всенаправленное когортное исследование Terli-Bleed. Часть I

Prevention of postpartum haemorrhage is one of the important tasks of modern obstetrics, anesthesiology and intensive care. Objective. To assess the efficacy and safety of terlipressin usage as a means of postpartum haemorrhage development prevention during caesarean section in high-risk pregnant women. Patients and methods. From February to December 2020, a multicenter comprehensive cohort study, in which 5 medical centers participated, was conducted. The study included 454 pregnant women who underwent caesarean section and who were divided into two groups: control group I (n = 351) and study group II (n = 103), with the use of terlipressin injected into myometrium. Evaluation of the preventive effect of the drug was carried out in several main directions: the volume of blood loss, the need for additional methods of surgical hemostasis, the safety of intraoperative use. Results. Considerable differences were found in the assessment of significant risk factors for the development of postpartum haemorrhage, associated pathologies and comorbidity between the groups. The study group turned out to be more threatened by the postpartum haemorrhage development. In the control group, additional measures of surgical hemostasis were more often used, including hysterectomy (2.6% versus 1.9%) and relaparotomy (1.9% versus 1%). The median blood loss was statistically lower in the study group (700 ml versus 800 ml). Nevertheless, the considerable spread of data on the volume of blood loss should be noted, with a maximum blood loss of 10,000 ml in the control group and 4,500 ml in the study group. There were no serious complications in both groups. Conclusion. The study showed that the use of terlipressin can reduce the volume of blood loss in women with high risk factors for postpartum haemorrhage, as well as reduce the number of hysterectomies and relaparotomies. It is necessary to continue the prospective part of the study with an increase in the randomized sample of patients. Key words: obstetric haemorrhage, caesarean section, terlipressin

Early Identification of Risk Factors for Primary Postpartum Hemorrhage at Admission

Background: Postpartum hemorrhage (PPH) is the world‘s leading cause of maternal mortality, accounting for one-third of all maternal deaths worldwide. Aim of the Study was early identification of risk factors of primary postpartum hemorrhage. Research Design: A descriptive cross-sectional research design was utilized. Subject and setting: The study was carried out over a period of six months in obstetrics and gynecology department at Minia University Hospital for Obstetric and Pediatric. Tools for Data Collection: two tools were used; Tool I: Socio-demographic characteristics, and Tool II: Risk factors assessment tools. Results: The study revealed that, study group had low risk factors of current PPH had(previous uterine incision, History of PPH ), moderate risk factors of current PPH in women had (prior cesarean birth or prior uterine incision, History of one previous PP), high risk factors of current PPH in women ( had two or more moderate symptoms of risk factors, platelets level <100,000/mm3, hematocrit level <30, placenta previa and suspected placenta accretes) with statistically significance differences. Conclusion: previous uterine incision, previous PPH, abnormality in platelet level, hematocrit level and coagulopathy were the most significant risk factors for primary PPH. Recommendation: Encourage regular antenatal visit to early detection of risk factors of PPH, and providing the women health education about PPH risk factors.

Incidences of Atonic Postpartum Hemorrhage and Related Risk Factors at a Tertiary Hospital in Saudi Arabia.

Background: In 2017, there were 295,000 maternal deaths worldwide from preventable causes related to birth. The leading cause of maternal mortality is obstetric hemorrhage. In Saudi Arabia, a paucity of evidence about incidences of atonic Postpartum Hemorrhage (PPH) and related risk factors exists. Therefore, aims were to (a) identify incidences of atonic PPH from 2015 to 2018 (b) determine risk factors of atonic PPH in vaginal birth. Methods: Retrospective chart review with purposive sampling conducted revealed 386 charts, 220 (57%) vaginal birth and 166 (43%) caesarian section (CS). Logistic regression analysis was used. Results: Incidences of atonic PPH were 2.5% from 2015 to 2017, with the rate increasing by 12% from 2017 to 2018. In vaginal birth, significant associations between the severity of blood loss with epidural (F = 6.314, df = 1, p = 0.013), episiotomy (F = 4.38, df = 1, p = 0.038), induction of labor (IOL) (F = 1.224, df = 1, p = 0.004), and Interaction between IOL, AUG, and epidural (F = 7.24, df = 1, p = 0.041) found. Discussion: Increasing rate of atonic PPH confirmed. Epidural, episiotomy, induction of labor, and induction with augmentation are factors associated with severe atonic PPH in vaginal birth.

Poor uterine contractility and postpartum hemorrhage among low-risk women: A case-control study of a large-scale database from Japan.

To examine the association between the risk of postpartum hemorrhage (PPH) and poor uterine contractility, which is suggested by the characteristics of labor. This case-control study used cases recorded in the Japan Perinatal Registry database during the period 2013-2016. After exclusion of women with specified known risk factors for PPH, we enrolled 174082 primiparas who had a full-term live singleton vaginal birth. Participants were classified into four classes according to the diagnosis of abnormal labor patterns and use of uterotonics. χ2 tests were used to compare PPH cases with controls, and odds ratios (OR) were calculated by univariate and multivariate analyses. Among the enrolled women, 10508 (6.0%) had PPH. Abnormal labor patterns were significantly associated with an increased risk of PPH. Compared with women without any abnormal labor patterns who had not used uterotonics, women with abnormal labor patterns were at a significantly increased risk for PPH regardless of whether they had used uterotonics (adjusted OR 1.23, 95% confidence interval [CI] 1.10-1.37) or not (adjusted OR 1.30, 95% CI 1.23-1.37). Our study suggests that among low-risk women with PPH, poor uterine contractility in labor could be a significant predisposing risk factor for PPH.

Influencing factors for prevention of postpartum hemorrhage and early detection of childbearing women at risk in Northern Province of Rwanda: beneficiary and health worker perspectives

BackgroundReduction of maternal mortality and morbidity is a major global health priority. However, much remains unknown regarding factors associated with postpartum hemorrhage (PPH) among childbearing women in the Rwandan context. The aim of this study is to explore the influencing factors for prevention of PPH and early detection of childbearing women at risk as perceived by beneficiaries and health workers in the Northern Province of Rwanda.MethodsA qualitative descriptive exploratory study was drawn from a larger sequential exploratory-mixed methods study. Semi‐structured interviews were conducted with 11 women who experienced PPH within the 6 months prior to interview. In addition, focus group discussions were conducted with: women’s partners or close relatives (2 focus groups), community health workers (CHWs) in charge of maternal health (2 focus groups) and health care providers (3 focus groups). A socio ecological model was used to develop interview guides describing factors related to early detection and prevention of PPH in consideration of individual attributes, interpersonal, family and peer influences, intermediary determinants of health and structural determinants. The research protocol was approved by the University of Rwanda, College of Medicine and Health Sciences Institutional Ethics Review Board.ResultsWe generated four interrelated themes: (1) Meaning of PPH: beliefs, knowledge and understanding of PPH: (2) Organizational factors; (3) Caring and family involvement and (4) Perceived risk factors and barriers to PPH prevention. The findings from this study indicate that PPH was poorly understood by women and their partners. Family members and CHWs feel that their role for the prevention of PPH is to get the woman to the health facility on time. The main factors associated with PPH as described by participants were multiparty and retained placenta. Low socioeconomic status and delays to access health care were identified as the main barriers for the prevention of PPH.ConclusionsAddressing the identified factors could enhance early prevention of PPH among childbearing women. Placing emphasis on developing strategies for early detection of women at higher risk of developing PPH, continuous professional development of health care providers, developing educational materials for CHWs and family members could improve the prevention of PPH. Involvement of all levels of the health system was recommended for a proactive prevention of PPH. Further quantitative research, using case control design is warranted to develop a screening tool for early detection of PPH risk factors for a proactive prevention.

Factors affecting the prevention of postpartum hemorrhage in Low- and Middle-Income Countries: A scoping review of the literature

Background and objectives: Postpartum hemorrhage is an important cause of maternal mortality worldwide. A host of literature highlights the difficulty in predicting which women will experience Postpartum hemorrhage. The present study aims at describing the research output on factors affecting the prevention of Postpartum hemorrhage in Low- and Middle- Income Countries.Methods: A total of 24 published research articles and 2 papers from grey literature published between 2010 and 2019 were retrieved from PubMed, Scopus, CINAHL and Nursing and Allied Health Database (ProQuest). Data were extracted based on main study features and the findings were described narratively. Arksey and O’Malley’s framework for scoping studies was used in this review.Results: Findings from the literature from Low- and Middle- Income Countries are grouped into three themes: Knowledge and understanding about the prevention of Postpartum hemorrhage; Postpartum hemorrhage risk factors among childbearing women; and use of prophylactic uterotonic drugs for PPH prevention and related policies. The majority of studies investigate pharmacological interventions for PPH prevention, while few address the early assessment of risk factors associated with Postpartum hemorrhage for proactive prevention.Conclusions: The present study suggests that assessing risk factors associated with PPH would be a practical method for early identification of clients at high-risk for developing Postpartum hemorrhage. The present scoping review highlights the paucity of research considering Postpartum hemorrhage risk factors in low- and middle- income countries, particularly in Rwanda. Further qualitative research on the perceptions of health care workers and beneficiaries about Postpartum hemorrhage risk factors is warranted, to enable the development of a tool to assess risk factors associated to Postpartum hemorrhage among childbearing women in Low- and Middle- Income Countries.

Relation of meconium-stained amniotic fluid and postpartum hemorrhage: a retrospective cohort study.

Postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. The purpose of this study was to evaluate if meconium-stained amniotic fluid (MSAF) is a risk factor for PPH after vaginal delivery. We retrospectively analyzed medical records of all patients who had a vaginal delivery at Fujian Provincial Maternity and Children's Hospital, between 1st January 2013 to 31st December 2018. Women with cesarean deliveries, multiple pregnancies, abnormal coagulation profile, and those with concomitant liver or kidney disorders were excluded. Patients were classified into MSAF (n=13686) and clear amniotic fluid (AF) (n=41511) groups. The incidence of PPH was significantly higher at 2.7% (370/13686) in the MSAF group as compared to 2.18% (904/41511) in the clear AF group (p=0.0004). There was no difference in the incidence of severe PPH between the two groups. Statistically significant difference in the incidence of PPH between MSAF and clear AF was seen in the maternal age groups of 30-34 and 35-39 years, gestational age>40weeks and >3 gravidity (p<0.05). Our study demonstrates that MSAF is a significant risk factor for minor and moderate PPH. Presence of meconium could therefore alert clinicians to expect PPH and make arrangements for further patient management. Further basic research is required to evaluate the mechanism by which meconium influences the incidence of PPH.

The Association between Uterine Leiomyoma and Postpartum Hemorrhage: A Meta-Analysis

Background:Some studies have shown a relationship between uterine fibroids and PPH, while other studies have not shown a risk increase for PPH with uterine fibroids.Objective:The aim of performing the present study was in order to assess the association between uterine leiomyoma and postpartum hemorrhage (PPH) based on epidemiology studies.Methods:We searched for several major international databases (PubMed, Scopus, EBSCO and Web of Science) till Oct 2019. OR was used to measure the association between uterine leiomyoma and postpartum hemorrhage. The combined OR and the corresponding 95 % CI were calculated using random-effects models. In order to control potential confounders, a meta-analysis was carried out based on crude and adjusted form. Homogeneity of effect size was tested by using the Q statistic and to measure the inconsistency across studies and the I2 statistic was used. Funnel plot and the Begg's test was employed to assess possible publication bias. Data were analyzed by the Stata software, version 14, with significance level 0.05.Results:Based on OR estimates obtained from adjusted studies, there was a significant relationship between the uterine leiomyoma and PPH (OR=1.44; 95% CI: 1.14, 1.73). We assessed the association according to statistical adjustment for confounding factors (crude/adjusted) and the association between uterine leiomyoma and PPH in both crude (OR=1.96; 95% CI: 1.03, 2.88) and adjusted (OR=1.23; 95% CI: 1.02, 1.44) report was statistically significant.Conclusion:In this study, uterine leiomyoma was a risk factor for PPH. Therefore, based on our findings in pregnant women with uterine leiomyoma, clinicians should be prepared to manage postpartum hemorrhage after vaginal births and cesarean deliveries.

Towards a universal definition of postpartum hemorrhage: retrospective analysis of Chinese women after vaginal delivery or cesarean section: A case-control study.

Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality, yet it is inconsistently defined, preventing accurate estimation of its incidence and identification of risk factors. Here we began to explore a unified definition of PPH that may be valid for vaginal delivery and cesarean section.Medical records of women who underwent vaginal delivery or cesarean section at our tertiary medical center between January and December 2018 were retrospectively analyzed. Patients who delivered by each route were compared in terms of PPH incidence and risk factors depending on different blood loss cut-off values.A total of 560 vaginal deliveries and 393 cesarean sections were analyzed. Vaginal deliveries were associated with significantly greater blood loss based on change of hemoglobin level, but significantly lower blood loss based on clinical estimation. When PPH was defined as blood loss ≥500 ml based on change of hemoglobin level, its incidence was 57.7% for vaginal deliveries and 28.2% for cesarean sections. The corresponding incidences were 15.4% and 3.3% when PPH was defined as blood loss ≥1000 ml based on change of hemoglobin levels. Independent risk factors for PPH in vaginal deliveries were lateral perineotomy (OR 2.835, 95%CI 1.694-4.743), suturing by a junior physician (OR 3.456, 95%CI 2.005-5.956), and long time from delivery of placenta to return to the recovery room (OR 1.013, 95%CI 1.003-1.022). A risk factor for PPH in cesarean sections was a long time from delivery of the fetus until the end of the operation.PPH is a significantly underestimated obstetric problem, especially in vaginal deliveries. Regardless of delivery route, hemoglobin-based blood loss of 500 ml and 1000 ml may be useful, respectively, as early warning and diagnostic cut-off values.

Duration of the Third Stage of Labor and Estimated Blood Loss in Twin Vaginal Deliveries.

Objective The main aim of this study was to characterize the duration of the third stage of labor and estimated blood loss in twin vaginal deliveries. Study Design This was a retrospective case–control study. The data was collected from deliveries at the University of Arkansas for Medical Sciences in Little Rock, Arkansas, from January 2013 to June 2017. Women were identified who had twin gestation, were delivered vaginally, and whose maternal age was greater than 18 years old. Women were excluded if they had an intrauterine fetal demise, delivered either/both fetuses via cesarean, history of a previous cesarean or a fetus with a congenital anomaly. If a subject met criteria to be included in the study, the next normal singleton vaginal delivery was used as the control subject. Results There were 132 singleton vaginal deliveries and 133 twin vaginal deliveries analyzed. There was no significant difference in the length of the third stage of labor between twin and singleton vaginal deliveries except in the 95th percentile of the distribution. Mothers delivering twins had an increase in third-stage duration by 7.618 minutes (95% confidence interval [CI]: 0.73, 14.50; p = 0.03) compared with those who delivered singletons. The twin group had a higher estimated blood loss than singleton deliveries. The increase in blood loss in the twin group was 149.02 mL (95% CI: 100.2, 197.8), 257.01 mL (95% CI: 117.9, 396.1), and 381.53 mL (95% CI: 201.1, 562.1) at the 50th, 90th, and 95th percentiles, respectively. When the third stage of labor was at the 90th percentile or less in twin pregnancy (14 minutes), estimated blood loss was less than 1000 mL. Conclusion Twin pregnancy is a known risk factor for postpartum hemorrhage. As the duration of the third stage prolongs, the risk for hemorrhage also increases. We recommend delivery of the placenta in twin pregnancies by 15 minutes to reduce this risk. Key Points The third stage is longer in twin pregnancy at extremes.Twin placentas should be delivered by 15 minutes.Manually extract the placenta when third stage is prolonged.

Postpartum haemorrhage in women with mild factor XI deficiency.

With the advent of direct-to-consumer genetic testing, mild factor XI deficiency is increasingly recognized. There are limited data regarding the risk of postpartum haemorrhage (PPH) among women with mild FXI deficiency following obstetrical delivery. To assess the risk of PPH among women with mild FXI deficiency undergoing vaginal or caesarean delivery. We conducted a retrospective, case-control study, in women with FXI levels between 20% and 70% of normal. For a control population, delivery outcomes were analysed in 200 women (between 2016 and 2018) without known bleeding disorders. There was no PPH among 45 vaginal deliveries in women with mild FXI deficiency compared with one PPH among 125 vaginal deliveries in the control cohort. The rate of PPH was significantly higher among the 26 caesarean deliveries in women with mild FXI deficiency relative to 75 control caesarean deliveries (odds ratio 2.73, 95% CI 1.02-7.26, P=.04). Prior history of haemorrhage was a strong predictor of PPH following caesarean delivery. All women who developed PPH following caesarean delivery had either a history of haemorrhage or independent risk factor for PPH. Due to the low rates of postpartum haemorrhage following vaginal delivery, routine prophylaxis to prevent postpartum haemorrhage in the setting of mild FXI deficiency does not appear warranted, especially in the absence of a bleeding history. Mild FXI deficiency is associated with an increased risk of PPH following caesarean delivery.

The Use of Tranexamic Acid to Prevent Postpartum Hemorrhage

Tranexamic acid (TXA) is an antifibrinolytic pharmacologic agent with demonstrated effectiveness for reducing the incidence of death from blood loss following trauma and major surgery. In intrapartum care, TXA is being used in in conjunction with uterotonic agents to treat postpartum hemorrhage (PPH). Based on the findings of the WOMAN trial that found TXA reduced maternal death due to PPH, the World Health Organization recommends that TXA be part of the standard comprehensive PPH treatment package, and US professional organizations recognize its use as adjunctive treatment for PPH. Evidence suggests that TXA used prophylactically in the setting of cesarean birth may decrease blood loss and the incidence of PPH. There is limited evidence for prophylactic use of TXA in women of all risk categories following vaginal birth but prophylactic use in women who have an a priori risk for PPH is being investigated. This article presents a case in which a midwife identifies a woman in active labor who has significant risk factors for PPH. In consultation with the collaborating obstetrician, TXA is given early during the third stage of labor in addition to the recommended components of active management for the purpose of preventing PPH.

Trends in Postpartum Hemorrhage in the United States From 2010 to 2014.

Postpartum hemorrhage (PPH) is a leading cause of morbidity and mortality in the United States; its prevalence increased during the 1990s-2000s. The purpose of this study was to reevaluate trends in PPH using the National Inpatient Sample. From 2010 to 2014, the prevalence of PPH increased from 2.9% (95% confidence interval [CI], 2.7%-3.1%) to 3.2% (95% CI, 3.1%-3.3%) of deliveries. Adjusting for PPH risk factors did not substantially attenuate this trend. Among patients with PPH, there was a decline in associated coagulopathy, acute respiratory failure, and maternal death, but an increase in sepsis and acute renal failure. Continued focus on PPH management is warranted.

Postpartum Hemorrhage and Very Advanced Maternal Age [28M

INTRODUCTION: Postpartum hemorrhage (PPH) is an important cause of maternal morbidity. Identifying women at increased risk for PPH can help reduce morbidity. The aim of this study was to determine if women over 45 years (very advanced maternal age, VAMA) are at increased risk for PPH. METHODS: Retrospective study of term, nulliparous women with singleton fetuses in vertex presentation who delivered at Kaiser Permanente Northern California Hospitals from 2010-2017 with complete data recorded. Incidence of PPH (estimated blood loss &gt;500 cc for vaginal delivery, &gt;1,000 cc for cesarean delivery, or other definitive chart evidence) among women over 45 years was compared to incidence of PPH among younger women. Logistic regression was used to adjust for confounders. RESULTS: There were 98,922 women included, including 177 women over 45 years. PPH occurred in 33.3% of women &gt;45 years as compared to 15.6% of women 45 years had significantly increased odds of PPH as compared to women &lt;35 years (OR 1.88, 95% CI 1.35–2.61). CONCLUSION: These data demonstrate that VAMA is an independent risk factor for PPH. This knowledge provides physicians with an opportunity to counsel patients over 45 years regarding the risk for PPH and to prepare for delivery with strategies including optimization of blood count, planning for delivery location and procurement of appropriate blood products before delivery.