Risk Factors For PPH Research Articles

Tranexamic acid by the intramuscular or intravenous route for the prevention of postpartum haemorrhage in women at increased risk: a randomised placebo-controlled trial (I’M WOMAN)

BackgroundPostpartum haemorrhage (PPH) causes about 70,000 maternal deaths every year. Tranexamic acid (TXA) is a life-saving treatment for women with PPH. Intravenous (IV) TXA reduces deaths due to PPH by one-third when given within 3 h of childbirth. Because TXA is more effective when given early and PPH usually occurs soon after childbirth, giving TXA just before childbirth might prevent PPH. Although several randomised trials have examined TXA for PPH prevention, the results are inconclusive. Because PPH only affects a small proportion of births, we need good evidence on the balance of benefits and harms before using TXA to prevent PPH. TXA is usually given by slow IV injection. However, recent research shows that TXA is well tolerated and rapidly absorbed after intramuscular (IM) injection, achieving therapeutic blood levels within minutes of injection.MethodsThe I’M WOMAN trial is an international, multicentre, three-arm, randomised, double-blind, placebo-controlled trial to assess the effects of IM and IV TXA for the prevention of PPH in women with one or more risk factors for PPH giving birth vaginally or by caesarean section.DiscussionThe trial will provide evidence of the benefits and harms of TXA for PPH prevention and the effects of the IM and IV routes of administration. The IM route should be as effective as the IV route for preventing bleeding. There may be fewer side effects with IM TXA because peak blood concentrations are lower than with the IV route. IM TXA also has practical advantages as it is quicker and simpler to administer. By avoiding the need for IV line insertion and a slow IV injection, IM administration would free up overstretched midwives and doctors to focus on looking after the mother and baby and expand access to timely TXA treatment.Trial registrationClinicalTrials.gov NCT05562609. Registered on 3 October 2022. ISRCTN Registry ISRCTN12590098. Registered on 20 January 2023. Pan African Clinical Trial Registry PACTR202305473136570. Registered on 18 May 2023.

Heat stable carbetocin or oxytocin for prevention of postpartum hemorrhage among women at risk: A secondary analysis of the CHAMPION trial.

To examine whether the observed non-inferiority of heat-stable carbetocin (HSC), compared with oxytocin, was influenced by biologic (macrosomia, parity 3 or more, or history of postpartum hemorrhage [PPH]) and/or pharmacologic (induction or augmentation) risk factors for PPH. The present study is a secondary analysis of the CHAMPION non-inferiority randomized trial-a two-arm, double-blind, active-controlled study conducted at 23 hospitals in 10 countries, between July 2015 and January 2018. Women with singleton pregnancies, expected to deliver vaginally with cervical dilatation up to 6 cm were eligible. Randomization was stratified by country, with 1:1 assignment. Women in the intervention and control groups received a single intramuscular injection of 100 μg of HSC or 10 IU of oxytocin, respectively. The drugs were administered immediately after birth, and the third stage of labor was managed according to the WHO guidelines. Blood was collected using a plastic drape. For this analysis, we defined a woman as being at risk if she had any one or more of the biologic or pharmacologic risk factor(s). The HSC and oxytocin arms contained 14 770 and 14 768 women, respectively. The risk ratios (RR) for PPH were 1.29 (95% confidence interval [CI] 1.08-1.53) or 1.73 (95% CI 1.51-1.98) for those with only biologic (macrosomia, parity 3 or more, and PPH in the previous pregnancy) or only pharmacologic (induced or augmented) risk factors, respectively, compared with those with neither risk factors. Findings reinforce previous evidence that macrosomia, high parity, history of PPH, and induction/augmentation are risk factors for PPH. We did not find a difference in effects between HSC and oxytocin for PPH among women who were neither induced nor augmented or among those who were induced or augmented.

C-reactive protein identifies patients at risk of postpancreatectomy hemorrhage

BackgroundPostpancreatectomy hemorrhage grade C (PPH C) is a dreaded complication after pancreaticoduodenectomy (PD) with high mortality rate. Concurrent risk factors for PPH C have been difficult to recognize. Connection between postoperative pancreatic fistulas (POPF) and PPH C is well known, but POPF is often unknown prior to the PPH. The aim of this retrospective study was to define potential predictive factors for PPH C.MethodsRetrospectively, 517 patients who underwent PD between 2003 and 2018 were included in the study. Twenty-three patients with PPH C were identified, and a matched control group of 92 patients was randomly selected. Preoperative data (body mass index, cardiovascular disease, history of abdominal surgery, biliary stent, C-reactive protein (CRP), ASA-score), perioperative data (bleeding, pancreatic anastomosis, operation time), and postoperative data (CRP, drain amylase, POPF, biliary fistula) were analyzed as potential predictors of PPH C.ResultsHigh postoperative CRP (median 140 mg/L on day 5 or 6) correlated with the development of PPH C (p < 0.05). Postoperative drain amylase levels were not clinically relevant for occurrence of PPH C. Grade C POPF or biliary leak was observed in the majority of the PPH C patients, but the leaking anastomoses were not detected before the bleeding started.DiscussionHigh postoperative CRP levels are related to an increased risk of PPH C.

A Study to decrease the incidence of PPH in our hospital setting

Objective: This study aimed to measure incidence, identify risk factors (pre‐existing or acquired) forPPH and to prevent progression to severe PPH. Methods: This is a prospective observational study.The causes are likely to be multifactorial with shifting demography and health status widely cited,e.g. age, obesity, comorbidity, multiple pregnancy and ethnicity. Results: Prepregnancy factors forPPH include age, ethnicity, BMI, previous PPH and assisted conception Conclusion: Prophylacticuterotonic agents in high-risk patients, use of intramuscular or intravenous oxytocin, timelyapplication of B –lynch suture, adequate and timely arrangement of blood and blood factors can helpprevent PPH.

Internal Iliac Artery Balloon Tamponade in Placenta Accreta; Outcomes From the Largest Tertiary Accreta Referral Centre in British Columbia

Objectives: Placenta accreta syndromes are well-recognized risk factors for severe PPH and are associated with significant maternal morbidity. Internal iliac artery balloon tamponade is an adjunctive procedure used to reduce blood loss at the time of caesarean hysterectomy (c-hyst) with variable results in the literature. We studied the outcomes of preoperative balloon tamponade at the largest tertiary referral centre for placenta accreta in British Columbia.

ASSESSMENT OF RISK FACTORS FOR PRIMARY POSTPARTUM HEMORRHAGE AT ZAGAZIG UNIVERSITY HOSPITALS

Background: Primary postpartum hemorrhage PPH is a major cause of maternal morbidity and mortality. Many risk factors for primary PPH have been evaluated, while with changes of obstetric population and technological advances, some of these factors became more important and others were less. Aim: To identify common risk factors of primary PPH and measure the association between these factors and the occurrence of primary PPH. Methods: A case control study was conducted in obstetrics and gynecology department at Zagazig University Hospitals. Participants were selected by systematic random sampling. Data were collected about the participants’ age and social class as well as studied risk factors for primary PPH including previous delivery mode, previous antipartum hemorrhage APH, previous PPH, parity, birth weight, gestational age, maternal obesity, maternal hemoglobin level, labor induction, current delivery mode, delivery trauma, episiotomy, placenta previa and retained placenta. Results: Primary PPH was significantly higher among older ages (> 34 years). Primary PPH showed significant associations with the following factors; Previous APH (OR= 3.57), previous PPH (OR= 2.85), macrosomia (OR= 9.57), maternal anemia (OR= 5.37), obesity (OR= 4.01), vaginal delivery (OR= 2.13), labor induction (OR= 2.88), trauma (OR= 3.53), retained placenta (OR= 8.51), and placenta previa (OR= 3.51). Conclusion: Maternal anemia, retained placenta, Macrosomia, and previous PPH were the most significant risk factors for primary PPH. Recommendations: Organized antenatal visits are recommended to help early detection of PPH risk factors and improve females’ knowledge about PPH risk. clinicians should optimize care for high risk women. Adequate supplies should be provided to health facilities for prompt management of PPH. Running header: Risk Factors for Primary Postpartum Hemorrhage Key words: Postpartum hemorrhage, Risk factors, Pregnant, Zagazig

Grouping parturients by parity, previous cesarean and mode of delivery identifies parturients at risk for postpartum-hemorrhage

Background: The prevalence of postpartum-hemorrhage varies between studies depending on the definition of postpartum-hemorrhage and the population studied. Significant differences are reported among sub-groups stratified by single risk factors including parity, mode of delivery and management of labor. Objective: Our primary goal was to form a clinical classification aimed to identify sub-groups of parturients at risk for postpartum-hemorrhage by combining clinical universal risk factors. Study design: Retrospective cohort including all women who delivered at Shaare Zedek Medical Center, an affiliated university medical center, managing 10% of national deliveries, between January 2006 and December 2014. Parturients were grouped according to three characteristics, all known as universal risk factors for PPH: parity (primiparous, multiparous), previous cesarean and mode of delivery (spontaneous vaginal delivery, instrumental delivery, non-planned and elective cesarean): P-C-MoD classification. All together the classification included 12 sub-groups. Postpartum-hemorrhage was defined as a decrease of ≤3 g% hemoglobin or transfusion of blood products and was calculated for each of the sub-groups independently. A univariate analysis followed by a multivariate analysis was performed to study the risk for postpartum-hemorrhage among the sub-groups studied, controlling for confounding factors including age, onset of delivery, number of fetus and fetal birth weight. Results: The crude rate of postpartum-hemorrhage, for all 126,693 parturients was 7%. The prevalence for PPH differed significantly between independent risk factors compared to the combined risk factors of the P-C-MoD classification. Among primiparous, the prevalence was 14%, this changed significantly when combining primiparous with mode of delivery, ranging from 11% for spontaneous vaginal delivery to 27% among those with instrumental delivery. The prevalence of PPH among multiparous varied between 3% (spontaneous vaginal delivery) and 20% (emergency CD). There was significant difference in the prevalence of PPH between the sub-groups of the P-C-MoD classification. Primiparous who underwent ID were at increased risk for PPH, approximately one of four women in this group (27%) experienced PPH. Applying a univariate analysis revealed that the risk for PPH was significantly increased for primiparous undergoing ID compared to all other sub-groups reaching an OR of 12.8 (95% CI: 11.9; 13.8) compared to multiparous undergoing SVD. Applying a multivariate analysis minimally altered the results. Conclusions: Grouping parturients by parity, previous cesarean and mode of delivery (P-C-MoD classification) is a useful tool to identify parturients at risk for postpartum-hemorrhage and is superior compared to single independent risk factors. Future studies are needed to confirm the external validity of this classification.

Can Intravenous Injection of Tranexamic Acid Be Used in Routine Practice With Active Management of the Third Stage of Labor in Vaginal Delivery? A Randomized Controlled Study

Obstetric hemorrhage accounts for ∼25% of maternal morbidity. Many methodologies are used to promote active management of the third stage of labor. Tranexamic acid successfully reduces blood loss and transfusion requirements in nonobstetric conditions. This double-blind, randomized, controlled trial was undertaken to estimate the effects of adding tranexamic acid to an active management protocol. The parturients were at 34 to 42 weeks’ gestation, with a live fetus in cephalic presentation, and expecting vaginal birth. The experimental group (n = 228) received 1 g/10 mL tranexamic acid diluted with 20 mL 5% glucose; the placebo group (n = 226) received 30mL5%glucose. Tranexamic acid or placebo was administered intravenously over 5 minutes at delivery of the fetus’ anterior shoulder. Standard management of the third and fourth stages of labor was applied. The primary outcome was the volume of blood loss during the third and fourth stages of labor. Other outcomes were the incidence of postpartum hemorrhage (PPH; >500 mL), severe PPH (>1000 mL), need for blood transfusion, need for additional uterotonic drugs, and adverse effects of tranexamic acid. Participants were contacted 3 weeks after delivery to assess the incidence of thromboembolic events. Data were analyzed on an intent-to-treat basis. The final analysis included 220 and 219 in the tranexamic acid and control groups, respectively. The groups were similar in patient characteristics and risk factors for PPH. At the third and fourth stages of labor, mean estimated blood losses were 261.5 ± 146.8 and 349.98 ± 188.85 mL in the tranexamic acid and control groups, respectively (P < 0.001). Four patients (1.8%) in the tranexamic acid group and 15 (6.8%) in the control group had PPH of greater than 500 mL (RR, 3.76; 95% CI, 1.27–11.15; P = 0.01). Six (2.7%) and 19 (8.7%) women in the tranexamic acid and control groups, respectively, required additional uterotonic agents (RR 3.18; 95% CI, 1.29–7.81; P = 0.007). The groups did not differ in need for blood transfusion. Predelivery hemoglobin and hematocrit levels were the same in the 2 groups, but at 1 day postpartum, hemoglobin levels were 9.9 T 1.4 and 9.3 T 0.9 g/dL (P G 0.001), and hematocrit levels were 30.2% ± 1.2% and 29.0% ± 1.3% (P < 0.001) in the tranexamic acid and placebo groups, respectively. No major complications and no significant changes in prothrombin time, active prothrombin time, or liver or renal function tests were noted in either group. Rates for nausea, vomiting, and diarrhea were 15.0%, 13.6%, and 7.3% in the tranexamic acid group and 5.5%, 6.4%, and 1.8% in the control group. At the clinical checkup 3 weeks postpartum, no episode of thrombosis was reported in patients given tranexamic acid. Tranexamic acid can reduce the average amount of blood loss during the third and fourth stages of labor. Determining the clinical settings in which this medication may be beneficial is critical for future research.

PL.39 Incidence and Risk Factors for Severe PPH: A Prospective South East Cohort Study (STOP)

IntroductionPostpartum haemorrhage(PPH) is common, rising and treatable (1). Most women are not compromised until estimated blood loss (EBL) exceeds 1000 ml (2). Major PPH remains a cause of maternal death...

How Birth Interval and Antenatal Care Affects Postpartum Haemorrhage Prevention in Maiduguri, Nigeria

The following work studied how birth interval and antenatal care contribute to occurence of postpartum haemorrhage and how these factors modulates the preventive efficacies of oxytocin injection and misoprostol tablets in postpartum haemorrhage. A total of 1140 pregnant women who have received either oxytocin injection or oral misoprostol in third stage of labour as a prophylaxis of postpartum haemorrhage, were enrolled within three health care facilities in Maiduguri, Nigeria. Each patient was observed at parturition and for 24 h after during which blood lost was estimated to the nearest ml. Maternal characteristics were recorded in a structured proforma. The relationship of the occurrence of PPH (blood loss > 500 ml) and mean blood loss was studied with respect to the prophylactic medication used and some obstetric factors. The occurrence of PPH in subjects that had ‘inadequate’ resting period (29.3 %) was higher than that of the ‘adequate’ resting period group (2 %). Misoprostol exhibited greater PPH prevention in the “inadequate” resting period category (83.9 versus 38.8%). The enrolees that had inadequate antenatal care exhibited higher occurrence of PPH than the adequate group (21.6 versus 16.6%). In the misoprostol medication sub-group, there was significantly (p < 0.001) higher occurrence of PPH in the “adequate ANC” category (37.6%) than in the “inadequate ANC” category (7.1%). Inadequate birth interval and inadequate antenatal care are risk factors for PPH. The relative efficacies of oral misoprostol and parenteral oxytocin significantly vary with varying level of antenatal care and birth interval.

Maternal obesity and postpartum haemorrhage after vaginal and caesarean delivery among nulliparous women at term: a retrospective cohort study

BackgroundIncreasing rates of postpartum haemorrhage in developed countries over the past two decades are not explained by corresponding changes in risk factors and conjecture has been raised that maternal obesity may be responsible. Few studies investigating risk factors for PPH have included BMI or investigated PPH risk among nulliparous women. The aim of this study was to determine in a cohort of nulliparous women delivering at term whether overweight and obesity are independent risk factors for major postpartum haemorrhage (PPH ≥1000ml) after vaginal and caesarean section delivery.MethodsThe study population was nulliparous singleton pregnancies delivered at term at National Women’s Hospital, Auckland, New Zealand from 2006 to 2009 (N=11,363). Multivariable logistic regression was adjusted for risk factors for major PPH.ResultsThere were 7238 (63.7%) women of normal BMI, 2631 (23.2%) overweight and 1494 (13.1%) obese. Overall, PPH rates were increased in overweight and obese compared with normal-weight women (n=255 [9.7%], n=233 [15.6%]), n=524 [7.2%], p <.001) respectively. There was an approximate twofold increase in risk in obese nulliparous women that was independent of confounders, adjusted odds ratio [aOR (95% CI)] for all deliveries 1.86 (1.51-2.28). Being obese was a risk factor for major PPH following both caesarean 1.73 (1.32-2.28) and vaginal delivery 2.11 (1.54-2.89) and the latter risk was similar after exclusion of women with major perineal trauma and retained placentae. Three additional factors were consistently associated with risk for major PPH regardless of mode of delivery: increasing infant birthweight, antepartum haemorrhage and Asian ethnicity.ConclusionNulliparous obese women have a twofold increase in risk of major PPH compared to women with normal BMI regardless of mode of delivery. Higher rates of PPH among obese women are not attributable to their higher rates of caesarean delivery. Obesity is an important high risk factor for PPH, and the risk following vaginal delivery is emphasised. We recommend in addition to standard practice of active management of third stage of labour, there should be increased vigilance and preparation for PPH management in obese women.

The State of Pregnancy Alters the Mean Number of Platelet Dense Granules

Abstract 4672Postpartum hemorrhage (PPH) is one of the leading causes of maternal mortality and is estimated to occur in 1–10% of all childbirths. Postpartum hemorrhage is defined as a blood loss of >500 ml for vaginal delivery or >1000 ml for cesarean delivery. The etiology of PPH is attributed most often to uterine atony (80%); the etiology of atony is unknown. Studies of rat and human myometrial tissues suggest that an increase of 5-HT2 receptors late in pregnancy might trigger parturition by increasing uterine contractility when presented with 5-HT released by mast cells and platelets. Furthermore, the up-regulated receptors may serve to maintain uterine tone postpartum. The most common cited risk factors for PPH include PPH in a previous pregnancy, chorioamnionitis, use of magnesium sulfate, labor induction and augmentation, increased birth weight, and retention of the placenta. The obstetrics literature discounts bleeding disorders as significant risk factors for PPH for the immediate postpartum period although acknowledging that if diagnosed, such disorders should be considered during management of pregnancy. In essence, bleeding disorders are thought to be rare causes of PPH. A few case reports in the literature suggest that platelet storage pool deficiency (SPD) may be a contributing factor for development of PPH.We report the first investigation of the platelet dense granule storage pool during pregnancy. Our hypotheses include that platelet (PLT) delta (δ) granule storage pool deficiency (δSPD) may be a risk factor for the development of PPH. As the PLT dense (δ) granules (DG) store the majority of 5HT excluding the central nervous system, δSPD would intuitively present less 5-HT at parturition potentially resulting in atony. Our IRB approved study is recruiting women during prenatal check-ups. To assess for potential bleeding tendencies, we are utilizing a modified Vincenza bleeding checklist (Tosetto, et al., 2007), a pictorial blood loss assessment (Jannsen, et al, 1995), and a blood sample for PLT whole mounts and biochemical assays.To date, a total of 32 women have been enrolled in the study having an average age of 24.2 ± 4. Bleeding scores average 0.24 ± 0.21 (normal <5) and the pictorial menorrhagia scores average 170.44 ± 30.94 (normal <185). Four women have scores ranging from 267–522 consistent with a clinical diagnosis of menorrhagia and suggesting that they may have a bleeding tendency although their bleeding scores are all within the normal range. The mean number of DG/PLT is 5.34 ± 0.58 which is significantly different than a vetted control group of women (n=26) who have an average of 4.16 ± 0.08 DG/PLT. These data suggest that the state of pregnancy includes an increase in the average number of DG/PLT. It is known that pregnancy results in a variety of hematologic deviations from normal CBC ranges in non-pregnant women including Hgb and Hct that decrease, related to a dilution effect of increased blood volume. Pregnancy is also related to an increased state of coagulability. The increased number of DG/PLT might suggest a potential for increased coagulability in preparation of parturition as all women studied have significantly increased DG numbers in comparison to control subjects. These results are in direct contradiction to our original hypothesis that δSPD might contribute to PPH. We have yet to analyze 5HT extracts from PLTs however these results will be presented with significantly more data as we continue with our recruitment of test subjects. Disclosures:No relevant conflicts of interest to declare.

The use of the Rusch balloon for management of severe postpartum haemorrhage

SummaryTamponade techniques using a uterine balloon in management of postpartum haemorrhage has been reported increasingly in recent years. The aim of this retrospective study is to evaluate the use of the Rusch hydrostatic balloon in the management of severe postpartum haemorrhage not controlled by medical measures. All women had risk factors for PPH. The Rusch balloon was used in all cases of PPH apart from traumatic PPH, which is considered as a contraindication for its use. The Rusch balloon was successful in seven out of the eight cases treated. We have introduced guidelines for using the Rusch balloon and they are provided in this paper.

RISK FACTORS FOR PULMONARY ARTERIAL HYPERTENSION

The present limitations in knowledge of the potential risk factors for PPH undoubtedly are attributable to the facts that PPH is a rare disease with an unknown pathogenesis and lacking large case series. Moreover, definite epidemiologic data are rare and ideally should be obtained from epidemiologic surveys such as large case-control studies. The increased incidence of the disease in young women, the familial cases, the association with autoimmune disorders, and the recent discovery that mutation of the PPH1 gene may not be restricted to familial PPH support the hypothesis that the development of pulmonary hypertension likely implies an individual susceptibility or predisposition, which is probably genetically determined. It is also now commonly believed that the development of pulmonary hypertension in some of these predisposed individuals could be hastened or precipitated by various expression factors (some of them yet unrecognized), such as ingestion of certain drugs or diets, portal hypertension, or HIV infection.