Risk Of Postpartum Hemorrhage Research Articles

Machine learning approaches for predicting postpartum hemorrhage: a comprehensive systematic literature review

Postpartum hemorrhage (PPH) represents a significant threat to maternal health, particularly in developing countries, where it remains a leading cause of maternal mortality. Unfortunately, only 60% of pregnant women at high risk for PPH are identified, leaving 40% undetected until they experience PPH. To address this critical issue and ensure timely intervention, leveraging rapidly advancing technology with machine learning (ML) methodologies for maternal health prediction is imperative. This review synthesizes findings from 43 selected research articles, highlighting the predominant ML techniques employed in PPH prediction. Among these, logistic regression (LR), extreme gradient boosting (XGB), random forest (RF), and decision tree (DT) emerge as the most frequently utilized methods. By harnessing the power of ML, we aim to foster technological advancements in the healthcare sector, with a particular focus on maternal health and ultimately contribute to the reduction of maternal mortality rates worldwide.

Development and Validation of an Automated, Real-Time Predictive Model for Postpartum Hemorrhage

OBJECTIVE: To develop and validate a predictive model for postpartum hemorrhage that can be deployed in clinical care using automated, real-time electronic health record (EHR) data and to compare performance of the model with a nationally published risk prediction tool. METHODS: A multivariable logistic regression model was developed from retrospective EHR data from 21,108 patients delivering at a quaternary medical center between January 1, 2018, and April 30, 2022. Deliveries were divided into derivation and validation sets based on an 80/20 split by date of delivery. Postpartum hemorrhage was defined as blood loss of 1,000 mL or more in addition to postpartum transfusion of 1 or more units of packed red blood cells. Model performance was evaluated by the area under the receiver operating characteristic curve (AUC) and was compared with a postpartum hemorrhage risk assessment tool published by the CMQCC (California Maternal Quality Care Collaborative). The model was then programmed into the EHR and again validated with prospectively collected data from 928 patients between November 7, 2023, and January 31, 2024. RESULTS: Postpartum hemorrhage occurred in 235 of 16,862 patients (1.4%) in the derivation cohort. The predictive model included 21 risk factors and demonstrated an AUC of 0.81 (95% CI, 0.79–0.84) and calibration slope of 1.0 (Brier score 0.013). During external temporal validation, the model maintained discrimination (AUC 0.80, 95% CI, 0.72–0.84) and calibration (calibration slope 0.95, Brier score 0.014). This was superior to the CMQCC tool (AUC 0.69 [95% CI, 0.67–0.70], P<.001). The model maintained performance in prospective, automated data collected with the predictive model in real time (AUC 0.82 [95% CI, 0.73–0.91]). CONCLUSION: We created and temporally validated a postpartum hemorrhage prediction model, demonstrated its superior performance over a commonly used risk prediction tool, successfully coded the model into the EHR, and prospectively validated the model using risk factor data collected in real time. Future work should evaluate external generalizability and effects on patient outcomes; to facilitate this work, we have included the model coefficients and examples of EHR integration in the article.

Predictive Modelling of Postpartum Haemorrhage Using Early Risk Factors: A Comparative Analysis of Statistical and Machine Learning Models.

Postpartum haemorrhage (PPH) is a significant cause of maternal morbidity and mortality worldwide, particularly in low-resource settings. This study aimed to develop a predictive model for PPH using early risk factors and rank their importance in terms of predictive ability. The dataset was obtained from an observational case-control study in northern Rwanda. Various statistical models and machine learning techniques were evaluated, including logistic regression, logistic regression with elastic-net regularisation, Random Forests, Extremely Randomised Trees, and gradient-boosted trees with XGBoost. The Random Forest model, with an average sensitivity of 80.7%, specificity of 71.3%, and a misclassification rate of 12.19%, outperformed the other models, demonstrating its potential as a reliable tool for predicting PPH. The important predictors identified in this study were haemoglobin level during labour and maternal age. However, there were differences in PPH risk factor importance in different data partitions, highlighting the need for further investigation. These findings contribute to understanding PPH risk factors, highlight the importance of considering different data partitions and implementing cross-validation in predictive modelling, and emphasise the value of identifying the appropriate prediction model for the application. Effective PPH prediction models are essential for improving maternal health outcomes on a global scale. This study provides valuable insights for healthcare providers to develop predictive models for PPH to identify high-risk women and implement targeted interventions.

The influence of uterine fibroids on adverse outcomes in pregnant women: a meta-analysis

ObjectiveThe objective of the meta-analysis was to determine the influence of uterine fibroids on adverse outcomes, with specific emphasis on multiple or large (≥ 5 cm in diameter) fibroids.Materials and methodsWe searched PubMed, Embase, Web of Science, ClinicalTrials.gov, China National Knowledge Infrastructure (CNKI), and SinoMed databases for eligible studies that investigated the influence of uterine fibroids on adverse outcomes in pregnancy. The pooled risk ratio (RR) of the variables was estimated with fixed effect or random effect models.ResultsTwenty-four studies with 237 509 participants were included. The pooled results showed that fibroids elevated the risk of adverse outcomes, including preterm birth, cesarean delivery, placenta previa, miscarriage, preterm premature rupture of membranes (PPROM), placental abruption, postpartum hemorrhage (PPH), fetal distress, malposition, intrauterine fetal death, low birth weight, breech presentation, and preeclampsia. However, after adjusting for the potential factors, negative effects were only seen for preterm birth, cesarean delivery, placenta previa, placental abruption, PPH, intrauterine fetal death, breech presentation, and preeclampsia. Subgroup analysis showed an association between larger fibroids and significantly elevated risks of breech presentation, PPH, and placenta previa in comparison with small fibroids. Multiple fibroids did not increase the risk of breech presentation, placental abruption, cesarean delivery, PPH, placenta previa, PPROM, preterm birth, and intrauterine growth restriction. Meta-regression analyses indicated that maternal age only affected the relationship between uterine fibroids and preterm birth, and BMI influenced the relationship between uterine fibroids and intrauterine fetal death. Other potential confounding factors had no impact on malposition, fetal distress, PPROM, miscarriage, placenta previa, placental abruption, and PPH.ConclusionThe presence of uterine fibroids poses increased risks of adverse pregnancy and obstetric outcomes. Fibroid size influenced the risk of breech presentation, PPH, and placenta previa, while fibroid numbers had no impact on the risk of these outcomes.

Agnostic identification of plasma biomarkers for postpartum hemorrhage risk.

Postpartum hemorrhage (PPH) is difficult to predict, is associated with significant maternal morbidity, and is the leading cause of maternal mortality worldwide. The identification of maternal biomarkers that can predict increased PPH risk would enhance clinical care and may uncover mechanisms that lead to PPH. This retrospective case-control study employed agnostic proteomic profiling of maternal plasma samples to identify differentially abundant proteins in controls and PPH cases. Maternal plasma samples were procured from a cohort of >60,000 participants in a single institution's perinatal repository. PPH was defined as a decrease in hematocrit of ≥10% or receipt of transfusion within 24 hours of delivery. PPH cases (N=30) were matched by maternal age and delivery mode (vaginal or cesarean) with controls (N=56). Mass spectrometry was used to identify differentially abundant proteins using integrated peptide peak areas. Statistically significant differences between groups were defined by a p-value of <0.05 after controlling for multiple comparisons. By study design, cases and controls did not differ in race, ethnicity, gestational age at delivery, blood type, or pre-delivery platelet count. Cases had slightly, but significantly lower pre- and post-delivery hematocrit and hemoglobin. Mass spectrometry detected 1140 proteins, including 77 proteins for which relative abundance differed significantly between cases and controls (fold change >1.15, P<0.05). Of these differentially abundant plasma proteins, most had likely liver or placental origins. Gene ontology term analysis mapped to protein clusters involved in responses to wound healing, stress response, and host immune defense. Significantly differentially abundant proteins with the highest fold change (prostaglandin D2 synthase, periostin, and several serine protease inhibitors) did not correlate with pre-delivery hematocrit or hemoglobin, but identified PPH cases with logistic regression modeling revealing good-to-excellent area under the operator receiver characteristic curves (AUROC 0.802-0.874). Incorporating pre-delivery hemoglobin with these candidate proteins further improved identification of PPH cases. Agnostic analysis of maternal plasma samples identified differentially abundant proteins in controls and PPH cases. Several of these proteins are known to participate in biologically plausible pathways for PPH risk and have potential value for predicting PPH. These findings identify candidate protein biomarkers for future validation and mechanistic studies.

Prediction of bleeding in labor in women with uterine scar as a tool to prevent massive blood loss: an observational cohort study

Background. Postpartum hemorrhage is recognized as a leading cause of maternal mortality and morbidity in the world. Predicting postpartum hemorrhage in high-risk patients with uterine scar enables preventive measures to be scheduled and costs of treatment and rehabilitation to be reduced.Objective. To determine antenatal predictors of high postpartum hemorrhage risk in pregnant women with uterine scar in order to improve the prevention of massive blood loss.Methods. An observational cohort study involves the medical records of 4494 maternity women with uterine scar (pregnancy and delivery histories) of the Perinatal Center of Regional Clinical Hospital No. 2, Krasnodar Krai. The study sample included data of maternity women coded O34.2 according to International Classification of Diseases, 10th Edition, for the period from 2017 to 2020. The sample participants were distributed into two groups depending on the blood loss during delivery, determined in compliance with clinical recommendations: a group of patients without massive blood loss during delivery and a group of patients with massive blood loss in labor/early postpartum period. The study was mainly focused on parameters of the prediction performance of bleeding in labor and early postpartum period in pregnant women with uterine scar using a multiparametric, logistic regression models. The study considered demographic data, comorbidity, obstetric history, pregnancy course, ultrasound data, and volume of blood loss at delivery. The performance of prediction for postpartum hemorrhage was calculated using multivariate binary logistic regression. Descriptive statistical analysis was carried out by means of statistical software package SPSS Version 26 (IBM, USA). Two-sided p-value &lt; 0.05 was taken as a statistically significant difference. A prognostic significance of predictors was determined by binary logistic regression. The Wald statistic was used to determine an observed significance. In order to define the performance of the model, the study involved calculating sensitivity, specificity, positive and negative predictive value, Nagelkerke coefficient of determination, as well as performing ROC analysis. The DeLong test was used for paired comparisons of ROC curves.Results. In the retrospective follow-up group (2017–2020) (n = 502), postpartum hemorrhage with massive blood loss occurred in 41 cases (8.17%). For the model based on clinical-anamnestic predictors, the prediction performance for postpartum hemorrhage comprised: sensitivity = 12.2% (95% confidence interval (CI) 4.1–26.2); specificity = 99.3% (95% CI 98.1–99.9); positive predictive value = 62.5% (95% CI 24.5–91.5); negative predictive value = 92.6% (95% CI 89.9–94.8); area under the ROC curve = 0.864 (95% CI 0.807–0.920), p &lt; 0.001. The prediction performance for the model based on three ultrasound predictors (asymmetry coefficient of placental thickness, uterine wall bulging in the scar and myometrial thickness in the placentation zone) comprised: sensitivity = 85.4% (95% CI 70.8–94.4); specificity = 98.5% (95% CI 96.9–99.4); positive predictive value = 83.3% (95% CI 68.6–93.0); negative predictive value = 98.7% (95% CI 97.2–99.5); area under the ROC curve = 0.919 (95% CI 0.855–0.983), p &lt; 0.001. No significant difference was revealed for the performance of the models ( p = 0.170). For the model based on ultrasound predictors and placenta previa, the prediction performance comprised: sensitivity = 85.4% (95% CI 70.8–94.4); specificity = 98.5% (95% CI 96.9–99.4); positive predictive value = 83.3% (95% CI 68.6–93.0); negative predictive value = 98.7% (95% CI 97.2–99.5); area under the ROC curve = 0.955 (95% CI 0.912–0.999), p &lt; 0.001. The model based on clinical-anamnestic and ultrasound indicators predicted postpartum hemorrhage with sensitivity equal to 85.4% (95% CI 70.8–94.4); specificity — 98.9% (95% CI 97.4–99.6); positive predictive value — 87.5% (95% CI 73.2–95.8); negative predictive value — 98.7% (95% CI 97.1–99.5); area under the ROC curve — 0.984 (95% CI 0.966–1.0), р &lt; 0,001. Thus, this model outperformed the model based on clinical-anamnestic data (p &lt; 0.001), based on ultrasound predictors (p = 0.006) and revealed no difference with the model considering placenta previa and ultrasound predictors (p = 0.127). Using prenatal prediction of postpartum hemorrhage based on ultrasound features, the incidence of massive blood loss at delivery decreased from 6.88/1000 deliveries (2019–2020) to 4.18/1000 deliveries (2021–2022) (p &lt; 0.001).Conclusion. Ultrasound predictors in pregnant women with uterine scar increase the sensitivity of antenatal prediction of postpartum hemorrhage based on the assessment of clinical and anamnestic risk factors, thereby enabling preventive measures to be scheduled in the risk group and incidence of massive blood loss to be reduced.

Risk of Postpartum Hemorrhage in Hypertensive Disorders of Pregnancy: Stratified by Severity.

We aimed to determine the composite maternal hemorrhagic outcome (CMHO) among individuals with and without hypertensive disorders of pregnancy (HDP), stratified by disease severity. Additionally, we investigated the composite neonatal adverse outcome (CNAO) among individuals with HDP who had postpartum hemorrhage (PPH) versus did not have PPH. Our retrospective cohort study included all singletons who delivered at a Level IV center over two consecutive years. The primary outcome was the rate of CMHO, defined as blood loss ≥1,000 mL, use of uterotonics, mechanical tamponade, surgical techniques for atony, transfusion, venous thromboembolism, intensive care unit admission, hysterectomy, or maternal death. A subgroup analysis was performed to investigate the primary outcome stratified by (1) chronic hypertension, (2) gestational hypertension and preeclampsia without severe features, and (3) preeclampsia with severe features. A multivariable regression analysis was performed to investigate the association of HDP with and without PPH on a CNAO which included APGAR <7 at 5 minutes, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, seizures, neonatal sepsis, meconium aspiration syndrome, ventilation >6 hours, hypoxic-ischemic encephalopathy, or neonatal death. Of 8,357 singletons, 2,827 (34%) had HDP. Preterm delivery <37 weeks, induction of labor, prolonged oxytocin use, and magnesium sulfate usage were more common in those with versus without HDP (p < 0.001). CMHO was higher among individuals with HDP than those without HDP (26 vs. 19%; adjusted relative risk [aRR] 1.11, 95% CI 1.01-1.22). In the subgroup analysis, only individuals with preeclampsia with severe features were associated with higher CMHO (n = 802; aRR 1.52, 95% CI 1.32-1.75). There was a higher likelihood of CNAO in individuals with both HDP and PPH compared to those with HDP without PPH (aRR 1.49, 95% CI 1.06-2.09). CMHO was higher among those with HDP. After stratification, only those with preeclampsia with severe features had an increased risk of CMHO. Among individuals with HDP, those who also had a PPH had worse neonatal outcomes than those without hemorrhage. · Individuals with HDP had an 11% higher likelihood of CMHO.. · After stratification, increased CMHO was limited to those with preeclampsia with severe features.. · There was a higher likelihood of CNAO in those with both HDP and PPH compared to HDP without PPH..

Prenatal anaemia and risk of postpartum haemorrhage: a cohort analysis of data from the Predict-PPH study

BackgroundMost previous clinical studies investigating the connection between prenatal anaemia and postpartum haemorrhage (PPH) have reported conflicting results.ObjectivesWe examined the association between maternal prenatal anaemia and the risk of PPH in a large cohort of healthy pregnant women in five health institutions in Lagos, Southwest Nigeria.MethodsThis was a prospective cohort analysis of data from the Predict-PPH study that was conducted between January and June 2023. The study enrolled n = 1222 healthy pregnant women giving birth in five hospitals in Lagos, Nigeria. The study outcome, WHO-defined PPH, is postpartum blood loss of at least 500 milliliters. We used a multivariable logistic regression model with a backward stepwise conditional approach to examine the association between prenatal anaemia of increasing severity and PPH while adjusting for confounding factors.ResultsOf the 1222 women recruited to the Predict-PPH study between January and June 2023, 1189 (97·3%) had complete outcome data. Up to 570 (46.6%) of the enrolled women had prenatal anaemia while 442 (37.2%) of those with complete follow-up data had WHO-defined PPH. After controlling for potential confounding factors, maternal prenatal anaemia was independently associated with PPH (adjusted odds ratio = 1.37, 95% confidence interval: 1.05–1.79). However, on the elimination of interaction effects of coexisting uterine fibroids and mode of delivery on this association, a sensitivity analysis yielded a lack of significant association between prenatal anaemia and PPH (adjusted odds ratio = 1.27, 95% confidence interval: 0.99–1.64). We also recorded no statistically significant difference in the median postpartum blood loss in women across the different categories of anaemia (P = 0.131).ConclusionOur study revealed that prenatal anaemia was not significantly associated with PPH. These findings challenge the previously held belief of a suspected link between maternal anaemia and PPH. This unique evidence contrary to most previous studies suggests that other factors beyond prenatal anaemia may contribute more significantly to the occurrence of PPH. This highlights the importance of comprehensive assessment and consideration of various maternal health factors in predicting and preventing this life-threatening obstetric complication.

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.

Maternal outcomes of planned mode of delivery for term breech in nulliparous women.

To estimate short- and long-term maternal complications in relation to planned mode of term breech delivery in first pregnancy. Register-based cohort study. Denmark. Nulliparous women with singleton breech delivery at term between 1991 and 2018 (n = 30,778). We used data from the Danish national health registries to identify nulliparous women with singleton breech presentation at term and their subsequent pregnancies. We performed logistic regression to compare the risks of maternal complications by planned mode of delivery. All data were proceeded and statistical analyses were performed in SAS 9.4 (SAS Institute Inc. Cary, NC, USA). Postpartum hemorrhage, operative complications, puerperal infections in first pregnancy and uterine rupture, placenta previa, post-partum hemorrhage, hysterectomy and stillbirth in the subsequent two pregnancies. We identified 19,187 with planned cesarean and 9,681 with planned vaginal breech delivery of which 2,970 (30.7%) delivered vaginally. Planned cesarean significantly reduced the risk of postoperative infections (2.4% vs 3.9% adjusted odds ratio (aOR): 0.54 95% confidence interval (CI) 0.44-0.66) and surgical organ lesions (0.06% vs 0.1%; (aOR): 0.29 95% CI 0.11-0.76) compared to planned vaginal breech delivery. Planned cesarean delivery in the first pregnancy was associated with a significantly higher risk of uterine rupture in the subsequent pregnancies but not with risk of postpartum hemorrhage, placenta previa, hysterectomy, or stillbirth. Compared to planned vaginal breech delivery at term, nulliparous women with planned cesarean breech delivery have a significantly reduced risk of postoperative complications but a higher risk of uterine rupture in their subsequent pregnancies.

Aspirin for preeclampsia prevention in low- and middle-income countries: mind the gaps

Preeclampsia is a syndrome that continues to be a major contributor to maternal and neonatal mortality, especially in low-income countries. Low-dose aspirin reduces the risk of preeclampsia, but the mechanism is still unknown. Risk factors to identify women at risk of preeclampsia are based on clinical characteristics. Women identified as high-risk would benefit from aspirin treatment initiated preferably at the end of the first trimester. Current efforts have largely focused on developing screening algorithms that incorporate clinical risk factors, maternal biomarkers, and uterine artery Doppler evaluated in the first trimester. However, most studies on preeclampsia are conducted in high-income settings, raising uncertainties about whether the information gained can be totally applied in low-resource settings. In low- and middle-income countries, lack of adequate antenatal care and late commencement of antenatal care visits pose significant challenges for both screening for preeclampsia and initiating aspirin treatment. Further, the preventive effect of first-trimester screening based on algorithms and subsequent aspirin treatment is primarily seen for preterm preeclampsia, and reviews indicate minimal or no impact on reducing the risk of term preeclampsia. The lack of evidence regarding the effectiveness of aspirin in preventing term preeclampsia is a crucial concern, as 75% of women will develop this subtype of the syndrome. Regarding adverse outcomes, low-dose aspirin has been linked to a possible higher risk of postpartum hemorrhage, a condition as deadly as preeclampsia in many low- and middle-income countries. The increased risk of postpartum hemorrhage among women in low-income settings should be taken into consideration when discussing which pregnant women would benefit from the use of aspirin and the ideal aspirin dosage for preventing preeclampsia. Additionally, women's adherence to aspirin during pregnancy is crucial for determining its effectiveness and complications, an aspect often overlooked in trials. In this review, we analyze the knowledge gaps that must be addressed to safely increase low-dose aspirin use in low- and middle-income countries and we propose directions for future research.

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.

Effect of type III female genital mutilation on obstetric outcomes: A systematic review and meta-analysis

BackgroundControversial evidence suggests a potential association between female genital mutilation (FGM/C) and adverse obstetric outcomes, with type III FGM/C (infibulation) carrying the greatest risk. The aim of this systematic review and meta-analysis was to assess current rate of adverse obstetric outcomes in women with type III female genital mutilation and cutting (FGM/C; infibulation) delivering across different settings worldwide. MethodsWe searched PubMed, Scopus, Embase, and ClinicalTrials.gov databases from inception to Jan 1, 2023. Studies were selected if they included the main outcome of postpartum haemorrhage (PPH) or secondary outcomes, which included major conditions affecting maternal-neonatal health during labour and delivery. DerSimonian-Laird random effects meta-analysis including pooled effect estimates with corresponding 95 % confidence intervals was performed. Heterogeneity was assessed using the I2 statistic. Meta regression for relevant covariates was performed when data on relevant confounders were available. The Newcastle-Ottawa scale (NOS) was used to assess quality of observational studies. The level of evidence was assessed with the GRADE method. Results14 observational studies including 15,320 type III FGM/C women and 59,347 controls were eligible. The risk for postpartum haemorrhage was significantly increased in type III FGM/C, in the main analysis (OR 1.83, 95 % CI 1.03 to 3.24, I2 = 93 %), in pooling of data adjusted for confounders (aOR 1.76, CI 1.42 to 2.17, I2 = 0 %), and in sensitivity analysis of higher quality studies with NOS≥7 (OR 2.76, CI 1.38 to 5.51, I2 = 95 %). Meta-regression showed that nulliparity was significantly and positively associated with postpartum haemorrhage. Similarly, analysis of data adjusted for confounders showed an increased risk of episiotomy in type III FGM/C (aOR 1.56, CI 1.03 to 2.35, I2 = 52 %). Sensitivity analysis of studies with NOS≥7 revealed a significant increase for episiotomy (OR 7.53, CI 1.19 to 47.54, I2 = 96 %), perineal tears (OR 4.24, CI 1.09 to 16.46, I2 = 66 %), prolonged second stage of labour (OR 5.19, 95 % CI 1.00 to 26.85, I2 = 66 %), and Apgar score less than 7 (OR 4.19, CI 1.64 to 10.70, I2 = 0 %). No difference was found regarding obstetric anal sphincter injuries and mode of delivery in these women. Deinfibulation achieved similar obstetric and neonatal outcomes to women who never had type III FGM. The overall quality of the studies was adequate (median NOS score: 7; IQR: 6–8), the level of evidence, according to the GRADE assessment, was low. ConclusionsThese results consistently show an increased risk of adverse obstetric outcomes in women with FGM/C type III. Infibulation substantially increases the risk for PPH, particularly in nulliparae. Systematic Review registration: PROSPERO CRD42023421993.

Postpartum hemorrhage in electronic health records: risk factors at admission and in-hospital occurrence.

Postpartum hemorrhage (PPH) is the leading cause of maternal death globally. Therefore, prevention strategies have been created. The study aimed to evaluate the occurrence of PPH and its risk factors after implementing a risk stratification at admission in a teaching hospital. A retrospective cohort involving a database of SISMATER® electronic medical record. Classification in low, medium, or high risk for PPH was performed through data filled out by the obstetrician-assistant. PPH frequency was calculated, compared among these groups and associated with the risk factors. The prevalence of PPH was 6.8%, 131 among 1,936 women. Sixty-eight (51.9%) of them occurred in the high-risk group, 30 (22.9%) in the medium-risk and 33 (25.2%) in the low-risk group. The adjusted-odds ratio (OR) for PPH were analyzed using a confidence interval (95% CI) and was significantly higher in who presented multiple pregnancy (OR 2.88, 95% CI 1.28 to 6.49), active bleeding on admission (OR 6.12, 95% CI 1.20 to 4.65), non-cephalic presentation (OR 2.36, 95% CI 1.20 to 4.65), retained placenta (OR 9.39, 95% CI 2.90 to 30.46) and placental abruption (OR 6.95, 95% CI 2.06 to 23.48). Vaginal delivery figured out as a protective factor (OR 0.58, 95% CI 0.34 to 0.98). Prediction of PPH is still a challenge since its unpredictable factor arrangements. The fact that the analysis did not demonstrate a relationship between risk category and frequency of PPH could be attributable to the efficacy of the strategy: Women classified as "high-risk" received adequate medical care, consequently.

Postpartum Haemorrhage Risk Prediction Model Developed by Machine Learning Algorithms: A Single-Centre Retrospective Analysis of Clinical Data

Postpartum Haemorrhage Risk Prediction Model Developed by Machine Learning Algorithms: A Single-Centre Retrospective Analysis of Clinical Data

Collateral Round Ligament Arterial Supply of Placenta Accreta Spectrum and Considerations for Prophylactic Balloon Occlusion Catheter Placement

Internal iliac artery (IIA) balloon occlusion catheters have been commonly inserted to decrease the risk of postpartum hemorrhage in placenta accreta spectrum disorders; however, there has been mixed success in clinical studies. Placement of an infrarenal aortic balloon has shown more consistent effectiveness in recent studies. A possible reason for this is collateral arterial supply to the placenta from external iliac artery branches. Retrospective chart review was conducted of angiography images during prophylactic IIA balloon occlusion catheter insertion over a 7-year period. Sixty-two individual cases were identified. Digital subtraction angiography (DSA) was performed in 32 (52%) cases, and 20 (62%) showed collateral blood supply from branches of the external iliac arteries, namely the round ligament artery. In conclusion, a high proportion of placenta accreta spectrum cases have arterial blood supply from branches of the external iliac artery, which may explain the discrepancy in effectiveness seen between IIA and infrarenal aortic sites of balloon occlusion catheter placement.

Hepatitis B virus infection during pregnancy and the risk of postpartum hemorrhage: a protocol for systematic review and meta-analysis

Background: Hepatitis B virus (HBV) infection is a significant public health issue worldwide, with a hepatitis B surface antigen (HBsAg) seroprevalence of 3.5%. Maternal HBV infection during pregnancy, a common comorbidity, is associated with an increase in the risk of adverse obstetric and perinatal outcomes. However, the relationship between maternal HBV infection and postpartum hemorrhage (PPH), a leading contributor to maternal morbidity and mortality, is currently uncertain. The aim of this study is to comprehensively clarify the potential impact of maternal HBV on PPH risk. Methods and Analysis: The authors initially searched five English databases and three Chinese databases from their inception to 26th June 2023. Two reviewers will independently conduct study selection, data extraction, and quality assessment. Cohort and case–control studies investigating the effect of maternal HBV infection on PPH will be included, with study quality assessed using the Newcastle–Ottawa Scale (NOS). Meta-analyses will be performed using a fixed-effects model for I 2≤50% or a random-effects model otherwise. Several categories of subgroup analyses (e.g. sample size more than 1000 vs. less than 1000) and sensitivity analyses (e.g. omit NOS scores less than 7) will be conducted, and publication bias will be assessed through funnel plots, Begg’s and Egger’s tests using STATA 18.0. Ethics and Dissemination: This systematic review and meta-analysis do not require ethics approval and the results will be published in peer-reviewed journals. The findings of this systematic review will provide evidence on the impact of maternal HBV infection on PPH, which will contribute to better prevention and management of PPH in clinical practice and a better understanding of the disease burden of HBV infection. PROSPERO registration number: CRD42023442626

Changes in the characteristics and outcomes of high-risk pregnant women who delivered prior to and after China’s universal two-child policy: a real-world retrospective study, 2010–2021

BackgroundIn 2016, the “universal two-child” policy, allowing each couple to have two children, was introduced in China. The characteristic change of the long-term period after the implementation of the universal two-child policy was unclear. We studied trends in the obstetric characteristics and their potential impact on the rates of cesarean section and preterm birth in the era of China’s universal two-child policy.MethodsA tertiary center-based study (2010–2021) retrospectively focused single high-risk pregnancies who delivered from the one-child policy period (OCP, 2010–2015) to the universal two-child policy period (TCP, 2016–2021). A total of 39, 016 pregnancies were enrolled. Maternal demographics, complications, delivery mode and obstetric outcomes were analyzed. Furthermore, logistic regression analysis was used to explore the association between the cesarean section rate, preterm birth and implementation of the universal two-child policy, adjusting maternal age, parity, and fetal distress.ResultsUltimately a total of 39,016 pregnant women met the criteria and were included in this analysis. The proportion of women with advanced maternal age (AMA) increased from 14.6% in the OCP to 31.6% in the TCP. The number of multiparous women increased 2-fold in the TCP. In addition, the overall rate of cesarean section significantly decreased over the policy change, regardless of maternal age, whereas the risk of preterm birth significantly increased in the TCP. Adjusting for maternal age, parity and fetal distress, the universal two-child policy showed a significantly favorable impact on the cesarean section rate (RR 0.745, 95%CI (0.714–0.777), P < 0.001). Compared to the OCP group, a higher increase in fetal distress and premature rupture of membranes (PROM) were observed in the TCP group. In pregnancies with AMA, there was no increase in the risk of postpartum hemorrhage, whereas more women who younger than 35 years old suffered from postpartum hemorrhage in TCP. The logistic regression model showed that the universal two-child policy was positively associated with the risk of postpartum hemorrhage (RR: 1.135, 95%CI: 1.025–1.257, P = 0.015).ConclusionsAfter the implementation of the universal two-child policy in China, the rate of the cesarean section significantly decreased, especially for women under 35 years old. However, the overall risk of postpartum hemorrhage increased in women under 35 years old, while there was no change in women with AMA. Under the new population policy, the prevention of postpartum hemorrhage in the young women should not be neglected.

Selective serotonin reuptake inhibitors (SSRIs) in women of reproductive age: a systematic review of local formularies.

Depression is the second most common chronic condition affecting women of reproductive age; 23.4% of women enter pregnancy with depression and use of selective serotonin reuptake inhibitors (SSRIs) in pregnancy is often necessary for maternal wellbeing. However, SSRI use during pregnancy can cause congenital malformations, postpartum haemorrhage (PPH), and persistent pulmonary hypertension of the newborn (PPHN). In UK primary care, prescribing formularies are one medium by which prescribers are provided with local medicines advice. To review all local prescribing formularies with respect to prescribing SSRIs in women of reproductive age, during pregnancy, and during breastfeeding. A systematic review of prescribing formularies in England and Wales. A systematic keyword search of all clinical commissioning group and Integrated Care Board websites in England and Local Health Board websites in Wales was undertaken between December 2021-22 to identify prescribing formularies. Data were extracted on prescribing guidance for SSRIs. Seventy-four prescribing formularies were reviewed. Of these, 14.9% (n = 11/74) provided links to the Medicines and Healthcare products Regulatory Agency guidance on congenital abnormalities associated with SSRIs, 28.4% (n = 21/74) provided links to guidance on PPH risk, and 1.4% (n = 1/74) provided links to guidance on PPHN. Specific local guidance was given on SSRI prescribing for women of reproductive age, during pregnancy, and during breastfeeding in 12.2% (n = 9/74), 23.0% (n = 17/74), and 21.6% (n = 16/74) of formularies, respectively. Our results suggest that prescribers may be poorly informed by local formularies about the risks of SSRI use around pregnancy. This could place babies at increased risk of unintentional SSRI exposure.

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.