Risk Of Postpartum Hemorrhage Research Articles

Maternal morbidity and mortality associated with mode of delivery in sickle cell disease

This retrospective observational study compared pregnancy outcomes based on mode of delivery in women with homozygous sickle cell disease (HbSS) to women without (HbAA) using delivery records of 48,600 parturients between January 1992 and January 2020. Fisher’s exact tests and Mann–Whitney’s test were used to analyse variables based on sickle cell status. Vaginal delivery and HbSS were more associated with labour induction/augmentation (AOR = 2.4, (0.7–7.8)), intrapartum complications (AOR = 2.6, (0.5–14)), postpartum haemorrhage (AOR = 2.8 (0.5–15.2)) and postpartum infections (AOR = 9.6 (1.7–54.4)). Caesarean delivery resulted in more postpartum infections in the HbSS group (AOR = 23.6 (0.9–638.4)). Vaginal delivery in HbSS resulted in more intrapartum complications and postpartum haemorrhage but caesarean delivery greatly increased the risk of postpartum infections and hypertensive disorders. Sickle cell disease (SCD) did not confer increased risk of adverse perinatal outcomes regardless of mode of delivery. Impact Statement What is already known on this subject? Women with homozygous sickle cell disease (SCD) are at an increased risk of postpartum infections, undergoing caesarean delivery, admission to the neonatal intensive care unit and overall perinatal mortality when compared to women with normal haemoglobin genotype. Comparisons have been made between homozygous SS disease and haemoglobin SC disease revealing higher rates of maternal and foetal morbidity in both groups. What do the results of this study add? Studies comparing maternal and foetal morbidity based on mode of delivery are lacking. To our knowledge, this study is the first examine maternal and perinatal outcomes in women with SCD undergoing vaginal and abdominal delivery compared to women with normal haemoglobin. We found that vaginal delivery in SCD is associated with more postpartum haemorrhage and caesarean delivery was linked to more hypertensive disorders and postpartum infections then compared to women with normal haemoglobin. Converse to other reports, there was no difference in perinatal outcomes based on mode of delivery. What are the implications of these findings for clinical practice and/or further research? Caesarean delivery and SCD greatly increased the risk of postpartum infections and hypertensive disorders but did not confer a higher risk of postpartum haemorrhage. There were more maternal deaths in SCD women who underwent caesarean vs. vaginal delivery and this requires further study to determine the pregestational predictors of adverse outcomes. Women with SCD who achieve a successful primary vaginal delivery may have reduced risk of complications in subsequent pregnancies, possibly comparable to women without the disease.

The indicators for early blood transfusion in patients with placental abruption with intrauterine fetal death: a retrospective review

BackgroundPlacental abruption (PA) with intrauterine fetal death (IUFD) is associated with a high risk of postpartum hemorrhage (PPH) resulting from severe disseminated intravascular coagulation (DIC). Therefore, blood products that are sufficient for coagulation factor replacement must be prepared, and delivery should occur at referral medical institutions that are equipped with sufficient blood products and emergency transfusion protocols. We retrospectively reviewed the records of patients with PA and IUFD (PA-IUFD) to identify possible factors that may indicate the need for early blood transfusion and investigated whether the Japanese scoring system for PPH can be applied in such cases.MethodsWe used a database of 16,058 pregnant patients who delivered at Yokohama City University Medical Center between January 2000 and February 2016. Thirty-three patients were diagnosed with PA-IUFD before delivery and categorized into two groups–blood transfusion and non-transfusion–to compare the maternal characteristics and pregnancy outcomes.ResultsIn patients with PA-IUFD, the transfusion group exhibited significantly more blood loss; lower fibrinogen levels and platelet counts; higher levels of fibrin degradation products (FDP), D-dimer, and prothrombin time; and a tendency for tachycardia on admission, compared to the non-transfusion group. Many patients in the transfusion group had normal fibrinogen levels on admission but later displayed markedly decreased fibrinogen levels. The Japan Society of Obstetrics and Gynecology (JSOG) DIC score was significantly higher in the transfusion than in the non-transfusion group.ConclusionsIn PA-IUFD, the fibrinogen level, platelet count, D-dimer, FDP, heart rate, and JSOG DIC score on admission may indicate the need for blood transfusion. However, even with normal fibrinogen levels on admission, continuous monitoring is indispensable for identifying progressive fibrinogen reductions in patients with PA-IUFD.

Complications during Delivery Hospitalizations in Women with Thalassemia: An Analysis of the National Inpatient Sample Database (2002-2019)

Background: Women with thalassemia generally have some degree of anemia that is exacerbated during pregnancy. A few studies have shown an association of thalassemia with adverse pregnancy outcomes like intrauterine growth restriction and low birth weight. However, there is a paucity of data regarding the burden of maternal complications during hospitalization for delivery. Methods: The National Inpatient Sample Database (NIS) was queried with the International Classification of Disease, Ninth Revision, and Tenth Revision (ICD-9, ICD-10) codes to identify delivery hospitalizations and thalassemia diagnosis. To strengthen the statistical analysis, case-control matching was performed for age, race, and general co-morbidities like diabetes, hypertension, hypothyroidism, liver disease, obesity, smoking, drug abuse, alcohol use disorder, and electrolyte abnormalities to match delivery hospitalizations with thalassemia to delivery hospitalizations without thalassemia. With the matched data, thalassemia hospitalizations were further subclassified into 'alpha-thalassemia', 'beta-thalassemia’ and 'thalassemia-other'. A secondary multinominal logistic regression was performed to account for median income, admission type, insurance type, preterm and/ or c-section deliveries in addition to the previously mentioned comorbidities to generate the odds ratio for the preselected outcomes. We also compared the cost-of-care for delivery hospitalization with among the three groups of thalassemia patients compared to those without thalassemia. Results: A data sample that constituted of 14,514,439 (14.5 million) delivery hospitalizations without thalassemia and 19,764 hospitalizations with thalassemia (0.1% of the sample) between 2002-2019 was taken. Unadjusted analysis revealed patients with thalassemia were older than those without thalassemia (30.1 years vs 28.3 years, p<0.001), had higher prevalence of obesity (4.7% vs 1.9%, p<0.001), hypothyroidism (4.6% vs 2.6%, p<0.001), liver disease (0.7% vs 0.2%, p<0.001), diabetes mellitus (1.2% vs 1.0%, p<0.001), chronic hypertension (0.4% vs 0.2%), and multiple gestation (2.7% vs 1.9%, p<0.001). Patients with thalassemia were also more likely to be black (24.4% vs 14.1%, p<0.001), or Asian/ Pacific Islanders (27.4% vs 5.5%, p<0.001) (Figure 1). A total of 17944 hospitalizations with thalassemia were matched with their 17944 counterparts by case-control matching. A multinominal logistic regression assessing for major outcomes revealed that patients with thalassemia of any type had higher odds of requiring a blood transfusion during the hospitalization- alpha thalassemia: odds ratio (OR)= 3.52, (95% CI: 2.57-4.83; p<0.001), beta-thalassemia: OR= 4.77, (95% CI: 3.62-6.28; p<0.001), thalassemia-unspecified: OR= 3.03, (95% CI: 2.58-3.55; p<0.001). Patients with thalassemia of any type also had a statistically higher risk of coagulopathy, preeclampsia, post-partum hemorrhage, and cardiac arrhythmias. An independent-samples Mann-Whitney U test revealed patients with thalassemia had a statistically higher median cost of hospitalization ($15,565 v $12,400; p<0.001). There was no statistical difference in length of stay or all cause mortality between patients with thalassemia compared to those without thalassemia. Conclusion: Despite an overall low prevalence of thalassemia in the US, these results suggest that pregnant women with thalassemia are at a higher risk of complications during hospitalization for delivery. This is especially important when considering that thalassemia is disproportionally more prevalent in minority groups. Though anemia is strongly associated with poor pregnancy outcomes, whether the genetic abnormalities with thalassemia confers additional risk merits further study. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Outcomes for women admitted for labour care to alongside midwifery units in the UK following a postpartum haemorrhage in a previous pregnancy: A national population-based cohort and nested case-control study using the UK Midwifery Study System (UKMidSS)

BackgroundWomen who have experienced a postpartum haemorrhage (PPH) ‘requiring treatment or transfusion’ are typically advised to plan birth in obstetric-led settings in subsequent pregnancies. Many UK alongside midwifery units (AMU) admit women for labour care following a previous PPH. We aimed to describe outcomes in women admitted for labour care to AMUs following a previous PPH, compare outcomes with other multiparous women admitted to the same AMUs, and explore risk factors for recurrence. MethodsA national cohort and nested case-control study using the UK Midwifery Study System (UKMidSS), between August 2018 and April 2019. Multivariable Poisson regression and logistic regression were performed to compare outcomes and investigate risk factors for recurrence. FindingsWomen who experienced a previous PPH were significantly more likely than comparison women to: have a PPH requiring transfer to obstetric care (4·2% vs. 2·4%, aRR=1·65, 95% CI 1·14–2·38), be transferred to obstetric care for any reason (17·8% vs 11·9%; aRR=1·41; 95% CI 1·09–1·83), and have any PPH≥ 500 ml (22·7% vs 11·1%, aRR=1·86, 95% CI 1·49–2·32). Among women with a previous PPH, previous blood loss > 1500 ml; uterotonics for previous PPH; Caesarean associated with previous PPH; gestation at admission and higher birthweight were independent risk factors for PPH. ConclusionWomen considering birth in an AMU after a previous PPH should be advised that they are at increased risk of experiencing a subsequent PPH requiring transfer to obstetric care, compared with other multiparous women who have not had a PPH. The absolute risk of a subsequent PPH in this group is low and comparable to the overall risk of having a PPH among women having a spontaneous vaginal birth in England.

Association between poverty and anaemia among mother–child pairs in India

The prevalence of anaemia among pregnant women in India continues to be high despite efforts to address the issue through iron-folic acid supplements under the national health program. It is estimated that about 50% of pregnant women, adolescent girls and children are anaemic. Anaemic women are at a significantly higher risk of morbidity, mortality, postpartum haemorrhage, and low birth outcomes, in addition to low birth weight and preterm birth of their babies due to poor intrauterine growth. The purpose of this study is to investigate anaemia among mother–child pairs — known as a double burden — in poor and non-poor households in India. The study uses data from the fourth round of the National Family Health Survey (NFHS). The survey collects information on the haemoglobin levels in mothers and children.Bivariate and multivariate analyses were used to determine the risk of anaemia in mother–child pairs among poor and non-poor households. Our survey found that, respectively, 57.1% and 58.7% of the mothers and children were suffering from anaemia; and the double burden was 36.8%. The double burden of anaemia was much higher among poor households (41.0%) as compared to the prevalence in non-poor households (33.1%). This pattern was observed across the background characteristics of the mothers, such as age, place of residence, education, caste, religion, Body Mass Index (BMI) and selected child factors. The adjusted odds for poor households, after controlling for significant background factors of the mothers and children, was found to 11% (OR:1.11, p-value:<0.001; 95%, CI:1.09–1.14) with higher odds of double burden as compared to non-poor households. The findings of the study point to the need for policies that are targeted at addressing the double burden of anaemia in poor households in India.

Risk of Severe Postpartum Hemorrhage in Twin Pregnancies According to the Sum of Birth Weights.

To characterize the strength and patterns of association between birth weights and severe postpartum hemorrhage in twin pregnancies. This was a secondary analysis of the JUMODA (JUmeaux Mode d'Accouchement) cohort, a national, prospective, population-based study of twin deliveries, conducted from February 2014 to March 2015 in France. We excluded patients with a fetal death, medically indicated termination of pregnancy, antepartum hemorrhage, placenta previa, placental abruption, or missing birth weight. The primary outcome was severe postpartum hemorrhage , defined as a postpartum hemorrhage requiring at least one of the following: transfusion of 4 or more units of red blood cells, uterine artery embolization, uterine balloon tamponade, vascular ligation, uterine suture, emergency hysterectomy, admission to an intensive care unit, or postpartum hemorrhage considered severe by the obstetrician or leading to maternal death. The exposure was the sum of the birth weights of the two twins. To assess the association between the sum of twins' birth weights and severe postpartum hemorrhage, we used multilevel multivariable modified Poisson regression modeling. Analyses were conducted for the overall population and by planned and actual mode of delivery. A total of 8,373 patients were analyzed. Severe postpartum hemorrhage occurred in 4.5% (379/8,372, 95% CI 4.1-5.0), from 2.1% (15/722) for a sum of twins' birth weights less than 3,000 g up to 8.8% (12/136) for a sum exceeding 6,500 g. In the multivariable analysis, the association between the sum of the twins' birth weights and severe postpartum hemorrhage was linear, with an adjusted relative risk of severe postpartum hemorrhage of 1.36 (95% CI 1.24-1.49) for each 500-g increase in the sum of twins' birth weights. In twin pregnancies, the risk of severe postpartum hemorrhage increased linearly with the sum of the twins' birth weights.

PSUN175 Impact of Maternal Low Weight on Pregnancy and Neonatal Outcomes

Abstract Underweight body mass index (BMI) is defined as a BMI &amp;lt;18.5 kg/m2 and a subset of low-weight women also meet DSM-5 criteria for a diagnosis of anorexia nervosa. Although anorexia nervosa is often associated with functional hypothalamic amenorrhea and resultant infertility, when women with anorexia nervosa do conceive, there is an increased risk of obstetrical and delivery complications, and poor neonatal outcomes, such as preterm birth, low birth weight, and smaller size for gestational age (SGA). Few studies have investigated such outcomes in women who are low weight, with or without a diagnosis of anorexia nervosa. The aim of the study was toexamine associations between underweight maternal BMI and pregnancy complications and neonatal outcomes in mothers and infants at a large academic medical center. There was a total of 16,780 mothers who delivered a singleton between 2015-2021 with either a BMI &amp;lt;18.5 kg/m2 (n=732) or who were normal-weight (18.5 kg/m2 &amp;lt; BMI &amp;lt;25 kg/m2, n=16,048) at their initial prenatal visit or within six months of that visit. We compared neonatal outcomes and pregnancy/delivery complications in the low-weight versus normal-weight mother-infant pairs. Neonatal outcomes included birthweight, gestational age, NICU stay, preterm birth, and fetal death; pregnancy and delivery complications included pre-eclampsia/eclampsia, premature rupture of membranes (PROM), and post-partum hemorrhage. Median BMI in underweight women was 17.8 [interquartile range: 17.2, 18.1] kg/m2 compared with 22.2 [20.7, 23.6] kg/m2 in normal-weight women. Underweight women were younger (27 [22, 31] years) and less likely to be married or have private insurance (p-value &amp;lt;0.0001 for all). Approximately 22% of the low-weight mothers were African American compared with 13.4% of normal-weight mothers (overall p-value for race/ethnicity &amp;lt;0.0001). Additionally, approximately 22% of infants born to low-weight mothers were SGA and 15% with low birthweight compared with 13.6% and 9% of infants born to normal-weight mothers, respectively (p-value &amp;lt;0.0001 for both SGA and low birthweight). These differences remained significant after adjusting for maternal age, race/ethnicity, marital and insurance status, and maternal depression; after adjusting for these potential confounders, infants born to low-weight mothers had increased risk for SGA (OR=1.23, 95% CI: 1.11-1.36) and low birthweight (OR=1.18, 95% CI: 1.04-1.33) compared with their normal-weight counterparts. In adjusted models, underweight women had decreased risk of PROM (OR=0.85, 95% CI: 0.74-0.98) and post-partum hemorrhage (OR=0.72, 95% CI: 0.54-0.96) compared to normal-weight women. No differences were noted for pre-eclampsia/eclampsia, NICU stay, preterm birth, and fetal death. In summary, underweight BMI during pregnancy is associated with an increased risk of infants who are SGA and low birthweight and a decreased risk for delivery complications including PROM and post-partum hemorrhage. These differences suggest underweight BMI during pregnancy increases the risk for adverse neonatal outcomes, while maternal-related pregnancy outcomes are less affected. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Tobacco Use Prevention and Cessation Programme For Pregnant Women Accessing Antenatal Care In Urban Public Health Facilities In Southern India

Abstract Backgrounds and problem By 2030, tobacco use is estimated to kill more than 8 million people worldwide annually, with LMICs accounting for over 80% of those deaths. In India, about 4.6% of women continue to use tobacco mainly (&amp;gt; 80%) in smokeless (SLT) form during pregnancy. This may lead to: higher risk of anemia (∼ 70%), hypertension, and postpartum hemorrhage; poor fetal development; and 2-3 times higher rate of low-birth and stillbirth babies. Importance Anti-tobacco initiatives often focus on smoking over SLT, which is commonly consumed by women. Drivers of SLT use among women include: cultural appropriateness, medicinal benefits, and poor social determinants of health. These factors must be taken into account while formulating effective anti-tobacco interventions for pregnant women, ensuring safe motherhood and neonatal health. Solution We propose integrating oral health interventions in mitigating tobacco use within the existing antenatal care (ANC) model. Women enrolled in public health facilities in an urban poor neighborhood in South India receive oral health education (OHE) integrated into ANC. The intervention promotes oral hygiene habits, dietary advices, improving dental healthcare utilization, and sensitization on the ill-effects of tobacco-use. Training for ANC providers focuses on delivering antenatal tobacco screening, cessation, and referral services. This includes expanding the medical history to record tobacco use, conduct oral examination and referrals to dentists and/or tobacco cessation centres. Final outcomes of OHE will be measured using pre and post KAP surveys informed by WHO Oral Health Surveys; and training programme using in-depth interviews among providers. Desired policy change is the inclusion of tobacco prevention and cessation programme in the Indian ANC guidelines.

Assessment of postpartum haemorrhage for placenta accreta: Is measurement of myometrium thickness and dark intraplacental bands using MRI helpful?

BackgroundThis study aimed to investigate the predictive values of magnetic resonance imaging (MRI) myometrial thickness grading and dark intraplacental band (DIB) volumetry for blood loss in patients with placenta accreta spectrum (PAS).MethodsImages and clinical data were acquired from patients who underwent placenta MRI examinations and were diagnosed with PAS from March 2015 to January 2021. Two radiologists jointly diagnosed, processed, and analysed the MR images of each patient. The analysis included MRI-based determination of placental attachment, as well as myometrial thickness grading and DIB volumetry. The patients included in the study were divided into three groups according to the estimated blood loss volume: in the general blood loss (GBL) group, the estimated blood loss volume was < 1000 ml; in the massive blood loss (MBL) group, the estimated blood loss volume was ≥ 1000 ml and < 2000 ml; and in the extremely massive blood loss (ex-MBL) group, the estimated blood loss volume was ≥ 2000 ml. The categorical, normally distributed, and non-normally distributed data were respectively analysed by the Chi-square, single-factor analysis of variance, and Kruskal–Wallis tests, respectively. The verification of correlation was completed by Spearman correlation analysis. The evaluation capabilities of indicators were assessed using receiver operating characteristic curves.ResultsAmong 75 patients, 25 were included in the GBL group, 26 in the MBL group, and 24 in the ex-MBL group. A significant negative correlation was observed between the grade of myometrial thickness and the estimated blood loss (P < 0.001, ρ = − 0.604). There was a significant positive correlation between the volume of the DIB and the estimated blood loss (P < 0.001, ρ = 0.653). The areas under the receiver operating characteristic curve of the two MRI features for predicting blood loss ≥ 2000 ml were 0.776 and 0.897, respectively.ConclusionsThe grading and volumetric MRI features, myometrial thickness, and volume of DIB, can be used as good prediction indicators of the risk of postpartum haemorrhage in patients with PAS.

Effect of grand multiparity on adverse maternal outcomes: A prospective cohort study.

BackgroundGrand multiparity remains a risk factor for a wide range of obstetric complications, especially in developing countries. Grand multiparity has been shown to increase the risks of medical and obstetric complications during pregnancies. However, in a research setting, the risk factors associated with adverse maternal outcomes have yet to be adequately investigated among grand multiparity. Furthermore, there is limited information that examines the effect of grand multiparity on pregnancy outcomes in Ethiopia through prospective follow-up design.ObjectiveThis study aimed to investigate the effect of grand multiparity on pregnancy outcomes in selected public hospitals in the Sidama Region State of Ethiopia.MethodsA prospective cohort study design was employed on 837 pregnant women who were admitted for delivery in selected public hospitals from January 1 to August 31, 2021. The study subjects were recruited during admission for labor and delivery. Every woman who was admitted to labor wards was screened for eligibility. The exposed group in this cohort was grand multiparity, and the non-exposed group was multiparity. Data collection was started from the first contact after admission and follow-up to discharge for adverse maternal outcomes. The risk factors for adverse maternal outcomes in grand multiparity were investigated using multivariable Poisson regression analysis. The risk factor was reported as an adjusted risk ratio (ARR) with a 95% confidence interval (CI). When the P-value was <0.05, statistical significance was declared.ResultsThe cohort's overall cumulative incidence of adverse maternal outcomes were 39.9% (95%CI: 36.6, 43.4%). Among exposed groups, the incidence of adverse maternal outcomes were 47.1% (95%CI: 41.0–53.2) and 36.3% (95% CI: 32.3–40.6) the multiparity. When compared to multiparous women, grand multiparity was associated with a greater risk of postpartum hemorrhage (ARR = 2.1; 95%CI:1.6–2.7) and malpresentation (ARR = 1.3; 95% CI: 1.01–1.7).ConclusionsPregnant women with grand multiparity have a higher incidence of adverse maternal outcomes. Grand multiparity increased the risk of adverse maternal outcomes such as postpartum bleeding and malpresentation. In low-resource settings, we recommend that community health education, the provision of accessible and effective contraceptive services, and increased awareness of the adverse maternal outcome among grand multiparity during pregnancy on obstetric performance should be prioritized. Also, trained health providers can effectively decrease the risk factor with good antenatal care and delivery.

Intravenous Carbetocin Versus Rectal Misoprostol for the Active Management of the Third Stage of Labor: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Globally, postpartum hemorrhage (PPH) is the top cause of maternal death. Multiple uterotonic medications are available to prevent PPH; however, it is still unclear whether one is the most effective. The current study compared the efficacy and safety of intravenous carbetocin with rectal misoprostol for the active management of the third stage of labor in order to prevent PPH. Eligible studies were found utilizing digital medical sources, including the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science (WOS), PubMed, Scopus, and Google Scholar, from inception until September 2022. Only randomized controlled trials (RCTs) that matched the inclusion requirements were chosen. We used the Cochrane Risk of Bias scale (version 2) to assess the quality of the included studies. The Review Manager (version 5.4 for Windows) was used to conduct the meta-analysis. The results were summarized as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI) in fixed- or random-effects models according to the degree of between-study heterogeneity. Collectively, we screened 621 articles after omitting duplicates and eventually included three RCTs for analysis. Overall, 404 patients were included in these studies; 202 patients were allocated to the intravenous carbetocin group whereas 202 patients were allocated to the rectal misoprostol group. Two RCTs were judged as “low” risk of bias, whereas one RCT was judged as having “some concerns” regarding the quality assessment. Regarding efficacy endpoints, the intravenous carbetocin group had significantly lower blood loss (n=3 RCTs, MD=-117.74 mL, 95% CI [-185.41, -50.07], p<0.001), need for additional uterotonics (n=2 RCTs, RR=0.06, 95% CI [0.01, 0.46], p=0.007), need for uterine massage (n=2 RCTs, RR=0.40, 95% CI [0.20, 0.80], p=0.009), and need for blood transfusion (n=2 RCTs, RR=0.38, 95% CI [0.15, 0.95], p=0.04) compared with the rectal misoprostol group. Regarding safety endpoints, the rates of diarrhea (n=3 RCTs, RR=0.18, 95% CI [0.06, 0.55], p=0.003) and chills (n=2 RCTs, RR=0.31, 95% CI [0.12, 0.83], p=0.02) were significantly lower in the intravenous carbetocin group compared with the rectal misoprostol group. However, there was no significant difference between both groups regarding the rates of headache (n=3 RCTs, RR=1.23, 95% CI [0.06, 1.91], p=0.35) and facial flushing (n=2 RCTs, RR=0.88, 95% CI [0.46, 1.68], p=0.70). In conclusion, it was discovered that intravenous carbetocin was a superior substitute for rectal misoprostol for the active management of the third stage of labor. With far fewer side effects, intravenous carbetocin decreased postpartum blood loss and further uterotonic use. For women who have a high risk of PPH, intravenous carbetocin is advised.

Postpartum Blood Loss in COVID-19 Patients-Propensity Score Matched Analysis.

The aim of this study was to compare the estimated blood loss and the frequency of obstetric hemorrhage among pregnant women with and without COVID-19 infection. The study was carried out in the Department of Obstetrics and Gynecology, at the Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, Poland. From 15 May 2020 to 26 April 2021, a total of 224 parturients with COVID-19 infection were admitted for labor. The control group consisted of 300 randomly recruited pre-pandemic deliveries that took place between 15 May 2019 and 26 April 2020 at the Department. The primary outcome was the presence of postpartum hemorrhage, defined as an estimated blood loss of ≥500 mL within 24 h after birth or the need to transfuse 2 or more units of packed red blood cells (pRBCs). Secondary outcomes were the difference between hemoglobin and hematocrit levels at 24 h postpartum, the number of pRBCs units transfused, and the need for transperitoneal drainage. After applying the propensity-score-matching procedure for postpartum bleeding risk factors, 325 eligible patients were included in the final analysis, divided into 203 COVID-19 positive and 122 COVID-19 negative prepandemic deliveries. SARS-CoV-2 infected patients were characterized by a longer activated partial thromboplastin time (APTT), a reduced prothrombin time (PT), and lower platelet count at initial presentation. COVID-19 deliveries were found to be associated with a higher frequency of postpartum hemorrhage, an increased estimated blood loss, the more frequent use of peritoneal drainage, and more pRBCs units transfused. During the pandemic, an increased risk of postpartum hemorrhage posed another threat to SARS-CoV-2 infected pregnant women. It is essential to be aware of this when approaching COVID-19 delivery and to implement efficient preventative methods.

Peripartum Outcomes Associated With COVID-19 Vaccination During Pregnancy

The risk and benefits of COVID-19 vaccination during pregnancy are under investigation. Pooled evidence regarding neonatal and maternal outcomes in association with COVID-19 vaccination during pregnancy is scarce. To evaluate the association between COVID-19 vaccination during pregnancy and peripartum outcomes. PubMed and EMBASE databases were searched on April 5, 2022. Language restrictions were not applied. Prospective trials and observational studies comparing the individuals who received at least 1 COVID-19 vaccination during pregnancy with those who did not and reporting the neonatal outcomes, including preterm birth, small for gestational age, low Apgar score, neonatal intensive care units (NICU) admission, and intrauterine fetal death (IFD). Two independent investigators extracted relevant data from each study. Odds ratios (ORs) were calculated using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The primary outcomes were the neonatal outcomes, including preterm birth, small for gestational age, low Apgar score, NICU admission, and IFD. The secondary outcomes were maternal outcomes, including maternal SARS-CoV-2 infection, cesarean delivery, postpartum hemorrhage, and chorioamnionitis. Nine observational studies involving 81 349 vaccinated (mean age, 32-35 years) and 255 346 unvaccinated individuals during pregnancy (mean age, 29.5-33 years) were included. COVID-19 vaccination during pregnancy was associated with lower risk of NICU admission (OR, 0.88; 95% CI, 0.80-0.97) and IFD (OR, 0.73; 95% CI, 0.57-0.94), whereas there was no statistically significant association with preterm birth (OR, 0.89; 95% CI, 0.76-1.04), small for gestational age (OR, 0.99; 95% CI, 0.94-1.04), and low Apgar score (OR, 0.94; 95% CI, 0.87-1.02). COVID-19 vaccination during pregnancy was associated with a lower risk of maternal SARS-CoV-2 infection (OR, 0.46; 95% CI, 0.22-0.93), whereas it was not associated with increased risk of cesarean delivery (OR, 1.05; 95% CI, 0.93-1.20), postpartum hemorrhage (OR, 0.95; 95% CI, 0.83-1.07), and chorioamnionitis (OR, 0.95; 95% CI, 0.83-1.07). COVID-19 vaccination during pregnancy was not associated with an increase in the risk of peripartum outcomes, was associated with a decreased risk of NICU admission, IFD, and maternal SARS-CoV-2 infection. Thus, COVID-19 vaccination should be encouraged for pregnant individuals.

The effect of maternity waiting homes on pregnancy outcomes in West Gojjam, northwest Ethiopia

Background/Aims Maternity waiting homes are temporary shelters for pregnant women located near a hospital or health centre and are designed to reduce adverse maternal and perinatal outcomes. However, studies assessing the association between maternity waiting home use and adverse pregnancy outcomes are limited. This study assessed the association between maternity waiting home use and adverse pregnancy outcomes in northwest Ethiopia. Methods A prospective cohort study was conducted among women attending antenatal care in public health facilities in West Gojjam, northwest Ethiopia. Pregnant women (28 weeks or more gestation) were enrolled and followed up until birth. Maternity waiting home use was classified as if a pregnant woman stayed for at least 1 week in a maternity waiting home before birth. Log-binomial regression analysis was used to calculate the effect of maternity waiting homes on adverse pregnancy outcomes and to control the effect of potential confounders. Results A total of 810 women completed follow up and were included in the analysis. The incidence of composite adverse pregnancy outcomes was lower among maternity waiting home users compared to non-users (16.3% vs 24.5%). Maternity waiting home users had a lower risk of perinatal death (P=0.003), low birth weight (P=0.004) and preterm birth (P=0.007) than non-users. There were no significant differences in the risk of prolonged labour and postpartum haemorrhage between maternity waiting home users and non-users. Conclusions Staying in a maternity waiting home was significantly associated with a lower risk of perinatal death, low birth weight and preterm birth, and maternity waiting home users had approximately 50% lower adverse perinatal outcomes than non-users. Therefore, the Amhara Regional Health Bureau, zonal health departments, district health offices and other stakeholders should strengthen the use of maternity waiting homes.

Prevalence and Risk Factors of Preterm Premature Rupture of Membranes in Pregnant Women admitted to Hospital, Pakistan

In both high- and low-income nations, preterm pre-labou membrane rupture is a significant contributor to perinatal, neonatal, and maternal illness and mortality. Premature membrane rupture puts a woman at risk for postpartum haemorrhage, intraamniotic infection, and even death. The purpose of this study was to ascertain the prevalence of preterm premature rupture of membranes and its related factors among pregnant women admitted to health institutions because little is known about the issue in the study region. A total of 300 participants participated in this research among which 100 had preterm PROM, 100 had PROM, and 100 had preterm deliveries. The ages of the participants ranged from 18-40 years with a mean age of 25.12 ± 4.43 years. Among 300 participants, 9.33, 17.33, 21, 24.33, and 28% were 18-20, 21-25, 26-30, 31-35, and 40 years of age, respectively. Among the total, 19 (6.33%), 271 (90.33%) and 10 (3.33%) were divorced, married and widowed, respectively. Among a total, 44, 40.33, and 15.66% of the participants were multigravida, primigravida, and grand-multigravida, respectively. The majority (87%) of mothers had ANC follow-up in their current pregnancy. In the large population, 255 (85%) had labor pain while 171 (578%) of mothers showed vaginal bleeding in the current pregnancy and 167 (55.67%) of mothers had cephalic presentation. 88.33% of pregnant women had no history of PROM. 97 (32.33%) of mothers had urinary tract infection in pregnancy, 32 (10.66%) had anaemia, and 41 (13.67%) had an abnormal vaginal discharge. The pregnant mothers had not used any cocaine, and cigarettes. Different risk factors associated with PPROM such as current urinary tract infection, gravidity, history of previous PPROM, preeclampsia, economic status, and anaemia were recorded. The major risk factors are use of smoking, chat, and cocaine. To lower the incidence of preterm premature rupture of membranes, early detection and treatment of urinary tract infections and atypical vaginal discharges were advised. Keywords: Preterm prelabour rupture of membranes; fetal outcome; Female urogenital disorders; maternal age; Pakistan

Age and Parity in the Incidence Of Primary Post Partum Hemorrhage at Panembahan Senopati Hospital, Bantul Yogyakarta

Post partum hemorrhage is the main cause of 150,000 maternal deaths every year in the world and almost 4 out of 5 deaths due to postpartum hemorrhage occur within 4 hours after delivery. The direct causes of maternal death in Indonesia are bleeding 45.20%, eclampsia 12.90%, abortion complications 11.10%, postpartum sepsis 9.60%, prolonged labor 6.50%, anemia 1.60% and indirect causes of death. by 14, 10%. The purpose of this study was to determine the relationship between parity and age with the incidence of primary postpartum hemorrhage at Panembahan Senopati General Hospital. Analytical survey studies or case control surveys use a retrospective time approach. The sampling technique was purposive sampling with a ratio of the number of samples 1: 1, namely the case sample was 70 and the control sample was 70. The analysis technique was Chi Square. The results of Chi Square analysis showed that age and parity had a significant relationship with the incidence of primary postpartum hemorrhage, age (OR = 14.22 and p-value 0.000) while parity (OR 3.010 and p-value 9.643). It means that mothers with maternal age at risk (&lt;20 and &gt; 35 years) have a risk of 14.22 greater than the age not at risk (20-35 years). Mothers with parity at risk (1 and &gt;3) had a 3.010 greater risk of primary postpartum hemorrhage than mothers with parity at no risk (2 and 3). This study concluded that there is a relationship between age and parity with the incidence of primary postpartum hemorrhage.

IMPACT OF VITAMIN D DEFICIENCY DURING PREGNANCY

Vitamin D deficiency (vdd) is a public health problem. 50% of the world population have inadequate levels of vitamin D. Vitamin D is necessary for the absorption and metabolism of calcium and phosphorus. More than 90% of pregnant women had vitamin D insufficiency. According to the vitamin D council, pregnancy is a known risk factor for vitamin D deficiency. Vitamin D deficiency during pregnancy increases the risk of pre‐eclampsia, gestational diabetes, preterm birth, and low birthweight. Pregnant mothers who are deficient in vitamin D should be treated with cholecalciferol or ergocalciferol. Supplementing pregnant women with vitamin D reduces the risk of pre-eclampsia, gestational diabetes, low birthweight and the risk of severe postpartum haemorrhage.

Comparison of Oral Misoprostol with Intravenous Oxtocin in the Prevention of Primary Postpartum Haemorrhage in ESUT Teaching Hospital: A Randomized Controlled Trial

Background: Postpartum haemorrhage (PPH) is one of the major causes of maternal mortality globally. About 14 million patients suffer from postpartum haemorrhage annually worldwide, of which about 140,000 die. The active management of third stage of labour with the use of uterotonic drugs has reduced the risk of postpartum haemorrhage significantly. The most common uterotonic drug currently in use is oxytocin but the problem of insufficient skilled manpower for its administration, inadequacy of electric power supply to ensure the stability of the drug at appropriate temperature, and its high cost have made widespread use of oxytocin difficult in the resource-poor countries. This has made the search for an effective, affordable, stable and available alternative necessary. Misoprostol, an analogue of prostaglandin-E1, has a good uterotonic activity, is highly affordable, does not require specialized skill to administer and is very stable at room temperature. It also has multiple routes of administration, which makes its use in resource-poor countries indispensable. Aim: To determine if there is any difference in the efficacy of intravenous oxytocin over oral misoprostol in the prevention of primary postpartum haemorrhage. Study Design: This was a prospective, double-blinded, randomized study of uncomplicated pregnant women who had vaginal delivery in ESUT Teaching Hospital, Enugu. Sample Size: Two hundred (200) pregnant women who satisfied the inclusion criteria were recruited in this study with each arm of the study accommodating 100 participants. Methodology: The eligible women were recruited on presentation to the labour ward after giving their consent. They were randomly allocated into 2 groups: A and B. Group A received 2 tablets (400mcg) of oral misoprostol and 1mililtre (ml) of sterile water intravenously while group B received 2 tablets of white vitamin c and 1ml (10iu) of intravenous oxytocin immediately after cord clamping and cutting following the delivery of the baby. Pre-weighed delivery mats and vulval pads were used to collect the blood at delivery and for the first 24 hours for weighing and estimation of blood loss. A proforma was used to record the necessary data. Statistical Analysis: Data collected from the study was analyzed with the Statistical Package for Social Sciences (SPSS) computer software version 20.0 for windows. Statistical analysis was both descriptive and inferential at 95% confidence level. The socio-demographic variables were used to categorize the data and this was subjected to comparative statistical evaluation to yield frequencies, means, and percentages. Test of significance between class differences was by Pearson’s Chi-square test for categorical variables and student’s t-test for continuous variables. All P&lt;0.05 at one degree of freedom (df=1) was considered statistically significant. Results: Two hundred pregnant women were recruited into the study with 100 women on each arm and all completed the study. The amounts of blood loss (in mililitre) in the misoprostol and oxytocin arms were 339.36 ± 122.28 and 378.52 ± 148.24, respectively. Forty-three women had PPH (blood loss ≥ 500ml) but there was no significant difference in the amount of blood loss and occurrence of PPH on both arms of the study. Conclusion: There was no difference in the efficacy of oxytocin over misoprostol in the management of the 3rd stage of labour for preventing PPH. We therefore, recommend that misoprostol can be adopted as an alternative/substitute to oxytocin in the management of the third stage of labour especially in the developing countries for prevention of PPH.

ENSEMBLE LEARNING BASED POSTPARTUM HEMORRHAGE DIAGNOSIS FOR 5G REMOTE HEALTH CARE

The fifth-generation (5G) communications enables various promising applications that were once impossible, e.g. remote healthcare with the help of fast and reliably delivery of medical data. Post-partum hemorrhage (PPH) refers to the massive blood loss after the birthing stage (within 24 hours), i.e.&gt;500ml for the vaginal delivery, and &gt;1000ml for the cesarean section. PPH is by far the most common cause of the mortality rate of pregnant women, as well as a primary cause of current pregnant mortality in China. Despite the great potential of prediction of PPH, there is currently no effective tool based on the limited raw data from the clinical trials. In the study, we retrospectively study the 3842 vaginal delivery cases in 2017 collected from Beijing Obstetrics and Gynecology Hospital, Capital Medical University. In particular, we obtain the prediction based diagnostic model relying on machine learning, and we adopt the ensemble learning to accomplish this task, by combining the results of various candidate methods. According to the experimental results, the accuracy of correct PPH diagnosis would approach 96.7%; the total disseminated intravascular coagulation (DIC) prediction accuracy approaches 90.3%. In this regard, we may conclude the proposed model based on machine learning would allow us to predict successfully the risk of PPH, and assess the critical level of PPH patient. We anticipate our study results would contribute to the reduction the mortality of pregnant women. According to the 2013 World Health Statistics, the maternal mortality rate in low-income countries were 410/100,000 live births. The majority of maternal deaths occurred mainly in Asian and African countries. Major causes of maternal deaths are similar across low-income countries, often obstetric in origin including hemorrhage, hypertensive diseases and maternal infections. 94% of births in Ethiopia are estimated to occur at home and 10% of maternal deaths are attributed to PPH. Uterine atony, or lack of effective contraction of the uterus, is the most common cause of PPH followed by infection, sub involution of the placental site, and inherited coagulation deficits. The majority of these fatal obstetric complications occur during labor and immediately after birth. In the low-income countries, more than three-quarters of maternal deaths due to the direct obstetric causes occur during and after birth. Organized diagnosis and management of PPH, including administration of uterotonic agents, controlled cord traction, and uterine massage after delivery of the placenta, are required to avoid maternal death.

Neutrophil extracellular traps in the pathogenesis of obstetric complications in COVID-19 (brief review)

Introduction. In the pathogenesis of the new coronavirus infection (COVID-19), innate cellular elements of the immune system are of great importance, among which special attention is paid to neutrophils and the mechanisms of their death – netosis, which leads to the formation of extracellular DNA traps. Neutrophil extracellular traps play an important role in the development of endothelial dysfunction and thrombotic disorders, which not only complicates the course of COVID-19 infection, but also causes severe obstetric complications that increase the risk of maternal and infant mortality. This review describes possible mechanisms for the formation of neutrophil extracellular traps, as well as their role in the pathogenesis of COVID-19.Materials and methods. An analysis of Russian (eLibrary) and foreign (PubMed) literature was carried out with a search depth of 2010-2021.Results. The pathogenesis of COVID-19 is directly related to the uncontrolled progression of systemic inflammation, which changes the innate immune response in the form of functional maladaptation and premature death of neutrophils with the formation of neutrophil extracellular traps. The neutrophils that were transformed by netosis play a key role in the development of thrombotic disorders of the microvasculature, which leads to the development of life-threatening complications such as acute respiratory distress syndrome and multiple organ failure, which increases the mortality of patients with COVID-19 infection. During pregnancy, increased formation of neutrophilic extracellular traps is the cause of hemodynamic disturbances of the fetoplacental complex, placental disorders and endothelial dysfunction, concomitant with the development of preterm labor and preeclampsia, which increases the risk of postpartum hemorrhage, maternal morbidity and mortality. Therefore, new data on neutrophil extracellular traps and mechanisms of formation may lead to a reconsideration of the pathogenesis of thrombotic disorders in pregnant women with COVID-19 infection, which is important for further management of pregnancy.