Risk Of Postpartum Hemorrhage Research Articles

Disparities in Incidences of Cesarean Section Among Women With Gestational Diabetes Mellitus in the United States.

BackgroundIn this study, we explored the interaction between women’s race/ethnicity and insurance type and determined how these interactions affect the incidences of cesarean section (CS) among women with gestational diabetes mellitus (GDM).MethodologyWe utilized the National Inpatient Sample (NIS) database from January 2000 to September 2015 to conduct a retrospective analysis of all GDM-associated hospitalizations. We then explored the interaction between race/ethnicity and insurance types and determined how these interactions affect the incidences of CS among GDM patients, controlling for traditional risk factors for CS and patients’ sociodemographics. Subsequently, we determined the risk of primary postpartum hemorrhage (PPH) in the CS group and a propensity score-matched control group who had vaginal deliveries.ResultsThere were 932,431 deliveries diagnosed with GDM in the NIS database from January 2000 to September 2015. The mean age of the study population was 30.6 ± 5.9 years, 44.5% were white, 14.0% were black, and 26.7% were Hispanic. The CS rate was 40.5%. After controlling for covariates, women who utilized private insurance had the highest CS rate across the different races/ethnicities; white (odds ratio (OR) = 1.21 (1.17-1.25)) blacks (OR = 1.33 (1.26-1.41)), and Hispanic (OR = 1.12 (1.06-1.18)). CS patients were less likely to develop PPH compared to their matched controls with vaginal deliveries (OR = 0.67 (0.63-0.71)).ConclusionsPrivate insurance is associated with higher incidences of CS among women with GDM, irrespective of race/ethnicity.

Association of maternal perfluoroalkyl substance exposure with postpartum haemorrhage in Guangxi, China

Postpartum haemorrhage (PPH) is the leading cause of maternal death worldwide, and it may be caused by environmental endocrine disruptors. Prenatal exposure to perfluoroalkyl substances (PFASs) in women has been linked to pregnancy disorders and adverse birth outcomes, but no data are available on the relationship between PFAS exposure during pregnancy and postpartum haemorrhage. This study aimed to explore the associations of maternal PFAS exposure with the postpartum haemorrhage risk and total blood loss. A total of 1496 mother-infant pairs in the Guangxi Zhuang birth cohort were included between June 2015 and May 2018. The concentration of PFASs in serum was detected using ultrahigh liquid chromatography-tandem mass spectrometry. Multiple binomial regression and linear regression models were used to analyse individual PFAS exposures. The mixture of PFASs was analysed using Bayesian Kernel Machine Regression (BKMR). In single substance exposure models, exposure to perfluorohexanesulfonic acid (PFHxS) increased the risk of postpartum haemorrhage (OR: 3.42, 95 % CI: 1.45, 8.07), while exposure to perfluorododecanoic acid (PFDoA) was inversely associated with the risk of postpartum haemorrhage (OR: 0.42, 95 % CI: 0.22, 0.80). The concentrations of perfluoroundecanoic acid (PFUnA) (β: 0.06, 95 % CI: 12.32, 108.82) and perfluorononanoic acid (PFNA) (β: 0.05, 95 % CI: 0.40, 88.95) exposure were positively correlated with the amount of postpartum haemorrhage; this result occurred only in the absence of covariate adjustment. In BKMR models, the risk of postpartum haemorrhage increased with increasing exposure to a PFAS mixture. In conclusion, our study suggested that maternal serum PFAS exposure during pregnancy was associated with the risk of postpartum haemorrhage.

Obstetric complications and outcomes of singleton pregnancy with previous caesarean section according to maternal age

IntroductionTo delineate obstetric complications and neonatal outcomes by maternal age in singleton pregnancies with previous caesarean section (CS). MethodsA retrospective study involved 7715 singleton gestations with previous CS was conducted in a single centre. Statistical methods were used to describe and analyse the incidence of various complications and adverse outcomes classified by maternal ages. After selecting the reference group (30–34 years), multivariate logistic-binomial regression model was used to investigate the outcomes using SPSS. ResultsFrom 2013 to 2017, the proportion of advanced maternal age (AMA, ≥35 years) women with a history of CS increased yearly, especially in the 35–39 years age group. AMA women accounted for 39.4% of all pregnancies and has a high incidence of in vitro fertilization(IVF), progesterone therapy in early pregnancy, pregnancy-induced hypertension (PIH), gestational diabetes mellitus (GDM), placenta previa, premature rupture of membranes (PROM) and postpartum haemorrhage (PPH). Compared to the 30–34 years group, the risks of PIH, GDM, placenta previa, PROM and PPH increased in AMA pregnancies. Very advanced age (≥40 years) may be associated with placenta accreta while young mothers (20–24 years) have a higher prevalence of premature birth. Vaginal bleeding during pregnancy is a risk factor for maternal complications, maternal and neonatal morbidity. DiscussionAMA is associated with increased risk of PIH, GDM, placenta previa, PROM and PPH. Vaginal bleeding may be a predictor during pregnancy.

Benefits and risks of low molecular weight heparin use on reproductive outcomes: A retrospective cohort study

ObjectiveLow molecular weight heparin (LMWH) has been given to reproductive-age women with various indications. This study aims to assess the benefits and risks of such use. Materials and methodsWe retrospectively reviewed data (n = 204) between Jan 2016 and May 2019. Logistic regression analysis was conducted to evaluate the correlation between indications and reproductive outcomes. ResultsLMWH use had higher odds of live birth in women less than 30 years of age (OR: 4.98; 95% CI = 1.13–21.98; p = 0.034) and with protein S deficiency (OR: 3.90; 95% CI = 1.77–8.59; p = 0.001). For the subgroup of recurrent pregnant loss, LMWH use was only advantageous to women with protein S deficiency (OR: 2.45; 95%:1.01–5.97; p = 0.048). Risks such as preterm delivery, small-for-gestational-age, placental abruption, antepartum/postpartum hemorrhage were not significantly increased among subgroups. Women treated with LMWH and who had successful live births (n = 171) had a slightly increased risk of postpartum hemorrhage compared to controls (n = 8058) during this period in our institution (2.9% vs 1.2%, p < 0.001). ConclusionLMWH administration produces a higher chance of live-birth to women younger than 30 years of age or with protein S deficiency. However, risk of postpartum hemorrhage is increased.

Influence of previous laparoscopic surgical and pathological diagnosis of endometriosis on pregnancy outcomes in women with adenomyosis

ObjectivesPrevious studies demonstrated that endometriosis and adenomyosis are closely linked to lots of adverse pregnancy outcomes while the role of endometriosis in pregnant women with adenomyosis has not been explored yet. The present study aimed to evaluate the influence of previous laparoscopic surgical and pathological diagnosis of endometriosis on pregnancy outcomes in women with adenomyosis. MethodsA total of 60 pregnant women who were diagnosed with adenomyosis before or during pregnancy were included in this study. Among them, 8 were also diagnosed with endometriosis by previous laparoscopic surgery. The demographic characteristics and pregnancy outcomes were compared between women with adenomyosis only and those with the surgical history of endometriosis. ResultsCompared with women with adenomyosis only, those concomitant with the surgical history of endometriosis had significantly higher age at delivery [37.5(36.25–39.75) vs. 35(33.25–37), P ​= ​0.016] and an increased risk of postpartum hemorrhage (PPH) (adjusted OR: 5.992, 95% CI: 1.03–34.857, P ​= ​0.046) while no significant differences were found in other adverse pregnancy outcomes between these two groups. Then we further detected the risk factor of PPH in women with adenomyosis and found that the surgical history of endometriosis (OR: 6.995, 95% CI: 1.16–42.171, P ​= ​0.034) and assisted reproductive technology (ART) (OR: 5.062, 95% CI: 1.494–17.146, P ​= ​0.009) were the parameters closely associated with the occurrence of PPH. ConclusionsThe history of previous laparoscopic surgical and pathological diagnosis of endometriosis in pregnant women with adenomyosis may increase the risk of PPH, which still needs to be verified by future studies with a large sample size. Besides, pregnancy through ART is also an increased risk factor for PPH in women with adenomyosis. Pregnant women with adenomyosis who conceived with the surgical history of endometriosis or by ART should be closely monitored for the reason of being at high risk of PPH.

Thrombocytopenia in the first trimester predicts adverse pregnancy outcomes in obstetric antiphospholipid syndrome.

BackgroundThrombocytopenia is a common manifestation of antiphospholipid syndrome (APS), and is a main concern for bleeding on the standard treatment of low dose aspirin (LDA) and low molecular weight heparin (LMWH) in obstetric APS (OAPS).ObjectiveThis study assesses the possible relationship between thrombocytopenia during the first trimester and adverse pregnancy outcomes (APOs) in OAPS patients.MethodsA case-control study was conducted at Peking University People’s Hospital, Beijing, China. The clinical, immunologic, and pregnancy outcomes of the OAPS patients were collected. Univariate and multivariate logistic regression analyses were applied to assess the relationship between APOs and thrombocytopenia in the first trimester.ResultsA total of 115 participants were included in the analysis. There were no difference on antepartum and postpartum hemorrhage between the two groups. The gestational age in the thrombocytopenia group was less than that in the control group (34.12 ± 8.44 vs. 37.44 ± 3.81 weeks, p = 0.002). Hypocomplementemia, double aPL positive, and high titers of anti-β2 glycoprotein I were more frequent in APS patients with thrombocytopenia (p < 0.05). Compared to the control group, thrombocytopenia in the first trimester was correlated with SGA (12.12% vs. 31.25%, p = 0.043), premature birth <37 weeks (16.16% vs 43.75%, p = 0.010) and intrauterine fetal death (2.02% vs 12.50%, p = 0.033). Thrombocytopenia in first-trimester independently increased the risk of preterm birth <37 weeks (OR = 5.40, 95% CI: 1.35-21.53, p = 0.02) after adjusting for demographic and laboratory factors. After adding medication adjustments, these factors above become insignificant (p > 0.05). Of note, the number of platelets increased after delivery in 14 thrombocytopenia patients with live fetuses (p = 0.03).ConclusionThis study demonstrates that thrombocytopenia in the first trimester increases the risks of preterm birth in women with APS. The effective OAPS treatments may improve pregnancy outcomes and not increase the risk of antepartum and postpartum hemorrhage.

Comparative Study of Oxytocin Versus Tranexamic Acid and Ethamsylate for Reducing Blood Loss in Patient Undergoing Lower Segment Elective Cesarean Section at High Risk for Post-Partum Haemorrhage

Comparative Study of Oxytocin Versus Tranexamic Acid and Ethamsylate for Reducing Blood Loss in Patient Undergoing Lower Segment Elective Cesarean Section at High Risk for Post-Partum Haemorrhage

Association between Trimester-Specific Gestational Weight Gain Rate and Maternal and Neonatal Outcomes

Background: To investigate the associations of adjusting gestational weight gain rate (GWGr) with maternal and neonatal outcomes. Methods: We analyzed 6235 singleton pregnancies among women with normal pre-pregnancy body mass index at two medical centers in China during 2016~2018 to figure out whether pregnancy outcomes could be improved by adjusting GWGr timely when the first-trimester weight gain rate (GWGr-1) and/or the second-trimester weight gain rate (GWGr-2) were inappropriate. Results: When GWGr-1 was excessive, excessive GWGr during the second and third trimesters of pregnancy (late GWGr) was associated with a higher risk of cesarean section (CS), postpartum hemorrhage (PPH), obstructed and prolonged labor and large for gestational age (LGA), and inadequate late GWGr was associated with a lower prevalence of CS and hypertensive disorders of pregnancy (HDP). In pregnancies with inadequate GWGr-1, excessive late GWGr was related to a higher rate of CS, LGA and HDP. Among women with adequate GWGr-1, excessive GWGr in the third trimester (GWGr-3) was positively associated with CS, HDP, and obstruction and prolongation of labor if their GWGr-2 was excessive, and excessive GWGr-3 was associated with a higher risk of CS even though tFheir GWGr-2 was inadequate. Conclusions: Prompt control of GWGr, even during late pregnancy, was beneficial to improving pregnancy outcomes.

Predicting postpartum haemorrhage: A systematic review of prognostic models.

Postpartum haemorrhage (PPH) remains a leading cause of maternal mortality and morbidity worldwide, and the rate is increasing. Using a reliable predictive model could identify those at risk, support management and treatment, and improve maternal outcomes. To systematically identify and appraise existing prognostic models for PPH and ascertain suitability for clinical use. MEDLINE, CINAHL, Embase, and the Cochrane Library were searched using combinations of terms and synonyms, including 'postpartum haemorrhage', 'prognostic model', and 'risk factors'. Observational or experimental studies describing a prognostic model for risk of PPH, published in English, were included. The Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist informed data extraction and the Prediction Model Risk of Bias Assessment Tool guided analysis. Sixteen studies met the inclusion criteria after screening 1612 records. All studies were hospital settings from eight different countries. Models were developed for women who experienced vaginal birth (n= 7), caesarean birth (n= 2), any type of birth (n= 2), hypertensive disorders (n= 1) and those with placental abnormalities (n= 4). All studies were at high risk of bias due to use of inappropriate analysis methods or omission of important statistical considerations or suboptimal validation. No existing prognostic models for PPH are ready for clinical application. Future research is needed to externally validate existing models and potentially develop a new model that is reliable and applicable to clinical practice.

Effect of induction of labor on maternal and perinatal outcomes in low-risk singleton pregnancies: a retrospective case-control study.

The aim of the study was to investigate the effect of induction of labor on maternal and fetal outcomes. This retrospective case-control study included 4386 pregnant women with low-risk singleton pregnancies who underwent regular prenatal examination and successful vaginal delivery at ≥41 weeks and 0 days of gestation in Fujian Maternal and Child Health Hospital between January 2014 and December 2018. Clinical data of women were retrospectively divided into the induction of labor group (2007 cases) and spontaneous onset of labor group (2361 cases) based on the mode of labor initiation. Two-sample independent t-test and χ2 tests were used to analyze the differences in clinical characteristics, such as maternal age and parity between the two groups. The induction of the labor group had a significantly longer total duration of labor (9.37±5.37 vs. 8.82±5.13 h; p<0.001), more postpartum blood loss (219.18±188.32 vs. 199.95±124.69 mL; p=0.01) and a significantly higher incidence of severe postpartum hemorrhage (PPH) comparing to the spontaneous onset of labor group [0.8% (16/2007) vs. 0.33% (8/2361); p=0.041]. However, no significant difference was found in the neonatal outcomes. After adjusting for age, induction of labor in nulliparous women was more likely to lead to PPH than the spontaneous onset of labor [2.74% (55/2007) vs. 1.65% (39/2361); odds ratio=1.557; 95% confidence interval: 1.039-2.332; p<0.05]. Induction of labor increases the duration of labor and postpartum blood loss, especially in primary parturient, leading to an increased risk of PPH. This increase may be related to the overall higher duration of labor, associated with IOL. Therefore, low-risk nulliparous women should try to avoid induction of labor without medical indications.

Predicting risk of postpartum haemorrhage during the intrapartum period in a general obstetric population

ObjectiveTo develop and validate (both internally and externally) a prediction model examining a combination of risk factors in order to predict postpartum haemorrhage (PPH) in a general obstetric Irish population of singleton pregnancies. Study designWe used data from the National Maternal and Newborn Clinical Management System (MN-CMS), including all singleton deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019. We defined PPH as an estimated blood loss of ≥ 1000 ml following the birth of the baby. Multivariable logistic regression with backward stepwise selection was used to develop the prediction model. Candidate predictors included maternal age, maternal body mass index, parity, previous caesarean section, assisted fertility, gestational age, fetal macrosomia, mode of delivery and history of PPH. Discrimination was assessed using the area under the receiver operating characteristic curve (ROC) C-statistic. We used bootstrapping for internal validation to assess overfitting, and conducted a temporal external validation using data from all singleton deliveries at CUMH during 2020. ResultsOut of 6,077 women, 5,807 with complete data were included in the analyses, and there were 270 (4.65%) cases of PPH. Four variables were considered the best combined predictors of PPH, including parity (specifically nulliparous), macrosomia, mode of delivery (specifically operative vaginal delivery, emergency caesarean section and prelabour caesarean section), and history of PPH. These predictors were used to develop a nomogram to provide individualised risk assessment for PPH. The original apparent C-statistic was 0.751 (95% CI: 0.721, 0.779) suggesting good discriminative performance. There was minimal optimism adjustment to the C-statistic after bootstrapping, indicating good internal performance (optimism adjusted C-statistic: 0.748). Results of external validation were comparable with the development model suggesting good reproducibility. ConclusionsFour routinely collected variables (parity, fetal macrosomia, mode of delivery and history of PPH) were identified when predicting PPH in a general obstetric Irish population of singleton pregnancies. Use of our nomogram could potentially assist with individualised risk assessment of PPH and inform clinical decision-making allowing those at highest risk of PPH be actively managed.

Prediction of Maternal Hemorrhage Using Machine Learning: Retrospective Cohort Study

BackgroundPostpartum hemorrhage remains one of the largest causes of maternal morbidity and mortality in the United States.ObjectiveThe aim of this paper is to use machine learning techniques to identify patients at risk for postpartum hemorrhage at obstetric delivery.MethodsWomen aged 18 to 55 years delivering at a major academic center from July 2013 to October 2018 were included for analysis (N=30,867). A total of 497 variables were collected from the electronic medical record including the following: demographic information; obstetric, medical, surgical, and family history; vital signs; laboratory results; labor medication exposures; and delivery outcomes. Postpartum hemorrhage was defined as a blood loss of ≥1000 mL at the time of delivery, regardless of delivery method, with 2179 (7.1%) positive cases observed. Supervised learning with regression-, tree-, and kernel-based machine learning methods was used to create classification models based upon training (21,606/30,867, 70%) and validation (4630/30,867, 15%) cohorts. Models were tuned using feature selection algorithms and domain knowledge. An independent test cohort (4631/30,867, 15%) determined final performance by assessing for accuracy, area under the receiver operating curve (AUROC), and sensitivity for proper classification of postpartum hemorrhage. Separate models were created using all collected data versus models limited to data available prior to the second stage of labor or at the time of decision to proceed with cesarean delivery. Additional models examined patients by mode of delivery.ResultsGradient boosted decision trees achieved the best discrimination in the overall model. The model including all data mildly outperformed the second stage model (AUROC 0.979, 95% CI 0.971-0.986 vs AUROC 0.955, 95% CI 0.939-0.970). Optimal model accuracy was 98.1% with a sensitivity of 0.763 for positive prediction of postpartum hemorrhage. The second stage model achieved an accuracy of 98.0% with a sensitivity of 0.737. Other selected algorithms returned models that performed with decreased discrimination. Models stratified by mode of delivery achieved good to excellent discrimination but lacked the sensitivity necessary for clinical applicability.ConclusionsMachine learning methods can be used to identify women at risk for postpartum hemorrhage who may benefit from individualized preventative measures. Models limited to data available prior to delivery perform nearly as well as those with more complete data sets, supporting their potential utility in the clinical setting. Further work is necessary to create successful models based upon mode of delivery and to validate the findings of this study. An unbiased approach to hemorrhage risk prediction may be superior to human risk assessment and represents an area for future research.

How to boost an obstetrician's confidence in vaginal delivery after high-intensity focused ultrasound: a comparison study on delivery outcomes

Objective To assess the feasibility of vaginal delivery after HIFU. Methods A total of 37 women who met the trial of labor after HIFU (TOLAH) inclusion criteria and 368 women who met the trial of labor after cesarean delivery (TOLAC) inclusion criteria gave birth at Shanghai First Maternity and Infant Hospital between 14th June 2018 and 24th September 2021. The delivery outcomes of the two groups were compared. Multivariable logistic regression analysis was used to estimate the adjusted risk of postpartum hemorrhage (PPH). Results In the Qualified Candidates for TOLAH group, vaginal delivery is substantially less common (p = 0.000). The prevalence of PPH in the Qualified Candidates for TOLAH group is lower than in the Candidates for TOLAC group (8.82% vs 10.51%, p = 0.534; 0% vs 2.51%, p = 0.418). Hemoglobin drop in the Qualified Candidates for TOLAH group is also lower (7.03 ± 7.39vs 12.11 ± 12.62, p = 0.001). The rate of using more than two types of uterotonic medications to promote contraction is significantly lower in the Qualified Candidates for TOLAH group (54.05% vs 69.84%, p = 0.04), and the percentage of abnormal uterine contraction is lower in the Qualified Candidates for TOLAH group (35.14% vs 49.18%, p = 0.072). PPH is strongly predicted by abnormal uterine contraction (aOR: 17.177, 95% CI:5.046 ∼ 58.472, p = 0.000), but not by HIFU (aOR:1.105; 95% CI:0.240 ∼ 5.087, p = 0.898). No uterine rupture occurred in the cases after HIFU. Conclusions No uterine rupture occurred in our study group after HIFU. HIFU is not a risk for PPH. It is promising for those after HIFU to choose vaginal delivery.

Effect of structured teaching programme on knowledge regarding modified partograph among auxiliary nurse midwives in selected community health centers

Maternal mortality remains one of the major problems in developing countries. In India the incidence of women dying while giving birth is among the highest in the world. The partograph has been considered as one of the valuable tool in the improvement of maternity services.Partogram serves an “early warning system” and assist in early decision on transfer, augmentation and termination of labour. It also increases the quality and regularity of all observations on the fetus and the mother in labour, and aids early recognition of problems with either. Partograph prevents prolonged labour effectively and thus reduces the risk of postpartum hemorrhage, sepsis uterine rupture, operative interventions and improving neonatal outcomes and reducing fetal mortality and morbidity. A pre-experimental one group pre-test, post-test design was used to observe the effect of structured teaching programe among Auxiliary Nurse Midwives regarding modified partograph. Reliability of the tool was tested by Karl Pearson (Correlation Coefficient) formula and it was found reliable r = 0.803. 60 samples were selected for the main study by non-probability convenient sampling technique. Highest percentage of Auxiliary Nurse Midwives (38.3%) were in the age group &amp;#62;35 years and (88.3%) were married. Highest percentage of Auxiliary Nurse Midwives (66.6%) were having high school basic qualification and (85%) were from 18 months revised auxiliary nurse midwives MPHW (F). Highest percentage of Auxiliary Nurse Midwives (58.3%) had 9 years and above total clinical experience, (41.6%) had 7 and above years of experience in labour room and (33.3%) Auxiliary Nurse Midwives had seldom used partograph in labour room. Highest percentage of Auxiliary Nurse Midwives (86.6%) had previous source of information during training. Highest percentage of Auxiliary Nurse Midwives (46.6%) agreed that partograph sheet is been supplied by the concerning department, (75%) agreed that use of partograph is allowed by medical officers / gynaecologists where (63.3%) are confident in using partograph.

Anesthetic Management in Parturients With Fontan Physiology

Anesthetic Management in Parturients With Fontan Physiology

Maternal and perinatal outcome in pregnancies complicated with portal hypertension: a systematic review and meta-analysis.

Portal hypertension is secondary to either cirrhotic or non-cirrhotic causes, and complicating pregnancy poses a challenge to the treating team. A systematic review was performed to determine maternal and perinatal outcomes in women with portal hypertension. Outcomes were compared among those with cirrhotic (CPH) with non-cirrhotic portal hypertension (NCPH) as well as non-cirrhotic portal fibrosis (NCPF) with extra-hepatic portal vein obstruction (EHPVO). Medline and EMBASE databases were searched for studies reporting outcomes among pregnant women with portal hypertension. Reference lists from relevant papers and reviews were hand-searched for appropriate citations. Data were extracted to describe maternal complications, obstetric and neonatal outcomes. A random-effects model was used to derive pooled estimates of various outcomes, and final estimates were reported as percentages with a 95% confidence interval (CI). Cumulative, sequential and sensitivity analysis was studied to assess the temporal trends of outcomes over the period. Information on 895 pregnancies among 581 patients with portal hypertension was included from 26 studies. Portal hypertension was diagnosed during pregnancy in 10% (95% CI 4-24%). There were 22 maternal deaths (0%, 95% CI 0-1%), mostly following complications from variceal bleeding or hepatic decompensation. Variceal bleeding complicated in 14% (95% CI 9-20%), and endoscopic interventions were performed in 12% (95% CI 8-17%) during pregnancy. Decompensation of liver function occurred in 7% (95% CI 3-12%). Thrombocytopenia was the most common complication (41%, 95% CI 23-60%). Miscarriages occurred in 14% (95% CI 8-20%), preterm birth in 27% (95% CI 19-37%), and low birth weights in 22% (95% CI 15-30%). Risk of postpartum hemorrhage was higher (RR 5.09, 95% CI 1.84-14.12), and variceal bleeding was lower (RR 0.51, 95% CI 0.30-0.86) among those with CPH compared to NCPH. Risk of various outcomes was comparable between NCPF and EHPVO. One in ten pregnancies complicated with portal hypertension is diagnosed during pregnancy, and thrombocytopenia is the most common complication. Hepatic decompensation and variceal bleeding remain the most common cause of maternal deaths, with reduced rates of bleeding and its complications reported following the introduction of endoscopic procedures during pregnancy. CPH increases the risk of postpartum hemorrhage, whereas variceal bleeding is higher among NCPH.

Association between the second-stage duration of labor and perinatal outcomes in women with a prior cesarean delivery

BackgroundThe cesarean delivery (CD) rate has been increasing globally. Trial of labor after cesarean delivery (TOLAC) has been used as a key method for the reduction of the CD rate. Little is known, however, about the association between the second-stage duration of TOLAC and adverse maternal and neonatal outcomes. This study evaluated the association between perinatal outcomes and the duration of second-stage labor in women undergoing TOLAC.MethodsA 10-year retrospective cohort study was performed at the Department of Obstetrics and Gynecology, Third Affiliated Hospital of Guangzhou Medical University, between January 2010 and January 2020. Women undergoing TOLAC who reached the second stage of labor were included in this study. Duration of the second stage of labor was examined as a categorical variable (group I: <0.5 h, group II: 0.5–2 h and group III: ≥2 h) and as a continuous variable to evaluate the association with adverse perinatal outcomes by using multivariable regression models and a Cox proportional hazards regression model adjusting for potential confounders.ResultsOf the 1,174 women who met the inclusion criteria, the median (interquartile range) length of the second stage was 0.5 h (0.3–0.9 h). Among them, 1,143 (97.4%) delivered vaginally and 31 underwent an unplanned CD. As the second-stage duration increased, operative vaginal delivery (OVD), CD, and postpartum hemorrhage (PPH) rates increased. Women in group III had higher risks of OVD (aOR = 11.34; 95% CI [5.06–25.41]), CD (aOR = 4.22; 95% CI [1.32–13.43]), and PPH (aOR = 2.43; 95% CI [1.31–4.50]) compared with group I. Correspondingly, blood loss and the oxytocin used to treat PPH increased significantly, while the postpartum hemoglobin reduced significantly in group III compared with group I. The incidence of uterine rupture, uterine atony, cervical laceration, red blood cell transfusion, and intensive care unit admission were similar in all three groups. Neonatal outcomes were not affected by the second-stage duration.ConclusionsWomen undergoing TOLAC with second-stage duration of ≥2 h have higher odds of OVD, unplanned intrapartum CD, and PPH.

Non-diabetic fetal macrosomia: outcomes of elective delivery versus expectant management.

BackgroundMacrosomia in the absence of diabetes can be associated with increased neonatal and maternal morbidity. Management is usually undertaken on a case-by-case basis.AimsIn order to inform local practice, this study aimed to evaluate the outcomes of the management of non-diabetic macrosomia in an Irish tertiary center.MethodsA retrospective observational study was performed on all women with estimated fetal weight over 4000 g after 37 weeks’ gestation. Maternal demographics and obstetric and neonatal outcomes were recorded using the hospital information system. Women with diabetes, previous caesarean section, non-cephalic presentation, or any other complicating condition were excluded. Women were divided into two groups:Active management: Elective delivery for macrosomia—between 38 + 0 and 40 + 6 weeks’ gestationExpectant management: with induction of labour offered after 41 weeks' gestationResultsThere were 397 women included, 188 with active and 209 with expectant management. There was no difference in adverse neonatal outcomes, major maternal morbidity, or mode of delivery, after exclusion of pre-labor caesarean section. Women with expectant management were more likely to go into spontaneous labor (46.9 vs 1.6%, p < 0.001) and to have a favorable cervix at the onset of induction of labor if nulliparous (86.1 vs 70.0%, p = 0.021), but have higher rates of episiotomy (28.6 vs 18.2%, p = 0.021). With active management, nulliparas with an unfavorable cervix had increased risk of anal sphincter injury (6.5 vs 0.0%, p = 0.007) and postpartum hemorrhage (59.0 vs 35.5%, p = 0.003).ConclusionsOverall, there was no difference in major maternal or neonatal outcomes between management options for fetal macrosomia. However, inducing nulliparas with an unfavorable cervix for non-diabetic macrosomia was associated with obstetric anal sphincter injury and postpartum hemorrhage.

JTH in Clinic ‐ Obstetric bleeding: VWD and other inherited bleeding disorders

Individuals with inherited bleeding disorders (IBDs) have higher bleeding risk during pregnancy, childbirth, and the postpartum period. Clinical management requires recognition of the IBD as high risk for postpartum hemorrhage and a personalized multidisciplinary approach that includes the patient in decision making. When the fetus is known or at risk to inherit a bleeding disorder, fetal and neonatal bleeding risk also need to be considered. In pregnant IBD patients, it is common for providers to need to make decisions in the absence of high level of certainty evidence. We here present the case of a pregnant von Willebrand disease patient that reached multiple decision points where there is currently clinical ambiguity due to a lack of high level of certainty evidence. For each stage of her care, from diagnosis to the postpartum period, we discuss current literature and describe our approach. This is followed by a brief overview of considerations in other IBDs and pregnancy.

How Every Postpartum Hemorrhage Harms Every Other Birthing Person on the Unit

Every birthing person on a unit is harmed when a postpartum hemorrhage (PPH) occurs because staff, blood, medication, supplies, and more are diverted to attend to the crisis. When caring for a woman with PPH, multiple nurses are pulled from their existing patients (often set up as 1:1 nurse:patient ratio) to assist, thus increasing the chances of another safety event. Instead, unit staff should minimize the risk for PPH with limited obstetric interventions, support physiological birth, prepare for PPH (i.e., through simulations, maintaining the hemorrhage cart, making medications easily available, having a blood replacement plan in place, closely assessing the postpartum patient). Plan to reduce elective inductions and multiple obstetric-unit closures that have created a bottleneck situation in care resources during a highly acute care situation. Information is provided on the obstetric-unit closures in Philadelphia during the last 20 years. Risk predictive models are limited in their utility, but known risks exist.