Risk Of Postpartum Hemorrhage Research Articles

Association of adverse outcomes with three-tiered risk assessment tool for obstetrical hemorrhage

Guidelines promote stratification for the risk for postpartum hemorrhage among parturients, although the evidence for the associated differential morbidity among the groups remains inconsistent among published reports. Using the California Maternal Quality Care Collaborative schema modified by the American College of Obstetrics and Gynecology, we compared the composite maternal hemorrhagic outcome and the composite neonatal adverse outcome among singletons who were categorized after delivery by the researchers as low-, medium-, or high-risk for postpartum hemorrhage. We hypothesized that the composite outcomes would be significantly different among the individuals in the different 3-tiered categories. This was a retrospective cohort study of all singleton parturients with a gestational age of at least 14 weeks who delivered at a single site within 1 year. The composite maternal hemorrhagic outcome included any of the following: estimated blood loss ≥1000 mL, use of uterotonics (excluding prophylactic oxytocin) or Bakri balloon, surgical management of postpartum hemorrhage, blood transfusion, hysterectomy, thromboembolism, admission to the intensive care unit, or maternal death. The composite neonatal adverse outcome included Apgar score <7 at 5 minutes, birth injury, bronchopulmonary dysplasia, intraventricular hemorrhage, neonatal seizure, sepsis, ventilation > 6 hrs., brachial plexus palsy, hypoxic-ischemic encephalopathy, or neonatal death. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted relative risks with 95% confidence intervals. Of the 4544 deliveries in the study period, 4404 (96.7%) met the inclusion criteria, and among them, 1745 (39.6%) were categorized as low, 1376 (31.2%) as medium, and 1283 (29.1%) as high risk. Overall, 941 (21.4%) participants experienced the composite maternal hemorrhagic outcome with 285 (16.4%) of those being in the low-risk group, 319 (23.2%) in the medium-risk group, and 337 (26.3%) in the high-risk group. Among all parturients, 95.7% in the low-, 89.4% in the medium-, and 85.3% in the high-risk group neither had an estimated blood loss or a quantified blood loss ≥1000 mL nor were transfused. After multivariable adjustment and when compared with the low-risk group, there was a significantly higher risk for the composite maternal hemorrhagic outcome in the medium-risk group (adjusted relative risk, 1.23; 95% confidence interval, 1.05-1.43) and in the high-risk group (adjusted relative risk, 1.51; 95% confidence interval, 1.31-1.75). Overall, 366 newborns (8.4%) developed the composite neonatal adverse outcome with 76 (4.2%) in of those being in the low-risk group, 153 (11.3%) in the medium-risk group, and 140 (11.1%) in the high-risk group. After multivariable adjustment and when compared with the low-risk group, there were no significant differences in the composite neonatal adverse outcome in the medium- (adjusted relative risk, 1.27; 95% confidence interval, 0.97-1.68) or the high-risk group (adjusted relative risk, 1.29; 95% confidence interval, 0.98-1.68). Although 8 of 10 parturients categorized as high risk neither had blood loss ≥1000 mL nor underwent transfusion, the risk stratification provides information regarding the composite maternal hemorrhagic outcome.

Incidence of postpartum hemorrhage based on the improved combined method in evaluating blood loss: A retrospective cohort study.

In view of the current clinical inaccuracies and underestimations of postpartum hemorrhage amount, this study aims to investigate the incidence, etiology, clinical characteristics of postpartum hemorrhage in different modes of delivery based on the combination of volumetric method, gravimetric method and area method in evaluating blood loss. This retrospective cohort study was conducted in Hangzhou Women's Hospital from January 2020 to June 2021, including 725 cases of postpartum hemorrhage among 18,977 parturients. Based on different modes of delivery, the participants were divided into three groups: vaginal delivery, forceps delivery, and cesarean section, for comparison. Using an improved combined assessment method for blood loss, we retrospectively analyzed a cohort of parturients with postpartum hemorrhage who underwent vaginal delivery, forceps delivery, or cesarean section and were hospitalized in Hangzhou Women's Hospital from January 2020 to June 2021. (1) Among the 18,977 parturients, 725 cases of postpartum hemorrhage occurred, with an incidence rate of 3.8%, and severe postpartum hemorrhage accounted for 0.4% of the cases. (2) The incidence of postpartum hemorrhage was significantly higher in the forceps delivery group than in the vaginal delivery group (χ2 = 19.27, P<0.001), while the incidence of severe postpartum hemorrhage was significantly higher in the cesarean section group than in the vaginal delivery group (χ2 = 8.71, P = 0.003). (3) The causes of postpartum hemorrhage were statistically different among the different delivery modes, with varying underlying factors (P<0.001). (4) Patients with postpartum hemorrhage in different delivery modes showed statistically significant differences in age, body mass index (BMI), birth weight, gestational age, gravidity, parity, the decline of postpartum peripheral blood hemoglobin concentration, and estimated blood loss (P<0.05). (5) The proportion of blood transfusion was significantly higher in the cesarean section group than in the vaginal delivery and forceps delivery groups (χ2 = 231.03, P<0.001). This study is a single-center retrospective study, which may have led to selection bias in case selection. Additionally, the implementation of the combined three blood loss assessment methods may not have been strictly followed in all cases. Moreover, due to the mixing of bleeding with amniotic and irrigation fluids, the accuracy of evaluation may have been affected, leading to the possibility of inaccuracy of blood loss. Forceps delivery and cesarean section increase the risk of postpartum hemorrhage, but forceps delivery does not significantly increase the incidence of severe postpartum hemorrhage. Uterine atony remains the leading cause of postpartum hemorrhage, while birth canal laceration and placental factors are the second most common causes of postpartum hemorrhage in forceps delivery and cesarean section, respectively. In this study, the volumetric method, gravimetric method and area method were combined to quantitatively assess postpartum hemorrhage amount. The combined method has strong clinical practicability and is less affected by subjective factors, although it also has limitations. In the future, we still need to focus on the early prediction and identification of postpartum hemorrhage, and further improve the quantitative assessment of postpartum blood loss.

Risk factors for postpartum haemorrhage in twin pregnancies and haemorrhage severity.

This study evaluated risk factors for postpartum haemorrhage (PPH) in twin pregnancies, particularly factors associated with major PPH (blood loss of >1000 mL), to facilitate identification of high-risk twin pregnancies. This retrospective cohort study included all women with twin pregnancies who delivered at a tertiary obstetric unit in Hong Kong from 2009 to 2018 and experienced PPH (blood loss of ≥500 mL). Postpartum haemorrhage was classified using three thresholds for blood loss volume: ≥500 mL (all PPH), >1000 mL (major PPH), and >1500 mL (severe PPH). Risk factors for each threshold of PPH were analysed. In total, there were 680 twin pregnancies. The overall incidence of all PPH (≥500 mL) in this cohort was 27.8%, including minor PPH (500-1000 mL, 20.1%), major but not severe PPH (1001-1500 mL, 4.4%), and severe PPH (>1500 mL, 3.2%). Logistic regression analysis showed that general anaesthesia and the use of oxytocin were significant risk factors for all PPH (≥500 mL); general anaesthesia, in vitro fertilisation, antepartum haemorrhage, placental abruption, and placenta praevia were significant risk factors for major PPH (>1000 mL); in vitro fertilisation, placenta praevia, and obesity were significant risk factors for severe PPH (>1500 mL). Women with twin pregnancies who have obesity, conception by in vitro fertilisation, or placenta praevia exhibit a high risk of severe PPH. They should deliver in obstetric units with readily available blood product transfusions and the appropriate expertise for prompt management of severe PPH.

Prophylactic Tranexamic Acid Prevents Postpartum Hemorrhage and Transfusions in Cesarean Deliveries: A Systematic Review and Meta-analysis.

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide and PPH resulting in transfusion is the most common maternal morbidity in the United States. Literature demonstrates that tranexamic acid (TXA) can reduce blood loss in cesarean deliveries; however, there is little consensus on the impact on major morbidities like PPH and transfusions. We conducted a systematic review/meta-analysis of randomized controlled trials (RCTs) to evaluate if administration of prophylactic intravenous (IV) TXA prevents PPH and/or transfusions following low-risk cesarean delivery. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. Five databases were searched: Cochrane, EBSCO, Ovid, PubMed, and ClinicalKey. RCTs published in English between January 2000 and December 2021 were included. Studies compared PPH and transfusions in cesarean deliveries between prophylactic IV TXA and control (placebo or no placebo). The primary outcome was PPH, and the secondary outcome was transfusions. Random effects models were used to calculate effect size (ES) of exposure in Mantel-Haenszel risk ratios (RR). All analysis was done at a confidence level (CI) of α = 0.5. Modeling showed that TXA led to significantly less risk of PPH than control (RR: 0.43; 95% CI: 0.28-0.67). The effect on transfusion was comparable (RR: 0.39; 95% CI: 0.21-0.73). Heterogeneity was minimal (I 2 = 0%). Due to the large sample sizes needed, many RCTs are not powered to interpret TXA's effect on PPH and transfusions. Pooling these studies in a meta-analysis allows for more power and analysis but is limited by the heterogeneity of studies. Our results minimize heterogeneity while demonstrating that prophylactic TXA can lower PPH occurrence and reduce the need for blood transfusion. We suggest considering prophylactic IV TXA as the standard of care in low-risk cesarean deliveries. KEY POINTS: · Consider TXA prior to incision for singleton, term pregnancies undergoing elective cesarean.. · Prophylactic TXA is effective in preventing PPH and blood transfusions.. · Routine use of TXA has the potential to decrease transfusion-related complications and costs..

Determinants of postpartum uterine atony in urban South Ethiopia: a community-based unmatched nested case–control study

BackgroundUterine atony is the most common cause of postpartum hemorrhage, which is the leading preventable cause of maternal morbidity and mortality. Despite several interventions uterine atony-related postpartum hemorrhage remains a global challenge. Identifying risk factors of uterine atony helps to reduce the risk of postpartum hemorrhage and subsequent maternal death. However, evidence about risk factors of uterine atony is limited in the study areas to suggest interventions. This study aimed to assess determinants of postpartum uterine atony in urban South Ethiopia.MethodsA community-based unmatched nested case–control study was conducted from a cohort of 2548 pregnant women who were followed-up until delivery. All women with postpartum uterine atony (n = 93) were taken as cases. Women who were randomly selected from those without postpartum uterine atony (n = 372) were taken as controls. Using a case to control ratio of 1:4, the total sample size was 465. An unconditional logistic regression analysis was done using R version 4.2.2 software. In the binary unconditional logistic regression model variables that have shown association at p < 0.20 were recruited for multivariable model adjustment. In the multivariable unconditional logistic regression model, statistically significant association was declared using 95% CI and p < 0.05. Adjusted odds ratio (AOR) used to measure the strength of association. Attributable fraction (AF) and population attributable fraction (PAF) were used to interpret the public health impacts of the determinants of uterine atony.ResultsIn this study, short inter-pregnancy interval < 24 months (AOR = 2.13, 95% CI: 1.26, 3.61), prolonged labor (AOR = 2.35, 95% CI: 1.15, 4.83), and multiple birth (AOR = 3.46, 95% CI: 1.25, 9.56) were determinants of postpartum uterine atony. The findings suggest that 38%, 14%, and 6% of uterine atony in the study population was attributed to short inter-pregnancy interval, prolonged labor, and multiple birth, respectively, which could be prevented if those factors did not exist in the study population.ConclusionsPostpartum uterine atony was related to mostly modifiable conditions that could be improved by increasing the utilization of maternal health services such as modern contraceptive methods, antenatal care and skilled birth attendance in the community.

Tranexamic Acid Versus Etamsylate in Reducing Blood Loss During Normal Vaginal Delivery in Patients with High Risk of Postpartum Hemorrhage: Randomized Controlled Trial

Tranexamic Acid Versus Etamsylate in Reducing Blood Loss During Normal Vaginal Delivery in Patients with High Risk of Postpartum Hemorrhage: Randomized Controlled Trial

Provider Awareness of Postpartum Hemorrhage Risk Assessment Tool at the Time of Admission at a Community Setting

Objectives: The primary objective of this study was to determine the provider's awareness of the postpartum hemorrhage risk assessment tool at the time of admission. In addition, in keeping with the organization’s continual performance improvement philosophy, education on postpartum hemorrhage risk was provided to survey respondents who self-reported that they were unaware or requested additional resources. Methods: This cross-sectional study utilized an anonymous survey methodology. We distributed a postpartum hemorrhage awareness risk assessment questionnaire and collected participant responses without personal identifiers over a 3 month time period, January 2023 – March 2023. Analysis was completed using Fischer’s exact test. Alpha level was set to 0.05. Results: 39 participants completed the questionnaire attending physicians: n=10 (25.6%), nursing staff: n=15 (38.5%), and resident physicians: n=14 (35.9%). 7 of the 10 attending physicians (70%) and 9 of the 15 nursing staff (60%) have worked over 10 years in their profession, while 11 of the 14 resident physicians (78.6%) have worked in their profession for 1-5 years (p=&lt;0.0001). 5 of the 10 attending physicians (50%) and 7 of 15 nursing staff (46.7%) were 36-50 years old, while 13 of 14 resident physicians (93%) were 25- 36 years old (p=&lt;0.0001). Majority of the participants were White; 5 attending physicians (50%), 11 nursing staff (73.3%), and 9 resident physicians (64.3%). Nursing staff had the most awareness of the postpartum hemorrhage awareness risk assessment tool at the time of admission (100%) in comparison with attending physicians (50%) and resident physicians (64.3%), (p=0.005). Nursing staff had the most knowledge of where to access the assessment (93.3%) in comparison to attending physicians (10%) and resident physicians (0%), (p=&lt;0.0001). Conclusions: Our study revealed a statistically significant difference in awareness of the postpartum hemorrhage risk assessment tool at the time of admission amongst the 3 groups of providers; attending physicians, nursing staff, and resident physicians. The nursing staff had the most awareness in comparison with other providers. The data also highlighted the inconsistencies with accessing the risk assessment and with communication of information obtained through the assessment among providers. A quality improvement project should involve notifying providers of patients that are stratified to high risk, developing a simpler method for all providers to readily access the risk assessment tool, and increasing preparedness by creating an algorithm or bundle.

Pepper fruit (Dennettia tripetala [annonaceae]) seed inhibits uterine contractions via blockade of intracellular calcium release and extracellular calcium influx in ex vivo studies

Dennettia tripetala (DT) is a tree found in rain forest belt of Nigeria, Cameroon and Ivory Coast. The seed is commonly used in preparing food for mothers after delivery because it is believed to play a role in postpartum uterine contraction. There is however no scientific evidence validating this claim. Hence, the study aimed to investigate the effects of DT seed on non-pregnant and pregnant uterus using mouse model. The dried seeds of DT were macerated in methanol and the effects of DT extract were investigated on uterus tissues isolated from non-pregnant and pregnant mice. DT extract was examined on spontaneous uterine contraction, contractions induced by oxytocin, and high potassium chloride (KCl)-induced depolarization. Its effect was also evaluated on calcium ion (Ca2+) release from internal stores. The DT extract suppressed spontaneous uterine contractility in both pregnant and non-pregnant uterus in a concentration-dependent manner. It significantly inhibited uterine contractions elicited by high KCl and oxytocin-induced contractions in both pregnant and non-pregnant uterus. The extract also inhibited uterine contractility induced by oxytocin in the Ca2+-free medium in pregnant and non-pregnant uterus. The study has provided scientific evidence that DT seed extract has uterine relaxing effect in both pregnant and non-pregnant mouse uterus possibly by blocking intracellular Ca2+ released and influx of extracellular Ca2+. The result has shown that DT has no benefit in reducing the risk of post-partum hemorrhage, however, it may have potential benefits in management of dysmenorrhea and preterm labour in non-gravid and gravid uteri respectively.

Maternal anaemia and the risk of postpartum haemorrhage: a cohort analysis of data from the WOMAN-2 trial

Worldwide, more than half a billion women of reproductive age are anaemic. Each year, about 70 000 women who give birth die from postpartum haemorrhage. Almost all deaths are in low-income or middle-income countries. We examined the association between anaemia and the risk of postpartum haemorrhage. We did a prospective cohort analysis of data from the World Maternal Antifibrinolytic-2 (WOMAN-2) trial. This trial enrols women with moderate or severe anaemia giving birth vaginally in hospitals in Pakistan, Nigeria, Tanzania, and Zambia. Moderate anaemia was defined as a haemoglobin concentration of 70-99 g/L and severe anaemia as less than 70 g/L. Hospitals in each country where anaemia in pregnancy is common were identified from a network established during previous obstetric trials. Women who were younger than 18 years without permission provided by a guardian, had a known tranexamic acid allergy, or developed postpartum haemorrhage before the umbilical cord was cut or clamped were excluded from the study. Prebirth haemoglobin, the exposure, was measured after hospital arrival and just before giving birth. Postpartum haemorrhage, the outcome, was defined in three ways: (1) clinical postpartum haemorrhage (estimated blood loss ≥500 mL or any blood loss sufficient to compromise haemodynamic stability); (2) WHO-defined postpartum haemorrhage (estimated blood loss of at least 500 mL); and (3) calculated postpartum haemorrhage (calculated estimated blood loss of ≥1000 mL). Calculated postpartum haemorrhage was estimated from the peripartum change in haemoglobin concentration and bodyweight. We used multivariable logistic regression to examine the association between haemoglobin and postpartum haemorrhage, adjusting for confounding factors. Of the 10 620 women recruited to the WOMAN-2 trial between Aug 24, 2019, and Nov 1, 2022, 10 561 (99·4%) had complete outcome data. 8751 (82·9%) of 10 561 women were recruited from hospitals in Pakistan, 837 (7·9%) from hospitals in Nigeria, 525 (5·0%) from hospitals in Tanzania, and 448 (4·2%) from hospitals in Zambia. The mean age was 27·1 years (SD 5·5) and mean prebirth haemoglobin was 80·7 g/L (11·8). Mean estimated blood loss was 301 mL (SD 183) for the 8791 (83·2%) women with moderate anaemia and 340 mL (288) for the 1770 (16·8%) women with severe anaemia. 742 (7·0%) women had clinical postpartum haemorrhage. The risk of clinical postpartum haemorrhage was 6·2% in women with moderate anaemia and 11·2% in women with severe anaemia. A 10 g/L reduction in prebirth haemoglobin increased the odds of clinical postpartum haemorrhage (adjusted odds ratio [aOR] 1·29 [95% CI 1·21-1·38]), WHO-defined postpartum haemorrhage (aOR 1·25 [1·16-1·36]), and calculated postpartum haemorrhage (aOR 1·23 [1·14-1·32]). 14 women died and 68 either died or had a near miss. Severe anaemia was associated with seven times higher odds of death or near miss (OR 7·25 [95% CI 4·45-11·80]) than was moderate anaemia. Anaemia is strongly associated with postpartum haemorrhage and the risk of death or near miss. Attention should be given to the prevention and treatment of anaemia in women of reproductive age. The WOMAN-2 trial is funded by Wellcome and the Bill & Melinda Gates Foundation.

O-009 The Role of Ethnicity and Polycystic Ovary Syndrome on Pregnancy Complications. An Analysis of a Population Database

Abstract Study question The goal of this study was to determine the independent effect of ethnicity on adverse obstetrical outcomes in women with Polycystic Ovary Syndrome (PCOS). Summary answer Among women with PCOS, African Americans, Hispanic and Asians are at an increased risk of certain adverse obstetrics outcomes, whereas Caucasians have fewer pregnancy complications. What is known already Polycystic ovarian syndrome is associated with an increased risk of pregnancy complications possibly due to the insulin resistance inherent in this syndrome. Variable ethnicities demonstrate different magnitudes of insulin resistance and in non-PCOS populations are known to be at modified pregnancy complication risks. Different ethnicities may have different phenotypes of PCOS, possibly further modifying outcomes. The role of ethnicity in women with PCOS and its effect on pregnancy complications has not been well studied. Study design, size, duration This retrospective population-based study utilized data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS), over 11 years from 2004 to 2014. The data are representative of 20% of admissions to US hospitals and geographically represent over 96% of the American population. Clinical modification ICD9-CM codes were used to identify women with PCOS and group them according to maternal ethnicity. In 2015 codes were changed to ICD-10 which are not comparable. Participants/materials, setting, methods All women with PCOS(n = 12782) were grouped according to maternal ethnicity: Caucasian(9107), African American(1098), Hispanic(1288), Asian(741), and other. Pregnancy, delivery, and neonatal outcomes were collected per group and compared to the rest. Chi-square tests were used to compare the baseline characteristics between the cohorts. Logistic regression analyses were conducted to explore associations between ethnicity and pregnancy outcomes through the estimation of odds ratio (OR) and 95% confidence intervals (CI) while controlling for confounding effects. Main results and the role of chance PCOS was found in 12,782 patients with included ethnicity results. Asian women had a higher prevalence of gestational diabetes(GDM) (aOR1.96, 95%CI 1.49-2.58, p &amp;lt; 0.001), chorioamnionitis (aOR3.41, 95%CI 2.12-5.47, p &amp;lt; 0.0001), operative vaginal delivery (aOR2.42, 95%CI 1.65-3.56, p &amp;lt; 0.001), postpartum hemorrhage(PPH) (aOR2.07, 95%CI 1.25-3.43, p = 0.004) and maternal infection (aOR2.84, 95%CI 1.80-4.49, p &amp;lt; 0.001). African Americans had a higher risk of pregnancy-induced hypertension (aOR1.38, 95% CI 1.06-1.80, p = 0.02), preeclampsia (aOR1.68, 95% CI 1.15-2.45, p = 0.007), preterm premature rupture of membrane (aOR2.75, 95%CI 1.58-4.78, p &amp;lt; 0.001), chorioamnionitis (aOR1.83, 95%CI 1.12-2.98, p = 0.016) and cesarean sections (aOR1.69, 95%CI 1.32-2.15, p &amp;lt; 0.001) and lower risk of operative vaginal delivery (aOR0.53, 95%CI 0.31-0.93, p = 0.03), spontaneous vaginal delivery (aOR0.67, 95%CI 0.52-0.85, p &amp;lt; 0.001), and maternal infection (aOR1.91, 95%CI 1.21-3.00, p = 0.005). The risk of GDM (aOR1.36, 95%CI 1.06-1.73, p &amp;lt; 0.014) and PPH (aOR1.58, 95%CI 1.01-2.47, p = 0.045) was increased among Hispanic patients. Caucasian patients were at lower risk of GDM(aOR0.67, 95%CI 0.57-0.79, p &amp;lt; 0.0001), chorioamnionitis (aOR0.39, 95%CI 0.28-0.55, p &amp;lt; 0.0001), casarean section (aOR0.83, 95%CI 0.73-0.95, p &amp;lt; 0.008), spontaneous vaginal deliveries (aOR1.25, 95% CI1.10-1.43, p &amp;lt; 0.001), PPH (aOR0.70, 95% CI0.50-0.98, p &amp;lt; 0.035), blood transfusion (aOR0.49, 95%CI 0.29-0.83, p &amp;lt; 0.007), maternal infection (aOR0.34, 95% CI 0.27-0.51, p &amp;lt; 0.0001) and small for gestational age infants (aOR0.64, 95%CI 0.44-0.93, p &amp;lt; 0.018). Rates of other pregnancy outcomes were similar for the groups. Limitations, reasons for caution This is a retrospective analysis utilizing an administrative database that relied on the accuracy and consistency of the individuals coding the data. There are known limitations to how accurately hospital coding is able to capture perinatal conditions and complications. Wider implications of the findings Our study demonstrated that among women with PCOS, specific ethnicities are at an increased risk of adverse obstetric outcomes. This underlines the importance of screening for certain pregnancy complications in PCOS women of African American, Hispanic, and Asian ethnicity. Studies should evaluate the role of insulin resistance in these outcomes. Trial registration number not applicable - This study used publicly accessible, anonymized data; therefore, according to articles 2.2, 2.4 of Tri-Council Policy Statement (2010), institutional review board approval was not required.

Family history of postpartum hemorrhage is a risk factor for postpartum hemorrhage after vaginal delivery: results from the French prospective multicenter Haemorrhages and Thromboembolic Venous Disease of the Postpartum cohort study

Postpartum hemorrhage (PPH) is a major component of perinatal morbidity and mortality affecting young women worldwide, and is still often unpredictable. Reducing the incidence of PPH is a major health issue, and identifying women at risk for PPH is a key element in preventing this complication. To estimate PPH prevalence after vaginal delivery and to identify PPH risk factors. Unselected pregnant women ≥ 16 years attending one of six maternity wards in Brittany (France) for vaginal birth after 15 weeks of gestation were recruited in this prospective multicenter cohort study between June 1, 2015 and January 31, 2019. PPH was defined as a blood loss ≥ 500 mL in the 24 hours following delivery. Independent risk factors for PPH were determined by logistic regression. Missing data were compensated by multiple imputation (MICE method). Among 16,382 included women, PPH prevalence was 5.37%. A first-degree family history of PPH (aOR = 1.63, 95%CI 1.24-2.14) and a personal transfusion history (aOR = 1.90, 95%CI 1.23-2.92) were significantly associated with PPH. The use of oxytocin during labor was also a risk factor for PPH (aOR = 1.24, 95%CI 1.06-1.44). Inversely, smoking during pregnancy and intrauterine growth restriction were associated with a reduced risk of PPH (aOR = 0.76, 95%CI 0.63-0.91, and 0.34, 95%CI 0.13-0.87, respectively). In addition to classical risk factors, this study identified PPH family history and personal transfusion history as new characteristics associated with PPH after vaginal delivery. The association of PPH with a family history of PPH suggests a hereditary hemorrhagic phenotype and calls for genetic studies. Identifying women at risk for PPH is a key element in being prepared for this complication.

Uterine atony prophylaxis with carbetocin versus oxytocin and the risk of major haemorrhage during caesarean section: A retrospective cohort study.

Carbetocin and oxytocin are commonly recommended agents for active management of the third stage of labour. Evidence is inconclusive whether either one more effectively reduces the occurrence of important postpartum haemorrhage outcomes at caesarean section. We examined whether carbetocin is associated with a lower risk of severe postpartum haemorrhage (blood loss ≥ 1000 ml) in comparison with oxytocin for the third stage of labour in women undergoing caesarean section. This was a retrospective cohort study among women undergoing scheduled or intrapartum caesarean section between 1 January 2010 and 2 July 2015 who received carbetocin or oxytocin for the third stage of labour. The primary outcome was severe postpartum haemorrhage. Secondary outcomes included blood transfusion, interventions, third stage complications and estimated blood loss. Outcomes were examined overall and by timing of birth, scheduled versus intrapartum, using propensity score-matched analysis. Among 21,027 eligible participants, 10,564 women who received carbetocin and 3836 women who received oxytocin at caesarean section were included in the analysis. Carbetocin was associated with a lower risk of severe postpartum haemorrhage overall (2.1% versus 3.3%; odds ratio, 0.62; 95% confidence interval 0.48 to 0.79; P < 0.001). This reduction was apparent irrespective of timing of birth. Secondary outcomes also favoured carbetocin over oxytocin. In this retrospective cohort study, the risk of severe postpartum haemorrhage associated with carbetocin was lower than that associated with oxytocin in women undergoing caesarean section. Randomised clinical trials are needed to further investigate these findings.

Baseline rotational thromboelastometry (ROTEM) values in a healthy, diverse obstetric population and parameter changes by pregnancy-induced comorbidities

Background Point-of-care testing provides a representation of the patient’s coagulability status during effective postpartum hemorrhage management. Baseline values of rotational thromboelastometry (ROTEM) have not yet been reported in a heterogeneous obstetric population. This study aimed to establish a baseline for a diverse population representative of the United States. The secondary aim was to evaluate the association of these hematologic parameters with comorbidities, race, and socioeconomic factors. Methods The study was a retrospective review of collected ROTEM values of women undergoing vaginal or cesarean delivery with a history of or at risk for postpartum hemorrhage. Patients were divided into healthy and comorbid groups. Exclusion criteria for both groups included active or recent bleeding, receipt of blood products or clot-enhancing factors, and liver disease. Mean values of ROTEM by race and comorbidities were included. Median values were reported for intrinsic pathway thromboelastometry (INTEM), extrinsic pathway thromboelastometry (EXTEM), and fibrin polymerization thromboelastometry (FIBTEM) amplitude at 10 minutes (A10) and 20 minutes (A20), coagulation time, clot formation time, and maximum clot firmness. Results A total of 681 records were reviewed; 485 met inclusion criteria, and 267 met healthy criteria. The mean (standard deviation) demographics for maternal age (years), body mass index (kg/m2), and gestational age (weeks) were 32.2 (5.7), 34 (7.3), and 35.4 (5), respectively. The median INTEM, EXTEM, and FIBTEM A10 were 63, 65, and 23 mm. The mean for INTEM, EXTEM, and FIBTEM A10 was increased for those who were Black or obese, whereas a decreased FIBTEM and EXTEM A10 was noted in those who were Asian or those who had the hemolysis, elevated liver enzymes, low platelet syndrome. Conclusions Our heterogeneous population presents ROTEM values within the interquartile range of those previously reported in European studies. Black race, obesity, and preeclampsia were associated with hypercoagulable profiles.

Incidence and risk factors for severe postpartum haemorrhage in women with anterior low-lying or praevia placenta and prior caesarean: prospective population-based study.

To assess the incidence and risk factors for severe postpartum haemorrhage (PPH) in women with an anterior low-lying or praevia placenta, prior caesarean and no prenatal suspicion of placenta accreta spectrum (PAS). Population-based study in 176 maternity units in France. All women with anterior low-lying (0-19 mm from the cervical internal os) or praevia placenta, diagnosed prospectively before birth, prior caesarean and no prenatal suspicion of PAS. Multivariable logistic regression to identify risk factors for severe PPH in the main population and after exclusion of women with PAS diagnosed only at birth. Severe PPH defined by a composite criterion either estimated blood loss of ≥1500 ml, transfusion of ≥4 or more units of packed red blood cells, embolisation or surgical treatment. Of the 520 114 women constituting the source population, 230 (0.44/1000 women; 95% confidence interval [CI] 0.38-0.50) met the inclusion criteria. Severe PPH rate was 24.8% (95% CI 19.2-30.4) overall, 27.5% (95% CI 21.8-33.3) in women with placenta praevia and 15.4% (95% CI 10.7-20.0) in women with low-lying placenta. PAS was diagnosed at birth in 22 women (9.9%; 95% CI 5.8-13.4), although previously unsuspected. After their exclusion, severe PPH incidence was 17.3% (95% CI 12.4-22.2). In multivariate analysis, the only factor associated with a higher severe PPH risk was placenta previa (aOR, 3.65; 95%CI, 1.20-15.8). Severe PPH is frequent among women with anterior low-lying or praevia placenta and prior caesarean, even after exclusion of women with PAS. The risk of severe PPH for those with praevia is nearly twice that with low-lying placenta.

Development of Clinical Risk-prediction Models for Uterine Atony Following Vaginal and Cesarean Delivery

(Int J Obstet Anesth. 2022;51:103550) As 2.5% of births in the United States are impacted by uterine atony, identifying high-risk women can promote timely treatment and subsequently minimize adverse outcomes. However, there is no current risk assessment model that solely focuses on the risk for uterine atony rather than the overall risk for postpartum hemorrhage (PPH). This retrospective study created and tested 2 risk prediction models for antepartum and intrapartum uterine atony.

Risk of Postpartum Hemorrhage is Associated With Ethnicity: A Cohort Study of 981,801 Births in England

(BJOG. 2022;129:1269–1277) Postpartum hemorrhage (PPH) is associated with increased risk of maternal morbidity, mortality, and postpartum depression. In the United States, United Kingdom, and beyond, maternal outcomes vary by ethnicity. In the United Kingdom, Black parturients have a higher risk of intensive care unit admission. This study aimed to investigate the association between the risk of PPH and ethnicity, and how socioeconomic background interacts with this association.

Real-time imaging as visual biofeedback in active second stage of labor among nulliparas: a randomized controlled trial

A prolonged second stage of labor increases the risk of severe perineal laceration, postpartum hemorrhage, operative delivery, and poor Apgar score. The second stage is longer in nulliparas. Maternal pushing during the second stage of labor is an important contributor to the involuntary expulsive force developed by uterine contraction to deliver the fetus. Preliminary data indicate that visual biofeedback during the active second stage hastens birth. This study aimed to evaluate if visual feedback focusing on the perineum reduced the length of the active second stage of labor in comparison with the control. A randomized controlled trial was conducted in the University Malaya Medical Centre from December 2021 to August 2022. Nulliparous women about to commence the active second stage, at term, with singleton gestation, reassuring fetal status, and no contraindication for vaginal delivery were randomized to live viewing of the maternal introitus (intervention) or maternal face (sham/placebo control) as visual biofeedback during their pushing. A video camera Bluetooth-linked to a tablet computer display screen was used; in the intervention arm, the camera was focused on the introitus, and in the control arm, on the maternal face. Participants were instructed to watch the display screen during their pushing. The primary outcomes were the intervention-to-delivery interval and maternal satisfaction with the pushing experience assessed using a 0-to-10 visual numerical rating scale. Secondary outcomes included mode of delivery, perineal injury, delivery blood loss, birthweight, umbilical cord arterial blood pH and base excess at birth, Apgar score at 1 and 5 minutes, and neonatal intensive care unit admission. Data were analyzed with the t test, Mann-Whitney U test, chi-square test, and Fisher exact test, as appropriate. A total of 230 women were randomized (115 to intervention and 115 to control arm). The active second stage duration (intervention-to-delivery interval) was a median (interquartile range) of 16 (11-23) and 17 (12-31) minutes (P=.289), and maternal satisfaction with the pushing experience was 9 (8-10) and 7 (6-7) (P<.001) for the intervention and control arm, respectively. Women randomized to the intervention arm were more likely to agree to recommend their management to a friend (88/115 [76.5%] vs 39/115 [33.9%]; relative risk, 2.26 [95% confidence interval, 1.72-2.97]; P<.001) and more likely to have less severe perineal injury (P=.018). Real-time viewing of the maternal introitus as visual biofeedback during pushing resulted in higher maternal satisfaction compared with the sham control of viewing the maternal face; however, the time to delivery was not significantly shortened.

Role of prophylactic use of tranexamic acid in reducing blood loss during caesarean section in a tertiary care hospital

Postpartum Haemorrhage (PPH) is an important cause of maternal death and severe maternal morbidity. Compared to vaginal delivery, women undergoing caesarean delivery incur the highest risk of PPH and haemorrhage related morbidity. Furthermore, evidence suggests that PPH during caesarean delivery is occurring more frequently. To study the effect of low dose intravenous tranexamic acid in reducing blood loss during Caesarean section.: This randomized control trial among 50 antenatal women aged &amp;#62;18 years undergoing Lower segment caesarean section in tertiary care centre. They were divided into Study group and control group. Study group received 1gm iv tranexamic acid and the Control group did not receive tranexamic acid. Data was entered in Microsoft Excel data sheet (MS-Excel) and analysed using commercially available SPSS 23 software package. MS Excel and MS word was used to obtain various types of graphs such as bar diagram. : Among the study population who underwent Lower section caesarean section in our study, we found that the requirement of additional oxytocin was nil with tranexamic acid group (p value&amp;#60;0.02). There were no side effects observed with the group administered tranexamic acid (p value&amp;#60;0.01). The difference in mean of bleeding from placental delivery to end of Caesarean Section, End of Caesarean Section to 2 hrs Postpartum was statistically significant (p value &amp;#60;0.05). The fall in Hb% between the two groups was significant, thereby showing the benefits of Tranexamic acid.: Tranexamic acid significantly reduces the amount of blood loss during and after lower segment caesarean section. It was not associated with any significant side effects and complications. It can be used effectively in all women undergoing caesarean section to reduce the postpartum Haemorrhage thereby reducing the maternal morbidity and mortality.

Tranexamic acid for the prevention of postpartum bleeding in women with anaemia: Statistical analysis plan for the WOMAN-2 trial: an international, randomised, placebo-controlled trial

Background: Postpartum haemorrhage (PPH) is responsible for over 50,000 maternal deaths every year. Most of these deaths are in low- and middle-income countries. Tranexamic acid (TXA) reduces bleeding by inhibiting the enzymatic breakdown of fibrin blood clots. TXA decreases surgical bleeding and reduces deaths from bleeding after traumatic injury. When given within three hours of birth, TXA reduces deaths from bleeding in women with PPH. However, for many women, treatment of PPH is too late to prevent death. World-wide, over one-third of pregnant women are anaemic and many are severely anaemic. These women have an increased risk of PPH and are more likely to die if PPH occurs. There is an urgent need to identify ways to prevent severe postpartum bleeding in anaemic women. The WOMAN-2 trial will quantify the effects of TXA on postpartum bleeding in women with anaemia. Results: This statistical analysis plan (version 1.0; dated 22 February 2023) has been written based on information in the WOMAN-2 Trial protocol version 2.0, dated 30 June 2022. The primary outcome of the WOMAN-2 trial is the proportion of women with a clinical diagnosis of primary PPH. Secondary outcomes are maternal blood loss and its consequences (estimated blood loss, haemoglobin, haemodynamic instability, blood transfusion, signs of shock, use of interventions to control bleeding); maternal health and wellbeing (fatigue, headache, dizziness, palpitations, breathlessness, exercise tolerance, ability to care for her baby, health related quality of life, breastfeeding); and other health outcomes (deaths, vascular occlusive events, organ dysfunction, sepsis, side effects, time spent in higher level facility, length of hospital stay, and status of the baby). Conclusions: WOMAN-2 will provide reliable evidence about the effects of TXA in women with anaemia. Registration: WOMAN-2 was prospectively registered at the International Standard Randomised Controlled Trials registry (ISRCTN62396133) on 07/12/2017 and ClinicalTrials.gov on 23/03/2018 (NCT03475342).

Efficacy of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control in patients with abnormally invasive placenta: a historical cohort study

BackgroundPatients with abnormally invasive placenta (AIP) are at high risk of massive postpartum hemorrhage. Resuscitative endovascular balloon occlusion of the aorta (REBOA), as an adjunct therapeutic strategy for hemostasis, offers the obstetrician an alternative for treating patients with AIP. This study aimed to evaluate the role of REBOA in hemorrhage control in patients with AIP.MethodsThis was a historical cohort study with prospectively collected data between January 2014 to July 2021 at a single tertiary center. According to delivery management, 364 singleton pregnant AIP patients desiring uterus preservation were separated into two groups. The study group (balloon group, n = 278) underwent REBOA during cesarean section, whereas the reference group (n = 86) did not undergo REBOA. Surgical details and maternal outcomes were collected. The primary outcome was estimated blood loss and the rate of uterine preservation.ResultsA total of 278 (76.4%) participants experienced REBOA during cesarean section. The patients in the balloon group had a smaller blood loss during cesarean Sect. (1370.5 [752.0] ml vs. 3536.8 [1383.2] ml; P < .001) and had their uterus salvaged more often (264 [95.0%] vs. 23 [26.7%]; P < .001). These patients were also less likely to be admitted to the intensive care unit after delivery (168 [60.4%] vs. 67 [77.9%]; P = .003) and had a shorter operating time (96.3 [37.6] min vs. 160.6 [45.5] min; P < .001). The rate of neonatal intensive care unit admission (176 [63.3%] vs. 52 [60.4%]; P = .70) and total maternal medical costs ($4925.4 [1740.7] vs. $5083.2 [1705.1]; P = .13) did not differ between the two groups.ConclusionsAs a robust hemorrhage-control technique, REBOA can reduce intraoperative hemorrhage in patients with AIP. The next step is identifying associated risk factors and defining REBOA inclusion criteria to identify the subgroups of AIP patients who may benefit more.