Risk Of PPH Research Articles

Pregnancy Outcomes with Intrahepatic Cholestasis

Introduction: ICP is a reversible rare disorder prevailing in 2% of pregnancies resulting in debilitating feto-maternal consequences. Maternal problems resolves soon after delivery but fetal complications result in multiple deteriorations. Present study was undertaken to assess the pregnancy outcomes with ICP on both mother and fetus. Methodology: A prospective study design was used and study was conducted in tertiary health care sector in department of obstetrics and gynecology for period of 2 years. 80 mothers with history of pruritus, aminotransferase levels > 30 IU/L and alkaline phosphatase > 300 IU/L were included in this study. Pregnancies with other liver disorders were excluded. Study was conducted after institutional approval. Data was analyzed using SPSS version 23.0 and descriptive statistics were used to display the data in the form of frequency and percentages. Results: ICP accounted for many adverse feto-maternal outcomes. Results show sleep disturbance in 68.75%, PROM in 73%, risk of PPH 10% and 75.5% births were through operative method attributable to ICP. ICP caused fetus distress in 20% cases, MSL in 23.75% of babies, preterm birth (25%) and LBW babies (18.75%), rate of NICU admission (18.75%) and still birth revealed in 2.5% cases in this study. Conclusion: Present study depict the ill effects of ICP on both mother and fetus. Maternal effects are reversible but fetal effect cause permanent impairment for rest of fetus life. There is need for vigilant monitoring of the pregnant women affected with ICP to avoid such painful events. Keywords: Pregnancy, Intrahepatic, Cholestasis, Outcomes.

C-reactive protein identifies patients at risk of postpancreatectomy hemorrhage

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

Frequency of Severe Postpartum Hemorrhage After Delivery Among Obese Pregnant Women

Objective: To determine the frequency of severe postpartum hemorrhage after delivery among obese pregnant women. Methods: This case series was carried out from 15th December 2015 to 15th October 2016 at Department of Obstetrics &amp; Gynaecology, Nishtar Hospital, Multan. A total of 505 obese pregnant women with gestational age 38–41 weeks and parity ≤ 3 undergone vaginal delivery or elective cesarean section were included. Women with history of hypertension, diabetes, renal disease and pre-eclampsia were excluded. In vaginal delivery women were given prostaglandin E2 vaginal gel 1 gm and the same dose repeated at six hourly intervals for maximum three doses under supervision of consultant. In patients undergone elective caesarean section, caesarean section was done by consultant gynecologist. After delivery, data was collected for severe postpartum hemorrhage. Results: Age range in this study was 25 to 35 years with mean age of 30.318 ± 2.71 years. Mean gestational age was 39.429 ±1.11 weeks and mean BMI was 28.289± 1.06 Kg/m2. Majority of the patients were of 25–30 years 268(53.1%). Parity of 2–3 was present in 69.3% women. Cesarean Section rate was 34.3% and vaginal delivery was 65.7%. Severe PPH was seen in 11.1% obese women. Conclusion: Obese women should be regarded as high risk for PPH. Keywords: Obesity, Mode of delivery, Severe postpartum hemorrhage

Risk of postpartum haemorrhage is associated with ethnicity: A cohort study of 981801 births in England.

To determine the association between ethnic group and risk of postpartum haemorrhage in women giving birth. Cohort study. Maternity units in England. A total of 981801 records of births between 1 April 2015 and 31 March 2017 in a national clinical database. Multivariable logistic regression analyses with multiple imputation to account for missing data and robust standard errors to account for clustering within hospitals. Postpartum haemorrhage of ≥1500ml (PPH). A total of 28268 (2.9%) births were complicated by PPH. Risks were higher in women from black (3.9%) and other (3.5%) ethnic backgrounds. Following adjustment for maternal and fetal characteristics, and care at birth, there was evidence of an increased risk of PPH in women from all ethnic minority groups, with the largest increase seen in black women (adjusted OR1.54, 95%CI 1.45-1.63). The increase in risk was robust to sensitivity analyses, which included changing the outcome to PPH of ≥3000ml. In England, women from ethnic minority backgrounds have an increased risk of PPH, when maternal, fetal and birth characteristics are taken into account. Factors contributing to this increased risk need further investigation. Perinatal care for women from ethnic minority backgrounds should focus on preventative measures to optimise maternal outcomes. Women with an ethnic minority background giving birth in England have an increased risk of postpartum haemorrhage, even when characteristics of the mother, the baby and the care received are taken into account.

Improving postpartum hemorrhage risk prediction using longitudinal electronic medical records.

ObjectivePostpartum hemorrhage (PPH) remains a leading cause of preventable maternal mortality in the United States. We sought to develop a novel risk assessment tool and compare its accuracy to tools used in current practice.Materials and MethodsWe used a PPH digital phenotype that we developed and validated previously to identify 6639 PPH deliveries from our delivery cohort (N = 70 948). Using a vast array of known and potential risk factors extracted from electronic medical records available prior to delivery, we trained a gradient boosting model in a subset of our cohort. In a held-out test sample, we compared performance of our model with 3 clinical risk-assessment tools and 1 previously published model.ResultsOur 24-feature model achieved an area under the receiver-operating characteristic curve (AUROC) of 0.71 (95% confidence interval [CI], 0.69-0.72), higher than all other tools (research-based AUROC, 0.67 [95% CI, 0.66-0.69]; clinical AUROCs, 0.55 [95% CI, 0.54-0.56] to 0.61 [95% CI, 0.59-0.62]). Five features were novel, including red blood cell indices and infection markers measured upon admission. Additionally, we identified inflection points for vital signs and labs where risk rose substantially. Most notably, patients with median intrapartum systolic blood pressure above 132 mm Hg had an 11% (95% CI, 8%-13%) median increase in relative risk for PPH.ConclusionsWe developed a novel approach for predicting PPH and identified clinical feature thresholds that can guide intrapartum monitoring for PPH risk. These results suggest that our model is an excellent candidate for prospective evaluation and could ultimately reduce PPH morbidity and mortality through early detection and prevention.

Uterine Leiomyoma and Pregnancy Outcome: An Experience at Tertiary Care Setup

Objective: To determine the impact of leiomyoma in pregnant women a tertiary care set up in Hyderabad. Methods: This prospective observational study conducted at OPD of Gynecology unit-III, Liaquat University of Medical and Health Science Hyderabad, from June 2018 to December 2018. A total of 18,402 pregnant women of age 20-45 years were attended, out of which 195 had leiomyoma and they were asked to take part in study. Data regarding demographic characteristics including complications during pregnancy, and indications of caesarean section was collected via study proforma. Results: Total 186 out of 195 females were studied, their mean age was 31.23+3.12 years, average gestational age was 33.12+3.15 weeks and average size of Leiomyoma was 3.12+2.15cm. The most common complications were PPH among 28.49% of cases, blood transfusion was required in 39.25% of the cases, miscarriage occurred in 6.45% of the cases, cord prolapse was seen in 24.3% cases, placental abruption in 5.91% cases, placenta previa in 11.32% cases and retained placenta was observed among 1.61% of the cases. Preterm labour occurred in 5.38% of the cases and IUGR was seen in 10.22% of the cases. Out of all cases, 10 females underwent preterm delivery, while 12 underwent fetus delivery before 24 weeks (miscarriage). Among all term pregnancies, 78.66% underwent C-Section due to failure in progress, cord prolapsed, fibroid in lower segment, breech presentation and low-lying placenta. Conclusion: Fibroid complicates pregnancy itself and also the outcome. Rural area dwelling women are at more risk, which include increase in caesarean section and a multifold increased risk of PPH and associated hysterectomy in these cases. Keywords: Leiomyoma, Uterine Fibroids, Pregnancy, complications.

Barriers inhibiting effective detection and management of postpartum hemorrhage during facility-based births in Madagascar: findings from a qualitative study using a behavioral science lens

BackgroundPostpartum hemorrhage (PPH) is the leading cause of maternal mortality in low-income countries, and is the most common direct cause of maternal deaths in Madagascar. Studies in Madagascar and other low-income countries observe low provider adherence to recommended practices for PPH prevention and treatment. Our study addresses gaps in the literature by applying a behavioral science lens to identify barriers inhibiting facility-based providers’ consistent following of PPH best practices in Madagascar.MethodsIn June 2019, we undertook a cross-sectional qualitative research study in peri-urban and rural areas of the Vatovavy-Fitovinany region of Madagascar. We conducted 47 in-depth interviews in 19 facilities and five communities, with facility-based healthcare providers, postpartum women, medical supervisors, community health volunteers, and traditional birth attendants, and conducted thematic analysis of the transcripts.ResultsWe identified seven key behavioral insights representing a range of factors that may contribute to delays in appropriate PPH management in these settings. Findings suggest providers’ perceived low risk of PPH may influence their compliance with best practices, subconsciously or explicitly, and lead them to undervalue the importance of PPH prevention and monitoring measures. Providers lack clear feedback on specific components of their performance, which ultimately inhibits continuous improvement of compliance with best practices. Providers demonstrate great resourcefulness while operating in a challenging context with limited equipment, supplies, and support; however, overcoming these challenges remains their foremost concern. This response to chronic scarcity is cognitively taxing and may ultimately affect clinical decision-making.ConclusionsOur study reveals how perception of low risk of PPH, limited feedback on compliance with best practices and consequences of current practices, and a context of scarcity may negatively affect provider decision-making and clinical practices. Behaviorally informed interventions, designed for specific contexts that care providers operate in, can help improve quality of care and health outcomes for women in labor and childbirth.

The Efficacy of Intravenous Tranexamic Acid in Reduction of Blood Loss in Women at High Risk of Postpartum Hemorrhage

Abstract Background Postpartum hemorrhage (PPH) is the leading cause of maternal mortality. All women who carry a pregnancy beyond 20 weeks’ gestation are at risk for PPH and its sequelae. Although maternal mortality rates have declined greatly in the developed world, PPH remains a leading cause of maternal mortality elsewhere. Aim of the Work To assess the efficacy and safety intravenous tranexamic acid in reduction of amount of blood loss in high risk women who deliver by cesarean section or vaginal delivery in postpartum period. Patients and Methods This prospective double blind randomized controlled clinical trial study was conducted on 200 patients planned for LSCS or vaginal delivery at Gestational Age ≥ 34 Weeks at Ain Shams University Maternity Hospital. Recruitment of data begun once the protocol was approved by research and ethical committee of the department of obstetrics and gynecology. Results No significant difference between Study and Control groups as regards age (p = 0.508), no significant difference between Study and Control groups as regards Gestational age (p = 0.447),total blood loss (p &amp;lt; 0.001) was significantly lower in study group than control group, Vaginal pads in the 1st 24 hours post-partum was significantly less soaked in study group than control group (p &amp;lt; 0.001). no significant difference between Study and Control groups as regards Preoperative Hemoglobin, Postoperative Hemoglobin was significantly higher in study group than control group (p &amp;lt; 0.001), Reduction in Hemoglobin was significantly less in study group than control group (p &amp;lt; 0.001), no significant difference between Study and Control groups as regards Preoperative Hematocrite, Postoperative Hematocrit was significantly higher in study group than control group (p &amp;lt; 0.001), Reduction in Hematocrite was significantly less in study group than control group (p &amp;lt; 0.001).Need to iron replacement or blood transfusion was significantly less frequent in study group than control group (p = 0.24). Conclusion The use of tranexamic acid prior to cesarean section or vaginal delivery is effective as a prophylaxis against post-partum hemorrhage as shown by the results of this study. It can significantly reduce blood loss during and after cesarean section or vaginal delivery.

Carbetocin Versus Oxytocin for Prevention of Postcesarean Hemorrhage in Pregnancy With High Risk for PPH

Carbetocin Versus Oxytocin for Prevention of Postcesarean Hemorrhage in Pregnancy With High Risk for PPH

Incidence and recurrence rate of postpartum hemorrhage and manual removal of the placenta: A longitudinal linked national cohort study in The Netherlands

ObjectiveWe studied the incidence of postpartum hemorrhage and manual removal of the placenta and their recurrence rate in a subsequent pregnancy. We hypothesized that the risk of recurrence was dependent on the gestational age at first birth and whether or not a manual removal of the placenta was necessary. Knowledge on this subject can potentially improve counselling, prevention and management in obstetric care for women at risk for PPH or identify women at low risk for recurrence. Study designThis was a retrospective national cohort study consisting of women with two consecutive singleton deliveries between 1999 and 2009 in the Netherlands.A longitudinal linked national cohort with information on subsequent singleton deliveries in the Netherlands was used. Main outcome measures were: postpartum hemorrhage (defined as ≥1000 mL after vaginal delivery or Caesarean section) and manual removal of the placenta. We calculated incidence and recurrence rates of postpartum hemorrhage and manual removal of the placenta for all women and stratified by gestational age. ResultsAfter application of in- and exclusion criteria 359 737 women were studied. A total of 5.4% women experienced postpartum hemorrhage in the first pregnancy and 2.7% of women had a manual removal of the placenta. The risk of postpartum hemorrhage in a subsequent pregnancy was significantly higher in women with a history of postpartum hemorrhage compared to women without a previous postpartum hemorrhage (18% vs 3.9%, adjusted odds ratio 4.5; 95% confidence interval 4.3–4.7). The risk of manual removal of the placenta in the second pregnancy was only 1.4% in women without a previous manual removal compared to 17% of women with a previous manual removal of the placenta. Women with a manual removal of the placenta in the first pregnancy between 32 and 37 weeks were most at risk for recurrence (adjusted odds ratio 8.9; 95% confidence interval 7.2–11). ConclusionWomen with a previous delivery complicated by postpartum hemorrhage or manual removal of the placenta are at increased risk for recurrence. The magnitude of this risk is highest in women with deliveries beyond 32 weeks in the first pregnancy.

Third stage of labour management practices: A secondary analysis of a prospective cohort study of Australian women and their associated outcomes

ObjectiveThis study aimed to describe practices used during the third stage of labour in a cohort of Australian women and explore clinical outcomes such as postpartum hemorrhage and clinical decision making associated with these practices. DesignThis study employed a prospective cohort design and reports a secondary analysis of a primary study that examined factors associated with PPH; specifically relating to third stage management practices. SettingIt was conducted in three linked sites, in Queensland, Australia: a regional hospital, rural hospital and a private-practising midwifery service. Data collected: type of third stage management chosen by the care provider, and why; use of uterotonic medications (including administration timing); determination of cord-clamp timing and why; and, use of controlled cord traction. ParticipantsConvenience sample of women birthing vaginally between October 2015 and April 2016 (n = 522). FindingsActive management was the most common self-reported third stage management practice across these birth settings despite local health service guidelines advocating modified active management for all births. Modified active third stage was associated with least risk of PPH; however considerable variation in modified active practices was evident, particularly relating to cord clamp timing and oxytocic administration. Professional discipline, birth setting and complications during labour were significantly associated with differences in third stage management. Midwives were more likely to engage in expectant management than obstetricians; while active management was more commonly used in the rural setting and when complications during labour were experienced. Key conclusionsModified active management was not associated with an increased risk of PPH consistent with contemporary evidence. However, a considerable proportion of providers may not be following evidence-based guidelines supporting modified active management which may be attributed to uncertainty around third stage practice definitions which has implications for education, practice, and policy. Implications for practiceDespite evidence-based guidelines, differences exist within modified active management including cord clamp timing, uterotonic administration and use of controlled cord traction. Modified active management was not associated with an increase in PPH.

Uterotonic drugs to prevent postpartum haemorrhage: a network meta-analysis.

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Prophylactic uterotonic drugs can reduce blood loss and are routinely recommended. There are several uterotonic drugs for preventing PPH, but it is still debatable which drug or combination of drugs is the most effective. To identify the most effective and cost-effective uterotonic drug(s) to prevent PPH, and generate a ranking according to their effectiveness and side-effect profile. The Cochrane Pregnancy and Childbirth's Trials Register (1 June 2015), ClinicalTrials.gov and the World Health Organization (WHO)'s International Clinical Trials Registry Platform (ICTRP) were searched for unpublished trial reports (30 June 2015). In addition, reference lists of retrieved studies (updated October 2017) were searched for randomised trials evaluating uterotonic drugs for preventing PPH. The study estimated relative effects and rankings for preventing PPH, defined as blood loss of ≥ 500 ml and ≥ 1000 ml. Pairwise meta-analyses and network meta-analysis were performed to determine the relative effects and rankings of all available drugs and combinations thereof [ergometrine, misoprostol (Cytotec®; Pfizer Inc., New York, NY, USA), misoprostol plus oxytocin (Syntocinon®; Novartis International AG, Basel, Switzerland), carbetocin (Pabal®; Ferring Pharmaceuticals, Saint-Prex, Switzerland), ergometrine plus oxytocin (Syntometrine®; Alliance Pharma plc, Chippenham, UK), oxytocin, and a placebo or no treatment]. Primary outcomes were stratified according to the mode of birth, prior risk of PPH, health-care setting, drug dosage, regimen and route of drug administration. Sensitivity analyses were performed according to study quality and funding source, among others. A model-based economic evaluation compared the relative cost-effectiveness separately for vaginal births and caesareans with or without including side effects. From 137 randomised trials and 87,466 women, ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin were found to reduce the risk of PPH blood loss of ≥ 500 ml compared with the standard drug, oxytocin [ergometrine plus oxytocin: risk ratio (RR) 0.69, 95% confidence interval (CI) 0.57 to 0.83; carbetocin: RR 0.72, 95% CI 0.52 to 1.00; misoprostol plus oxytocin: RR 0.73, 95% CI 0.6 to 0.9]. Each of these three strategies had 100% cumulative probability of being ranked first, second or third most effective. Oxytocin was ranked fourth, with an almost 0% cumulative probability of being ranked in the top three. Similar rankings were noted for the reduction of PPH blood loss of ≥ 1000 ml (ergometrine plus oxytocin: RR 0.77, 95% CI 0.61 to 0.95; carbetocin: RR 0.70, 95% CI 0.38 to 1.28; misoprostol plus oxytocin: RR 0.90, 95% CI 0.72 to 1.14), and most secondary outcomes. Ergometrine plus oxytocin and misoprostol plus oxytocin had the poorest ranking for side effects. Carbetocin had a favourable side-effect profile, which was similar to oxytocin. However, the analysis was restricted to high-quality studies, carbetocin lost its ranking and was comparable to oxytocin. The relative cost-effectiveness of the alternative strategies is inconclusive, and the results are affected by both the uncertainty and inconsistency in the data reported on adverse events. For vaginal delivery, when assuming no adverse events, ergometrine plus oxytocin is less costly and more effective than all strategies except carbetocin. The strategy of carbetocin is both more effective and more costly than all other strategies. When taking adverse events into consideration, all prevention strategies, except oxytocin, are more costly and less effective than carbetocin. For delivery by caesarean section, with and without adverse events, the relative cost-effectiveness is different, again because of the uncertainty in the available data. There was considerable uncertainty in findings within the planned subgroup analyses, and subgroup effects cannot be ruled out. Ergometrine plus oxytocin, carbetocin and misoprostol plus oxytocin are more effective uterotonic drug strategies for preventing PPH than the current standard, oxytocin. Ergometrine plus oxytocin and misoprostol plus oxytocin cause significant side effects. Carbetocin has a favourable side-effect profile, which was similar to oxytocin. However, most carbetocin trials are small and of poor quality. There is a need for a large high-quality trial comparing carbetocin with oxytocin; such a trial is currently being conducted by the WHO. The relative cost-effectiveness is inconclusive, and results are affected by uncertainty and inconsistency in adverse events data. This study is registered as PROSPERO CRD42015020005; Cochrane Pregnancy and Childbirth Group (substudy) reference number 0871; PROSPERO-Cochrane (substudy) reference number CRD42015026568; and sponsor reference number ERN_13-1414 (University of Birmingham, Birmingham, UK). Funding for this study was provided by the National Institute for Health Research Health Technology Assessment programme in a research award to the University of Birmingham and supported by the UK charity Ammalife (UK-registered charity 1120236). The funders of the study had no role in study design, data collection, data synthesis, interpretation or writing of the report.

Effect of Grand Multiparity on Pregnancy Outcomes in Women Under 35 Years of Age: a Comparative Study

Introduction:It is known for many years, that grand multiparity is associated with poor pregnancy outcome with or without considering increasing maternal age.Aim:To examine the impact of grand multiparity on pregnancy outcome in young women aged 18–34 years (Young grand multiparas).Material and Methods:A prospective comparative cross-sectional study conducted at Omdurman Maternity Hospital, Sudan from January to September 2018. A standard questionnaire was used to gather data on pregnancy outcome in the low-risk group, grand multiparas age < 35 years and grand multiparas age ≥ 35 years. The association between variables was tested with Chi-square test.Results:Young grand multiparas have a significant risk of PPH and increased length of hospital stay => 3 days and babies born to young grand multiparas women were more likely of low birth weight and have a higher rate of admission to NICU. Young grand multiparas were similar in their maternal and fetal complication to low-risk pregnancies and significantly less in several complications when compared to older grand multiparas women.Conclusion:Young grand multiparas are less likely to develop several pregnancy complications compared to older grand multiparas women. The occurrences of intra-partum complications match that in low-risk pregnancy.

Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis.

Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis.

Tranexamic acid for the prevention of postpartum bleeding in women with anaemia: study protocol for an international, randomised, double-blind, placebo-controlled trial

BackgroundPostpartum haemorrhage (PPH) is responsible for about 100,000 maternal deaths every year, most of which occur in low- and middle-income countries. Tranexamic acid (TXA) reduces bleeding by inhibiting the enzymatic breakdown of fibrin blood clots. TXA decreases blood loss in surgery and reduces death due to bleeding after trauma. When given within 3 h of birth, TXA reduces deaths due to bleeding in women with PPH. However, for many women, treatment of PPH is too late to prevent death. Over one third of pregnant women in the world are anaemic and many are severely anaemic. These women have an increased risk of PPH and suffer more severe outcomes if PPH occurs. There is an urgent need to identify a safe and effective way to reduce postpartum bleeding in anaemic women.Methods/designThe WOMAN-2 trial is an international, multicentre, randomised, double-blind, placebo-controlled trial to quantify the effects of TXA on postpartum bleeding in women with moderate or severe anaemia. Ten thousand women with moderate or severe anaemia who have given birth vaginally will be randomised to receive 1 g of TXA or matching placebo by intravenous injection immediately (within 15 min) after the umbilical cord is cut or clamped. The primary outcome is the proportion of women with a clinical diagnosis of primary PPH. The cause of PPH will be described. Data on maternal health and wellbeing, maternal blood loss and its consequences, and other health outcomes will be collected as secondary outcomes. The main analyses will be on an ‘intention-to-treat’ basis, irrespective of whether the allocated treatment was received. Results will be presented as appropriate effect estimates with a measure of precision (95% confidence intervals). Subgroup analyses will be based on the severity of anaemia (moderate versus severe) and type of labour (induced or augmented versus spontaneous). A study with 10,000 patients will have over 90% power to detect a 25% relative reduction from 10 to 7.5% in PPH. The trial will be conducted in hospitals in Africa and Asia.DiscussionThe WOMAN-2 trial should provide reliable evidence for the effects of TXA for preventing postpartum bleeding in women with anaemia.Trial registrationISRCTN, ISRCTN62396133. Registered on 7 December 2017;ClincalTrials.gov, ID: NCT03475342. Registered on 23 March 2018.

The effect of carbetocin compared to misoprostol in management of the third stage of labor and prevention of postpartum hemorrhage: a systematic review

BackgroundPostpartum hemorrhage (PPH) and the amount of blood loss are directly related to management of the third stage of labor. No previous report has compared the effects of carbetocin to those of misoprostol. The aim of this systematic review was to compare the effects of carbetocin to those of misoprostol for management of the third stage of labor and for the prevention of PPH.MethodsWe searched the Cochrane Library (Central), Web of Science, Scopus, Science Direct, Ovid, clinicaltrial.gov, and PubMed databases on December 28, 2017. Data extraction and risk of bias assessment were performed by 2 of the authors independently. Individual and pooled incidences were calculated for the included studies, with 95% confidence intervals (CIs). We used a fixed model for forest plots without heterogeneity and a random effect model for those with heterogeneity.ResultsOur search identified 117 studies; however, 29 studies were duplicate. Of the 88 non-duplicate studies, 5 met the inclusion criteria. Of these five studies, two are currently underway. Hence, three studies were finally included in our meta-analysis. The pooled estimate of the impact of carbetocin on PPH (500–1000 ml) was (OR 0.27, 95% CI 0.14–0.50). Carbetocin significantly reduced the need for additional uterotonics (RR 0.28, 95% CI 0.15 to 0.49). Reduction in the hemoglobin level and blood loss during the third stage of labor was significantly lower in women who received carbetocin than in those who received misoprostol. The length of the third stage of labor was significantly lower in women who received carbetocin than in those who received misoprostol. The incidence of side effects, such as heat sensation, metallic taste, fever, and shivering, were significantly lower in women who received carbetocin than in those who received misoprostol.ConclusionAlthough this review showed that carbetocin is effective for decreasing PPH, blood loss, the length of the third stage of labor, and the need for additional uterotonics, this conclusion should be considered with caution. Because assessment of PPH is a subjective issue and it is uncertain whether outcomes were assessed blindly in respect to treatment. We recommend future research to verify our findings. Also clinicians may like to consider use of carbetocin for women with low risk for PPH.

Per-Partum Anaemia and Missed Post-Partum Haemorrhage in Low Resources Settings

Background: Post-partum haemorrhage is the leading cause of maternal death throughout the world, and anaemia is one of its indirect causes. Anaemia during labour increases the risk of PPH and may lead to maternal mortality even after moderate PPH. Undiagnosed PPH and post-partum anaemia increases the risk of late maternal death in the community. The aim of this study was to assess the prevalence of anaemia on admission for labour, the occult early post-partum haemorrhage and the magnitude of post-partum anaemia in a low resource setting. Methods: This was a longitudinal study. We included pregnant women in labour. Haemoglobin concentration was measured on admission (H0), then 24 hours (H24) and 48 (H48) hours later. The post-partum blood loss was estimated by delta haemoglobin, using the criteria of M. Driessen et al. Results: We recruited 245 pregnant women. The mean age was 27.0 ± 6.0 years. The mean hemoglobin concentration was 11.7 ± 1.9 g/dl, the frequency of anaemia was 30.6% and was related to ethnicity (P = 0.042) gestational age (p < 0.001) marital status (p = 0.014) and the inter pregnancy time space (p = 0.001). Twenty-two-point two percent had post-partum haemorrhage among which 40% were undiagnosed. The mean blood loss was 375 ml and post-partum anaemia rate was 44.5%. Conclusion: Anaemia on admission was related to socio-demographic characteristics. The frequencies of anaemia during labour, missed PPH and undiagnosed post-partum anaemia were high. Haemoglobin concentration on admission for labour and after delivery, reliable method to assess PPH should be mandatory, to better identify per and post-partum anemia, and the management of PPH, in low income environments.

Lack of controlled studies investigating the risk of postpartum haemorrhage in cesarean delivery after prior use of oxytocin: a scoping review

BackgroundPostpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental and clinical studies indicate that prolonged oxytocin exposure in the first or second stage of labour may be associated with impaired uterine contractility and an increased risk of atonic PPH. Therefore, particularly labouring women requiring cesarean delivery constitute a subset of patients that may exhibit an unpredictable response to oxytocin. We mapped the evidence for comparative studies investigating the hypothesis whether the risk for PPH is increased in women requiring cesarean section after induction or augmentation of labour.MethodsWe performed a systematic literature search for clinical trials in Medline, Embase, Web of Science, and the Cochrane Library (May 2016). Additionally we searched for ongoing or unpublished trials in clinicaltrials.gov and the WHO registry platform. We identified a total of 36 controlled trials investigating the exogenous use of oxytocin in cesarean section. Data were extracted for study key characteristics and the current literature literature was described narratively.ResultsOur evidence map shows that the majority of studies investigating the outcome PPH focused on prophylactic oxytocin use compared to other uterotonic agents in the third stage of labour. Only 2 dose-response studies investigated the required oxytocin dose to prevent uterine atony after cesarean delivery for labour arrest. These studies support the hypotheses that labouring women exposed to exogenous oxytocin require a higher oxytocin dose after delivery than non-labouring women to prevent uterine atony after cesarean section. However, the study findings are flawed by limitations of the study design as well as the outcome selection. No clinical trial was identified that directly compared exogenous oxytocin versus no oxytocin application before intrapartum cesarean delivery.ConclusionDespite some evidence from dose-response studies that the use of oxytocin may increase the risk for PPH in intrapartum cesarean delivery, current research has not investigated the prepartal application of oxytocin in well controlled clinical trials. It was striking that most studies on exogenous oxytocin are focused on PPH prophylaxis in the third stage of labour without differing between the indications of cesarean section and hence the prepartal oxytocin status.

Adverse obstetric outcomes in pregnant women with uterine fibroids in China: A multicenter survey involving 112,403 deliveries.

ObjectiveTo estimate the association between uterine fibroids and adverse obstetric outcomes.MethodsThis was a retrospective cross-sectional study of 112,403 deliveries from 14 provinces and 39 different hospitals in 2011 in mainland China. We compared pregnancy outcomes in women with and without uterine fibroids who underwent detailed second trimester obstetric ultrasonography during 18 to 22 weeks. Obstetric outcomes include cesarean delivery, breech presentation, preterm delivery, placenta previa, placental abruption, premature rupture of membranes and neonatal birthweight. Univariate analyses and multivariate logistic regression analyses were performed.ResultsOf 112,403 women who underwent routine obstetric survey, 3,012 (2.68%) women were identified with at least 1 fibroid. By univariate and multivariate analyses, the presence of uterine fibroids was significantly associated with cesarean delivery (Adjusted odds radio [AOR] 1.8, 95% confidence interval [CI] 1.7–2.0), breech presentation (AOR 1.3, 95% CI 1.2–1.5) and postpartum hemorrhage (AOR 1.2, 95% CI 1.1–1.4). The size of uterine fibroids and location in uterus had important effect on the mode of delivery. The rates of PPH were significantly higher with increasing size of the uterine fibroid (P<0.001). And the location of fibroid (intramural, submucosal or subserosal) also have a statistically significant impact on the risk of PPH (5.6% [subserosal] vs 4.7% [submucosal] vs 8.6% [intramural]).ConclusionPregnant women with uterine fibroids are at increased risk for cesarean delivery, breech presentation and postpartum hemorrhage. And different characteristics of uterine fibroids affect obstetric outcomes through different ways. Such detailed information may be useful in risk-stratifying pregnant women with fibroids.

Protocol for a pilot, randomised, double-blinded, placebo-controlled trial of prophylactic use of tranexamic acid for preventing postpartum haemorrhage (TAPPH-1)

IntroductionPostpartum haemorrhage (PPH) is the leading cause of maternal morbidity and mortality worldwide. Despite the availability of multiple uterotonic agents, the incidence of PPH continues to rise. Tranexamic acid (TXA)...