Risk Of Severe Postpartum Haemorrhage Research Articles

Cephalad-caudad vs transverse blunt expansion of low transverse hysterotomy during caesarean section and risk of severe postpartum haemorrhage: A prospective comparative study

BackgroundThe global prevalence of caesarean section as a delivery method is increasing worldwide. However, there is notable divergence among countries in their national guidelines regarding the optimal technique for blunt expansion hysterotomy of the low transverse uterine incision during caesarean section (cephalad-caudad or transverse). AimTo compare the risk of severe postpartum haemorrhage (PPH) between cephalad-caudad and transverse blunt expansion hysterotomy during caesarean section. MethodsThis prospective comparative observational study was conducted in a university maternity hospital. All women who gave birth to one infant by caesarean section after 30 weeks of gestation between November 2020 and November 2021 were included in this study. The exclusion criteria were a coagulation disorder, the presence of placenta previa, multiple pregnancies, or enlargement of the hysterotomy with scissors. The choice between cephalad-caudad or transverse blunt expansion of the low transverse hysterotomy was left to the surgeon’s discretion. The primary outcome measure was severe PPH, defined as estimated blood loss ≥ 1000 ml. Univariate and multivariate analyses were employed to assess the risk of severe PPH associated with the two methods of enlarging the low transverse hysterotomy. ResultsThe study included 850 women, of whom 404 underwent transverse blunt expansion and 446 underwent cephalad-caudad blunt expansion. The overall incidence of severe PPH was 13.3 %. Univariate analysis revealed no significant difference in the frequency of severe PPH between the cephalad-caudad and transverse blunt expansion groups (13.9 % vs 12.6 %; p = 0.61). However, the use of additional surgical sutures (mainly additional haemostatic stitches) was less common with cephalad-caudad blunt expansion (26.7 % vs 36.9 %; p < 0.05). Multivariate analysis showed no significant difference in risk between the two techniques (odds ratio 1.17, 95 % confidence interval 0.77–1.78). ConclusionNo significant difference in the risk of severe PPH was found between cephalad-caudad and transverse blunt expansion of the low transverse hysterotomy during caesarean section.

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.

Interactions between ultrasonographic cervical length and placenta accreta spectrum on severe postpartum hemorrhage in women with placenta previa.

To explore the interactions between cervical length (CL) and placenta accreta spectrum (PAS) on severe postpartum hemorrhage (SPPH) in patients with placenta previa. A retrospective case-control study was conducted at four medical centers in China, and 588 patients with placenta previa were included. The logistic regression analysis and restricted cubic splines (RCS) were used to evaluate the association between CL and SPPH. Furthermore, the joint effect of CL and PAS on SPPH was assessed, and the additive and multiplicative interactions were calculated. After adjusting for potential confounders, the negative linear dose-response relationship was confirmed by RCS, and the change of odds ratio (OR) was more significant when CL was 2.5cm or less. The risk of SPPH was significantly higher when CL of 2.5cm or less co-existed with placenta increta/percreta than when CL of 2.5cm less, or placenta increta/percreta existed alone (adjusted OR [aOR]CL ≤2.5cm&placenta accreta/non-PAS 3.40, 95% confidence interval [CI] 1.37-8.45; aORplacenta increta/percreta&CL >2.5cm 4.75, 95% CI 3.03-7.47; aORCL ≤2.5cm&placenta increta/percreta 14.51, 95% CI 6.08-34.64), and there might be additive interaction between CL and placenta increta/percreta on SPPH (attributable proportion due to interaction 50.7%, 95% CI 6.1%-95.3%). If CL was routinely performed during PAS evaluation, the increased OR of short CL and PAS could allow better patient preparation through counseling.

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

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

IMPACT OF VITAMIN D DEFICIENCY DURING PREGNANCY

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

Development and validation of a predictive model for severe postpartum hemorrhage in women undergoing vaginal delivery: A retrospective cohort study.

To develop a predictive tool to accurately screen women at high risk of severe postpartum hemorrhage (SPPH) undergoing vaginal delivery. We analyzed 28150mothers who underwent vaginal delivery after 28weeks of pregnancy in the Third Affiliated Hospital of Guangzhou Medical University from January 2015 to August 2019. Two-thirds of the cohort were randomly allocated to a training set (n=18766) and the rest to a validation set (n=9384). In the training set, we built a radiomic nomogram based on multivariate logistic analysis, and calibration and C-index were evaluated. The performance of the validated nomogram was then tested in the validation cohort. Independent risk factors for SPPH in women undergoing vaginal delivery were previous cesarean section, history of PPH, in vitro fertilization, anemia, intrauterine death, prolonged labor, low-lying placenta, placental abruption, placenta accreta spectrum, and macrosomia. Good calibration was observed for the probability of SPPH in the validation cohort, and the C-index of the nomogram for the prediction of SPPH was 0.861 (95% confidence interval 0.820-0.902). This model would be a useful tool to accurately screen for women at high-risk of SPPH undergoing vaginal delivery. It would be expected to be an effective tool to guide clinical practice and further reduce maternal mortality.

Glanzmann’s Thrombasthenia in the Parturient Undergoing Cesarean Delivery- A Case Report and Discussion of Clinical Consideration

Glanzmann thrombasthenia (GT) is a rare hemorrhagic disorder characterized by the absence of IIb-IIIa platelet glycoprotein (GPIIbIIIa) on the platelet surface. Many GT patients experience recurrent bleeding and require frequent platelet transfusion. Therefore, they are at risk for alloimmunization against platelet glycoprotein or Human leucocyte antigen (HLA) epitopes resulting in platelet refractoriness and therapeutic failure. We report a unique case of GT in pregnancy at risk for severe postpartum hemorrhage due to anti-GP IIb/IIIa and anti-HLA antibodies and the use of pro-hemostatic agents to optimize outcomes. A multidisciplinary approach is essential to achieving the best possible outcomes for these patients.

Comparative study of changes in maternal and perinatal morbidity inequalities among migrant and native women over time, between 2008 and 2014 in France

BackgroundAn increased risk of severe maternal morbidity and mortality has been described in migrant women, particularly in those born in sub-Saharan Africa. The mechanisms in question are poorly identified and rarely studied specifically. ObjectiveTo compare changes in maternal and perinatal morbidity inequalities among migrant and native women over time, between 2008 and 2014. Material and methodA retrospective, single-centre study carried out at the Maternity Unit of the University of Caen Hospital in France. All women who gave birth in 2008 or 2014 were included. Twin pregnancies and delivery before reaching 22 weeks of pregnancy were excluded. Pre-pregnancy characteristics and maternal and perinatal morbidities were collected from the university hospital’s medical and administrative database. We compared the maternal and perinatal morbidity in 2008 and 2014 of women born in France to the morbidity of women born abroad. Secondly, we compared these migrant women between 2008 and 2014 to see if changes in the characteristics of migrant women were associated with a change in the type of maternal and perinatal complications. ResultsOf the 3,038 and 3,001 women included in 2008 and 2014, respectively, 272 (9.0 %) and 385 (12.8 %) women were migrants. Compared to women born in France, we found two times more severe postpartum hemorrhages in women born in sub-Saharan Africa (aOR = 2.1[1.1−3.9]) and a significant increase in the risk of gestational diabetes in women born in North Africa (aOR = 1.9[1.2−2.9]). We found a significant increase in the risk of severe postpartum hemorrhage (aOR = 2.1[1.5−3.0]) and gestational diabetes (aOR = 3.0[2.5−3.7]) in 2014 compared to 2008. We did not find a significant difference in perinatal morbidity between 2008 and 2014. ConclusionWe noted a significant increase in the risk of severe postpartum hemorrhage in women born in sub-Saharan Africa and gestational diabetes in women born in North Africa compared to those born in France, and these risks increase in 2014 relative to 2008.

Cesarean during labor: Is induction a risk factor for complications?

IntroductionEvaluate the impact of labor induction on maternal complications following caesarean section during labor. Material and methodsRetrospective, single-center study between 2015 and 2017. Were included singleton pregnancies who had cesarean section during labor after 37WG. Labor induction procedures included either transcervical balloon catheters or prostaglandins. Degree of emergency of the cesarean was decided according to color code (green, orange and red). We identified and compared intra and postoperative complications according to the mode of labor onset, and then to the mode of labor induction. Results882 patients were included, 416 with spontaneous labor and 464 with labor induction. No significant difference was found for postoperative complications between the two groups. Patients with spontaneous labor had fewer green-code caesareans than patients with elective induction (29.3% vs. 40.3% p<0.001) and had more uterine pedicle injuries (6.3% vs. 3.0% p=0.022). Nevertheless, no difference was found for postpartum hemorrhage (PPH) between these two groups (41.59% vs. 43.32% p=0.60). The subgroup study of patients with labor induction showed that those necessitating 2 methods of labor induction had more severe PPH (22.2% vs. 8.1% p after Bonferroni correction = 0.002). ConclusionsElective induction does not result in an increased risk of cesarean section during labor complications. Only the use of prostaglandin following transcervical balloon catheter increased the risk of severe postpartum hemorrhage.

Vitamin D supplementation for women during pregnancy.

Vitamin D supplementation for women during pregnancy.

Delivery and feto-neonatal outcomes of diamniotic twin pregnancies in women with no chronic disease or gestational complications: impact of mode of conception

Introduction: Autologous and heterologous assisted reproductive technology (ART) conceptions have been on the rise for the last few decades and alongside with that have the rate of multiple pregnancies. Multiple gestations are associated with high odds of gestational complications and, in turn, adverse delivery and feto-neonatal outcomes. Whether ART-conception further increases such elevated risk is still debated. ART is more commonly accessed by older women with chronic diseases, which relate to heightened likelihood of complications. We decided to investigate the influence of autologous and heterologous ART conception compared to spontaneous conception on delivery and feto-neonatal outcomes of diamniotic twin pregnancies in a cohort of healthy women with no chronic conditions or gestational complications.Materials and methods: Retrospective cohort study among diamniotic twin pregnancies in mothers without pregestational or gestational disease. Delivery and feto-neonatal outcomes were compared among three groups according to mode of conception: (1) spontaneous conception (SC, referent group, n = 251 pregnancies), (2) autologous ART-conception (A-ART, n = 87), and (3) heterologous ART-conception (H-ART, n = 22).Results: At adjusted analyses, twin pregnancies conceived by A-ART showed a twofold heightened risk of delivery by urgent/emergent cesarean section, as well as four and sevenfold increase in odds of blood loss >1000 and >1500 mL, respectively. H-ART pregnancies were at fivefold higher risk of undergoing prelabor cesarean section compared to SC, whereas no differences were identified for odds of severe post-partum hemorrhage. Also, A-ART and H-ART gestations displayed fetal and neonatal outcomes similar to SC pregnancies when analysis was adjusted for relevant confounding factors.Conclusion: Our results suggest that both A-ART and H-ART conception associate with increased odds of operative delivery among diamniotic twin pregnancies in healthy mothers with no chronic diseases or gestational complications. Also, a higher risk of severe postpartum hemorrhage appears to relate to A-ART independent of mode of delivery and maternal age. Further studies with larger series of uncomplicated twin pregnancies are warranted to improve our understanding of the relationship of ART to adverse delivery outcomes.

Paving the way for improved management of severe immune thrombocytopenia purpura in pregnancy.

Those of us who take care of women with blood disorders have few data on which to base our management of thrombocytopenia in pregnancy, particularly immune thrombocytopenia purpura (ITP). We extrapolate from the management of ITP in non-pregnant individuals and try to raise platelet counts in an attempt to meet the bleeding challenges of childbirth. Thirty years ago we believed that ITP conferred fetal risks similar to those conferred by alloimmune thrombocytopenia. Experience and small series have taught us otherwise, but fetal let alone maternal risks have not been well quantified. Care et al. have provided us with data from the largest series of ITP patients in pregnancy to date. Using the UK Obstetric Surveillance System (UKOSS), which has been developed to study rare disorders in pregnancy, the investigators identified pregnant women with severe ITP from 1 June 2013 through to 31 January 2015. Rather than researching the diagnosis, the investigators adopted a practical definition of severe ITP, which included: (1) thrombocytopenia with a nadir platelet count of <50 × 109 l−1 after obstetric and hereditary causes had been excluded; or (2) thrombocytopenia that was treated. All 202 UK hospitals with consultant-led maternity units were queried monthly. The investigators reported on the incidence of severe ITP in pregnancy, current management, and the maternal and fetal outcomes of pregnancy. They estimated that the incidence of severe ITP in pregnancy is 1 in 10 000 pregnancies. They found that outcomes for neonates were better than expected, with no cases of intracranial haemorrhage or death. They found that there were no cases of epidural, caesarean section wound, or perineal haematoma following delivery. They also found that severe ITP in pregnancy carries a high risk of severe postpartum haemorrhage. Although this was an observational as opposed to a randomised study, the treated and untreated groups were comparable, with no difference in the lowest platelet count prior to pregnancy. Treatment [with steroids, intravenous immunoglobulin (IVIG), or both] appeared to make no difference in either maternal or fetal outcomes. These findings are surprising. Perhaps we should not be surprised that fetal outcomes were good because, in theory, maternal autoantibodies should not significantly impact fetal platelets. More surprising, however, is that the rate of postpartum haemorrhage was five times higher than estimates from the literature, and that treatment of severe ITP in pregnancy, which is targeted at raising platelet counts to achieve a ‘safe’ threshold in pregnancy or to achieve a target platelet count for delivery, appears to be ineffective in protecting women with severe ITP from postpartum haemorrhage. By providing us with evidence for this rare disorder, the investigators have paved the way for improving the management of severe ITP in pregnancy. They have shown us that existing treatments, which may improve platelet counts, may not improve platelet function, and do not appear to reduce the high risk of postpartum haemorrhage. Randomised trials in rare disorders are often not feasible, but it is time to consider alternative treatments and alternative study designs to capture the results of such treatments. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Severe primary autoimmune thrombocytopenia in pregnancy: a national cohort study.

To quantify the incidence of severe autoimmune thrombocytopenia (ITP) in pregnancy in the UK, determine current treatment strategies, and establish maternal and neonatal morbidity and mortality associated with severe ITP in pregnancy. A prospective national cohort study. UK. Women with severe ITP, defined as platelets <50 × 109 /L in pregnancy or antenatal treatment of isolated low platelets. Data collected via the UK Obstetric Surveillance System (UKOSS) between 1 June 2013 and 31 January 2015 from all UK consultant-led obstetric units. Incidence of severe ITP in pregnancy. The estimated incidence of severe ITP in pregnancy is 0.83 per 10 000 maternities (95% CI 0.68-1.00). A total of 22 pregnant women (21%) did not receive any antenatal therapy, and 85 pregnant women (79%) received therapy. There was no difference between asymptomatic treated and untreated cohorts in severity of disease or outcome. Postpartum haemorrhage (51%) and severe postpartum haemorrhage (21%) was reported more frequently than the rate reported in the general pregnant population (5-10%). No neonates required treatment for thrombocytopenia and there were no cases of neonatal intracranial bleeding. Current UK management of severe ITP in pregnancy results in an exceptionally low morbidity and mortality for the neonate. Mothers with ITP remain at increased risk of severe postpartum haemorrhage, and should be delivered at units that have the capacity to manage severe PPH effectively. Whilst balancing the risks for pregnancy from prophylactic antenatal treatment in asymptomatic women against observed low disease morbidity, we may be over treating asymptomatic patients. UKOSS study of severe ITP in pregnancy shows exceptionally low neonatal morbidity with current UK management.

Duration of labor and the risk of severe postpartum hemorrhage: A case-control study.

ObjectiveOur main objective was to investigate the association between duration of active labor and severe postpartum hemorrhage. We examined the effect of the total duration of active labor, the effect of each stage of active labor, and the gradient effect of duration of labor on severe postpartum hemorrhage.MethodsA case-control study was generated from a source population of all women admitted for delivery at Oslo University Hospital and Drammen Hospital in Buskerud municipality during the time period January 1, 2008 to December 31, 2011. The study population included all cases of severe postpartum hemorrhage (n = 859) and a random sample of controls (n = 1755). Severe postpartum hemorrhage was defined as postpartum blood loss ≥1500 mL or need for blood transfusion. Prolonged labor was defined as duration of active labor >12 hours according to the definition of the World Health Organization. We used logistic multivariable regression in the analysis.ResultsWe observed a significantly longer mean duration of labor in women who experienced severe postpartum hemorrhage compared to controls (5.4 versus 3.8 hours, p<0.001). Women with severe postpartum hemorrhage also had a longer duration of all stages of active labor compared to controls. The association between the duration of active labor and severe postpartum changed from a linear dose-response association to a threshold association after adjusting for augmentation with oxytocin, induction of labor, primiparity, and fever during labor. Compared to controls, women with severe postpartum hemorrhage were more likely to have a prolonged labor >12 hours (adjusted odds ratio = 2.44, 95% confidence interval: 1.69–3.53, p< 0.001).ConclusionProlonged active labor (duration >12 hours) was associated with severe postpartum hemorrhage. Increased vigilance seems required when the labor is prolonged to reduce the risk of severe postpartum hemorrhage.

Assisted reproductive technology and severe postpartum haemorrhage: a case-control study.

To investigate the association between assisted reproductive technology and severe postpartum haemorrhage. Case-control study. The study was conducted in Norway; Division of Gynaecology and Obstetrics at Oslo University Hospital and Department of Obstetrics and Gynaecology at Drammen Hospital. A source population including all women admitted for delivery at Oslo University Hospital and Drammen Hospital during the time period 1 January 2008 to 31 December 2011. The study population consisted of all cases of severe postpartum haemorrhage (n = 1064) and a random sample of controls (n = 2059). We used an explanatory strategy in the analysis, with multivariable logistic regression. Severe postpartum haemorrhage; defined as blood loss ≥1500 ml or need for blood transfusion. Assisted reproductive technology was associated with an increased risk of severe postpartum haemorrhage (crude OR = 2.92; 95% CI 2.18-3.92, P < 0.001). Mode of delivery and anticoagulant medication had significant confounding effects. Strong interaction was found for multiple pregnancies. After adjusting for confounding and interaction, an increased risk was observed both in the strata of multiple pregnancies (adjusted OR = 7.00, 95% CI 2.70-18.12, P < 0.001), and in the strata of single gestation (adjusted OR = 1.58, 95% CI 1.12-2.24, P = 0.010). Our findings warrant an increased awareness of the risk of severe postpartum haemorrhage in women conceiving with assisted reproductive technology. Furthermore, the high risk of severe postpartum haemorrhage in the presence of a twin or triplet pregnancy is an additional argument for single embryo transfer. Assisted reproductive technology is associated with an increased risk of severe postpartum haemorrhage.

Initial management of postpartum hemorrhage: A cohort study in Benin and Mali

ObjectiveTo determine the components of initial management associated with a decreased risk of severe postpartum hemorrhage (PPH) in Benin and Mali. MethodsA cohort study was conducted between May 2013 and September 2014 that included all women who delivered vaginally in seven participating centers and who presented excessive bleeding after birth. Severe PPH was defined as PPH that required surgical treatment (vascular ligature and/or hysterectomy), and/or blood transfusion, and/or transfer to an intensive care unit, and/or an outcome of maternal death. Logistic regression was used to identify the components of initial PPH management that were associated with severe PPH, adjusting for case mix. ResultsA total of 223 women presented a primary PPH presumably caused by uterine atony. Among those, 88 (39.5%) had severe PPH. Nearly one-third of women (30.4%) had a late injection of oxytocin (>10 minutes) after PPH diagnosis or no injection. Oxytocin injection within 10 minutes after the PPH diagnosis was significantly associated with a decreased risk of severe PPH (adjusted OR=0.3; 95% CI, 0.14–0.77). ConclusionDecrease in the delays in oxytocin administration is a key determinant to improve maternal outcomes related to PPH in this context.

A double centre retrospective study into rates of postpartum haemorrhage in women on low molecular weight heparin

A double centre retrospective study into rates of postpartum haemorrhage in women on low molecular weight heparin

Nitroglycerin for management of retained placenta.

Retained placenta affects 0.5% to 3% of women following delivery, with considerable morbidity if left untreated. Use of nitroglycerin (NTG), either alone or in combination with uterotonics, may be of value to minimise the need for manual removal of the placenta in theatre under anaesthesia. To evaluate the benefits and harms of NTG as a tocolytic, either alone or in addition to uterotonics, in the management of retained placenta. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (14 January 2015), reference lists of retrieved studies and contacted experts in the field. Any adequately randomised controlled trial (RCT) comparing the use of NTG, either alone or in combination with uterotonics, with no intervention or with other interventions in the management of retained placenta. All women having a vaginal delivery with a retained placenta, regardless of the management of the third stage of labour (expectant or active). We included all trials with haemodynamically stable women in whom the placenta was not delivered at least within 15 minutes after delivery of the baby. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We included three randomised controlled trials (RCTs) with 175 women. The three published RCTs compared NTG alone versus placebo. The detachment status of retained placenta was unknown in all three RCTs. Collectively, among the three included trials, two were judged to be at low risk of bias and the third trial was judged to be at high risk of bias for two domains: incomplete outcome data and selective reporting. The three trials reported seven out of 23 of the review's pre-specified outcomes.The primary outcome "manual removal of the placenta" was reported in all three studies. No differences were seen between NTG and placebo for manual removal of the placenta (average risk ratio (RR) 0.83, 95% confidence interval (CI) 0.47 to 1.46; women = 175; I² = 81%). A random-effects model was used because of evidence of substantial heterogeneity in the analysis. There were also no differences between groups for risk of severe postpartum haemorrhage (RR 0.93, 95% CI 0.62 to 1.39; women = 150; studies = two; I² = 0%). Blood transfusion was only reported in one study (40 women) and again there was no difference between groups (RR 1.00, 95% CI 0.07 to 14.90; women = 40; I² = 0%). Mean blood loss (mL) was reported in the three studies and no differences were observed (mean difference (MD) -115.31, 95% CI -306.25 to 75.63; women = 169; I² = 83%). Nitroglycerin administration was not associated with an increase in headaches (RR 1.09, 95% CI 0.80 to 1.47; women = 174; studies = three; I² = 0%). However, nitroglycerin administration was associated with a significant, though mild, decrease in systolic and diastolic blood pressure and a significant increase in pulse rate (MD -3.75, 95% CI -7.47 to -0.03) for systolic blood pressure, and (MD 6.00, 95% CI 3.07 to 8.93) for pulse rate (beats per minute) respectively (reported by only one study including 24 participants). Maternal mortality and addition of therapeutic uterotonics were not reported in any study. In cases of retained placenta, currently available data showed that the use of NTG alone did not reduce the need for manual removal of placenta. This intervention did not increase the incidence of severe postpartum haemorrhage nor the need for blood transfusion. Haemodynamically, NTG had a significant though mild effect on both pulse rate and blood pressure.

Aktive Leitung der Nachgeburtsperiode - Das Ende eines 50-jährigen Dogmas?

Post-partum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. Since more than 50 years AMTSL has been proposed for the prevention of PPH and is still recommended in current guidelines. The 3 key components of AMTSL are the prophylactic administration of oxytocin, clamping and cutting of the umbilical cord immediately after delivery of the baby and controlled cord traction. AMTSL has proven to reduce the rate of severe PPH by 70%. Despite of the long tradition of AMTSL it is still unclear, which of the 3 components significantly contributes to the reduction in PPH. Cochrane analyses and a recent metaanalysis gave strong evidence, that prophylactic oxytocin administration reduces the risk of PPH significantly, however, the optimal dose and mode of application is still a matter of debate.Until a little while ago no randomized controlled studies exist regarding the significance of controlled cord traction and the time of cord clamping in AMTSL. A randomized WHO trial 2012 and the 2013 published TRACOR (Traction of the CORd)-trial from France could clearly demonstrate that controlled cord traction is not associated with a significant reduction in postpartum blood loss and in the risk of severe PPH. A Cochrane analysis 2008 and a recent randomized trial from Sweden came to the conclusion, that there are no significant -differences between early (< 15 s) and delayed (> 1-3 min) cord clamping in the reduction of PPH and severe PPH. Uterine massage after delivery of the placenta, placental cord drainage and umbilical vein injection of uterotonics after delivery of the baby as part of AMTSL are not evidence-based methods. It has taken 50 years since AMTSL was first described for it to become clear that prophylactic oxytocin is the most important and the only evidence-based component of AMTSL. Future guidelines and textbooks should consider these new -findings.

Risk of Severe Postpartum Hemorrhage in Low‐Risk Childbearing Women in New Zealand: Exploring the Effect of Place of Birth and Comparing Third Stage Management of Labor

Primary postpartum hemorrhage is a leading cause of maternal mortality and morbidity internationally. Research comparing physiological (expectant) and active management of the third stage of labor favors active management, although studies to date have focused on childbirth within hospital settings, and the skill levels of birth attendants in facilitating physiological third stage of labor have been questioned. The aim of this study was to investigate the effect of place of birth on the risk of postpartum hemorrhage and the effect of mode of management of the third stage of labor on severe postpartum hemorrhage. Data for 16,210 low-risk women giving birth in 2006 and 2007 were extracted from the New Zealand College of Midwives research database. Modes of third stage management and volume of blood lost were compared with results adjusted for age, parity, ethnicity, smoking, length of labor, mode of birth, episiotomy, perineal trauma, and newborn birthweight greater than 4,000 g. In total, 1.32 percent of this low-risk cohort experienced an estimated blood loss greater than 1,000 mL. Place of birth was not found to be associated with risk of blood loss greater than 1,000 mL. More women experienced blood loss greater than 1,000 mL in the active management of labor group for all planned birth places. In this low-risk cohort, those women receiving active management of third stage of labor had a twofold risk (RR: 2.12, 95% CI: 1.39-3.22) of losing more than 1,000 mL blood compared with those expelling their placenta physiologically. Planned place of birth does not influence the risk of blood loss greater than 1,000 mL. In this low-risk group active management of labor was associated with a twofold increase in blood loss greater than 1,000 mL compared with physiological management. (BIRTH 39:2 June 2012).