Rotational thromboelastometry (ROTEM) provides rapid, point-of-care coagulation data. However, the specific effect of its use for coagulopathy management on blood component transfusions during severe postpartum hemorrhage remains undetermined. We aimed to assess whether the use of ROTEM was associated with reduced administration of hemostatic blood products and blood transfusions in women with postpartum hemorrhage ≥1000 mL. In this single-center retrospective pre-post matched study, administration of hemostatic blood products and packed red blood cells was compared in two groups of adult patients with postpartum hemorrhage ≥1000 mL. The Control group consisted of patients managed empirically or based on laboratory results between 2016 and 2018. The ROTEM group consisted of patients managed using a ROTEM-guided coagulopathy protocol between 2021 and 2023. Exact matching was applied for qualitative variables, and propensity score matching was used for quantitative variables. A 1:1 matching procedure was performed using 14 confounders. Odds ratios were estimated using conditional logistic regression. After matching, 102 patients were included in each group. ROTEM use was associated with significantly lower transfusion rates of any hemostatic blood product (25% vs. 38%; OR: 0.46 [95% CI: 0.22 to 0.94]), fibrinogen concentrates (25% vs. 37%; OR: 0.48 [95% CI: 0.23-0.98]), fresh frozen plasma (3% vs. 17%; OR: 0.13 [95% CI: 0.03-0.54], and packed red blood cells (29% vs. 49%; OR: 0.38 [95% CI: 0.19-0.73]). The use of ROTEM to manage hemostatic impairment in postpartum hemorrhage ≥1000 mL was associated with a significant reduction in the transfusion of hemostatic blood products and red blood cells.

To evaluate the effects of aortic occlusion (AO) on severe postpartum hemorrhage (PPH)-a leading cause of preventable maternal mortality-using a nationwide maternal death registry in Japan. A nationwide retrospective observational study of hemorrhage-related maternal deaths was conducted in Japan between 2010 and 2024. Patients were classified into an AO group (resuscitative endovascular balloon occlusion of the aorta [REBOA] and/or resuscitative thoracotomy with aortic cross-clamping [RT-ACC]) and a non-AO group. The primary outcome was the achievement of definitive hemostatic procedures. Secondary outcomes included 24-h survival. Among 109 hemorrhage-related maternal deaths, 19 patients underwent AO (13REBOA, six RT-ACC). Patients in the AO group were more frequently transferred to tertiary care centers than those in the non-AO group (84.2% (16/19) vs 43.3% (39/90), P < 0.01). Achievement of definitive hemostasis was significantly higher in the AO group (78.9% (15/19) vs 42.2% (38/90), P < 0.01), as were 24-h survival (42.1% (8/19)vs 15.6% (14/90), P = 0.02). Approximately 90% of AO procedures (17/19) were performed at tertiary centers, and only 16% (3/19) were initiated before cardiopulmonary arrest. AO, including REBOA and RT-ACC, was associated with higher rates of hemostasis and short-term survival among cases of maternal death due to severe PPH. Earlier application of AO before cardiopulmonary arrest may be critical to improving outcomes.

Evaluation of the Implementation of a Checklist for the Management of Postpartum Hemorrhage Following Vaginal Delivery

Prophylactic oxytocin (5-10 IU) after vaginal birth is a grade A recommendation in France. During cesarean delivery, carbetocin is increasingly used as an alternative to oxytocin to reduce the risk and burden of postpartum hemorrhage (PPH). Its role after vaginal birth remains uncertain, largely because of higher costs. This study assessed the cost-effectiveness of carbetocin for PPH prevention in vaginal deliveries. We performed a retrospective single-center, observational before-after cohort study with a medico-economic component in a French tertiary maternity unit. All women who delivered vaginally between January 1 and March 31, 2024 (oxytocin period), and between November 1, 2024, and January 31, 2025 (carbetocin period), were included. These two periods corresponded to the institutional protocol change replacing oxytocin with carbetocin for prophylaxis of postpartum hemorrhage after vaginal delivery. A total of 1404 women were analyzed (702 per group). The overall PPH rate was similar between groups (9.0% vs. 7.8%). Severe PPH (≥1000 mL) occurred less frequently with carbetocin than with oxytocin (1.3% vs. 3.0%, P = 0.0244). Weighted mean costs per patient were €17.28 in the carbetocin group and €9.07 in the oxytocin group, with a mean difference of €8.11 (95% confidence interval [CI]: 0.31-15.48). The incremental cost-effectiveness ratio (ICER) was €511.87 per severe PPH avoided. Despite higher drug costs, prophylactic carbetocin significantly reduced severe PPH compared with oxytocin and showed favorable cost-effectiveness in vaginal deliveries. These findings support carbetocin as a valuable alternative for PPH prevention in this setting.

Assessment of coagulation markers and decision curve analysis for predicting transfusions and hemostatic interventions in severe postpartum hemorrhage: A nationwide observational study in Japan.

The World Health Organization proposed a clinical care bundle as a first response for postpartum haemorrhage (PPH), a leading cause of maternal deaths. A large trial was conducted to evaluate its effectiveness, with Tanzania among the participating countries. We explored the experiences of healthcare workers during the early implementation of this bundle within the broader trial. An exploratory qualitative study was conducted to understand the early implementation experiences of the PPH bundle. We held six focus group discussions (FGDs) with healthcare workers, clinical leads designated as champions, and research nurses from all six facilities that implemented the intervention in Tanzania. A d-eductive qualitative thematic analysis was performed using the Consolidated Framework for Implementation Research to structure our findings. We reported on four domains: the intervention and its implementation, individual attributes, and the inner and outer contexts. Healthcare workers reported positive experiences during implementation of the PPH first-response bundle. The innovation included several known components: calibrated drape for early detection, on-site training, facility audits, champions and the PPH care bundle comprising uterine massage, oxytocics, tranexamic acid and intravenous fluids. Individual participants appreciated the multi-component strategies that addressed chronic issues, including the lack of objective measurement of blood loss, inadequate skills, and supply shortages. Additionally, local clinical leads who served as champions increased local ownership and accountability. Facility-level challenges included staff rotation and a lack of clear communication, particularly when managing at-risk women. The availability of external support for training, supplies, and drugs required to administer the bundle, along with strong support from the districts and regional health management teams, enhanced the adoption and implementation process. The components of the bundle and the implementation strategies were well received and perceived as reducing the risk of severe postpartum haemorrhage and potentially saving lives. The perceived successes were contributed by the interconnectedness of the different strategies used. Facilities and countries aiming to scale need to harness these strategies that target the health system. In addition, there is a need to strengthen local facility audits, document and address chronic challenges affecting staff dynamics and supplies. District, regional and national leadership in adopting and integrating new clinical practices are key.

Anemia is a public world health problem among pregnant females especially in developing countries. China is a representatively developing country with vast territory and significant economic and cultural differences in different regions. Currently most studies on anemia in pregnancy ignored economically backward and resource-poor cities or districts and anemia during pregnancy in China was not accurately estimated. The goal of this study was to assess the prevalence, risk factors, and adverse outcomes of anemia among pregnant females across different regions of China using a large, nationally representative dataset from 2012 to 2020. A large representative multicenter retrospective study collected data from the National Maternal Near Miss Surveillance System (NMNMSS). The study covered 30 provinces (Tibet excluded), eastern, central, and western regions, both rural and urban areas, as well as medical institutions at all levels. A total of 438 medical institutions participated, with 12, 572, 647 singleton pregnant women and 237, 864 multiple pregnant women enrolled. Socio-demographic characteristics, hemoglobin levels, risk factors and pregnancy outcomes were collected via the online NMNMSS platform from all the participants and the study showed the current real situation of anemia during pregnancy in China during 2012-2020. A total of 12,810,511 pregnant females aged 15 to 49 years were included. The overall prevalence of pregnancy-associated anemia was 21.25%, with 8.44% mild anemia, 12.03% moderate, 0.58% severe, and 0.20% of unknown severity. The anemia prevalence was 21.08% among singleton pregnancies (1,063,104 mild, 1,492,873 moderate, 69,402 severe, 24,922 unknown severity) and 30.31% among multiple pregnancies (18,156 mild, 48,686 moderate, 4,710 severe, 24,922 unknown severity). Notably, moderate anemia accounted for the largest proportion of anemic cases across all pregnancies. Compared with the singleton pregnancy group, the multiple pregnancy group had significantly higher risks of moderate and severe anemia, which were 1.7-fold and 10-fold higher, respectively. Additionally, gestational anemia was significantly associated with maternal age 15-19 years, parity, previous caesarean sections, education status and most maternal complications during pregnancy. Moderate and severe anemia exhibited a significant proportional association with maternal outcomes, including uterine rupture, placenta previa, placental abruption, postpartum hemorrhage, severe postpartum hemorrhage, blood transfusion, intensive care unit (ICU) admission and multiple organ dysfunction syndrome (MODS), and these conditions were further linked to an elevated risk of low birth weight, poor Apgar scores at birth, and stillbirth. No significant elevation in adverse outcome risk was observed in instances of mild anemia. Based on large-sample nationwide data of 12.8million pregnant women in China, this study identified a substantial anemia burden (prevalence: 21.25%), with moderate/severe anemia (12.61%) significantly associated with elevated clinical risks. Multiple pregnancy, as a major risk factor for pregnancy-associated anemia, was associated with a higher anemia prevalence (30.31%) and significantly increased risks of moderate and severe anemia compared with singleton pregnancy (21.08%), with aOR = 1.64 (95% CI: 1.52-1.76). Other risk factors included adolescent pregnancy (15-19 years), low education and obstetric complications. Notably, moderate/severe anemia was associated with heightened maternal and neonatal adverse outcomes, whereas mild anemia exhibited no such associations of risk-stratified screening and preventive strategies to reduce the morbidity and adverse outcomes potentially associated with pregnancy-associated anemmia.

Based on the hypothesis that the effect of general anesthesia (GA) vs. neuraxial anesthesia (NA) on postpartum hemorrhage (PPH) varies according to its underlying etiology, this study aimed to investigate the impact of the anesthetic technique on the risk of severe PPH indistinct clinical scenarios: (1) emergency cesarean deliveries at risk for uterine atony and (2) cases of placenta accreta spectrum (PAS) at risk for massive surgical hemorrhage. In this retrospective dual-cohort study, patients receiving GA in Cohort 1 were matched 1:3 to NA patients using propensity score matching (PSM). Cohort 2 comprised patients with PAS who underwent scheduled cesarean hysterectomy. The primary endpoint was severe PPH, and the results were analyzed statistically. In the matched Cohort 1 (n = 600), the incidence of severe PPH was significantly higher in the GA group compared to the NA group (21.3 vs. 9.8%). After adjusting for operative duration and tranexamic acid use, GA was independently associated with an almost threefold increased risk of severe PPH [Adjusted Odds Ratio (aOR): 2.91; 95% Confidence Interval (CI): 1.80-4.69; p < 0.001]. In contrast, in Cohort 2 (n = 75), the rate of severe PPH was high in both groups, with no significant difference observed (91.1 vs. 86.7%; p > 0.05). However, post-hoc Bayesian analysis indicated a > 99 and 91% probability that GA is associated with increased blood loss in Cohort 1 and Cohort 2, respectively. In our matched cohort, general anesthesia was associated with an almost threefold increase in the risk of severe PPH in emergency cesarean deliveries susceptible to uterine atony. In cases such as the placenta accreta spectrum, the primary determinant of hemorrhage is the underlying surgical pathology, and the role of anesthetic management appears to be secondary. However, these findings for the PAS cohort should be considered exploratory due to the small sample size. In general, these results strongly support the personalization of anesthetic strategies based on the expected etiology of hemorrhage to reduce maternal morbidity and mortality.

Vacuum-induced tamponade using urological catheters for postpartum hemorrhage.

This study aimed to evaluate maternal and neonatal outcomes of women who had chorioamnionitis during their primary term cesarean delivery (CD), in their subsequent delivery.This multicenter retrospective cohort study (2005-2022) included women who attempted trial of labor after CD (TOLAC) following a primary term emergency CD. Women were grouped by the presence or absence of chorioamnionitis at the primary CD. Primary outcome was mode of delivery in the subsequent delivery. Secondary outcomes included adverse maternal and neonatal outcomes, including uterine rupture and adhesions. Multivariable logistic regression identified predictors of recurrent chorioamnionitis and adverse outcomes.Of 2,626 women included, 258 (9.8%) had chorioamnionitis during their primary CD (Chorio-PCD). In the subsequent delivery, this group as opposed to women without chorioamnionitis, had higher rates of emergency repeat CD (31.4 vs. 24.3%, p = 0.012), recurrent chorioamnionitis (14.3 versus 5.1%, p < 0.001), and postpartum readmission (2.3 vs. 0.5%, p = 0.006). Nevertheless, having previous chorioamnionitis did not impact the rate of uterine rupture among women who attempted TOLAC. Among women undergoing repeat non-elective CD, rates of severe adhesions (38.3 vs. 25.6%, p = 0.016) and postpartum hemorrhage (13.6 vs. 6.9%, p = 0.034) were significantly higher in the Chorio-PCD group. Chorio-PCD in previous pregnancy independently predicted composite adverse maternal outcome (aOR = 1.50, 95% CI: 1.13-1.99, p = 0.005).Chorioamnionitis at primary term CD is associated with increased maternal morbidity in subsequent delivery. These findings support the need for careful delivery planning and postpartum management in this population. · Chorio-PCD linked to emergency CD in univariate, but not in multivariate, analysis.. · Chorio-PCD was significantly associated with adverse maternal outcomes at the subsequent delivery.. · Chorio-PCD was not associated with increased risk of preterm delivery or uterine rupture..

This study aimed to investigate pregnancy outcomes after conservative treatment for severe postpartum hemorrhage (PPH) following cesarean delivery (CD). A total of 9,366 women who underwent CD for two consecutive pregnancies were included. Bakri balloon tamponade was employed in 87 women, and compression sutures were used in 87 women to control PPH during the first CD. The subsequent pregnancy outcomes and operative findings during the second CD were compared among the groups. The preterm delivery rate was 3.2% in the control group, 12.6% in the Bakri group, and 11.5% in the compression suture group (P < 0.001). The rates of placenta accreta (1.4% vs. 1.3% vs. 5.3%, P = 0.017), PPH (0.9% vs. 3.9% vs. 8.0%, P < 0.001), and pelvic adhesions (5.2% vs. 6.5% vs. 13.3%, P = 0.004) were significantly greater in the compression suture group. After adjustment, conservative treatment increased the rate of preterm birth in subsequent pregnancies threefold. A compression suture increased the risk of placenta accreta by fourfold and the incidence of pelvic adhesions by more than twofold in subsequent CD. Conservative treatment for PPH following CD is associated with an increased risk of subsequent preterm birth. Women receiving compression sutures have an increased risk of placenta accreta and pelvic adhesions in subsequent pregnancies.

Pregnant women with von Willebrand disease (VWD) receive prophylactic von Willebrand factor (VWF) concentrate based on third trimester VWF/factor (F)VIII levels to reduce the risk of severe postpartum hemorrhage (PPH, ≥ 1000 mL). Due to high severe PPH rates, Dutch guidelines were revised in 2018. Consensus was reached to increase the third trimester threshold for prophylaxis from < 50 to < 80 IU/dL, and peak target levels during childbirth from ≥ 100 to ≥ 150 IU/dL. To assess the severe PPH incidence after guideline revision. Pregnant Dutch women with VWD were prospectively enrolled (2018-2024). VWF/FVIII activity levels and hematologic and obstetric outcomes were compared with those of a historical cohort (2012-2017). Statistics included descriptives and logistic regression to correct for confounders. Severe PPH occurred in 18.1% (n = 29/160) without thrombosis or exsanguinations. Prophylaxis in those with third trimester levels of < 80 IU/dL led to PPH rates similar to those with spontaneous a rise > 80 IU/dL. Compared with the historical cohort (prophylaxis cutoff, < 50 IU/dL), severe PPH incidence did not decrease (n = 20/151 vs n = 29/160; odds ratio [OR], 1.45; 95% CI, 0.78-2.69). Moreover, in the third trimester 50- to 80-IU/dL subgroup and third trimester < 50-IU/dL subgroup, the risk for severe PPH was similar (n = 31/160 vs n = 23/151; OR, 0.86; 95% CI, 0.23-3.28; and n = 64/160 vs n = 48/151; OR, 2.59; 95% CI, 0.78-8.60, respectively), despite increased peak target levels of 150 IU/dL. Increasing the third trimester VWF and FVIII cutoff to < 80 IU/dL and aiming for ≥ 150 IU/dL at delivery did not decrease severe PPH. More research is needed on optimal peripartum hemostatic prophylaxis in VWD.

To assess the association between the risk of severe postpartum hemorrhage (PPH) and the annual twin delivery volume of maternity units. JUmeaux MODe d'Accouchement (JUMODA) was a national observational prospective population-based cohort of twin deliveries in 176 French maternity units performing more than 1500 annual deliveries. Our analysis included 7348 women who delivered after 32 weeks' gestation. The primary outcome was severe PPH. The exposure of interest was the volume of annual twin deliveries defined as the number of annual twin deliveries per center in the study population, divided in three terciles. We compared the risk of severe PPH in maternity units with a low or moderate annual twin delivery volume to high volume group and used a propensity score weighting approach to control for confounding. Severe PPH occurred in 3.5% of women in the low-volume group (4-24 twin deliveries per year), 4.2% in the moderate-volume group (25-47), and 5.0% in the high-volume group (48-184) (P = 0.081). After propensity score weighting, as compared to women delivering in the high-volume group, the risk of severe PPH did not significantly differ for those in the low-volume group (OR 0.73, 95% CI: 0.49-1.07) or in the moderate-volume group (OR 0.84, 95% CI: 0.63-1.12). Absolute risk difference was 1.64% (95% CI: -3.04-0.24) for the low- between high-volume group and -0.72% (95% CI: -3.04-0.24) for the moderate- versus high-volume group. Results were similar after stratifying by mode of delivery and when only very severe PPH was considered. Severe PPH rates in twin pregnancies do not differ by the annual twin delivery volume of the maternity hospital, which questions the relevance of using this characteristic to limit where women can give birth, provided that a skilled obstetric and onsite anesthesiology team are available. Caution is therefore warranted when generalizing these results to other healthcare settings, particularly in low- and middle-income countries, where health system organization, resource availability, may substantially differ.

Postpartum haemorrhage (PPH) causes ~70 000 maternal deaths annually, making it one of the leading causes of preventable maternal mortality. This study evaluated the effectiveness of individualised goal-directed bleeding management (GDBM) in severe PPH in our centre with unique geographical challenges. We conducted a retrospective analysis of severe PPH requiring massive transfusion over 1 years. Patients were classified into a fixed ratio (1:1:1) massive transfusion protocol (Group 1) and GDBM (Group 2). Study outcomes included blood utilisation, persistence of coagulopathy after resuscitation and mortality. The target was to keep a fibrinogen level of >200 mg/dL during the resuscitation. Thromboelastography was used to guide GDBM, and data were analysed using mean, median, percentage changes, chi-square test, student t test, and Mann-Whitney U-test. Out of 96 patients (42 were in Group 1 and 54 in Group 2), GDBM led to increased cryoprecipitate utilisation (410 vs. 297 units) and a higher post-resuscitation fibrinogen value (252 [185.32-426.42] mg/dL vs. 204.6 [154.5-274.05] mg/dL, p = 0.02). The cryoprecipitate turnaround time was improved (41 vs. 73 min, p < 0.001) with GDBM ensuring timely administration. Increased fibrinolysis activity was observed in 24% of the patients in TEG. The persistence of coagulopathy after deactivation of MTP was lower in GDBM (7.4% vs. 26.19%). Out of the three patients who did not survive, two were in Group 1. Individualised GDBM optimises blood utilisation, reduces turnaround time and improves coagulopathy in PPH and needs to be prioritised.

There is a scarcity of literature documenting how women facing maternal morbidity issues deal with challenges to breastfeeding. This case study documents challenges faced by two women, one who underwent major abdominal surgery immediately after a Caesarean section at 32 weeks, and the other who had a primary and secondary postpartum hemorrhage with repeated hospital admissions. In the first case, the key issues for lactation were the mother-infant separation and difficulty in initiation and sustaining breastfeeding due to abdominal surgery after her Caesarean section. Early and frequent removal of milk are critical for establishing and sustaining supply and were challenging for the mother in the intensive care unit for 3 weeks. The second case involved a mother experiencing severe postpartum hemorrhage. Having lost over 3 L of blood, this mother faced a significant risk of a reduction in prolactin and activation of her milk supply. Her subsequent weakness and dyspnoea due to anaemia meant breastfeeding required extraordinary effort. Establishing lactation under these circumstances was challenging. Both mothers needed guidance and encouragement to build up and maintain their supply and the practical support of family to care for the infant. In Case Study 1, donor milk was used and alternated with artificial breastmilk substitutes until the mother re-established her supply after discharge. In Case Study 2, the mother required help to express, position, and hold the baby while she breastfed. Despite overwhelming medical and physiological odds, it is possible to establish exclusive breastfeeding with consistent personalized health-system support/training and relentless determination.

Inflammatory bowel disease (IBD) and chronic liver disease (CLD) are each associated with adverse pregnancy outcomes, but the impact of coexisting IBD and CLD on pregnancy remains understudied. To assess CLD prevalence among pregnant women with and without IBD and evaluate maternal and perinatal outcomes. We conducted a retrospective cohort study of delivery hospitalisations among women ≥ 18 years using the 2016-2022 United States National Inpatient Sample. Deliveries were categorised as IBD + CLD, IBD, CLD or neither using ICD-10 codes. Weighted multivariable regression adjusted for demographics, comorbidities and cirrhosis. Among 21,304,600 deliveries, 178,025 had CLD, 47,555 had IBD and 680 had IBD + CLD. Chronic viral hepatitis was the most common CLD, while autoimmune liver disease accounted for half of cirrhosis in IBD + CLD. Compared to IBD or CLD, IBD + CLD had higher odds of hyperemesis gravidarum (2.64 vs. 3.68), preterm birth (2.50 vs. 1.69), hypertensive disorders of pregnancy (HDP) (1.96 vs. 1.60), caesarean delivery (1.92 vs. 1.61), perinatal mood disorder (1.75 vs. 1.45) and premature rupture of membranes (1.35 vs. 1.39). IBD + CLD had greater odds of fetal death (1.97) versus CLD and of severe maternal morbidity (1.76) and postpartum haemorrhage (1.56) versus IBD. All p ≤ 0.05. Coexisting IBD and CLD confer compounded maternal and perinatal risks beyond either condition alone. Multidisciplinary care and risk-based screening for underlying CLD in pregnant women are warranted.

Background: Postpartum hemorrhage (PPH) remains one of the leading causes of maternal morbidity and mortality worldwide. When medical and conservative measures fail to control hemorrhage, surgical interventions such as internal iliac artery ligation (IIAL) become essential to reduce pelvic blood flow and achieve hemostasis. Internal iliac artery ligation is considered an important fertility-preserving procedure in the management of severe obstetric hemorrhage. Objectives: To find out the efficacy of Internal Iliac artery ligation (IIAL) in postpartum haemorrhage and its maternal outcomes. Methods: This prospective observational study was conducted in the Department of Obstetrics and Gynaecology of a tertiary care teaching hospital over a period of 18 months. A total of 70 women with postpartum hemorrhage requiring internal iliac artery ligation were included. Data regarding demographic characteristics, gestational age, referral status, mode of delivery, indications for internal iliac artery ligation, intraoperative findings, blood loss, blood transfusion requirements, associated surgical procedures, and postoperative outcomes were collected using a structured proforma. Data were analyzed using descriptive statistics and expressed as frequencies and percentages. Results: The majority of patients were aged 21-25 years (44.2%) and most deliveries occurred at term (>37 weeks) (45.7%). Caesarean section was the mode of delivery in 82.8% of cases. The most common indication for internal iliac artery ligation was atonic postpartum hemorrhage (27.1%), followed by placenta previa (24.2%) and abruptio placenta (17.1%). Uterine artery ligation (80%) and B-Lynch/Hayman sutures (28%) were commonly performed adjunct procedures. Blood loss exceeded 2000 ml in 50% of patients, and most required 4-5 units of blood transfusion. More than half of the patients required ICU stay for 1-2 days. Conclusion: Internal iliac artery ligation is an effective and life-saving surgical procedure for controlling severe postpartum hemorrhage and plays a vital role in fertility preservation when conservative management fails.

Introduction: Placenta accreta spectrum (PAS) represents a significant contributor to maternal mortality, primarily as a result of severe postpartum hemorrhage. The most prominent risk factors associated with PAS are the placenta previa and a history of cesarean delivery. Nevertheless, a normal location of placenta does not exclude PAS, although this is underreported. Case Report: We report a G3P2L0 female who was booked with us since her first trimester and had two previous cesarean deliveries, but with no live issue. During her elective lower segment cesarean section at term with all routine preparations, the placenta did not separate with the routine prophylactic dose of oxytocin, even though placenta was placed fundally. Non-separation of the placenta with a well-contracted uterus led us to consider manual removal of the placenta; however, no plane of cleavage was felt or seen, raising a suspicion of the placenta accreta syndrome. As we were at a secondary care setup without any ICU and blood bank facility, given no postpartum hemorrhage, a decision to leave the placenta in situ was taken, and the patient was shifted to a tertiary care setup for observation. She underwent an emergency hysterectomy at the referral center. Conclusion: In non-previa PAS cases, guidelines for management, tools for early suspicion and management when encountered as a surprise, and research toward its pathogenesis have a long way to go. Conservative management, particularly in uterine body PAS and resource-limited settings, with leaving the placenta in situ, should be strongly considered.

Pregnant hemophilia carriers receive prophylactic factor [F]VIII or FIX concentrate based on third trimester FVIII/FIX activity to reduce the risk of severe postpartum hemorrhage (PPH, ≥ 1000 mL). Due to persistently high severe PPH rates, Dutch guidelines were revised in 2018. Consensus was reached to increase the third trimester threshold for prophylaxis from < 50 to < 80 IU/dL and peak target levels during childbirth from ≥ 100 to ≥ 150 IU/dL. To assess the severe PPH incidence after guideline revision. Pregnant hemophilia carriers were prospectively enrolled (2018-2024) in Dutch hemophilia treatment centers to assess the severe PPH incidence after implementation of the revised guideline. FVIII/FIX activity and hematologic and obstetric outcomes were recorded and compared with a historical cohort (2012-2017). Statistics included descriptives and logistic regression to correct for confounders. Severe PPH occurred in 12.4% of 170 deliveries. No thrombosis was recorded. Prophylaxis in the subgroup with third trimester levels of < 80 IU/dL led to similar PPH rates to those with spontaneous rises of > 80 IU/dL. Compared with the historic cohort with the third trimester cutoff of < 50 IU/dL, the severe PPH incidence did not decrease (n = 170 vs n = 197; odds ratio, 1.16; 95% CI, 0.46-2.93), neither in the third trimester of the 50- to 80-IU/dL subgroup (n = 28/170 vs n = 21/197; odds ratio, 1.0; 95% CI, 0.20-2.90). Increasing the third trimester cutoff to < 80 IU/dL and aiming for ≥ 150 IU/dL at delivery did not decrease the risk for severe PPH in hemophilia carriers. More research is needed on optimal clotting factor levels during delivery to prevent severe PPH.

Background: Postpartum hemorrhage is a major cause of maternal morbidity and mortality, particularly in vaginal delivery, with uterine atony as the most common etiology. Therefore, the administration of uterotonic agents during the third stage of labor plays an important role in preventing postpartum hemorrhage. Methylergometrine is still widely used; however, data regarding its effect on the severity of postpartum hemorrhage in Indonesia remain limited. Purpose: To compare the severity of postpartum hemorrhage among women with normal vaginal delivery who received and did not receive methylergometrine at RSUD Dr. Moewardi Surakarta. Method: This study was an observational analytic study with a retrospective cohort design using secondary data from medical records. A total of 92 women with normal vaginal delivery who experienced primary postpartum hemorrhage during the period 2022–2024 were included and divided into groups receiving and not receiving methylergometrine. The severity of postpartum hemorrhage was classified into mild–moderate and severe. Data were analyzed using univariate and bivariate analyses with the Fisher’s exact test at a significance level of p &lt; 0.05. Results: All women who received methylergometrine experienced mild–moderate postpartum hemorrhage, whereas 9.5% of severe postpartum hemorrhage cases were found in the group that did not receive methylergometrine. There was a significant association between methylergometrine administration and the severity of postpartum hemorrhage (p = 0.026), with an odds ratio of 0.905 (95% CI: 0.820–0.998). Conclusion: Methylergometrine administration was significantly associated with a reduced severity of postpartum hemorrhage in women with normal vaginal delivery.