Severe Postpartum Research Articles

Fibrinogen Concentrate and Maternal Outcomes in Severe Postpartum Hemorrhage: A Population-based Cohort Study With a Propensity Score-matched Analysis

(J Clin Anesth. 2022;81:110874) Severe postpartum hemorrhage (PPH) is a leading cause of maternal mortality globally. While fibrinogen concentrate (FC) has been shown to mitigate blood loss in parturients, there is limited evidence on fibrinogen concentrate’s impact on maternal outcomes in the setting of severe PPH. This study aimed to identify the association between FC administration and maternal outcomes in patients with severe PPH requiring red blood cell (RBC) transfusion.

Intrauterine Tamponade Balloon for Management of Severe Postpartum Haemorrhage: Does Early Insertion Change the Outcome? A Retrospective Study on Blood Loss.

To evaluate the role of the timing of IUTB insertion and to assess the correlation between the time of insertion and outcome. A retrospective study in two tertiary care centres, including patients transferred for severe PPH management. A total of 81 patients were included: 52 patients with IUTB inserted before 15 min (group 1) and 29 patients with IUTB inserted after 15 min (group 2). The mean volume of blood loss in the group of patients with IUTB inserted before 15 min was significantly lower than in group of patients with IUTB set after 15 min. An IUTB could be inserted simultaneously with a uterotonic agent, within 15 min and not after 15 min as suggested by local guidelines, but further prospective studies are required to confirm this.

Adverse maternal outcomes associated with major fetal malformations after singleton live birth

Major fetal malformations complicate 2% to 5% of live births. It is unclear what effect fetal malformations have on severe maternal morbidity. This study aimed to compare maternal outcomes between individuals with a fetus with major or minor fetal malformations and those with a fetus without major or minor fetal malformations. This was a secondary analysis of the Consortium on Safe Labor database. Our study was limited to the current analysis of pregnant individuals with a singleton live birth. Major fetal malformations based on the Centers for Disease Control and Prevention's criteria were defined. Fetal malformations that did not meet the criteria for major fetal malformations were categorized as minor fetal malformations. Our primary maternal outcome was severe maternal morbidity as defined by the Centers for Disease Control and Prevention. Missing values were imputed by multiple imputation using the k-nearest neighbor imputation method. Poisson regression with robust error variance was used to obtain adjusted relative risks with 95% confidence intervals, controlling for confounders. Of 216,881 deliveries, there were 201,860 cases (93.1%) with no congenital malformation, 12,106 cases (5.6%) with minor fetal malformations, and 2845 cases (1.3%) with major fetal malformations. Compared with individuals with no fetal malformation, those with major fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.2%; adjusted relative risk, 1.51; 95% confidence interval, 1.07-2.12), postpartum hemorrhage (3.6% vs 6.9%; adjusted relative risk, 1.76; 95% confidence interval, 1.50-2.06), preeclampsia (5.1% vs 8.3%; adjusted relative risk, 1.48; 95% confidence interval, 1.31-1.67), and cesarean delivery (26.7% vs 42.3%; adjusted relative risk, 1.51; 95% confidence interval, 1.45-1.58). Compared with individuals with no fetal malformation, those with minor fetal malformations were more likely to have severe maternal morbidity (0.7% vs 1.4%; adjusted relative risk, 1.73; 95% confidence interval, 1.48-2.02), maternal death (0.01% vs 0.03%; adjusted relative risk, 4.50; 95% confidence interval, 1.18-17.19), postpartum hemorrhage (3.6% vs 6.1%; adjusted relative risk, 1.54; 95% confidence interval, 1.41-1.68), preeclampsia (5.1% vs 8.6%; adjusted relative risk, 1.50; 95% confidence interval, 1.41-1.60), superimposed preeclampsia (1.2% vs 2.4%; adjusted relative risk, 1.25; 95% confidence interval, 1.14-1.38), cesarean delivery (26.7% vs 39.6%; adjusted relative risk, 1.38; 95% confidence interval, 1.35-1.41), chorioamnionitis (3.0% vs 4.7%; adjusted relative risk, 1.41; 95% confidence interval, 1.29-1.53), and postpartum endometritis (0.6% vs 1.0%; adjusted relative risk, 1.58; 95% confidence interval, 1.31-1.90). Major and minor congenital fetal malformations are independent risk factors for severe maternal morbidity and other pregnancy complications.

Risk factors for severe postpartum hemorrhage requiring blood transfusion after cesarean delivery for twin pregnancy: a nationwide cohort study.

Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality. Twin pregnancy and cesarean delivery are well-known risk factors for PPH. However, few studies have investigated PPH risk factors in mothers who have undergone cesarean delivery for twin pregnancies. Therefore, this study investigated the risk factors associated with severe PPH after cesarean delivery for twin pregnancies. We searched and reviewed the Korean Health Insurance Review and Assessment Service's claims data from July 2008 to June 2021 using the code corresponding to cesarean delivery for twin pregnancy. Severe PPH was defined as hemorrhage requiring red blood cell (RBC) transfusion during the peripartum period. The risk factors associated with severe PPH were identified among the procedure and diagnosis code variables and analyzed using univariate and multivariate logistic regressions. We analyzed 31,074 cesarean deliveries for twin pregnancies, and 4,892 patients who underwent cesarean deliveries for twin pregnancies and received RBC transfusions for severe PPH were included. According to the multivariate analysis, placental disorders (odds ratio, 4.50; 95% confidence interval, 4.09-4.95; P < 0.001), general anesthesia (2.33, 2.18-2.49; P < 0.001), preeclampsia (2.20, 1.99-2.43; P < 0.001), hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome (2.12, 1.22-3.68; P = 0.008), induction failure (1.37, 1.07-1.76; P = 0.014), and hypertension (1.31, 1.18-1.44; P < 0.001) predicted severe PPH. Placental disorders, hypertensive disorders such as preeclampsia and HELLP syndrome, and induction failure increased the risk of severe PPH after cesarean delivery for twin pregnancy.

Knowledge, Attitude and Practices on the Use of Uterine Tamponade in the Management of Severe Postpartum Hemorrhage in Public Health Facilities of Niger State

Background: Obstetric hemorrhage is a contributor to worldwide maternal morbidity and mortality in low-resource countries. The aim of this study was to assess knowledge, attitude and practices on the use of uterine tamponade in managing severe postpartum hemorrhage (PPH) by healthcare personnel.&#x0D; Method: The study was descriptive and cross-sectional. A self-administered, structured questionnaire was used to collect data on uterine tamponade from untrained and trained health workers who take deliveries in labour wards of selected health facilities. Respondents were selected by cluster sampling technique. Data was analyzed using SPSS version 20. Frequencies were determined and chi-square was used to test the hypothesis. A p-value of &lt;0.05 was considered statistically significant.&#x0D; Results: The mean age of the respondents was 35 years ± 11.7. Slightly less than half of the respondents 62 (42.5%) had poor knowledge of uterine tamponade. The majority of respondents 120 (82.2%) had positive attitudes about uterine tamponade. This was associated with point of service, professional group, and previous training on uterine tamponade insertion (p&lt;0.05). About 70% (46; 69.7%) of respondents who had managed cases of refractory postpartum hemorrhage, had never conducted uterine tamponade. Reasons include inadequate knowledge (29; 63.0%) and unavailability of the commodities (9; 19.6%)&#x0D; Conclusion: Though knowledge about uterine tamponade was poor, attitude towards uterine tamponade in managing severe post- partum hemorrhage was good. However, this did not translate to good practices on the use of uterine tamponade in managing severe PPH. Training and re-training on the application of uterine tamponade should be conducted and commodities made available in every health facility.

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

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

Women with severe postpartum hemorrhage have a decreased endogenous thrombin potential before delivery

BackgroundSevere postpartum hemorrhage (PPH), defined as a blood loss ≥1000 mL, is associated with maternal morbidity and mortality. ObjectivesWe aimed at characterizing coagulation properties of predelivery plasmas from pregnant women with thrombin generation assay and hemostatic biomarkers (plasminogen activator inhibitor-1, tissue factor [TF], and thrombomodulin). MethodsA nested case-control study was conducted within the “Study of Biological Determinants of Bleeding Postpartum,” a French prospective cohort study, in order to compare women with severe PPH (cases) and controls matched for age, body mass index, term, and mode of delivery. Plasma was collected at entry in the delivery room, and blood loss was measured objectively. The predelivery endogenous thrombin generation potential (ETP) was measured in plasma using calibrated automated thrombinography and low TF concentration. Hemostatic biomarkers were measured using ELISA kits. ResultsA total of 142 women (71 cases and 71 controls) were investigated. There was no difference in the median lag phase, thrombin peak, and time to peak between cases and controls. However, median predelivery ETP was lower in cases than in controls (2170 vs 2408 nM.min, P < .0001), independently of mode of delivery and PPH etiology. Median plasminogen activator inhibitor-1 and TF levels were higher in cases compared with controls (107.4 vs 68.1 ng/mL, P = .0003; 34.4 vs 27.4 pg/mL, P = .007), whereas thrombomodulin levels did not differ between the 2 groups. ConclusionAmong thrombin generation assay parameters, predelivery ETP levels may have a predictive value for severe PPH.

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

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

The Efficacy and Safety of Dinoprostone Vaginal Insert for Labor Induction Following Optimization of Standard Operating Procedure: A Retrospective Study in China

Background: The study aimed to assess the efficacy and safety of dinoprostone vaginal insert in labor induction following optimization of standard operating procedure (SOP) and to discover independent predictors of vaginal delivery. Methods: This study comprised 551 pregnant women who required cervical ripening with dinoprostone before induction of labor. Using univariate and multivariate analyses, independent predictors of vaginal delivery were identified. Results: 443 of the 551 women (80.4%) gave birth vaginally. Vaginal delivery was predicted by maternal age (24–30 vs. &lt; 24, P &lt; 0.001; 30–35 vs. &lt; 24, P = 0.03), gestational age (P = 0.005), birth weight (P &lt; 0.001), parity (P = 0.001), pre-pregnancy BMI (P &lt; 0.001), premature rupture of membranes (P = 0.001), meconium-stained amniotic fluid (P &lt; 0.001), fundal height (P &lt; 0.001) and the Bishop score (P &lt; 0.001). None of the women exhibited severe postpartum hemorrhage. Conclusions: The maternal age, gestational age, birth weight, parity, body mass index, premature membrane rupture, amniotic fluid contamination, fundal height, and the Bishop score were independent predictors of vaginal delivery. These may guide the clinical use of dinoprostone for induction of labor.

Effect of uterine artery embolization on fertility preservation in the treatment of symptomatic uterine fibroids

Introduction: Uterine fibroids are the most common benign tumors of the uterus. Most often they are asymptomatic, but in their course there may be ailments such as: abnormal bleeding, anaemia, pain, constipation, problems with urination. These tumors are also one of the many causes of infertility. They are most often detected during a standard ultrasound examination. Pharmacological, minimally invasive and surgical treatment is currently available.&#x0D; Aim: The aim of our study was to review scientific articles in order to demonstrate whether the treatment of uterine fibroids with uterine artery embolization has an impact on fertility and pregnancy outcomes.&#x0D; Materials and methods: Review of the latest PubMed literature, Google Scholar in the period 2017 - 2023 and evaluation of available randomized controlled trials using uterine artery embolization in terms of fertility preservation by assessing ovarian reserve, number of pregnancies, miscarriages and perinatal complications.&#x0D; Conclusions: Uterine artery embolization is a safe and effective method in reducing symptoms associated with uterine fibroids. This procedure shortens hospitalization and recovery time compared to myomectomy or hysterectomy. Unfortunately, for women who want children, this method is not recommended due to the risk of reduced ovarian reserve and miscarriage, premature birth, placental abnormality, and severe postpartum hemorrhage.&#x0D;

Clinical significance of retained products of conception in placenta previa: a retrospective analysis

BackgroundRetained products of conception (RPOC) often cause severe postpartum hemorrhage (PPH) but the clinical significance of RPOC in placenta previa is unclear. This study aimed to investigate the clinical significance of RPOC in women with placenta previa. The primary outcome was to evaluate risk factors of RPOC and the secondary outcome was to consider risk factors of severe PPH.MethodsSingleton pregnant women with placenta previa who underwent cesarean section (CS) and placenta removal during the operation at the National Defense Medical College Hospital between January 2004 and December 2021 were identified. A retrospective analysis was performed to examine the frequency and risk factors of RPOC and the association of RPOC with severe PPH in pregnant women with placenta previa.ResultsThis study included 335 pregnant women. Among these, 24 (7.2%) pregnant women developed RPOC. Pregnant women with prior CS (Odds Ratio (OR) 5.98; 95% Confidence Interval (CI) 2.35–15.20, p < 0.01), major previa (OR 3.15; 95% CI 1.19–8.32, p < 0.01), and placenta accreta spectrum (PAS) (OR 92.7; 95% CI 18.39–467.22, p < 0.01) were more frequent in the RPOC group. Multivariate analysis revealed that prior CS (OR 10.70; 95% CI 3.47–33.00, p < 0.01,) and PAS (OR 140.32; 95% CI 23.84–825.79, p < 0.01) were risk factors for RPOC. In pregnant women who have placenta previa with RPOC or without RPOC, the ratio of severe PPH were 58.3% and 4.5%, respectively (p < 0.01). Furthermore, the occurrence of prior CS (OR 9.23; 95% CI 4.02–21.20, p < 0.01), major previa (OR 11.35; 95% CI 3.35–38.38, p < 0.01), placenta at the anterior wall (OR 3.44; 95% CI 1.40–8.44, p = 0.01), PAS (OR 16.47; 95% CI 4.66–58.26, p < 0.01), and RPOC (OR 29.70; 95% CI 11.23–78.55, p < 0.01) was more in pregnant women with severe PPH. In the multivariate analysis for severe PPH, prior CS (OR 4.71; 95% CI 1.29–17.13, p = 0.02), major previa (OR 7.50; 95% CI 1.98–28.43, p < 0.01), and RPOC (OR 13.26; 95% CI 3.61–48.63, p < 0.01) were identified as risk factors.ConclusionsPrior CS and PAS were identified as risk factors for RPOC in placenta previa and RPOC is closely associated with severe PPH. Therefore, a new strategy for RPOC in placenta previa is needed.

Prevention of Post-Partum Hemorrhage: Comparison of Oxytocin and Misoprostol. A Two center study in the Bamenda and Nkwen Health Districts

Background: Postpartum hemorrhage is one of the most common obstetrical complications affecting up to 18% of deliveries. Globally, it is responsible for 35 – 55% of peripartum maternal deaths. In Cameroon, the maternal mortality rate is at 406 maternal death per 100,000 live births, with PPH being the leading cause accounting for about 25%. This study aimed to compare the efficacy and safety of misoprostol versus oxytocin in the prevention of postpartum hemorrhage in the Bamenda Health District and Nkwen Health District. Methods: This was a hospital-based randomized clinical trial study in the Bamenda Regional Hospital and Nkwen District Hospital. The study was conducted from March 1st to May 31st 2021 including pregnant women who delivered at the maternity at these two hospitals. All their pregnancy was singleton gestation at term and haven given their informed consent. Women with known history of cardiac, renal, hepatic diseases or any coagulopathy, Cesarean delivery were excluded. We randomized 308 participants in a 1:1 ratio to receive 800 μg of oral misoprostol or 10IU of oxytocin intramuscularly during the active management of third stage of labor (AMSTL). The Hemoglobin (Hb) concentration and hematocrit (HCT) of the participants were measured before and 24hrs after delivery. Our primary outcome of interest was (Post-Partum Hemorrhage) PPH, defined as Hb change ≥ 1g/dl within 24hrs of delivery. Secondary outcomes included; mean Hb change, Hb change ≥2g/dl (severe PPH). Dichotomous outcomes between study groups were compared by estimating crude relative risks (RRs) with 95% confidence intervals. Logistic regression (the chi-square test) was done to determine the factors associated with the occurrence of postpartum hemorrhage, with a level of significance at 5%. Results: After 24hrs, Postpartum hemorrhage (PPH) occurred in 41 (26.6%) and 47 (30.5%) participants in the misoprostol and oxytocin groups respectively (RR= 0.87, 95% C.I= 0.61 - 1.24, p=0.449). Severe postpartum hemorrhage occurred in 3 (1.9%) and 5 (3.2%) participants in the misoprostol and oxytocin groups respectively (RR= 0.6, 95% C.I=0.15 - 2.47, p=0.723). Past history of PPH (aOR=10.1 (3.5 – 28.6), p&lt;0.0001), augmentation of labor (aOR=3.4 (1.6 – 7.1), p=0.0011), fetal birth weight ≥3.5Kg (aOR=2.5 (1.3 – 4.8), p=0.0074) and retained products (aOR= 8.4 (4.2 – 16.7), p&lt;0.0001) were risk factors of PPH. Participants in the misoprostol group more commonly experienced shivering (RR 3.2, 95% CI 2.0 - 5.1, p&lt;0.0001) and nausea/vomiting (RR 35.5, 95% CI 8.9 – 142.2, p&lt;0.0001). Conclusion: Oral misoprostol at the dose of 800μg is as effective as 10 IU IM Oxytocin in the prevention of PPH and is a potent alternative to oxytocin. Most common risk factors of PPH are past history of PPH, augmentation of labor, fetal weight ≥ 3.5kg and retained products. Side effects were mostly associated with 800μg of oral Misoprostol.

Association of severe maternal morbidity with bonding impairment and self-harm ideation: A multicenter prospective cohort study

BackgroundEvidence on the association between severe maternal morbidity (SMM) and mother-infant bonding and self-harm ideation is limited. We aimed to examine these associations and the mediating effect of Neonatal Intensive Care Unit (NICU) admission at one-month postpartum. MethodsThis multicenter, prospective cohort study was conducted in Japan (n = 5398). SMM included preeclampsia, eclampsia, severe postpartum hemorrhage, placental abruption, and a ruptured uterus. Lack of affection (LA) and Anger and Rejection (AR) were assessed using the Mother-Infant Bonding Scale (MIBS), and self-harm ideation was assessed using the 10th item of the Edinburgh Postnatal Depression Scale (EPDS). Linear and logistic regression models were used to examine the association between SMM and MIBS score and self-harm ideation. A structural equation model (SEM) was employed to examine the mediating effect of NICU admission on the association between SMM and mother-infant bonding and postpartum depressive symptoms. ResultsWomen with SMM had a 0.21 (95 % confidence interval [CI]: 0.03–0.40) point higher MIBS score and a decreasing trend in the risk of self-harm ideation (odds ratio 0.28, 95 % CI: 0.07–1.14) compared to those without SMM. SEM analysis revealed that SMM was associated with MIBS partially through NICU admission. LimitationsEPDS scores during pregnancy could be an unmeasured confounder. ConclusionsWomen with SMM had higher MIBS scores, particularly on the LA subscale, which was partially mediated by NICU admission. Psychotherapy to support parent-infant relationships is necessary for women with SMM.

#6437 INTRABDOMINAL ABSCESS: AN UNEXPECTED CAUSE OF POSTPARTUM SEPSIS IN A VAGINALLY DELIVERED WOMAN WITH PREGNANCY RELATED ACUTE KIDNEY INJURY

Abstract Pregnancy related-Acute kidney injury (PR-AKI) is a life-threatening complication with substantial fetal and maternal mortality and morbidity. AKI is associated with increased risk of infection and/or sepsis. Intra-abdominal infections account for 11.9% of infections that complicate AKI among critically ill patients. The pathophysiology is not fully understood, several theories have been proposed; of which, AKI associated hypervolemia leads to tissue edema and bacterial translocation. Moreover, AKI induces a hyper-inflammatory state and suppresses the immune system, this may present a greater predisposition for infection. Here we report a rare case of intra-abdominal abscess presented in a woman with recovering PR-AKI three months following normal vaginal delivery. Case presentation A 20-year-old, previously healthy female patient, was admitted due to severe postpartum hemorrhage (PPH) complicating a full-term vaginal delivery. On admission, blood pressure was 170/70, heart rate was 100 beats/min, and respiratory rate was 22 breaths/min. The patient developed oliguria, generalized edema, and fever (38.50c). The blood tests are revealed in Table I. The patient had elevated liver enzymes (SGOT 197 IU/L, and SGPT 117 IU/L). The patient was started on supportive treatment with packed RBC, platelet transfusion, and fresh frozen plasma. Empiric antibiotic was administrated. The patient subsequently had general improvement and was discharged 17 days after delivery with partial recovery of kidney function. Three months later, the patient presented with throbbing pain in the lower abdomen and fever. Abdominal examination revealed pelvi-abdominal fullness along with mild tenderness with no guarding or rigidity. No obvious palpable lumps were detected. No abnormities were detected in per vaginal and per rectal examinations. CT scan was performed and revealed a large sized collection in the lower abdomen sized 6.5x5x9 cm. Ultrasound guided aspiration of 60 ml pus confirmed the diagnosis of intraabdominal abscess. Intravenous antibiotics were started with percutaneous drainage of the abscess. Discussion Intraabdominal abscess is a serious ailment, and it is associated with high mortality and morbidity if left untreated. An intra-abdominal abscess can cause symptoms such as prolonged ileus, anorexia, fever, and abdominal pain. Septic shock may eventually develop in case of delayed treatment. However rare, there should be a causative factor. Intraabdominal abscess following a normal vaginal delivery is very rare and not reported with PR-AKI. CT scan is still the most useful technique for diagnosis and treatment. Additionally, it can help guide percutaneous drainage by locating the abscess in relation to the viscera of the abdomen. The use of adequate antimicrobial drug therapy in combination is a fundamental approach. It is therefore of great importance to consider symptoms such as atypical abdominal distension or pain in women in the postpartum period and to provide thorough comprehensive evaluation. Early diagnostic consideration greatly lessens patients’ morbidity and mortality.

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.

Impaired hypoglycaemia awareness in early pregnancy increases risk of severe hypoglycaemia in the mid-long term postpartum irrespective of breastfeeding status in women with type 1 diabetes

IntroductionInformation regarding the postpartum period in women with type 1 diabetes (T1D) is scarce. We aim to evaluate the relation of impaired hypoglycaemia awareness (IAH) in early pregnancy and breastfeeding status (its presence and duration) with severe postpartum hypoglycaemia (SH). Materials and methodsRetrospective cohort study of women with T1D followed during pregnancy between 2012 and 2019. Data on SH were recorded before and during pregnancy. IAH was evaluated at the first antenatal visit. Data on breastfeeding and the long-term postpartum period were collected by questionnaire and from medical records. ResultsA total of 89 women with T1D were included with a median follow-up after pregnancy of 19.2 [8.7–30.5] months. Twenty-eight (32%) women had IAH at the first antenatal visit. At discharge, 74 (83%) started breastfeeding during a median of 8 [4.4–15] months. A total of 18 (22%) women experienced ≥1 SH during postpartum. The incidence of SH significantly increased from pregestational to the gestational and post-partum period (0.09, 0.15 and 0.25 episodes/patient-year, respectively). Postpartum SH rates were comparable in breastfeeding and non-breastfeeding women (21.4% vs. 25%, respectively, p>0.05). Clarke test score at the first antenatal visit was associated with postpartum SH (for each 1-point increase: OR 1.53; 95% CI, 1.06–2.21) adjusted for confounders. No other diabetes and pregnancy-related variables were identified as predictors of SH in this period. ConclusionsSH are common in the long-term postpartum period independently of breastfeeding. Assessing IAH in early pregnancy could identify those at an increased risk of SH in the postpartum period.

Aberrant structural and functional alterations in postpartum depression: a combined voxel-based morphometry and resting-state functional connectivity study.

Postpartum depression (PPD) is a severe postpartum psychiatric disorder with unclear pathogenesis. Previous neuroimaging studies have reported structural or functional alterations in areas associated with emotion regulation, cognitive disorder, and parenting behaviors of PPD. The primary goal of this investigation was to explore the presence of brain structural alterations and relevant functional changes in PPD patients. A total of 28 patients and 30 matched healthy postnatal women (HPW) underwent both three-dimensional T1-weighted magnetic resonance imaging (MRI) and resting-state functional MRI. Structural analysis was performed by voxel-based morphometry (VBM), followed by resting-state functional analysis using a seed-based whole-brain functional connectivity (FC) approach with abnormal gray matter volume (GMV) regions as seed. Compared with HPW, the PPD patients showed increased GMV in the left dorsolateral prefrontal cortex (DLPFC.L), the right precentral gyrus (PrCG.R), and the orbitofrontal cortex (OFC). In the PPD group, the DLPFC.L showed increased FC with the right anterior cingulate and paracingulate gyri (ACG.R) and the right middle frontal gyrus (MFG.R); the FC between the PrCG.R and the right median cingulate and paracingulate gyri (DCG.R) exhibited enhanced; the OFC showed increased FC with MFG.R and the left inferior occipital gyrus (IOG.L). In PPD, GMV of DLPFC.L was positively correlated with EDPS scores (r = 0.409 p = 0.031), and FC of PrCG.R-DCG.R was positively correlated with EDPS scores (r = 0.483 p = 0.020). Structural and functional damage of the DLPFC.L and OFC is associated with cognitive disorders and parenting behaviors in PPD, while structural abnormalities of the DLPFC.L and PrCG.R are involved in impaired executive function. The increased GMV of DLPFC.L may be a unique structural pathological mechanism of PPD related to the inability of PPD patients to withstand long-term parenting stress. These findings have important implications for understanding neural mechanisms in PPD.

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

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

Postpartum Blues in Fathers: Prevalence, Associated Factors, and Impact on Father-to-Infant Bond.

In this study we explored, in men, one of the most common postpartum syndromes in women: the postpartum blues. The aims of the study were (a) to evaluate the prevalence of postpartum blues in fathers, (b) to explore the sociodemographic and perinatal factors that may be associated with its intensity, and (c) to investigate the relationship between the intensity of blues symptoms and the quality of father-to-infant bonding. Three hundred and three French-speaking fathers living in France completed a sociodemographic and obstetrical questionnaire, the Maternity Blues Questionnaire, and the Postpartum Bonding Questionnaire. The fathers were recruited from two maternity hospitals and a Child and Maternal Health Centre within 10 days of their infant's birth, or from online forums devoted to parenting. At least 17.5% of fathers experienced postpartum blues. A high level of education was associated with a higher level of postpartum blues symptoms. Dissatisfaction with the maternity care and significant father involvement during pregnancy and delivery predicted more severe postpartum blues symptoms. Symptoms of postpartum blues were positively correlated with impairment in the father-to-infant bond. This study lends support to the existence of postpartum blues among fathers and highlights its possible consequences on early father-infant relationships.

Exploring trends of severe postpartum haemorrhage: a hospital-based study

BackgroundOver the past two decades several high-income countries have reported increased rates of postpartum haemorrhage (PPH). Many of the studies are registry studies with limited access to detailed information. We aimed to explore trends of severe PPH in the largest labour ward in Norway during a 10-year period with a hospital based study. Our population constituted all women who gave birth after week 22 at Oslo University Hospital between 2008 and 2017. The main outcome measure was severe PPH, defined as registered blood loss greater than 1500 ml, or transfusion of blood products due to PPH.MethodsWe estimated the incidence of severe PPH and blood transfusions, and performed temporal trend analysis. We performed Poisson regression analysis to investigate associations between pregnancy characteristics and severe PPH, presented using crude incidence rate ratios (IRR) with 95% confidence intervals (CI)s. We also estimated annual percentage change of the linear trends.ResultsAmong 96 313 deliveries during the 10-year study period, 2621 (2.7%) were diagnosed with severe PPH. The incidence rate doubled from 17.1/1000 to 2008 to 34.2/1000 in 2017. We also observed an increased rate of women receiving blood transfusion due to PPH, from 12.2/1000 to 2008 to 27.5/1000 in 2017. The rates of invasive procedures to manage severe PPH did not increase, and we did not observe a significant increase in the number of women defined with maternal near miss or massive transfusions. No women died due to PPH during the study period.ConclusionWe found a significant increasing trend of severe PPH and related blood transfusions during the 10-year study period. We did not find an increase in massive PPH, or in invasive management, and we suspect that the rise can be at least partly explained by increased awareness and early intervention contributing to improved registration of severe PPH.