Uncontrolled Postpartum Hemorrhage Research Articles

Trends in Indications, Intraoperative Findings and Outcome of Relaparotomy after Caesarean Section at a Tertiary Hospital in Eastern Zone Tanzania; Five Years’ Review

Background: The increased incidences of caesarean section rate is associated with a number of post-operative complications; one being re-laparotomy which is considered a maternal near-miss. The purpose of a re-laparotomy is to manage complications of the previous surgery such as unsecured hemostasis, manage intraabdominal infection, repairing of iatrogenic damaged organs like bowels, ureters and bladder, relieve intestinal obstruction and maintain intestinal continuity or to carry out delayed curative surgery. In general, second surgery increases not only the morbidity but also the risk of maternal mortality. Methods: The study was cross sectional, conducted at the Department of Obstetrics and Gynecology in MNH. It involved review of medical records of all women who necessitated re-laparotomy following Caesarean Section (CS) that was performed either at MNH or from referring health facilities during the study period. Results: There were 193 relaparotomy cases, 98% were referrals. Atonic uterus and sepsis (septic uterus, pelvic abscess and pus in peritoneal cavity) as intraoperative finding showed statistical significance in our study. Atonic uterus for those women who underwent relaparotomy due to post-partum hemorrhage (PPH) increase from 1(7.7%) in 2017 to 6(14%) in 2021 with an average increase of 2.31 % every year. Number of cases for sepsis (combination of septic uterus, pelvic abscess and pus in peritoneal cavity) was significant decreasing every year from 22(37.3%) in 2018 to 7(16.3%) 2021with an average decrease of 3.15% every year from 2017 to 2021. The number of cases who had hysterectomy as one of the post-operative outcomes was statistically significant decreasing from 44(74.6%) to 26(60.5%) over the study period with an average decrease of 5.89% every year from 2018 to 2021. Conclusion: The most frequent indication for relaparotomy after CS was a burst abdomen. For the women who had relaparotomy due to uncontrollable PPH, the main intraoperative .......

Early treatment with Fibrinogen γ-chain peptide-coated, ADP-encapsulated Liposomes (H12-(ADP)-liposomes) ameliorates post-partum hemorrhage with coagulopathy caused by amniotic fluid embolism in rabbits

Amniotic fluid embolism is an unpredictable and sometimes lethal complication of childbirth. Fibrinogen γ-chain peptide-coated, ADP-encapsulated Liposomes (H12-(ADP)-liposomes), which were developed as a platelet substitute, may be useful to control postpartum hemorrhage with consumptive coagulopathy. This study aimed to establish a hemodynamically stable amniotic fluid embolism animal model and evaluate the efficacy of H12-ADP-liposome infusion in the initial management of postpartum hemorrhage complicated with amniotic fluid embolism-involved coagulopathy. Pregnant New Zealand white rabbits (28th day of pregnancy or normal gestation period of 29-35 days) underwent cesarean delivery, followed by intravenous administration of amniotic fluid (a total of 3.0 mL administered in 4 doses over 9 minutes). Thereafter, uncontrolled postpartum hemorrhage was induced by transecting the right midartery and concomitant vein in the myometrium. After initial bleeding for 5 minutes, rabbits received isovolemic fluid resuscitation through the femoral vein with an equivalent volume of blood loss every 5 minutes for 60 minutes. The transfusion regimens included platelet-rich plasma, platelet-poor plasma, and a bolus administration of H12-ADP-liposomes followed by platelet-poor plasma transfusion (8 rabbits per group). Moreover, 60 minutes after initiation of bleeding, rabbits received surgical hemostasis by ligation of bleeding vessels, except in cases with spontaneous hemostasis. The administration of amniotic fluid caused thrombocytopenia (56±3 × 103/μL) and prolonged both clotting time (before administration: 130.0±3.0 to 171.0±5.0 seconds) and prothrombin time (4.5±0.1 to 4.7±0.1 seconds). After the initial 5-minute bleeding in the rabbits, the mean arterial pressure fell to 43±2 mm Hg. Platelet-poor plasma transfusion alone further prolonged clotting time and prothrombin time at 60 minutes (192.0±10.0 and 5.2±0.1 seconds, respectively) with decreasing mean arterial pressure to <40 mm Hg. By contrast, the administration of H12-ADP-liposomes followed by platelet-poor plasma transfusion reduced the prolonged clotting time (153.0±5.0 seconds) and prothrombin time (4.9±0.1 seconds) similar to platelet-rich plasma transfusion (154.0±11.0 and 4.9±0.1 seconds, respectively) at 60 minutes. These rabbits maintained a mean arterial pressure of >45 mm Hg throughout the experiment. H12-ADP-liposome infusion and platelet-poor plasma transfusion and platelet-rich plasma transfusion yielded spontaneous hemostasis in 4 of 8 rabbits, whereas platelet-poor plasma transfusion did not stop bleeding in any of the rabbits. The total blood loss was 59±17 mL in the H12-ADP-liposomes and platelet-poor plasma group, which was half of that in the platelet-poor plasma group (124±10 mL). H12-ADP-liposome infusion may be effective in the initial management of postpartum hemorrhage complicated with amniotic fluid embolism, resulting in mitigation of consumptive coagulopathy.

Assessment of the self-confidence of obstetrics & gynecology fellows to perform a postpartum hemostasis hysterectomy.

Hemostasis Hysterectomy (HH) is a last resort surgical procedure performed in situations of uncontrolled post-partum hemorrhage in maternity wards. The chances of being confronted with this situation are scarce during residency, and the situation is not well suited for teaching. Nevertheless, every obstetrician-gynecologist can be confronted with this stressful situation, and should therefore possess the surgical competence required, regardless of his routine practice. The aim of the present study is to evaluate clinical exposure and self-awareness concerning HH amongst obstetrics and gynecology residents and fellows. We performed a survey amongst French obstetrics and gynecology fellows. An anonymous survey was sent by email between December 1, 2020 to July 1, 2021. Half of the interrogated fellows had practiced (as operator) an HH during residency with a senior and only 22,6% in post-residency. During the last year of residency 70% of them had performed less than 10 scheduled hysterectomies as primary operator. The laparoscopic approach was the most frequently practiced. Very few hysterectomies were performed as primary operator. Fellows with a surgical or mixed activity (both gynecological surgery and obstetrical activity in current practice) felt significantly more capable of performing HH compared to those with exclusive obstetrical or reproductive medicine activity; respectively 60% vs 36%, p=0.008; Odds Ratio: 2.629 (95% CI 1.2214; 5.8094). The number of scheduled hysterectomies or HH performed as primary operator is very low during residency or fellowship. It remains largely inferior to the number deemed necessary in previous publications about the learning curve for scheduled hysterectomy, which varies from 18 to 80 interventions. Nowadays, the increasing number of residents, added to the decrease of hemostasis hysterectomies through better management of post-partum hemorrhage, pushes towards the development of specific training, such as "damage control simulation".

PERIPARTUM HYSTERECTOMY- A RETROSPECTIVE ANALYSIS

Background: Peripartum hysterectomy (PH) is the removal of the uterus performed in obstetrical complications such as irreparable uterine rupture, uncontrolled postpartum hemorrhage (PPH) and placenta accrete syndrome. In spite of increased medical facilities its incidence has increased in recent years. Methods: A retrospective analysis of 20 cases of peripartum hysterectomy performed from January 2014 to June 2021 was done. The total numbers of caesarean and vaginal deliveries were recorded. Main outcome measures were the incidence, indication, management option used, maternal and fetal outcome. Results: There were a total of 6824 deliveries; 3901 vaginal and 2923 caesarean sections. Atotal of 20 patients underwent PH. The incidence of PH in our study was 2.9/1000 total deliveries and 6.8 /1,000 caesarean births. The main indication was rupture uterus with total of 10 cases (50%). Majority of cases 13 (65%) were in the age group of 20-30years and 17 (85%) were unbooked. 17 (85%) cases were referred from peripheral centers. All women who had uterine rupture were referrals from other centers. Intensive care management was required in 17(85%) women postoperatively. The common maternal complications were febrile morbidity, bladder injury, and surgical site infection. There was no maternal mortality. But neonatal mortality was in 10 cases (50%). The average period of hospital stay was 10 days. Conclusion: The most common indication for peripartum hysterectomy was rupture uterus. Correct assessment with quick intervention with a multidisciplinary team approach is the main key to prevent maternal mortality and morbidity.

PLACENTA PREVIA AND PLACENTA ACCRETA SPECTRUM (PAS) DISORDER: INCIDENCE, RISK FACTOR AND FETOMATERNAL OUTCOME IN A TERTIARY CARE CENTER

Introduction: Placenta Previa is characterised by Placental implantation into the lower uterine segment covering whole or part of the cervix . It complicates 0.4% of pregnancy at term The average incidence is 0.3% or 1 case per 300 to 400 deliveries. The presence of placenta previa can also increase a woman's risk for placenta accreta spectrum (PAS). This spectrum of conditions includes placenta accreta, increta, and percreta. Uncontrolled postpartum hemorrhage from placenta previa or PAS may necessitate a blood transfusion, hysterectomy thus leaving the patient infertile, admission to the ICU, or even death. Material and method: Study was conducted in department of obstetrics &amp; gynecology , swaroop rani hospital, Allahabad for 1 year . A total of 102 pregnant women presenting to antenatal OPD or admitted in IPD with history of antepartum hemorrhage and conrmed case of PP or MAP in Ultrasonography were selected. The follow up till the fetomaternal outcome was done and risk factors were evaluated for 102 cases. Result: Out of the total 2342 deliveries in one year 95 patients had PP and the incidence was 4.04% and 7 patients had morbidily adherent Placenta which accounts to an incidence of 0.29%. Previous LSCS, Multiparity, increase maternal age, Dialatation and curettage were risk factors in both Placenta Previa and Morbidily Adherent Placenta. Antenatal complication were antepartum hemmorrhage , Anemia, preterm labor. Emergency LSCS is more common mode of delivery in cases of Placenta previa. Caesarean hysterectomy were done in 3.2% cases of Placenta Previa and all cases of Morbidily adherent placenta . Most common perinatal complications in both groups were prematurity and low birth weight. Conclusion: Now a days Placenta previa and Morbidily adherent placenta are very common. Incidence increases as the rate of cesaerean section or abdominal surgery were increases.Earlydiagnosis and pre plan mode of delivery will decrease the risk of prematurity and low birth weight.

Incidence, Management and Outcomes in Women Undergoing Peripartum Hysterectomy in a Tertiary Care Centre in India.

BackgroundPeripartum hysterectomy (PRH) is the surgical removal of the uterus performed in obstetrical complications such as uncontrolled postpartum haemorrhage (PPH), unrepairable uterine rupture, and sepsis. Its incidence has increased in recent years. The objective of this study was to review all the cases of PRH in a tertiary care teaching hospital over three years (January 2017-December 2019) to determine its incidence and analyse clinico-demographic characteristics in these women.MethodAll women undergoing PRH from January 2017 to December 2019 were included in the study. Data were collected retrospectively from medical records, of patients who underwent a PRH at the time of delivery, or within 24 hours, or performed any time before discharge from the same hospitalization and obstetric event. The total number of deliveries including caesarean and vaginal deliveries were recorded. Main outcome measures were the incidence of PRH, indication for hysterectomy, management option used, maternal outcomes (PPH, bladder injury and maternal death) and fetal outcomes (stillbirth).ResultsThere were a total of 3904,4 deliveries; 27,337 vaginal and 11,697 caesarean sections in three years. A total of 50 patients underwent a PRH. The incidence of PRH in our study was 1.3 per 1,000 deliveries and 3.5/1,000 caesareans, respectively. PRH was found to be more common following cesarean sections than vaginal deliveries (odds ratio 22.86 [95% CI: 8.16 to 63.98]). Morbid adherent placenta (MAP) (n=30, 62%) was the most common indications of PRH. Seven (15%) women had PRH due to uterine rupture. Twenty-seven women of the 30 women (90%) with the MAP had a previous caesarean delivery. The case fatality rate per hysterectomy was 4%. Stillbirth rate (SBR: n=8,16%) among women having PRH was seven-fold higher than overall SBR in our country.ConclusionThere has been a rise in MAP as an indication of PRH in our study for a decade in comparison to uterine atony. Caesarean delivery is a significant risk factor for PRH. Previous caesarean section and major placenta previa were common occurring obstetric risk factors present in the MAP in our cohort. Our maternal mortality in PRH was low and the stillbirth rate was high when compared with national data.

Healthcare providers experiences of using uterine balloon tamponade (UBT) devices for the treatment of post-partum haemorrhage: A meta-synthesis of qualitative studies.

Postpartum haemorrhage (PPH) is a leading cause of maternal mortality and severe morbidity globally. When PPH cannot be controlled using standard medical treatments, uterine balloon tamponade (UBT) may be used to arrest bleeding. While UBT is used by healthcare providers in hospital settings internationally, their views and experiences have not been systematically explored. The aim of this review is to identify, appraise and synthesize available evidence about the views and experiences of healthcare providers using UBT to treat PPH. Using a pre-determined search strategy, we searched MEDLINE, CINAHL, PsycINFO, EMBASE, LILACS, AJOL, and reference lists of eligible studies published 1996-2019, reporting qualitative data on the views and experiences of health professionals using UBT to treat PPH. Author findings were extracted and synthesised using techniques derived from thematic synthesis and confidence in the findings was assessed using GRADE-CERQual. Out of 89 studies we identified 5 that met our inclusion criteria. The studies were conducted in five low- and middle-income countries (LMICs) in Africa and reported on the use of simple UBT devices for the treatment of PPH. A variety of cadres (including midwives, medical officers and clinical officers) had experience with using UBTs and found them to be effective, convenient, easy to assemble and relatively inexpensive. Providers also suggested regular, hands-on training was necessary to maintain skills and highlighted the importance of community engagement in successful implementation. Providers felt that administration of a simple UBT device offered a practical and cost-effective approach to the treatment of uncontrolled PPH, especially in contexts where uterotonics were ineffective or unavailable or where access to surgery was not possible. The findings are limited by the relatively small number of studies contributing to the review and further research in other contexts is required to address wider acceptability and feasibility issues.

Post-contrast Acute Kidney Injury Following Emergency Transcatheter Arterial Embolization for Uncontrollable Postpartum Hemorrhage.

The aim of this study was to investigate the incidence of post-contrast acute kidney injury (PC-AKI) in patients with uncontrollable postpartum hemorrhage undergoing emergency transcatheter arterial embolization (TAE). Data collected included patient characteristics, serum creatinine (SCr) level before and after TAE, iodine quantity of contrast media, time between computed tomography and TAE, diabetes mellitus, hemorrhage volume, and blood transfusion volume. For the diagnosis of PC-AKI, the criteria of the European Society of Urogenital Radiology Guidelines (version 10.0) were used. A total of 71 TAE procedures were performed over a 5-year period, and 47 patients met the inclusion criteria. Preprocedural renal function and change of SCr were positively correlated (P < .001), although no patients met the PC-AKI criteria and none showed renal impairment on the follow-up examination (95% upper confidence limit = 6.2%). Total iodine quantity was not correlated with SCr change. Postpartum hemorrhage was finally controlled in all 47 patients, and they were subsequently discharged. In conclusion, emergency TAE for patients with uncontrollable postpartum hemorrhage was a safe and effective procedure, not only in terms of bleeding-related and other outcomes but also with respect to the risk of PC-AKI.

Conservative Management of Retained Placenta Accreta Postpartum

Retained placenta accreta is difficult to diagnose in the series of processes involved in parturition. It is usually discovered after delivery, when massive and uncontrollable postpartum hemorrhage occurs. A histological examination of residual placental tissue is the gold standard for the diagnosis of retained placenta accreta and indicates the degree of placental invasion into the myometrium. If the placenta is forcefully removed, maternal morbidity and mortality is high. Therefore, the management is essential when the placenta cannot be delivered spontaneously or manually. We present a case of a 35-year-old woman (G4P2A1L2) who had a high risk of placenta accreta due to past history of placenta accreta and previous myomectomy. After successful delivery, the placenta was not delivered as expected. Consequently, she experienced massive post-partum hemorrhage of 1,500 mL for up to 2 days post-partum, necessary of an extensive blood transfusion. Following spontaneous vaginal delivery and a failed attempt to manually remove the placenta, a uterine artery embolization was performed, and the patient improved over a few weeks. Thus, this case was successfully managed with conservative treatment, avoiding hysterectomy or other additional surgical treatments. No secondary postpartum complications were observed, and the menstrual cycle returned to normal within 6 months.

A Uterus-Preserving Treatment for Uncontrollable Postpartum Hemorrhage: Esike's Technique.

A Uterus-Preserving Treatment for Uncontrollable Postpartum Hemorrhage: Esike's Technique.

A Uterus-Preserving Treatment for Uncontrollable Postpartum Hemorrhage: Esike's Technique.

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality worldwide, with uterine atony responsible in 80% of cases. In intractable cases, hysterectomy is the final treatment, but it has complications. Many doctors in developing countries with high maternal mortality rates from postpartum hemorrhage can perform cesarean deliveries but cannot perform hysterectomy. Patients with postpartum hemorrhage who need hysterectomy in these countries will die in such cases, whereas, if doctors know this simple, easily learned technique, such patients may survive. Esike's technique is a uterine-compression method that uses supplies generally available at delivery hospitals. Six sutures are placed in the lower uterine segment, three anteriorly and three posteriorly. Starting with the middle sutures, the sutures are tied at the fundus with the help of an assistant to provide uterine compression. The more laterally placed sutures are then tied similarly, resulting in uterine compression and stoppage of postpartum hemorrhage. Esike's technique was used in controlling life-threatening, uncontrollable postpartum hemorrhage in 18 women and was successful in 16 (89%) without requiring hysterectomy. Esike's technique is effective in controlling life-threatening postpartum hemorrhage and can be used in low-resource settings with commonly available supplies and performed by doctors with a common level of training.

Successful management of uncontrolled postpartum hemorrhage due to morbidly adherent placenta with Resuscitative endovascular balloon occlusion of the aorta during emergency cesarean section - A case report -

BackgroundMorbidly adherent placenta (MAP) may cause life-threatening postpartum hemorrhage (PPH) requiring massive transfusions. Furthermore, it could endanger the lives of both mother and baby. Despite various efforts, such as adjuvant endovascular embolization and hysterectomy, massive PPH due to MAP still occurs and is difficult to overcome.CaseHerein, we described the case of a 40-year-old woman with placenta previa totalis who experienced massive bleeding during a cesarean section. We used resuscitative endovascular balloon occlusion of the aorta (REBOA) and it improved the condition of the surgical field and the hemodynamic stability of the patient temporarily. The patient was successfully managed without further complications.ConclusionsREBOA can be used as a rescue procedure for uncontrolled bleeding situations in patients with MAPs. Anesthesiologists should consider and recommend REBOA as another resuscitative therapeutic option in the case of massive PPH.

The Treatment of Post-Partum Bleeding With Embolization

Aim: To assess safety and efficacy of transcatheter embolization in the treatment of post-partum bleedings.&#x0D; Materials and Methods: In a single institution, the outcome of 15 patients who underwent trans arterial embolization (TAE) for post-partum hemorrhages (PPH) were retrospectively reviewed.&#x0D; Eleven patients presented with hemodynamic instability requiring blood transfusion (73 %), four patients were hemodynamically stable (27 %). Arterial embolization was performed with gelatin sponge, particles and coils.&#x0D; Results: Mean follow-up time was 21.2 months (range 12-48 months). Technical success rate was 100%. The overall clinical success rate was 100%. No major complications that required intensive care treatment were registered during or after the procedures. No patient required emergency surgery and subsequent hysterectomy. During follow-up, four patients become pregnant after transcatheter arterial embolization, and delivered full-term and healthy infants.&#x0D; Conclusions: TAE is a safe method that allows to avoid surgery and hysterectomy for uncontrollable post-partum hemorrhage; a future normal pregnancy after embolization may be hypothesized.

Mechanical Properties of the Every Second Matters for Mothers-Uterine Balloon Tamponade (ESM-UBT) Device: In Vitro Tests.

Objective Postpartum hemorrhage (PPH) is the most common cause of maternal mortality and morbidity worldwide, most of which occurs in resource-poor settings. Placement of a uterine balloon may be life-saving in uncontrolled PPH. The Every Second Matters for Mothers-Uterine Balloon Tamponade (ESM-UBT) device is an ultra-low-cost uterine balloon designed for global access. The purpose of this study was to evaluate the mechanical properties of the ESM-UBT device. Study design Intraluminal pressures, diameters, and burst volumes of condom uterine balloons and Foley catheter balloons of ESM-UBT devices were measured in open air and inside uterus models. Condom uterine balloons were tested with uterus model sizes of 100, 250, and 500mL. The condom-catheter O-ring attachment tensile strength was also evaluated. Results All 28 samples of ESM-UBT condom uterine balloons maintained their integrity for at least 3 hours when subjected to pressures of 200 mm Hg or greater across each of the tested uterine volumes. No Foley catheter balloons burst after instillation of 30mL, O-rings withstood forces of 15.4 ± 2.1 N, and condom uterine balloons stretched to 35.8 ± 2.1 cm without loss of integrity. Conclusion The mechanical properties of the ESM-UBT device make it attractive for scale across resource-poor settings.

Etiology of Maternal Mortality at Nepalgunj Medical College

Introduction: Maternal mortality is an indicator of the quality of obstetric care in a community directly reflecting the utilization of health care services available. Maternal mortality has been recognised as a public health problem in the developing countries.&#x0D; Aim and Objective: To analyse the etiology of maternal deaths.&#x0D; Material and Methods: This descriptive study was conducted in the gynaecology and obstetrics department of the Nepalgunj Medical College Teaching Hospital Banke Nepal for a period of two years from august 2016-august 2018. All cases of maternal deaths in line with the definition of World Health Organization have been&#x0D; included. Data were collected and analyzed.&#x0D; Results: Twenty three (23) maternal deaths were identified during the study period. 69.56% of deaths occurred due to direct obstetric causes. Uncontrollable postpartum haemorrhage with 37.5 % was the leading cause of maternal death followed by eclampsia (18.75%) and sepsis (18.75%). Indirect causes were dominated by heart disease. Maximum 56.5% of deaths had occurred after 48 hours of admission.&#x0D; Conclusions: Haemorrhage, eclampsia and infections are the main causes of maternal deaths in our study. access to emergency medication, transfusion and anaesthetic and surgical teams in hospitals but also through the involvement of religious leaders, traditional and any community to better understand the population obstacles to reducing maternal mortality.

Role of intrauterine balloon tamponade in controlling massive primary post partum haemorrage

Postpartum haemorrhage (PPH) Remains a significant complication of child birth worldwide. The most common cause of PPH is uterine atony. Recently, uterine tamponade using intrauterine condom appearsto be an effective tools in the management of uncontrolled primary PPH. Objectives of our studywas to see the effectiveness of large volume fluid filled condom catheter in the management of primary PPH. Methods: a condom was inserted in the uterus by means of a size 16 rubber catheter and inflated with 250 to 300ml normal saline until the bleeding was controlled. The condom was kept in situ for 24 to 48 hours. Results: Out of 53 cases, PPH was controlled in 52 cases. One patient died as the patient was eclamptic &amp; develped disseminated intravascular coagulation (DIC). No patient required surgical intervention. Conclusion: fluid filled intrauterine condom is an effective method in the management of primary PPH when usual measures &amp; drugs fail to control PPH.TAJ 2016; 29(1): 52-54

Safety of a condom uterine balloon tamponade (ESM-UBT) device for uncontrolled primary postpartum hemorrhage among facilities in Kenya and Sierra Leone

BackgroundPostpartum hemorrhage is the leading cause of maternal mortality in low- and middle-income countries. While evidence on uterine balloon tamponade efficacy for severe hemorrhage is encouraging, little is known about safety of this intervention. The objective of this study was to evaluate the safety of an ultra-low-cost uterine balloon tamponade package (named ESM-UBT) for facility-based management of uncontrolled postpartum hemorrhage (PPH) in Kenya and Sierra Leone.MethodsData were collected on complications/adverse events in all women who had an ESM-UBT device placed among 92 facilities in Sierra Leone and Kenya, between September 2012 and December 2015, as part of a multi-country study. Three expert maternal health investigator physicians analyzed each complication/adverse event and developed consensus on whether there was a potential causal relationship associated with use of the ESM-UBT device. Adverse events/complications specifically investigated included death, hysterectomy, uterine rupture, perineal or cervical injury, serious or minor infection, and latex allergy/anaphylaxis.ResultsOf the 201 women treated with an ESM-UBT device in Kenya and Sierra Leone, 189 (94.0%) survived. Six-week or longer follow-up was recorded in 156 of the 189 (82.5%). A causal relationship between use of an ESM-UBT device and one death, three perineal injuries and one case of mild endometritis could not be completely excluded. Three experts found a potential association between these injuries and an ESM-UBT device highly unlikely.ConclusionThe ESM-UBT device appears safe for use in women with uncontrolled PPH.Trial registrationTrial registration was not completed as data was collected as a quality assurance measure for the ESM-UBT kit.

Clinical outcomes of 23 patients who had repeat pelvic arterial embolisation for uncontrolled post-partum haemorrhage at a single centre

To evaluate the safety and efficacy of repeated pelvic arterial embolisation (PAE) for uncontrolled postpartum haemorrhage (PPH) after a single session of PAE and to compare angiographic findings between the two sessions of PAE. A total of 23 consecutive patients (age range, 23-44 years) who underwent repeated PAE for uncontrolled PPH between March 2001 and January 2016 in Severance Hospital were reviewed. The interval times between the two sessions of PAE, the angiographic findings, embolic materials, arteries embolised during PAE, and the clinical outcomes were reviewed retrospectively. Overall clinical success was achieved after repeated PAE in 21 of 23 patients (91.3%). There were no procedure-related, major complications. On angiography, active bleeding from the uterine collateral arteries was more frequently observed in the second session of PAE (p>0.05), and embolisation of the anterior division of the internal iliac artery was significantly higher during the second session of PAE. Use of permanent embolic materials was significantly higher during the second session of PAE. Recanalisation of a previously embolised artery was identified in 14 patients (60.9%) during the second session. Repeated PAE is safe and effective for managing recurrent bleeding after a single session of PAE. Repeated PAE is related to a higher chance of embolisation of the anterior division of the internal iliac artery, with the use of permanent embolic materials. Recanalisation of a previously embolised artery seems to be a principal source of rebleeding during a repeated session of PAE.

Retrospective analysis: Conservative treatment of placenta increta with methotrexate.

To evaluate the efficacy of conservative treatment with methotrexate against placenta increta by two different routes of administration through retrospective analysis. A total of 54 women diagnosed with placenta increta after vaginal delivery were enrolled in this retrospective study. The participants accepted conservative management with methotrexate through either intravenous injection or local multi-point injection under ultrasound guidance. The treatment was considered effective if no hysterectomy was mandatory during the follow-up period. Out of the 54 cases, 21 patients were treated with methotrexate intravenously (group 1), and 33 patients received local multi-point injection to the placenta increta under ultrasound guidance (group 2). No maternal death occurred. In group 1, 10 patients expelled the placentas spontaneously, 7 patients underwent uterine curettage and 4 patients underwent hysterectomy for uncontrollable post-partum hemorrhage and infection. In group 2, 25 patients expelled placentas spontaneously and 8 patients underwent uterine curettage with no incidence of hysterectomy. The success rate in group 1 and group 2 was 17/21 and 33/33, respectively. The average time of the spontaneous placenta expulsion was 79.13 ± 29.87 days in group 1 and 42.42 ± 31.83 days in group 2. Local multi-point methotrexate injection under ultrasound guidance is a better alternative for patients with placenta increta, especially for preserving fertility.

Surgical Interventions for Interstitial Pregnancy in the Third Trimester with Placenta Accreta

Background: The clinical features of interstitial pregnancy in the third trimester with placenta accreta are not well documented, and there are no management guidelines to recommend for these patients. Most such cases in the literature reports received complete or subtotal hysterectomy for placenta accreta or uncontrolled postpartum hemorrhage. Methods: We performed a retrospective review of the medical records of patients with interstitial pregnancies in the third trimester with placenta accreta who were admitted to our obstetrical department as normal intrauterine pregnancies. The diagnostic evidence was based on the definition of the condition in combination with intraoperative surgical findings. Surgical interventions were performed on the patients to control postpartum hemorrhage. Findings: Of 16063 patients, a total of 87 patients had an enlargement of uterine cornu in the third trimester with entire placenta accreta. Of 87 cases, 70 cases were excluded from this study, which including angular pregnancies, cornual pregnancies, cases without surgical photographs or the surgical photographs were indistinct, and vaginal deliveries. 17 cases of interstitial pregnancies in the third trimester with placenta accreta were identified based on the combination of the definition and surgical findings. Evidence of the extremely bulged cornu, an empty uterine cavity, an absence of myometrium in the cornual-fundus and placenta accreta was found in all patients. Same surgical interventions were performed on them to manage placenta accreta and control postpartum hemorrhage. All patients kept their uteruses intact through surgical interventions without further traumatic interventions. Most of them had a spontaneous recurrence of menstruation. Interpretation: A bulged cornu, empty uterine cavity, placenta accreta and absence of cornual myometrium were the main characteristics of interstitial pregnancies in the third trimester with placenta accreta. Such patients can preserve their uterus through suitable surgical interventions. Funding Statement: The authors state: There was no funding for this study. Declaration of Interests: The authors state: None reported. Ethics Approval Statement: The study was designed by the first author and was approved by the Review Committee of the hospital. The first author vouches for the truthfulness and accuracy of the data. All patients provided written informed consent.