FIGO recommendations on the management of postpartum hemorrhage 2022

A rapid and effective approach to building a life-saving multidisciplinary team for transferred postpartum haemorrhage patients: leveraging trauma experience-a retrospective study

BACKGROUND

Establishing an efficient multidisciplinary team for transferred postpartum haemorrhage (PPH) cases is challenging due to limited clinical exposure. We hypothesised that leveraging trauma team experience could effectively facilitate the development of such a team within a short timeframe.

METHODS

In September 2019, a multidisciplinary team was established at our tertiary care centre to provide rapid management of critical PPH cases transferred from the obstetric clinic, prioritising immediate resuscitation and haemostatic interventions. This historical cohort study (2017-2022) compared outcomes before (2017-2018, before group [BG]) and after (2019-2022, after group [AG]) team establishment. Outcomes included process-related quality indicators, clinical measures such as length of hospital stay, intensive care unit (ICU) days, presence of the lethal triad, and hysterectomy rate.

RESULTS

Of the 71 PPH patients transferred during the study period, 24 were in the BG and 47 in the AG. The AG demonstrated higher use of tranexamic acid (33.33% vs. 74.47%, P = 0.002), shorter time to the first blood transfusion (11 vs. 8 min, P = 0.029), and increased rates of arrival in the operating room within 60 min (25% vs. 80%, P = 0.014). Clinical outcomes showed reduced rates of cardiopulmonary resuscitation (16.67% vs. 0%, P = 0.011) and shorter ICU stays (4 vs. 1 day, P = 0.005) in the AG.

CONCLUSIONS

Leveraging trauma team expertise is an effective strategy for establishing a multidisciplinary PPH team, significantly improving outcomes for critically ill PPH patients transferred from obstetric clinics.

Duration of the second and third stages of labor and risk of postpartum hemorrhage: a cohort study stratified by parity

BACKGROUND

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide. It is therefore important to improve our understanding of the risk factors for PPH according to parity, in particular, those linked to modifiable obstetric practices. The aim of this study was to assess the risk of PPH by the duration of the second and third stages of labor, stratified by parity.

METHODS

This study was based on secondary analysis of data from participants in a randomized controlled trial. A sample of women from three university hospitals in France aged at least 18 years, with a singleton pregnancy, in the first stage of labor, at 36-42 weeks of gestation, with epidural anesthesia and a vaginal delivery were included. The main outcome was PPH rates, defined by blood loss > 500 mL within 2 h after delivery. Characteristics of mothers, newborns, labor, and delivery, and their relation to PPH were explored with multivariable regression models.

RESULTS

Of 1598 women included, 864 were nulliparous and 680 parous; their respective PPH rates were 9.1% (79/864) and 7.4% (54/680) (P = 0.2), and the overall rate 8.3% (133/1598). The multivariable analysis found that PPH was associated with the durations of both oxytocin exposure (aOR 1.10, 95%CI 1.01-1.20) and the third stage of labour (aOR 1.80, 95%CI 1.37-2.38) among nulliparous women, and the PPH risk increased with both duration of the third stage (aOR 2.10, 95%CI 1.56-2.83) and history of PPH (aOR 3.02, 95%CI 1.38-6.59) among parous women.

CONCLUSIONS

The duration of oxytocin exposure was found to be a risk factor for PPH among nulliparous women as was a history of PPH among parous women. Future studies should focus on duration of third stage of labor, especially when active management of the third stage of labor (AMTSL) is routinely used.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov NCT01113229.

Shock index reference ranges in the first 48 h postpartum following elective cesarean delivery: A prospective cohort study

PURPOSE

To determine the reference values for the shock index (SI) in postpartum patients undergoing elective cesarean delivery with regional anesthesia.

METHODS

This prospective study was conducted at our tertiary center between August 1, 2023, and March 1, 2024. We calculated the reference values for the SI within the first 48 h postpartum for patients who underwent elective cesarean delivery after the 34th week of gestation. We excluded cases of vaginal delivery, post-term delivery (≥42 weeks of gestation), multiple pregnancies, stillbirths, fetal abnormalities, maternal cardiac disease, anemia, untreated hypo- or hyperthyroidism, and any hypertensive disorders diagnosed before or during pregnancy. Data collection, measurement of vital signs, and the administration of fluids pre-, intra-, and post-operatively, as well as the use and dosing of uterotonic agents for the prevention of postpartum hemorrhage (PPH), were standardized for all patients.

RESULTS

Our final analysis included 311 patients, with a mean SI value of approximately 0.7 (0.67-0.77) for all measurement performed within the first 48 h of the postpartum period. Further analyses revealed that the 90th and 95th percentiles of SI were around 0.9 throughout the study period. Additionally, SI reference values analyzed at different time points were consistent. Our analysis demonstrated that SI values were not influenced by the presence of a previous caesarean section, the administration of oxytocin or carbetocin, or parity in this particular cohort. Our analyses of vital signs also indicated that the 95th percentile of heart rate (HR) ranged from 96 to 100 bpm.

DISCUSSION

An SI value of 0.9 represents the 95th percentile of SI values throughout the first 48 h of the postpartum period. Any greater value should be evaluated carefully for potential adverse outcomes.

Major Bleeding in the Emergency Department: A Practical Guide for Optimal Management

Major bleeding is a life-threatening condition with high morbidity and mortality. Trauma, gastrointestinal bleeding, haemoptysis, intracranial haemorrhage or other causes of bleeding represent major concerns in the Emergency Department (ED), especially when complicated by haemodynamic instability. Severity and source of bleeding, comorbidities, and prior use of anticoagulants are pivotal factors affecting both the clinical status and the patients' differential response to haemorrhage. Thus, risk stratification is fundamental in the initial assessment of patients with bleeding. Aggressive resuscitation is the principal step for achieving haemodynamic stabilization of the patient, which will further allow appropriate interventions to be made for the definite control of bleeding. Overall management of major bleeding in the ED should follow a holistic individualized approach which includes haemodynamic stabilization, repletion of volume and blood loss, and reversal of coagulopathy and identification of the source of bleeding. The aim of the present practical guide is to provide an update on recent epidemiological data about the most common etiologies of bleeding and summarize the latest evidence regarding the bundles of care for the management of patients with major bleeding of traumatic or non-traumatic etiology in the ED.

Viscoelastic haemostatic assays to guide therapy in elective surgery: an updated systematic review and meta-analysis

BACKGROUND

Patients undergoing major surgery frequently experience major uncontrolled bleeding. The aim of this systematic review and meta-analysis was to evaluate the clinical efficacy of using viscoelastic haemostatic assays to manage peri-operative bleeding in elective surgery.

METHODS

We searched PubMed/MEDLINE and Embase databases for randomised controlled trials according to pre-determined criteria. The primary outcomes were blood product requirements; duration of stay in the operating theatre or ICU; and surgical reintervention rate.

RESULTS

We included 20 randomised controlled trials. The overall risk of bias was low to moderate. Twelve studies used thromboelastography-based transfusion algorithms, while eight used thromboelastometry. Viscoelastic haemostatic assay-guided therapy was associated with a statistically significant reduction in transfusion of red blood cells (standardised mean difference (95%CI) 0.16 (-0.29 to 0.02)), platelets (standardised mean difference (95%CI) -0.33 (-0.56 to -0.10)) and fresh frozen plasma (standardised mean difference (95%CI) -0.64 (-1.01 to -0.28)). There was no evidence of an effect of viscoelastic haemostatic assay-guided therapy on surgical reintervention (relative risk (95%CI) 1.09 (0.70-1.69)). Viscoelastic haemostatic assay-guided therapy was associated with lower blood loss and shorter ICU duration of stay. There was no evidence of any effect on total duration of stay and all-cause mortality.

CONCLUSIONS

Viscoelastic haemostatic assay-guided therapy may reduce peri-operative blood product transfusion requirements and blood loss during major elective surgery, with no discernible effect on patient-centred outcomes. The overall quality of evidence was modest.

Time to redefine prolonged third stage of labor? A systematic review and meta-analysis of the length of the third stage of labor and adverse maternal outcome after vaginal birth

OBJECTIVE

This study aimed (1) to assess the association between the length of the third stage of labor and adverse maternal outcome after vaginal birth and (2) to evaluate whether earlier manual placenta removal reduces the risk of adverse outcome.

DATA SOURCES

PubMed, MEDLINE, Embase, ClinicalTrials.gov, the Cochrane Library, Journals@Ovid, and the World Health Organization International Clinical Trials Registry were searched from January 1, 2000, to June 13, 2023.

STUDY ELIGIBILITY CRITERIA

All studies that assessed adverse maternal outcome, defined as any maternal complication after vaginal birth, concerning the length of the third stage of labor and the timing of manual placenta removal were included.

METHODS

The included studies were evaluated using the Conducting Systematic Reviews and Meta-Analyses of Observational Studies of Etiology methodology. Pooled odds ratios with 95% confidence intervals were calculated. Heterogeneity (I2 test) was assessed, subgroup analyses were performed, and 95% prediction intervals were calculated.

RESULTS

To meet the first objective, 18 cohort studies were included. The assessed cutoff values for the length of the third stage of labor were 15, 30, and 60 minutes. Women with a third stage of labor of ≥15 minutes had an increased risk of postpartum hemorrhage compared with those with a third stage of labor of <15 minutes (odds ratio, 5.55; 95% confidence interval, 1.74-17.72). For women without risk factors for postpartum hemorrhage, the odds ratio was 2.20 (95% confidence interval, 0.75-6.49). Among women with a third stage of labor of ≥60 minutes vs women with a third stage of labor of <60 minutes, the odds ratio was 3.72 (95% confidence interval, 2.36-5.89). The incidence of red blood cell transfusion was higher for a third stage of labor of ≥30 minutes than for a third stage of labor of <30 minutes (odds ratio, 3.23; 95% confidence interval, 2.26-4.61). Of note, 3 studies assessed the timing of placenta removal and the risk of adverse maternal outcome. However, the results could not be pooled because of the different outcome measures. Moreover, 1 randomized controlled trial (RCT) reported a significantly higher incidence of hemodynamic compromise in women with manual placenta removal at 15 minutes than in women with manual placenta removal at 10 minutes (30/156 [19.2%] vs 10/156 [6.4%], respectively), whereas 2 observational studies reported a lower risk of bleeding among women without manual placenta removal.

CONCLUSION

Although the risk of adverse maternal outcome after vaginal birth increases when the third stage of labor exceeds 15 minutes, there is no convincing supporting evidence that reducing the length of the third stage of labor by earlier manual removal of the placenta can reduce the incidence of adverse maternal outcome.

Platelet transfusion

PURPOSE OF REVIEW

Platelet transfusions, used as prophylaxis or treatment for bleeding, are potentially life-saving. In many countries, demand for platelet transfusion is rising. Platelets are a limited and costly resource, and it is vital that they are used appropriately. This study will explore the evidence behind platelet transfusions in different contexts, in particular recent and important research in this area.

RECENT FINDINGS

Recent randomized clinical trials demonstrate the efficacy of platelet transfusions in some contexts but potential detrimental effects in others. Platelet transfusions also carry risk of transfusion reactions, bacterial contamination and platelet transfusion refractoriness. Observational and clinical studies, which highlight approaches to mitigate these risks, will be discussed. There is growing interest in cold-stored or cryopreserved platelet units, which may improve platelet function and availability. Clinical trials also highlight the efficacy of other supportive measures such as tranexamic acid or thrombopoietin receptor agonists in patients with bleeding.

SUMMARY

Although platelet transfusions are beneficial in many patients, there remain many settings in which the optimal use of platelet transfusions is unclear, and some situations in which they may have detrimental effects. Future clinical trials are needed to determine optimal use of platelet transfusions in different patient populations.

Step forward: implementation and evaluation of STEPS program to optimize postpartum hemorrhage management in vaginal deliveries

BACKGROUND

Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide, particularly in resource-limited settings. Enhancing maternal safety in relation to PPH requires optimizing care protocols, continuous monitoring, and timely interventions. However, integrating these methodologies into vaginal delivery practices remains underexplored.

OBJECTIVE

To assess the impact and sustainability of a recently implemented Strategies and Tools to Enhance Parturient Safety (STEPS) program on PPH management.

METHODS

This before-and-after study included women who delivered vaginally between January 2020 and November 2023. Clinical practices and PPH-related outcomes were compared for 2-year periods before and after STEPS implementation, initiated in January 2022. The program involved enhanced perinatal care bundles, interdisciplinary team training, and continuous monitoring using statistical process control (SPC) tools. The primary outcome was PPH incidence (≥500 mL blood loss within 24 hours).

RESULTS

During the 4-year observation period, 24,235 women underwent vaginal deliveries. The incidence of PPH was 11.1% (1,473/13272) before STEPS and 11.8% (1,293/10963) after STEPS (aRR, 1.09; 95% CI, 1.00-1.18; P=.042). Severe PPH rates remained unchanged (aRR, 1.09; 95% CI, 0.90-1.33; P=.391). However, the proportion requiring blood transfusion significantly decreased (aRR, 0.77; 95% CI, 0.61-0.98; P=.035). Compared to preintervention period, a higher proportion of women experiencing PPH were identified as being at elevated risk prior to delivery in the postintervention period (P<.001). Notably, blood transfusion rates (P=.047) and hospital stay durations for women with PPH (P<.001) significantly declined.

CONCLUSIONS

The STEPS program effectively improved PPH management by enhancing risk identification, increasing targeted interventions, and reducing blood transfusion rates and hospital stays. These findings highlight the importance of a comprehensive approach that integrates risk assessment, monitoring, and tailored interventions for managing PPH in vaginal deliveries, particularly in resource-limited settings.

Management of Postpartum Hemorrhage in Low- and Middle-Income Countries: Emergency Need for Updated Approach Due to Specific Circumstances, Resources, and Availabilities

Postpartum hemorrhage (PPH) represents a critical emergency condition and the principal cause of maternal morbidity and mortality worldwide. It encompasses excessive bleeding following childbirth, which can arise from various causes. Prompt recognition and management are essential to mitigate severe outcomes and ensure maternal safety. The incidence of PPH in low- and middle-income countries (LMICs) is higher than in developed countries. Healthcare systems in developing countries face multiple challenges that may impact PPH management at policy, facility, and community levels. The mentioned barriers could be addressed by providing an empowering environment via the implementation of supportive policies, access to PPH care, planning supplies, allying strategies, providing training, and utilization of guidelines and algorithms for PPH management. Evidence-based international guidelines should serve as an integral part of appropriate management. On the other hand, LMICs have limited opportunities to implement the proposed international algorithms and guidelines. Therefore, some amendments based on the resource/expertise availability should be considered at the specific clinical site. This review summarizes and updates the accumulated knowledge on postpartum hemorrhage, focusing on challenging management options in developing countries. In many LMICs, maternal morbidity and mortality linked to PPH were improved after the implementation of standardized protocols and timely and purposeful interventions. International support in healthcare professionals' training, enhancing resources, and the provision of an adapted evidence-based approach could assist in improving the management of PPH in LMICs. Refining our understanding of specific local circumstances, international support in specialists' training, and the provision of evidence-based approaches may assist in improving the management of PPH in LMICs and contribute to safer childbirth.

Incidence, Causes and Outcomes of Postpartum Hemorrhage in Eastern Ethiopia: A Multicenter Surveillance Study

OBJECTIVES

Maternal mortality remains an unfinished global agenda and postpartum hemorrhage (PPH) remains one of the leading causes. The aims of this study were to describe the incidence, underlying causes, and case fatality rate of PPH in public hospitals in eastern Ethiopia.

METHODS

This study was part of a larger Ethiopian Obstetric Surveillance System (EthOSS) project - a multicenter surveillance of women admitted to 13 public hospitals in eastern Ethiopia due to any of the five major obstetric conditions: obstetric hemorrhage, eclampsia, uterine rupture, sepsis, and severe anemia - conducted from April 1, 2021 to March 31, 2022. All registers in maternity units of those hospitals were reviewed to identify eligible women and collect data on sociodemographic and obstetric characteristics, management and maternal outcomes at discharge or death. Findings were reported using descriptive statistics.

RESULTS

Among 38,782 births registered during the study period, 2043 women were admitted with at least one of the five major obstetric conditions. Of these 2043, 306 women (15%) had PPH corresponding with an incidence rate of 8 (95% CI: 7-9) per 1000 births. Uterine atony was the main underlying cause in 77%; 81% of women with PPH received at least one uterotonic drug, and 72% of women for whom blood was requested received at least one unit. Of the 70 hospital based maternal deaths, 19 (27%) died from PPH, making a case fatality rate of 6 per 100.

CONCLUSIONS

Although the overall incidence of PPH appeared low, it was still the underlying cause of death in one out of four women who died. The contributing factors might be that one in five women with PPH did not receive any uterotonic drug and the low blood transfusion. Ongoing audit, followed by targeted action, is essential to improve care quality and reduce adverse maternal outcome. The relatively low incidence may reflect under-recording in paper-based records, implying that further research into methods to optimize the surveillance is needed.

Short and long-term menstrual, reproductive, and mental health outcomes after the intrauterine use of chitosan tamponade or the Bakri balloon for severe postpartum hemorrhage: an observational study

OBJECTIVE

This retrospective follow-up study analyzes the effect of intrauterine postpartum hemorrhage (PPH) therapy on menstrual, reproductive, and mental health outcomes.

METHODS

All women who delivered at a university hospital between 2016 and 2021 with PPH and who needed intrauterine therapy were included. A questionnaire on well-being, menses, fertility, and reproductive outcomes was mailed to the patients. Those who did not reply were surveyed by telephone.

RESULTS

A total of 214 women treated with chitosan-covered gauze (group A) and 46 women treated with a balloon tamponade (group B) were recruited, and their short-term courses were analyzed. For long-term follow-up, 71 women of group A (33%) and 21 women of group B (46%) could be reached. A total of 89% of group A and 95% of group B had regular menstrual bleeding in the most recent 12 months; 27% (group A) and 29% (group B) were trying to conceive again, and all of them did so successfully. There were 12 deliveries, 3 ongoing pregnancies, 3 miscarriages, and 2 terminations of pregnancies (TOP) in group A and 4 deliveries, 1 miscarriage, and 2 TOPs in group B. More than half of our study participants was sorted into grade II or III of the Impact of Events Scale, indicating they experienced clinical impacts in the form of psychological sequelae. One-quarter of patients had symptoms of post-traumatic stress disorder.

CONCLUSION

Chitosan gauze as well as balloon tamponade appear to have few adverse effects on subsequent menstrual and reproductive function. Women after PPH are at increased risk of long-term adverse psychological outcomes.

Effects of tranexamic acid preconditioning on the incidence of postpartum haemorrhage in vaginal deliveries with identified risk factors in China: a prospective, randomized, open-label, blinded endpoint trial

OBJECTIVE

This study aimed to evaluate the effects of tranexamic acid (TXA) in preventing postpartum haemorrhage (PPH) among women with identified risk factors for PPH undergoing vaginal delivery in China.

METHODS

This prospective, randomized, open-label, blinded endpoint (PROBE) trial enrolled 2258 women with one or more risk factors for PPH who underwent vaginal delivery. Participants were randomly assigned in a 1:1 ratio to receive an intravascular infusion of 1 g TXA or a placebo immediately after the delivery of the infant. The primary outcome assessed was the incidence of PPH, defined as blood loss ≥500 mL within 24 h after delivery, while severe PPH was considered as a secondary outcome and defined by total blood loss ≥1000 mL within 24 h.

RESULTS

2245 individuals (99.4%) could be followed up to their primary outcome. PPH occurred in 186 of 1128 women in the TXA group and in 215 of 1117 women in the placebo group (16.5% vs. 19.2%; RR, 0.86; 95% CI, 0.72 to 1.02; p = 0.088). Regarding secondary outcomes related to efficacy, women in the TXA group had a significant lower rate of severe PPH than those in the placebo group (2.7% vs. 5.6%; RR, 0.49; 95% CI, 0.32 to 0.74; p = 0.001; adjusted p = 0.002). Similarly, there was a significant reduction in the use of additional uterotonic agents (7.8% vs. 15.6%; RR, 0.50; 95% CI, 0.39 to 0.63; p < 0.001; adjusted p = 0.001). No occurrence of thromboembolic events and maternal deaths were reported in both groups within 30 days after delivery.

CONCLUSIONS

In total population with risk factors for PPH, the administration of TXA following vaginal delivery did not result in a statistically significant reduction in the incidence of PPH compared to placebo; however, it was associated with a significantly lower incidence of severe PPH.

Five-year retrospective analysis of Bakri balloon tamponade for obstetric haemorrhage and patient survey at a single tertiary centre

BACKGROUND

Intrauterine balloon tamponade (IUBT), specifically the usage of Bakri balloon tamponade (BBT), is an effective conservative management technique for postpartum haemorrhage (PPH). The primary objective was to evaluate local guidelines and contribute to evidence regarding ideal duration for BBT. The secondary objectives were to consider impacts on maternal-foetal wellbeing, and optimise healthcare efficiency by reducing length of ICU admissions.

METHODS

This five-year retrospective case series analysed 132 cases of obstetric ICU admissions requiring Bakri balloon insertion for PPH within our centre. Additionally, a prospective patient experience survey was conducted over six-month period, involving 22 obstetric patients who required unplanned ICU admissions.

RESULTS

Bakri balloon insertion was successful in 95%, whilst 5% experienced failure, necessitating further interventions (uterine artery embolisation) or return to theatre (hysterectomy). The success group demonstrated significant reductions in median blood loss (1.8 L vs. 2.5 L, p = 0.016) and difference in median duration of BBT (18.3 vs. 3.92 hours, p = 0.001). The prospective patient survey revealed a high level of satisfaction of care. Approximately 50% breastfed prior to discharge, on average commencing 23.4 hours post-delivery. This study demonstrates a high success rate of BBT, with failures typically occurring within median duration 3.9 hours.

CONCLUSIONS

Considering the separation of mother from baby during the Bakri balloon's presence in ICU, we propose timely removal at around six hours, as failures are unlikely post this timeframe, or nursing these women in a neonatal care setting to facilitate earlier mother-baby bonding.

Characteristics and outcomes of patients with postpartum hemorrhage undergoing transcatheter arterial embolization: A nationwide observational study

OBJECTIVE

To elucidate the demographics, clinical characteristics, and outcomes of patients with postpartum hemorrhage (PPH) who underwent transcatheter arterial embolization (TAE).

METHODS

We conducted a retrospective observational study using the Japanese Diagnosis Procedure Combination inpatient database, which covers roughly 90% of all tertiary emergency hospitals in Japan, between April 2012 to March 2020. We identified patients with PPH who underwent TAE using the Japanese medical procedure status and code, and the device or drug code. We examined the patient characteristics, interventions administered, and clinical outcomes.

RESULTS

Among 64 893 patients diagnosed with PPH, we identified 2705 (4.2%) patients with PPH who underwent TAE. The most common cause of PPH was uterine atony (68.7%), followed by disseminated intravascular coagulation after labor (30.0%) and placenta accreta spectrum disorders (23.4%). The proportion of patients who underwent repeat TAE and a hysterectomy was 64 (2.4%) and 188 (7.0%), respectively. Among hysterectomies (n = 188), 26 (13.8%) had the procedure performed before TAE, 73 (38.8%) underwent hysterectomy on the same day as TAE, and 89 (47.4%) had the procedure conducted after TAE. Of those who underwent a hysterectomy after TAE (n = 89), 33 (37%) were performed more than 1-week after initial TAE. Overall in-hospital mortality was 14/2705 (0.5%).

CONCLUSION

Even if hemostasis is achieved through TAE, one must be mindful that a hysterectomy may become necessary more than 1 week after the procedure. These results could be helpful in clinical decision making and providing patients with additional treatment options for PPH that preserve patient fertility.

Research agenda for ending preventable maternal deaths from postpartum haemorrhage: a WHO research prioritisation exercise

INTRODUCTION

Postpartum haemorrhage (PPH) remains the leading cause of maternal death. Yet there is a lack of clarity around what research is needed to determine what works and how best to deliver proven PPH interventions. This article describes a WHO-led effort to develop a global PPH research agenda for 2023-2030, to reinvigorate research and innovation while avoiding duplication and waste.

METHODS

Potential questions were culled from evidence gaps in a forthcoming Lancet PPH series, a pipeline analysis on PPH medicines and devices, international PPH guidelines, previous research prioritisation efforts and submissions from a reference group of PPH experts and stakeholders. Questions were deduplicated and consolidated, categorised into three tracks (innovation, implementation and cross-cutting) and subjected to an online prioritisation survey. Survey participants (n=120) assessed these questions using five criteria (answerability, effectiveness, deliverability, maximum potential for disease burden reduction and equity) following the Child Health and Nutrition Research Initiative methodology. The outcome of this exercise was complemented by an in-person consensus meeting (Global PPH Summit from 7 March 2023 to 10 March 2023 in Dubai, United Arab Emirates) to finalise the research agenda.

RESULTS

Fifteen research questions (five per track) were identified as top priority. The top question per track called for research on the comparative effectiveness and safety of alternative routes of administration (other than the intravenous route) of tranexamic acid in the treatment of PPH (innovation); identifying barriers and facilitators affecting the adoption and use of evidence-based recommendations for PPH management (implementation) and the effectiveness of a strategy of early detection and first response treatment using a bundle of recommended interventions for improving PPH-related outcomes (cross-cutting).

CONCLUSION

This shared research agenda should guide future investments into PPH studies with high potential to transform policy and clinical practice in the near term to medium term. Funding for the new research priorities is urgently needed.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a strategy for postpartum haemorrhage management: A narrative review

Postpartum hemorrhage (PPH) remains one of the leading causes of maternal mortality worldwide, with a significant impact on global health. Optimal management of PPH involves distinct steps executed simultaneously by a multidisciplinary approach, with anesthesiologists playing a key role in hemodynamic control and patient resuscitation. In this context, an aortic blood flow interruption through an internal balloon should be considered a rescue option among the various opportunities, to treat or prevent abdominal hemorrhages. Given this perspective, there is increasing interest in the role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), originally used in trauma and military medicine, which has emerged as a novel strategy for managing PPH. Indeed, this technique has shown promise in managing severe cases of PPH, especially where traditional measures are insufficient. It also offers potential as a prophylactic measure in pregnancies with high risk for PPH, such as in the case of placenta accrete spectrum. This review aims to examine the efficacy, safety, and potential applications of REBOA in PPH management and prevention. At the same time, challenges such as the need for skilled operators, potential complications, costs, and the consideration of fetal safety were also discussed. REBOA presents as a promising tool against PPH, with efficacy in reducing blood loss, preserving fertility, and potentially decreasing maternal mortality and improving outcomes. However, its implementation requires careful consideration, training, and further research to establish clear guidelines for its use in obstetric care.

Uterine isthmic tourniquet left in situ as a new approach for placenta previa-accreta surgery: a comparative study

OBJECTIVES

Placenta previa-accreta spectrum disorders are a cause of obstetric hemorrhage that can lead to maternal fetal mortality and morbidity. We aimed to describe the use of a uterine isthmic tourniquet left in situ as a new uterus-preserving approach for patients with placenta previa-accreta.

METHODS

In this retrospective comparative study, the patients who underwent surgery for placenta previa between 2017 and 2024 at our tertiary hospital were reviewed. Primary outcome of the study is to evaluate feasibility of uterine isthmic tourniquet left in situ for uterine preserving by preventing postpartum hemorrhage for patients with placenta previa-accreta. As a secondary outcome, group 1 (n=28) patients who were managed with uterine isthmic tourniquet left in place were compared with patients in group 2 (n=32) who were managed with only bilateral uterine artery ligation.

RESULTS

This new approach uterine isthmic tourniquet technique prevented postpartum hemorrhage with a rate of 100 percent in group 1 patients, while uterine artery ligation prevented postpartum hemorrhage with a rate of 75 % in group 2. Postoperative additional interventions (relaparotomy hysterectomy, balloon tamponade application, uterine or vaginal packing) were performed for eight patients in group 2 (25 %) but not in group 1 (0 %) (p=0.015). The haemoglobin levels before caesarean section were similar in both groups (p=0.235), while the postoperative haemoglobin levels were lower in group 2 (9.69 ± 1.37 vs. 8.15 ± 1.32) (p=0.004). Erythrocyte suspension was given to two patients in group 1 and 12 patients in group 2 (2/28 7 % vs. 12/32 37 %, p=0.018).

CONCLUSIONS

The uterine isthmic tourniquet left in situ technique is a safe, simple and effective for preventing postpartum hemorrhage and preserving uterus during placenta previa accreta surgery as superior to uterine artery ligation alone.

Current practice of ultrasound in the management of postpartum hemorrhage: a secondary analysis of a national survey

OBJECTIVES

Although frequently employed in the delivery room, current guidelines do not recommend the use of ultrasound in the setting of postpartum hemorrhage (PPH). The aim of this survey was to evaluate the routine use of ultrasonography during PPH.

METHODS

A questionnaire, composed by a series of questions that assess participant characteristics and ultrasound use during PPH, was sent to members of the Italian Society of Ultrasound in Obstetrics and Gynecology currently employed in obstetrical units. Answers were subsequently grouped based on participant characteristics.

RESULTS

Based on the responses of 200 participants it was found that ultrasound was routinely employed by 67 % of participants during PPH, by 85 % if Retained Products of Conception (RPOC) was suspected, by 67 % during Bakri balloon placement and by 69 % during curettage procedures. Routine ultrasound use was higher amongst participants working in hospitals with a higher number of deliveries, by those with more years of experience using ultrasound in labor, and by those that had attended specific postgraduate training courses.

CONCLUSIONS

Despite the lack of recommendations in the current guidelines, the results of this survey show that ultrasound seems to be commonly employed by maternal fetal medicine practitioners in the management of PPH.

Tranexamic Acid as a Preventive Strategy Against Periprosthetic Joint Infection in Aseptic Revision Arthroplasty: A Comprehensive Review

Periprosthetic joint infection (PJI) is a severe complication following joint replacement surgeries, particularly in aseptic revision arthroplasty, where infection rates are higher compared to primary procedures. The extended surgical time, increased blood loss, and the presence of scar tissue contribute to the higher susceptibility to PJI in revision surgeries. Tranexamic acid (TXA), a synthetic antifibrinolytic agent, is widely used in orthopaedic surgery to reduce intraoperative and postoperative bleeding. By stabilising blood clots and reducing the need for blood transfusions, TXA improves patient outcomes and reduces complications related to excessive bleeding. Emerging evidence suggests that TXA may also play a role in reducing PJI, as minimising bleeding and haematoma formation can reduce bacterial colonisation and blood transfusions are associated with increased infection risks due to immunomodulation. This review explores the potential of TXA as a preventive strategy against PJI in aseptic revision arthroplasty, evaluating its mechanisms, clinical applications, and current evidence. While TXA's efficacy in reducing blood loss is well-established, its role in infection prevention, particularly through indirect mechanisms such as limiting haematoma formation, warrants further investigation. By incorporating TXA into multimodal strategies aimed at reducing PJI, surgeons can potentially improve patient outcomes and reduce the financial burden on healthcare systems. This review provides a comprehensive examination of the available data on TXA's role in preventing PJI in revision arthroplasty, with an emphasis on understanding its mechanisms and identifying gaps in current knowledge that require further research.

Quantitative blood loss measurement methods for early detection of primary postpartum haemorrhage following vaginal birth: A scoping review

AIM

To map the commonly used quantitative blood loss measurement methods in clinical practice and provide a solid foundation for future studies.

DESIGN AND METHOD

This study adhered to the JBI methodology for scoping reviews and preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews. We conducted a literature search using five databases to retrieve articles published between January 2012 and September 2022. The search was repeated on 29 February 2024. Data extraction and verification were carried out by two independent researchers using a self-designed data extraction form.

RESULTS

Ultimately, 26 studies published between 2012 and 2024 were considered eligible for inclusion. Six categories of methods were identified from the 26 articles. Among the included studies, only two involved randomized controlled trials, with the majority being observational studies. The World Health Organization (2012) version of the postpartum haemorrhage diagnostic criteria was predominantly used in most studies. Gravimetric and volumetric methods emerged as the most commonly used methods for quantifying postpartum haemorrhages. The timing of blood collection was inconsistent among the included studies. Only 12 studies mentioned measures for the management of amniotic fluid.

CONCLUSIONS

This scoping review supports the replacement of the visual estimation of blood loss with quantitative assessment methods. Supporting a specific assessment approach is not feasible due to the variability of the study. Future research should focus on establishing the best practices for specific quantitative methods to standardize the management of postpartum haemorrhage and reduce the incidence of postpartum haemorrhage-related adverse outcomes.

RELEVANCE TO CLINICAL PRACTICE

Healthcare professionals need to acknowledge the low accuracy of visual estimation methods and implement quantitative methods to assess postpartum blood loss. Given the limitations inherent in each assessment method, quantification of blood loss should be combined with assessment of maternal vital signs, physiologic indicators and other factors.

Predicting Intra- and Postpartum Hemorrhage through Artificial Intelligence

Background and Objectives: Intra/postpartum hemorrhage stands as a significant obstetric emergency, ranking among the top five leading causes of maternal mortality. The aim of this study was to assess the predictive performance of four machine learning algorithms for the prediction of postpartum and intrapartum hemorrhage. Materials and Methods: A prospective multicenter study was conducted, involving 203 patients with or without intra/postpartum hemorrhage within the initial 24 h postpartum. The participants were categorized into two groups: those with intra/postpartum hemorrhage (PPH) and those without PPH (control group). The PPH group was further stratified into four classes following the Advanced Trauma Life Support guidelines. Clinical data collected from these patients was included in four machine learning-based algorithms whose predictive performance was assessed. Results: The Naïve Bayes (NB) algorithm exhibited the highest accuracy in predicting PPH, boasting a sensitivity of 96.3% and an accuracy of 98.6%, with a false negative rate of 3.7%. Following closely were the Decision Tree (DT) and Random Forest (RF) algorithms, each achieving sensitivities exceeding 94% with a false negative rate of 5.9%. Regarding severity classification I, the NB and Support Vector Machine (SVM) algorithms demonstrated superior predictive capabilities, achieving a sensitivity of 96.4%, an accuracy of 92.1%, and a false negative rate of 3.6%. The most severe manifestations of HPP were most accurately predicted by the NB algorithm, with a sensitivity of 89.3%, an accuracy of 82.4%, and a false negative rate of 10.7%. Conclusions: The NB algorithm demonstrated the highest accuracy in predicting PPH. A notable discrepancy in algorithm performance was observed between mild and severe forms, with the NB and SVM algorithms displaying superior sensitivity and lower rates of false negatives, particularly for mild forms.

Prehospital Management of Postpartum Hemorrhage-A National, Cross-Sectional Study in Norway

INTRODUCTION

Postpartum hemorrhage (PPH) is a critical birth complication, and is stated by the World Health Organization (WHO) as among the five most frequent causes of death during pregnancy. External aortic compression (EAC) is recommended by the WHO as an intervention to achieve temporary bleeding control. An increasing number of births outside hospital underlines the importance of competence in handling potential birth complications, such as PPH. The aim of this study was to assess prehospital personnel's education, training, knowledge, and experiences regarding PPH and EAC across Norway.

METHODS

Prehospital personnel were invited to respond to a questionnaire through social media. Questions included those on education, training, knowledge, and experience regarding PPH and EAC. The Statistical Package for the Social Sciences (SPSS) version 28 was used to analyze the data, using descriptive statistics.

RESULTS

Over a two-month period, 211 prehospital personnel responded to the questionnaire, of whom 55.5% were male. The respondents had an average of 10.3 years of prehospital experience. About half of the respondents had received education (48.6%) and training (62.4%) in PPH management. Still, 95.7 percent reported a need for more education and training. On knowledge questions, only half of the responses were correct (43.7% to 60.5%). Only 21 percent of the respondents had experienced patients with PPH, and of these only 3.8 percent had used EAC. Bimanual uterine compression was the most frequent intervention used (62.5%) across hospital trusts.

CONCLUSIONS

Even if prehospital personnel receive education and training in the management of PPH and EAC, almost all report needing more. The results indicate a national variation, which may be discussed as to whether it is appropriate.

Thromboelastography as an early prediction method for hypofibrinogenemia in emergency department patients with primary postpartum hemorrhage

BACKGROUND

Timely and accurate assessment of coagulopathy is crucial for the management of primary postpartum hemorrhage (PPH). Thromboelastography (TEG) provides a comprehensive assessment of coagulation status and is useful for guiding the treatment of hemorrhagic events in various diseases. This study aimed to evaluate the role of TEG in predicting hypofibrinogenemia in emergency department (ED) patients with primary PPH.

METHODS

We conducted a retrospective observational study in the ED of a university-affiliated tertiary hospital between November 2015 and August 2023. TEG was performed upon admission. The cutoff value for hypofibrinogenemia was 200 mg/dL. The primary outcome was the presence of hypofibrinogenemia.

RESULTS

Among the 174 patients, 73 (42.0%) had hypofibrinogenemia. The need for massive transfusion was higher in the hypofibrinogenemia group (37.0% vs. 5.0%, p < 0.001). Among the TEG parameters, all values were significantly different between the groups, except for lysis after 30 min, suggesting a tendency toward hypocoagulability. Multivariable analysis revealed that the alpha angle (odds ratio (OR) 0.924, 95% confidence interval (CI) 0.876-0.978) and maximum amplitude (MA) (OR 0.867, 95% CI 0.801-0.938) were independently associated with hypofibrinogenemia. The optimal cutoff values for the alpha angle and maximum amplitude (MA) for hypofibrinogenemia were 63.8 degrees and 56.1 mm, respectively.

CONCLUSION

Point-of-care TEG could be a valuable tool for the early identification of hypofibrinogenemia in ED patients with primary PPH.

Using Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a Rescue Strategy in Severe Postpartum Hemorrhage: A Case Report

Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality. Routine treatment of PPH includes uterotonics, tranexamic acid, curettage, uterine (balloon) tamponade, compression sutures, uterine artery ligation, and, if available, transcatheter arterial embolization (TAE). In cases of severe PPH refractory to standard medical and surgical management, hysterectomy is usually the ultima ratio, and is equally associated with a higher rate of complications. In addition, this sudden loss of fertility, especially in young women, can be devastating. Here, we report a case of a 29-year-old woman who suffered from severe PPH with a blood loss > 1500 mL and hemodynamic instability after delivery of her first baby at a smaller hospital. She was consequently successfully treated with resuscitative endovascular balloon occlusion of the aorta (REBOA) by first placing a balloon catheter into the infra-renal aorta and subsequent TAE after failure of all other available treatment options prior to hysterectomy. TAE has been suggested in PPH treatment to avoid hysterectomies and thus to preserve patients' reproductive function. If hemodynamic stabilization cannot be achieved with mass transfusion, REBOA seems to be an effective rescue strategy with which to achieve hemodynamic stabilization and gain additional time for embolization. Although REBOA is already recommended in several PPH guidelines, this approach seems relatively unknown in German-speaking countries.

The suboptimal clinical applicability of prognostic prediction models for severe postpartum hemorrhage: a meta-epidemiological study

OBJECTIVES

To systematically investigate clinical applicability of the current prognostic prediction models for severe postpartum hemorrhage (SPPH).

STUDY DESIGN AND SETTING

A meta-epidemiological study of prognostic prediction models was conducted for SPPH. A pre-designed structured questionnaire was adopted to extract the study characteristics, predictors and the outcome, modeling methods, predictive performance, the classification ability for high-risk individuals, and clinical use scenarios. The risk of bias among studies was assessed by the Prediction model Risk Of Bias ASsessment Tool (PROBAST).

RESULTS

Twenty-two studies containing 27 prediction models were included. The number of predictors in the final models varied from 3 to 53. However, one-third of the models (11) did not clearly specify the timing of predictor measurement. Calibration was found to be lacking in 10 (37.0%) models. Among the 20 models with an incidence rate of predicted outcomes below 15.0%, none of the models estimated the area under the precision-recall curve, and all reported positive predictive values were below 40.0%. Only two (7.4%) models specified the target clinical setting, while seven (25.9%) models clarified the intended timing of model use. Lastly, all 22 studies were deemed to be at high risk of bias.

CONCLUSION

Current SPPH prediction models have limited clinical applicability due to methodological flaws, including unclear predictor measurement, inadequate calibration assessment, and insufficient evaluation of classification ability. Additionally, there is a lack of clarity regarding the timing for model use, target users, and clinical settings. These limitations raise concerns about the reliability and usefulness of these models in real-world clinical practice.

Postpartum haemorrhage management: A randomized controlled trial comparing transvaginal uterine artery clamp, vacuum-assisted uterine contraction and condom tamponade

OBJECTIVE

While there have been numerous innovations recently for the management of postpartum haemorrhage (PPH), a limited body of research supports their application during this critical complication, which contributes significantly to maternal mortality worldwide. This randomized controlled trial (RCT) aimed to evaluate the effectiveness of three interventions - transvaginal uterine artery clamp (TVUAC), vacuum-assisted uterine contraction using a suction cannula (SC), and condom tamponade (CT) - in the management of atonic PPH.

METHODS

An open-label RCT was conducted among women who delivered vaginally and developed atonic PPH at a tertiary care obstetric facility. Block randomization with sealed envelopes was used to allocate eligible participants into three interventional arms with a 1:1:1 ratio. The exclusion criteria were twin deliveries, haemodynamically unstable patients, and individuals who did not provide informed consent. The primary outcome variables assessed were blood loss post-application, total blood loss, time taken for application, and time required to achieve haemostasis within each trial arm. The secondary outcomes were the need for a second instrument or surgical intervention to control bleeding, and requirement for blood transfusion. Effectiveness outcomes were analysed as intention-to-treat, whilst safety outcomes were analysed as as-treated.

RESULTS

Sixteen participants were randomized to each intervention group (n = 48). TVUAC and SC demonstrated comparable outcomes, while CT lagged in all examined parameters. Following device application, blood loss was similar in both the TVUAC (235 ± 187 ml) and SC (246.5 ± 189 ml) groups. However, following the use of CT, there was blood loss of 431 ± 427 ml, although this difference was not significant (p = 0.113). When considering total blood loss, the TVUAC group (903 ± 234 ml) showed slightly higher values than the SC group (887 ± 184 ml). However, the CT group exhibited notably higher total blood loss (1068 ± 455 ml) than the TVUAC and SC groups. In terms of application time, both TVUAC (1.8 ± 1.1 min) and SC (1.6 ± 0.9 min) significantly outperformed CT (3 ± 1.3 min) (p = 0.002). Furthermore, the time interval from the diagnosis of PPH to achieving haemostasis (defined as the time taken for active haemostasis) was significantly shorter in the TVUAC group (6 ± 4 min) and the SC group (5.7 ± 1.6 min) compared with the CT group (9.7 ± 3.8 min) (p = 0.002).

CONCLUSIONS

TVUAC and SC are more effective for the management of PPH than CT. However, both TVUAC and SC have advantages and disadvantages. While these results suggest a potential preference for TVUAC and SC over CT for the management of PPH, further research is necessary to validate these findings.

The cost-effectiveness of preventing, diagnosing, and treating postpartum haemorrhage: A systematic review of economic evaluations

BACKGROUND

Postpartum haemorrhage (PPH) is an obstetric emergency. While PPH-related deaths are relatively rare in high-resource settings, PPH continues to be the leading cause of maternal mortality in limited-resource settings. We undertook a systematic review to identify, assess, and synthesise cost-effectiveness evidence on postpartum interventions to prevent, diagnose, or treat PPH.

METHODS AND FINDINGS

This systematic review was prospectively registered on PROSPERO (CRD42023438424). We searched Medline, Embase, NHS Economic Evaluation Database (NHS EED), EconLit, CINAHL, Emcare, Web of Science, and Global Index Medicus between 22 June 2023 and 11 July 2024 with no date or language limitations. Full economic evaluations of any postpartum intervention for prevention, detection, or management of PPH were eligible. Study screening, data extraction, and quality assessments (using the CHEC-E tool) were undertaken independently by at least 2 reviewers. We developed narrative syntheses of available evidence for each intervention. From 3,993 citations, 56 studies were included: 33 studies of preventative interventions, 1 study assessed a diagnostic method, 17 studies of treatment interventions, 1 study comparing prevention and treatment, and 4 studies assessed care bundles. Twenty-four studies were conducted in high-income countries, 22 in upper or lower middle-income countries, 3 in low-income countries, and 7 studies involved countries of multiple income levels. Study settings, methods, and findings varied considerably. Interventions with the most consistent findings were the use of tranexamic acid for PPH treatment and using care bundles. In both cases, multiple studies predicted these interventions would either result in better health outcomes and cost savings, or better health outcomes at acceptable costs. Limitations for this review include that no ideal setting was chosen, and therefore, a transferability assessment was not undertaken. In addition, some sources of study uncertainty, such as effectiveness parameters, were interrogated to a greater degree than other sources of uncertainty.

CONCLUSIONS

In this systematic review, we extracted, critically appraised, and summarised the cost-effectiveness evidence from 56 studies across 16 different interventions for the prevention, diagnosis, and treatment of PPH. Both the use of tranexamic acid as part of PPH treatment, and the use of comprehensive PPH bundles for prevention, diagnosis, and treatment have supportive cost-effectiveness evidence across a range of settings. More studies utilizing best practice principles are required to make stronger conclusions on which interventions provide the best value. Several high-priority interventions recommended by World Health Organization (WHO) such as administering additional uterotonics, non-pneumatic anti-shock garment, or uterine balloon tamponade (UBT) for PPH management require robust economic evaluations across high-, middle-, and low-resource settings.

Tranexamic acid in preventing postpartum blood loss in vaginal delivery: a double-blinded randomized controlled trial

BACKGROUND

Postpartum hemorrhage (PPH) is an obstetrical emergency that occurs in 1% to 10% of all deliveries and contributes to nearly one-quarter of all maternal deaths worldwide. Tranexamic acid has been established as an adjunct in the treatment of PPH but its role in its prevention of PPH following vaginal delivery has not been widely studied.

OBJECTIVE

This study aimed to assess the effect of prophylactic tranexamic acid (1 g) along with active management of the third stage of labor in reducing postpartum blood loss and the incidence of postpartum hemorrhage after vaginal delivery.

STUDY DESIGN

In this randomized controlled trial, 650 women with singleton pregnancies at ≥34 weeks of gestation who were undergoing vaginal delivery were included. Eligible women were randomly assigned to receive either 1 g of tranexamic acid or placebo intravenously along with active management of the third stage of labor. Calibrated blood collection bags were used to measure postpartum blood loss during the third and fourth stages of labor.

RESULTS

Of 886 women approached for the study, 650 who met the inclusion criteria were enrolled, and 320 in group A and 321 in group B were analyzed. The maternal characteristics were similar between the groups. The mean blood loss did not differ significantly between the intervention and placebo groups (378.5±261.2 mL vs 383.0±258.9 mL; P=.93). The incidence of primary postpartum hemorrhage was comparable in both groups (15.9% in group A and 15.3% in group B; P=.814). The median quantitative decreases in hemoglobin levels within 12 to 24 hours after delivery were 0.60 g% (interquartile range, 0.40-0.90) in group A and 0.60 g% (interquartile range, 0.40-0.80) in group B, which were comparable in both groups (P=.95). The most common adverse effect reported was dizziness, and there was no thromboembolic event at 3 months follow-up in either group.

CONCLUSION

The use of tranexamic acid as a prophylactic measure along with active management of the third stage of labor does not provide additional benefit in reducing the postpartum blood loss and incidence of postpartum hemorrhage after vaginal delivery. El resumen está disponible en Español al final del artículo.

Effect of administration routes of oxytocin on hemoglobin in neonates with delayed umbilical cord clamping: a multi-centre randomized controlled clinical trial

PURPOSE

To evaluate the effect of intravenous infusion versus intramyometrial injection of oxytocin on hemoglobin levels in neonates with delayed umbilical cord clamping during cesarean section.

METHODS

The multi-centre randomized controlled trial was performed at three hospitals from February to June 2023. Women with term singleton gestations scheduled for cesarean delivery were allocated to receive an intravenous infusion of 10 units of oxytocin or a myometrial injection of 10 units of oxytocin during the surgery. The primary outcome was neonatal hemoglobin at 48 to 96 h after birth. Secondary outcomes were side-effects of oxytocin, postpartum haemorrhage, phototherapy for jaundice, feeding at 1 month, maternal and neonatal morbidity and re-admissions.

RESULTS

A total of 360 women were randomized (180 women in each group). The mean neonatal hemoglobin did not show a significant difference between the intravenous infusion group (194.3 ± 21.7 g/L) and the intramyometrial groups (195.2 ± 24.3 g/L) (p = 0.715). Secondary neonatal outcomes, involving phototherapy for jaundice, feeding at 1 month and neonatal intensive care unit admission were similar between the two groups. The maternal outcomes did not differ significantly between the two groups, except for a 200 mL higher intraoperative infusion volume observed in the intravenous group compared to the intramyometrial group.

CONCLUSION

Among women undergoing elective cesarean delivery of term singleton pregnancies, there was no significant difference in neonatal hemoglobin at 48 to 96 h after birth between infants with delayed cord clamping, whether the oxytocin was administrated by intravenous infusion or intramyometrial injection.

TRIAL REGISTRATION

Chinese Clinical trial registry: ChiCTR2300067953 (1 February 2023).

Predelivery Haemostatic Biomarkers in Women with Non-Severe Postpartum Haemorrhage

Background: Postpartum haemorrhage (PPH) is a frequent complication of childbirth that is difficult to predict. Predelivery coagulation biomarkers may help to guide preventive strategies. Our objective was to evaluate the association of predelivery haemostatic biomarkers with non-severe PPH. Methods: A nested case-control study was conducted within the « Study of Biological Determinants of Bleeding Postpartum » in order to compare different haemostatic biomarkers in plasma from pregnant women with non-severe PPH (cases) and controls without PPH matched for age, body mass index, term, and mode of delivery. Blood was collected at entry in the delivery room. Global haemostatic assays (thrombin generation assay (TGA) and plasmin generation assay (PGA)) were then performed on freshly thawed aliquots of platelet-poor plasma. Results: A total of 370 pregnant women (185 cases and 185 controls) were included. Median [interquartile range] predelivery platelet count was lower in PPH cases than in controls (217 [181-259] versus 242 [196-280] G/L). TGA and PGA parameters were similar between cases and controls. In a subset analysis of vaginal deliveries (n = 144), median predelivery TGA thrombin peak was lower, and median predelivery PGA lag phase was longer in cases compared to controls. In multivariable analysis, only predelivery platelet count was independently associated with non-severe PPH. Conclusions: Predelivery platelet count is associated with non-severe PPH. Differences in other haemostatic parameters are tenuous, questioning their usefulness in predicting non-severe PPH.

Novel biomarkers for prediction of atonic postpartum hemorrhage among 'low-risk' women in labor

Background

Postpartum hemorrhage (PPH) is the primary cause of maternal mortality globally, with uterine atony being the predominant contributing factor. However, accurate prediction of PPH in the general population remains challenging due to a lack of reliable biomarkers.

Methods

Using retrospective cohort data, we quantified 48 cytokines in plasma samples from 40 women diagnosed with PPH caused by uterine atony. We also analyzed previously reported hemogram and coagulation parameters related to inflammatory response. The least absolute shrinkage and selection operator (LASSO) and logistic regression were applied to develop predictive models. Established models were further evaluated and temporally validated in a prospective cohort.

Results

Fourteen factors showed significant differences between the two groups, among which IL2Rα, IL9, MIP1β, TNFβ, CTACK, prenatal Hb, Lymph%, PLR, and LnSII were selected by LASSO to construct predictive model A. Further, by logistic regression, model B was constructed using prenatal Hb, PLR, IL2Rα, and IL9. The area under the curve (AUC) values of model A in the training set, internal validation set, and temporal validation set were 0.846 (0.757-0.934), 0.846 (0.749-0.930), and 0.875 (0.789-0.961), respectively. And the corresponding AUC values for model B were 0.805 (0.709-0.901), 0.805 (0.701-0.894), and 0.901 (0.824-0.979). Decision curve analysis results showed that both nomograms had a high net benefit for predicting atonic PPH.

Conclusion

We identified novel biomarkers and developed predictive models for atonic PPH in women undergoing "low-risk" vaginal delivery, providing immunological insights for further exploration of the mechanism underlying atonic PPH.

Development of antepartum risk prediction model for postpartum hemorrhage in Lagos, Nigeria: A prospective cohort study (Predict-PPH study)

OBJECTIVES

There is currently a limited ability to accurately identify women at risk of postpartum hemorrhage (PPH). We conducted the "Predict-PPH" study to develop and evaluate an antepartum prediction model and its derived risk-scoring system.

METHODS

This was a prospective cohort study of healthy pregnant women who registered and gave birth in five hospitals in Lagos, Nigeria, from January to June 2023. Maternal antepartum characteristics were compared between women with and without PPH. A predictive multivariable model was estimated using binary logistic regression with a backward stepwise approach eliminating variables when P was greater than 0.10. Statistically significant associations in the final model were reported when P was less than 0.05.

RESULTS

The prevalence of PPH in the enrolled cohort was 37.1%. Independent predictors of PPH such as maternal obesity (adjusted odds ratio [aOR] 3.25, 95% confidence interval [CI] 2.47-4.26), maternal anemia (aOR 1.32, 95% CI 1.02-1.72), previous history of cesarean delivery (aOR 4.24, 95% CI 3.13-5.73), and previous PPH (aOR 2.65, 95% CI 1.07-6.56) were incorporated to develop a risk-scoring system. The area under the receiver operating characteristic curve (AUROC) for the prediction model and risk scoring system was 0.72 (95% CI 0.69-0.75).

CONCLUSION

We recorded a relatively high prevalence of PPH. Our model performance was satisfactory in identifying women at risk of PPH. Therefore, the derived risk-scoring system could be a useful tool to screen and identify pregnant women at risk of PPH during their routine antenatal assessment for birth preparedness and complication readiness.

The Effect of Inhaled Oxygen on Postpartum Hemorrhage: A Systematic Review and Meta-Analysis

Background

Postpartum Hemorrhage (PPH) is a significant problem that can increase the risk of maternal mortality. Previous studies investigated the effect of Inhaled Oxygen (IO) on PPH. They found some conflicting results. Thus, the current systematic review and meta-analysis aimed to determine the effect of IO on PPH.

Materials and Methods

Randomized trials were searched according to the PRISMA framework until the end of November 2022 in Web of Science, PubMed, Scopus, and Cochrane Library databases. Statistical analyses were performed in the STATA v. 14 software. I2 statistic was applied to assess heterogeneity between studies. The random effect model, sample size, and mean and standard deviation of each group were applied to report the pooled effect size. Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to evaluate the risk of bias in the included studies. Finally, five articles were included in the meta-analysis. Two and three studies reported the mean of bleeding after vaginal delivery during one- and two-hours oxygen therapy, respectively.

Results

Results showed that IO significantly reduced bleeding by 38.91 mL in the intervention group compared to routine care (WMD: -38.91, 95%CI: -60.18 to -17.64) after vaginal delivery. In addition, IO during one (WMD: -38.42, 95%CI: -71.62 to -5.22) and two (WMD: -41.93, 95%CI: -60.15 to - 23.71) hours significantly decreased bleeding in the intervention.

Conclusion

According to the present study, IO can significantly reduce PPH in the intervention group compared to routine care. However, more rigorously randomized clinical trials are required to decide better about this issue.

Conservative approaches to postpartum haemorrhage

Postpartum haemorrhage (PPH) and PPH-related deaths are disproportionately higher in low-income countries, with sub-Saharan Africa and Southern Asia accounting for approximately 85% of the global burden of PPH-related maternal deaths. Although PPH-related mortality is directly related to the amount and duration of bleeding, the high maternal death burden in resource-limited countries suggests that a great majority of these deaths would be avoidable with the appropriate resources and effective use of evidence-based interventions. Non-surgical management is often the first-line approach for PPH, but conservative surgical interventions may be required if bleeding persists or if the underlying cause is not responsive to the initial conservative measures. The appropriate interventions should be selected based on the individual's specific circumstances and clinical condition.

Effectiveness of care bundles for prevention and treatment of postpartum hemorrhage: a systematic review

OBJECTIVE

Care bundles are a promising approach to reducing postpartum hemorrhage-related morbidity and mortality. We assessed the effectiveness and safety of care bundles for postpartum hemorrhage prevention and/or treatment.

DATA SOURCES

We searched MEDLINE, Embase, Cochrane CENTRAL, Maternity and Infant Care Database, and Global Index Medicus (inception to June 9, 2023) and ClinicalTrials.gov and the International Clinical Trials Registry Platform (last 5 years) using a phased search strategy, combining terms for postpartum hemorrhage and care bundles.

STUDY ELIGIBILITY CRITERIA

Peer-reviewed studies evaluating postpartum hemorrhage-related care bundles were included. Care bundles were defined as interventions comprising ≥3 components implemented collectively, concurrently, or in rapid succession. Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies (controlled or uncontrolled) were eligible.

METHODS

Risk of bias was assessed using RoB 2 (randomized trials) and ROBINS-I (nonrandomized studies). For controlled studies, we reported risk ratios for dichotomous outcomes and mean differences for continuous outcomes, with certainty of evidence determined using GRADE. For uncontrolled studies, we used effect direction tables and summarized results narratively.

RESULTS

Twenty-two studies were included for analysis. For prevention-only bundles (2 studies), low-certainty evidence suggests possible benefits in reducing blood loss, duration of hospitalization, and intensive care unit stay, and maternal well-being. For treatment-only bundles (9 studies), high-certainty evidence shows that the E-MOTIVE intervention reduced risks of composite severe morbidity (risk ratio, 0.40; 95% confidence interval, 0.32-0.50) and blood transfusion for bleeding, postpartum hemorrhage, severe postpartum hemorrhage, and mean blood loss. One nonrandomized trial and 7 uncontrolled studies suggest that other postpartum hemorrhage treatment bundles might reduce blood loss and severe postpartum hemorrhage, but this is uncertain. For combined prevention/treatment bundles (11 studies), low-certainty evidence shows that the California Maternal Quality Care Collaborative care bundle may reduce severe maternal morbidity (risk ratio, 0.64; 95% confidence interval, 0.57-0.72). Ten uncontrolled studies variably showed possible benefits, no effects, or harms for other bundle types. Nearly all uncontrolled studies did not use suitable statistical methods for single-group pretest-posttest comparisons and should thus be interpreted with caution.

CONCLUSION

The E-MOTIVE intervention improves postpartum hemorrhage-related outcomes among women delivering vaginally, and the California Maternal Quality Care Collaborative bundle may reduce severe maternal morbidity. Other bundle designs warrant further effectiveness research before implementation is contemplated.

Prospective observational study to measure the incidence of chest pain and its association with perioperative factors among parturients undergoing lower segment cesarean section with subarachnoid blocks

Background

Intraoperative chest pain is common in parturients undergoing lower segment cesarean section (LSCS) with subarachnoid block (SAB). The study aimed to quantify the incidence of intraoperative chest pain after oxytocin in patients undergoing LSCS with SAB and to find out its association with relevant factors.

Methods

Consenting parturients undergoing LSCS with SAB were recruited. Those who had any cardiac disease, altered sensorium, had the suboptimal effect of SAB, or needed the use of any other anesthetic agent or additional uterotonic were excluded. Chest pain was graded as follows: Grade 1 - Patient lifted shoulder without restlessness, Grade 2 - Patient lifted shoulder with restlessness, Grade 3 - Patient explicitly complained of chest pain, and Grade 4 - Patient complained of chest pain with desaturation or hypotension or both.

Results

Of 2086 subjects recruited, 4.84% had chest discomfort/pain. The age and the volume of bupivacaine used in SAB were comparable between the groups who had chest pain and those without. Thirty-five (34.65%), 18 (17.82%), 21 (20.8%), and 27 (26.73%) patients had Grade 1, 2, 3, and 4 chest pain/discomfort, respectively. Logistic regression analysis showed that with an increase in age by 1 unit, the odds of chest pain decreased by 1%. With an increase in parity by one, the odds of chest pain decreased by 8%, while those who did not have comorbidities had 11.7% less odds of occurrence of chest pain than those with comorbidities.

Conclusion

The study reliably measured the incidence and characteristics of chest pain/discomfort following oxytocin during LSCS under SAB and its association with relevant factors.

The profile of patients with postpartum hemorrhage admitted to the obstetric intensive care: a cross-sectional study

Objective

In Brazil, postpartum hemorrhage (PPH) is a major cause of maternal morbidity and mortality. Data on the profile of women and risk factors associated with PPH are sparse. This study aimed to describe the profile and management of patients with PPH, and the association of risk factors for PPH with severe maternal outcomes (SMO).

Methods

A cross-sectional study was conducted in Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) obstetric intensive care unit (ICU) between January 2012 and March 2020, including patients who gave birth at the hospital and that were admitted with PPH to the ICU.

Results

The study included 358 patients, of whom 245 (68.4%) delivered in the IMIP maternity, and 113 (31.6%) in other maternity. The mean age of the patients was 26.7 years, with up to eight years of education (46.1%) and a mean of six prenatal care. Uterine atony (72.9%) was the most common cause, 1.6% estimated blood loss, 2% calculated shock index (SI), 63.9% of patients received hemotransfusion, and 27% underwent hysterectomy. 136 cases of SMO were identified, 35.5% were classified as maternal near miss and 3.0% maternal deaths. Multiparity was associated with SMO as an antepartum risk factor (RR=1.83, 95% CI1.42-2.36). Regarding intrapartum risk factors, abruptio placentae abruption was associated with SMO (RR=2.2 95% CI1.75-2.81). Among those who had hypertension (49.6%) there was a lower risk of developing SMO.

Conclusion

The principal factors associated with poor maternal outcome were being multiparous and placental abruption.

A 3D-printed condom intrauterine balloon tamponade: Design, prototyping, and technical validation

Post-partum haemorrhage is among the main causes of (preventable) mortality for women in low-resource settings (LRSs), where, in 2017, the mortality ratio was 462 out of every 100 000 live births, over 10 times higher than for high-resource settings. There are different treatments available for post-partum haemorrhage. The intrauterine balloon tamponade is a medical device that proved to be a simple and cost-effective approach. Currently, there are several balloon tamponades available, with different design and working principles. However, all these devices were designed for high-resource settings, presenting several aspects that could be inappropriate for many lower-income countries. This paper presents the results of a preclinical study aiming at informing the design, prototyping and validation of a 3D-printed intrauterine balloon tamponade concept, contributing towards the United Nation's Sustainable Development Goal 3: Good health and Well-being. Frugal engineering concepts and contextualised design techniques were applied throughout, to define the design requirements and specifications. The performance of the final prototype was validated against the requirements of the UK National Health System (NHS) technical guidelines and relevant literature, measuring the water leak and pressure drop over time, both open air and in a approximate uterus model. The resulting prototype is made up of six components, some of which are easy to retrieve, namely a water bottle, a silicone tube and an ordinary condom, while others can be manufactured locally using 3D printers, namely a modified bottle cap, a flow stopper and a valve for holding the condom in place. Validation testing bore promising results with no water or pressure leak open air, and minimal leaks in the approximate uterus model. This demonstrates that the 3D printed condom-based intrauterine balloon tamponade is performing well against the requirements and, when compared to the state of the art, it could be a more appropriate and more resilient solution to low-resource settings, as it bypasses the challenges in the supply of consumables and presents a greener option based on circular economy.

Current concepts in the use of cell salvage in obstetrics

PURPOSE OF REVIEW

The worldwide leading cause of maternal death is severe maternal hemorrhage. Maternal hemorrhage can be profound leading to an entire loss of blood volume. In the past two decades, Patient Blood Management has evolved to improve patient's care and safety. In surgeries with increased blood loss exceeding 500 ml, the use of cell salvage is strongly recommended in order to preserve the patient's own blood volume and to minimize the need for allogeneic red blood cell (RBC) transfusion. In this review, recent evidence and controversies of the use of cell salvage in obstetrics are discussed.

RECENT FINDINGS

Numerous medical societies as well as national and international guidelines recommend the use of cell salvage during maternal hemorrhage.

SUMMARY

Intraoperative cell salvage is a strategy to maintain the patient's own blood volume and decrease the need for allogeneic RBC transfusion. Historically, cell salvage has been avoided in the obstetric population due to concerns of iatrogenic amniotic fluid embolism (AFE) or induction of maternal alloimmunization. However, no definite case of AFE has been reported so far. Cell salvage is strongly recommended and cost-effective in patients with predictably high rates of blood loss and RBC transfusion, such as women with placenta accreta spectrum disorder. However, in order to ensure sufficient practical experience in a multiprofessional obstetric setting, liberal use of cell salvage appears advisable.

Roles and challenges encountered by midwives in the management of postpartum haemorrhage following normal vaginal delivery: A scoping review

AIMS

To establish a comprehensive understanding of the roles of midwives and the challenges they encounter in the prevention, diagnosis and management of postpartum haemorrhage (PPH) following normal vaginal delivery.

DESIGN

We conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews (PRISMA-ScR) recommendations.

METHODS

We considered studies related to the roles of midwives and the challenges they encounter in the prevention, diagnosis and management of PPH during vaginal delivery. We excluded guidelines, consensuses, abstracts of meetings and non-English language studies. Databases, including the Cochrane Library, PubMed, Web of Science, Ovid, Medline, Embase, JBI EBP and BIOSIS Previews, were searched on January 1, 2023, with no time limitations.

RESULTS

We included 28 publications. Midwives play important roles in the prevention, diagnosis and management of postpartum haemorrhage during vaginal delivery. In the prevention of PPH, midwives' roles include identifying and managing high-risk factors, managing labour and implementing skin-to-skin contact. In the diagnosis of PPH, midwives' roles include early recognition and blood loss estimation. In the management of PPH, midwives are involved in mobilizing other professional team members, emergency management, investigating causes, enhancing uterine contractions, the repair of perineal tears, arranging transfers and preparation for surgical intervention. However, midwives face substantial challenges, including insufficient knowledge and skills, poor teamwork skills, insufficient resources and the need to deal with their negative emotions. Midwives must improve their knowledge, skills and teamwork abilities. Health care system managers and the government should give full support to midwives. Future research should focus on developing clinical practice guidelines for midwives for preventing, diagnosing and managing postpartum haemorrhage.

Postpartum Hemorrhage: Enhancing Outcomes for Mothers by Effective Management

Postpartum hemorrhage (PPH) remains a significant contributor to maternal morbidity and mortality worldwide. In India, PPH affects approximately 12% of women. The prevention and management of PPH are the significant challenges in obstetrics, with accurate assessment of blood loss and timely intervention being critical. Active Management of the Third Stage of Labor is a gold standard strategy for prevention. Recent advancements in PPH management include the use of recombinant activated factor VIIa, which has shown promise in decreasing the need for invasive procedures and second-line therapies. Additionally, surgical and radiological interventions have been effective in cases of refractory PPH. Overall, ongoing research and advancements in PPH management continue to enhance the quality of care and maternal outcomes experiencing this potentially life-threatening complication of childbirth. This editorial explores prevention and management of Atonic PPH with encompassing medical and surgical strategies, to enhance understanding and optimize clinical care for mothers at risk of this obstetric emergency.

Clinical and biological factors associated with red blood cell transfusion during severe postpartum haemorrhage - A single-center retrospective cohort study

INTRODUCTION

Red blood cell (RBC) transfusions are of utmost importance in the management of severe post-partum haemorrhage. Although the recommendations for blood transfusion protocols are regularly issued, there are significant differences in management depending on the context and the medical teams involved.

OBJECTIVE

To determine during the first 24 h, the clinical and biological factors associated with the decision for RBC transfusion during severe PPH (≥1000 mL) for vaginal and caesarean deliveries.

STUDY DESIGN

Monocentric retrospective study conducted in a tertiary care university maternity unit (CHI-Creteil) including all parturients from November 23th 2018 to 31th December 2020 with severe PPH (≥1000 mL).

RESULTS

Over the study period, we reported 7103 deliveries, out of which 682 were complicated by PPH (9.6 %) with 200 cases of PPH ≥1000 mL (2.8 %). In our study, 40 % of patients (80/200) required a RBC transfusion". After multivariate analysis, severe PPH caused by placental abruption, uterine rupture or placental implantation disorders (aOR = 3.48 IC95 [1.27-9.52], p < 0.001), estimated blood loss ≥1500 mL (aOR = 9.60 IC95 [3.69-24.95], p < 0. 001), invasive measures such as uterine balloon tamponade, arterial ligation and uterine packing (aOR = 4.15 IC95 [1.80-9.61], p < 0.001), pre-labor hemoglobin <10 g/dL (aOR =4.88 IC95 [1.57-15.15], p < 0.001) or abnormal biological results in the acute phase (including hemoglobin <7.0 g/dL and/or fibrinogen <2 g/L and/or platelets <100 G/L) (aOR =356 IC95 [1,05-12,10], p < 0.001) were significantly and independently associated with the decision to initiate RBC transfusions.

CONCLUSIONS

In a monocentric retrospective study including 200 consecutive cases of severe PPH (≥1000 mL) we identified groups of clinical and biological factors directly accessible to clinicians, significantly and independently associated with RBC transfusion in the first 24 h of management.

Amniotic fluid embolism rescued using venoarterial extracorporeal membrane oxygenation without initial anticoagulation: A case report and literature review

RATIONALE

Amniotic fluid embolism (AFE) is a fatal obstetric condition that often rapidly leads to severe respiratory and circulatory failure. It is complicated by obstetric disseminated intravascular coagulation (DIC) with bleeding tendency; therefore, the introduction of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is challenging. We report the case of a patient with AFE requiring massive blood transfusion, rescued using VA-ECMO without initial anticoagulation.

PATIENTS CONCERNS

A 39-year-old pregnant patient was admitted with a complaint of abdominal pain. An emergency cesarean section was performed because a sudden decrease in fetal heart rate was detected in addition to DIC with hyperfibrinolysis. Intra- and post-operatively, the patient had a bleeding tendency and required massive blood transfusions. After surgery, the patient developed lethal respiratory and circulatory failure, and VA-ECMO was introduced.

DIAGNOSIS

Based on the course of the illness and imaging findings, the patient was diagnosed with AFE.

INTERVENTIONS

By controlling the bleeding tendency with a massive transfusion and tranexamic acid administration, using an antithrombotic ECMO circuit, and delaying the initiation of anticoagulation and anti-DIC medication until the bleeding tendency settled, the patient was managed safely on ECMO without complications.

OUTCOMES

By day 5, both respiration and circulation were stable, and the patient was weaned off VA-ECMO. Mechanical ventilation was discontinued on day 6. Finally, she was discharged home without sequelae.

LESSONS

VA-ECMO may be effective to save the lives of patients who have AFE with lethal circulatory and respiratory failure. For safe management without bleeding complications, it is important to start VA-ECMO without initial anticoagulants and to administer anticoagulants and anti-DIC drugs after the bleeding tendency has resolved.

Rationale for the Potential Use of Recombinant Activated Factor VII in Severe Post-Partum Hemorrhage

Severe post-partum hemorrhage (PPH) is a major cause of maternal mortality worldwide. Recombinant activated factor VII (rFVIIa) has recently been approved by the European Medicines Agency for the treatment of severe PPH if uterotonics fail to achieve hemostasis. Although large randomized controlled trials are lacking, accumulated evidence from smaller studies and international registries supports the efficacy of rFVIIa alongside extended standard treatment to control severe PPH. Because rFVIIa neither substitutes the activity of a missing coagulation factor nor bypasses a coagulation defect in this population, it is not immediately evident how it exerts its beneficial effect. Here, we discuss possible mechanistic explanations for the efficacy of rFVIIa and the published evidence in patients with severe PPH. Recombinant FVIIa may not primarily increase systemic thrombin generation, but may promote local thrombin generation through binding to activated platelets at the site of vascular wall injury. This explanation may also address safety concerns that have been raised over the administration of a procoagulant molecule in a background of increased thromboembolic risk due to both pregnancy-related hemostatic changes and the hemorrhagic state. However, the available safety data for this and other indications are reassuring and the rates of thromboembolic events do not appear to be increased in women with severe PPH treated with rFVIIa. We recommend that the administration of rFVIIa be considered before dilutional coagulopathy develops and used to support the current standard treatment in certain patients with severe PPH.

Effect of intraoperative cell salvage on coagulation function outcomes in patients with massive post-Cesarean section hemorrhage

OBJECTIVE

To examine the impact of using intraoperative cell salvage (ICS) for the restoration of coagulation function in cases of massive Post-Cesarean Section Hemorrhage (PCSH).

METHODS

A retrospective analysis was conducted on 60 cases of massive PCSH meeting inclusion criteria at Suqian Maternity and Children's Hospital from January 2020 to July 2022. Patients were divided into two groups: allogeneic blood transfusion group (Group A, n = 30) and ICS group (Group B, n = 30), based on transfusion methods. Blood parameters, coagulation function, and adverse reactions were assessed before (T0) and after (T1) transfusion. Patients were categorized into good prognosis (GP) and poor prognosis (PP) groups based on adverse reaction occurrence. Clinical profiles were compared between groups, and multivariate binary logistic regression analysis was employed to evaluate the factors that may affect the prognosis in women with PCSH.

RESULTS

No significant differences in routine blood parameters were observed between groups at T0 and T1 (P>0.05). At T0, no significant differences in PT, APTT, TT, or FIB were found between groups (P>0.05). Both groups showed a reduction in PT, APTT, and TT values at T1 compared to T0, with Group B experiencing a more significant decrease than Group A (P<0.05). FIB increased in both groups at T1 compared to T0, with Group B demonstrating a higher increase than Group A (P<0.05). Both groups showed increased blood pressure at T1 compared to T0, with Group B showing a more pronounced elevation than Group A (P<0.05). The occurrence of adverse reactions was significantly lower in Group B (1/30, 3.33%) compared to Group A (7/30, 23.33%) (P<0.05). Logistic regression analysis identified FIB<1.52 g/L and HR<45.35 times/min as factors associated with increased risk of unfavorable outcome in women with PCSH.

CONCLUSION

In patients experiencing significant PCSH, ICS may lead to better postoperative recovery of blood parameters, faster restoration of coagulation function, and reduced risk of adverse events compared to ABT. Moreover, early detection of coagulation function and blood gas indexes is crucial for clinicians to implement timely prevention and treatment measures.

Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus

OBJECTIVE

There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth.

DESIGN

Systematic review and three-stage modified Delphi expert consensus.

SETTING

International.

POPULATION

Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance.

OUTCOME MEASURES

Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth.

RESULTS

Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman's haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman's haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach.

CONCLUSION

These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.

Timely use of Bakri intrauterine balloon tamponade contributes to the effectiveness in controlling severe postpartum hemorrhage

The aim of the present study was to explore the effectiveness of Bakri intrauterine balloon tamponade (IUBT) in treating severe postpartum hemorrhage (SPPH). A cohort of 198 women with SPPH using IUBT were retrospectively selected. The baseline and maternal outcome characteristics were examined. The results demonstrated that women with SPPH had a high proportion of placenta accrete (53.0%). Bakri IUBT demonstrated a global effectiveness of 84.5% in SPPH treatment, accounting for 82.9% in women with placenta accrete. Compared with women with Bakri failure, women who experienced Bakri success had reduced rates of less use of pre-/post-IUBT intervention, blood transfusion, lower genital tract trauma, estimated blood loss (EBL), and a longer indwelling duration (P<0.05). Logistic regression revealed that the pre-IUBT intervention (OR=3.910; 95% CI: 1.684-9.079; P=0.002) was positively associated with hemostasis success, while lower genital tract trauma was negatively associated with Bakri success (OR=0.091; 95% CI: 0.009-0.894; P=0.040). Moreover, women diagnosed with placenta accrete underwent a greater number of transabdominal placed Bakri IUBT and pre-IUBT interventions than those without placenta accrete (P<0.05). No significant differences were observed in Bakri success, total EBL, pre-/post-IUBT EBL, infused volume of IUBT, IUBT indwelling duration, even the rate of hemostasis, lower genital tract trauma, blood transfusion, post-IUBT intervention, and puerperal fever between women with and without placenta accrete (P>0.05). In conclusion, placenta accrete may be the leading cause of SPPH. Bakri IUBT is an effective and safe measure for SPPH. Pre-IUBT intervention may be predictive of Bakri's success. The timely use of IUBT during labor may mitigate the impact of risk factors identified on PPH.