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Yang WJ, Kang D, Sung JH, Song MG, Park H, Park T, Cho J, Seo TS, Oh SY. Association between uterine artery embolization for postpartum hemorrhage and second delivery on maternal and offspring outcomes: a nationwide cohort study. Hum Reprod Open 2024; 2024:hoae043. [PMID: 39036364 PMCID: PMC11259214 DOI: 10.1093/hropen/hoae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 06/11/2024] [Indexed: 07/23/2024] Open
Abstract
STUDY QUESTION What are the maternal and neonatal outcomes of second delivery in women who underwent uterine artery embolization (UAE) during their first delivery? SUMMARY ANSWER Women who underwent UAE during their first delivery exhibited higher risks of placental problems, preterm births, and postpartum hemorrhage (PPH) in second delivery and the second offspring also showed increased risk of major congenital malformations, admission to the neonatal intensive care units (NICU), necrotizing enterocolitis, intraventricular hemorrhage, and bronchopulmonary dysplasia. WHAT IS KNOWN ALREADY UAE is a minimally invasive procedure used as an alternative to hysterectomy for managing severe PPH. However, recent studies have raised concerns about potential obstetric complications, including recurrent PPH, placenta accreta spectrum (PAS), and fetal growth restriction in subsequent delivery following UAE. STUDY DESIGN SIZE DURATION This was a nationwide retrospective cohort study using the Korean National Health Insurance Service (K-NHIS) database, covering 50 million individuals from 2004 to 2020. The cohort included 3 616 923 women with live births between 1 January 2005 and 31 December 2019 with follow-up data extending to 31 December 2020. PARTICIPANTS/MATERIALS SETTING METHODS The study included women who had their first live birth between 2005 and 2019, excluding those who underwent hysterectomy (without UAE = 3 612 389, UAE = 4534). Among them, we selected women who had single gestation secondary delivery (without UAE = 1 694 600, UAE = 1146). Propensity score matching was used to control for confounding factors, resulting in 11 184 women without UAE and 1119 women with UAE for subsequent analysis. MAIN RESULTS AND THE ROLE OF CHANCE Women in the UAE group had significantly higher risks of PAS (odds ratio (OR) = 38.91, 95% CI = 18.61-81.34), placenta previa (OR = 6.98, 95% CI = 5.57-8.75), and preterm birth (OR = 2.23, 95% CI = 1.71-2.90) during their second delivery. The risk of recurrent PPH was also significantly higher (OR = 8.94, 95% CI = 7.19-11.12). Their second offspring were more likely to have major congenital malformations (OR = 1.62, 95% CI = 1.25-2.11) and adverse neonatal outcomes, including NICU admissions (OR = 1.83, 95% CI = 1.48-2.25). Long-term outcomes showed a higher risk of attention-deficit/hyperactivity disorder (hazard ratio = 1.64, 95% CI = 1.03-2.63) but were otherwise comparable to those in the without UAE group. LIMITATIONS REASONS FOR CAUTION Retrospective nature of the study may have introduced exposure and outcome misclassifications, despite the reliability of the K-NHIS database. Unmeasured confounders and selection bias due to only including live births could also have influenced the results. WIDER IMPLICATIONS OF THE FINDINGS Women with a history of UAE require meticulous prenatal care and close monitoring during subsequent deliveries due to increased risks of complications. Counseling and referral to high-risk medical centers may improve outcomes. Further research is needed to understand the mechanisms of complications in both mothers and offspring at sequential delivery, as well as to refine UAE procedures. STUDY FUNDING/COMPETING INTERESTS This study supported by Patient-Centered Clinical Research Coordinating Center (PACEN) funded by the Ministry of Health & Welfare, Republic of Korea (HC21C0123). This study was funded by S.-Y.O. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Woo Jin Yang
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Danbee Kang
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | - Ji-Hee Sung
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myung Gyu Song
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyejeong Park
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | - Taegyun Park
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Department of Big Data Research and Development, National Health Insurance Service, Wonju, Republic of Korea
| | - Juhee Cho
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | - Tae-Seok Seo
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Soo-Young Oh
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Chatani S, Inoue A, Lee T, Uemura R, Imai Y, Takaki K, Tomozawa Y, Murakami Y, Sonoda A, Tsuji S, Watanabe Y. Clinical outcomes and future fertility after uterine artery embolization for postpartum and post-abortion hemorrhage. Acta Radiol 2024; 65:670-677. [PMID: 38584381 DOI: 10.1177/02841851241244489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) and post-abortion hemorrhage (PAH) are life-threatening conditions. PURPOSE To evaluate the efficacy and safety of uterine arterial embolization (UAE) for PPH and PAH and to investigate future fertility after UAE. MATERIAL AND METHODS This study included 57 consecutive patients (mean age = 34 years) who underwent UAE for PPH (n = 46) and PAH (n = 11) at our institution between January 2011 and December 2022. Technical success, non-visualization of the peripheral portion of bilateral uterine arteries on angiography, and clinical success, complete hemostasis after UAE, were assessed. UAE-associated complications and factors related to clinical success were analyzed. Pregnancy outcomes after UAE and complications during subsequent pregnancy were investigated in 16 patients who desired fertility and were followed up for >1 year. RESULTS The technical and clinical success rates were 100% and 84.2%, respectively. Sepsis (n = 1) and uterine empyema (n = 1) were observed as severe complications. Placental disorder, bleeding within 24 h after delivery or abortion, ≥1.5 shock index, ≥6 units of transfusion erythrocytes, and ≥8 obstetrical disseminated intravascular coagulation score were significantly associated with unfavorable clinical outcomes. In total, 16 pregnancies were observed in 12 patients after UAE, three of which were miscarriages and 13 were successful live births. During pregnancy, uterine rupture (n = 1) and accreta (n = 1) were observed. CONCLUSION UAE is an effective treatment for PPH and PAH. Although UAE could preserve future fertility, careful attention should be paid to perinatal management for unusual complications.
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Affiliation(s)
- Shohei Chatani
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Akitoshi Inoue
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tokuko Lee
- Department of Radiology, Koseikai Takeda Hospital, Kyoto, Japan
| | - Ryo Uemura
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yugo Imai
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Kai Takaki
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yuki Tomozawa
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yoko Murakami
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Akinaga Sonoda
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yoshiyuki Watanabe
- Department of Radiology, Shiga University of Medical Science, Otsu, Shiga, Japan
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Yin H, Liu H, Hu R. Uterine necrosis following uterine artery embolization as treatment for postpartum hemorrhage: A case report and literature review. Int J Gynaecol Obstet 2024. [PMID: 38800885 DOI: 10.1002/ijgo.15710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 05/29/2024]
Abstract
Uterine necrosis is a rare complication of uterine artery embolization for postpartum hemorrhage and most patients end up having a hysterectomy. Here we report a case in which the patient experienced a recurrent fever 28 days after uterine artery embolization as treatment for postpartum hemorrhage and had no response to antibiotics. Magnetic resonance imaging of the pelvis revealed a mass which was approximately 12-cm in size with air bubbles in the uterus, suggesting necrosis with infection. Transvaginal clamping of the uterine mass was performed and necrotic tissue removed under laparoscopic monitoring, which successfully spared the necessity for a hysterectomy. The patient's subsequent progress was favorable. In the present study we review the high-risk factors of uterine necrosis following uterine artery embolization and summarize the key points of early diagnosis. In addition, we propose a strategy to successfully spare the necessity for a hysterectomy without the spread of infection or uterine perforation.
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Affiliation(s)
- Huifen Yin
- Obstetrics Department, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Haiyan Liu
- Obstetrics Department, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Rong Hu
- Obstetrics Department, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
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de Vries PLM, Deneux-Tharaux C, Baud D, Chen KK, Donati S, Goffinet F, Knight M, D'Souzah R, Sueters M, van den Akker T. Postpartum haemorrhage in high-resource settings: Variations in clinical management and future research directions based on a comparative study of national guidelines. BJOG 2023; 130:1639-1652. [PMID: 37259184 DOI: 10.1111/1471-0528.17551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 04/15/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH. DESIGN Comparative study. SETTING High-resource countries. POPULATION Women with PPH. METHODS Systematic comparison of guidance on PPH from eight high-income countries. MAIN OUTCOME MEASURES Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour. CONCLUSIONS Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines. RESULTS Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.
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Affiliation(s)
- Pauline L M de Vries
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Port-Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Catherine Deneux-Tharaux
- Université Paris Cité, Inserm, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), CRESS, Paris, France
| | - David Baud
- Department of Gynaecology and Obstetrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Kenneth K Chen
- Departments of Medicine & ObGyn, Brown University, Providence, Rhode Island, USA
| | - Serena Donati
- National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanità-Italian National Institute of Health, Rome, Italy
| | - Francois Goffinet
- Port-Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rohan D'Souzah
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Departments of Obstetrics & Gynaecology and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Obstetrics and Gynaecology, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marieke Sueters
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
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Song KH, Choi ES, Kim HY, Ahn KH, Kim HJ. Patient blood management to minimize transfusions during the postpartum period. Obstet Gynecol Sci 2023; 66:484-497. [PMID: 37551109 PMCID: PMC10663398 DOI: 10.5468/ogs.22288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/11/2023] [Accepted: 07/20/2023] [Indexed: 08/09/2023] Open
Abstract
Patient blood management is an evidence-based concept that seeks to minimize blood loss by maintaining adequate hemoglobin levels and optimizing hemostasis during surgery. Since the coronavirus disease 2019 pandemic, patient blood management has gained significance due to fewer blood donations and reduced amounts of blood stored for transfusion. Recently, the prevalence of postpartum hemorrhage (PPH), as well as the frequency of PPH-associated transfusions, has steadily increased. Therefore, proper blood transfusion is required to minimize PPH-associated complications while saving the patient's life. Several guidelines have attempted to apply this concept to minimize anemia during pregnancy and bleeding during delivery, prevent bleeding after delivery, and optimize recovery methods from anemia. This study systematically reviewed various guidelines to determine blood loss management in pregnant women.
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Affiliation(s)
- Kwan Heup Song
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
| | - Eun Saem Choi
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, Korea University College of Medicine, Seoul,
Korea
| | - Ho Yeon Kim
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
| | - Ki Hoon Ahn
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, Korea University College of Medicine, Seoul,
Korea
| | - Hai Joong Kim
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
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Tipiani-Rodríguez O, Elías-Estrada JC, Bocanegra-Becerra YL, Ponciano-Biaggi MA. Treatment of ectopic pregnancy implanted on cesarea scar: cohort study 2018-2022, Lima, Peru. REVISTA COLOMBIANA DE OBSTETRICIA Y GINECOLOGIA 2023; 74:15-30. [PMID: 37253244 PMCID: PMC10237182 DOI: 10.18597/rcog.3958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/21/2023] [Indexed: 06/01/2023]
Abstract
Objectives To describe the clinical characteristics and treatment of ectopic pregnancy arising in the cesarean section scar, as well as its complications and obstetric prognosis. Material and methods Retrospective cohort study of pregnant women with the diagnosis of a scar pregnancy in accordance with Maternal-Fetal Medicine Society criteria, seen between January 2018 and March 2022 in two high complexity institutions of the social security system, located in Lima, Peru. Consecutive sampling was used. Baseline sociodemographic and clinical variables were measured, including diagnosis, type of treatment, complications and obstetric prognosis. A descriptive analysis was performed. Results Out of 29,919 deliveries, 17 patients were included. Of these, 41.2 % received medical management and the rest were treated surgically. Successful management with intra-gestational sac methotrexate was performed in two patients with ectopic pregnancy type 2. Four patients required total hysterectomy. Six patients became pregnant after the treatment and 4 completed their pregnancy with healthy mother and neonate pairs. Conclusions Ectopic pregnancy implanted in a cesarean section scar is an infrequent occurrence for which medical and surgical management options are available with apparently good outcomes. Further studies of better methodological quality and random assignment are needed in order to help characterize the safety and effectiveness of the various therapeutic options for women with suspected scar pregnancy.
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Jeon GU, Jeon GS, Kim YR, Ahn EH, Jung SH. Uterine artery embolization for postpartum hemorrhage with placenta accreta spectrum. Acta Radiol 2023:2841851231154675. [PMID: 37093745 DOI: 10.1177/02841851231154675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND The reported success rate of uterine artery embolization (UAE) for postpartum hemorrhage (PPH) differs by the cause of bleeding; in some reports, UAE shows less successful results in patients with placenta accreta spectrum (PAS). PURPOSE To evaluate the outcome of UAE for treating PPH associated with PAS. MATERIAL AND METHODS From September 2011 to September 2021, 227 patients (mean age = 34.67±4.06 years; age range = 19-47 years) underwent UAE for managing intractable PPH. Patients were divided into two groups: those with PAS (n = 46) and those without PAS (n = 181). Delivery details, embolization details, and procedure-related outcomes were compared between the two groups. P values <0.05 were considered statistically significant. RESULTS The technical success rate was 96.9% (n = 222) and the clinical success rate was 93.8% (n = 215). There were no significant differences in outcome of UAE between the two patient groups. The technical success rate was 95.7% (n = 44) in patients with PAS and 98.3% (n = 178) in patients without PAS (P = 0.267). The clinical success rate was 91.3% (n = 42) in patients with PAS and 95.6% (n = 173) in patients without PAS (P = 0.269). There were 24 cases of immediate complications, including pelvic pain (n = 20), urticaria (n = 3), and puncture site hematoma (n = 1). No major complication was reported. CONCLUSION UAE is a safe and effective method to control intractable PPH for patients with or without PAS.
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Affiliation(s)
- Go Un Jeon
- Department of Radiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Gyeong Sik Jeon
- Department of Radiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Young Ran Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Eun Hee Ahn
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Sang Hee Jung
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
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Tavcar J, Movilla P, Carusi DA, Loring M, Reddy H, Isaacson K, Morris SN. Incidence and Clinical Implications of Placenta Accreta Spectrum after Treatment for Asherman Syndrome. J Minim Invasive Gynecol 2023; 30:192-198. [PMID: 36442752 DOI: 10.1016/j.jmig.2022.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/14/2022] [Accepted: 11/17/2022] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE To investigate the incidence, predictors, and clinical implications of placenta accreta spectrum (PAS) in pregnancies after hysteroscopic treatment for Asherman syndrome (AS). DESIGN This is a retrospective cohort study, conducted through a telephone survey and chart review. SETTING Minimally invasive gynecologic surgery center in an academic community hospital. PATIENTS Database of 355 patients hysteroscopically treated for AS over 4 years. We identified patients who achieved pregnancy past the first trimester and evaluated the incidence and predictors for PAS as well as associated clinical implications. INTERVENTIONS Telephone survey. MEASUREMENTS AND MAIN RESULTS We identified 97 patients meeting the inclusion criteria. Among these patients, 23 (23.7%) patients had PAS. History of cesarean delivery was the only variable statistically significantly associated with having PAS (adjusted odds ratio 4.03, 95% confidence interval 1.31-12.39). PAS was diagnosed antenatally in 3 patients (14.3%), with patients having placenta previa more likely to be diagnosed (p <.01). Nine patients (39.13%) with PAS required cesarean hysterectomy, which is 9.3% of those with a pregnancy that progressed past the first trimester. Factors associated with cesarean hysterectomy were the etiology of AS (dilation and evacuation after the second trimester pregnancy or postpartum instrumentation, p <.01), invasive placenta (increta or percreta, p <.05), and history of morbidly adherent placenta in previous pregnancies (p <.05). Two patients with PAS (9.5%) had uterine rupture, and another 2 (9.5%) experienced uterine inversion. CONCLUSION There is a high incidence of PAS and associated morbidity in pregnancies after hysteroscopic treatment for AS. There is a low rate of antenatal diagnosis as well as a lack of reliable clinical predictors, which both stress the importance of clinical awareness, careful counseling, and delivery planning.
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Affiliation(s)
- Jovana Tavcar
- Center for Minimally Invasive Gynecologic Surgery, Newton Wellesley Hospital, Mass General Brigham, Newton (Drs. Tavcar, Movilla, Loring, Isaacson, and Morris).
| | - Peter Movilla
- Center for Minimally Invasive Gynecologic Surgery, Newton Wellesley Hospital, Mass General Brigham, Newton (Drs. Tavcar, Movilla, Loring, Isaacson, and Morris)
| | - Daniela A Carusi
- Department for Obstetrics and Gynecology, Brigham and Women's Hospital, Mass General Brigham, Boston (Drs. Carusi and Reddy), Massachusetts
| | - Megan Loring
- Center for Minimally Invasive Gynecologic Surgery, Newton Wellesley Hospital, Mass General Brigham, Newton (Drs. Tavcar, Movilla, Loring, Isaacson, and Morris)
| | - Himabindu Reddy
- Department for Obstetrics and Gynecology, Brigham and Women's Hospital, Mass General Brigham, Boston (Drs. Carusi and Reddy), Massachusetts
| | - Keith Isaacson
- Center for Minimally Invasive Gynecologic Surgery, Newton Wellesley Hospital, Mass General Brigham, Newton (Drs. Tavcar, Movilla, Loring, Isaacson, and Morris)
| | - Stephanie N Morris
- Center for Minimally Invasive Gynecologic Surgery, Newton Wellesley Hospital, Mass General Brigham, Newton (Drs. Tavcar, Movilla, Loring, Isaacson, and Morris)
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Amat Pérez R, Gómez Valdés J, Lonjedo Vicent E, Sarrió Llavata M, Quirante Cascales J, Ruiz Guanter A. Eficacia y seguridad de la embolización de arterias uterinas en el manejo de la hemorragia posparto. RADIOLOGIA 2023. [DOI: 10.1016/j.rx.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Püchel J, Sitter M, Kranke P, Pecks U. Procedural techniques to control postpartum hemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:371-382. [PMID: 36513432 DOI: 10.1016/j.bpa.2022.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
Postpartum hemorrhage can occur unexpectedly and with high dynamics. The mother's life often depends on quick action and good communication within an interdisciplinary team. Knowledge of each other's therapeutic options plays a major role. Treatment procedures include obstetric, surgical, and radiologic techniques. In addition to availability and experience with the techniques, two important aspects must be considered in the selection process: the type of delivery and the cause of the hemorrhage. In particular, the distinction between pregnancies with or without disturbed placentation from the placenta accreta spectrum is crucial. From these two points of view, we discuss here different uterus-preserving and uterus-removing techniques. We describe in detail the advantages and disadvantages of each procedure. Because most therapeutic options are based on small case series and uncontrolled studies, local circumstances and physician experience are critical in setting internal standards.
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Affiliation(s)
- Jodok Püchel
- Department of Gynaecology and Obstetrics, University Hospital of Cologne, Germany.
| | - Magdalena Sitter
- Department of Anaesthesia, Critical Care Medicine, Emergency Medicine and Pain Medicine, University Hospital of Wuerzburg, Germany.
| | - Peter Kranke
- Department of Anaesthesia, Critical Care Medicine, Emergency Medicine and Pain Medicine, University Hospital of Wuerzburg, Germany.
| | - Ulrich Pecks
- Department of Gynaecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
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Uterine Artery Embolization of Uterine Arteriovenous Malformation: A Systematic Review of Success Rate, Complications, and Posterior Pregnancy Outcomes. J Pers Med 2022; 12:jpm12071098. [PMID: 35887595 PMCID: PMC9324499 DOI: 10.3390/jpm12071098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/10/2022] [Accepted: 06/27/2022] [Indexed: 12/02/2022] Open
Abstract
Uterine Arteriovenous Malformation (UAVM) is a rare but life-threating cause of uterine bleeding. The clinical management of this condition is challenging, and there is a need to describe the most adequate approach for these patients. Uterine artery embolization (UAE) is the most widely-published treatment in the literature in recent years, although there is a need to update the evidence on this treatment and to compare it with other available therapies. Thus, the objective of this systematic review is to quantify the efficacy of UAE of UAVM. In addition, we evaluated the clinical context of the patients included, the treatment complications, and the pregnancy outcomes after UAE. With this goal in mind, we finally included 371 patients spread over all continents who were included in 95 studies. Our results show that, similar to other medical therapies, the global success rate after embolization treatment was 88.4%, presenting a low risk of adverse outcomes (1.8%), even in women with later pregnancy (77% had no complications). To date, this is the largest systematic review conducted in this field, although there are still some points to address in future studies. The results obtained in our study should be outlined in UAE protocols and guidelines to aid in clinical decision-making in patients with UAVM.
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Giacalone S, Kottmann A, Darioli V, Carron PN, Desseauve D, Albrecht R, Pasquier M. Clinical characteristics and haemodynamic state of patients undergoing interhospital transfer for postpartum haemorrhage: A study of a single-centre helicopter emergency medical service. Eur J Obstet Gynecol Reprod Biol 2021; 268:48-55. [PMID: 34800817 DOI: 10.1016/j.ejogrb.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/24/2021] [Accepted: 11/02/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Uterine artery embolization is an attractive option for the management of postpartum haemorrhage, however it is not available in every hospital. We compared the clinical characteristics and haemodynamic state of patients with postpartum haemorrhage, before and after helicopter transfer to a tertiary hospital for possible uterine artery embolization. We also analysed whether the type of treatment could modify the outcome. STUDY DESIGN Between 1999 and 2019 in Switzerland, we retrospectively found 82 consecutive patients with postpartum haemorrhage who were transferred by a physician-staffed helicopter emergency medical service to the tertiary hospital for potential uterine artery embolization. The collected data included the type of delivery, estimated blood loss, shock index and blood lactate levels before transfer and at destination, uterine artery embolization rate and hospital mortality rate. Our primary outcome was to describe the clinical characteristics, outcomes and haemodynamic state of the patients with postpartum haemorrhage before and after helicopter transfer. Our secondary outcome was to report the treatments performed at the tertiary hospital. The collected data were analysed with Stata version 14 (Stata Corporation, College Station, TX, USA). Continuous data are compared by using the Student's t-test or the Mann-Whitney U test, as appropriate. RESULTS We included 69 patients. Postpartum haemorrhage occurred after vaginal delivery in 38 cases (55%). Blood loss prior to transfer exceeded 2 L in 34% of cases. The median shock index was 1 (IQR 0.8-1.1) before transfer and 0.9 (IQR 0.8-1.1) after transfer (p = 0.41). The median lactate level was 2.9 mmol/L (IQR 2.1-6.8) before, and 2.1 mmol/L (IQR 1.55-3.5) after transfer (p = 0.90). Forty-four patients underwent uterine artery embolization (64%), with an overall success rate of 93%. One patient died (1.4%), from a haemorrhagic shock of abdominal origin. CONCLUSIONS Interhospital helicopter transfer of patients with postpartum haemorrhage to a tertiary hospital seems to be safe in our setting, despite a significant proportion of patients exhibiting signs of haemodynamic instability. Decision criteria would be helpful to better guide choices regarding the transfer of patients with postpartum haemorrhage.
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Affiliation(s)
- S Giacalone
- Emergency Department, Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland
| | - A Kottmann
- Emergency Department, Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland; Swiss Air Ambulance (Rega), Zürich, Switzerland
| | - V Darioli
- Emergency Department, Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland
| | - P N Carron
- Emergency Department, Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland
| | - D Desseauve
- Department of Gynaecology and Obstetrics, Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland
| | - R Albrecht
- Swiss Air Ambulance (Rega), Zürich, Switzerland
| | - M Pasquier
- Emergency Department, Lausanne University Hospital, and University of Lausanne, Lausanne, Switzerland.
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A systematic review and meta-analysis of obstetric and maternal outcomes after prior uterine artery embolization. Sci Rep 2021; 11:16914. [PMID: 34413380 PMCID: PMC8377070 DOI: 10.1038/s41598-021-96273-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 08/09/2021] [Indexed: 12/29/2022] Open
Abstract
This study aimed to review the obstetric complications during subsequent pregnancies after uterine artery embolization (UAE) for postpartum hemorrhage (PPH) by exploring the relationship between prior UAE and obstetric complications through a meta-analysis. We conducted a systematic literature review through March 31, 2021, using PubMed, Scopus, and the Cochrane Central Register of Controlled Trials in compliance with the PRISMA guidelines and determined the effect of prior UAE for PPH on the rate of placenta accreta spectrum (PAS), PPH, placenta previa, hysterectomy, fetal growth restriction (FGR), and preterm birth (PTB). Twenty-three retrospective studies (2003–2021) met the inclusion criteria. They included 483 pregnancies with prior UAE and 320,703 pregnancies without prior UAE. The cumulative results of all women with prior UAE indicated that the rates of obstetric complications PAS, hysterectomy, and PPH were 16.3% (34/208), 6.5% (28/432), and 24.0% (115/480), respectively. According to the patient background-matched analysis based on the presence of prior PPH, women with prior UAE were associated with higher rates of PAS (odds ratio [OR] 20.82; 95% confidence interval [CI] 3.27–132.41) and PPH (OR 5.32, 95% CI 1.40–20.16) but not with higher rates of hysterectomy (OR 8.93, 95% CI 0.43–187.06), placenta previa (OR 2.31, 95% CI 0.35–15.22), FGR (OR 7.22, 95% CI 0.28–188.69), or PTB (OR 3.00, 95% CI 0.74–12.14), compared with those who did not undergo prior UAE. Prior UAE for PPH may be a significant risk factor for PAS and PPH during subsequent pregnancies. Therefore, at the time of delivery, clinicians should be more attentive to PAS and PPH when women have undergone prior UAE. Since the number of women included in the patient background-matched study was limited, further investigations are warranted to confirm the results of this study.
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14
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Yang CC, Chou YC, Kuo TN, Liou JY, Cheng HM, Kuo YT. Prophylactic Intraoperative Uterine Artery Embolization During Cesarean Section or Cesarean Hysterectomy in Patients with Abnormal Placentation: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 2021; 45:488-501. [PMID: 34282489 DOI: 10.1007/s00270-021-02921-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/05/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE To evaluate the effectiveness and safety of prophylactic intraoperative uterine artery embolization (UAE) performed immediately after fetal delivery during planned cesarean section or cesarean hysterectomy in patients with placenta accreta spectrum disorder or placenta previa. METHODS A systematic search was conducted on Ovid MEDLINE and Embase, PubMed, Web of Science, and Cochrane databases. Studies were selected using the Population/Intervention/Comparison/Outcomes (PICO) strategy. The intraoperative blood loss and the rate of emergent peripartum hysterectomy (EPH) were the primary outcomes, whereas the length of hospital stay and volume of blood transfused were the secondary outcomes. A random-effects model was employed to pool each effect size. The cumulative values of the primary outcomes were calculated using the generic inverse variance method. RESULTS Eleven retrospective cohort studies and five case series were included, recruiting 421 women who underwent prophylactic intraoperative UAE (UAE group) and 374 women who did not (control group). Compared with the control group, the UAE group had significantly reduced intraoperative blood loss (p = 0.020) during cesarean section or cesarean hysterectomy. Furthermore, the EPH rate was also significantly decreased (p = 0.020; cumulative rate: 19.65%), but not the length of hospital stay (p = 0.850) and volume of pRBC transfused (p = 0.140), after cesarean section in the UAE group. The incidence of major complications was low (3.33%), despite two patients with uterine necrosis. CONCLUSION The currently available data provides encouraging evidence that prophylactic intraoperative UAE may contribute to hemorrhage control and fertility preservation in women with abnormal placentation. REGISTRATION PROSPERO registration code: CRD42021230581. https://clinicaltrials.gov/ct2/show/CRD42021230581 LEVEL OF EVIDENCE: Level 2a, systematic review of retrospective cohort studies.
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Affiliation(s)
- Cheng-Chun Yang
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Yi-Chen Chou
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Tian-Ni Kuo
- Department of Obstetrics and Gynecology, Chi Mei Medical Center, Tainan, Taiwan
| | - Jyun-Yan Liou
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Hua-Ming Cheng
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Yu-Ting Kuo
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan.
- Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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15
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Paternal and maternal long-term psychological outcomes after uterine artery embolization for severe post-partum hemorrhage. Sci Rep 2021; 11:13990. [PMID: 34234162 PMCID: PMC8263630 DOI: 10.1038/s41598-021-92847-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 06/15/2021] [Indexed: 02/02/2023] Open
Abstract
This study intend to compare the long-term psychological impact (depression, post-traumatic stress disorder) on both partners between patients that underwent uterine artery embolization (UAE) for post-partum hemorrhage (PPH) and uneventful deliveries. Women who experienced severe PPH treated by UAE in our institution between 2003 and 2013 were identified in our obstetrical database. These cases were matched to controls with uneventful deliveries. Matching criteria were maternal age, parity, ethnicity, year of delivery, birthweight, gestational age and mode of delivery. Patients and their partners completed validated questionnaires measuring post-traumatic stress (TSQ), as well as depression symptoms (MINI). A total of 63 cases of PPH and 189 matched controls (1:3) participated in a study exploring gynecological and obstetrical outcomes. With a mean of 8 years post-index delivery, patients after PPH showed increased risk of depression (p = 0.015) and post-traumatic stress disorder (22.2% versus 4.8%, p < 0.005) compared to controls. PPH remains strongly associated with post-traumatic stress disorder, even after adjustment for depression (adjusted odds ratio 5.1; 95% confidence intervals 1.5–17.5). Similarly, partners of patients with PPH showed a propensity to depression (p = 0.029) and post-traumatic stress disorder (11.5% versus 1.5%, p = 0.019). In conclusion, both women and their partners are at increased risk of long-term psychological adverse outcomes after PPH. Couples may benefit from psychological support.
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16
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Cezar C, Torres de la Roche LA, Hennefründ J, Verhoeven HC, Devassy R, De Wilde RL. Can uterine artery embolization be an alternative to plastic and reconstructive uterus operation by minimally invasive surgery? GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2021; 10:Doc07. [PMID: 34194918 PMCID: PMC8204672 DOI: 10.3205/iprs000157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: Plastic and reconstructive minimally invasive surgery has been established as gold standard in myomectomy. Therapy failure eventually leads to future surgical interventions or hysterectomy: surgeons and patients should be aware of the risks and benefits. We conducted a systematic review to analyse the evidence on the therapeutic indications and adverse events associated with uterine artery embolization and thereby evaluating if this method could be a valid alternative therapy. Methods: In concordance with PRISMA guidelines, literature research was made in PubMed, Cochrane Library, UpToDate, Amboss and Medline databases. Clinical trials, reviews and case reports published in English between January 2010 and June 2020 were included. Results: 44 articles were included out of 838 papers identified at initial search. Regarding uterine fibroids, three original papers and one Cochrane review reported the benefits of the procedure as an alternative to surgery, even in large and giant fibroids. Furthermore, several studies discussed the use of embolization for postpartum haemorrhage to decrease rates of hysterectomy after other haemostatic methods were exhausted, because of the potential risk of abnormal placentation in a future pregnancy. The procedure can also be successfully used as prophylactic method in different obstetrical procedures. Conclusions: The use of embolization in different uterine pathologies is a minimally invasive procedure as an alternative to surgery, especially in women who desire to preserve their uterus. Its related complications are described and can be avoided by a stringent indication of the procedure. More evidence regarding fertility after UAE, use of the procedure prophylactically in obstetrical haemorrhage or in adenomyosis is needed.
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Affiliation(s)
- Cristina Cezar
- University Hospital for Gynecology, Pius Hospital, Carl von Ossietzky University Oldenburg, Germany
| | | | | | - Hugo Christian Verhoeven
- Private Center for Endocrinology, Preventive Medicine, Reproductive Medicine and Gynecology, Dusseldorf, Germany
| | - Rajesh Devassy
- University Hospital for Gynecology, Pius Hospital, Carl von Ossietzky University Oldenburg, Germany
| | - Rudy Leon De Wilde
- University Hospital for Gynecology, Pius Hospital, Carl von Ossietzky University Oldenburg, Germany
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17
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Mitsui T, Mishima S, Ohira A, Tani K, Maki J, Eto E, Hayata K, Masuyama H. hCG values and gestational sac size as indicators of successful systemic methotrexate treatment in cesarean scar pregnancy. Taiwan J Obstet Gynecol 2021; 60:454-457. [DOI: 10.1016/j.tjog.2021.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 12/26/2022] Open
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18
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The Emergent Pelvic Artery Embolization in the Management of Postpartum Hemorrhage: A Systematic Review and Meta-analysis. Obstet Gynecol Surv 2021; 76:234-244. [PMID: 33908615 PMCID: PMC8081441 DOI: 10.1097/ogx.0000000000000887] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Postpartum hemorrhage (PPH) is an emergent obstetric complication and the leading cause of maternal mortality. Pelvic arterial embolization (PAE) is an effective treatment for intractable PPH. However, a unique protocol has not been accepted in obstetrical practice. Objective To evaluate its efficiency, safety, complications, and outcomes, we conducted a systematic review and meta-analysis of PAE for PPH in the literature. Evidence Acquisition The Medline, the database of abstract of reviews, the index to allied health literature, and the Chinese database Sino-Med were searched on March 31, 2020, for studies on PAE for PPH. The data for PAE indication, agents, arteries, success rate, complications, and outcomes were extracted and syncretized for meta-analysis. Results From 1075 identified articles, 113 abstracts or full articles were retrieved and 43 studies were finally identified as meeting the including criteria. The results demonstrated that the indications for PAE were as follows: uterine atony, placental abnormality, delivery tract injury, disseminated intravascular coagulation, arteriovenous malformation, and vaginal hematoma. The embolization agents mostly in order were gelatin sponge particles, polyvinyl alcohol particles, Gelfoam, N-butyl cyanoacrylate, microcoil, and glue; for arteries, they were mostly uterine artery and internal iliac artery. The clinical success rate was 90.5%, whereas the technical success rate was 99.3%. The most common complications of PAE were postembolization syndrome and menstrual abnormality. Conclusions and Relevance The emergent PAE is a safe and effective method with high success rate in life-threatening PPH management. Gelatin sponge granules measuring 500 to 1000 μm in diameter have safe results. Pelvic arterial embolization may affect the recovery of menses and increase PPH in the subsequent pregnancy, but there was no noted correlation with fetal growth restriction.
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19
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Eggel B, Bernasconi M, Quibel T, Horsch A, Vial Y, Denys A, Baud D. Gynecological, reproductive and sexual outcomes after uterine artery embolization for post-partum haemorrage. Sci Rep 2021; 11:833. [PMID: 33436979 PMCID: PMC7804269 DOI: 10.1038/s41598-020-80821-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/23/2020] [Indexed: 01/27/2023] Open
Abstract
In this case control study, long-term gynecological, reproductive and sexual outcomes after uterine artery embolization (UAE) for postpartum hemorrhage (PPH) were evaluated. The study was performed in a single referral hospital for PPH in Lausanne from 2003 to 2013. Each woman whose delivery was complicated by PPH and treated by UAE was included, and compared to a control group of women whose delivery was uncomplicated. Cases were matched by maternal age, parity, ethnicity, year and mode of delivery, birth weight and gestational age in a 1–3 ratio. A total of 77 patients treated by UAE for PPH were identified in our obstetrical database. Among them, 63 were included and compared to 189 matched patients (no PPH). The mean interval time between UAE and this study was 8.1 years. Time to menstrual cycle recovery after delivery (3.9 vs 5.6 months, p = 0.66), spotting (7.9% vs 7.2%, p = 0.49), dysmenorrhea (25.4% vs 22.2%, p = 0.60) and amenorrhea (14.3% vs 12.2%, p = 0.66) were similar between the two groups. There was no difference in the FSFI score between the groups (23.2 ± 0.6 vs 23.8 ± 0.4; p = 0.41). However, the interval time to subsequent pregnancy was longer for patients after UAE than the control group (35 vs 18 months, p = 0.002). In case of pregnancy desire, the success rate was lower after UAE compared to controls (55% vs 93.5%, p < 0.001). The rate of PPH was higher in those with previous PPH (6.6% vs 36.4%, p = 0.010). Patients treated by UAE for PPH did not report higher rates of gynecological symptoms or sexual dysfunction compared to patients with uneventful deliveries. The inter-pregnancy interval was increased and the success rate was reduced. In subsequent pregnancies, a higher rate of PPH was observed in those that underwent UAE.
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Affiliation(s)
- Béatrice Eggel
- Materno-Fetal and Obstetrics Research Unit, Department "Femme-Mère-Enfant"-"Woman-Mother-Child", University of Lausanne and Lausanne University Hospital, 1011, Lausanne, Switzerland
| | - Maude Bernasconi
- Materno-Fetal and Obstetrics Research Unit, Department "Femme-Mère-Enfant"-"Woman-Mother-Child", University of Lausanne and Lausanne University Hospital, 1011, Lausanne, Switzerland
| | - Thibaud Quibel
- Materno-Fetal and Obstetrics Research Unit, Department "Femme-Mère-Enfant"-"Woman-Mother-Child", University of Lausanne and Lausanne University Hospital, 1011, Lausanne, Switzerland
| | - Antje Horsch
- Institute of Higher Education in Healthcare Research, University of Lausanne and Lausanne University Hospital, 1011 Lausanne, Switzerland.,Neonatology Service, Department Woman-Mother-Child, University of Lausanne and Lausanne University Hospital, 1011 Lausanne, Switzerland
| | - Yvan Vial
- Materno-Fetal and Obstetrics Research Unit, Department "Femme-Mère-Enfant"-"Woman-Mother-Child", University of Lausanne and Lausanne University Hospital, 1011, Lausanne, Switzerland
| | - Alban Denys
- Department of Radiology, University of Lausanne and Lausanne University Hospital, 1011, Lausanne, Switzerland
| | - David Baud
- Materno-Fetal and Obstetrics Research Unit, Department "Femme-Mère-Enfant"-"Woman-Mother-Child", University of Lausanne and Lausanne University Hospital, 1011, Lausanne, Switzerland. .,Obstetric Service, Department "Femme-Mère-Enfant"-"Woman-Mother-Child", Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne and Lausanne University Hospital, 1011, Lausanne, Switzerland.
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20
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Jung YM, Kim HJ, Choi WS, Park JY, Seong NJ, Oh KJ, Hong JS, Yoon CJ. CT angiography for the management of postpartum hemorrhage refractory to conservative treatment. J Matern Fetal Neonatal Med 2020; 35:4081-4088. [PMID: 33207995 DOI: 10.1080/14767058.2020.1846708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality. Computerized tomographic (CT) angiography is a useful tool to identify hemorrhage from various conditions. However, the feasibility of CT angiography for the management of PPH has not been well evaluated. OBJECTIVE To evaluate the clinical usefulness of CT angiography in the management of PPH refractory to the conservative treatment. METHODS This retrospective cohort study consisted of 528 consecutive patients who were transferred to our institute after delivery at 28 primary maternity hospitals for the management of PPH between 2009 and 2017. Immediate intervention such as arterial embolization and hysterectomy were performed on 278 patients. Of the remaining 250 patients, CT angiography was performed on 61 patients with hemodynamic stability but with sustained hemorrhage refractory to medical treatment. The diagnostic index was assessed using conventional angiography as the reference standard. The clinical outcome was compared between patients with and without contrast extravasation on CT angiography. RESULTS (1) The prevalence of contrast extravasation was found in 61% of patients (37/61); (2) conventional angiography and arterial embolization were performed in 78% of patients (29/37) with contrast extravasation on CT angiography. Contrast extravasation was confirmed in 83% of patients (24/29) by conventional angiography; (3) among the 24 patients without contrast extravasation on CT angiography, 96% (23/24) were managed conservatively; (4) the patients with contrast extravasation on CT angiography received more packed red blood cell (PRBC) transfusion than those without that condition (7.3 ± 5.2 units vs. 3.8 ± 2.9 units, p = .009). Massive transfusion (defined as transfusion of 10 or more units of PRBC) was more common in patients with contrast extravasation than in those without (27% [10/37] vs. 0% [0/24], p = .004). CONCLUSIONS Conservative treatment succeeded in 96% of patients without contrast extravasation on CT angiography. CT angiography is useful to identify patients requiring intervention in the management of hemorrhage refractory to medical treatment.
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Affiliation(s)
- Young Mi Jung
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University, Seoul, Korea.,Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | - Hyeon Ji Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University, Seoul, Korea.,Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Won Seok Choi
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jee Yoon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University, Seoul, Korea.,Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Nak Jong Seong
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Joon Oh
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University, Seoul, Korea.,Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joon-Seok Hong
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University, Seoul, Korea.,Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chang Jin Yoon
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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Lee HJ, Kim M, Lim BB, Kim YR, Jeon GS, Jung SH. Transcatheter Arterial Embolization in the Management of Postpartum Hemorrhage due to Genital Tract Injury after Vaginal Delivery. J Vasc Interv Radiol 2020; 32:99-105. [PMID: 33158669 DOI: 10.1016/j.jvir.2020.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 08/08/2020] [Accepted: 08/08/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate efficacy and safety of transcatheter arterial embolization (TAE) in managing postpartum hemorrhage (PPH) due to genital tract injury after vaginal delivery and to investigate factors associated with outcome of TAE. MATERIALS AND METHODS A retrospective review of 43 women (mean age, 32.6 years) who underwent TAE to manage PPH secondary to genital tract injury after vaginal delivery was performed at a single institution between January 2007 and December 2018. Clinical data and outcomes were obtained. Patients were classified into clinical success (n = 39) and failure (n = 4) groups, and comparisons between the groups were performed. RESULTS The clinical success rate of TAE for PPH due to genital tract injury was 90.7%. In the clinical failure group, transfusion volumes were higher (failure vs success: packed red blood cells, 14 pt ± 3.37 vs 6.26 pt ± 4.52, P = .003; platelets, 10.33 pt ± 4.04 vs 2.92 pt ± 6.15, P = .036); hemoglobin levels before the procedure were lower (failure vs success: 7.3 g/dL vs 10.7, P = .016). Periprocedural complications included pulmonary edema (25.6%), fever (23.3%), and pain (9.3%). Twenty-four patients were either followed for > 6 months or answered a telephone survey; 23 (95.8%) recovered regular menstruation, and pregnancy was confirmed in 11 (45.8%). Regarding fertility desires, 7 women attempted to conceive, 6 of whom (85.7%) became pregnant. CONCLUSIONS TAE is an effective and safe method for managing PPH due to genital tract injury after vaginal delivery. Lower hemoglobin levels before the procedure and higher transfusion volumes were associated with clinical failure of TAE.
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Affiliation(s)
- Hyun Jung Lee
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, College of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam-si 13496, South Korea
| | - Migang Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, College of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam-si 13496, South Korea
| | - Bo-Bae Lim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, College of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam-si 13496, South Korea
| | - Young Ran Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, College of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam-si 13496, South Korea
| | - Gyeong Sik Jeon
- Department of Diagnostic Radiology, CHA Bundang Medical Center, CHA University, College of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam-si 13496, South Korea
| | - Sang Hee Jung
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University, College of Medicine, 59 Yatap-ro, Bundang-gu, Seongnam-si 13496, South Korea.
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22
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Radaelli T, Ferrari MM, Duiella SF, Gazzola FG, Campoleoni M, Merlini C, Martinetti L, Ambrosini MT, Ossola MW, Nicolini A. Prophylactic intraoperative uterine artery embolization for the management of major placenta previa. J Matern Fetal Neonatal Med 2020; 35:3359-3364. [PMID: 32928020 DOI: 10.1080/14767058.2020.1818218] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Placenta previa is a major cause of maternal morbidity and mortality, associated to a high risk of peripartum hemorrhage and hysterectomy. We aimed to verify if prophylactic intraoperative uterine artery embolization in patients with placenta previa and at least one additional risk of bleeding (major placenta previa), can reduce hemorrhage, need for blood transfusions, peripartum hysterectomy and maternal morbidity. MATERIALS AND METHODS We enrolled 76 patients with major placenta previa; a specific multidisciplinary protocol was designed for management, including ultrasound evaluation, hospitalization at 34 weeks, antenatal corticosteroids and scheduled cesarean section at 35-36 weeks. 44 patients (control group or CTR) were treated with elective cesarean section, 32 patients (embolized group or EMB) underwent selective catheterization of bilateral uterine arteries before cesarean section and subsequent uterine embolization. In both cases cesarean section was performed by a senior surgeon. RESULTS Significant differences were found in term of intraoperative blood loss (CTR: 1431 ml; EMB: 693 ml); despite an high percentage of CTR patients had a bleeding greater than 1000 ml (56%), the need for blood transfusion was not significantly different between the two groups. Time of surgery was higher in the EMB group, considering that embolization procedure required approximatively 30 min. Three patients from the CTR group needed hysterectomy and ICU admission, compared to none in the EMB group. Duration of hospitalization and neonatal outcome were similar. Uterine embolization was not related to any short or long-term complications; return to normal menses and preservation of fertility were confirmed at follow up. CONCLUSIONS Our results are promising, although we believe that a major contribution is referable to the multidisciplinary approach rather than the procedure itself. Nevertheless, we demonstrated the feasibility and safety of preventive uterine embolization in patients with placenta previa; in order to establish its prophylactic role in the prevention of peripartum hemorrhage, randomized trial should be carried out, on a larger population.
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Affiliation(s)
- Tatjana Radaelli
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Maria M Ferrari
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Silvia F Duiella
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Federica G Gazzola
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Mauro Campoleoni
- Department of Medical Physics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Claudia Merlini
- Department of Anesthesiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Laura Martinetti
- Department of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Maria T Ambrosini
- Department of Anesthesiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Manuela W Ossola
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Antonio Nicolini
- Department of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
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Li C, Yang P, Luo H. Prediction of Delivery Complications by First-Trimester Ultrasound Measurement of the Gestational Sac's Distance From a Previous Cesarean Section Scar. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1563-1571. [PMID: 32073684 DOI: 10.1002/jum.15245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 01/14/2020] [Accepted: 01/22/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES This study was designed to investigate the clinical relationship between labor complications in the second and third trimesters and the distance from the gestational sac to a previous cesarean section (CS) scar. METHODS We conducted a retrospective review of the electronic medical records and included all 7- to 9-week transvaginal ultrasound examination reports from pregnancies with a history of a single cesarean delivery in our hospital between January 2015 and December 2017. Women were divided into 6 groups according to the distance of the gestational sac to the CS scar (groups A-F). A composite of pregnancy outcomes (gestational age at birth, delivery mode, placental abnormality, blood loss, uterine rupture, and hysterectomy) and other maternal and neonatal outcomes were assessed. RESULTS A total of 699 cases were included in our study. The median gestational age was 39.0 (range, 38.1-39.9) weeks. The median intrapartum blood loss volume was 400 (range, 300-500) mL. The results showed no statistically significant difference in blood loss (P = .297) or birth weight of the neonate (P = .318) among the distance subgroups. Overall, the fetuses were stillborn in 9 of 699 cases (1.29%). There was a statistically significant difference in a morbidly adherent placenta, placenta previa, and preterm labor, and their incidence increased with decreasing distance (P < .001; P for trend < .05). There was no statistically significant difference in uterine rupture (P = .597) or the delivery mode (P = .187) among the subgroups. CONCLUSIONS The relative positions of a CS scar and the gestational sac in the first trimester are associated with the incidence of placental abnormalities. As the distance decreases, the extent of a morbidly adherent placenta increases.
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Affiliation(s)
- Cong Li
- Department of Ultrasonography, West China Second University Hospital, Sichuan University, Chengdu, China
- Department Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second Hospital, Sichuan University, Chengdu, China
| | - Pan Yang
- Department of Ultrasonography, West China Second University Hospital, Sichuan University, Chengdu, China
- Department Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second Hospital, Sichuan University, Chengdu, China
| | - Hong Luo
- Department of Ultrasonography, West China Second University Hospital, Sichuan University, Chengdu, China
- Department Key Laboratory of Birth Defects and Related Diseases of Women and Children, West China Second Hospital, Sichuan University, Chengdu, China
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Fiocchi F, Monelli F, Besutti G, Casari F, Petrella E, Pecchi A, Caporali C, Bertucci E, Busani S, Botticelli L, Facchinetti F, Torricelli P. MRI of placenta accreta: diagnostic accuracy and impact of interventional radiology on foetal-maternal delivery outcomes in high-risk women. Br J Radiol 2020; 93:20200267. [PMID: 32706979 DOI: 10.1259/bjr.20200267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess accuracy and reproducibility of MRI diagnosis of invasive placentation (IP) in high-risk patients and to evaluate reliability of MRI features. Secondary aim was to evaluate impact of interventional radiology (IR) on delivery outcomes in patients with IP at MRI. METHODS 26 patients (mean age 36.24 y/o,SD 6.16) with clinical risk-factors and echographic suspicion of IP underwent 1.5 T-MRI. Two readers reviewed images. Gold-standard was histology in hysterectomised patients and obstetric evaluation at delivery for patients with preserved uterus. Accuracy and reproducibility of MRI findings were calculated. RESULTS Incidence of IP was 50% (13/26) and of PP was 11.54% (3/26). MRI showed 100% sensitivity (95% CI = 75.3-100%) and 92.3% specificity (95% CI = 64.0-100%) in the diagnosis of IP. Gold-standard was histology in 10 cases and obstetric evaluation in 16. MRI findings with higher sensitivity were placental heterogeneity, uterine bulging and black intraplacental bands. Uterine scarring, placental heterogeneity, myometrial interruption and tenting of the bladder showed better specificity. MRI inter-rater agreement with Cohen's K was 1. 11 patients among 14 with MRI diagnosis of IP received IR assistance with positive impact on delivery outcomes in terms of blood loss, red cells count, intense care unit length of stay, days of hospitalisation and risk of being transfused. CONCLUSION MRI is an accurate and reproducible technique in prenatal diagnosis of IP. MRI helps planning a safe and appropriate delivery eventually assisted by IR, which positively affects foetal and maternal outcomes. ADVANCES IN KNOWLEDGE The adoption of MRI evaluation in patients with high risk of invasive placentation allows a more accurate diagnosis in terms of both presence of the disease and its extension to or through or even beyond the myometrium. This led to a better dedicated delivery management with eventual adoption of interventional radiology with a global positive effect on foetal and maternal outcomes.
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Affiliation(s)
- Federica Fiocchi
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
| | - Filippo Monelli
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
| | - Giulia Besutti
- University of Modena and Reggio Emilia, Clinical and Experimental Medicine PhD program, Modena, Italy
| | - Federico Casari
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
| | - Elisabetta Petrella
- Department of Medical and SurgicaSciences for Mothers, Children and Adults, Azienda ospedaliero - universitaria Policlinico di Modena, Modena, Italy
| | - Annarita Pecchi
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
| | - Cristian Caporali
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
| | - Emma Bertucci
- Department of Medical and SurgicaSciences for Mothers, Children and Adults, Azienda ospedaliero - universitaria Policlinico di Modena, Modena, Italy
| | - Stefano Busani
- Departement of intensive care medicine, Azienda ospedaliero - universitaria Policlinico di Modena, Modena, Italy
| | - Laura Botticelli
- Departement of Pathology, Azienda ospedaliero - universitaria Policlinico di Modena, Modena, Italy
| | - Fabio Facchinetti
- Department of Medical and SurgicaSciences for Mothers, Children and Adults, Azienda ospedaliero - universitaria Policlinico di Modena, Modena, Italy
| | - Pietro Torricelli
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
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Kim MJ, Kim IJ, Kim S, Park IY. Postpartum hemorrhage with uterine artery embolization: the risk of complications of uterine artery embolization. MINIM INVASIV THER 2020; 31:276-283. [PMID: 32662700 DOI: 10.1080/13645706.2020.1789662] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the efficacy and adverse effects of uterine artery embolization (UAE) to treat postpartum hemorrhage (PPH) and determine the factors associated with clinical outcomes. MATERIAL AND METHODS This study included 117 patients who underwent UAE for PPH between January 2010 and November 2018. Their medical records were retrospectively reviewed to assess the mode of delivery, causes of bleeding, detailed laboratory results, clinical outcomes, time from delivery to UAE, and embolizing material used. RESULTS The clinical UAE success rate was 99.1%. Late complications were found in 11 patients. Two total hysterectomies were performed. Most PPH cases treated with UAE had early-onset PPH caused by uterine atony. Late-onset PPH was caused by placenta-related problems (remnant placenta, placenta accreta). Body mass index, cesarean section, the use of mixed embolizing materials, placenta abruption as the cause of PPH, and transferred patients were associated with uterine necrosis. Age, re-embolization, and the use of mixed embolizing materials were associated with adverse complications. CONCLUSIONS Although UAE is a safe and effective way to manage PPH, a long-term follow-up is needed to determine the complications of UAE. When uterine necrosis is suspected, prompt and adequate treatment should be performed due to the effects of necrosis on menstrual cycles, fertility, and subsequent pregnancies.
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Affiliation(s)
- Min Jung Kim
- Department of Obstetrics and Gynecology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Il Jung Kim
- Department of Radiology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Shinyoung Kim
- Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In Yang Park
- Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Kellie FJ, Wandabwa JN, Mousa HA, Weeks AD. Mechanical and surgical interventions for treating primary postpartum haemorrhage. Cochrane Database Syst Rev 2020; 7:CD013663. [PMID: 32609374 PMCID: PMC8407481 DOI: 10.1002/14651858.cd013663] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Primary postpartum haemorrhage (PPH) is commonly defined as bleeding from the genital tract of 500 mL or more within 24 hours of birth. It is one of the most common causes of maternal mortality worldwide and causes significant physical and psychological morbidity. An earlier Cochrane Review considering any treatments for the management of primary PPH, has been split into separate reviews. This review considers treatment with mechanical and surgical interventions. OBJECTIVES To determine the effectiveness and safety of mechanical and surgical interventions used for the treatment of primary PPH. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 July 2019) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) of mechanical/surgical methods for the treatment of primary PPH compared with standard care or another mechanical/surgical method. Interventions could include uterine packing, intrauterine balloon insertion, artery ligation/embolism, or uterine compression (either with sutures or manually). We included studies reported in abstract form if there was sufficient information to permit risk of bias assessment. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and risk of bias, independently extracted data and checked data for accuracy. We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included nine small trials (944 women) conducted in Pakistan, Turkey, Thailand, Egypt (four trials), Saudi Arabia, Benin and Mali. Overall, included trials were at an unclear risk of bias. Due to substantial differences between the studies, it was not possible to combine any trials in meta-analysis. Many of this review's important outcomes were not reported. GRADE assessments ranged from very low to low, with the majority of outcome results rated as very low certainty. Downgrading decisions were mainly based on study design limitations and imprecision; one study was also downgraded for indirectness. External uterine compression versus normal care (1 trial, 64 women) Very low-certainty evidence means that we are unclear about the effect on blood transfusion (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.66 to 8.23). Uterine arterial embolisation versus surgical devascularisation plus B-Lynch (1 trial, 23 women) The available evidence for hysterectomy to control bleeding (RR 0.73, 95% CI 0.15 to 3.57) is unclear due to very low-certainty evidence. The available evidence for intervention side effects is also unclear because the evidence was very low certainty (RR 1.09; 95% CI 0.08 to 15.41). Intrauterine Tamponade Studies included various methods of intrauterine tamponade: the commercial Bakri balloon, a fluid-filled condom-loaded latex catheter ('condom catheter'), an air-filled latex balloon-loaded catheter ('latex balloon catheter'), or traditional packing with gauze. Balloon tamponade versus normal care (2 trials, 356 women) One study(116 women) used the condom catheter. This study found that it may increase blood loss of 1000 mL or more (RR 1.52, 95% CI 1.15 to 2.00; 113 women), very low-certainty evidence. For other outcomes the results are unclear and graded as very low-certainty evidence: mortality due to bleeding (RR 6.21, 95% CI 0.77 to 49.98); hysterectomy to control bleeding (RR 4.14, 95% CI 0.48 to 35.93); total blood transfusion (RR 1.49, 95% CI 0.88 to 2.51); and side effects. A second study of 240 women used the latex balloon catheter together with cervical cerclage. Very low-certainty evidence means we are unclear about the effect on hysterectomy (RR 0.14, 95% CI 0.01 to 2.74) and additional surgical interventions to control bleeding (RR 0.20, 95% CI 0.01 to 4.12). Bakri balloon tamponade versus haemostatic square suturing of the uterus (1 trial, 13 women) In this small trial there was no mortality due to bleeding, serious maternal morbidity or side effects of the intervention, and the results are unclear for blood transfusion (RR 0.57, 95% CI 0.14 to 2.36; very low certainty). Bakri balloon tamponade may reduce mean 'intraoperative' blood loss (mean difference (MD) -426 mL, 95% CI -631.28 to -220.72), very low-certainty evidence. Comparison of intrauterine tamponade methods (3 trials, 328 women) One study (66 women) compared the Bakri balloon and the condom catheter, but it was uncertain whether the Bakri balloon reduces the risk of hysterectomy to control bleeding due to very low-certainty evidence (RR 0.50, 95% CI 0.05 to 5.25). Very low-certainty evidence also means we are unclear about the results for the risk of blood transfusion (RR 0.97, 95% CI 0.88 to 1.06). A second study (50 women) compared Bakri balloon, with and without a traction stitch. Very low-certainty evidence means we are unclear about the results for hysterectomy to control bleeding (RR 0.20, 95% CI 0.01 to 3.97). A third study (212 women) compared the condom catheter to gauze packing and found that it may reduce fever (RR 0.47, 95% CI 0.38 to 0.59), but again the evidence was very low certainty. Modified B-Lynch compression suture versus standard B-Lynch compression suture (1 trial, 160 women) Low-certainty evidence suggests that a modified B-Lynch compression suture may reduce the risk of hysterectomy to control bleeding (RR 0.33, 95% CI 0.11 to 0.99) and postoperative blood loss (MD -244.00 mL, 95% CI -295.25 to -192.75). AUTHORS' CONCLUSIONS There is currently insufficient evidence from RCTs to determine the relative effectiveness and safety of mechanical and surgical interventions for treating primary PPH. High-quality randomised trials are urgently needed, and new emergency consent pathways should facilitate recruitment. The finding that intrauterine tamponade may increase total blood loss > 1000 mL suggests that introducing condom-balloon tamponade into low-resource settings on its own without multi-system quality improvement does not reduce PPH deaths or morbidity. The suggestion that modified B-Lynch suture may be superior to the original requires further research before the revised technique is adopted. In high-resource settings, uterine artery embolisation has become popular as the equipment and skills become more widely available. However, there is little randomised trial evidence regarding efficacy and this requires further research. We urge new trial authors to adopt PPH core outcomes to facilitate consistency between primary studies and subsequent meta-analysis.
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Affiliation(s)
- Frances J Kellie
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Julius N Wandabwa
- Department of Obstetrics and Gynaecology, Busitema University, Mbale, Uganda
| | - Hatem A Mousa
- University Department of Obstetrics and Gynaecology, Fetal and Maternal Medicine Unit, Leicester Royal Infirmary, Leicester, UK
| | - Andrew D Weeks
- Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
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Surbek D, Vial Y, Girard T, Breymann C, Bencaiova GA, Baud D, Hornung R, Taleghani BM, Hösli I. Patient blood management (PBM) in pregnancy and childbirth: literature review and expert opinion. Arch Gynecol Obstet 2020; 301:627-641. [PMID: 31728665 PMCID: PMC7033066 DOI: 10.1007/s00404-019-05374-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/31/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Patient blood management [PBM] has been acknowledged and successfully introduced in a wide range of medical specialities, where blood transfusions are an important issue, including anaesthesiology, orthopaedic surgery, cardiac surgery, or traumatology. Although pregnancy and obstetrics have been recognized as a major field of potential haemorrhage and necessity of blood transfusions, there is still little awareness among obstetricians regarding the importance of PBM in this area. This review, therefore, summarizes the importance of PBM in obstetrics and the current evidence on this topic. METHOD We review the current literature and summarize the current evidence of PBM in pregnant women and postpartum with a focus on postpartum haemorrhage (PPH) using PubMed as literature source. The literature was reviewed and analysed and conclusions were made by the Swiss PBM in obstetrics working group of experts in a consensus meeting. RESULTS PBM comprises a series of measures to maintain an adequate haemoglobin level, improve haemostasis and reduce bleeding, aiming to improve patient outcomes. Despite the fact that the WHO has recommended PBM early 2010, the majority of hospitals are in need of guidelines to apply PBM in daily practice. PBM demonstrated a reduction in morbidity, mortality, and costs for patients undergoing surgery or medical interventions with a high bleeding potential. All pregnant women have a significant risk for PPH. Risk factors do exist; however, 60% of women who experience PPH do not have a pre-existing risk factor. Patient blood management in obstetrics must, therefore, not only be focused on women with identified risk factor for PPH, but on all pregnant women. Due to the risk of PPH, which is inherent to every pregnancy, PBM is of particular importance in obstetrics. Although so far, there is no clear guideline how to implement PBM in obstetrics, there are some simple, effective measures to reduce anaemia and the necessity of transfusions in women giving birth and thereby improving clinical outcome and avoiding complications. CONCLUSION PBM in obstetrics is based on three main pillars: diagnostic and/or therapeutic interventions during pregnancy, during delivery and in the postpartum phase. These three main pillars should be kept in mind by all professionals taking care of pregnant women, including obstetricians, general practitioners, midwifes, and anaesthesiologists, to improve pregnancy outcome and optimize resources.
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Affiliation(s)
- Daniel Surbek
- Department of Obstetrics and Gynaecology, Bern University Hospital, Insel Hospital, University of Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland.
| | - Yvan Vial
- Service of Obstetrics, Department Woman-Mother-Child, University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Thierry Girard
- Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Christian Breymann
- Obstetric Research-Feto Maternal Haematology Unit, University Hospital Zurich, Zurich, Switzerland
| | | | - David Baud
- Service of Obstetrics, Department Woman-Mother-Child, University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - René Hornung
- Department of Obstetrics and Gynaecology, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | | | - Irene Hösli
- Clinic of Obstetrics and Gynaecology, University Hospital Basel, Basel, Switzerland
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Grönvall M, Tikkanen M, Paavonen J, Loukovaara M, Stefanovic V. Is there an association between postpartum hemorrhage, interventional radiology procedures, and psychological sequelae? J Matern Fetal Neonatal Med 2019; 34:1792-1796. [PMID: 31389295 DOI: 10.1080/14767058.2019.1649389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) may cause post-traumatic psychological sequelae. Interventional radiology procedures (IRP) have been established in the management of PPH when conventional management fails. IRP is also used prophylactically in women who are at high risk for PPH in pregnancies with abnormally invasive placentation. We sought to determine if there is an association between PPH, IRP, and psychological sequelae. OBJECTIVES Seventy-three women who underwent IRP due to PPH or were at high risk for PPH. METHOD A structured questionnaire was sent to all women. RESULTS Overall 49 women returned the questionnaire. Two-thirds of the women developed psychological sequelae and one-third reported a lack of professional support. Nine women had symptoms of post-traumatic stress disorder. Psychological sequelae were not associated with a volume of bleeding, whether or not hysterectomy was performed, or whether the IRP was performed as an emergency procedure or prophylactically. However, women who had elective IRP and no hysterectomy performed had significantly less fear of death compared to the rest of the study population. CONCLUSIONS We observed a high rate of psychological sequelae associated with IRP. Lack of proper professional support may have contributed to the development of post-traumatic psychological sequelae suggesting a need for debriefing in such women.
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Affiliation(s)
- Maiju Grönvall
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Minna Tikkanen
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jorma Paavonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mikko Loukovaara
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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The Key Role of Warm and Cold Ischemia in Uterus Transplantation: A Review. J Clin Med 2019; 8:jcm8060760. [PMID: 31146406 PMCID: PMC6616576 DOI: 10.3390/jcm8060760] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/20/2019] [Accepted: 05/22/2019] [Indexed: 01/29/2023] Open
Abstract
Introduction: Uterus transplantation (UTx) is a promising treatment for uterine infertility that has resulted in several births since 2014. Ischemia is a key step in organ transplantation because it may lead to changes jeopardizing graft viability. Method: We performed a systematic review of animal and human studies relating to uterine ischemia. Results: We retained 64 studies published since 2000. There were 35 studies in animals, 24 in humans, and five literature reviews. Modest preliminary results in large animals and humans are limited but encouraging. In small animals, pregnancies have been reported to occur after 24 h of cold ischemia (CI). In ewes, uterine contractions have been detected after 24 h of CI. Furthermore, it has been shown in animals that uterine tolerance to CI and to warm ischemia (WI) can be increased by pharmacological products. In women, mean CI time in studies of births from uteri obtained from live donors was between 2 h 47 min and 6 h 20 min from a deceased donor; with only one birth in this case. Muscle contractions have also been demonstrated in myometrial samples from women, after six or more hours of CI. Conclusion: The uterus seems to be able to tolerate a prolonged period of CI, of at least six hours. Studies of the ischemia tolerance of the uterus and ways to improve it are essential for the development of UTx, particularly for procedures using grafts from deceased donors.
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Abstract
The placenta accreta spectrum has become an important contributor to severe maternal morbidity. The true incidence is difficult to ascertain, but likely falls near 1/1000 deliveries. This number seems to have increased along with the rate of risk factors. These include placenta previa, previous cesarean section, use of assisted reproductive technologies, uterine surgeries, and advanced maternal age. With increased uterine conservation, previous retained placenta or placenta accreta have become significant risk factors. Understanding placenta accreta spectrum risk factors facilitates patient identification and safe delivery planning. Patients considering elective uterine procedures or delayed childbirth should consider the impact on peripartum morbidity.
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Acretismo placentario focal tratado mediante embolización de arterias uterinas. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2019. [DOI: 10.1016/j.gine.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Jauniaux E, Alfirevic Z, Bhide AG, Belfort MA, Burton GJ, Collins SL, Dornan S, Jurkovic D, Kayem G, Kingdom J, Silver R, Sentilhes L. Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a. BJOG 2018; 126:e1-e48. [PMID: 30260097 DOI: 10.1111/1471-0528.15306] [Citation(s) in RCA: 223] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Imai H, Hasegawa J, Suzuki Y, Kondo H, Suzuki N. Total abnormal invasive placenta in a woman with a history of placental abruption and severe hemorrhage. CASE REPORTS IN PERINATAL MEDICINE 2018. [DOI: 10.1515/crpm-2017-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Abnormal invasive placenta (AIP) is subdivided into total, partial and focal types. A diagnosis of total AIP is made when the entire placenta adheres to the uterine myometrium. We experienced a patient with total AIP who had a history of an emergency cesarean section at 36 weeks of gestation due to placental abruption, and massive hemorrhage due to severe uterine atony treated conservatively with blood transfusion. From our experience with the present case, we hypothesize that total AIP resulted from thinning of the entire endometrium, as can occur with an ischemic change of the entire uterus after disruption of Nitabuch’s layer in severe placental abruption and intramuscular extravasation with uterine atony. This situation might adversely affect placental implantation in the current pregnancy.
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Affiliation(s)
- Haruka Imai
- Department of Obstetrics and Gynecology , St. Marianna University School of Medicine , Kanagawa , Japan
| | - Junichi Hasegawa
- Department of Obstetrics and Gynecology , St. Marianna University School of Medicine , 2-16-1 Sugao, Miyamae-ku , Kawasaki, Kanagawa 216-8511 , Japan , Tel.: +81-44 (977) 8111 ext. 3332
| | - Yuki Suzuki
- Department of Obstetrics and Gynecology , St. Marianna University School of Medicine , Kanagawa , Japan
| | - Haruhiro Kondo
- Department of Obstetrics and Gynecology , St. Marianna University School of Medicine , Kanagawa , Japan
| | - Nao Suzuki
- Department of Obstetrics and Gynecology , St. Marianna University School of Medicine , Kanagawa , Japan
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Endovascular interventional modalities for haemorrhage control in abnormal placental implantation deliveries: a systematic review and meta-analysis. Eur Radiol 2018; 28:2713-2726. [DOI: 10.1007/s00330-017-5222-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/20/2017] [Accepted: 11/28/2017] [Indexed: 11/27/2022]
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Pala Ş, Atilgan R, Başpınar M, Kavak EÇ, Yavuzkır Ş, Akyol A, Kavak B. Comparison of results of Bakri balloon tamponade and caesarean hysterectomy in management of placenta accreta and increta: a retrospective study. J OBSTET GYNAECOL 2017; 38:194-199. [DOI: 10.1080/01443615.2017.1340440] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Şehmus Pala
- Department of Obstetrics and Gynecology, Firat University School of Medicine, Elazig, Turkey
| | - Remzi Atilgan
- Department of Obstetrics and Gynecology, Firat University School of Medicine, Elazig, Turkey
| | - Melike Başpınar
- Department of Obstetrics and Gynecology, Firat University School of Medicine, Elazig, Turkey
| | - Ebru Çelik Kavak
- Department of Obstetrics and Gynecology, Firat University School of Medicine, Elazig, Turkey
| | - Şeyda Yavuzkır
- Department of Obstetrics and Gynecology, Firat University School of Medicine, Elazig, Turkey
| | - Alparslan Akyol
- Department of Obstetrics and Gynecology, Firat University School of Medicine, Elazig, Turkey
| | - Burçin Kavak
- Department of Obstetrics and Gynecology, Firat University School of Medicine, Elazig, Turkey
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Carlson NS. Current Resources for Evidence-Based Practice, May/June 2017. J Obstet Gynecol Neonatal Nurs 2017; 46:e37-e45. [PMID: 28343942 DOI: 10.1016/j.jogn.2017.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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