Iron Deficiency Anaemia and Atonic Postpartum Haemorrhage Following Labour

A comparative analysis of methods of preinduction cervical ripening and induction of labor in Poland and in Germany (Part II): maternal and neonatal outcomes

The benefits and risks of delivery should always be considered before initiating preinduction cervical ripening and labor induction. Understanding the benefits and potential complications is crucial for healthcare professionals to make informed decisions and provide optimal care. The research was conducted retrospectively between January 2019 and July 2022. It involved the analysis of the medical records of 154 pregnant women staying in the Clinic of Obstetrics and Gynecology in the city of Szczecin and 150 pregnant women hospitalized in the Clinic of Obstetrics and Gynecology in the town of Schwedt/Oder in Germany. Inclusion criteria were consent to participate and the implementation of internal written protocols in line with national guidelines for labor induction. The research concerned a group of pregnant women with postdate pregnancy, calculated according to the Naegele's rule and confirmed by the USG examination conducted in the first trimester of the pregnancy, as well as an unfavorable cervix that received less than 6 points in the Bishop score. Moreover, the pregnant patients with a low biophysical profile and an abnormal record of CTG or comorbidities were also included, as these factors determined the classification of the group above. The study did not include patients who had undergone cesarean section. The average change in evaluation of the cervix marked on the Bishop Score was higher in Germany, and it was 2.7 points, whereas in Poland, it was 1.6 points. The largest percentage of the scores on the Apgar Scale in the first, third and fifth minutes after birth was in the norm and indicated a good health condition of infants. They reached 8 to 10 points in both countries. Significantly more infants in Germany received pH from the umbilical cord within the limits of the norm. And it marks the welfare of neonates (7.20-7.45). The duration of hospitalization in Poland was shorter than in Germany. It was 3.8 days in the case when the median equalled 3. The number of days of preinduction cervical ripening and induction was similar in both countries. The levels of haemoglobin were comparable in both countries. The most common postpartum complications in Poland and Germany were first-degree perineal tears, episiotomies and anemia. Among the postpartum complications, cervical tears, revision of the uterine cavity, and episiotomy were significantly more common in Poland. First- and second-degree perineal tears were more frequent in Germany.

Antenatal screening - The roles of medical and family history, routine tests, and examination findings

Routine antenatal care includes history, examination, and several standard laboratory tests. Other than the original objectives, the generated data is seldom utilised for screening for adverse obstetric and perinatal outcomes. Although new approaches and sophisticated tests improve prediction of complications such as pre-eclampsia, these may not be available globally. Maternal age, race/ethnicity, anthropometry, and method of conception can influence the occurrence of pregnancy complications. The importance of medical and obstetric history is well documented but often ignored. Routine test results including blood picture, hepatitis B and rubella serology, and sexually transmitted diseases, have additional health implications. The awareness of, and the ability to utilise, available antenatal data and tests in obstetric management will enhance individualised obstetric risk assessment thus facilitating the targeting of high-risk gravidae for further management, including the use of specific and technology-driven tests where available, and close monitoring and treatment, in a cost-effective manner.

Does induction or augmentation of labor increase the risk of postpartum hemorrhage in pregnant women with anemia? A multicenter prospective cohort study in India

OBJECTIVE

To investigate whether induction/augmentation of labor in pregnant women with anemia increases the risk of postpartum hemorrhage (PPH) and whether this risk varied by indications for labor induction/augmentation and by anemia severity in pregnancy.

METHODS

In a prospective cohort study of 9420 pregnant women from 13 hospitals across India, we measured hemoglobin concentrations at recruitment (≥28 weeks of gestation) and blood loss after childbirth during follow-up and collected clinical information about PPH. Clinical obstetric and childbirth information at both visits were extracted from medical records. Anemia severity in the third trimester was categorized using hemoglobin concentrations (no/mild anemia: hemoglobin ≥10 g/dL; moderate: hemoglobin 7 to 9.9 g/dL; severe: hemoglobin <7 g/dL), while PPH was defined based on blood loss volume (vaginal births: ≥500 mL or cesarean sections: ≥1000 mL) and clinical diagnosis. Indications for labor induction/augmentation were classified as clinically indicated and elective as per guidelines. We performed multivariable modified Poisson regression analyses to investigate the associations of anemia severity and indications for labor induction/augmentation, including their interaction, with PPH, adjusted for potential confounders.

RESULTS

PPH was associated with anemia but not with indications for labor induction/augmentation. However, there was a significant interaction between the two factors in relation to PPH (P = 0.003). Among pregnant women with severe anemia, a higher risk of PPH was associated with elective (adjusted risk ratio, 3.44 [95% confidence interval, 1.29-9.18]) but not with clinically indicated (adjusted risk ratio, 1.22 [95% confidence interval, 0.42-3.55]) labor induction/augmentation. No associations were observed among pregnant women with no/mild and moderate anemia.

CONCLUSION

The risk of PPH is higher in women who have moderate-severe anemia in late pregnancy. Induction/augmentation of labor is generally safe for women with anemia, but it can increase the risk of PPH in women with severe anemia if performed electively.

Assessment of Structural and Process Readiness for Postpartum Haemorrhage Care in Uganda and Ghana: A Mixed Methods Study

OBJECTIVE

To determine structural and process readiness for postpartum haemorrhage (PPH) care at referral-level facilities in Ghana and Uganda to identify opportunities for strengthening.

DESIGN

Mixed-methods cross-sectional study.

SETTING

Three districts in Ghana and two in Uganda.

POPULATION OR SAMPLE

Nine hospitals in Ghana and seven in Uganda; all hospitals had theoretical capacity for caesarean section and blood transfusion.

METHODS

We deployed a modular quantitative health facility assessment to explore structural readiness (drugs, equipment, staff) complemented by in-depth interviews with maternity health service providers to understand process readiness (knowledge, attitudes, and practices as related to World Health Organization [WHO] guidance on PPH care).

MAIN OUTCOME MEASURES

Availability of essential structural components needed to support key PPH processes of care.

RESULTS

In both countries, there was generally good structural readiness for PPH care. However, key common gaps included inadequate staffing (especially specialist physicians), and unavailability of blood for transfusion. Interviews highlighted particularly good process readiness in the provision of uterotonics, recognising and responding to retained placenta, and repairing tears. However, there were clear gaps in the utilisation of tranexamic acid and uterine balloon tamponade.

CONCLUSIONS

We have identified good structural and process readiness across both Ghanaian and Ugandan health facilities to support PPH responses. However, some key missed opportunities-to align with current WHO guidance on providing bundles of interventions for PPH care-could be strengthened with minimal investment but promising impact.

Global burden of maternal disorders attributable to malnutrition from 1990 to 2019 and predictions to 2035: worsening or improving?

Background and aims

Maternal malnutrition is a major global public health problem that can lead to serious maternal diseases. This study aimed to analyze and predict the spatio-temporal trends in the burden of maternal disorders attributable to malnutrition, and to provide a basis for scientific improvement of maternal malnutrition and targeted prevention of maternal disorders.

Methods

Data on maternal disorders attributable to malnutrition, including number of deaths, disability-adjusted life years (DALYs), population attributable fractions (PAFs), age-standardized mortality rates (ASMRs), and age-standardized DALY rates (ASDRs) were obtained from the Global Burden of Disease Study 2019 to describe their epidemiological characteristics by age, region, year, and type of disease. A log-linear regression model was used to calculate the annual percentage change (AAPC) of ASMR or ASDR to reflect their temporal trends. Bayesian age-period-cohort model was used to predict the number of deaths and mortality rates to 2035.

Results

Global number of deaths and DALYs for maternal disorders attributable to malnutrition declined by 42.35 and 41.61% from 1990 to 2019, with an AAPC of -3.09 (95% CI: -3.31, -2.88) and -2.98 (95% CI: -3.20, -2.77) for ASMR and ASDR, respectively. The burden was higher among younger pregnant women (20-29 years) in low and low-middle socio-demographic index (SDI) regions, whereas it was higher among older pregnant women (30-39 years) in high SDI region. Both ASMR and ASDR showed a significant decreasing trend with increasing SDI. Maternal hemorrhage had the highest burden of all diseases. Global deaths are predicted to decline from 42,350 in 2019 to 38,461 in 2035, with the ASMR declining from 1.08 (95% UI: 0.38, 1.79) to 0.89 (95% UI: 0.47, 1.31).

Conclusion

Maternal malnutrition is improving globally, but in the context of the global food crisis, attention needs to be paid to malnutrition in low SDI regions, especially among young pregnant women, and corresponding measures need to be taken to effectively reduce the burden of disease.

Characteristics and outcomes of pregnant women hospitalized with severe maternal outcomes in eastern Ethiopia: Results from the Ethiopian Obstetric Surveillance System study

OBJECTIVE

The aim of the present study was to identify facility-based incidence of severe obstetric complications through a newly established obstetric surveillance system in eastern Ethiopia.

METHODS

Monthly registration of obstetric hemorrhage, eclampsia, uterine rupture, severe anemia and sepsis was introduced in 13 maternity units in eastern Ethiopia. At each hospital, a designated clinician reported details of women admitted during pregnancy, childbirth or within 42 days of termination of pregnancy from April 01, 2021 to March 31, 2022 developing any of these conditions. Detailed data on sociodemographic characteristics, obstetric complications and status at discharge were collected by trained research assistants.

RESULTS

Among 38 782 maternities during the study period, 2043 (5.3%) women had any of the five conditions. Seventy women died, representing a case fatality rate of 3.4%. The three leading reasons for admission were obstetric hemorrhage (972; 47.6%), severe anemia (727; 35.6%), and eclampsia (438; 21.4%). The majority of the maternal deaths were from obstetric hemorrhage (27/70; 38.6%) followed by eclampsia (17/70; 24.3%).

CONCLUSION

Obstetric hemorrhage, severe anemia and eclampsia were the leading causes of severe obstetric complications in eastern Ethiopia. Almost one in 29 women admitted with obstetric complications died. Audit of quality of care is indicated to design tailored interventions to improve maternal survival and obstetric complications.

Hemostatic biomarkers associated with postpartum hemorrhage: a systematic review and meta-analysis

Postpartum hemorrhage (PPH) is a leading cause of maternal morbi-mortality. Although obstetric risk factors are well described, the impact of predelivery hematologic and hemostatic biomarkers remains incompletely understood. In this systematic review, we aimed to summarize the available literature on the association between predelivery hemostatic biomarkers and PPH/severe PPH. Searching MEDLINE, EMBASE, and CENTRAL databases from inception to October 2022, we included observational studies on unselected pregnant women without bleeding disorder reporting on PPH and on predelivery hemostatic biomarkers. Two review authors independently performed title, abstract and full-text screening, upon which quantitative syntheses of studies reporting on the same hemostatic biomarker were conducted, calculating the mean difference (MD) between women with PPH/severe PPH and controls. A search on 18 October 2022 yielded 81 articles fitting our inclusion criteria. The heterogeneity between studies was considerable. With regard to PPH, the estimated average MD in the investigated biomarkers (platelets, fibrinogen, hemoglobin, Ddimer, activated partial thromboplastin time, and prothrombin time) were not statistically significant. Women who developed severe PPH had lower predelivery platelets than controls (MD = -26.0 109/L; 95% confidence interval, -35.8 to -16.1), whereas differences in predelivery fibrinogen concentration (MD = -0.31 g/L; 95% confidence interval, -0.75 to 0.13) and levels of factor XIII or hemoglobin were not statistically significant in women with and without severe PPH. Predelivery platelet counts were, on average, lower in women with severe PPH compared with controls, suggesting the potential usefulness of this biomarker for predicting severe PPH. This trial was registered at the International Prospective Register of Systematic Reviews as CRD42022368075.

Prevention of postpartum hemorrhage in vaginal deliveries

Identification of patients at risk for postpartum hemorrhage (PPH) may allow for prompt diagnosis and intervention. Individual risk factors, risk assessment tools and prediction models have been used for determining a patient's risk of PPH. Measures for the prevention of PPH include identification and management of iron deficiency anemia, unit readiness and preparedness through performing regular simulations and having a PPH cart or medication kit readily available, prophylactic uterotonic - carbetocin alone or dual agents such as oxytocin and misoprostol or oxytocin and methylergometrine or antifibrinolytic (oxytocin and tranexamic acid) use in the third stage of labor immediately after fetal head delivery, and controlled cord traction.

Patient Blood Management programs for post-partum hemorrhage

Patient blood management (PBM) strategies aim to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss to improve patient outcomes. Because postpartum hemorrhage (PPH) is a leading cause of maternal mortality and blood product utilization, PBM principles can be applied in its therapeutic approach. First, pre-operative identification of risk factors for PPH and identification of peri-delivery anemia should be conducted. Iron supplementation should be used to optimize hemoglobin concentration before delivery; it can also be used to treat anemia in the postpartum period after severe PPH. Both acute normovolemic hemodilution and intraoperative cell salvage can be effective techniques to reduce allogeneic blood transfusion during or after surgical procedures. Furthermore, these strategies appear to be safe when used in the pregnant population.