Labor induction with dinoprostone or oxytocine and postpartum disseminated intravascular coagulation: a hospital-based case-control study

Maintenance oxytocin in the immediate postpartum period: Frequency, determinants and practices in a tertiary maternity unit

OBJECTIVE

To prevent post-partum haemorrhage (PPH), national and international guidelines recommend the administration of a prophylactic injection of oxytocin after all vaginal births. Although additional maintenance oxytocin is not recommended in the immediate postpartum, its administration is quite common (30 % of French births in 2021). To assess in a single center, the frequency and determinants associated with the administration of maintenance oxytocin in immediate postpartum.

STUDY DESIGN

A retrospective observational single-centre study was conducted in a tertiary-care university centre in Paris (France), with data from April-May 2022. All women who gave birth vaginally at or after 37 weeks, except for those with immediate PPH. Univariate and multivariate analysis were performed to compare determinants between the group receiving maintenance oxytocin and the control group without this intervention. A sensitivity analysis in a population of women at low risk of PPH was performed. Maternal, obstetrical, perinatal and organisational determinants were collected.

RESULTS

This study included 584 patients, 278 (47.6 %) of whom received maintenance oxytocin. We observed a significantly higher rate of maintenance oxytocin administration to parous women (OR 1.57, 90 %CI 1.09-2.27) and women with a history of PPH (OR 2.88, 90 %CI 1.08-9.08). Additional maintenance oxytocin was also administered more often when the midwife handling the birth had more than 5 years of practice since completion of training (OR 1.77, 1.24-2.53) or during night-time births (OR 1.47, 90 %CI 1.03-2.10).

CONCLUSION

Maintenance oxytocin administration is a frequent practice, performed for almost half the patients in our center. This practice is associated with maternal and obstetric factors, but also with health professionals' individual decisions and practices.

Desmopressin-induced Moschcowitz-like syndrome after treatment of uterine atonic bleeding in a 28-year-old pregnant woman: case report and overview of the literature

Here we report of a patient who developed a Moschcowitz-like syndrome following a desmopressin treatment of severe postpartum hemorrhage. The patient got an anaphylactic reaction after cervical ripening with dinoproston, leading to an emergency cesarean. A postpartum uterine atony with a blood loss more than 1500 ml resulted in a disseminated intravascular coagulation that was treated with mass transfusion of blood products, including platelets and factor VII. Desmopressin is used as rescue medication in situations of severe bleeding. It was given in this life-threatening situation and presumably triggered a Moschcowitz-like syndrome. Desmopressin exerts its haemostatic effect by releasing von Willebrand factor, which is elevated in pregnancy per se. This results in an increased risk of developing microthrombi, leading to a Moschcowitz-like syndrome. In conclusion, desmopressin should not be administered in pregnant patients owing to its potential risk of triggering the development of thrombotic-thrombocytopenic purpura.

Is dinoprostone safe? A report of three maternal deaths

We report three maternal deaths which might be in possible association with the use of intravaginal dinoprostone for cervical ripening and induction of labor. All cases occurred at our institution between January 2006 and December 2007. Uterine atony and profuse bleeding followed by disseminated intravascular coagulation (DIC), characterized by severe hypofibrinogenemia developed shortly after delivery of the first two patients. The third patient developed respiratory symptoms in the active labor followed by hemodynamic changes manifested by tetanic uterine contractions and fetal heart rate decelerations. Cardiac arrest developed in all patients shortly after the occurrence of symptoms with no response to any medical intervention. The pharmacologic induction of labor with dinoprostone may be in association with increased risk of maternal death because of increased risk of postpartum DIC and amnionic fluid embolism. Further investigations seem to be needed.

What can we learn from a cross-country comparison of the costs of child delivery?

This study provides a comparative analysis of the costs of normal delivery in hospital in nine European countries using the data collected as part of the HealthBASKET project. The results show that both the level of input (medical labour) prices and the skill mix used for delivery are major determinants of total delivery costs. At the hospital level, there seems to be room for greater efficiency through specialisation and task shifting from doctors to midwives and nurses. More generally, the results of our study suggest that the costs of delivery in hospital are not independent of supplementary home care provided outside of hospitals. The cost information and analysis in this study may also be useful for developing healthcare-specific purchasing power parities (PPPs) that allow for healthcare expenditures to be compared across countries.