Major obstetric hemorrhage

FairEmbo Concept for Postpartum Hemorrhage: Evaluation of the Efficacy of Suture Fragment Compared with Gelatin Sponge Torpedo Embolization in a Post-Gravid Swine Model

BACKGROUND

Postpartum hemorrhage is the leading cause of maternal mortality in emerging countries. This study aims to evaluate the effectiveness and safety of uterine artery embolization (UAE) using suture fragment (FairEmbo concept) in a swine model.

METHODS

Seven female swine uteri were embolized. The left uterine artery was embolized with 1 cm fragments of absorbable suture (Optime^® 0), and with gelatin sponge torpedoes for the contralateral side for comparison. The embolization effectiveness and the time for arterial recanalization with digital subtraction angiography (DSA) controls at D0, D7, and M1, were evaluated. Follow-up protocol also included clinical monitoring and macroscopical analyses at M1. A Mann-Whitney test (significance at P 0.05) was used for statistics.

RESULTS

A technical success was obtained for the seven arteries on each side, with no off-target embolization. The procedure time (10 min versus 3.7 min) and number of fragments (13.8 versus 5.7) required for complete occlusion were significantly greater in the FairEmbo group. All arteries were repermeabilized at M1. No necrosis was macroscopically visible at harvest at M1.

CONCLUSION

This experimental study suggests that UAE with SBM FairEmbo method is feasible, safe, and effective in comparison with gelatin sponge procedure.

Target areas to reduce the burden of maternal death due to obstetric hemorrhage in Ethiopia

BACKGROUND

Obstetric hemorrhage is defined as active bleeding of more than 500 ml in vaginal delivery or 1000ml following cesarean delivery. It is the leading cause of maternal death, which contributes to up to 50% of maternal deaths in Ethiopia. This study aims to assess the relationships between adverse maternal health exposure (personal and medical factors) and delay in health care (hesitancy in opting to seek care, lag in reaching a health facility, and wait in receiving health care at the facility) and adverse outcomes of obstetric hemorrhage among reviewed maternal deaths in Ethiopia.

METHODS

This study utilizes 4530 reported maternal death surveillance data obtained from Ethiopian maternal death surveillance and response (MDSR) system between 2013 to 2020. Latent class analysis was applied to identify underlying patterns of adverse maternal health exposures. Furthermore, the associations between latent classes and adverse outcomes of obstetric hemorrhage were analyzed using multilevel logistics regression model adjusted for clustering within reporting provinces.

RESULTS

Nearly 56% of the reviewed maternal deaths were due to the adverse outcome of obstetric hemorrhage, among which nearly 75% died during the postpartum period. The study identified six separate sub-groups of women based on their vulnerability to adverse maternal health conditions. The six subgroups identified by this study are 1) women who travelled for a long duration to reach a health care provider, 2) those who had no access to a health facility (HF) within a 5Km radius, 3) those who failed to decide to go to a health facility: 4) those with multiparity,5) those who were injured during delivery with history of coagulopathy, and 6) those who got injured during delivery and failed to decide to go to a health facility. Women in the class of grand multipara have demonstrated the highest risk of death due to the adverse outcomes of obstetric hemorrhage (β = 1.54, SE = 0.09, p<0.0001).

CONCLUSIONS

The study has attempted to identify women that are at a higher risk for the adverse outcomes of obstetric hemorrhage. Henceforth, targeted intervention should be taken on women of reproductive age group, and those identified as at a higher risk, to reduce the high rate of maternal death due to obstetric hemorrhage.

Acute kidney injury during pregnancy and puerperium: an Egyptian hospital-based study

INTRODUCTION

While acute kidney injury (AKI) in pregnancy is currently a rare entity in developed countries, it is still a common occurrence in developing countries, representing a major cause of maternal and fetal morbidity and mortality. Scarce data are published regarding pregnancy-related acute kidney injury (PRAKI) in Middle Eastern and African countries. The aim of this work is to report on the frequency, the underlying causes, and the outcomes of patients with PRAKI in an Egyptian tertiary care hospital.

METHODS

This is a prospective observational study that included 40 patients representing all women who presented to the Mansoura Nephrology and Dialysis Unit with PRAKI over two years. All patients were followed up for three months after hospital discharge to assess renal outcome, and till the end of pregnancy to assess the maternal and fetal outcomes.

RESULTS

PRAKI was reported  in about 1% of women who presented to the obstetrics service, and accounted for 14% of all AKI patients who presented to the renal service in our hospital. Preeclampsia (PE) and obstetric hemorrhage were the commonest causes of PRAKI. Maternal mortality occurred in 22.5% of PRAKI patients. The majority of survivors (62.5%) fully recovered, while the remaining (37.5%) individuals became dialysis dependent. Unfavorable fetal events occurred in 24 pregnancies (60%).

CONCLUSION

In our hospital in Mansoura, Egypt, PRAKI represents a relevant burden with potential ominous outcomes obstetric hemorrhage and preeclampsia were the major causes. Further research is needed to understand the causes and improve the outcomes of pregnancy-related AKI.

Early and systematic administration of fibrinogen concentrate in postpartum haemorrhage following vaginal delivery: the FIDEL randomised controlled trial

OBJECTIVE

To assess the benefits and safety of early human fibrinogen concentrate in postpartum haemorrhage (PPH) management.

DESIGN

Multicentre, double-blind, randomised placebo-controlled trial.

SETTING

30 French hospitals.

POPULATION

Patients with persistent PPH after vaginal delivery requiring a switch from oxytocin to prostaglandins.

METHODS

Within 30 minutes after introduction of prostaglandins, patients received either 3 g fibrinogen concentrate or placebo.

MAIN OUTCOME MEASURES

Failure as composite primary efficacy endpoint: at least 4 g/dl of haemoglobin decrease and/or transfusion of at least two units of packed red blood cells within 48 hours following investigational medicinal product administration. Secondary endpoints: PPH evolution, need for haemostatic procedures and maternal morbidity-mortality within 6 ± 2 weeks after delivery.

RESULTS

437 patients were included: 224 received FC and 213 placebo. At inclusion, blood loss (877 ± 346 ml) and plasma fibrinogen (4.1 ± 0.9 g/l) were similar in both groups (mean ± SD). Failure rates were 40.0% and 42.4% in the fibrinogen and placebo groups, respectively (odds ratio [OR] = 0.99) after adjustment for centre and baseline plasma fibrinogen; (95% CI 0.66-1.47; P = 0.96). No significant differences in secondary efficacy outcomes were observed. The mean plasma FG was unchanged in the Fibrinogen group and decreased by 0.56 g/l in the placebo group. No thromboembolic or other relevant adverse effects were reported in the Fibrinogen group versus two in the placebo group.

CONCLUSIONS

As previous placebo-controlled studies findings, early and systematic administration of 3 g fibrinogen concentrate did not reduce blood loss, transfusion needs or postpartum anaemia, but did prevent plasma fibrinogen decrease without any subsequent thromboembolic events.

TWEETABLE ABSTRACT

Early systematic blind 3 g fibrinogen infusion in PPH did not reduce anaemia or transfusion rate, reduced hypofibrinogenaemia and was safe.

Endometriosis and Risk of Adverse Pregnancy Outcome: A Systematic Review and Meta-Analysis

Background: This systematic review and meta-analysis summarizes the evidence for the association between endometriosis and adverse pregnancy outcome, including gestational hypertension, pre-eclampsia, low birth weight, and small for gestational age, preterm birth, placenta previa, placental abruption, cesarean section, stillbirth, postpartum hemorrhage, spontaneous hemoperitoneum in pregnancy, and spontaneous bowel perforation in pregnancy. Methods: We performed the literature review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), by searches in PubMed and EMBASE, until 1 November 2020 (PROSPERO ID CRD42020213999). We included peer-reviewed observational cohort studies and case-control studies and scored them according to the Newcastle–Ottawa Scale, to assess the risk of bias and confounding. Results: 39 studies were included. Women with endometriosis had an increased risk of gestational hypertension, pre-eclampsia, preterm birth, placenta previa, placental abruption, cesarean section, and stillbirth, compared to women without endometriosis. These results remained unchanged in sub-analyses, including studies on spontaneous pregnancies only. Spontaneous hemoperitoneum in pregnancy and bowel perforation seemed to be associated with endometriosis; however, the studies were few and did not meet the inclusion criteria. Conclusions: The literature shows that endometriosis is associated with an increased risk of gestational hypertension, pre-eclampsia, preterm birth, placenta previa, placental abruption, cesarean section, and stillbirth.

Transcatheter Arterial Embolization in the Management of Postpartum Hemorrhage due to Genital Tract Injury after Vaginal Delivery

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.

Perspective of the comparative effectiveness of non-pharmacologic managements on postpartum hemorrhage using a network meta-analysis

OBJECTIVE

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide and is both unpredictable and inevitable. While uterotonic drugs are routinely recommended, there is ongoing debate on the ideal intervention to control uterine bleeding. This review aims to compare the use of non-pharmacologic treatments with peripartum hysterectomy in cases of life-threatening uncontrolled obstetric hemorrhage. The review's objective is to use a network meta-analysis to help prevent maternal deaths and rank the treatments according to success rates.

METHODS

We searched MEDLINE (PubMed), Embase, and the Cochrane Library, from January 2014 until December 2018. A second search was carried out in April 2019 before the final data analysis. Network meta-analysis allows for the calculation of the effect size between treatment groups through indirect treatment comparison.

RESULTS

We confirmed that balloon-assisted management is the best intervention for uncontrolled postpartum bleeding with pharmacologic treatment. This is followed by uterine artery embolization and surgical procedures, which can help avoid the need for a hysterectomy. The balloon tamponade demonstrated lower failure rate than the surgical procedure with odds ratio (OR) of 0.44 and 95% confidence intervals (CIs) 0.50-30.54. Uterine artery embolization had a lower risk for hysterectomy than the surgical procedure group (OR, 0.74; 95% CI, 0.22-2.50).

CONCLUSION

For the quick treatment of postpartum bleeding, balloon tamponade is the best method for uncontrolled postpartum bleeding with pharmacologic treatment, followed by uterine artery embolization and surgical procedures.

Bilateral cervix apex clamping procedure can be used as a new noninvasive second line therapy for postpartum hemorrhage

In this study, we present a noninvasive procedure of bilateral cervix apex clamping (BCAC) procedure to control refractory postpartum hemorrhage (PPH) in vaginal delivery as a new second line therapy for refractory PPH. The procedure clamps the anterior and posterior walls of the cervical apex using toothless ovum forceps to arrest bleedingafter the failure of the first line therapy for PPH. 44 women were performed BCAC to control persistent bleeding in 13,359 vaginal deliveries from 1 January 2016 to 31 May 2018. In all of the BCAC, it can reduce bleeding significantly. The bleeding speed after BCAC was far less than that before it (2.64 ± 4.99 ml/min vs 20.23 ± 9.40 ml/min P < 0.001). The blood loss after BCAC was less than that before it (146.57 ± 170.83 vs 797.84 ± 200.73 ml P < 0.001). 41 (93.2%) BCACsucceeded and 3(6.8%) failed turned to intrauterine balloon tamponade, 2 succeeded and 1 failed turned to hysterectomy. In the successful group the bleeding speed after the BCAC was 1.38 ± 0.99 ml/min less than that 19.84 ± 6.27 ml/min in the failure group. (p < 0.001). The blood loss in the success group is also less than that in the failure ones after BCAC (107.29 ± 78.36mL vs 683.33 ± 202.07 ml P < 0.001) Even in the failure group, the bleeding speed also reduced after BCAC compared with that before BCAC (19.84 ± 6.27 vs 29.17 ± 7.12 ml/min p = 0.02). But the blood loss had no statistical difference (683.33 ± 202.07 vs 950 ± 132.29 ml p = 0.27) In all of the 13,359 vaginal deliveries, the incidence of PPH was 1.21% while the severe PPH was only 0.27%. The BCAC may reduce the incidence of severe PPH (0.27%) and also can reduce the necessity of IUBT (3/13,359 0.22‰), uterine artery embolization (UAE) (0/13,359) and even the exploratory laparotomy hysterectomy (1/13,359). Because it is effective, convenient, cheap and noninvasive, so we think it can be used as a new second line noninvasive treatment for PPH.

The inferior vena cava diameter is a useful ultrasound finding for predicting postpartum blood loss

Purpose: To assess whether the ultrasonographic measurement of the inferior vena cava (IVC) diameter in postpartum women is a useful parameter in evaluating the actual blood loss during delivery due to massive postpartum hemorrhage. Materials and methods: In postpartum women with blood loss ≥500 g, abdominal ultrasonography was performed 1 hour after delivery. The IVC diameter was measured during inspiration (IVCi) and expiration (IVCe). The maternal heart rate, blood pressure, and shock index (heart rate/systolic blood pressure) were also measured. The predictive value of these parameters for severe anemia (hemoglobin <7.0 g/dL) a day after delivery was evaluated via receiver operating characteristic (ROC) analyses. Results: Seven patients with severe anemia and 77 controls were included in the analysis. The area under the curve (AUC) for IVCi (0.905) and IVCe (0.926) was higher than that for the shock index (0.890), heart rate (0.874), or systolic blood pressure (0.752). Among the examined parameters, the best sensitivity was achieved by IVCe and systolic blood pressure (71.4%). Conclusions: The ultrasonographic measurement of the IVC diameter was found to be the most useful parameter in evaluating the actual maternal blood loss after delivery.

Safety and efficacy of tranexamic acid for prevention of obstetric haemorrhage: an updated systematic review and meta-analysis

BACKGROUND

A number of clinical systematic review and meta-analysis have been published on the use of tranexamic in the obstetric setting. The aim of this meta-analysis was to evaluate the safety and effectiveness of tranexamic acid in reducing blood loss when given prior to caesarean delivery.

MATERIALS AND METHODS

We searched the Cochrane Wounds Specialized Register, Cochrane Central, MEDLINE (through PUBMED), Embase, and SCOPUS electronic databases. We also searched clinical trials registries for ongoing and unpublished studies, and checked reference lists to identify additional studies. We used no restrictions with respect to language and date of publication. Two review authors independently performed study selection, "Risk of bias" assessment, and data extraction. Initial disagreements were resolved by discussion, or by including a third review author when necessary.

RESULTS

We found 18 randomised controlled trials (RCTs) that met our inclusion criteria. Overall, 1,764 women receiving intravenous tranexamic acid for prevention of bleeding following caesarean sections and 1,793 controls receiving placebo were enrolled in the 18 RCTs evaluated. The use of tranexamic acid compared to controls (placebo or no intervention) reduces post-partum haemorrhage >400 mL (risk ratio [RR] 0.40, 95% confidence interval [CI] 0.24-0.65; 5 trials with a total of 786 participants), severe post-partum haemorrhage >1,000 mL (RR 0.32, 95% CI: 0.12-0.84; 5 trials with a total of 1,850 participants), and need for red blood cell transfusion (RR 0.30, 95% CI: 0.18-0.49; 10 trials with a total of 1,873 participants). No particular safety concerns on the use of this antifibrinolytic agent emerged from the analysis of the 18 RCTs included.

DISCUSSION

Overall, the results of this meta-analysis support the evidence of a beneficial effect of tranexamic acid in reducing blood loss and need for blood transfusion in pregnant women undergoing caesarean section.

Collaborative Strategies for Management of Obstetric Hemorrhage

Obstetric hemorrhage is a significant cause of perinatal morbidity and mortality that requires prompt recognition and collaborative intervention to prevent poor outcomes. Medical and surgical management goals include controlling bleeding, supporting tissue oxygenation and perfusion, and monitoring for coagulopathies and complications.

Incidence and outcome of severe ante-partum hemorrhage at the Teaching Hospital Yalgado Ouédraogo in Burkina Faso

BACKGROUND

Hemorrhage is the main cause of maternal death during pregnancy. This study aims to evaluate incidence and outcomes of Severe Ante Partum Hemorrhage (SAPH) during the third trimester of pregnancy prior to delivery.

METHODS

Analytical cross-sectional study with prospective data collection during 12 months in Yalgado Ouedraogo Hospital, Ouagadougou, Burkina Faso. In this context SAPH is specifically referring to Ante Partum Hemorrhage (APH) and Intra Partum Hemorrhage (IPH) in the 3rd trimester. Postpartum Hemorrhage (PPH) was not included.

RESULTS

During our study 7,469 women were admitted in obstetrics and 122 cases of SAPH were recorded. SAPH represented 1.6% (n = 122) of hospitalizations causes and 14.5% (n = 1083) of hemorrhages during pregnancy. Mean age was 27.8 ± 6.9 years, mean parity 2.8 ± 1.3 and mean duration of pregnancy was 37 Weeks Amenorrhea (WA). Evacuation from other facilities was the main mode of admission (91.8%, n = 112) and blood transfusion was the essence of resuscitation. Complications were observed in 80.3% (n = 98). During the study, 118 maternal deaths were reported of which 15.6% (n = 19) related to SAPH. Among SAPH cases who died (n = 19) majority (n = 16) had severe anemia (n = 16; 82.6%, p = 0.004). Ten women (8.19%) were admitted in Intensive Care Unit (ICU). Fifteen premature births (12.3%) and 22 perinatal deaths (18.1%) were recorded. Evacuation (p = 0.04), critical clinical condition during admission (p = 0.004), and Uterine Rupture (UR) (p = 0.002) were associated with poor outcome. The Retroplacental Hemorrhage (RPH) (40.9%) was the most common cause of fetal death (p = 0.005) and was associated with High Blood Pressure (HBP) and pre-eclampsia.

CONCLUSION

APH is a complication associated with significant maternal and fetal morbidity and mortality.

Morbidly Adherent Placenta: Interprofessional Management Strategies for the Intrapartum Period

"Morbidly adherent placenta" is a term that describes the continuum of placenta accreta, increta, and percreta. The incidence of this type of abnormal placentation has increased significantly over recent decades. The reason is probably multifactorial but, partly, because of factors such as the increasing number of cesarean births. Women at greatest risk are those who have myometrial damage caused by a previous cesarean birth, with either anterior or posterior placenta previa overlying the uterine scar. This condition poses significant risks of morbidity and/or mortality to the pregnant woman and her fetus. A multidisciplinary approach to care throughout pregnancy is essential. This article describes the classification of morbidly adherent placenta, risk factors, methods of diagnosis, potential maternal and fetal complications, and intrapartum clinical management strategies to optimize outcomes.

Randomized double-blind placebo-controlled trial of buccal misoprostol to reduce the need for additional uterotonic drugs during cesarean delivery

OBJECTIVE

To determine whether buccal misoprostol during cesarean delivery in conjunction with active management of the third stage of labor reduces the need for additional uterotonic drugs.

METHOD

A double-blind, randomized, placebo-controlled trial was performed in Monterrey, Mexico, between February 2008 and December 2013. Eligible women had risk factors for uterine atony and were to undergo cesarean delivery under epidural block. Using a computer-generated sequence and blocks of six, patients were randomly assigned to receive 400μg misoprostol or 800μg placebo buccally after cord clamping. Both groups received an intravenous oxytocin infusion. The primary outcome was the need for additional uterotonic drugs. Analyses were performed per protocol. Patients, investigators, and data analysts were masked to group assignment.

RESULTS

A total of 120 women were included in analyses (60 in each group). At least one additional uterotonic drug was required in 24 (40%) women in the placebo group versus 6 (10%) women in the misoprostol group (relative risk 0.16; 95% confidence interval 0.06-0.44). No adverse effects due to misoprostol were recorded.

CONCLUSION

Buccal misoprostol during cesarean delivery reduced the need for additional uterotonic drugs to treat uterine atony. ClinicalTrials.gov:NCT01733329.

Histological characteristics of the myometrium in the postpartum hemorrhage of unknown etiology: a possible involvement of local immune reactions

The aim of this study was to evaluate the histological characteristics of the myometrium obtained in postpartum hemorrhage (PPH) of unknown etiology secondary to uterine atony. These characteristics were selected from among registered cases of clinically suspected amniotic fluid embolism (AFE) and classified as PPH of unknown etiology because of no obvious cause of PPH at Hamamatsu University School of Medicine, a registration center for clinical AFE in Japan. Immunohistochemical studies were performed on myometrium using anti-mast cell tryptase, anti-neutrophil elastase, anti-CD68, anti-CD88, anti-CD3, and anti-ZnCP-1 antibodies. Massive infiltrations of inflammatory cells with mast cell degranulation within the myometrium secondary to complement activation were observed in PPH of unknown etiology (n=34), but not in control pregnant women (n=15) or after delivery in women without PPH (n=18). The concomitant immunohistochemical detection of meconium in myometrium suggests that amniotic fluids or fetal materials are one of the candidates for inducing maternal local immune activation in the PPH of unknown etiology. Postpartum acute myometritis in the absence of an infective etiology may be a histological characteristic of PPH of unknown etiology.

Recombinant human FVIIa for reducing the need for invasive second-line therapies in severe refractory postpartum hemorrhage: a multicenter, randomized, open controlled trial

BACKGROUND

Case reports on recombinant human factor VIIa (rhuFVIIa) use in women with severe postpartum hemorrhage (PPH) showed encouraging results, but no randomized controlled trial (RCT) is available.

PATIENTS AND METHODS

Eighty-four women with severe PPH unresponsive to uterotonics were randomized to receive one early single rhuFVIIa infusion (n = 42) or standard care (no rhuFVIIa; n = 42). The primary efficacy outcome measure was the reduction of the need for specific second-line therapies, such as interventional hemostatic procedures, for blood loss and transfusions. The primary safety outcome measure was the number of deaths and thrombotic events during the 5 days following rhuFVIIa infusion.

RESULTS

rhuFVIIa was associated with a reduction in the number of patients who needed second-line therapies compared with controls (standard care). Specifically, 39/42 (93%) patients in the standard care arm received second-line therapies and 22/42 (52%) patients in the rhuFVIIa arm (absolute difference, 41%; range, 18-63%; relative risk RR, 0.56 [0.42-0.76]). The delivery mode (vaginal or Cesarean section) did not affect the primary outcome. No death occurred. Two venous thrombotic events were recorded in the rhuFVIIa arm: one ovarian vein thrombosis and one deep vein thrombosis with a non-severe pulmonary embolism.

CONCLUSION

This open RCT in women with severe PPH refractory to uterotonics shows that rhuFVIIa reduces the need for specific second-line therapies in about one in three patients, with the occurrence of non-fatal venous thrombotic events in one in 20 patients.

Cost-effectiveness of the non-pneumatic anti-shock garment (NASG): evidence from a cluster randomized controlled trial in Zambia and Zimbabwe

BACKGROUND

Obstetric hemorrhage is the leading cause of maternal mortality, particularly in low resource settings where delays in obtaining definitive care contribute to high rates of death. The non-pneumatic anti-shock garment (NASG) first-aid device has been demonstrated to be highly cost-effective when applied at the referral hospital (RH) level. In this analysis we evaluate the incremental cost-effectiveness of early NASG application at the Primary Health Center (PHC) compared to later application at the RH in Zambia and Zimbabwe.

METHODS

We obtained data on health outcomes and costs from a cluster-randomized clinical trial (CRCT) and participating study hospitals. We translated health outcomes into disability-adjusted life years (DALYs) using standard methods. Econometric regressions estimated the contribution of earlier PHC NASG application to DALYs and costs, varying geographic covariates (country, referral hospital) to yield regression models best fit to the data. We calculated cost-effectiveness as the ratio of added costs to averted DALYs for earlier PHC NASG application compared to later RH NASG application.

RESULTS

Overall, the cost-effectiveness of early application of the NASG at the primary health care level compared to waiting until arrival at the referral hospital was $21.78 per DALY averted ($15.51 in added costs divided by 0.712 DALYs averted per woman, both statistically significant). By country, the results were very similar in Zambia, though not statistically significant in Zimbabwe. Sensitivity analysis suggests that results are robust to a per-protocol outcome analysis and are sensitive to the cost of blood transfusions.

CONCLUSIONS

Early NASG application at the PHC for women in hypovolemic shock has the potential to be cost-effective across many clinical settings. The NASG is designed to reverse shock and decrease further bleeding for women with obstetric hemorrhage; therefore, women who have received the NASG earlier may be better able to survive delays in reaching definitive care at the RH and recover more quickly from shock, all at a cost that is highly acceptable.

Contribution of antepartum and intrapartum hemorrhage to the burden of maternal near miss and death in a national surveillance study

OBJECTIVE

To evaluate the occurrence of severe obstetric complications associated with antepartum and intrapartum hemorrhage among women from the Brazilian Network for Surveillance of Severe Maternal Morbidity.

DESIGN

Multicenter cross-sectional study.

SETTING

Twenty-seven obstetric referral units in Brazil between July 2009 and June 2010.

POPULATION

A total of 9555 women categorized as having obstetric complications.

METHODS

The occurrence of potentially life-threatening conditions, maternal near miss and maternal deaths associated with antepartum and intrapartum hemorrhage was evaluated. Sociodemographic and obstetric characteristics and the use of criteria for management of severe bleeding were also assessed in these women.

MAIN OUTCOME MEASURES

The prevalence ratios with their respective 95% confidence intervals adjusted for the cluster effect of the design, and multiple logistic regression analysis were performed to identify factors independently associated with the occurrence of severe maternal outcome.

RESULTS

Antepartum and intrapartum hemorrhage occurred in only 8% (767) of women experiencing any type of obstetric complication. However, it was responsible for 18.2% (140) of maternal near miss and 10% (14) of maternal death cases. On multivariate analysis, maternal age and previous cesarean section were shown to be independently associated with an increased risk of severe maternal outcome (near miss or death).

CONCLUSION

Severe maternal outcome due to antepartum and intrapartum hemorrhage was highly prevalent among Brazilian women. Certain risk factors, maternal age and previous cesarean delivery in particular, were associated with the occurrence of bleeding.

Manual removal of the placenta after vaginal delivery: an unsolved problem in obstetrics

The third stage of labor is associated with considerable maternal morbidity and mortality. The major complication is postpartum hemorrhage (PPH), which is the leading cause of maternal morbidity and mortality worldwide. Whereas in the event of PPH due to atony of the uterus there exist numerous treatment guidelines; for the management of retained placenta the general consensus is more difficult to establish. Active management of the third stage of labour is generally accepted as standard of care as already its duration is contributing to the risk of PPH. Despite scant evidence it is commonly advised that if the placenta has not been expelled 30 minutes after delivery, manual removal of the placenta should be carried out under anaesthesia. Pathologic adhesion of the placenta in the low risk situation usually is diagnosed at the time of delivery; therefore a pre- or intrapartum screening opportunity for placenta accreta would be desirable. But diagnosis of abnormalities of placentation other than placenta previa remains a challenge. Nevertheless the use of ultrasound and doppler sonography might be helpful in the third stage of labor. An improvement might be the implementation of standardized operating procedures for retained placenta which could contribute to a reduction of maternal morbidity.

[An update of the obstetrics hemorrhage treatment protocol]

Obstetric hemorrhage is still a major cause of maternal and fetal morbimortality in developed countries. This is an underestimated problem, which usually appears unpredictably. A high proportion of the morbidity of obstetric hemorrhage is considered to be preventable if adequately managed. The major international clinical guidelines recommend producing consensus management protocols, adapted to local characteristics and keep them updated in the light of experience and new scientific publications. We present a protocol updated, according to the latest recommendations, and our own experience, in order to be used as a basis for those anesthesiologists who wish to use and adapt it locally to their daily work. This last aspect is very important to be effective, and is a task to be performed at each center, according to the availability of resources, personnel and architectural features.

Severe postpartum hemorrhage from uterine atony: a multicentric study

Objective. Postpartum hemorrhage (PPH) is an important cause of maternal mortality (MM) around the world. Seventy percent of the PPH corresponds to uterine atony. The objective of our study was to evaluate multicenter PPH cases during a 10-month period, and evaluate severe postpartum hemorrhage management. Study Design. The study population is a cohort of vaginal delivery and cesarean section patients with severe postpartum hemorrhage secondary to uterine atony. The study was designed as a descriptive, prospective, longitudinal, and multicenter study, during 10 months in 13 teaching hospitals. Results. Total live births during the study period were 124,019 with 218 patients (0.17%) with severe postpartum hemorrhage (SPHH). Total maternal deaths were 8, for mortality rate of 3.6% and a MM rate of 6.45/100,000 live births (LB). Maternal deaths were associated with inadequate transfusion therapy. Conclusions. In all patients with severe hemorrhage and subsequent hypovolemic shock, the most important therapy is intravascular volume resuscitation, to reduce the possibility of target organ damage and death. Similarly, the current proposals of transfusion therapy in severe or massive hemorrhage point to early transfusion of blood products and use of fresh frozen plasma, in addition to packed red blood cells, to prevent maternal deaths.

Trends in the rates of peripartum hysterectomy and uterine artery embolization

The objective of this study was to determine the trends in national rates of peripartum hysterectomy (PH) and uterine arterial embolization (UAE) in Korea. We used data collected by the Health Insurance Review & Assessment Service of Korea and analyzed data from patients who gave birth during the period from 2005 to 2008. There were 1785,178 deliveries during the study period, including 2636 cases of PH (1.48 per 1000 deliveries). The PH rate in 2005 was 1.57 per 1000 deliveries and in 2008 it was 1.33 per 1000 deliveries. UAE was performed in 161 women (incidence, 0.38 per 1000 deliveries) and 447 women (incidence, 0.98 per 1000 deliveries) in 2005 and 2008, respectively. In Korea, the rate of PH decreased slightly, while the rate of UAE rate increased dramatically during the period from 2005 to 2008. Further studies are needed to evaluate the effects of UAE on the rate of PH performed.

A local hemostatic agent for the management of postpartum hemorrhage due to placenta previa and placenta accreta: a cross-sectional study

PURPOSE

To describe the use of a local hemostatic agent (LHA) for the management of postpartum hemorrhage (PPH) due to bleeding of the placental bed in patients taken to caesarean section at Fundación Santa Fe de Bogotá University Hospital.

SAMPLE

A total of 41 pregnant women who had a caesarean section and developed PPH.

METHODS

A cross-sectional study. Analysis of all cases of PPH during caesarean section presented from 2006 up to and including 2012 at Fundación Santa Fe de Bogotá University Hospital.

MAIN OUTCOME MEASURE

Emergency hysterectomy due to PPH.

RESULTS

The proportion of hysterectomies was 5 vs. 66 % for the group that received and did not receive management with a LHA respectively (PR 0.07, CI 95 % 0.01-0.51 p < 0.01). For the group managed without a LHA, 80 % of patients needed hemoderivatives transfusion vs. 20 % of patients in the group managed with a LHA (PR 0.24, CI 95 % 0.1-0.6 p < 0.01). A reduction in the mean days of hospitalization in addition to a descent in the proportion of patients admitted to the intensive care unit (ICU) was noticed when comparing the group that received a LHA versus the one that did not.

CONCLUSION

An inverse association between the use of a LHA in patients with PPH due to bleeding of the placental bed and the need to perform an emergency obstetric hysterectomy was observed. Additionally there was a significant reduction in the mean duration of hospital stay, use of hemoderivatives and admission to the ICU.

[General anaesthesia and obstetric bleeding in caesarean section. One year's experience in a university hospital]

INTRODUCTION

Obstetric haemorrhage is an important worldwide cause of morbidity and mortality. General anaesthesia for caesarean section is rarely used. Our goal is to analyse the incidence, causes and risk factors associated with general anaesthesia for caesarean section, and the prevalence of obstetric haemorrhage (HO), its risk factors and predictors of post-caesarean HO together with the use of blood in our hospital population.

METHODS

A retrospective study was conducted on all caesarean section discharge reports from PACU in 2008.

RESULTS

General anaesthesia was required in 12.4% of the patients. Epidural catheter failure as a cause of general anaesthesia was infrequent (2.8%) and within the recommended standards.

CONCLUSIONS

The most frequent indications for caesarean section under general anaesthesia included mainly life-threatening emergencies, and the most important risk factors for general anaesthesia, including coagulation disorders, bleeding in the third trimester, foetal distress and severe pre-eclampsia. General anaesthesia is a risk factor for transfusion, as is abruptio placentae, placenta previa and pre-eclampsia.

Uterine healing after therapeutic intrauterine administration of TachoSil (hemostatic fleece) in cesarean section with postpartum hemorrhage caused by placenta previa

Background. Application of hemostatic fleece (TachoSil) directly onto the bleeding surfaces of the lower uterine segment has been used to obtain hemostasis during cesarean section caused by placenta previa. Methods. Eleven of 15 patients treated with TachoSil for excessive postpartum haemorrhage due to placenta previa were enrolled. An evaluation of the cesarean section scar by transvaginal ultrasound, the uterine cavity and endometrium by hysteroscopy, and the endometrium by biopsy were made. The main outcome measures were intrauterine adhesions, recovery of endometrium at the site of TachoSil application, visible remnants of TachoSil, and scar healing. Results. Eight patients had small remnants of TachoSil in the uterine cavity together with signs of resorption. All had a normal endometrial mucosa, and none had adhesions in the uterine cavity. All cesarean section scars were healed without defects. Conclusion. TachoSil did not seem to impair healing of the endometrium or scar formation in the uterus after intrauterine application. Resorption of TachoSil seems to progress individually. Intrauterine treatment with TachoSil is a valuable supplement to the traditional treatment of post partum haemorrhage and may help retain reproductive capability. This is a small study, and it will require more studies to confirm the reproducibility.

Transfusion practice in major obstetric haemorrhage: lessons from trauma

The management of massive haemorrhage with blood products is changing as evidence arrives from civilian and military trauma. Rapid early replacement of coagulation factors and platelets is now becoming central to improving outcome, usually given in higher ratios with respect to red cell units than previously recommended and using empiric transfusion based on clinical rather than laboratory parameters. The management of three cases of major obstetric haemorrhage based on these principles is presented. Packed red blood cells, fresh frozen plasma, platelets and cryoprecipitate were transfused in the ratios 5:2:2:1, 4.5:1:1:1 and 4.5:2:1:1. Each patient had acceptable full blood count and coagulation results after surgery and all made an uneventful recovery. These outcomes support the opinion that major obstetric haemorrhage can be managed in a similar fashion to blood loss in trauma. Recommendations from the Association of Anaesthetists of Great Britain and Ireland, and the UK National Patient Safety Agency should be considered during major obstetric haemorrhage.

Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment

OBJECTIVE

The purpose of this study was to evaluate the efficiency and morbidity of multiple square sutures in severe postpartum hemorrhage.

STUDY DESIGN

A retrospective study encompassed 30 multiple square sutures that were performed for severe postpartum hemorrhage in 26,605 deliveries in a tertiary maternity center. The main outcome measures were the ability to stop hemorrhage and the assessment of the uterine cavity by hysteroscopy at 3 months.

RESULTS

Multiple square sutures stopped postpartum hemorrhage in 28 of 30 cases (93%). Twenty women underwent hysteroscopy after multiple square sutures. Eight women (40%) did not have intrauterine adhesions. Nine women (45%) had thin and localized intrauterine adhesions that were removed easily by the tip of the hysteroscope; 2 women had moderate intrauterine adhesions that were resected. One patient had endometritis followed by severe intrauterine adhesions.

CONCLUSION

Multiple square sutures are effective and safe for the control of severe postpartum hemorrhage and for uterine conservation in most cases. Although some patients had moderate or severe adhesions, a normal uterine cavity or minimal intrauterine adhesions that were removed easily were the most frequent findings at hysteroscopy. A prospective study may be helpful to compare the safety and efficiency of square and brace sutures.

The management of the critically ill obstetric patient

Hypertensive disorders, postpartum hemorrhage, and sepsis are the most common indications for intensive care unit admission among obstetric patients. In general, ICU mortality is low, and better than would be predicted using available mortality prediction tools. Provision of care to this special population requires an intimate understanding of physiologic changes that occur during pregnancy. Clinicians must be aware of the way various diagnostic and treatment choices can affect the mother and fetus. Most clinically necessary radiographic tests can be safely performed and fall under the maternal radiation exposure limit of less than 0.05 Gray (Gy). Careful attention must be paid to acid-base status, oxygenation, and ventilation when faced with respiratory failure necessitating intubation. Cesarean delivery can be justified after 4 minutes of cardiac arrest and may improve fetal and maternal outcomes. The treatment of obstetric patients in the ICU introduces complexities and challenges that may be unfamiliar to many critical care physicians; teamwork and communication with obstetricians is crucial.

[Post-partum haemorrhage in delivery room: anaesthetists' practioner in Auvergne]

OBJECTIVE

To assess the management of post-partum haemorrhage (PPH) in delivery rooms by the anaesthetists of the Auvergne region.

STUDY DESIGN

Cross sectional study.

METHODS

An anonymous postal survey was sent to all the anaesthetists working in a public or private hospital with a maternity unit.

RESULTS

The response rate was about 70 %. Eight percent of the respondents never practiced in obstetrics; others all declared to have managed PPH at least once. Only 66 % declared to know the right definition of PPH, 98 % declared to have guidelines in the delivery room, 87 % to use graduate blood receipt pockets, 85 % to work under midwives-directed delivery at expulsion, 88 % to have a HemoCue™ system. More than 80 % declared to use first oxytocin and to switch for prostaglandins in case of failure, to put two venous catheters and a urinary catheter, to administer broad-spectrum prophylactic antibiotic and to draw a blood sample for early biology. Packed red cells, platelets and fresh frozen plasma were accessible in less than 30 minutes for 98 %. Transfusion guidelines were applied. Only 27 % could have arterial radiologic embolisation on site. The knowledge about PPH and its consensual care tended to be poorer in practitioners from the university hospital, and younger under 40 also.

CONCLUSION

This survey, with a good response rate, showed a practice generally fitting to the guidelines, although with some failures depending on the practioner's age and type of hospital.

High-dose tranexamic acid reduces blood loss in postpartum haemorrhage

Introduction

Our purpose in conducting this study was to determine whether administration of high-dose tranexamic acid (TA) at the time of diagnosis of postpartum haemorrhage (PPH) could reduce blood loss.

Methods

This was a randomised, controlled, multicentred, open-label trial. Women with PPH >800 mL following vaginal delivery were randomly assigned to receive TA (loading dose 4 g over 1 hour, then infusion of 1 g/hour over 6 hours) or not. In both groups, packed red blood cells (PRBCs) and colloids could be used according to French guidelines. The use of additional procoagulant treatments was permitted only in cases involving intractable bleeding. The primary objective was to assess the efficacy of TA in the reduction of blood loss in women with PPH, and the secondary objectives were the effect of TA on PPH duration, anaemia, transfusion and the need for invasive procedures.

Results

A total of 144 women fully completed the protocol (72 in each group). Blood loss between enrolment and 6 hours later was significantly lower in the TA group than in the control group (median, 173 mL; first to third quartiles, 59 to 377) than in controls (221 mL; first to third quartiles 105 to 564) (P = 0.041). In the TA group, bleeding duration was shorter and progression to severe PPH and PRBC transfusion was less frequent than in controls (P < 0.03). Invasive procedures were performed in four women in the TA group and in seven controls (P = NS). PPH stopped after only uterotonics and PRBC transfusion in 93% of women in the TA group versus 79% of controls (P = 0.016). Mild, transient adverse manifestations occurred more often in the TA group than in the control group (P = 0.03).

Conclusions

This study is the first to demonstrate that high-dose TA can reduce blood loss and maternal morbidity in women with PPH. Although the study was not adequately powered to address safety issues, the observed side effects were mild and transient. A larger international study is needed to investigate whether TA can decrease the need for invasive procedures and reduce maternal morbidity in women with PPH.

Trial registration

Controlled Trials ISRCTN09968140.

Trends in maternal mortality due to obstetric hemorrhage in urban and rural China, 1996-2005

OBJECTIVE

To analyze the characteristics and trends of maternal deaths due to obstetric hemorrhage in urban and rural areas during the period of 1996-2005 in China, and to provide evidence for decision-making for further reducing the national maternal mortality ratio (MMR).

METHODS

We analyzed national maternal mortality data collected from the Maternal and Child Health Surveillance System of China.

RESULTS

The decline of MMR due to obstetric hemorrhage contributed to 91.98% of the overall MMR decline. The adjusted average annual decline rate (AADR) of MMR due to obstetric hemorrhage was 7.30% in rural areas and 2.07% in urban areas. The maternal deaths due to postpartum hemorrhage accounted for the vast majority of maternal deaths due to hemorrhage, and the adjusted AADR was higher in rural areas (7.45%) than in urban areas (1.56%).

CONCLUSION

Although the risk of maternal deaths from hemorrhage decreased substantially, the gap between urban and rural areas is obvious. Efforts to lower MMR should focus on obstetric hemorrhage, especially postpartum hemorrhage, in rural areas. It is recommended that policy-makers should focus on improving the accessibility to and quality of obstetric service in rural areas.

Use of clotting factors and other prohemostatic drugs for obstetric hemorrhage

PURPOSE OF REVIEW

To guide the optimal use of blood products and to clarify the indications for prohemostatic drugs in obstetric hemorrhage.

RECENT FINDINGS

The literature emphasizes the usefulness of transfusing packed red blood cells, fresh frozen plasma and platelets earlier and in defined ratios to prevent dilutional coagulopathy during obstetric hemorrhage. The value of fibrinogen concentrate and prohemostatic drugs such as tranexamic acid and recombinant factor VIIa is also pointed out.

SUMMARY

It seems reasonable to use blood products for transfusion earlier and in a 1: 1 fresh frozen plasma: red blood cell ratio during acute obstetric hemorrhage; however, this analysis is mainly based on trauma literature. Fibrinogen concentrate should be added if the fibrinogen plasma level remains below 1.0 g l(-1) and perhaps even as soon as it falls below 1.5-2.0 g l(-1); the addition of tranexamic acid (1 g) is cheap, likely to be useful and appears safe. Data on the proactive administration of platelets are insufficient to recommend this practice routinely. Presently, recombinant factor VIIa (60-90 microg kg(-1)) is advocated only after failure of other conventional therapies, including embolization or conservative surgery, but prior to obstetric hysterectomy. Prospective randomized controlled trials are highly desirable.

Exploring the role of uterine artery embolization in the management of postpartum hemorrhage

Postpartum hemorrhage is a potentially life-threatening obstetric emergency that requires prompt nursing and medical interventions. In the majority of cases, initial strategies such as fundal massage and uterotonic medications will effectively stop excessive bleeding. Unfortunately, the incidence and severity of postpartum hemorrhage are on the rise and peripartum hysterectomy remains a life-saving intervention in cases of intractable bleeding. As an emerging alternative to hysterectomy, uterine artery embolization (UAE) has demonstrated success rates of more than 90% in controlling postpartum hemorrhage unresponsive to other therapies. Research to date has shown UAE to be a safe, minimally invasive procedure with few reported complications and minimal effects on future fertility. For patients who are hemodynamically stable with access to an interventional radiology suite, UAE is an important consideration in the treatment of severe postpartum bleeding. This article explores the role of UAE as a part of this management algorithm. The technical aspects of this procedure, reported complications, and effects on future fertility are described. The prophylactic use of intra-arterial balloon catheters in the management of abnormal placentation is also discussed.

[Abruptio placentae]

Retroplacental haematoma (RPH) is a complication affecting 0.25 to 0.4% of all pregnancies and 4% of severe PEs. It is of acute onset, usually unpredictable and its symptoms are not specific: Isolated metrorrhagia, foetal distress, uterine hypertonicity. Clinical, biological and sonographic features suggesting a RPH can be early or late. Haemoconcentration and the forming of notches on Doppler examination of the uterus can appear weeks before the event, whereas raised D-Dimers and foetal tachycardia are identified within days of the event. Although Caesarian section reduces the perinatal death rate by 20 to 50% in a setting of RPH with a live foetus, vaginal delivery is indicated in cases of RPH with fetal demise, following the control of haemorrhagic shock, clotting disorders and uterine hypotonicity.

Factors associated with peripartum hysterectomy

OBJECTIVE

To identify factors associated with peripartum hysterectomy performed within 30 days postpartum.

METHODS

This was a population-based case-control study using Washington State birth certificate registry (1987-2006) linked to the Comprehensive Hospital Abstract Reporting System. Cases underwent hysterectomy within 30 days postpartum. Controls were frequency matched 4:1. Exposures included factors related to hemorrhage, delivery method, multiple gestations, and infection. Incidence rates of peripartum hysterectomy and maternal and neonatal morbidity and mortality were assessed. Adjusted odds ratios (aORs) by maternal age, parity, gestational age, year of birth, and mode of delivery and 95% confidence intervals (CIs) were computed.

RESULTS

There were 896 hysterectomies. Incidence rates ranged from 0.25 in 1987 to 0.82 per 1,000 deliveries in 2006 (chi for trend, P<.001). Factors related to hemorrhage were strongly related to peripartum hysterectomy. Placenta previa (192 cases compared with 23 controls; aOR 7.9, 95% CI 4.1-15.0), abruptio placenta (71 compared with 55; aOR 3.2, 95% CI 1.8-5.8), and retained placenta (214 compared with 28; aOR 43.0, 95% CI 19.0-97.7) increased the risk of hysterectomy, as did uterine atony, uterine rupture, and thrombocytopenia. Having multiple gestations did not. As compared with vaginal delivery, vaginal delivery after cesarean (27 cases compared with 105 controls; aOR 1.9, 95% CI 1.2-3.0), primary cesarean (270 compared with 504; aOR 4.6, 95% CI 3.5-6.0), and repeat cesarean (296 compared with 231; aOR 7.9, 95% CI 5.8-10.7) increased the risk of peripartum hysterectomy. Among the 111 women who had hysterectomy on readmission (12.8% of cases), hemorrhage- and infection-related factors were still strongly associated with peripartum hysterectomy.

CONCLUSION

Incidence rates of peripartum hysterectomy are increasing over time. The most important risk factor for peripartum hysterectomy is hemorrhage, most notably caused by uterine rupture, retained placenta, and atony of uterus.

LEVEL OF EVIDENCE

II.