Maternal morbidity associated with placenta praevia among women who had elective caesarean section

Magnetic Resonance Imaging-Based Radiomics Nomogram to Predict Intraoperative Hemorrhage of Placenta Previa

OBJECTIVE

Placenta previa (PP) is associated with intraoperative and postpartum hemorrhage, increased maternal morbidity and mortality. We aimed to develop a magnetic resonance imaging (MRI)-based nomogram to preoperative prediction of intraoperative hemorrhage (IPH) for PP.

STUDY DESIGN

A total of 125 PP pregnant women were divided into a training set (n = 80) and a validation set (n = 45). An MRI-based model was built for the classification of patients into IPH and non-IPH groups in a training set and a validation set. Multivariate nomograms were built according to radiomics features. Receiver operating characteristic (ROC) curve was used to assess the model. Predictive accuracy of nomogram were assessed by calibration plots and decision curve analysis.

RESULTS

In multivariate analysis, placenta position, placenta thickness, cervical blood sinus, and placental signals in the cervix were significantly independent predictors for IPH (all ps < 0.05). The MRI-based nomogram showed favorable discrimination between IPH and non-IPH groups. The calibration curve showed good agreement between the estimated and the actual probability of IPH. Decision curve analysis also showed a high clinical benefit across a wide range of probability thresholds. Area under the ROC curve was 0.918 (95% confidence interval [CI]: 0.857-0.979) in the training set and 0.866 (95% CI: 0.748-0.985) in the validation set by the combination of four MRI features.

CONCLUSION

The MRI-based nomograms might be a useful tool for the preoperative prediction of IPH outcomes for PP. Our study enables obstetricians to perform adequate preoperative evaluation to reduce blood loss and cesarean hysterectomy.

KEY POINTS

· MRI is an important method for preoperative assessment of the risk of placenta previa.. · MRI-based nomogram can assess the risk of intraoperative bleeding of placenta previa.. · MRI is helpful for more comprehensive evaluation of placenta previa and adequate preoperative preparation..

Risk factors and perinatal outcomes for persistent placenta previa in nulliparas

BACKGROUND

Placenta previa diagnosed on midtrimester ultrasound often resolves by the third trimester. Multiparity and previous cesarean delivery have been associated with persistence of placenta previa at delivery. Risk factors for persistent placenta previa in nulliparas are not well characterized.

OBJECTIVE

This study aimed to identify risk factors for persistent placenta previa in the nulliparous population, and evaluate differences in outcomes between persistent and resolved placenta previa.

STUDY DESIGN

This was a secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b), a prospective cohort study that observed 10,037 nulliparous individuals throughout pregnancy. Nulliparas diagnosed with placenta previa on midtrimester ultrasound were included in this analysis. Baseline characteristics and delivery outcomes of nulliparas with persistent placenta previa were compared with those of nulliparas with resolved placenta previa. Multivariate logistic regression with stepwise model selection was used for adjusted analyses.

RESULTS

A total of 171 nulliparas (1.7%) in the nuMoM2b study were diagnosed with placenta previa on midtrimester ultrasound, of whom 17% (n=29) had persistent placenta previa at delivery. When compared with those with resolved placenta previa, nulliparas with persistent placenta previa were more likely to be older (median, 32 years [interquartile range, 30-37] vs 29 years [interquartile range, 25-31]; P<.01), have a previous pregnancy of <20 weeks (48.3% vs 22.5%; P=.01), have a previous dilation and curettage/evacuation procedure (27.6% vs 10.6%; P=.03), or have a pregnancy that resulted from assisted reproductive technology (31% vs 4.9%; P=.01). After adjusting for potential confounders, maternal age (adjusted odds ratio, 1.11; 95% confidence interval, 1.02-1.21), in vitro fertilization (adjusted odds ratio, 9.00; 95% confidence interval, 1.97-41.14), and previous pregnancy of <20 weeks (adjusted odds ratio, 2.77; 95% confidence interval, 1.10-6.95) remained statistically significant risk factors for persistent placenta previa. Persistent placenta previa was also associated with higher likelihood of antepartum admission (10.3% vs 0%; P<.01), preterm delivery (34.5% vs 12%; P<.01), lower neonatal birthweight (median, 2847 g [interquartile range, 2655-3310] vs 3263 g [interquartile range, 2855-3560]), and cesarean delivery (100% vs 20.4%; P<.001), but there were no differences in overall pregnancy or neonatal outcomes.

CONCLUSION

In nulliparous individuals diagnosed with placenta previa on midtrimester ultrasound, older maternal age, previous pregnancy of <20 weeks, and in vitro fertilization are associated with persistent placenta previa at delivery.

A unique placenta previa risk factor profile for pregnancies conceived with assisted reproductive technology

OBJECTIVE

To define specific risk factors for placenta previa in pregnancies conceived with assisted reproductive technology (ART).

DESIGN

Retrospective cohort.

SETTING

Fertility centers and inpatient obstetric units in Massachusetts.

PATIENT(S)

Patients conceiving with ART and delivering at 20 weeks gestation or later between 2011 and 2017 in Massachusetts.

INTERVENTION(S)

Patient demographic and medical factors and specific components of their cycles. Data were obtained by linking vital records of the State of Massachusetts to reproductive clinic data obtained from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System, and then supplementing this information with laboratory and obstetric data from 2 large academic hospitals.

MAIN OUTCOME MEASURE

Associations were tested between multiple cycle- and patient-related factors and placenta previa or low-lying placenta at delivery. After testing for confounders, multivariate models were adjusted for maternal age, history of prior cesarean delivery and birth plurality, and are reported as adjusted relative risks (aRR).

RESULT(S)

We included 18,939 pregnancies, with 553 (2.9%) having placenta previa at delivery. Advanced maternal age (aRR, 1.25; 95% confidence interval [CI], 1.06-1.48), endometriosis, (aRR, 2.22; 95% CI, 1.71-2.86), and controlled ovarian hyperstimulation (aRR, 1.33; 95% CI, 1.12-1.59) were associated with placenta previa, whereas multiple births (aRR, 0.63; 95% CI, 0.48-0.81) and a history of polycystic ovary syndrome or ovulation disorders (aRR, 0.59; 95% CI, 0.46-0.75) had negative associations. The endometriosis association was strong in nulliparas and the controlled ovarian hyperstimulation association was strong in parous patients in a stratified analysis. No association was seen with prior history of cesarean delivery.

CONCLUSION(S)

Patients conceiving with ART do not have the typical previa risk factors of prior cesarean delivery and multiple gestations, whereas endometriosis and fresh embryo transfers contributed moderate risk. The embryo transfer process itself may affect previa development in this population.

Cervical tourniquet during cesarean section to reduce bleeding in morbidly adherent placenta: a pilot study

Objective:

To evaluate a modified surgical technique aiming to reduce bleeding and preserve fertility in morbidly adherent placenta by cervical tourniquet in cesarean sections.

Methods:

The cesarean section operations and the cervical ligation approach were performed by a single expert consultant obstetrician. The general demographics and clinical characteristics for all participants were collected and studied.

Results:

Eleven participants were involved. The uterus was preserved in nine patients, whereas two patients had hysterectomy. The mean blood loss was 1688.8 ml for patients whose uterus was preserved. The mean length of stay was 5.5 days.

Conclusion:

Cervical ligation is a simple method that can be applied by junior and experienced obstetricians to preserve the uterus.

Placenta accreta is the abnormal adhesion of placenta into the uterine wall. It carries a significant risk for hysterectomy, intrapartum and postpartum hemorrhage, and maternal morbidity and mortality. As the preservation of fertility and femininity is desired by many women, numerous methods were adapted to avoid hysterectomy in patients with placenta accreta. In this study, we describe and evaluate a novel technique to preserve the uterus by ligating the cervix with a Foley catheter.

Fetal and Maternal Outcomes in Women With Major Placenta Previa Among Sudanese Women: A Prospective Cross-Sectional Study

Background

Placenta previa is a major obstetric problem with high rates of fetomaternal mortality and morbidity. This study aimed to determine the prevalence and fetal and maternal outcomes of major degree placenta previa among Sudanese women.

Method

This is a prospective descriptive study conducted in the period from January 1 to June 30, 2109, at Omdurman Maternity Hospital, Khartoum, Sudan. Fetal and maternal complications associated with major degree placenta were analyzed using descriptive statistics.

Results

The total number of deliveries was 22,000, of which 87 cases were of major degree placenta previa, giving a prevalence rate of 0.4%, the hysterectomies rate was 23% (n= 20), and the total maternal deaths were 6.9% (n= 6). Intraoperative interventions used to control the bleeding were multiple hemostatic sutures in 34.5% (n=30) of cases, followed by uterine backing (20.7%; n= 18), and uterine artery ligation (12.6%; n=11). The common reported maternal complications were bladder injuries (28.7%; n= 25) followed by bowel injuries (4.6%; n=5). Of all mothers, 48.27% (n=42) were admitted to the intensive care unit (ICU). Of all deliveries, 26.4% (n=23) were preterm, and 38% (n=33) of neonates were admitted to the newborn intensive care unit (NICU), and 9.2% (n=8) were fresh stillbirth (FSB).

Conclusion

Neonatal complications were comparable to other studies but maternal deaths were relatively high. The study indicated the need for effective management protocols and more training of the medical staff in order to overcome the problem.

Caesarean Section on Maternal Request: An Italian Comparative Study on Patients' Characteristics, Pregnancy Outcomes and Guidelines Overview

In recent years, the rate of caesarean sections has risen all over the world. Accordingly, efforts are being made worldwide to understand this trend and to counteract it effectively. Several factors have been identified as contributing to the selection of caesarean section (CS), especially an obstetricians' beliefs, attitudes and clinical practices. However, relatively few studies have been conducted to understand the mechanisms involved, to explore influencing factors and to clearly define the risks associated with the caesarean section on maternal request (CSMR). This comparative study was conducted to elucidate the factors influencing the choice of CSMR, as well as to compare the associated risks of CSMR to CS for breech presentation among Italian women. From 2015 to 2018, a total of 2348 women gave birth by caesarean section, of which 8.60% (202 women) chose a CSMR. We found that high educational attainment, use of assisted reproductive technology, previous operative deliveries and miscarriages within the obstetric history could be positively correlated with the choice of CSMR in a statistically significant way. This trend was not confirmed when the population was stratified based on patients' characteristics, obstetric complications and gestational age. Finally, no major complications were found in patients that underwent CSMR. We believe that it is essential to evaluate patients on a case-by-case basis. It is essential to understand the personal experience, to explain the knowledge available on the subject and to ensure a full understanding of the risks and benefits of the medical practice to guarantee the patients not only their best scientific preparation but also human understanding.

Neonatal and Maternal Complications of Placenta Praevia and Its Risk Factors in Tikur Anbessa Specialized and Gandhi Memorial Hospitals: Unmatched Case-Control Study

Background

Placenta praevia is a disorder that happens during pregnancy when the placenta is abnormally placed in the lower uterine segment, which at times covers the cervix. The incidence of placenta praevia is 3-5 per 1000 pregnancies worldwide and is still rising because of increasing caesarean section rates.

Objective

To assess and identify the risk factors and maternal and neonatal complications associated with placenta praevia. Method and Materials. Target populations for this study were all women diagnosed with placenta praevia transvaginally or transabdominally either during the second and third trimesters of pregnancy or intraoperatively in Tikur Anbessa Specialized and Gandhi Memorial Hospitals. The study design was unmatched case-control study. Data was carefully extracted from medical records, reviewed, and analyzed. Unconditional logistic regression analysis was performed using adjusted odds ratios (AOR) with 95% confidence intervals.

Results

Pregnancies complicated by placenta praevia were 303. Six neonatal deaths were recorded in this study. The magnitude of placenta praevia observed was 0.7%. Advanced maternal age (≥35) (AOR 6.3; 95% CI: 3.20, 12.51), multiparity (AOR 2.2; 95% CI: 1.46, 3.46), and previous history of caesarean section (AOR 2.7; 95% CI: 1.64, 4.58) had an increased odds of placenta praevia. Postpartum anemia (AOR 14.6; 95% CI: 6.48, 32.87) and blood transfusion 1-3 units (AOR 2.7; 95% CI: 1.10, 6.53) were major maternal complications associated with placenta praevia. Neonates born to women with placenta praevia were at increased risk of respiratory syndrome (AOR 4; 95% CI: 1.24, 13.85), IUGR (AOR 6.3; 95% CI: 1.79, 22.38), and preterm birth (AOR 8; 95% CI: 4.91, 12.90).

Conclusion

Advanced maternal age, multiparity, and previous histories of caesarean section were significantly associated risk factors of placenta praevia. Adverse maternal outcomes associated with placenta praevia were postpartum anemia and the need for blood transfusion. Neonates born from placenta praevia women were also at risk of being born preterm, intrauterine growth restriction, and respiratory distress syndrome.

Bilateral Internal Iliac Artery Ligation, a Rational Choice of Surgery in Placenta Previa, a Hospital-Based Retrospective Study on the Prevention of Hysterectomy and Control of Postpartum Hemorrhage

Background

Placenta previa is one condition, where the bleeding is from the thinned out lower segment, which faces difficulty in contracting as compared to the upper uterine segment. To combat postpartum hemorrhage and hysterectomy, there were various techniques adopted in obstetric practice. Here the aim is to study the bilateral internal iliac artery ligation (BIL) as a technique to minimize postpartum bleeding and preserve the uterus for future pregnancy.

Methods

This retrospective study was conducted in 31 patients with abnormal placentation. They underwent BIL during LSCS. The surgery was elective in non-bleeding patients and as an emergency in bleeding patients. The primary outcome is to minimize blood loss and postpartum blood transfusion. The secondary outcome is the prevention of hysterectomies after delivery and preservation of the uterus for the mother to have future pregnancies.

Results

Out of 31 women, 19 underwent elective surgery (61.3%) and 12 underwent emergency surgery (38.7%). Out of 12 emergency surgeries, 8 needed blood transfusion due to blood loss. Out of 19 elective surgeries, none required the blood transfusion. Blood transfusion was required in 50% of the patient in emergency BIL surgery, whereas none required blood transfusion in elective BIL surgery. Postpartum hysterectomy was avoided in all study participants except one elective surgery patient.

Conclusion

BIL surgery can be an effective procedure for handling high-risk obstetric hemorrhage in addition to the chances of future fertility through the preservation of uteri.

Prophylactic intraoperative uterine or internal iliac artery embolization in planned cesarean for pernicious placenta previa in the third trimester of pregnancy: An observational Study (STROBE compliant)

The aim of this study was to evaluate the efficacy and safety of prophylactic intraoperative bilateral uterine or internal iliac artery embolization in planned cesarean for pernicious placenta previa in the third trimester of pregnancy.The patients with pernicious placenta previa were retrospectively included from January 2011 to May 2018, being divided into embolization group and control group. Intraoperative uterine artery embolization (UAE) or internal iliac artery embolization (IIAE) was undertaken to stop intrapartum and postpartum hemorrhage in embolization group.There were no significant differences on age, pregnancy times, gestational age, neonatal weight, neonatal asphyxia, prenatal bleeding, placental implantation, and mortality between embolization group and control group (P > .05). The amount of intraoperative and postoperative bleeding in embolization group was significantly greater than that in control group (P < .05). However, the hysterectomy rate in the embolization group was significantly lower than that in the control group (P < .05). Two (6.25%, 2/32) cases had undergone the second time embolotherapy after 8 hours of cesarean surgery because of severe vaginal bleeding. One case (3.13%, 1/32) died of diffuse intravascular coagulation because of hemorrhagic shock in embolization group. Transient and self-remitted lumbosacral pain was present in 28 (95%, 28/32) patients and no other severe interventional complications were reported in embolization group. All babies in 2 groups were healthy at half to 5 years' follow-up.The prophylactic intraoperative embolization of bilateral UAE or IIAE may be an effective strategy to treat intractable peripartum hemorrhage and preserve the fertility in patients with pernicious placenta previa.

Associated factors of blood transfusion for Caesarean sections in pure placenta praevia pregnancies

INTRODUCTION

This study aimed to evaluate associated factors of blood transfusion for Caesarean sections in pure placenta praevia pregnancies.

METHODS

A case-control study was conducted among 405 pregnant women with placenta praevia who underwent Caesarean delivery between August 2004 and December 2013. 135 of the women received blood transfusions. Another 270 women who did not receive any blood transfusion were randomly selected and served as controls. Maternal demographic data, reproductive history, antepartum profiles and obstetric outcomes were compared between the two groups.

RESULTS

Women in the case group were significantly more likely to be multiparous, deliver at a gestational age of less than 37 weeks, have a prior Caesarean delivery, experience preoperative bleeding and anaemia, and have major and anterior placenta praevia (p < 0.05). Multivariate analysis demonstrated that significant, independently associated factors of blood transfusion were: previous Caesarean section (adjusted odds ratio [OR] 2.30, 95% confidence interval [CI] 1.36-3.90), anterior placenta praevia (adjusted OR 2.30, 95% CI 1.15-4.60), major placenta praevia (adjusted OR 2.39, 95% CI 1.34-4.22), preoperative bleeding of more than 250 mL (adjusted OR 6.11, 95% CI 2.35-15.90), preoperative anaemia (adjusted OR 2.31, 95% CI 1.34-4.00) and emergency Caesarean section (adjusted OR 2.14, 95% CI 1.08-4.22).

CONCLUSION

Previous Caesarean section, anterior placentation, major placenta praevia, preoperative bleeding of more than 250 mL, preoperative anaemia and emergency Caesarean section were independent factors that increased the risk of blood transfusion for Caesarean section in pure placenta praevia pregnancies.

Outcomes and Complications After Repeat Cesarean Sections Among King Abdulaziz University Hospital Patients

INTRODUCTION

Cesarean section (CS) is a surgical procedure that often saves the lives of both the mother and the baby, while a previous CS is one of the main indications for cesarean delivery in current pregnancy.

AIM

Our aim was to determine the surgical and obstetrical outcomes and complication for the mother and the neonate after 4 or more CSs and compare it with mothers who had less than 4 previous CSs.

METHODS

This case-control study was conducted by reviewing the records of all women who underwent multiple CSs from 2013 to 2018. Our study group comprised of 394 women who had 4 or more CSs, and our control group comprised of similar number of women who had previous history of two or three CSs.

RESULTS

A total of 788 patients were enrolled in our study. We found that adhesions were the most common complications in our study group with a considerable increase in number of both moderate and severe adhesions in the study group compared to the controls with p-value of <0.001.

CONCLUSION

Increasing number of CSs leads to an increase of the complications risk. Among the complications, adhesions were the most common in our study group, followed by intraoperative bleeding.

The effect of uterine artery ligation in patients with central placenta pevia: a randomized controlled trial

BACKGROUND

Placenta previa is major obstetric surgical risk as it is associated with higher percentage of intraoperative and postpartum hemorrhage (PPH), increased requirement of blood transfusion and further surgical procedures. The current study aimed to evaluate uterine artery ligation prior to uterine incision as a procedure to minimize blood loss during cesarean section in patients with central placenta previa.

METHODS

One hundred and four patients diagnosed with central placenta previa antenatally and planned to have elective caesarean section were recruited from the antenatal clinic at Minia Maternity University hospital. Patients were randomly allocated into either ligation group or control group.

RESULTS

Both groups were similar regarding demographic features and preoperative risk factors for bleeding. The intraoperative blood loss was significantly lower in the ligation group as compared with the control group (569.3 ± 202.1 mL vs. 805.1 ± 224.5 mL respectively, p = 0.002). There was a significant increase in the requirement for blood transfusion in the control group as compared with the ligation group (786 ± 83 mL vs. 755 ± 56 mL respectively, p = 0.03) Three cases in the control group required further surgical interventions to control intraoperative bleeding, while no cases in the ligation required further surgical techniques and that was statistically significant (p = 0.001).

CONCLUSION

Uterine artery ligation prior to uterine incision may be a helpful procedure to minimize intraoperative and postpartum blood loss in cases with central placenta previa.

TRIAL REGISTRATION

Retrospectively registered in ClinicalTrials.gov Identifier: NCT02002026 - December 8, 2013.

Complete Placenta Previa: Ultrasound Biometry and Surgical Outcomes

Objective  To evaluate the relationship between surgical outcomes and ultrasound measurement of placental extension beyond the cervical os in women with placenta previa. Study Design  This is a retrospective cohort study of singleton pregnancies with placenta previa undergoing third-trimester ultrasound and delivering at our institution from 2002 through 2011. For study purposes, an investigator measured placental extension, defined as the placental distance from the internal os across the placenta continuing out to the lowest placental edge. If morbidly adherent placentation was suspected, women were excluded. Receiver operating characteristic (ROC) curves were developed for pertinent surgical outcomes, and multivariate analysis was performed to determine the placental extension with the best predictive discriminatory zone. Results  In total, 157 women had placenta previa, ultrasound, and delivery data: 86 (55%) had a placental extension of <40 mm, and 71 (45%) had a placental extension of ≥40 mm. Women with placental extension of ≥40 mm had increased surgical time, blood loss > 2,000 mL, blood transfusion, and rate of peripartum hysterectomy. After multivariate analysis, only peripartum hysterectomy and surgical time > 90 minutes remained significant, p ≤ 0.05 and p ≤ 0.01, respectively. Conclusion  In women with placenta previa, the placental extension ultrasound measurement of ≥40 mm is a predictor of adverse surgical outcomes.

MRI findings of complications related to previous uterine scars

Although the World Health Organization suggests 10–15% as the adequate cesarean delivery rate to assure optimal prognosis for mother and children, cesarean rates have continuously increased worldwide over the last three decades, even in primiparous women. Moreover, uterine scars after myomectomies, complications of obstetrical interventions and more recently, after fetal surgery, are often observed. This review article describes the most commonly seen complications related to prior uterine scars and discusses their imaging findings, with emphasis on the increasing role of Magnetic Resonance Imaging for diagnosis.

Anesthesia management of complete versus incomplete placenta previa: a retrospective cohort study

PURPOSE

Placenta previa (PP) is a major cause of obstetric hemorrhage. Clinical diagnosis of complete versus incomplete PP has a significant impact on the peripartum outcome. Our study objective is to examine whether distinction between PP classifications effect anesthetic management.

METHODS AND MATERIALS

This multi-center, retrospective, cohort study was performed in two tertiary university-affiliated medical centers between the years 2005 and 2013. Electronic delivery databases were reviewed for demographic, anesthetic, obstetric hemorrhage, and postoperative outcomes for all cases.

RESULTS

Throughout the study period 452 cases of PP were documented. We found 134 women (29.6%) had a complete PP and 318 (70.4%) had incomplete PP. Our main findings were that women with complete PP intraoperatively had higher incidence of general anesthesia (p = .017), higher mean estimated blood loss (p < .001), increased blood components transfusions (p < .001), and significant increase in cesarean hysterectomy rate (p < .001) than women with incomplete PP. Additionally, complete PP was associated with more postoperative complications: higher incidence of admission to the intensive care unit (ICU) (p < .001), more mechanical ventilation (p = .02), a longer median postoperative care unit (PACU) (p = .02), ICU (p = .002), and overall length of stay in the hospital (p < .001).

CONCLUSIONS

Complete PP is associated with increased risk of hemorrhage compared with incomplete PP. Therefore distinction between classifications should be factored into anesthetic management protocols.

Routinely collected English birth data sets: comparisons and recommendations for reproductive epidemiology

BACKGROUND

In England there are four national routinely collected data sets on births: Office for National Statistics (ONS) births based on birth registrations; Hospital Episode Statistics (HES) deliveries (mothers' information); HES births (babies' information); and NHS Numbers for Babies (NN4B) based on ONS births plus gestational age and ethnicity information. This study describes and compares these data, with the aim of recommending the most appropriate data set(s) for use in epidemiological research and surveillance.

METHODS

We assessed the completeness and quality of the data sets in relation to use in epidemiological research and surveillance and produced detailed descriptive statistics on common reproductive outcomes for each data set including temporal and spatial trends.

RESULTS

ONS births is a high quality complete data set but lacks interpretive and clinical information. HES deliveries showed good agreement with ONS births but HES births showed larger amounts of missing or unavailable data. Both HES data sets had improved quality from 2003 onwards, but showed some local spatial variability. NN4B showed excellent agreement with ONS and HES deliveries for the years available (2006-2010). Annual number of births increased by 17.6% comparing 2002 with 2010 (ONS births). Approximately 6% of births were of low birth weight (2.6% term low birth weight) and 0.5% were stillbirths.

CONCLUSIONS

Routinely collected data on births provide a valuable resource for researchers. ONS and NN4B offer the most complete and accurate record of births. Where more detailed clinical information is required, HES deliveries offers a high quality data set that captures the majority of English births.

Major Placenta Previa: Rate, Maternal and Neonatal Outcomes Experience at a Tertiary Maternity Hospital, Sohag, Egypt: A Prospective Study

INTRODUCTION

Major degree placenta is a serious health issue and is associated with high fetal-maternal morbidity and mortality. Literature from developing countries is scant.

AIM

To determine the prevalence and maternal and neonatal outcomes among women with major placenta previa (PP).

MATERIALS AND METHODS

A prospective descriptive study of 52 singleton pregnancies with PP was evaluated in this study. The study was conducted at Sohag University Hospital, Egypt from January through June 2014. Outcome measures, including the prevalence of PP, maternal and neonatal outcomes, and case-fatality rate.

RESULTS

The total number of deliveries performed during the study period was 3841, of them, 52 cases were placenta previa. Thus, the prevalence of PP was 1.3%. The mean of previous cesarean scars was 2.2±1.4. Of women with PP, 26.4% (n=14) had placenta accreta. In total, 15.1% (n=8) of women underwent an obstetric hysterectomy. From the total no. of babies, 13.2% (n=7) were delivered fresh stillborn babies. Of the surviving babies (n=45), 20% (n=9) required admission to NICU. The frequencies of bowel and bladder injuries were 3.8% (n=2) and 13.2% (n=7) respectively. There was no maternal death in this study.

CONCLUSION

The rate of PP is comparable to previous studies, however, the rate of placenta accreta is high. Also, there are high rates of neonatal mortality and intraoperative complications which can be explained by accreta. The study highlights the need to revise maternity and child health services.

Indications for and Risks of Elective Cesarean Section

BACKGROUND

Rates of cesarean section have risen around the world in recent years. Accordingly, much effort is being made worldwide to understand this trend and to counteract it effectively. A number of factors have been found to make it more likely that a cesarean section will be chosen, but the risks cannot yet be clearly defined.

METHODS

This review is based on pertinent publications that were retrieved by a selective search in the PubMed, Scopus, and DIMDI databases, as well as on media communications, analyses by the German Federal Statistical Office, and guidelines of the Association of Scientific Medical Societies in Germany (AWMF).

RESULTS

The increased rates of cesarean section are thought to be due mainly to changed risk profiles both for expectant mothers and for their yet unborn children, as well as an increase in cesarean section by maternal request. In 1991, 15.3% of all newborn babies in Germany were delivered by cesarean section; by 2012, the corresponding figure was 31.7%, despite the fact that a medical indication was present in less than 10% of all cases. This development may perhaps be explained by an increasing tendency toward risk avoidance, by risk-adapted obstetric practice, and increasing media attention. The intraoperative and postoperative risks of cesarean section must be considered, along with complications potentially affecting subsequent pregnancies.

CONCLUSION

Scientific advances, social and cultural changes, and medicolegal considerations seem to be the main reasons for the increased acceptibility of cesarean sections. Cesarean section is, however, associated with increased risks to both mother and child. It should only be performed when it is clearly advantageous.

Identifying complications of interventional procedures from UK routine healthcare databases: a systematic search for methods using clinical codes

BACKGROUND

Several authors have developed and applied methods to routine data sets to identify the nature and rate of complications following interventional procedures. But, to date, there has been no systematic search for such methods. The objective of this article was to find, classify and appraise published methods, based on analysis of clinical codes, which used routine healthcare databases in a United Kingdom setting to identify complications resulting from interventional procedures.

METHODS

A literature search strategy was developed to identify published studies that referred, in the title or abstract, to the name or acronym of a known routine healthcare database and to complications from procedures or devices. The following data sources were searched in February and March 2013: Cochrane Methods Register, Conference Proceedings Citation Index - Science, Econlit, EMBASE, Health Management Information Consortium, Health Technology Assessment database, MathSciNet, MEDLINE, MEDLINE in-process, OAIster, OpenGrey, Science Citation Index Expanded and ScienceDirect. Of the eligible papers, those which reported methods using clinical coding were classified and summarised in tabular form using the following headings: routine healthcare database; medical speciality; method for identifying complications; length of follow-up; method of recording comorbidity. The benefits and limitations of each approach were assessed.

RESULTS

From 3688 papers identified from the literature search, 44 reported the use of clinical codes to identify complications, from which four distinct methods were identified: 1) searching the index admission for specified clinical codes, 2) searching a sequence of admissions for specified clinical codes, 3) searching for specified clinical codes for complications from procedures and devices within the International Classification of Diseases 10th revision (ICD-10) coding scheme which is the methodology recommended by NHS Classification Service, and 4) conducting manual clinical review of diagnostic and procedure codes.

CONCLUSIONS

The four distinct methods identifying complication from codified data offer great potential in generating new evidence on the quality and safety of new procedures using routine data. However the most robust method, using the methodology recommended by the NHS Classification Service, was the least frequently used, highlighting that much valuable observational data is being ignored.

Factors associated with placenta praevia in primigravidas and its pregnancy outcome

Aim. To examine the factors associated with placenta praevia in primigravidas and also compare the pregnancy outcomes between primigravidas and nonprimigravidas. Method. A retrospective cohort study was conducted in women who underwent caesarean section for major placenta praevia in a tertiary university hospital from January 2007 till December 2013. Medical records were reviewed. Result. Among 243 with major placenta praevia, 56 (23.0%) were primigravidas and 187 (77.0%) were nonprimigravidas. Factors associated with placenta praevia in the primigravidas were history of assisted conception (P = 0.02) and history of endometriosis (P = 0.01). For maternal outcomes, the nonprimigravidas required earlier delivery than primigravidas (35.76 ± 2.54 weeks versus 36.52 ± 1.95 weeks, P = 0.03) and had greater blood loss (P = 0.04). A vast majority of the primigravidas had either posterior type II or type III placenta praevia. As for neonatal outcomes, the Apgar score at 1 minute was significantly lower for the nonprimigravidas (7.89 ± 1.72 versus 8.39 ± 1.288.39 ± 1.28, P = 0.02). Conclusion. This study highlighted that endometriosis and assisted conception were highly associated with placenta praevia in primigravida. Understanding the pregnancy outcomes of women with placenta praevia can assist clinicians in identifying patients who are at higher risk of mortality and morbidity. Identifying potential risk factors in primigravida may assist in counseling and management of such patients.

Maternal and fetal outcomes in placenta accreta after institution of team-managed care

INTRODUCTION

Placenta accreta significantly contributes to maternal morbidity and mortality. We evaluated whether planned delivery and experienced, team-managed surgical intervention results in improved outcomes. We also examined whether risk factors differed for accreta, increta, and percreta and evaluated whether excess lower segment uterine vascularity correlates with disease severity.

METHODS

We retrospectively analyzed patients before versus after institution of a management protocol. Of the 58 044 deliveries over 10 years, there were 67 women whose pregnancies were histopathologically confirmed as placenta accreta, increta, or percreta (1/866). Clinical outcome measures were estimated blood loss (EBL), packed red blood cells (pRBCs) transfused, maternal and fetal complications, intensive care unit admission, and length of stay.

RESULTS

There were no maternal or infant deaths. In the managed cohort, EBL was reduced by 48% (P < .001), intraoperative pRBCs transfused by 40% (P < .01), total transfused pRBCs per case by 50% (P < .01), and surgical intensive care unit admissions by >50% (P < .01). Assessment of maternal risk factors by diagnosis revealed marked differences between accreta versus increta and percreta. Clinically assessed excess vascularity of the lower uterine segment correlated with disease severity. The incidence of neonatal complications was similar in both cohorts.

CONCLUSIONS

Targeted delivery at 34 weeks and team-managed diagnosis, treatment, and care of patients with placenta accreta were associated with improved maternal, but not neonatal outcomes.

How we manage the haematological aspects of major obstetric haemorrhage

Major obstetric haemorrhage (MOH) remains an important medical challenge worldwide, contributing to significant maternal morbidity and mortality. Prompt and appropriate management is essential if we are to improve outcomes and reduce substandard care that may result in adverse consequences. This review describes the current understanding of the pathophysiological aspects of MOH together with the principles of transfusion and haemostatic therapy, with emphasis on a coordinated multidisciplinary approach. We also highlight the current lack of evidence available from randomized controlled trials to inform best practice and the need to prioritize research in this key clinical area.

Practice audits to reduce caesareans in a tertiary referral hospital in south-western China

OBJECTIVE

To assess the effectiveness of a three-stage intervention to reduce caesarean deliveries in a Chinese tertiary hospital.

METHODS

A retrospective study was conducted to assess whether educating staff, educating patients and auditing surgeon practices (introduced in 2005) had reduced caesarean delivery rates. Multiple logistic regression was used to check for a potential association between caesarean rates and rates of admission to the neonatal intensive care unit (NICU).

FINDINGS

The caesarean delivery rate ranged from 53.5% to 56.1% in 2001-2004 and from 43.9% to 36.1% in 2005-2011. When 2001-2004 and 2005-2011 were treated as "before" and "after" periods to evaluate the intervention's impact on the mean caesarean section rate, a significant reduction was noted: from 54.8% to 40.3% (odds ratio, OR: 0.56; 95% confidence interval, CI: 0.52-0.59; χ(2) test: P < 0.001). The overall drop in the caesarean section rate was significant (χ(2) test: P < 0.001) and inversely correlated with the years (Spearman's ρ: -0.096; P < 0.001). Although complicated pregnancies increased after 2004, the primary caesarean section rate decreased annually by 20% on average in 2005-2011, after practice audits were implemented. Multiple logistic regression showed a positive association between the caesarean delivery rate and the rate of admission to the NICU (adjusted OR: 1.26; 95% CI: 1.14-1.40).

CONCLUSION

Patient and staff education and practice audits reduced the Caesarean section rate in a tertiary referral hospital without an increase in admissions to the NICU.