Analyse descriptive du volume des pertes sanguines au cours de l’accouchement par voie basse et par césarienne

The effect of assisted reproductive technology on postpartum bleeding: hormonal cycle frozen embryo transfer might increase blood loss

BACKGROUND

Among assisted reproductive technologies, frozen thawed embryo transfer (FET) is associated with increased blood loss at delivery. Anesthesiologists need to be aware of new factors that affect postpartum blood loss. This study investigated whether FET cycles with or without hormonal support affect the amount of postpartum bleeding.

METHODS

We conducted a retrospective cohort study of patients admitted for delivery at a single university hospital between January 2015 and December 2018. Patients were divided into no-assisted reproductive technology (No-ART), hormonal cycle FET (HC-FET) and natural cycle FET (NC-FET) group. The primary outcome was the amount of blood loss after delivery (median [interquartile range]), which was compared among the three groups. Multiple regression analysis was performed to investigate the factors affecting blood loss.

RESULTS

Between 2015 and 2018, 3187 women delivered neonates. In vaginal delivery, postpartum blood loss in the HC-FET group (1060 [830] g) was significantly greater than in the NC-FET group (650 [485] g, P = 0.001) and in the No-ART group (590 [420] g P < 0.001). Multiple linear regression analysis showed that HC-FET (P < 0.001) was one of the independent factors for the amount of bleeding. In cesarean delivery, the HC-FET group had more blood loss than the No-ART group (910 [676] g vs. 784 [524] g, P = 0.039). However, HC-FET was not an independent factor for postpartum blood loss.

CONCLUSIONS

The HC-FET group had more blood loss than the No-ART group for both vaginal and cesarean deliveries. Furthermore, HC-FET was an independent factor that increased postpartum blood loss in vaginal deliveries.

Tranexamic acid for the prevention of blood loss after cesarean among women with twins: a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery randomized clinical trial

BACKGROUND

Although prophylactic tranexamic acid administration after cesarean delivery resulted in a lower incidence of calculated estimated blood loss of >1000 mL or red cell transfusion by day 2, its failure to reduce the incidence of hemorrhage-related secondary clinical outcomes (TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial) makes its use questionable. The magnitude of its effect may differ in women at higher risk of blood loss, including those with multiple pregnancies.

OBJECTIVE

This study aimed to compare the effect of tranexamic acid vs placebo to prevent blood loss after cesarean delivery among women with multiple pregnancies.

STUDY DESIGN

This was a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial data, a double-blind, randomized controlled trial from March 2018 to January 2020 in 27 French maternity hospitals, that included 319 women with multiple pregnancies. Women with a cesarean delivery before or during labor at ≥34 weeks of gestation were randomized to receive intravenously 1 g of tranexamic acid (n=160) or placebo (n=159), both with prophylactic uterotonics. The primary outcome was a calculated estimated blood loss of >1000 mL or a red blood cell transfusion by 2 days after delivery. The secondary outcomes included clinical and laboratory blood loss measurements.

RESULTS

Of the 4551 women randomized in this trial, 319 had a multiple pregnancy and cesarean delivery, and 298 (93.4%) had primary outcome data available. This outcome occurred in 62 of 147 women (42.2%) in the tranexamic acid group and 67 of 152 (44.1%) receiving placebo (adjusted risk ratio, 0.97; 95% confidence interval, 0.68-1.38; P=.86). No significant between-group differences occurred for any hemorrhage-related clinical outcomes: gravimetrically estimated blood loss, provider-assessed clinically significant hemorrhage, additional uterotonics, postpartum blood transfusion, arterial embolization, and emergency surgery (P>.05 for all comparisons).

CONCLUSION

Among women with a multiple pregnancy and cesarean delivery, prophylactic tranexamic acid did not reduce the incidence of any blood loss-related outcomes.

Time Course Analysis of Transcriptome in Human Myometrium Depending on Labor Duration and Correlating With Postpartum Blood Loss

The maintenance of coordinated powerful episodic contractions of the uterus is the crucial factor for normal labor. The uterine contractility is gradually enhanced with the progression of labor, which is related to the gene expression of the myometrium. Competing endogenous RNA (ceRNA) can also regulate the gene expression. To better understand the role of ceRNA network in labor, transcriptome sequencing was performed on the myometrium of 17 parturients at different labor durations (0–24 h). From this, expression levels of mRNA, long non-coding RNA (lncRNA), circular RNA (circRNA), and microRNA (miRNA) were correlated with labor duration. Then, targeting relationships between mRNAs, lncRNAs, circRNAs, and miRNAs were predicted, and the ceRNA regulatory network was established. The mRNA expression patterns associated with cervical dilation and postpartum bleeding were further investigated. This analysis identified 932 RNAs positively correlated with labor duration (859 mRNAs, 28 lncRNAs, and 45 circRNAs) and 153 RNAs negatively correlated with labor duration (122 mRNAs, 28 lncRNAs, and 3 miRNAs). These mRNAs were involved in protein metabolism, transport, and cytoskeleton functions. According to the targeting relationship among these ceRNAs and mRNAs, a ceRNA network consisting of 3 miRNAs, 72 mRNAs, 2 circRNAs, and 1 lncRNA was established. In addition, two mRNA expression patterns were established using time-series analysis of mRNA expression in different phases of cervical dilation. A ceRNA network analysis for blood loss was performed; postpartum bleeding was closely related to inflammatory response, angiogenesis, and hemostasis. This study identified human myometrial transcriptome and established the ceRNA regulatory network depending on labor duration and highlighted the dynamic changes that occur at ceRNAs during parturition, which need to be considered more in the future to better understand how changes in gene expression are relevant to functional changes in human myometrium at labor.

The Efficiency of Temporary Uterine Artery Ligation on Prevention of the Bleeding in Cesarean Section

OBJECTIVE

We aimed to evaluate the effect of temporary ligation of the uterine artery on postpartum bleeding during uncomplicated cesarean section.

DESIGN

This was a prospective, randomized, and controlled study. We recruited a total of 200 patients, including 100 cases and 100 controls.

METHODS

The bilateral uterine artery was temporarily clamped 2 cm below the uterine incision in the study group and compared with controls. Patient demographics, the amount of intraoperative bleeding, the duration of the operation, the closure time of the uterine incision, the need for additional uterotonics, the need for additional sutures, and the hemoglobin values before and after birth were assessed.

RESULTS

The mean value of the amount of bleeding in the clamped and control groups was 267.3 ± 131.8 mL and 390.2 ± 116.4 mL, respectively. The amount of bleeding was significantly decreased for clamped group (p < 0.001). A significant reduction occurred in the results of pre- and postoperative values of hemoglobin and hematocrit difference, operation duration, and the closing time of the uterine incision in the experimental group which has temporary uterine artery clamping.

LIMITATIONS

The cases of recurrent cesareans were not included in this study.

CONCLUSION

Temporary uterine artery ligation can be used to reduce the amount of bleeding during uncomplicated cesarean delivery and prevent postpartum hemorrhage.

Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery

BACKGROUND

Prophylactic administration of tranexamic acid has been associated with reduced postpartum blood loss after cesarean delivery in several small trials, but evidence of its benefit in this clinical context remains inconclusive.

METHODS

In a multicenter, double-blind, randomized, controlled trial, we assigned women undergoing cesarean delivery before or during labor at 34 or more gestational weeks to receive an intravenously administered prophylactic uterotonic agent and either tranexamic acid (1 g) or placebo. The primary outcome was postpartum hemorrhage, defined as a calculated estimated blood loss greater than 1000 ml or receipt of a red-cell transfusion within 2 days after delivery. Secondary outcomes included gravimetrically estimated blood loss, provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, and postpartum blood transfusion.

RESULTS

Of the 4551 women who underwent randomization, 4431 underwent cesarean delivery, 4153 (93.7%) of whom had primary outcome data available. The primary outcome occurred in 556 of 2086 women (26.7%) in the tranexamic acid group and in 653 of 2067 (31.6%) in the placebo group (adjusted risk ratio, 0.84; 95% confidence interval [CI], 0.75 to 0.94; P = 0.003). There were no significant between-group differences in mean gravimetrically estimated blood loss or in the percentage of women with provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, or postpartum blood transfusion. Thromboembolic events in the 3 months after delivery occurred in 0.4% of women (8 of 2049) who received tranexamic acid and in 0.1% of women (2 of 2056) who received placebo (adjusted risk ratio, 4.01; 95% CI, 0.85 to 18.92; P = 0.08).

CONCLUSIONS

Among women who underwent cesarean delivery and received prophylactic uterotonic agents, tranexamic acid treatment resulted in a significantly lower incidence of calculated estimated blood loss greater than 1000 ml or red-cell transfusion by day 2 than placebo, but it did not result in a lower incidence of hemorrhage-related secondary clinical outcomes. (Funded by the French Ministry of Health; TRAAP2 ClinicalTrials.gov number, NCT03431805.).

Cesarean section complications according to degree of emergency during labour

OBJECTIVE

Evaluate the complications rate of cesarean section delivery based on degree of labour emergency.

STUDY DESIGN

Monocentric (Lille, France), retrospective study of all term, singleton, and cesarean deliveries during labour. Three groups were categorized based on the degree of emergency according to a color code: green (no time limit between surgical decision and birth), orange (birth within 30 min), and red (birth within 20 min). Scheduled cesareans were excluded. Complications were defined as minor/major and intra-/post-operative.

RESULTS

A total of 881 patients were included. Among these, 303 (34.5 %) were in the green group, 353 (40.1 %) in the orange group, and 225 (25.4 %) in the red group. Major intra-operative complications, mainly postpartum hemorrhage, were more frequent in the red group compared with the green group (16.9 % vs. 9.9 %, p = 0.05; OR 1.9; 95 % CI [1.1-3.1]). Among the minor complications, there was no difference on moderate postpartum hemorrhage and four times uterine artery wounds in the red group (1.7 % vs. 7.1 %, respectively; p = 0.007; OR 4.6; 95 % CI [1.6-12.6]). The overall major post-operative complication rate, mainly infectious morbidity, was 6.1 % and this was more frequent in the red group compared with the green group (12.4 % vs. 1.7 %, respectively; p < 0.0001; OR 8.5; 95 % CI [3.2-22.3]).

CONCLUSION

Pre- and post-operative complications of cesarean section delivery during labour (i.e., emergency cesarean) increase with the degree of labour emergency. It would be ideal to identify women in labour who are at increased risk of emergency cesarean earlier, so that the situation does not escalate to a red code cesarean.

Randomized controlled trial of the effect of bilateral uterine artery ligation during cesarean among women at risk of uterine atony

OBJECTIVE

To assess the effectiveness of prophylactic bilateral uterine artery ligation (BUAL) in reducing the incidence of postpartum hemorrhage (PPH) during cesarean delivery among women at risk of uterine atony.

METHODS

A randomized clinical trial at Cairo University Maternity Hospital, Egypt, from December 2017 to December 2018. Women at risk of uterine atony undergoing scheduled or emergency cesarean were randomized to two groups. In the BUAL group, women underwent BUAL before placental delivery; in the control group, women had cesarean delivery without BUAL. The primary outcome was the estimated blood loss during cesarean.

RESULTS

Intraoperative blood loss during cesarean was significantly lower in the BUAL group than in the control group (523.4 ± 41.0 vs 619.6 ± 36.1 mL; P=0.003). Blood loss in the first 6 hours after cesarean was also significantly lower in the BUAL group than in the control group (246.1 ± 21.4 vs 326.1 ± 18.5 mL; P=0.006). There was no difference in operative time between the two groups (52.1 ± 6.1 vs 52.2 ± 6.8, P=0.880).

CONCLUSION

BUAL during cesarean was found to be an effective method for decreasing blood loss during and after cesarean delivery among women at risk of uterine atony and subsequent PPH. CLINICALTRIALS.GOV: NCT03591679.

TRAAP2 - TRAnexamic Acid for Preventing postpartum hemorrhage after cesarean delivery: a multicenter randomized, doubleblind, placebo- controlled trial - a study protocol

Background

An antifibrinolytic agent that blocks lysine-binding sites on plasminogen molecules, tranexamic acid reduces bleeding-related mortality in women with postpartum hemorrhage (PPH), especially administered fairly soon after delivery. According to the randomized controlled trials thus far reported for PPH prevention after cesarean deliveries (n = 16), women who received tranexamic acid had significantly less postpartum blood loss and no increase in severe adverse effects. These were, however, primarily small single-center studies that had fundamental methodological flaws. Multicenter randomized controlled trials with adequate power are necessary to demonstrate its value persuasively before tranexamic acid goes into widespread use for the prevention of PPH after cesarean deliveries.

Methods/design

This study will be a multicenter, double-blind, randomized controlled trial with two parallel groups including 4524 women with cesarean deliveries before or during labor, at a term ≥34 weeks, modeled on our previous study of tranexamic acid administered after vaginal deliveries. Treatment (either tranexamic acid 1 g or placebo) will be administered intravenously just after birth. All women will also receive a prophylactic uterotonic agent. The primary outcome will be the incidence of PPH, defined by a calculated estimated blood loss > 1000 mL or a red blood cell transfusion before day 2 postpartum. This study will have 80% power to show a 20% reduction in the incidence of PPH, from 15.0 to 12.0%.

Discussion

As an, inexpensive, easy to administer drug that can be add to the routine management of cesarean births in delivery rooms, tranexamic acid is a promising candidate for preventing PPH after these births. This large, adequately powered, multicenter randomized placebo-controlled trial seeks to determine if the benefits of the routine prophylactic use of tranexamic acid after cesarean delivery significantly outweigh its risks.

Trial registration

ClinicalTrials.gov NCT03431805 (February 12, 2018).

Cesarean during labor: Is induction a risk factor for complications?

INTRODUCTION

Evaluate the impact of labor induction on maternal complications following caesarean section during labor.

MATERIAL AND METHODS

Retrospective, single-center study between 2015 and 2017. Were included singleton pregnancies who had cesarean section during labor after 37WG. Labor induction procedures included either transcervical balloon catheters or prostaglandins. Degree of emergency of the cesarean was decided according to color code (green, orange and red). We identified and compared intra and postoperative complications according to the mode of labor onset, and then to the mode of labor induction.

RESULTS

882 patients were included, 416 with spontaneous labor and 464 with labor induction. No significant difference was found for postoperative complications between the two groups. Patients with spontaneous labor had fewer green-code caesareans than patients with elective induction (29.3% vs. 40.3% p<0.001) and had more uterine pedicle injuries (6.3% vs. 3.0% p=0.022). Nevertheless, no difference was found for postpartum hemorrhage (PPH) between these two groups (41.59% vs. 43.32% p=0.60). The subgroup study of patients with labor induction showed that those necessitating 2 methods of labor induction had more severe PPH (22.2% vs. 8.1% p after Bonferroni correction = 0.002).

CONCLUSIONS

Elective induction does not result in an increased risk of cesarean section during labor complications. Only the use of prostaglandin following transcervical balloon catheter increased the risk of severe postpartum hemorrhage.

The effect of mechanical cervical dilatation during scheduled cesarean section on the blood loss: a randomized controlled trial

Objective: This study evaluates the effects of mechanical cervical dilatation during scheduled cesarean section (CS) on intra- and postoperative blood loss.Methods: A single-center randomized double-blind controlled trial (NCT03444792) conducted at a tertiary University Hospital in the period between 1 April 2017 and 31 March 2018 included all women scheduled for scheduled CS under spinal anesthesia if they met our inclusion criteria. Eligible participants were randomized to one of two groups. Group (I): Women with intraoperative cervical dilatation and Group (II): women with no intraoperative cervical dilatation. The primary outcome of this study was the mean volume of total blood loss during CS. The secondary outcomes included the mean reduction in the hemoglobin and hematocrit, the rate of primary postpartum hemorrhage, the duration of surgery, the duration of hospital stay, the rate of wound infection and endometritis.Results: No statistical significant difference between both study groups regarding the baseline characteristics. No significant difference in the intraoperative blood loss between both groups (p = .21); however, there was significantly more postoperative blood loss in group II (p = .001). The total blood loss was significantly higher in group II (912.6 ± 242.1 versus 845.8 ± 188.9 mL) in group I (p = .029). There were significantly lower postoperative hemoglobin and hematocrit levels in group II (p = .014 and .033 respectively). The mean duration of CS was significantly shorter in the cervical dilatation group (p = .002). No difference between both groups regarding the rate of postpartum hemorrhage (PPH) (p = .21), the duration of hospital stay (p = .17), the rate of wound infection (p = .32), the rate of endometritis (p = .82).Conclusions: Mechanical cervical dilatation during scheduled CS could be associated with lower postoperative blood loss, higher postoperative hemoglobin & hematocrit levels and shorter duration of CS.

Moyamoya Disease in Pregnancy: A 20-Year Single-Center Experience and Literature Review

BACKGROUND

Pregnancy is a potential risk factor for stroke in women with Moyamoya disease. However, the rarity of the disease has limited clinical expertise to ensure a healthy pregnancy. The aim of the present study was to explore the possible risk factors for hemorrhagic and ischemic stroke in pregnant women with Moyamoya disease.

METHODS

A retrospective review of cases in our hospital during a 20-year period and a review of the reported data were conducted to investigate pregnancy-related cerebrovascular events in women with Moyamoya disease.

RESULTS

Thirty pregnancies in 20 women with Moyamoya disease were identified in the case review of our hospital. All were previously diagnosed cases, and no stroke had occurred during the study period. In the reported data review, pregnancy-related stroke in women with Moyamoya disease was identified in 54 (44 intracranial hemorrhage and 10 cerebral infarction). Intracranial hemorrhage occurred most commonly during the antepartum period (n = 39; 88.6%), with most events occurring at ≥24 weeks. Of the intracranial hemorrhage cases, 7 (15.9%) were complicated by hypertensive disorders of pregnancy, and 8 patients (18.2%) died of stroke. The onset of cerebral infarction was either in the antepartum (n = 4; 40.0%) or postpartum (n = 6; 60.0%) period. All postpartum cases occurred within 3-7 days after delivery.

CONCLUSION

Pregnancy-related stroke in patients with Moyamoya disease might be susceptible to gestational age. Intracranial hemorrhage is prone to occur during the antepartum period, especially at ≥24 weeks, and cerebral infarction tends to occur postpartum.

The effect of initiating intravenous oxytocin infusion before uterine incision on the blood loss during elective cesarean section: a randomized clinical trial

Objective: This study compares the effect of starting intravenous oxytocin infusion early before uterine incision versus late after umbilical cord clamping on the blood loss during elective cesarean section (CS). Methods: A single-blinded randomized clinical trial conducted on 200 pregnant women at term (>37 weeks) gestation scheduled for elective CS were assigned to either IV infusion of 30 IU of oxytocin started before uterine incision (Group I) or started immediately after clamping the umbilical cord (Group II). The primary outcome was the mean volume of blood loss during CS. The secondary outcomes included the mean volume of postoperative blood loss, the mean reduction in the hemoglobin and hematocrit levels, the need for additional uterotonics, blood transfusion and additional surgical procedures. Results: The baseline characteristics of both groups are quiet similar. No statistical significant difference between both groups as regard to pre- and postpartum hemoglobin levels (p = .06 and 0.24 respectively) and hematocrit values (p = .12 and .51 respectively). There was a significant reduction in the intraoperative blood loss in group I compared with group II (432.7 ± 90.6 versus 588.9 ± 96.3 mL respectively, p = .001). The need for additional uterotonics was more frequent in the group II (19 women) than in group I (seven women) with statistical significance (p = .002). No differences between both groups regarding the need for blood transfusion or additional surgical procedures. Conclusions: Initiating intravenous oxytocin infusion before uterine incision during elective CS could be associated with reduction in the intraoperative blood loss and the need for additional uterotonics.

Maternal heart rate during the first 48h postpartum: a retrospective cross sectional study

OBJECTIVES

1) Describe the distribution of heart rate in the first 48h postpartum in women with no evidence of sepsis, anaemia or haemorrhage. 2) Investigate the relationship between postpartum heart rate and other maternal factors.

STUDY DESIGN

A retrospective cross-sectional study of postpartum women who delivered between July 2012 and June 2015 in a tertiary hospital. Data was analysed from the local maternity system and electronic vital signs database. The main outcome measures: Heart rate at 6, 12, 24 and 48h postpartum.

RESULTS

Data were obtained on 11401 women. After exclusion of women with possible sepsis, anaemia or haemorrhage, 7627 heart rate readings from 5164 women were analysed. Mean heart rate (+2SD/+3SD) at 6h was 83.6 (108.2/120.6), 12h 84.5 (109.4/121.9), 24h 85.4 (110.4/122.9), and 48h 84.3 (109.7/122.4). There was statistical correlation of post partum heart rate with body mass index (BMI), age and discharge haemoglobin.

CONCLUSION

This study describes the distribution of maternal heart rate in the early postpartum period, in women with no evidence of sepsis, anaemia or major haemorrhage. This will facilitate identification and appropriate investigation of women with abnormal heart rates. Although correlation with BMI, age and discharge haemoglobin was demonstrated, the differences were small and not clinically meaningful. Further work investigating the relationship between postpartum heart rate and poor maternal outcomes is required.

Postpartum haemorrhage: prevention and treatment

INTRODUCTION

Postpartum hemorrhage (PPH) is one of the leading causes of maternal death and severe maternal morbidity worldwide and strategies to prevent and treat PPH vary among international authorities. Areas covered: This review seeks to provide a global overview of PPH (incidence, causes, risk factors), prevention (active management of the third stage of labor and prohemostatic agents), treatment (first, second and third-line measures to control PPH), by also underlining recommendations elaborated by international authorities and using algorithms. Expert commentary: When available, oxytocin is considered the drug of first choice for both prevention and treatment of PPH, while peripartum hysterectomy remains the ultimate life-saving procedure if pharmacological and resuscitation measures fail. Nevertheless, the level of evidence for preventing and treating PPH is globally low. The emergency nature of PPH makes randomized controlled trials (RCT) logistically difficult. Population-based observational studies should be encouraged as they can usefully strengthen the evidence base, particularly for components of PPH treatment that are difficult or impossible to assess through RCT.