Intrapartum hemorrhage

Intrapartum care algorithms for liquor abnormalities: oligohydramnios, meconium, blood and purulent discharge

AIM

To construct evidence-based algorithms for the assessment and management of common amniotic fluid abnormalities detected during labour.

POPULATION

Low-risk singleton, term pregnant women in labour.

SETTING

Birth facilities in low- and middle-income countries.

SEARCH STRATEGY

We searched international guidelines published by the American College of Obstetricians and Gynecologists (ACOG), the National Institute for Health and Care Excellence (NICE), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetrics and Gynaecology (SOGC) and the World Health Organization (WHO). We also searched The Cochrane Library and MEDLINE up to 20 January 2020 using keywords for relevant systematic reviews and randomised trials.

CASE SCENARIOS

We developed evidence-based intrapartum care algorithms for four case scenarios: oligohydramnios; meconium-stained amniotic fluid; bloody amniotic fluid or vaginal bleeding; and purulent amniotic fluid or discharge. These conditions may be associated with fetal and /or maternal morbidity. Differential diagnosis includes uteroplacental insufficiency, fetal growth restriction, fetal distress, abruption, placenta or vasa praevia, uterine rupture and intra-amniotic infection, respectively. Algorithms include how to assess for, diagnose and manage these conditions.

CONCLUSIONS

Four algorithms are presented, to provide a systematic approach and guidance on the clinical management for the following amniotic fluid abnormalities: oligohydramnios; meconium-stained liquor; bloody amniotic fluid or vaginal bleeding; and purulent amniotic fluid or discharge. These algorithms may be beneficial in supporting clinical decision making, particularly in low-resource settings.

TWEETABLE ABSTRACT

Evidence based algorithms for management of common amniotic fluid abnormalities seen during labour.

Short: Prediction of fetal blood oxygen content in response to partial occlusion of maternal aorta

Acute hemorrhage in pregnancy may lead to maternal and/or fetal morbidity or mortality. In emergency medicine, blockage of the aorta via an inflatable endovascular balloon, technically referred to Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), is used to manage hemorrhage. However, the application of REBOA in pregnancy needs to strike a balance between two competing objectives of limiting maternal blood loss and ensuring fetal wellness, for which one would need to predict the impact of regulated blood pressure on fetal wellness. To address this problem, we propose an efficient machine learning-based method to predict the temporal impact of the distal Mean Arterial Blood Pressure (dMAP) controlled by the REBOA on the oxygen content in the fetal blood. Evaluation of the algorithm on data collected from in-vivo experiments from pregnant ewe animal models exhibits mean absolute error of 0.61, 1.09, 1.42, 1.70 mmHg, and coefficient of determination of 0.95, 0.86, 0.76, 0.64 for prediction of partial pressure of oxygen in fetal arterial blood, a key predictor of fetal wellness, in 2.5, 5, 7.5, 10-minute prediction horizons, respectively.

Retrospective Evaluation of Anesthetic Management in Cesarean Sections of Pregnant Women with Placental Anomaly

Background

In this study, patients who underwent cesarean section and had placenta previa and placenta accreta were examined and compared in terms of haemorrhagic indicators and perioperative anesthetic management.

Methods

A retrospective study was conducted in a university hospital in Kahramanmaras, Turkey. It included 95 pregnant women who had placental anomaly and underwent cesarean section between December 15, 2014, and February 15, 2016.

Results

The pregnant women were divided into two groups: Group P (previa) (n = 67) and Group A (accreta) (n = 28). The types of anesthesia administered were general anesthesia (GA), which was administered to 50 patients (74.6%) in Group P and 27 patients (96.4%) in Group A, and spinal anesthesia (SA), which was administered to 17 patients (25.4%) in Group P and one patient (3.6%) in Group A.. The mean blood loss was 685.82 ± 262.82 in Group P and 1582.14 ± 790.71 in Group A, and the given amount of crystalloid was higher in Group A with an average of 1628.57 ± 728.19 ml. The use of erythrocyte and fresh frozen plasma solution was higher in Group A than Group P. Eleven patients were intubated and taken to the Intensive Care Unit (ICU) in Group A. Postoperative mechanical ventilation duration was significantly higher in Group A (75.14 ± 43.84 h) (p < 0.001). ICU stay was longer in Group A with 2.80 ± 1.13 days. (p < 0.001).

Conclusion

The intraoperative management and the availability of postoperative ICU conditions are important in placental anomalies cases. The communication between operation team with regard to the development of a standard protocol for these cases will be of great benefit in reducing morbidity and mortality.

Identification and Management of Obstetric Hemorrhage

Obstetric hemorrhage remains the leading cause of maternal death and severe morbidity worldwide. Although uterine atony is the most common cause of peripartum bleeding, abnormal placentation, coagulation disorders, and genital tract trauma contribute to adverse maternal outcomes. Given the inability to reliably predict patients at high risk for obstetric hemorrhage, all parturients should be considered susceptible, and extreme vigilance must be exercised in the assessment of blood loss and hemodynamic stability during the peripartum period. Obstetric-specific hemorrhage protocols, facilitating the integration and timely escalation of pharmacologic, radiological, surgical, and transfusion interventions, are critical to the successful management of peripartum bleeding.

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.

Prophylactic uterine artery embolization assisted cesarean section for the prevention of intrapartum hemorrhage in high-risk patients

Purpose

To evaluate the safety and efficacy of prophylactic uterine artery embolization (UAE)-assisted cesarean section for the prevention of intrapartum hemorrhage.

Materials and Methods

Twelve consecutive pregnant women (mean age 31 years; range 25–38) with uterine scarring and placenta previa and/or placenta accreta underwent UAE in conjunction with cesarean section to prevent intrapartum hemorrhage. For UAE, the left uterine artery was catheterized prophylactically under fluoroscopic guidance before the cesarean section incision was made. After the infant had been delivered, bilateral UAE was performed with the placenta still in situ. After successful bilateral UAE, the placenta was detached from the uterine wall.

Results

Technical success was achieved in all 12 cases. Ten patients retained their uterus, and the other 2 underwent hysterectomy. The mean operative blood loss was 1,391 mL (range 600–3,600 mL). The total mean fluoroscopy time and mean absorbed dose (air kerma) were 9 min 40 s (range 4 min 35 s–15 min 24 s) and 91.79 mGy (range 30.2–171), respectively. The average fetal fluoroscopy time was 1 min 42 s (range 41 s to 3 min 16 s) with an average X-ray dose of 17.66 mGy (range 6.04–23.90).

Conclusion

UAE-assisted cesarean section is safe and effective in the prevention of intrapartum hemorrhage in patients with uterine scarring and/or placental abnormalities.