Trends in conservative procedures and peripartum hysterectomy rates in severe postpartum haemorrhage

Adenomyosis among patients undergoing postpartum hysterectomy for uncontrollable uterine bleeding: A multicenter, observational, retrospective, cohort study on histologically-based prevalence and clinical characteristics

OBJECTIVE

To assess the prevalence of adenomyosis at pathologic examination, and its association with obstetric complications, peripartum maternal clinical characteristics and neonatal birth weight in patients undergoing postpartum hysterectomy due to postpartum hemorrhage (PPH).

METHODS

A multicenter, observational, retrospective, cohort study was carried out including all women who underwent postpartum hysterectomy due to PPH at gestational week 23+0 or later, between January 2010 and May 2023. Patients were categorized into two groups based on the presence of adenomyosis at pathologic examination, and were compared for obstetric complications, peripartum maternal clinical characteristics, and neonatal birth weight.

RESULTS

The histologically-based prevalence of adenomyosis in patients undergoing postpartum hysterectomy due to PPH was 39.4%. Adenomyosis was associated with a longer hospitalization time (regression coefficient: 4.43 days, 95% CI: 0.34-8.52, P = 0.034) and a higher risk of hypertensive disorders (OR: 5.82, 95% CI: 1.38-24.46, P = 0.016), threatened preterm labor (OR: 3.34, 95% CI: 1.08-10.31, P = 0.036), urgent/emergency C-section (OR: 24.15, 95% CI: 2.60-223.96, P = 0.005), postpartum maternal complications (OR: 4.96, 95% CI: 1.48-16.67, P = 0.012), maternal intensive care unit admission (OR: 3.56, 95% CI: 1.05-12.05, P = 0.041), and low birth weight neonates (OR: 3.8, 95% CI: 1.32-11.02, P = 0.013).

CONCLUSION

In patients undergoing postpartum hysterectomy due to PPH, adenomyosis is a highly prevalent condition among, and is associated with adverse obstetric, maternal, and neonatal outcomes.

Incidence, Indications, Risk Factors, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis

OBJECTIVE

To describe the incidence, indications, risk factors, outcomes, and management of emergency peripartum hysterectomy globally and to compare outcomes among different income settings.

DATA SOURCES

PubMed, MEDLINE, EMBASE, ClinicalTrials.gov, Cochrane Library, Web of Science, and Emcare databases up to December 10, 2021.

METHODS OF STUDY SELECTION

Update of a systematic review and meta-analysis (2016). Studies were eligible if they reported the incidence of emergency peripartum hysterectomy, defined as surgical removal of the uterus for severe obstetric complications up to 6 weeks postpartum. Title and abstract screening and full-text review were performed using Endnote data-management software. Of 8,775 articles screened, 26 were included that were published after 2015, making the total number of included studies 154. A subanalysis was performed for the outcomes of interest per income setting.

TABULATION, INTEGRATION, AND RESULTS

The meta-analysis included 154 studies: 14,409 emergency peripartum hysterectomies were performed in 17,127,499 births in 42 countries. Overall pooled incidence of hysterectomy was 1.1 per 1,000 births (95% CI 1.0-1.3). The highest incidence was observed in lower middle-income settings (3/1,000 births, 95% CI 2.5-3.5), and the lowest incidence was observed in high-income settings (0.7/1,000 births, 95% CI 0.5-0.8). The most common indications were placental pathology (38.0%, 95% CI 33.9-42.4), uterine atony (27.0%, 95% CI 24.6-29.5), and uterine rupture (21.2%, 95% CI 17.8-25.0). In lower middle-income countries, uterine rupture (44.5%, 95% CI 36.6-52.7) was the most common indication; placental pathology (48.4%, 95% CI 43.5-53.4) was most frequent in high-income settings. To prevent hysterectomy, uterotonic medication was used in 2,706 women (17%): 53.2% received oxytocin, 44.6% prostaglandins, and 17.3% ergometrine. Surgical measures to prevent hysterectomy were taken in 80.5% of women, the most common being compressive techniques performed in 62.6% (95% CI 38.3-81.9). The most common complications were febrile (29.7%, 95% CI 25.4-34.3) and hematologic (27.5%, 95% CI 20.4-35.9). The overall maternal case fatality rate was 3.2 per 100 emergency peripartum hysterectomies (95% CI 2.5-4.2) and was higher in lower middle-income settings (11.2/100 emergency peripartum hysterectomies 95% CI 8.9-14.1) and lower in high-income settings (1.0/100 emergency peripartum hysterectomies 95% CI 0.6-1.6).

CONCLUSION

Substantial differences across income settings exist in the incidence of emergency peripartum hysterectomy. Women in lower-income settings have a higher risk of undergoing emergency peripartum hysterectomy and suffer more procedure-related morbidity and mortality. The frequency of emergency peripartum hysterectomy is likely to increase in light of increasing cesarean delivery rates.

Use of balloon tamponade in management of vaginal laceration and its possible complication of urinary stress incontinence: a case report

BACKGROUND

Postpartum haemorrhage from vaginal lacerations can occasionally be refractory to suturing and vaginal packing. Bakri uterine balloon has been widely adopted to stop uterine bleeding, but its use to stop bleeding in vaginal lacerations and its possible complications have seldom been reported.

CASE PRESENTATION

We report a patient who had vacuum delivery for fetal distress and subsequently had postpartum hemorrhage due to previous caesarean uterine scar rupture and multiple vaginal lacerations. The severe bleeding persisted despite total abdominal hysterectomy, pelvic embolization and vaginal gauze packing, but was finally controlled by a Bakri balloon tamponade inserted into the vagina. The patient suffered from severe stress incontinence after delivery. The possible use of balloon tamponade in vaginal lacerations and the different types of vaginal balloons that are available in the market for this purpose are reviewed. The possible causes leading to stress incontinence is reported to alert the obstetrician that such management is not free of complications.

CONCLUSION

The use of Bakri balloon can help to control bleeding in severe vaginal lacerations that are unresponsive to traditional vaginal gauze packing. Further studies are needed to evaluate the risks of stress incontinence as a possible complication of vaginal balloon tamponade.

Old and novel insights into emergency peripartum hysterectomy: a time-trend analysis

PURPOSE

To assess changing trends, role of the triad patient-pregnancy-health professionals and health care cost in emergency peripartum hysterectomy (EPH).

METHODS

Demographics, indications, perinatal outcomes, perioperative complications in EPH cases performed in a 10-year period were extracted from the local birth registry. Experience of health professionals in the management of the post-partum haemorrhage was valued. Two subgroups (Period I, 2009-2013 vs. Period II, 2014-2018) were recognized. Overall and detailed EPH ratios/1000 deliveries were calculated. Cost analysis was achieved in agreement with the diagnosis-related group (DGR) system.

RESULTS

A total of 39 EPH were performed among 36,053 deliveries. EPH incidence increased from 0.8 to 1.32‰ across study periods (p < 0.001). The mean maternal age (36.9 ± 4.7 vs. 38.9 ± 5.9 years, p = 0.035) and the high socio-economic status (0 vs. 19.2%, p = 0.027) were statistically different. Multiparity (84.6 vs. 96.2%, p = 0.005), previous caesarean section (CS) (0.9 ± 0.9 vs. 1.2 ± 1.6, p = 0.049), and emergent CS (7.7 vs. 19.2%, p = 0.048) were found statistically different. In Period II, increased attempts in conservative approaches (7.7 vs. 36.8%, p = 0.007), reduction in blood loss (3184 ± 1753 vs. 2511 ± 1252 mL, p = 0.045), advanced age of gynecologists performing EPH (54.5 ± 9.2 vs. 60.3 ± 6.4 years, p = 0.024), and augmented health care costs (mean DRG of € 2.782 vs. 3.371,95, p < 0.001) were observed.

CONCLUSIONS

As a "near-miss" event, advances on identification of EPH factors are mandatory. Time-trend analyses might add information and address novel strategies.

Training for the surgical management of postpartum hemorrhage: a multicenter survey of resident physicians

Background: To actively address maternal morbidity and mortality in Mexico, proficiency among obstetrics and gynecology (OBGYN) residents in the surgical management of postpartum hemorrhage (PPH) is a priority. However, the capacity of programs to provide this training is unknown.Objective: The self-reported knowledge, education, and proficiency of common surgical techniques for the management of PPH among OBGYN residents in Mexico was evaluated. Educational resources, perceived barriers to acquiring skills, and clinical decision-making were explored.Materials and methods: In July of 2018, an anonymous electronic survey was sent to 86 residents at four hospitals throughout Mexico. Surgical techniques queried included uterine tamponade (UT), uterine compression sutures (UCS), uterine devascularization (UD), hypogastric artery ligation (HAL), and gravid hysterectomy (HT). Participants also answered case-based questions about a patient with PPH.Results: The survey response rate was 59.3% (51/86). Seventy-nine percent of residents reported understanding the rationale and techniques for the surgical intervention of PPH. However, 43.9% reported limited ability to perform these procedures with autonomy. Eighty-six percent of residents reported exposure to these techniques while performing a rescue procedure during PPH and 49% reported learning these procedures while performing prophylactic techniques in patients without PPH. Only 25.5% had been exposed to simulation training. Lack of a training module for these skills in their curriculum was noted by 74.5%. The majority of the participants chose UCS, UD, HAL, and HT as the first, second, third, and fourth rescue procedures to perform for PPH, respectively.Conclusion: Most residents reported theoretical knowledge of surgical interventions for PPH, but their self-rated ability to independently perform such skills and a curriculum focused on PPH management was suboptimal.

The use of Zhukovsky vaginal and intrauterine balloons to improve the outcome of postpartum hysterectomies in patients with severe bleeding

Aim: To assess the efficacy of a Zhukovsky obstetric double balloon for improving outcomes in women undergoing hysterectomy for postpartum hemorrhage.Materials and methods: This was a randomized controlled study. Participants were divided into two groups to undergo insertion of a Zhukovsky obstetric double balloon prior to hysterectomy (n = 16) or conventional hysterectomy (n = 25).Results: The main reasons for major obstetric hemorrhage were placenta accreta (53.6%), uterine atony (26.8%), uteroplacental apoplexy (14.6%), and amniotic fluid embolism (4.8%). The use of a Zhukovsky obstetric double balloon during postpartum hysterectomy was associated with a 1.7-fold reduction in blood loss and a 2.3-fold reduction in blood loss > 2000 ml compared with conventional hysterectomy.Conclusion: The use of a Zhukovsky obstetric double balloon represents a potent tool for improvement of immediate outcomes of hysterectomy in women with severe postpartum bleeding.

Menstrual and reproductive outcomes after use of balloon tamponade for severe postpartum hemorrhage

BACKGROUND

The use of intrauterine balloon tamponade to manage postpartum hemorrhage is increasing. However, there is lack of studies on the menstrual and reproductive outcomes after such treatment. The purpose of this study is to explore the menstrual and reproductive outcomes for patients who had been managed by intrauterine balloon tamponade for severe postpartum hemorrhage in her index pregnancy.

METHODS

All patients who had delivered in United Christian Hospital from January 2011 to June 2016 with severe postpartum hemorrhage (PPH) (blood loss> = 1 L) were identified by the labour ward delivery registry and a comprehensive obstetric database. Patients who had intrauterine balloon tamponade inserted were compared with those managed solely by uterotonic agents as controls. Patients who had hysterectomy or additional procedures performed, such as compression sutures or uterine artery embolization were excluded from both groups. A questionnaire on menses, fertility and reproductive outcomes was mailed to both groups of patients. Those that had not replied within 4 weeks would receive a telephone survey.

RESULTS

A total of 39 patients in the balloon tamponade group and 161 patients in the control group were recruited, which represented 87.0% of all eligible patients within the study period. The median follow up period was 45 months. All patients in the balloon tamponade group had return of menses after delivery. The majority of the patients (87.2%) in the balloon tamponade group had normal menstrual patterns in the 12 months after the index delivery as well as in the most recent 12 months. After excluding the patients with contraception, the subsequent pregnancy rate was 42.9% (9/21) in the balloon tamponade group compared to 45.9% (28/61) in the control group (p = 0.81). Among the 9 subsequent pregnancies in the balloon tamponade group, there were two miscarriages, one scar pregnancy, one induced abortion, while the remaining five were normal pregnancies with full term deliveries without intrauterine growth restriction. The majority of patients replied that they were satisfied with using Bakri balloon for PPH management in their index pregnancy.

CONCLUSIONS

Intrauterine balloon tamponade for the management of severe PPH appeared to pose little adverse effects on subsequent menstrual and reproductive function.

The role of Th17/Treg-mediated immunoregulation in abortion mice

In the study, we investigated the immune factors related to T helper 17 (Th17) cells and T regulatory (Treg) cells in spontaneous abortion mice. The expression of Th17 was analyzed by interleukin (IL)-6, IL-17A secretion, RAR-related orphan receptor γt (RORγt) expression, and proportion of CD4+IL-17+ cells. The levels of IL-10, transforming growth factor β (TGF-β), Foxp3, and CD4+Foxp3+ cells were presented the Treg expression. Higher embryo absorption rate was found in spontaneous abortion group than that in normal pregnancy group ( P < 0.01). Compared with the normal pregnancy mice, spontaneous abortion mice showed higher levels of IL-6 and IL-17A and lower levels of IL-10 and TGF-β in serum and in decidua ( P < 0.05). Furthermore, the expressions of Foxp3 and CD4+Foxp3+ cells were significantly decreased in spontaneous abortion mice than those in normal pregnancy mice ( P < 0.05). However, the levels of RORγt and CD4+IL-17+ cells remarkably increased in spontaneous abortion mice ( P < 0.05). The results reveal that Th17/Treg cells may play a vital role in immunoregulation during pregnancy.

Intraluminal pressure of uterine balloon tamponade in the management of severe post-partum hemorrhage

AIM

Intrauterine balloon tamponade has been increasingly used for the management of post-partum hemorrhage (PPH) in recent years. However, data on the precise mechanisms and pressure required for the balloon tamponade are scanty in the literature. This study aims to review the intraluminal pressure (ILP) generated by the Bakri intrauterine balloon that is necessary to produce a 'positive tamponade test' during severe PPH.

METHODS

This was a prospective cohort study. The ILP of the Bakri balloon was measured using a manometer after a positive tamponade test was clinically achieved during severe PPH (blood loss >1 L). The patient's blood pressure was recorded, and ultrasound scan was performed to verify the position of the balloon and the presence of forward flow in the uterine arteries. The main outcome measure is the ILP of the Bakri balloon required to achieve a positive tamponade test.

RESULTS

Twenty patients were included for final analysis. The net ILP measured ranged from 67 to 92 mmHg, and this pressure was lower than the concurrent systolic pressure in all cases. Color Doppler confirmed positive forward flow in the uterine vessels in all cases. There were no differences in the pressure measured with the balloon position, and there was no relationship between the volumes of saline infused and the net pressure.

CONCLUSION

A positive tamponade test in an intrauterine balloon is probably achieved by local compression pressure exerted on the vasculature of the placental bed rather than by generating an ILP exceeding systemic blood pressure or by occlusion of flow to the uterine arteries.