Maternal haemorrhage

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.

Multidisciplinary approach to obstetric disseminated intravascular coagulopathy management in low-income country: A survey

OBJECTIVE

To assess the uptake of a multidisciplinary team approach in obstetric disseminated intravascular coagulopathy (DIC) management in a low- to middle-income country.

METHODS

A cross-sectional observational study, in which a semi-structured and pre-tested questionnaire was used to collect data on the uptake by Nigerian obstetricians of the multidisciplinary team approach to obstetric DIC management.

RESULTS

A total of 171 obstetricians responded, 82 (48.0%) were consultants and 89 (52.0%) were specialist registrars. Most (165; 96.5%) practiced in tertiary healthcare facilities and the multidisciplinary team approach was the most preferred (162; 94.7%) management approach. In all, 142 (83.0%) supported the invitation of hematologists always in the management whereas 115 (67.3%) participants recommended that involvement of specialists in the treatment should be when clinical presentation was suggestive of DIC. No significant association existed between years of obstetric practice and adoption of a multidisciplinary team-based approach (χ2 = 9.590; P = 0.252).

CONCLUSION

A multidisciplinary approach is widely adopted in the management of obstetric DIC, with hematologists being a key member of the team.

A Systematic Review and Meta-analysis of Prenatal, Birth, and Postnatal Factors Associated with Attention-Deficit/Hyperactivity Disorder in Children

Previous studies have shown mixed results on the relationship between prenatal, birth, and postnatal ("pregnancy-related") risk factors and attention-deficit/hyperactivity disorder (ADHD). We conducted meta-analyses to identify potentially modifiable pregnancy-related factors associated with ADHD. A comprehensive search of PubMed, Web of Science, and EMBASE in 2014, followed by an updated search in January 2021, identified 69 articles published in English on pregnancy-related risk factors and ADHD for inclusion. Risk factors were included in the meta-analysis if at least three effect sizes with clear pregnancy-related risk factor exposure were identified. Pooled effect sizes were calculated for ADHD overall, ADHD diagnosis, inattention, and hyperactivity/impulsivity. Odds ratios (OR) were calculated for dichotomous measures and correlation coefficients (CC) for continuous measures. Prenatal factors (pre-pregnancy weight, preeclampsia, pregnancy complications, elevated testosterone exposure), and postnatal factors (Apgar score, neonatal illness, no breastfeeding) were positively associated with ADHD overall; the findings for ADHD diagnosis were similar with the exception that there were too few effect sizes available to examine pre-pregnancy weight and lack of breastfeeding. Prenatal testosterone was significantly associated with inattention and hyperactivity/impulsivity. Effect sizes were generally small (range 1.1-1.6 ORs, -0.16-0.11 CCs). Risk factors occurring at the time of birth (perinatal asphyxia, labor complications, mode of delivery) were not significantly associated with ADHD. A better understanding of factors that are consistently associated with ADHD may inform future prevention strategies. The findings reported here suggest that prenatal and postnatal factors may serve as potential targets for preventing or mitigating the symptoms of ADHD.

Management of Postpartum Hemorrhage in Critical Care Transport

Postpartum hemorrhage is a relatively common and highly morbid complication of the postpartum period that often requires management by specialized providers at tertiary care facilities. Critical care transport teams may be tasked with transporting postpartum patients who are already experiencing postpartum hemorrhage, but they should also be aware that other peripartum patients may be at risk for developing postpartum hemorrhage while in the process of transport. As such, it is imperative that transport providers understand the signs, symptoms, causes, and complications of postpartum hemorrhage as well as the options for intervention and treatment. This article reviews the current clinical evidence regarding resuscitation and medical management strategies that transport teams should be familiar with as well as more advanced and invasive management techniques they may encounter and be expected to monitor during transport, such as balloon tamponade and aortic balloon occlusion.

A Longitudinal Study of Thrombosis and Bleeding Outcomes With Thromboprophylaxis in Pregnant Women at Intermediate and High Risk of VTE

BACKGROUND

The efficacy and safety of thromboprophylaxis in pregnancy at intermediate to high risk of venous thrombo-embolism (VTE) is an area of ongoing research.

AIM

This study aimed to assess thrombosis and bleeding outcomes associated with thromboprophylaxis in women at risk of VTE.

METHODS

A cohort of 129 pregnancies, who received thromboprophylaxis for the prevention of VTE, were identified from a specialist obstetric clinic in Johannesburg, South Africa. Intermediate-risk pregnancies, with medical comorbidities or multiple low risks, were managed with fixed low-dose enoxaparin antepartum and for a median (interquartile range) of 4 (4) weeks postpartum. High-risk pregnancies, with a history of previous VTE, were managed with anti-Xa adjusted enoxaparin antepartum and for a median of 6 (0) weeks postpartum. Pregnancy-related VTE was objectively confirmed. Major bleeding, clinically relevant nonmajor bleeding (CRNMB) and minor bleeding were defined according to the International Society on Thrombosis and Hemostasis Scientific Subcommittee.

RESULTS

Venous thrombo-embolism occurred antepartum in 1.4% (95% CI: 0.04-7.7) of intermediate and 3.4% (95% CI: 0.4-11.7) of high-risk pregnancies. Bleeding events occurred in 7.1% (95% CI: 2.4-15.9) of intermediate and 8.5% (95% CI: 2.8-18.7) of high-risk pregnancies. Of these bleeding events, 3.1% (95% CI: 1.0-8.0) were classified as major bleeding. On univariate analysis, no independent predictors of bleeding were identified.

CONCLUSION

The rates of thrombosis and bleeding in this predominantly African population were consistent with similar studies and can be used to inform pregnant women of the benefits of anticoagulation and the risks of potential bleeding.

Epidemiology and definition of PPH worldwide

Postpartum/peripartum hemorrhage (PPH) is an obstetric emergency complicating 1-10% of all deliveries and is a leading cause of maternal mortality and morbidity worldwide. However, the incidence of PPH differs widely according to the definition and criteria used, the way of measuring postpartum blood loss, and the population being studied with the highest numbers in developing countries. Despite all the significant progress in healthcare, the incidence of PPH is rising due to an incomplete implementation of guidelines, resulting in treatment delays and suboptimal care. A consensus clinical definition of PPH is needed to enable awareness, early recognition, and initiation of appropriate intensive treatment. Unfortunately, the most used definition of PPH based on blood loss ≥500 ml after delivery suffers from inaccuracies in blood loss quantification and is not clinically relevant in most cases, as the amount of blood loss does not fully reflect the severity of bleeding.

Hemorrhagic shock due to colonic arteriovenous malformation in late pregnancy: a case report

Background

Intestinal arteriovenous malformations are difficult to detect because they often present asymptomatically. However, pregnancy increases the hemorrhagic risk of intestinal arteriovenous malformations. This can lead to massive bleeding and hemodynamic instability, threatening the lives of both the mother and fetus. We describe a life-threatening case of hemorrhagic shock due to a colonic intestinal arteriovenous malformation during late pregnancy that was successfully treated through endovascular management.

Case presentation

A 36-year-old gravida 1, para 1 woman at 35 weeks’ gestation presented with hemodynamic instability and painless hematochezia. The patient had hemorrhagic shock and required massive transfusion. A colonoscopy failed to secure a visual field due to bloody fluid, and endoscopic hemostasis was difficult. Before the bleeding could be controlled, the condition of the fetus continued to deteriorate, showing bradycardia dysrhythmia. Therefore, an emergency cesarean section was performed, which was successful. However, the bleeding did not subside, with the patient’s hemodynamic instability and hematochezia persisting. An angiogram revealed an ascending colonic intestinal arteriovenous malformation, with extravasation of the contrast medium from a branch of the ileocolic artery. Localized blood flow control and hemodynamic stability were achieved via angioembolization. The patient had an uneventful postoperative recovery and was discharged on postoperative day 12. The newborn was admitted to the neonatal intensive care unit. She successfully recovered and was discharged when she was 22 days old.

Conclusions

We reported a case of colonic intestinal arteriovenous malformation resulting in hemodynamic instability due to hematochezia during late pregnancy, which was successfully treated via angioembolization. Intestinal arteriovenous malformation should be considered as a differential diagnosis in pregnant patients with hemodynamic instability and hematochezia.

Nonovert disseminated intravascular coagulation (DIC) in pregnancy: a new scoring system for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion

BACKGROUND

Nonovert disseminated intravascular coagulation (DIC) is a subclinical hemostatic dysfunction that has not yet reached the decompensation stage. The detection of pregnant patients at this stage may assist in the identification of those who will develop severe obstetrical hemorrhage, as it is one of the leading causes for preventable maternal mortality. Currently, nonovert DIC is diagnosed by a scoring system based on nonpregnant patients, originally generated by the International Society on Thrombosis and Hemostasis (ISTH), which does not address the physiologic changes of the hemostatic system during pregnancy.

OBJECTIVES

(1) To develop a pregnancy-specific nonovert DIC score, (2) to determine the diagnostic performance of this score in detecting women at risk for obstetrical hemorrhage requiring blood product transfusion, and (3) to compare it to the existing ISTH nonovert DIC score.

STUDY DESIGN

This retrospective study has longitudinal and cross-sectional components and includes three steps: (1) characterization of the longitudinal changes in the components of modified ISTH nonovert DIC scores, including these parameters - fibrinogen, antithrombin III, protein C, prothrombin time (PT), platelets, thrombin-antithrombin (TAT) complex, and D-dimer - during gestation in a group of normal pregnancies (n = 50); (2) development of a pregnancy-specific nonovert DIC score in a cross-sectional design of high-risk (n = 152) and control (n = 50) pregnancies, based on the predictive performance of each analyte for the detection of women at risk for obstetrical hemorrhage requiring blood product transfusion and a logistic regression model; and (3) comparison between the diagnostic performance of the pregnancy-specific nonovert DIC score and the modified ISTH nonovert DIC score to detect, upon admission, women who are at increased risk for subsequent development of obstetrical hemorrhage requiring blood product transfusion.

RESULTS

(1) The study cohort included 202 patients, of which 21 (10%) had obstetrical hemorrhage that required blood product transfusion and were considered to have nonovert DIC; (2) using the nonpregnant ISTH nonovert DIC score, 92% of the patients had a D-dimer concentration above the 0.5 mg/L threshold, and only 2% were identified to have a low fibrinogen concentration (<100 mg/dL); thus, this scoring system was unable to identify any of the patients with nonovert DIC based on the suggested cutoff of a score of ≥5; (3) the parameters included in the pregnancy-specific nonovert DIC score were selected based on their contribution to the performance of the model for the prediction of women at risk for obstetrical hemorrhage requiring blood product transfusion; as a result, we excluded the PT difference parameter from the score and the TAT complex concentration was added; and (4) a pregnancy-specific nonovert DIC score of ≥3 had a sensitivity of 71.4% and a specificity of 77.9% to identify patients at risk for obstetrical hemorrhage requiring blood product transfusion.

CONCLUSION

We propose (1) a pregnancy-specific nonovert DIC score adjusted for the physiologic changes in the hemostatic system during gestation; and (2) that the pregnancy-specific nonovert DIC score can be a useful tool for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion.

The Use of Whole Blood Transfusion During Non-Traumatic Resuscitation

BACKGROUND

Evidence from military populations showed that resuscitation using whole blood (WB), as opposed to component therapies, may provide additional survival benefits to traumatically injured patients. However, there is a paucity of data available for the use of WB in uninjured patients requiring transfusion. We sought to describe the use of WB in non-trauma patients at Brooke Army Medical Center (BAMC).

MATERIALS AND METHODS

Between January and December 2019, the BAMC ClinComp electronic medical record system was reviewed for all patients admitted to the hospital who received at least one unit of WB during this time period. Patients were sorted based on their primary admission diagnosis. Patients with a primary trauma-based admission were excluded.

RESULTS

One hundred patients were identified who received at least one unit of WB with a primary non-trauma admission diagnosis. Patients, on average, received 1,064 mL (750-2,458 mL) of WB but received higher volumes of component therapy. Obstetric/gynecologic (OBGYN) indications represented the largest percentage of non-trauma patients who received WB (23%), followed by hematologic/oncologic indications (16%).

CONCLUSION

In this retrospective study, WB was most commonly used for OBGYN-associated bleeding. As WB becomes more widespread across the USA for use in traumatically injured patients, it is likely that WB will be more commonly used for non-trauma patients. More outcome data are required to safely expand the indications for WB use beyond trauma.

Criteria for placenta accreta spectrum in the International Federation of Gynaecology and Obstetrics classification, and topographic invasion area are associated with massive hemorrhage in patients with placenta previa

INTRODUCTION

Placenta previa with placenta accreta spectrum (PAS) is a life-threatening disease that results in massive hemorrhage. The clinical and histologic criteria of PAS were adopted according to the International Federation of Gynaecology and Obstetrics (FIGO) classification. We aimed to investigate whether FIGO criteria and topography were associated with maternal complications in patients with placenta previa.

MATERIAL AND METHODS

Patients with placenta previa who underwent cesarean section at our institution between January 2003 and December 2019 were identified. First, they were divided based on FIGO classification, as follows: Group A, with clinical criteria; Group B, with histologic criteria; and Group C: without clinical or histologic criteria. Next, cases with PAS were classified according to the topographic invasion area, as follows: type 1, upper posterior bladder; type 2, lower posterior bladder; type 3, parametrium; type 4, posterior lower uterine segment. Predictive factors for massive hemorrhage were retrospectively analyzed.

RESULTS

Among the 350 patients, 24 (6.9%) were classified as Group A, 16 (4.6%) as Group B and 310 (88.5%) as Group C. Regarding maternal history and hemostatic procedures, there were no significant factors other than hysterectomy (p < .01) in Groups A and B. The volume of blood loss in both Groups A and B was greater than in Group C (p < .01). The rates of uterine artery embolization and blood transfusion were higher in Groups A and B than in Group C (p < .01). In addition, there were no significant factors other than hysterectomy between Groups A and B. In the multivariate analysis for massive hemorrhage, Group A (odds ratio: 2.73, p = .04) and Group B (odds ratio: 12.69, p < .01) were identified as independent predictive factors. In addition, massive hemorrhage was closely related to the lower posterior bladder and parametrial invasion in both Groups A and B.

CONCLUSIONS

Both clinical and histologic criteria for PAS in the FIGO classification were associated with massive hemorrhage. Diagnosing clinical PAS using the FIGO classification, additional hemostatic procedures might be necessary according to the topographic invasion area.

Gestational weight gain and delivery outcomes: A population-based cohort study

BACKGROUND

Gestational weight gain is a modifiable factor that could impact maternal and infant health. However, its effect on delivery outcomes is not well established.

OBJECTIVES

To investigate the associations between gestational weight gain and delivery outcomes stratified by early-pregnancy body mass index (BMI).

METHODS

The study population included singleton livebirths in the Stockholm-Gotland obstetric cohort (January 2008 to October 2014; n = 174 953). The exposure was total gestational weight gain standardised into gestational-age-specific z-scores by using previously defined Swedish pregnancy weight gain-for-gestational age charts. The outcomes included caesarean delivery (overall, elective, and emergency), instrumental vaginal delivery, induction of labour, and postpartum haemorrhage. Confounders included maternal age, maternal height, parity, smoking status, cohabitation status, chronic hypertension, and pre-pregnancy diabetes. Logistic regression models with marginal standardisation were used to estimate risk ratios (RR) with 95% confidence intervals (CI) for each delivery outcome stratified by early-pregnancy BMI.

RESULTS

Above average weight gain (z-score ≥ 0.50 SD) increased risks of caesarean delivery (from RR 1.08, 95% CI 1.00, 1.15 to RR 1.45, 95% CI 1.35, 1.55 across BMI groups), induction of labour (from RR 1.14, 95% CI 1.04, 1.23 to RR 1.38, 95% CI 1.25, 1.51 across BMI groups except underweight), and postpartum haemorrhage (from RR 1.13, 95% CI 1.07, 1.19 to RR 1.25, 95% CI 1.09, 1.41 among normal and overweight). Below average weight gain (z-score <-0.50 SD) decreased caesarean delivery risk (from RR 0.77, 95% CI 0.61, 0.93 to RR 0.89, 95% CI 0.84, 0.95 across BMI groups except underweight).

CONCLUSIONS

In normal and overweight women, the risks of caesarean delivery, induction of labour, and postpartum haemorrhage increased with gestational weight gain. In obese women, higher gestational weight gain increased risks of caesarean delivery and induction of labour. Low gestational weight gain reduced risk of caesarean delivery in all BMI groups except underweight.

To Clot or Not: HELLP Syndrome and Disseminated Intravascular Coagulation in an Eclamptic Patient with Intrauterine Fetal Demise

A 39-year-old G2P1001 female presented from an outside hospital following an eclamptic seizure in the setting of HELLP syndrome. This condition was complicated by intrauterine fetal demise and disseminated intravascular coagulation, which required an emergent cesarean section. We report the work-up and intraoperative and postoperative management of this complex patient with multiple medical needs. We focus on the hemostatic abnormalities in this patient and describe how our management would differ from that of a similar, nonpregnant patient.

Optimal Profile Limits for Maternal Mortality Rates (MMR) Influenced by Haemorrhage and Unsafe Abortion in South Sudan

Maternal mortality rate (MMR) is one of the main worldwide public health challenges. Presently, the high levels of MMR are a common problem in the world public health and especially, in developing countries. Half of these maternal deaths occur in Sub-Saharan Africa where little or nothing progress has been made. South Sudan is one of the developing countries which has the highest MMR. Thus, this paper deploys statistical analysis to identify the significant physiological causes of MMR in South Sudan. Prediction models based on Poisson Regression are then developed to predict MMR in terms of the significant physiological causes. Coefficients of determination and variance inflation factor are deployed to assess the influence of the individual causes on MMR. Efficacy of the models is assessed by analyzing their prediction errors. The paper for the first time has used optimization procedures to develop yearly lower and upper profile limits for MMR. Hemorrhaging and unsafe abortion are used to achieve UN 2030 lower and upper MMR targets. The statistical analysis indicates that reducing haemorrhaging by 1.91% per year would reduce MMR by 1.91% (95% CI (42.85–52.53)), reducing unsafe abortion by 0.49% per year would reduce MMR by 0.49% (95% CI (11.06–13.56)). The results indicate that the most influential predictors of MMR are; hemorrhaging (38%), sepsis (11.5%), obstructed labour (11.5%), unsafe abortion (10%), and indirect causes such as anaemia, malaria, and HIV/AIDs virus (29%). The results also show that to obtain the UN recommended MMR levels of minimum 21 and maximum 42 by 2030, the Government and other stakeholders should simultaneously, reduce haemorrhaging from the current value of 62 to 33.38 and 16.69, reduce unsafe abortion from the current value of 16 to 8.62 and 4.31. Thirty years of data is used to develop the optimal reduced Poisson Model based on hemorrhaging and unsafe abortion. The model with R² of 92.68% can predict MMR with mean error of −0.42329 and SE-mean of 0.02268. The yearly optimal level of hemorrhage, unsafe abortion, and MMR can aid the government and other stakeholders on resources allocation to reduce the risk of maternal death.

Evaluation of decision to delivery time interval and its effect on feto-maternal outcomes and associated factors in category-1 emergency caesarean section deliveries: prospective cohort study

Background

Category-1 emergency caesarean section delivery is the commonly performed surgical procedure in pregnant women associated with significant mortality and morbidity both in the mother and fetus. The decision to delivery time interval is recommended to be less than 30 min by the Royal College of Obstetricians and Gynecologists as well as the American College of Obstetricians and Gynecologists. This study was designed to evaluate the decision to delivery time interval and its effect on feto-maternal outcomes and the associated factors during category-1 emergency caesarean section deliveries.

Method

A prospective observational cohort study was conducted from March to May 2018 at the University of Gondar Comprehensive Specialized Hospital obstetrics Operation Theater and postnatal ward. A total of 163 clients who were undergone category-1 emergency caesarean section were included in this study. Statistical analysis was performed using SPSS version 20 (IBM Corporate). Bivariate and multivariate logistic regression with a 95% confidence interval was used to determine the association of decision to delivery time interval with predictor variables and feto-maternal outcomes.

Results

Only 19.6% of women had a decision to delivery time interval below 30 min. The average decision to delivery time interval was 42 ± 21.4 min, the average time from the decision of category-1 emergency caesarean section arrival to the operation theater was 21.58 ± 19.76 min and from theater to delivery of anesthesia was 11.5 ± 3.6 min. Factors that were associated with prolonged decision to delivery time interval were: time taken to collect surgical materials (AOR = 13.76, CI = 1.12–168.7), time taken from decision and arrival to the operation theater (AOR = 0.75, CI = 0.17–3.25) and time taken from arrival at the operation theater to the immediate start of skin incision (AOR = 0.43, CI = 0.28–0.65).

Conclusion

Delivery was not achieved within the recommended time interval in the majority of category-1 emergency caesarean sections. The average decision to delivery time interval was longer than the recommended time but it did not affect feto-maternal outcomes.

Exploring maternal and health professional beliefs about the factors that affect whether women in Saudi Arabia attend antenatal care clinic appointments

OBJECTIVE

Effective antenatal care is important for the health and wellbeing of pregnant women and infants. However, in Saudi Arabia, attendance rates are low, increasing the risk of negative birth outcomes. The aim of this research is to understand the beliefs of pregnant women and health professionals about the factors leading to these low attendance rates.

METHODOLOGY

A qualitative exploratory study-using semi structured face-to-face interviews. Interviews were conducted exploring (a) attitudes to the use of antenatal care by pregnant Saudi women, (b) beliefs of women regarding the value of antenatal care and (c) perceived barriers to attendance.

SETTING

Data were collected from three hospitals in two regions of Saudi Arabia.

PARTICIPANTS

Women at any stage of their pregnancy attending for antenatal care or ultrasound, women attending postnatal clinic, and health professionals (obstetricians) who support women during pregnancy and birth.

FINDINGS

Although mothers viewed antenatal care as important for maternal and infant health, several barriers to attending care were identified by mothers and professionals. These factors were classified into three themes: physical barriers (e.g., lack of transport), low maternal education, and inadequate healthcare facilities (including negative staff attitudes and poor communication). These factors were exacerbated by the beliefs of partners and family. Notably, the theme of low maternal education was raised only by health professionals, whilst the theme of staff attitudes and communication was raised only by mothers.

KEY CONCLUSIONS

Barriers to antenatal care exist at the personal, social, socioeconomic and health services level. Some health professionals may be unaware of the importance of their communication style. Interventions to improve attendance must be multifaceted rather than focussing on individual women alone.

IMPLICATIONS FOR PRACTICE

Barriers for women attending antenatal healthcare must be addressed in order to increase attendance rates. Specific practice-based interventions may involve changing the time or location of services and exploring changes to staff communication with women.

ebb® Complete Tamponade System: effective hemostasis for postpartum hemorrhage

As a leading cause of maternal death, postpartum hemorrhage (PPH) remains a worldwide obstetrical problem. However, in most cases, mortality and morbidity can be averted if efforts are immediately undertaken to achieve hemostasis. Uterine balloon tamponade has been shown to provide effective control of PPH and avoid more invasive surgical procedures and even the emergency peripartum hysterectomy. Recent clinical recommendation suggests that balloon tamponade should be considered earlier in the treatment cascade in conjunction with uterotonic agents to ensure hemostasis in the most timely fashion and maximize clinical outcomes. This paper profiles the ebb^® Complete Tamponade System, a unique dual-balloon single-use device that was developed specifically for hemostatic management of PPH. The ebb system combines a uterine conforming balloon that can be rapidly deployed with a vaginal balloon that eliminates the need for vaginal packing. The description, indications for use, procedural steps, and clinical characterization of this device are presented.

Low molecular weight heparin use during pregnancy and risk of postpartum hemorrhage: a systematic review and meta-analysis

INTRODUCTION

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide with a prevalence rate of approximately 6%. Although most cases of PPH have no identifiable risk factors, the incidence of PPH has been associated to the thromboprophylaxis in pregnancy with low molecular weight heparin (LMWH). Thus, the aim of the study is to evaluate the risk of PPH in cases of pregnant women exposed to LMWH.

MATERIALS AND METHODS

Electronic research was performed in OVID, Scopus, ClinicalTrials.gov, MEDLINE, the PROSPERO International Prospective Register of Systematic Reviews, EMBASE, and the Cochrane Central Register of Controlled Trials through April 2016. We included randomized controlled trials, cohort and case-control studies of women who underwent thromboprophylaxis with LMWH during pregnancy compared to a control group (either placebo or no treatment). The primary outcome was the incidence of PPH. The summary measures were reported as relative risk (RR) or as mean differences (MD) with 95% confidence interval (CI).

RESULTS

Eight studies including 22,162 women were analyzed. Of the 22,162 women, 1320 (6%) were administered LMWH, 20,842 (94%) women formed the nonexposed group (control group). Women treated with LMWH had a higher risk of PPH (RR 1.45, 95%CI 1.02-2.05) compared to controls; there was no difference in mean of blood loss at delivery (MD -32.90, 95%CI 68.72-2.93) and in risk of blood transfusion at delivery (RR 1.24, 95%CI 0.62-2.51), respectively.

CONCLUSIONS

Women who receive LMWH during pregnancy have a significantly higher risk of developing PPH. Women who receive LMWH during pregnancy have neither significantly higher mean blood loss at delivery nor higher risk of blood transfusion.

Uterine Tamponade Device to Control Atonic Primary Postpartum Haemorrhage in Resource-Poor Settings

This paper proposes and presents the proof of concept for an improvised device adapted from the condom tamponade used for controlling atonic primary postpartum haemorrhage in resource-poor settings. The device has been designed to address the setbacks of the conventional condom tamponade. The setbacks of the condom tamponade were assessed. Using the systematic engineering design process, a device was designed to address the setbacks of the condom tamponade. The device comprises an inflation/deflation system, blood drainage system and clamping system. Results from testing show that for an inexperienced user, the device has quicker inflation (3.36 ± 1.70 minutes/ 500 ml) and faster set-up time (3.60 ± 1.50 minutes), as compared to the conventional condom tamponade. The clamping system of the device also ensures effective control of fluid dynamics and prevents backflow. The device, however, was not tested on human subjects to prove its efficacy for actual treatment of patients. The device also can be easily and quickly set-up and operated by frontline healthcare providers with limited expertise, in resource-poor settings. It has further been designed for safety (use of biocompatible materials and elimination of sharp edges for the parts expected to have direct contact with the uterus).

Why women bleed and how they are saved: a cross-sectional study of caesarean section near-miss morbidity

Background

Maternal deaths from ‘bleeding during and after caesarean section’ (BDACS) have increased in South Africa, and have now become the largest sub-cause of deaths from obstetric haemorrhage. The aim of this study was to describe risk factors and causes of near-miss related to BDACS and interventions used to arrest haemorrhage and treat its effects.

Methods

Cross-sectional prospective study in 13 urban public hospitals in South Africa, from July to December 2014.

Results

There were 93 cases of near-miss related and 7 maternal deaths related to BDACS. The near-miss rate was 2.1/1000 live births, and the case fatality rate was 3.5/10 000 caesarean sections. Associated near-miss risk factors were previous caesarean section in 60% of multiparas, pre-operative anaemia (55%), abruptio placentae (20%) and placenta praevia and/or accreta (20%). Atonic uterus (43%) was the most frequent anatomical cause of bleeding for near-miss, followed by surgical trauma (29%). The median duration of the operations resulting in near-miss was 90 min, with 81% noted as difficult by the surgeon. Interventions in cases of near-miss included second-look laparotomy (46%), hysterectomy (41%), B-Lynch brace suture (9%), intensive care unit admission (32%) and red cell transfusion ≥3 units (21%).

Conclusion

Cases from maternal near-miss from BDACS were frequently associated with pre-operative risk factors. Extensive life-saving interventions were required during and after the operations. An important factor in initiating the sequence of interventions is the realisation by the surgeon that the caesarean section is difficult, so that the progression from uneventful operation to near-miss to death can be arrested.

The parturient in the interventional radiology suite: New frontier in obstetric anaesthesia

The anaesthesiologist's presence during interventional radiology (IR) is increasing due to increasingly ill patients and intricate procedures. The management of a parturient in IR suite is complex in terms of logistics of an unfamiliar procedure in an unfamiliar area. The literature available is largely written by radiologists with little attention paid to anaesthetic details and considerations. In the Indian scenario, in the absence of hybrid operating rooms (ORs), logistics involve transport of a parturient back and forth between the IR suite and the OR. As members of a multidisciplinary team, anaesthesiologists should utilise their expertise in fluid management, transfusion therapy and critical care to prevent and treat catastrophic events that may accompany severe peri-partum bleeding. Ensuring familiarity with the variety of IR procedures and the peri-procedure requirements can help the anaesthesiologist provide optimum care in the IR suite.

Relation between Birth Weight and Intraoperative Hemorrhage during Cesarean Section in Pregnancy with Placenta Previa

Background

Placenta previa, one of the most severe obstetric complications, carries an increased risk of intraoperative massive hemorrhage. Several risk factors for intraoperative hemorrhage have been identified to date. However, the correlation between birth weight and intraoperative hemorrhage has not been investigated. Here we estimate the correlation between birth weight and the occurrence of intraoperative massive hemorrhage in placenta previa.

Materials and Methods

We included all 256 singleton pregnancies delivered via cesarean section at our hospital because of placenta previa between 2003 and 2015. We calculated not only measured birth weights but also standard deviation values according to the Japanese standard growth curve to adjust for differences in gestational age. We assessed the correlation between birth weight and the occurrence of intraoperative massive hemorrhage (>1500 mL blood loss). Receiver operating characteristic curves were constructed to determine the cutoff value of intraoperative massive hemorrhage.

Results

Of 256 pregnant women with placenta previa, 96 (38%) developed intraoperative massive hemorrhage. Receiver-operating characteristic curves revealed that the area under the curve of the combination variables between the standard deviation of birth weight and intraoperative massive hemorrhage was 0.71. The cutoff value with a sensitivity of 81.3% and specificity of 55.6% was −0.33 standard deviation. The multivariate analysis revealed that a standard deviation of >−0.33 (odds ratio, 5.88; 95% confidence interval, 3.04–12.00), need for hemostatic procedures (odds ratio, 3.31; 95% confidence interval, 1.79–6.25), and placental adhesion (odds ratio, 12.68; 95% confidence interval, 2.85–92.13) were independent risk of intraoperative massive hemorrhage.

Conclusion

In patients with placenta previa, a birth weight >−0.33 standard deviation was a significant risk indicator of massive hemorrhage during cesarean section. Based on this result, further studies are required to investigate whether fetal weight estimated by ultrasonography can predict hemorrhage during cesarean section in patients with placental previa.

Disseminated intravascular coagulation in pregnancy: insights in pathophysiology, diagnosis and management

Disseminated intravascular coagulation (DIC) is a life-threatening situation that can arise from a variety of obstetrical and nonobstetrical causes. Obstetrical DIC has been associated with a series of pregnancy complications including the following: (1) acute peripartum hemorrhage (uterine atony, cervical and vaginal lacerations, and uterine rupture); (2) placental abruption; (3) preeclampsia/eclampsia/hemolysis, elevated liver enzymes, and low platelet count syndrome; (4) retained stillbirth; (5) septic abortion and intrauterine infection; (6) amniotic fluid embolism; and (7) acute fatty liver of pregnancy. Prompt diagnosis and understanding of the underlying mechanisms of disease leading to this complication in essential for a favorable outcome. In recent years, novel diagnostic scores and treatment modalities along with bedside point-of-care tests were developed and may assist the clinician in the diagnosis and management of DIC. Team work and prompt treatment are essential for the successful management of patients with DIC.

Using in situ simulation to evaluate operational readiness of a children's hospital-based obstetrics unit

INTRODUCTION

Relocating obstetric (OB) services to a children's hospital imposes demands on facility operations, which must be met to ensure quality care and a satisfactory patient experience. We used in situ simulations to prospectively and iteratively evaluate operational readiness of a children's hospital-based OB unit before it opened for patient care.

METHODS

This project took place at a 314-bed, university-affiliated children's hospital. We developed 3 full-scale simulation scenarios depicting a concurrent maternal and neonatal emergency. One scenario began with a standardized patient experiencing admission; the mannequin portrayed a mother during delivery. We ran all 3 scenarios on 2 dates scheduled several weeks apart. We ran 2 of the scenarios on a third day to verify the reliability of key processes. During the simulations, content experts completed equipment checklists, and participants identified latent safety hazards. Each simulation involved a unique combination of scheduled participants who were supplemented by providers from responding ancillary services.

RESULTS

The simulations involved 133 scheduled participants representing OB, neonatology, and anesthesiology. We exposed and addressed operational deficiencies involving equipment availability, staffing, interprofessional communication, and systems issues such as transfusion protocol failures and electronic order entry challenges. Process changes between simulation days 1 to 3 decreased the elapsed time between transfusion protocol activation and blood arrival to the operating room and labor/delivery/recovery/postpartum setting.

CONCLUSIONS

In situ simulations identified multiple operational deficiencies on the OB unit, allowing us to take corrective action before its opening. This project may guide other children's hospitals regarding care processes likely to require significant focus and possible modification to accommodate an OB service.

Genetic contribution to postpartum haemorrhage in Swedish population: cohort study of 466,686 births

OBJECTIVE

To investigate the familial clustering of postpartum haemorrhage in the Swedish population, and to quantify the relative contributions of genetic and environmental effects.

DESIGN

Register based cohort study.

SETTING

Swedish population (multi-generation and medical birth registers).

MAIN OUTCOME MEASURE

Postpartum haemorrhage, defined as >1000 mL estimated blood loss.

PARTICIPANTS

The first two live births to individuals in Sweden in 1997-2009 contributed to clusters representing intact couples (n = 366,350 births), mothers with separate partners (n = 53,292), fathers with separate partners (n = 47,054), sister pairs (n = 97,228), brother pairs (n = 91,168), and mixed sibling pairs (n = 177,944).

METHODS

Familial clustering was quantified through cluster specific tetrachoric correlation coefficients, and the influence of potential sharing of known risk factors was evaluated with alternating logistic regression. Relative contributions of genetic and environmental effects to the variation in liability for postpartum haemorrhage were quantified with generalised linear mixed models.

RESULTS

The overall prevalence of postpartum haemorrhage after vaginal deliveries in our sample was 4.6%. Among vaginal deliveries, 18% (95% confidence interval 9% to 26%) of the variation in postpartum haemorrhage liability was attributed to maternal genetic factors, 10% (1% to 19%) to unique maternal environment, and 11% (0% to 26%) to fetal genetic effects. Adjustment for known risk factors only partially explained estimates of familial clustering, suggesting that the observed shared genetic and environmental effects operate in part through pathways independent of known risk factors. There were similar patterns of familial clustering for both of the main subtypes examined (atony and retained placenta), though strongest for haemorrhage after retained placenta.

CONCLUSIONS

There is a maternal genetic predisposition to postpartum haemorrhage, but more than half of the total variation in liability is attributable to factors that are not shared in families.

Maternal mortality due to hemorrhage in Brazil

OBJECTIVE

to analyze the rates of maternal mortality due to hemorrhage identified in Brazil from 1997 to 2009.

METHODS

the time series and population data from the Brazilian Health Ministry, Mortality Information System and Live Birth Information System were examined. From the Mortality Information System, we initially selected all reported deaths of women between 10 and 49 years old, which occurred from January 1, 1997 to December 31, 2009 in Brazil, recorded as a "maternal death".

RESULTS

during the research period, 22,281 maternal deaths were identified, among which 3,179 were due to hemorrhage, accounting for 14.26% of the total deaths. The highest rates of maternal mortality were found in the North and Northeast areas of Brazil.

CONCLUSIONS

the Brazilian scenario shows regional inequalities regarding maternal mortality. It presents hemorrhaging as a symptom and not as a cause of death.

[Declarative survey about postpartum haemorrhage management by anaesthesiologists in Pays de la Loire area (France): what's the adherence to clinical practice guidelines?]

OBJECTIVE

To assess the management of postpartum hemorrhage (PPH) by anaesthesiologists in Pays de la Loire area.

METHODS

A declarative survey was conducted from November 2011 to January 2012 with an online questionnaire to assess prevention and PPH specific care and to clarify the PPH transfusion practices and interest of new therapies. Nine indicators of adherence to clinical practice guidelines were selected to distinguish two groups: one group "adhering to the RCP" and another "not adhering to the RCP".

RESULTS

Response rate 53%. One hundred and one responses were analyzed. Use of a collection bag graded blood receipt pockets 93%, start time of PPH noted: 76%, leaf specific monitoring: 67%, management of the third part of the work: 78%. The evacuation of the placenta is performed within 30minutes in 75% of cases. The transfusion strategy happens early (92% before the biological assessment results) and "aggressive" (ratio RCB/FFP is 1/1 for 72%). The use of tranexamic acid is not systematic (53%). Seventy-nine percent of respondents adhere to the RCP. Practitioners in maternity level 1 (with few deliveries) don't follow these RCP as much.

CONCLUSION

Some inappropriate practices remain in structures not used to support them. The use of new therapies remain controversial. The priority at this time is the implementation and enforcement of the current RCP, not their modifications.

DIC score in pregnant women--a population based modification of the International Society on Thrombosis and Hemostasis score

Objectives

The objectives of this study were: 1) To determine the component needed to generate a validated DIC score during pregnancy. 2) To validate such scoring system in the identification of patients with clinical diagnosis of DIC.

Material and Methods

This is a population based retrospective study, including all women who gave birth at the ‘Soroka University Medical Center’ during the study period, and have had blood coagulation tests including complete blood cell count, prothrombin time (PT)(seconds), partial thromboplastin time (aPTT), fibrinogen, and D-dimers. Nomograms for pregnancy were established, and DIC score was constructed based on ROC curve analyses.

Results

1) maternal plasma fibrinogen concentrations increased during pregnancy; 2) maternal platelet count decreased gradually during gestation; 3) the PT and PTT values did not change with advancing gestation; 4) PT difference had an area under the curve (AUC) of 0.96 (p<0.001), and a PT difference ≥1.55 had an 87% sensitivity and 90% specificity for the diagnosis of DIC; 5) the platelet count had an AUC of 0.87 (p<0.001), an 86% sensitivity and 71% specificity for the diagnosis of DIC; 6) fibrinogen concentrations had an AUC of 0.95 (p<0.001) and a cutoff point ≤3.9 g/L had a sensitivity of 87% and a specificity of 92% for the development of DIC; and 7) The pregnancy adjusted DIC score had an AUC of 0.975 (p<0.001) and at a cutoff point of ≥26 had a sensitivity of 88%, a specificity of 96%, a LR(+) of 22 and a LR(−) of 0.125 for the diagnosis of DIC.

Conclusion

We could establish a sensitive and specific pregnancy adjusted DIC score. The positive likelihood ratio of this score suggests that a patient with a score of ≥26 has a high probability to have DIC.

Ruptured splenic artery aneurysms and the use of an adapted fast protocol in reproductive age women with hemodynamic collapse: case series

Nontraumatic symptomatic hypotension in all patients requires prompt diagnosis and appropriate treatment for optimum outcome. The female population specifically has an expanded differential diagnosis that should be considered when these patients present with hemodynamic collapse. While the most common causes of hypotension in pregnant patients are dehydration, ruptured ectopic pregnancy, and placental and uterine abnormalities, less common nonobstetrical etiologies such as hepatic rupture and ruptured abdominal and visceral artery aneurysms should also be considered. Splenic artery aneurysms are associated with high rates of mortality and in cases of pregnancy, maternal and fetal mortality. These high rates can be attributed to the asymptomatic nature of the aneurysm, rapid deterioration after rupture, and frequent misdiagnosis. In patients with hemodynamic collapse, the role of traditional imaging is limited mainly due to the critical condition of the patient. Bedside ultrasound has emerged as a diagnostic imaging resource in patients with undifferentiated hypotension and in patients with traumatic injuries. However, its use has not been studied specifically in the female population. We present two patients with ruptured splenic artery aneurysms, discuss the role of bedside ultrasound in their management, and introduce a new ultrasound protocol for use in reproductive age female patients with hemodynamic collapse.

[An update of the obstetrics hemorrhage treatment protocol]

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

Role of interventional radiology in treating obstetric haemorrhages

PURPOSE

The aim of this study was to evaluate the efficacy and the safety of selective uterine artery embolisation in patients with a high risk of haemorrhage due to obstetric issues.

MATERIALS AND METHODS

We retrospectively reviewed the angiographic examinations of 63 patients (average age ± SD, 32.6 years ± 4.8), affected by an obstetric disease with a high risk of haemorrhage (22 cases of ectopic pregnancy, 41 of postpartum haemorrhage) and treated with an interventional approach. In particular, we considered the rate of second treatment with interventional technique or conservative or radical surgery, the incidence of postprocedural complications, and the absorbed radiation dose.

RESULTS

Immediate technical success, defined as the cessation of active bleeding, was achieved in all cases. Uterine artery embolisation was able alone to control the haemorrhage in 95.24 % of cases. Three patients required a second treatment to achieve haemostasis. No peri- or postprocedural complications were observed. At the 12-month follow-up after embolisation, 22/49 conservatively treated patients were found to be pregnant and successfully completed their pregnancy.

CONCLUSIONS

Selective uterine artery embolisation allows for safe and complete control of haemorrhage in patients with obstetric disease, with a very low incidence of complications and preservation of fertility.

Racial/ethnic disparities in maternal morbidities: a statewide study of labor and delivery hospitalizations in Wisconsin

We examined racial/ethnic disparities in maternal morbidities (MM) and the number of MM during labor and delivery among hospital discharges in Wisconsin. We conducted a retrospective cohort study of hospital discharge data for 206,428 pregnant women aged 13-53 years using 2005-2007 Healthcare Cost and Utilization Project State Inpatient Dataset (HCUP-SID) for Wisconsin. After adjustments for covariates, MM (preterm labor, antepartum and postpartum hemorrhage, hypertension in pregnancy, gestational diabetes, membrane-related disorders, infections and 3rd and 4th perineal lacerations) were examined using logistic regression models, and number of MM (0, 1, 2, >2 MM) were examined using multivariable ordered logistic regressions with partial proportional odds models. African-Americans had significantly higher likelihood of infections (OR = 1.74; 95% CI 1.60-1.89), preterm labor (OR = 1.42; 1.33-1.50), antepartum hemorrhage (OR = 1.63; 1.44-1.83), and hypertension complicating pregnancy (OR = 1.39; 1.31-1.48) compared to Whites. Hispanics, Asian/Pacific Islanders, and Native Americans had significantly higher likelihood of infections, postpartum hemorrhage, and gestational diabetes than Whites. Major perineal lacerations were significantly higher among Asian/Pacific Islanders (OR = 1.53; 1.34-1.75). All minority racial/ethnic groups, except Asians, had significantly higher likelihood of having 0 versus 1, 2 or >2 MM, 0 or 1 versus 2 or >2 MM, and 0, 1 or 2 versus >2 MM than white women. Findings show significant racial/ethnic disparities in MM, and suggest the need for better screening, management, and timely referral of these conditions, particularly among racial/ethnic women. Disparities in MM may be contributing to the high infant mortality and adverse birth outcomes among different racial/ethnic groups in Wisconsin.

[Massive obstetric haemorrhage in a patient with placenta percreta]

We present a case of a 38 year-old patient with prenatal diagnosis of placenta praevia. When the elective caesarean began it was found a placenta accreta. In spite of an emergency hysterectomy, embolisation using interventional radiography was needed after a massive obstetric haemorrhage. The post-operative period progressed without incidents.

Tissue factor-dependent thrombin generation across pregnancy

OBJECTIVE

Normal pregnancy results in a prothrombotic state. Studies that have investigated the capacity of pregnant women to generate thrombin are limited. Our aim was to evaluate thrombin generation longitudinally from the preconception period, through pregnancy, and after pregnancy.

STUDY DESIGN

We evaluated young, healthy nulligravid women (n = 20) at 4 time points and compared the data with 10 control women at 2 time points. Coagulation was initiated with tissue factor in contact pathway inhibited plasma, and thrombin generation was determined in the presence of a fluorogenic substrate.

RESULTS

The maximum level and rate of thrombin generation increased during pregnancy; the highest level and rate occurred in late pregnancy compared with prepregnancy (P < .001). Subsequently, thrombin generation decreased in the postpregnancy samples that included maximum level, rate, and area under the curve (P < .001).

CONCLUSION

Our data provide evidence for an increase in tissue factor-dependent thrombin generation with pregnancy progression, followed by a return to prepregnancy thrombin levels.

Anesthetic review of emergency peripartum hysterectomy following vaginal and cesarean delivery: a retrospective study

Background

The purpose of this study was to review incidence, indications, complications, and the anesthetic management of emergency obstetric hysterectomies.

Methods

This was a retrospective study of the cases of emergency obstetric hysterectomies performed at the Woman's Hospital over a 3 year period between January 2008 and December 2010. The indication for surgery, anesthetic management, operating time, estimated blood loss, pre- and postoperative hemoglobin and hematocrit values, need for blood transfusion, and perioperative complications were obtained.

Results

During the study period there were 46 emergency obstetric hysterectomies for 20147 deliveries, giving an incidence of 2.28/1000 deliveries. The number of emergency hysterectomies was significantly higher with the cesarean deliveries than with the vaginal deliveries. The most common indication for emergency obstetric hysterectomy was placenta accreta. Postoperatively, Dissemimated Intravascular Coagulation (DIC) was the most common complication.

Conclusions

Abnormal placenta has been an main indication of emergency hysterectomy. Anesthesiologists should be eligible to aware of high risk of emergency hysterectomy and deal with massive hemorrhage.

Labor and delivery in a patient with hemophilia B

Hemophilia B is a rare X-linked disorder that may cause dramatic bleeding. Women account for only 3.2% of those clinically affected. The X-linked inheritance frequently delays the diagnosis in women and may expose the patient to an increased risk of adverse events. There is limited experience with these patients during labor and delivery. A 28-year-old primiparous woman with hemophilia B (bleeding phenotype) delivered a male infant by an unplanned cesarean delivery under general anesthesia following treatment with factor IX and normalization of her coagulation parameters, guided by thromboelastography. Postpartum vaginal bleeding required transfusion of two units of packed red blood cells. Factor IX supplementation continued for one week. Once diagnosed with hemophilia B, a multidisciplinary approach and advanced antenatal planning can increase the likelihood of a safe delivery. Neuraxial approaches and cesarean delivery are recommended only after normalization of the coagulation profile. The male fetus of a hemophilia A or B patient requires special attention. Operative vaginal delivery and invasive fetal monitoring should be avoided. Thromboelastography is an excellent technique to assess parturients with bleeding disorders or peripartum hemorrhage and may be underused.