Risk Factors for Atonic Postpartum Hemorrhage: A Systematic Review and Meta-analysis

Interpretable Machine Learning Predicts Postpartum Hemorrhage with Severe Maternal Morbidity in a Lower Risk Laboring Obstetric Population

BACKGROUND

Early identification of patients at increased risk for postpartum hemorrhage (PPH) associated with severe maternal morbidity (SMM) is critical for preparation and preventative intervention. However, prediction is challenging in patients without obvious risk factors for postpartum hemorrhage with severe maternal morbidity. Current tools for hemorrhage risk assessment use lists of risk factors rather than predictive models.

OBJECTIVE

To develop, validate (internally and externally), and compare a machine learning model for predicting PPH associated with SMM against a standard hemorrhage risk assessment tool in a lower-risk laboring obstetric population.

STUDY DESIGN

This retrospective cross-sectional study included clinical data from singleton, term births (>=37 weeks' gestation) at 19 US hospitals (2016-2021) using data from 44,509 births at 11 hospitals to train a generalized additive model (GAM) and 21,183 births at 8 held-out hospitals to externally validate the model. The outcome of interest was PPH with severe maternal morbidity (blood transfusion, hysterectomy, vascular embolization, intrauterine balloon tamponade, uterine artery ligation suture, uterine compression suture, or admission to intensive care). Cesarean birth without a trial of vaginal birth and patients with a history of cesarean were excluded. We compared the model performance to that of the California Maternal Quality Care Collaborative (CMQCC) Obstetric Hemorrhage Risk Factor Assessment Screen.

RESULTS

The GAM predicted PPH with an area under the receiver-operating characteristic curve (AUROC) of 0.67 (95% CI 0.64-0.68) on external validation, significantly outperforming the CMQCC risk screen AUROC of 0.52 (95% CI 0.50-0.53). Additionally, the GAM had better sensitivity of 36.9% (95% CI 33.01, 41.02) than the CMQCC screen sensitivity of 20.30% (95% CI 17.40, 22.52) at the CMQCC screen positive rate of 16.8%. The GAM identified in-vitro fertilization as a risk factor (adjusted OR 1.5; 95% CI 1.2-1.8) and nulliparous births as the highest PPH risk factor (adjusted OR 1.5; 95% CI; 1.4-1.6).

CONCLUSION

Our model identified almost twice as many cases of PPH as the CMQCC rules-based approach for the same screen positive rate and identified in-vitro fertilization and first-time births as risk factors for PPH. Adopting predictive models over traditional screens can enhance PPH prediction.

The outcome of reduced and non-reduced triplet pregnancies managed in a tertiary hospital during a 15-year-period - a retrospective cohort study

OBJECTIVES

Triplet pregnancies involve several complications, the most important being prematurity as virtually all triplets are born preterm. We conducted this study to compare the outcomes of reduced vs. non-reduced triplet pregnancies managed in the largest tertiary hospital in Finland.

METHODS

This was a retrospective cohort study in the Helsinki University Hospital during 2006-2020. Data on the pregnancies, parturients and newborns were collected from patient records. The fetal number, chorionicity and amnionicity were defined in first-trimester ultrasound screening. The main outcome measures were perinatal and neonatal mortality of non-reduced triplets, compared to twins and singletons selectively reduced of triplet pregnancies.

RESULTS

There were 57 initially triplet pregnancies and 35 of these continued as non-reduced triplets and resulted in the delivery of 104 liveborn children. The remaining 22 cases were spontaneously or medically reduced to twins (9) or singletons (13). Most (54.4 %) triplet pregnancies were spontaneous. There were no significant differences in gestational age at delivery between triplets (mean 33+0, median 34+0) and those reduced to twins (mean 32+5, median 36+0). The survival at one week of age was higher for triplets compared to twins (p<0.00001).

CONCLUSIONS

Most pregnancies continued as non-reduced triplets, which were born at a similar gestational age but with a significantly higher liveborn rate compared to those reduced to twins. There were no early neonatal deaths among cases reduced to singletons. Prematurity was the greatest concern for multiples in this cohort, whereas the small numbers may explain the lack of difference in gestational age between these groups.

Investigation of health inequities in maternal and neonatal outcomes of patients with placenta accreta spectrum: a multicenter study

BACKGROUND

Placenta accreta spectrum is associated with significant maternal and neonatal morbidity and mortality. There is limited established data on healthcare inequities in the outcomes of patients with placenta accreta spectrum.

OBJECTIVE

This study aimed to investigate health inequities in maternal and neonatal outcomes of pregnancies with placenta accreta spectrum.

STUDY DESIGN

This multicentered retrospective cohort study included patients with a histopathological diagnosis of placenta accreta spectrum at 4 regional perinatal centers between January 1, 2013, and June 30, 2022. Maternal race and ethnicity were categorized as either Hispanic, non-Hispanic Black, non-Hispanic White, or Asian or Pacific Islander. The primary outcome was a composite adverse maternal outcome: transfusion of ≥4 units of packed red blood cells, vasopressor use, mechanical ventilation, bowel or bladder injury, or mortality. The secondary outcomes were a composite adverse neonatal outcome (Apgar score of <7 at 1 minute, morbidity, or mortality), gestational age at placenta accreta spectrum diagnosis, and planned delivery by a multidisciplinary team. Multivariable logistic regression was used to estimate the associations of race and ethnicity with maternal and neonatal outcomes.

RESULTS

A total of 408 pregnancies with placenta accreta spectrum were included. In 218 patients (53.0%), the diagnosis of placenta accreta spectrum was made antenatally. Patients predominantly self-identified as non-Hispanic White (31.6%) or non-Hispanic Black (24.5%). After adjusting for institution, age, body mass index, income, and parity, there was no difference in composite adverse maternal outcomes among the racial and ethnic groups. Similarly, adverse neonatal outcomes, gestational age at prenatal diagnosis, rate of planned delivery by a multidisciplinary team, and cesarean hysterectomy were similar among groups.

CONCLUSION

In our multicentered placenta accreta spectrum cohort, race and ethnicity were not associated with inequities in composite maternal or neonatal morbidity, timing of diagnosis, or planned multidisciplinary care. This study hypothesized that a comparable incidence of individual risk factors for perinatal morbidity and geographic proximity reduces potential inequities that may exist in a larger population.

A Resolved Placenta Previa Is Still Associated with Postpartum Hemorrhage

OBJECTIVE

 Our objective was to determine whether resolution of a low-lying placenta or placenta previa is associated with postpartum hemorrhage (PPH).

STUDY DESIGN

 This is a retrospective, matched-control cohort study of women who underwent transvaginal sonography during fetal anatomic survey between 18 and 24 weeks of gestation at the University of Pennsylvania from January 2017 to May 2019. Exposure was defined as low-lying placenta (≤1 cm from the internal cervical os) or placenta previa (covering the os) at anatomic survey that was found to be resolved by transvaginal ultrasound in the third trimester. For each exposure, we identified a control patient whose placenta was > 1 cm from internal os at anatomic survey performed on the same day. The primary outcome was PPH at delivery, defined as estimated blood loss ≥ 1,000 mL.

RESULTS

 A total of 450 women were included (225/group). The exposed group of resolved placental previa included 85.0% with resolved low-lying placenta and 15.0% with resolved previa. The rate of PPH was significantly higher in the exposed group versus controls (9.8% vs. 4.4%, p = 0.03). Women with resolved previa were 2.5 times more likely to experience PPH than controls (adjusted odds ratio = 2.58, 95% confidence interval: 1.17-5.69), even when controlling for parity, prior cesarean, and delivery mode. Women with resolved previa were also more likely to present to triage with bleeding (16.4% vs. 8.0%, p = 0.006), receive antenatal corticosteroids, (9.3% vs. 3.1%, p = 0.006), and receive intravenous iron postpartum (7.6% vs. 3.1%, p = 0.04).

CONCLUSION

 Our data demonstrate that women with a resolved low-lying placenta or placenta previa remain at significantly increased risk of bleeding-related complications in pregnancy and during delivery when compared with those who never had a previa. Clinicians should consider this association when counseling patients and performing hemorrhage risk stratification.

KEY POINTS

· Women with resolved previa or low-lying placenta were 2.5 times more likely to experience PPH.. · Women with resolved previa or low-lying placenta were more likely to be induced for bleeding.. · Resolved previa or low-lying placenta is still associated with adverse hemorrhage-related outcomes..

Intrapartum Risk Factors and Prediction of Obstetric Hemorrhage-Related Morbidity

OBJECTIVE

 The aim of this study was to assess whether inclusion of intrapartum risk factors improves our obstetric hemorrhage risk stratification tool in predicting obstetric hemorrhage, transfusion, and related severe morbidity.

STUDY DESIGN

 This is a retrospective cohort study using all live deliveries at a single institution over a 2-year period (n = 5,332). Obstetric hemorrhage risk factors, hemorrhage burden, and severe maternal morbidity index outcomes were assessed through chart abstraction. Hemorrhage risk was assessed at (1) "time of admission" through chart abstraction and (2) "predelivery" by calculation after inclusion of all abstracted intrapartum risk factors. Admission high risk was compared with predelivery high risk for sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio in predicting obstetric hemorrhage, obstetric hemorrhage requiring transfusion, and obstetric hemorrhage-related severe morbidity. Significance levels were calculated using descriptive statistical methods including chi-squared tests and McNemar's tests.

RESULTS

 The sensitivities of the risk assessment tool using admission risk classification for high-risk patients is 25% for obstetric hemorrhage, 37% for obstetric hemorrhage requiring transfusion, and 22% for obstetric hemorrhage-related severe morbidity. After intrapartum factor inclusion, the sensitivities increase to 55% for obstetric hemorrhage, 59% for obstetric hemorrhage requiring transfusion, and 47% for obstetric hemorrhage-related severe morbidity. This "predelivery" risk assessment is significantly more sensitive across all three end points (p < 0.001 for all three outcomes). While the positive likelihood ratios for obstetric hemorrhage are equal on admission and predelivery (2.10 on admission and predelivery), they increase after intrapartum factor inclusion for obstetric hemorrhage requiring transfusion and obstetric hemorrhage-related severe morbidity (on admission, 2.74 and 1.6, respectively, and predelivery: 4.57 and 3.58, respectively).

CONCLUSION

 Inclusion of intrapartum risk factors increases the accuracy of this obstetric hemorrhage risk stratification tool in predicting patients requiring hemorrhage management with transfusion and obstetric hemorrhage-related severe morbidity.

KEY POINTS

· There are little data to validate intrapartum hemorrhage risk reassessment.. · Including intrapartum factors improves risk stratification for transfusion and related morbidity.. · Future research should clinically validate risk reassessment in the intrapartum period..

Characteristics and treatment for severe postpartum haemorrhage in different midwifery hospitals in one district of Beijing in China: an institution-based, retrospective cohort study

OBJECTIVE

To identify the characteristics and treatment approaches for patients with severe postpartum haemorrhage (SPPH) in various midwifery institutions in one district in Beijing, especially those without identifiable antenatal PPH high-risk factors, to improve regional SPPH rescue capacity.

DESIGN

Retrospective cohort study.

SETTING

This study was conducted at 9 tertiary-level hospitals and 10 secondary-level hospitals in Haidian district of Beijing from January 2019 to December 2022.

PARTICIPANTS

The major inclusion criterion was SPPH with blood loss ≥1500 mL or needing a packed blood product transfusion ≥1000 mL within 24 hours after birth. A total of 324 mothers with SPPH were reported to the Regional Obstetric Quality Control Office from 19 midwifery hospitals.

OUTCOME MEASURES

The pregnancy characteristics collected included age at delivery, gestational weeks at delivery, height, parity, delivery mode, antenatal PPH high-risk factors, aetiology of PPH, bleeding amount, PPH complications, transfusion volume and PPH management. SPPH characteristics were compared between two levels of midwifery hospitals and their association with antenatal PPH high-risk factors was determined.

RESULTS

SPPH was observed in 324 mothers out of 106 697 mothers in the 4 years. There were 74.4% and 23.9% cases of SPPH without detectable antenatal PPH high-risk factors in secondary and tertiary midwifery hospitals, respectively. Primary uterine atony was the leading cause of SPPH in secondary midwifery hospitals, whereas placental-associated disorders were the leading causes in tertiary institutions. Rates of red blood cell transfusion over 10 units, unscheduled returns to the operating room and adverse PPH complications were higher in patients without antenatal PPH high-risk factors. Secondary hospitals had significantly higher rates of trauma compared with tertiary institutions.

CONCLUSION

Examining SPPH cases at various institutional levels offers a more comprehensive view of regional SPPH management and enhances targeted training in this area.

Patisiran exposure in early pregnancy: a case report

We describe here the first case of exposure to patisiran treatment, a small interfering RNA molecule, during early pregnancy of a 36-year-old woman with symptomatic hereditary transthyretin-related amyloidosis. There were no major complications during pregnancy and delivery, except for a postpartum hemorrhage due to uterine atony. Vitamin A levels had to be closely monitored during pregnancy, and vitamin A substitution adapted accordingly. There was no sign of minor or major congenital abnormalities of the baby. One month after delivery, the patient showed slight clinical and electrophysiological signs of neuropathy progression due to patisiran treatment withdrawal. Patisiran infusions were resumed 3 months after delivery. Due to the unknown teratogenic potential of patisiran, the risk of neuropathy worsening associated with withholding treatment must of course be weighed against a potential teratogenic risk of treatment during pregnancy. Vitamin A levels need to be closely assessed, and substitution must be adapted accordingly, to avoid embryofetal adverse outcome due to vitamin A deficiency or toxicity.

Efficacy and safety of nalbuphine for epidural labor analgesia at high altitude: An observational study

Xining is located at the eastern edge of the Qinghai-Tibet Plateau, with an average altitude of >7000 feet (>2000 m). Nalbuphine is a kappa-opioid receptor agonist that can provide analgesia with fewer side effects than other opioid analgesics. This study aimed to evaluate pain control, side effects, and neonatal outcomes from combining nalbuphine with sufentanil and ropivacaine in 600 women during epidural anesthesia while giving birth at a high altitude in Xining, China. A total of 600 parturients receiving epidural labor analgesia were randomly divided into 2 groups, each group 300 parturients. The nalbuphine group received nalbuphine, sufentanil, and ropivacain, the control group only received sufentanil and ropivacain. The analgesic effect was evaluated through the Visual Analogue Scale scores. Neonatal outcomes were mainly evaluated through the Apgar Scores. Compared to the control group, the nalbuphine group showed lower Visual Analogue Scale scores at all time points after analgesia (P < .05). In comparison with the control group, parturients in the nalbuphine group showed lower incidence rates of fever at delivery, 24-hour postpartum bleeding, and pruritus (P < .05). However, between the 2 groups, there were no statistically significant differences in the remaining maternal and infant outcomes and neonatal outcomes (P > .05). Moreover, no adverse effects on neonatal outcomes were observed. The findings from this study support findings from previous studies that nalbuphine provided safe epidural analgesia without significant side effects for the mother and infant, and showed both safety and efficacy when used during labor at high altitude.

Postpartum hemorrhage in electronic health records: risk factors at admission and in-hospital occurrence

Objective

Postpartum hemorrhage (PPH) is the leading cause of maternal death globally. Therefore, prevention strategies have been created. The study aimed to evaluate the occurrence of PPH and its risk factors after implementing a risk stratification at admission in a teaching hospital.

Methods

A retrospective cohort involving a database of SISMATER® electronic medical record. Classification in low, medium, or high risk for PPH was performed through data filled out by the obstetrician-assistant. PPH frequency was calculated, compared among these groups and associated with the risk factors.

Results

The prevalence of PPH was 6.8%, 131 among 1,936 women. Sixty-eight (51.9%) of them occurred in the high-risk group, 30 (22.9%) in the medium-risk and 33 (25.2%) in the low-risk group. The adjusted-odds ratio (OR) for PPH were analyzed using a confidence interval (95% CI) and was significantly higher in who presented multiple pregnancy (OR 2.88, 95% CI 1.28 to 6.49), active bleeding on admission (OR 6.12, 95% CI 1.20 to 4.65), non-cephalic presentation (OR 2.36, 95% CI 1.20 to 4.65), retained placenta (OR 9.39, 95% CI 2.90 to 30.46) and placental abruption (OR 6.95, 95% CI 2.06 to 23.48). Vaginal delivery figured out as a protective factor (OR 0.58, 95% CI 0.34 to 0.98).

Conclusion

Prediction of PPH is still a challenge since its unpredictable factor arrangements. The fact that the analysis did not demonstrate a relationship between risk category and frequency of PPH could be attributable to the efficacy of the strategy: Women classified as "high-risk" received adequate medical care, consequently.

The MRI estimations of placental volume, T2 dark band volume, and cervical length correlate with massive hemorrhage in patients with placenta accreta spectrum disorders

PURPOSE

To identify whether placental volume, T2 dark band volume, and cervical length measured by MRI correlate with massive hemorrhage (MH) in patients with placenta accreta spectrum (PAS) disorders.

METHODS

A total of 163 pregnant women with PAS underwent preoperative MRI examination were divided into MH group and non-MH group. The placental volume, T2 dark band volume, and cervical length of PAS patients were measured and evaluated their ability to identify MH in patients with PAS.

RESULTS

Patients with MH had a significantly larger placental volume, larger T2 dark band volume, and shorter cervical length than patients without MH (all P < 0.001). Multivariable logistic regression showed that placental volume (> 890 cm3), T2 dark band volume (> 35 cm3), and cervical length (< 30 mm) were significant independent risk factor in identification of MH. In all PAS patients, a positive linear correlation was found between placental volume and amount of blood loss (r = 0.527), and between T2 dark band volume and amount of blood loss (r = 0.642), and a negative linear correlation was found between cervical length and amount of blood loss (r = - 0.597). When combined with the three MRI indicators, the sensitivity and specificity in identifying cases at high risk for MH were 91.638% and 94.051%, respectively, with area under the curve (AUC) of 0.923.

CONCLUSION

The placental volume, T2 dark band volume, and cervical length might be used to predict MH in patients with PAS.

Optimal gestational weight gain in Taiwan: A retrospective cohort study

OBJECTIVE

Maternal body mass index (BMI) and gestational weight gain (GWG) are believed to be associated with fetal conditions and maternal complications. The aim of this study was investigating the influence of maternal prepregnancy BMI and GWG on pregnancy outcomes and exploring the optimal GWG in Taiwanese singleton women.

MATERIALS AND METHODS

Retrospective records of 8146 singleton pregnant women between 2017 and 2019, obtained from a tertiary center in Taiwan were reviewed, and the associations between maternal prepregnancy BMI, GWG, and perinatal outcomes were analyzed. The patients were divided into five groups based on prepregnancy BMIs, defined by Taiwan Health Promotion Administration, as underweight (BMI <18.5 kg/m2), normal-weight (18.5 ≤ BMI <24 kg/m2), overweight (24.0 ≤ BMI <27.0 kg/m2), mild obese (27.0 ≤ BMI <30 kg/m2) and moderate-to-severe obese (BMI ≥30.0 kg/m2), and the lowest risks of different complications were summarized in each group. Also, using the Institute of Medicine and Japanese guidelines as reference, the Taiwanese recommendations for GWG were revised.

RESULTS

The rate of cesarean section, hypertensive disorder, preeclampsia, preeclampsia with severe features, and preterm birth were higher in prepregnancy overweight and obese women than in normal-weight women (p < 0.05). In the Taiwanese population, the recommended GWG for underweight pregnant women is 11-15 kg, for normal-weight pregnant women, it is 9.4-13.5 kg, for overweight pregnant women, it is 7.9-11.4 kg, for mild obese pregnant women, it is 7.3-10 kg, and for moderate-to-severe obese pregnant women, it is 4.9-9 kg with lowest perinatal complications.

CONCLUSIONS

Unsatisfactory controlled prepregnancy weight (BMI ≥24) and inappropriate body weight gain during pregnancy can increase the risk of adverse pregnancy complications. Taiwanese GWG guidelines should be revised based on the characteristics and clinical data of the local population.

Safety and efficacy of pelvic arterial embolization for primary postpartum hemorrhage in hemodynamically stable and hemodynamically unstable patients: Is it "time" for a paradigm change?

BACKGROUND

Pelvic artery embolization (PAE) is an effective and safe technique for treating postpartum hemorrhage (PPH) with hemodynamic stability. However, its use in hemodynamically unstable patients remains controversial.

PURPOSE

To determine the safety and efficacy of pelvic arterial embolization (PAE) according to the hemodynamic state of primary postpartum hemorrhage (PPH) patients.

METHODS

This cohort study was conducted retrospectively, using data from January 2004 to December 2021, in a resource-rich setting at a tertiary Level 1 trauma academic center. A total of 437 patients were diagnosed with PPH during the study period. Of these 437 patients, 161 with primary PPH who underwent PAE were enrolled in the study. The outcomes assessed included the clinical success rate, mortality, the overall success rate, predictive factors for failed PAE, and time-dependent changes in hemodynamic parameters, such as systolic blood pressure (SBP), heart rate (HR), and shock index (SI). Propensity score (PS) matching analysis was performed to assess the influence of specific variables or conditions on the outcomes.

RESULTS

Of the 161 patients who underwent PAE for primary PPH (mean age, 32.9 ± 4.3 [SD]), 85 were retrospectively categorized as having hemodynamic stability (mean age, 32.6 ± 4.1 [SD]), while 76 were categorized as having hemodynamic instability (mean age, 33.3 ± 4.4 [SD]). This study showed PAE for primary PPH had a success rate of 91.9 %, with no significant difference in mortality rates between the groups. The clinical success rate was 98.8 % for patients with hemodynamic stability and 84.2 % for those with hemodynamic instability (p < .001). The overall success rate was 98.8 % for hemodynamic stability and 89.5 % for hemodynamic instability (p = .014). After propensity score matching, the clinical success rate was higher in hemodynamically stable patients than in unstable ones (100 % vs. 86.3 %, p = .013). However, there was no significant difference in the overall success rate (100 % vs. 90.2 %, p = .056). Among the PS-matched population, predictive factors for the failed PAE in primary PPH were hemodynamic instability (adjusted odds ratio [aOR] 21.22, 95 % CI 1.27-355.76; p = .034) and emergency Cesarean delivery with accompanying hemorrhag (aOR 54.00, 95 % CI 11.93-244.56; p = .008). In three groups within a PS-matched population - hemodynamically stable, unstable with successful outcomes, and unstable with unsuccessful outcomes, a generalized linear mixed model (GLMM) analysis for time-dependent changes in hemodynamic parameters revealed a statistically significant difference in SBP, HR, and SI at various time points.

CONCLUSION

Pelvic arterial embolization of primary postpartum bleeding in hemodynamic instability has been identified as an alternative, safe, and effective life-saving procedure for multidisciplinary treatment in resource-rich environments even after the baseline characteristics are balanced by the PS matching, suggesting it is a primary care option.

Association between duration of intrapartum oxytocin exposure and obstetric hemorrhage

PURPOSE

Prolonged duration of intrapartum oxytocin exposure is included as a risk factor within widely adopted obstetric hemorrhage risk stratification tools. However, the duration of exposure that confers increased risk is poorly understood. This study aimed to assess the association between duration of intrapartum oxytocin exposure and obstetric blood loss, as measured by quantitative blood loss, and hemorrhage-related maternal morbidity.

METHODS

This was a retrospective cohort study of all deliveries from 2018 to 2019 at a single medical center. We included patients who had received any intrapartum oxytocin, and we categorized them into 1 of 5 groups: > 0-2, ≥ 2-4, ≥ 4-6, ≥ 6-12, and ≥ 12 h of intrapartum oxytocin exposure. The primary outcomes were mean quantitative blood loss, proportion with obstetric hemorrhage (defined as quantitative blood loss ≥ 1000 mL), and proportion with obstetric hemorrhage-related morbidity, a composite of hemorrhage-related morbidity outcomes. Secondary outcomes were hemorrhage-related pharmacologic and procedural interventions. A stratified analysis was also conducted to examine primary and secondary outcomes by delivery mode.

RESULTS

Of 5332 deliveries between January 1, 2018 and December 31, 2019 at our institution, 2232 (41.9%) utilized oxytocin for induction or augmentation. 326 (14.6%) had exposure of > 0-2 h, 295 (13.2%) ≥ 2-4 h, 298 (13.4%) ≥ 4-6 h, 562 (25.2%) ≥ 6-12 h, and 751 (33.6%) ≥ 12 h. Across all deliveries, there was higher mean quantitative blood loss (p < 0.01) as well as increased odds of obstetric hemorrhage (adjusted odds ratio [aOR] 1.52, 95% confidence interval [CI] 1.21-1.91) for those with ≥ 12 h of oxytocin compared to all groups between > 0-12 h of exposure. In our stratified analysis, ≥ 12 h of oxytocin exposure was associated with higher mean quantitative blood loss (p = 0.04) and odds of obstetric hemorrhage in vaginal deliveries (aOR 1.47, 95% CI: 1.03-2.11), though not in cesarean deliveries (aOR 1.16, 95% CI 0.82-1.62). There were no differences in proportion with obstetric hemorrhage-related morbidity across all deliveries (p = 0.40) or in the stratified analysis.

CONCLUSION

Intrapartum oxytocin exposure of ≥ 12 h was associated with increased quantitative blood loss and odds of obstetric hemorrhage in vaginal, but not cesarean, deliveries.

Heat stable carbetocin or oxytocin for prevention of postpartum hemorrhage among women at risk: A secondary analysis of the CHAMPION trial

OBJECTIVE

To examine whether the observed non-inferiority of heat-stable carbetocin (HSC), compared with oxytocin, was influenced by biologic (macrosomia, parity 3 or more, or history of postpartum hemorrhage [PPH]) and/or pharmacologic (induction or augmentation) risk factors for PPH.

METHODS

The present study is a secondary analysis of the CHAMPION non-inferiority randomized trial-a two-arm, double-blind, active-controlled study conducted at 23 hospitals in 10 countries, between July 2015 and January 2018. Women with singleton pregnancies, expected to deliver vaginally with cervical dilatation up to 6 cm were eligible. Randomization was stratified by country, with 1:1 assignment. Women in the intervention and control groups received a single intramuscular injection of 100 μg of HSC or 10 IU of oxytocin, respectively. The drugs were administered immediately after birth, and the third stage of labor was managed according to the WHO guidelines. Blood was collected using a plastic drape. For this analysis, we defined a woman as being at risk if she had any one or more of the biologic or pharmacologic risk factor(s).

RESULTS

The HSC and oxytocin arms contained 14 770 and 14 768 women, respectively. The risk ratios (RR) for PPH were 1.29 (95% confidence interval [CI] 1.08-1.53) or 1.73 (95% CI 1.51-1.98) for those with only biologic (macrosomia, parity 3 or more, and PPH in the previous pregnancy) or only pharmacologic (induced or augmented) risk factors, respectively, compared with those with neither risk factors.

CONCLUSIONS

Findings reinforce previous evidence that macrosomia, high parity, history of PPH, and induction/augmentation are risk factors for PPH. We did not find a difference in effects between HSC and oxytocin for PPH among women who were neither induced nor augmented or among those who were induced or augmented.

Effects of oxytocin induction on early postpartum hemorrhage, perineal integrity, and breastfeeding: a case-control study

OBJECTIVE

The aim of this study was to evaluate the postpartum hemorrhage, perineal integrity, and breastfeeding results of mothers who underwent oxytocin induction in the first stage of labor in the early postpartum period.

METHODS

This single-center observational case-control study was conducted in the obstetric unit of a public hospital in Istanbul. The study sampling included 44 pregnant women who received oxytocin induction (case group) and 44 pregnant women who did not receive oxytocin (control group). The Personal Information Form, LATCH Breastfeeding Assessment Tool, Breastfeeding Self-Efficacy Scale, Redness, Edema, Ecchymosis, Discharge, and Approximation Scale, and Postpartum Hemorrhage Collection Bag were used in data collection, and pad follow-up was carried out.

RESULTS

The amount of hemorrhage in the first 24 h of the postpartum period and the mean Redness, Edema, Ecchymosis, Discharge, and Approximation Scale score were significantly higher in the case group. While 47.7% of the oxytocin-induced women had 1st or 2nd, and 11.4% had 3rd or 4th degrees of lacerations, 20.5% of the control group had 1st or 2nd, and 2.3% had 3rd or 4th degrees of lacerations. There was no significant difference between the mean scores of the Breastfeeding Self-Efficacy Scale and LATCH Breastfeeding Assessment Tool in both groups.

CONCLUSION

According to the study findings, it was determined that oxytocin induction administered in the first stage of labor increased hemorrhage and perineal trauma in the early postpartum period but did not affect the results of breastfeeding.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04441125.

Effect of Third Interstitial Fluid on Adverse Outcomes in Patients with Severe Pre-eclampsia and Twin Pregnancy: A 5-year Single-center Retrospective Study

OBJECTIVE

This study aims to identify the effect of third interstitial fluid on adverse outcomes in twin pregnancies with severe pre-eclampsia, and explore the differences in bad ending between twins and singletons.

METHODS

The present retrospective cohort study was conducted on patients with severe pre-eclampsia, who delivered in Tongji Hospital, Wuhan, China, between 2017 and 2022. The adverse outcomes in singleton and twin pregnancies with severe pre-eclampsia were initially investigated. Then, the diverse maternal and fetal consequences between singleton and twin pregnancies in patients with severe pre-eclampsia were compared after merging with the third interstitial fluid.

RESULTS

A total of 709 patients were included for the present study. Among these patients, 68 patients had twin pregnancies, and 641 patients had singleton pregnancies. The rate of postpartum hemorrhage (2.81% vs. 13.24%, P<0.001), and admission rate to the Neonatal Intensive Care Unit (NICU) after birth (30.73% vs. 63.24%, P=0.011) were significantly higher in twin pregnancies. The neonatal weight of twins was statistically lower than singletons (1964.73±510.61 g vs. 2142.92±731.25 g, P=0.008). For the groups with the third interstitial fluid, the delivery week (P=0.001) and rate of admission to the NICU after birth were significantly advanced in twin pregnancy group, when compared to singleton pregnancy group (P=0.032), and the length of hospital stay was shorter (P=0.044). Furthermore, there was no statistically significant difference between the twin pregnancy group and the singletony pregnancy group without the third interstitial fluid.

CONCLUSION

The maternal and fetal adverse outcomes of patients with severe pre-eclampsia increased in twin pregnancies, when compared to singleton pregnancies. Thus, when patients develop the third interstitial fluid, twin pregnancies would more likely lead to adverse fetal outcomes, when compared to singleton pregnancies, and there would be no significant difference in maternal adverse outcomes. More attention should be given to patients who merge with the third interstitial fluid.

Utilization of non-pneumatic anti-shock garment for treating obstetric hemorrhage and associated factors among obstetric care providers in Ethiopia: A systematic review and meta-analysis

BACKGROUND

The non-pneumatic anti-shock garment (NASG) is a life-saving device that can help to avoid delays and prevent further complications in the case of obstetric hemorrhage. Although there are many fragmented primary studies on the NASG utilization in Ethiopia, the pooled utilization rate is unknown. In addition, a disagreement was observed among those studies while reporting the associated factors. Therefore, this study was intended to determine the pooled level of NASG utilization and its associated factors among obstetric care providers in Ethiopia.

METHODS

A total of 51 studies were retrieved from PubMed, Google Scholar, the African Journal of Online, direct open-access journals, and Ethiopian universities' institutional repositories. This study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The quality of studies was evaluated using the modified Newcastle-Ottawa quality assessment tool. The data were extracted by two authors independently using Microsoft Excel and analyzed by Stata version 11. A random-effects model was applied to calculate the pooled level of NASG utilization and its associated factors. The PROSPERO registration number for the review is CRD42023414043.

RESULT

A total of 8 studies comprising 2,575 study participants were involved in this meta-analysis. The pooled utilization rate of NASG was found to be 39.56%. Having NASG training (pooled odds ratio (OR) = 3.99, 95%CI = 2.35, 6.77), good knowledge about NASG (OR = 2.92, 95%CI = 2.04, 4.17), a positive attitude towards NASG (OR = 3.17, 95%CI = 2.10, 4.79), and having ≥ 2 NASGs in the health facility (OR = 10.59, 95%CI = 6.59, 17.01) were significantly associated with NASG utilization.

CONCLUSION

Utilization of NASG for the treatment of obstetric hemorrhage was low in Ethiopia. To increase its utilization, Ministry of Health should improve the accessibility of NASG at each health facility and increase the Health professionals' knowledge and attitude through in-service and pre-service training.

Secondary postpartum hemorrhage due to uterine scar dehiscence, a case report

INTRODUCTION

Secondary postpartum hemorrhage is rare. The most common cause is retained placenta. Having a uterine scar dehiscence as an etiology is unusual. Complete dehiscence of the uterine scar is even rarer. This rare but serious cause of post-partum haemorrhage can be potentially life threatening due to severe hemorrhage if not managed in adequate time.

PRESENTATION OF CASE

We present the case of a 35-year-old patient, gravida 2 para 2. She had undergone two caesarean sections in our department and, after the last one in March 2021, she presented twice to our emergency department with relatively abundant metrorrhagia, but neither the clinical nor the radiological examinations revealed any abnormalities. At 43 days postpartum, she presented to the emergency with severe bleeding per vaginum. The bleeding was profuse, causing hemodynamic instability and severe acute anaemia. An explorative laparotomy was necessary to diagnose the etiology and manage the treatment. Surgical exploration revealed a lateral uterine rupture in the broad ligament and complete dislocation of the caesarean scar. An urgent hysterectomy was performed.

DISCUSSION

Partial or complete dehiscence of the hysterorrhoea is a rare cause of secondary postpartum hemorrhage after caesarean section. When hysterorrhaphy dehiscence does occur, the origin of the bleeding is likely to be related to erosion of the vessels at the incision angles.

CONCLUSION

The diagnosis of partial or complete dehiscence of the uterine scar may be misleading in the absence of specific clinical or radiological signs. This condition must therefore be considered and suspected in cases of secondary postpartum hemorrhage.

Fetal Macrosomia and Postpartum Hemorrhage in Latin American and Caribbean Region: Systematic Review and Meta-analysis

OBJECTIVE

 To determine the association between fetal macrosomia (FM) and postpartum hemorrhage (PPH) in Latin American and Caribbean (LAC) women.

DATA SOURCES

 Studies evaluating the association between FM and PPH (≥ 500 ml) and severe PPH (≥ 1,000 ml) until November 4, 2021, indexed in CINHAL, Scopus, Embase, Cochrane Library, MEDLINE, LILACS, and SciELO.

SELECTION OF STUDIES

 Inclusion criteria were cohort and case-control studies that provided the number of PPH and FM cases. Exclusion criteria were studies lacking information about the number of cases, with a population of women who were not from LAC; published in a language other than English, Spanish, or Portuguese, and with a different design.

DATA COLLECTION

 Data extraction was performed independently by two authors, and discrepancies were resolved with a third author. Data regarding FM and PPH cases were retrieved.

DATA SYNTHESIS

 Of the 1,044 articles evaluated, 5 studies were included, from 6 different countries: Argentina and Uruguay (multi-country), West Indies, Antigua and Barbuda, French Guyana, and Suriname. The pooled odds ratio (OR) for FM and PPH in the meta-analysis (five studies) was 2.10 (95% confidence interval [CI]: 1.79-2.47; I2: 0%), with estimates within this 95% CI in the sensitivity analysis. The combined OR for severe PPH (3 studies) was 1.61 (95% CI: 0.40-6.48; I2: 91.89%), showing high heterogeneity.

CONCLUSION

 There was a positive association between FM and PPH in the LAC, increasing the risk of the presence of this event 2-fold. The high heterogeneity of the studies that measured severe PPH does not allow drawing conclusions about the estimates obtained.

Effect of the smartphone application on caesarean section in women with overweight and obesity: a randomized controlled trial in China

BACKGROUND

The rate of caesarean section (CS) is increasing worldwide. While a CS can be life-saving when medically indicated, it can cause adverse health effects for both women and children. This trial aims to evaluate the effect of the smartphone application, which aims to control the gestational weight gain, on the rate of CS in overweight and obese women.

METHODS

Overweight and obese primiparas (BMI ≥ 24 kg/m2) with age between 20 and 40 years old were recruited at Beijing Obstetrics and Gynecology Hospital, and randomly assigned into the intervention group (143 cases) and the control group (138 cases). The intervention group applied the smartphone application (App) to control gestational weight gain in addition to the usual care, and the control group received the usual care. Primary outcome was cesarean section (CS) rate. Secondary outcomes included gestational hypertension, preeclampsia and eclampsia, gestational diabetes mellitus, postpartum hemorrhage, neonatal asphyxia, and macrosomia.

RESULTS

There was a significant difference in CS rate, with 53.3% in the intervention group and 65.4% in the control group (P = 0.044). The difference still exists in the overweight subgroup (32.6% vs. 55.6%, P = 0.04), but disappears in the obesity subgroup (63.0% vs. 69.1%, P = 0.381). The median of gestational weight gain (GWG) of the intervention group is 8.5 kg (IQR 5.5, 11.0), which is significantly less than that of the control group (median 10.0 kg, IQR [6.0, 14.0], P = 0.008). The intervention group has significantly lower rate of postpartum hemorrhage (5.19%) than the control group (12%) (P = 0.045). There were no significant differences between the groups in gestational hypertension, gestational diabetes mellitus, neonatal asphyxia, and macrosomia.

CONCLUSION

The smartphone assisted weight control may help reduce CS rate. The effects of the smartphone application might be via the management of gestational weight gain.

TRAIL REGISTRATION

This trial was registered at Chinese Clinical Trial Registry. Registration number is ChiCTR2300068845 (retrospectively registered, 01/03/2023).

Association of adverse outcomes with three-tiered risk assessment tool for obstetrical hemorrhage

BACKGROUND

Guidelines promote stratification for the risk for postpartum hemorrhage among parturients, although the evidence for the associated differential morbidity among the groups remains inconsistent among published reports.

OBJECTIVE

Using the California Maternal Quality Care Collaborative schema modified by the American College of Obstetrics and Gynecology, we compared the composite maternal hemorrhagic outcome and the composite neonatal adverse outcome among singletons who were categorized after delivery by the researchers as low-, medium-, or high-risk for postpartum hemorrhage. We hypothesized that the composite outcomes would be significantly different among the individuals in the different 3-tiered categories.

STUDY DESIGN

This was a retrospective cohort study of all singleton parturients with a gestational age of at least 14 weeks who delivered at a single site within 1 year. The composite maternal hemorrhagic outcome included any of the following: estimated blood loss ≥1000 mL, use of uterotonics (excluding prophylactic oxytocin) or Bakri balloon, surgical management of postpartum hemorrhage, blood transfusion, hysterectomy, thromboembolism, admission to the intensive care unit, or maternal death. The composite neonatal adverse outcome included Apgar score <7 at 5 minutes, birth injury, bronchopulmonary dysplasia, intraventricular hemorrhage, neonatal seizure, sepsis, ventilation > 6 hrs., brachial plexus palsy, hypoxic-ischemic encephalopathy, or neonatal death. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted relative risks with 95% confidence intervals.

RESULTS

Of the 4544 deliveries in the study period, 4404 (96.7%) met the inclusion criteria, and among them, 1745 (39.6%) were categorized as low, 1376 (31.2%) as medium, and 1283 (29.1%) as high risk. Overall, 941 (21.4%) participants experienced the composite maternal hemorrhagic outcome with 285 (16.4%) of those being in the low-risk group, 319 (23.2%) in the medium-risk group, and 337 (26.3%) in the high-risk group. Among all parturients, 95.7% in the low-, 89.4% in the medium-, and 85.3% in the high-risk group neither had an estimated blood loss or a quantified blood loss ≥1000 mL nor were transfused. After multivariable adjustment and when compared with the low-risk group, there was a significantly higher risk for the composite maternal hemorrhagic outcome in the medium-risk group (adjusted relative risk, 1.23; 95% confidence interval, 1.05-1.43) and in the high-risk group (adjusted relative risk, 1.51; 95% confidence interval, 1.31-1.75). Overall, 366 newborns (8.4%) developed the composite neonatal adverse outcome with 76 (4.2%) in of those being in the low-risk group, 153 (11.3%) in the medium-risk group, and 140 (11.1%) in the high-risk group. After multivariable adjustment and when compared with the low-risk group, there were no significant differences in the composite neonatal adverse outcome in the medium- (adjusted relative risk, 1.27; 95% confidence interval, 0.97-1.68) or the high-risk group (adjusted relative risk, 1.29; 95% confidence interval, 0.98-1.68).

CONCLUSION

Although 8 of 10 parturients categorized as high risk neither had blood loss ≥1000 mL nor underwent transfusion, the risk stratification provides information regarding the composite maternal hemorrhagic outcome.

Excessive Pregestational Weight and Maternal Obstetric Complications: The Role of Adipokines

There is a high frequency of overweight and obesity in women of reproductive age. Women who start pregnancy with overweight or obesity have an increased risk of developing maternal obstetric complications such as gestational hypertension, pre-eclampsia, gestational diabetes mellitus, postpartum hemorrhage, and requiring C-section to resolve the pregnancy with a higher risk of C-section surgical site infection. Excessive weight in pregnancy is characterized by dysregulation of adipokines, the functions of which partly explain the predisposition of pregnant women with overweight or obesity to these maternal obstetric complications. This review compiles, organizes, and analyzes the most recent studies on adipokines in pregnant women with excess weight and the potential pathophysiological mechanisms favoring the development of maternal pregnancy complications.

Family history of postpartum hemorrhage is a risk factor for postpartum hemorrhage after vaginal delivery: results from the French prospective multicenter Haemorrhages and Thromboembolic Venous Disease of the Postpartum cohort study

BACKGROUND

Postpartum hemorrhage is a major component of perinatal morbidity and mortality that affects young women worldwide and is still often unpredictable. Reducing the incidence of postpartum hemorrhage is a major health issue and identifying women at risk for postpartum hemorrhage is a key element in preventing this complication.

OBJECTIVE

This study aimed to estimate postpartum hemorrhage prevalence after vaginal delivery and to identify postpartum hemorrhage risk factors.

STUDY DESIGN

Unselected pregnant women ≥16 years of age admitted to 1 of 6 maternity wards in Brittany (France) for vaginal birth after 15 weeks of gestation were recruited in this prospective, multicenter cohort study between June 1, 2015, and January 31, 2019. Postpartum hemorrhage was defined as blood loss ≥500 mL in the 24 hours following delivery. Independent risk factors for postpartum hemorrhage were determined using logistic regression. Missing data were imputed using the Multivariate Imputation by Chained Equations method.

RESULTS

Among 16,382 included women, the postpartum hemorrhage prevalence was 5.37%. A first-degree family history of postpartum hemorrhage (adjusted odds ratio, 1.63; 95% confidence interval, 1.24-2.14) and a personal transfusion history (adjusted odds ratio, 1.90; 95% confidence interval, 1.23-2.92) were significantly associated with postpartum hemorrhage. The use of oxytocin during labor was also a risk factor for postpartum hemorrhage (adjusted odds ratio, 1.24; 95% confidence interval, 1.06-1.44). Inversely, smoking during pregnancy and intrauterine growth restriction were associated with a reduced risk for postpartum hemorrhage (adjusted odds ratio, 0.76; 95% confidence interval, 0.63-0.91, and 0.34; 95% confidence interval, 0.13-0.87, respectively).

CONCLUSION

In addition to classical risk factors, this study identified a family history of postpartum hemorrhage and personal transfusion history as new characteristics associated with postpartum hemorrhage after vaginal delivery. The association of postpartum hemorrhage with a family history of postpartum hemorrhage suggests a hereditary hemorrhagic phenotype and calls for genetic studies. Identifying women at risk for postpartum hemorrhage is a key element of being prepared for this complication.

Prediction models for perineal lacerations during childbirth: A systematic review and critical appraisal

BACKGROUND

Perineal lacerations could lead to substantial morbidities for women. A reliable prediction model for perineal lacerations has the potential to guide the prevention. Although several prediction models have been developed to estimate the risk of perineal lacerations, especially third- and fourth-degree perineal lacerations, the evidence about the model quality and clinical applicability is scarce.

OBJECTIVES

To systematically review and critically appraise the existing prediction models for perineal lacerations.

METHODS

Seven databases (PubMed, Embase, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, SinoMed, China National Knowledge Infrastructure, and Wanfang Data) were systematically searched from inception to July 2022. Studies that developed prediction models for perineal lacerations or performed external validation of existing models were considered eligible to include in the systematic review. Two reviewers independently conducted data extraction according to the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. The risk of bias and the applicability of the included models were assessed with the Prediction Model Risk of Bias Assessment Tool. A narrative synthesis was performed to summarize the characteristics, risk of bias, and performance of existing models.

RESULTS

Of 4345 retrieved studies, 14 studies with 22 prediction models for perineal lacerations were included. The included models mainly aimed to estimate the risk of third- and fourth-degree perineal lacerations. The top five predictors used were operative vaginal birth (72.7 %), parity/previous vaginal birth (63.6 %), race/ethnicity (59.1 %), maternal age (50.0 %), and episiotomy (40.1 %). Internal and external validation was performed in 12 (54.5 %) and seven (31.8 %) models, respectively. 13 studies (92.9 %) assessed model discrimination, with the c-index ranging from 0.636 to 0.830. Seven studies (50.0 %) evaluated the model calibration using the Hosmer-Lemeshow test, Brier score, or calibration curve. The results indicated that most of the models had fairly good calibration. All the included models were at higher risk of bias mainly due to unclear or inappropriate methods for handling missing data and continuous predictors, external validation, and model performance evaluation. Six models (27.3 %) showed low concerns about applicability.

CONCLUSIONS

The existing models for perineal lacerations were poorly validated and evaluated, among which only two have the potential for clinical use: one for women undergoing vaginal birth after cesarean delivery, and the other one for all women undergoing vaginal birth. Future studies should focus on robust external validation of existing models and the development of novel models for second-degree perineal laceration.

PROSPERO REGISTRATION NUMBER

CRD42022349786.

TWEETABLE ABSTRACT

The existing models for perineal lacerations during childbirth need external validation and updating. Tools are needed for second-degree perineal laceration.

The Anaphylactoid Syndrome of Pregnancy: Two Autopsy Cases

The anaphylactoid syndrome of pregnancy (ASP) is a rare emergency with significant mortality and morbidity, in which the amniotic fluid and fetal cells enter the maternal circulation leading to respiratory failure, altered mental status, hypotension, and disseminated intravascular coagulation. The term ASP was recently introduced to replace the term amniotic fluid embolism since the clinical manifestations of the entity were more similar to a septic or anaphylactic shock rather than that of an embolic event. Two autopsy cases are described, regarding a 35-year-old gravida 2 para 1 and a 34-year-old gravida 1 para 0, where the cause of death was determined to be ASP.

Peripartum Maternal Admission to the Intensive Care Unit: An Observational Study over a 15-Year Period at a Tertiary Center in Austria

Peripartum maternal admission to the intensive care unit is challenging for anesthesiologists, obstetricians, and all personnel involved. An understanding of altered maternal physiology, fetal considerations, and acute peripartum emergencies is required to ensure adequate maternal and neonatal outcomes. In this study, we analyzed data of peripartum maternal admissions to the intensive care unit at our large tertiary referral center in order to define trends and changes over time. This study retrospectively analyzed maternal morbidity, admission diagnoses, treatments, and outcomes of women with peripartum admission to the intensive care unit at our tertiary care center over a 15-year period. We found that patient characteristics and admission diagnoses remained remarkably consistent over the observational period; however, there was a significant increase in postpartum hemorrhage (r = 0.200, p < 0.001) and cesarean hysterectomy (r = 0.117, p = 0.027) over time. Moreover, we found a reduction in preterm births (r = -0.154, p = 0.004) and a decreased peripartum neonatal intensive care unit admission rate (r = -0.153, p = 0.006) among women who were transferred to the intensive care unit. Based on our long-term observational data, there is consistent need for intensive care in obstetrics due to a small number of different etiologies. Specialized training for the predominant diagnoses involved as well as multidisciplinary care of the affected patients are both warranted.

Pathologically diagnosed placenta accreta spectrum without placenta previa: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to assess clinical characteristics related to pathologically proven placenta accreta spectrum without placenta previa.

DATA SOURCES

A literature search of PubMed, the Cochrane database, and Web of Science was performed from inception to September 7, 2022.

STUDY ELIGIBILITY CRITERIA

The primary outcomes were invasive placenta (including increta or percreta), blood loss, hysterectomy, and antenatal diagnosis. In addition, maternal age, assisted reproductive technology, previous cesarean delivery, and previous uterine procedures were investigated as potential risk factors. The inclusion criteria were studies evaluating the clinical presentation of pathologically diagnosed PAS without placenta previa.

METHODS

Study screening was conducted after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis.

RESULTS

Among 2598 studies that were initially retrieved, 5 were included in the review. With the exception of 1 study, 4 studies were included in the meta-analysis. This meta-analysis showed that placenta accreta spectrum without placenta previa was associated with less risk of invasive placenta (odds ratio, 0.24; 95% confidence interval, 0.16-0.37), blood loss (mean difference, -1.19; 95% confidence interval, -2.09 to -0.28) and hysterectomy (odds ratio, 0.11; 95% confidence interval, 0.02-0.53), and more difficult to diagnose prenatally (odds ratio, 0.13; 95% confidence interval, 0.04-0.45) than placenta accreta spectrum with placenta previa. In addition, assisted reproductive technology and a previous uterine procedure were strong risk factors for placenta accreta spectrum without placenta previa, whhereas previous cesarean delivery was a strong risk factor for placenta accreta spectrum with placenta previa.

CONCLUSION

The differences in clinical aspects of placenta accreta spectrum with and without placenta previa need to be understood.

A prolonged latent phase: An early career in oxytocin during birth

•The author, a nurse-midwife scientist, shares her path to the study of the causes and consequences of clinical oxytocin use.•This paper highlights mentors and key research that informed new thinking about the role of oxytocin during parturition.•Future directions for improving maternal care during childbirth are presented, including genetic and epigenetic perspectives.

Health care provider decision-making and the quality of maternity care: An analysis of postpartum care in Kenyan hospitals

Evidence suggests that health care providers' non-adherence to clinical guidelines is widespread and contributes to poor patient outcomes across low- and middle-income countries. Through observations of maternity care in Kenya, we found limited adherence to guideline-recommended active monitoring of patients for signs of postpartum hemorrhage, the leading cause of maternal mortality, despite providers' having the necessary training and equipment. Using survey vignettes conducted with 144 maternity providers, we documented evidence consistent with subjective risk and perceived uncertainty driving providers' decisions to actively monitor patients. Motivated by these findings, we introduced a simple model of providers' decision-making about whether to monitor a patient, which may depend on their perceptions of risk, diagnostic uncertainty, and the value of new information. The model highlights key trade-offs between gathering diagnostic information through active monitoring versus waiting for signs and symptoms of hemorrhage to manifest. Our work provides a template for understanding provider decision-making and could inform interventions to encourage more proactive obstetric care.

The association between body mass index and postpartum hemorrhage after cesarean delivery

We aimed to evaluate the association between obesity and postpartum hemorrhage (PPH) after cesarean delivery (CD). This was a retrospective cohort study using a multicenter database of 20 hospitals in the United States. We analyzed 27,708 patients undergoing CD from 2015 to 2019. The exposure of interest was BMI, and the primary outcome was PPH (estimated blood loss [EBL] ≥ 1000 mL). Simple logistic regression was used to evaluate the relationship between obesity and intrapartum complications. Multivariable logistic regression was used to adjust for any confounding demographic variables. Hosmer and Lemeshow's purposeful selection algorithm was adapted to develop a multivariable logistic regression model of PPH. Analyses were conducted using STATA 16.1 (College Station, Texas) with p ≤ 0.05 considered significant. BMI exerted a significant effect on the frequency of PPH (p = 0.004). Compared to patients with BMI 18.5-24.9 kg/m², patients with BMI between 25 and 59.9 kg/m² had an increased odds of PPH. The odds of PPH in patients with BMI > 60 kg/m² was not increased compared to patients with BMI 18.5-24.9 kg/m². Obesity was associated with a decreased odds of blood transfusion (aOR 0.73, 95% CI 0.55-0.97). In conclusion, higher BMI was associated with PPH yet a lower odds of transfusion after CD.

Investigation of Intrapartum Parenteral Magnesium Sulfate as an Independent Risk Factor for Postpartum Hemorrhage Using Quantitative Blood Loss Assessment

BACKGROUND

Magnesium sulfate is used for seizure prophylaxis in preeclampsia and for fetal neuroprotection when delivery is anticipated before 32 weeks of gestation. Existing risk assessment tools for postpartum hemorrhage often identify the use of magnesium sulfate as an intrapartum risk factor. Previous studies examining the association between the use of magnesium sulfate and postpartum hemorrhage have relied largely on qualitative estimates of blood loss rather than quantitative estimates of blood loss.

OBJECTIVE

This study aimed to determine whether intrapartum administration of magnesium sulfate is associated with an increased risk of postpartum hemorrhage using a quantitative blood loss assessment via the use of graduated drapes and weight differences in surgical supplies.

STUDY DESIGN

This case-control study was conducted to test the hypothesis that intrapartum parenteral administration of magnesium sulfate is not independently associated with postpartum hemorrhage. All deliveries at our tertiary-level academic medical center between July 2017 and June 2018 were reviewed. Of note, 2 categories of postpartum hemorrhage were defined: the traditional definition (>500 mL for vaginal delivery and >1000 mL for cesarean delivery) and the contemporary definition (>1000 mL regardless of delivery mode). Statistical analyses using the chi-square test, Fisher exact test, t test, or Wilcoxon rank-sum test were performed to compare the patients who did and did not receive magnesium sulfate concerning the rates of postpartum hemorrhage, pre- and postdelivery hemoglobin level, and rates of blood transfusion.

RESULTS

A total of 1318 deliveries were included, with postpartum hemorrhage rates of 12.2% (traditional definition) and 6.2% (contemporary definition). Multivariate logistic regression did not find the use of magnesium sulfate as an independent risk factor by either definition (odds ratio, 1.44 [95% confidence interval, 0.87-2.38] and 1.34 [95% confidence interval, 0.71-2.54]). The only significant independent risk factor was cesarean delivery, by both definitions (odds ratio, 2.71 [95% confidence interval, 1.85-3.98] and 19.34 [95% confidence interval, 8.55-43.72]).

CONCLUSION

In our study population, intrapartum administration of magnesium sulfate was not found to be an independent risk factor for postpartum hemorrhage. Cesarean delivery was determined as an independent risk factor, consistent with previous reports.

Postpartum Hemorrhage-Epidemiology, Risk Factors, and Causes

The incidence of postpartum hemorrhage (PPH) is increasing worldwide and in the United States. Coinciding, is the increased rate of severe maternal morbidity with blood transfusion in the United States over the past 2 decades. Consequences of PPH can be life-threatening and carry significant cost burden to the health care system. This review will discuss the current trends, distribution, and risk factors for PPH. Causes of PPH will be explored in detail.

Early versus late amniotomy during induction of labor using oxytocin: A randomized controlled trial

OBJECTIVE

To assess the effect of early amniotomy on labor duration, maternal and neonatal outcomes during induction of labor (IOL).

METHODS

This was a randomized controlled trial, conducted over a period of eight months at a monocentric site. Singleton pregnancies in nulliparous and parous patients with cephalic presentation and Bishop score ≥ 6 were enrolled in the study. One hundred participants were randomized into two groups: early amniotomy (initiating IOL with amniotomy followed by oxytocin) versus late amniotomy (initiating IOL with oxytocin followed by amniotomy 4 hours later). The primary endpoint was the time to active phase (cervical dilation ≥ 5 cm) during IOL. Secondary outcomes were time to vaginal delivery, mode of delivery, and maternal and fetal outcomes.

RESULTS

Early amniotomy reduced time to active phase by 2 hours and 46 minutes compared to the late amniotomy group (3 h 42 min vs. 6 h 28 min; p<0.0001). It also reduced time to vaginal delivery by 2 hours and 52 minutes (5 h 17 min vs. 8 h 9 min; p = 0.0003). The rate of cesarean section (CS) for failed IOL was significantly lower in the early amniotomy group (31.2% vs. 70.0%; p = 0.02), without any significant difference in the overall rate of cesarean section between the two groups (32.0% vs. 40.8%; p = 0.36). There was no significant difference in maternal or fetal outcomes.

CONCLUSIONS

Early amniotomy in IOL significantly shortens the time to active phase as well as the overall duration of labor without compromising maternal and neonatal safety.

Exploring trends of severe postpartum haemorrhage: a hospital-based study

BACKGROUND

Over the past two decades several high-income countries have reported increased rates of postpartum haemorrhage (PPH). Many of the studies are registry studies with limited access to detailed information. We aimed to explore trends of severe PPH in the largest labour ward in Norway during a 10-year period with a hospital based study. Our population constituted all women who gave birth after week 22 at Oslo University Hospital between 2008 and 2017. The main outcome measure was severe PPH, defined as registered blood loss greater than 1500 ml, or transfusion of blood products due to PPH.

METHODS

We estimated the incidence of severe PPH and blood transfusions, and performed temporal trend analysis. We performed Poisson regression analysis to investigate associations between pregnancy characteristics and severe PPH, presented using crude incidence rate ratios (IRR) with 95% confidence intervals (CI)s. We also estimated annual percentage change of the linear trends.

RESULTS

Among 96 313 deliveries during the 10-year study period, 2621 (2.7%) were diagnosed with severe PPH. The incidence rate doubled from 17.1/1000 to 2008 to 34.2/1000 in 2017. We also observed an increased rate of women receiving blood transfusion due to PPH, from 12.2/1000 to 2008 to 27.5/1000 in 2017. The rates of invasive procedures to manage severe PPH did not increase, and we did not observe a significant increase in the number of women defined with maternal near miss or massive transfusions. No women died due to PPH during the study period.

CONCLUSION

We found a significant increasing trend of severe PPH and related blood transfusions during the 10-year study period. We did not find an increase in massive PPH, or in invasive management, and we suspect that the rise can be at least partly explained by increased awareness and early intervention contributing to improved registration of severe PPH.

Nomogram to predict postpartum hemorrhage in cesarean delivery for twin pregnancies: a retrospective cohort study in China

Background

Postpartum hemorrhage (PPH) is the most common cause of maternal morbidity and mortality worldwide. A reliable risk assessment tool for PPH could optimize available interventions to reduce adverse maternal outcomes.

Objective

The objective of this study was to explore a nomogram predicting the risk of postpartum hemorrhage after cesarean delivery for twin pregnancies.

Methods

This single-center retrospective cohort study conducted twin pregnancies who underwent cesarean delivery between January 2014 and July 2021. Propensity score matching at baseline was used to match PPH (blood loss ≥1000 mL) and non-PPH group (blood loss <1000 mL). A nomogram was developed to predict the risk of PPH in cesarean delivery for twin pregnancies. The receiver operating characteristic curve (ROC), calibration plot, and decision curve analysis (DCA) were, respectively, used to evaluate the discrimination, calibration, and clinical utility of the prediction models.

Results

After propensity score matching, 186 twin pregnancies in the PPH group were matched with 186 controls in the non-PPH group. Seven independent prognostic variables, including antepartum albumin, assisted reproductive technology, hypertensive disorders of pregnancy, placenta previa, placenta accrete spectrum, intrapartum cesarean delivered, and estimated weights of twins, were used to build the nomogram. Based on the performance of the model, it appears that a good calibration (Hosmer-Lemeshow χ2 = 4.84, P > 0.05), an excellent predictive ability (area under the curve: 0.778, 95% CI: 0.732-0.825), and a good positive net benefit in the predictive model have been achieved.

Conclusion

The nomogram was first generated to predict PPH in cesarean delivery for twin pregnancies, which could help clinicians to provide a reference for the preoperative surgical plan, choose optimal treatments, optimize healthcare resources, and thereby reduce the associated adverse maternal outcomes.

More than time: travel time to the delivery ward and maternal outcomes - onset of labour, postpartum haemorrhage and obstetric anal sphincter injury

BACKGROUND

Closing delivery units increases travel time for some women. Whether increased travel time is associated with maternal outcomes is important for understanding the consequences of such closures. Previous studies are limited in measuring travel time and restricted to the outcome of caesarean section.

METHODS

Our population-based cohort includes data from the Swedish Pregnancy Register for women giving birth between 2014 and 2017 (N = 364,630). We estimated travel time from home to the delivery ward using coordinate pairs of actual addresses. The association between travel time and onset of labour was modelled using multinomial logistic regression, and logistic regression was used for the outcomes postpartum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS).

FINDINGS

Over three-quarters of women had ≤30 min travel time (median 13.9 min). Women who travelled ≥60 min arrived to care sooner and laboured there longer. Women with further to travel had increased adjusted odds ratio (aOR) of having an elective caesarean section (31-59 min aOR 1.11; 95% confidence interval [CI] 1.07-1.16; ≥60 min aOR 1.25; 95% CI 1.16-1.36) than spontaneous onset of labour. Women (at full term with spontaneous onset) living ≥60 min away had reduced odds of having a PPH (aOR 0.84; 95% CI 0.76-0.94) or OASIS (aOR 0.79; 95% CI 0.66-0.94).

INTERPRETATION

Longer travel time increased the odds of elective caesarean section. Women with furthest to travel arrived sooner and spent more time in care; although they had a lower risk of PPH or OASIS, they also tended to be younger, have a higher body mass index and were Nordic born.

Maternal plasma cytokines and the subsequent risk of uterine atony and postpartum hemorrhage

OBJECTIVES

To determine whether the maternal plasma concentrations of cytokines are higher in pregnant women with postpartum hemorrhage (PPH) compared to pregnant women without PPH.

METHODS

A retrospective case-control study included 36 women with PPH and 72 matched controls. Cases and controls were matched for gestational age at delivery, labor status, delivery route, parity, and year of sample collection. Maternal plasma samples were collected up to 3 days prior to delivery. Comparison of the plasma concentrations of 29 cytokines was performed by using linear mixed-effects models and included adjustment for covariates and multiple testing. A false discovery rate adjusted p-value <0.1 was used to infer significance. Random forest models with evaluation by leave-one-out and 9-fold cross-validation were used to assess the combined value of the proteins in predicting PPH.

RESULTS

Concentrations of interleukin (IL)-16, IL-6, IL-12/IL-23p40, monocyte chemotactic protein 1 (MCP-1), and IL-1β were significantly higher in PPH than in the control group. This difference remained significant after adjustment for maternal age, clinical chorioamnionitis, and preeclampsia. Multi-protein random forest proteomics models had moderate cross-validated accuracy for prediction of PPH [area under the ROC curve, 0.69 (0.58-0.81) by leave-one-out cross validation and 0.73 (0.65-0.81) by 9-fold cross-validation], and the inclusion of clinical and demographic information did not increase the prediction performance.

CONCLUSIONS

Pregnant women with severe PPH had higher median maternal plasma concentrations of IL-16, IL-6, IL-12/IL-23p40, MCP-1, and IL-1β than patients without PPH. These cytokines could serve as biomarkers or their pathways may be therapeutic targets.

The impact of assisted reproductive technology on the risk of postpartum hemorrhage: Difference by the mode of delivery and embryo transfer

AIM

The frequency of postpartum hemorrhage (PPH) is increasing in developed countries, and some reports suggest that assisted reproductive technology (ART) increases various perinatal complications, including PPH. We investigated whether the effect of ART pregnancies on the incidence of PPH is modified by the mode of delivery.

METHODS

A retrospective cohort study was performed. We analyzed the medical records of 2914 pregnant women, including 411 pregnancies achieved by ART, which were delivered in our hospital from 2017 to 2020. PPH was defined as hemorrhage exceeding the 90th percentile of blood loss per the mode of delivery and number of fetuses. Multivariable logistic regression analysis was used to assess the association between ART and PPH. Propensity score-matched analyses were used to assess the difference in the incidence of PPH by the mode of delivery.

RESULTS

As previously reported, multivariable logistic regression analysis showed that ART pregnancy is an independent risk factor for PPH. Propensity score-matched analysis for with and without ART showed a 3.39-fold higher incidence of PPH for ART pregnancy in the vaginal delivery group (p < 0.001).

CONCLUSIONS

The effect of ART pregnancies on the incidence of PPH differed depending on the mode of delivery. Only in vaginal delivery, ART pregnancy increased the incidence of PPH.

Prevalence and Predictors of Chronic Postsurgical Pain After Video-Assisted Thoracoscopic Surgery: A Systematic Review and Meta-analysis

INTRODUCTION

Determining the prevalence of chronic postsurgical pain (CPSP) after video-assisted thoracoscopic surgery (VATS) and identifying CPSP predictors should improve the prognosis of patients undergoing VATS. Although several studies have investigated predictors of CPSP after VATS, there were significant dissimilarities in the findings due to the confounding of predictors.

METHODS

PubMed, Cochrane, MEDLINE, Web of Science, Chinese Biomedical Literature, and China National Knowledge Infrastructure databases were comprehensively searched using the Medical Subject Headings terms "pain, postoperative," "thoracic surgery, video-assisted," and all related free terms from inception until March 27, 2022. The Stata metaprop package was used to comprehensively analyze the incidence of CPSP following VATS. Furthermore, the pooled odds ratios (OR) or the standardized mean differences (SMD) and their corresponding 95% confidence intervals (95% CI) were calculated, and qualitative analyses were performed for predictors that could not be assessed quantitatively to evaluate the effects of the included risk factors on the occurrence of CPSP. Unadjusted odds ratios were utilized to consider the impact of non-significant estimates if the original study did not report them.

RESULTS

Of the 4302 studies, 183 were considered eligible, and 17 were finally included in this study. The overall incidence of CPSP after VATS was 35.3% (95% CI 27.1-43.5%). The qualitative synthesis results revealed that female sex, age, and acute postoperative pain were definite predictors of CPSP after VATS. The number of ports, operation time, duration of drainage, and insufficient analgesia were also considered predictors. Consistent, quantitative synthesis results also showed that the aforementioned predictors were closely related to the occurrence of CPSP after VATS. Only by quantitative analysis, postoperative chemotherapy and an educational level less than junior school were also risk factors for CPSP. Other predictors displayed no evidence or unclear evidence of association with CPSP after VATS.

CONCLUSION

This study preliminarily determined the incidence of CPSP after VATS based on the existing literature. Female sex, age, and acute pain were identified as risk factors for CPSP after VATS, and other potential risk factors were also identified and analyzed. However, as a result of the inclusion of retrospective studies and inevitable limitations in this systematic review and meta-analysis, the results of this study still need to be verified by large-scale prospective clinical studies.

TRIAL REGISTRATION

CRD42022323179.

Postpartum hemorrhage among twin pregnancies - Medically assisted versus spontaneously conceived

INTRODUCTION

In singleton pregnancies, an increased risk of Postpartum hemorrhage (PPH) have been linked with assisted reproductive technology (ART) and abnormal placentation. It is unknown wheather such association exists in twin pregnancies conceived by Medically assisted reproduction (MAR). The aim of the current study was to compare maternal blood loss among twin pregnancies conceived by different types of MAR treatments to spontaneously conceived twins and to identify the cycle characteristics if an association exits.

METHODS

Retrospective study conducted on data collected between 2011 and 2020. The study cohort included all twin pregnancies conceived by MAR and born at our institution. Controls were spontaneously conceived twins matched for maternal age on a 1:2 (study: controls) ratio.

RESULTS

Overall 113 MAR twin births categorized into three groups; 25 ovulation induction, 59 fresh ART, 29 frozen-thawed ART cycles, and 226 controls were included. The incidence of PPH was higher among MAR twin pregnancies (5.3%) compared to the controls (4%). The highest incidence was observed among women in the frozen-thawed group (13.8%) which differed significantly compared with the controls (p = 0.024). A significant difference was also observed in the mean decrease of postpartum hemoglobin levels between these two groups (2.13 g/dL versus 1.3 g/dL respectively, p = 0.002). Blood transfusion was nearly 2.5 times more common in the frozen-thawed group (3.4%) compared to the control group (1.3%).

DISCUSSION

The present study demonstrates that frozen embryo transfer (FET) ART-conceived twin pregnancies are associated with a markedly increased rate of PPH compared to spontaneously conceived twins.

Oxytocin receptor DNA methylation is associated with exogenous oxytocin needs during parturition and postpartum hemorrhage

BACKGROUND

The oxytocin receptor gene (OXTR) is regulated, in part, by DNA methylation. This mechanism has implications for uterine contractility during labor and for prevention or treatment of postpartum hemorrhage, an important contributor to global maternal morbidity and mortality.

METHODS

We measured and compared the level of OXTR DNA methylation between matched blood and uterine myometrium to evaluate blood as an indicator of uterine methylation status using targeted pyrosequencing and sites from the Illumina EPIC Array. Next, we tested for OXTR DNA methylation differences in blood between individuals who experienced a postpartum hemorrhage arising from uterine atony and matched controls following vaginal birth. Bivariate statistical tests, generalized linear modeling and Poisson regression were used in the analyses.

RESULTS

Here we show a significant positive correlation between blood and uterine DNA methylation levels at several OXTR loci. Females with higher OXTR DNA methylation in blood had required significantly more exogenous oxytocin during parturition. With higher DNA methylation, those who had oxytocin administered during labor had significantly greater relative risk for postpartum hemorrhage (IRR 2.95, 95% CI 1.53-5.71).

CONCLUSIONS

We provide evidence that epigenetic variability in OXTR is associated with the amount of oxytocin administered during parturition and moderates subsequent postpartum hemorrhage. Methylation can be measured using a peripheral tissue, suggesting potential use in identifying individuals susceptible to postpartum hemorrhage. Future studies are needed to quantify myometrial gene expression in connection with OXTR methylation.

Aspirin use during pregnancy may be a potential risk for postpartum hemorrhage and increased blood loss: a systematic review and meta-analysis

OBJECTIVE

The association between aspirin use during pregnancy and the risk of postpartum hemorrhage remains unclear. This study aimed to explore the incidence of postpartum hemorrhage and the amount of postpartum blood loss among women who used aspirin during pregnancy.

DATA SOURCES

From inception to October 2022, this study searched the following databases: MEDLINE, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials.

STUDY ELIGIBILITY CRITERIA

Studies comparing pregnancy outcomes that covered the incidence of postpartum hemorrhage or the amount of postpartum blood loss in pregnancies with aspirin vs placebo (or no aspirin) were included.

METHODS

Reviewers separately ascertained studies, obtained data, and gauged study quality. The meta-analysis was conducted using a random effects model owing to the probable heterogeneity of the included studies. The rates of postpartum hemorrhage or the mean amounts of postpartum blood loss were compared, and the odds ratios or mean differences with 95% confidence intervals were estimated. Of note, 2 parts performed both a pooled analysis of randomized controlled trials and cohort studies and a separate analysis of randomized controlled trials.

RESULTS

Overall, 21 studies with 373,926 women were included in the postpartum hemorrhage part, and 7 studies with 10,163 women were included in the postpartum blood loss part. The results suggested that aspirin use during pregnancy was associated with an increased incidence of postpartum hemorrhage (odds ratio, 1.20; 95% confidence interval, 1.07-1.34). When only randomized controlled trials were retained, the results remained significant (odds ratio, 1.12; 95% confidence interval, 1.00-1.25). In the second part, higher total blood loss after delivery was obtained (mean difference, 12.85 mL; 95% confidence interval, 3.28-22.42), and the result was unaltered when cohort studies were eliminated (mean difference, 13.72 mL; 95% confidence interval, 4.63-22.81). The conclusions are more likely to be obtained in developed countries.

CONCLUSION

Aspirin use during pregnancy is a potential risk of postpartum hemorrhage and does slightly increase the amount of postpartum blood loss. Without denying the combined value of aspirin, our conclusions raised an alarm for clinicians about postpartum hemorrhage in women using aspirin during pregnancy.

Construction and application of a prediction model for the delivery outcome of women with scarred uterus based on ultrasonic parameters

OBJECTIVE

To explore the application value of the prediction model for delivery outcome of women with scarred uterus based on ultrasonic parameters.

METHODS

In this retrospective study, a total of 100 pregnant women with scarred uterus who delivered in Cangzhou Hospital of Integrated Traditional Chinese Medicine and Western Medicine were selected as the research subjects. Adverse pregnancy outcomes included premature delivery, low birth weight, neonatal asphyxia, postpartum hemorrhage, and uterine rupture. In line with delivery outcome, the pregnant women were segmented into good outcome group (n = 78) and poor outcome group (n = 22). We collected and compared the clinical data and the ultrasonic parameters of pregnant women of the two groups. Multivariate logistic regression analysis was conducted to explore the risk factors affecting the delivery outcome of women with scarred uterus and to establish a prediction model.

RESULTS

Multivariate logistic regression analysis showed that low hemoglobin (Hb) before delivery, high grade of uterine scar, low muscle thickness of lower uterine segment, and low blood flow index were the risk factors for poor delivery outcome of women with scarred uterus. According to the risk factors, the prediction model was obtained: Prob = 1/[1 + e^ (-5.110-2.568 * Pre-delivery Hb - 1.697 * uterine scar grade -2.895 * lower uterine muscle thickness + 19.584 * blood flow index)]. The sensitivity, specificity and area under the curve were 90.0, 91.0 and 0.959, respectively. After validation, the sensitivity and specificity were 85.71 and 87.04, respectively.

CONCLUSION

Low Hb before delivery, low grade of uterine scar, low musculature thickness of lower uterine segment, and low blood flow index were the risk factors for poor delivery outcome of women with scarred uterus. The establishment of prediction model based on risk factors could effectively evaluate the risk of poor delivery outcome of women with scarred uterus.

Postpartum Hemorrhage Trends and Outcomes in the United States, 2000-2019

OBJECTIVE

To analyze temporal trends in and risk factors for postpartum hemorrhage and to analyze the association of risk factors with postpartum hemorrhage-related interventions such as blood transfusion and peripartum hysterectomy.

METHODS

This repeated cross-sectional study analyzed delivery hospitalizations from 2000 to 2019 in the National (Nationwide) Inpatient Sample. Trends analyses were conducted using joinpoint regression to estimate the average annual percent change (AAPC) with 95% CIs. Unadjusted and adjusted survey-weighted logistic regression models were performed to evaluate the relationship between postpartum hemorrhage risk factors and likelihood of 1) postpartum hemorrhage, 2) postpartum hemorrhage that requires blood transfusion, and 3) peripartum hysterectomy in the setting of postpartum hemorrhage, with unadjusted odds ratios and adjusted odds ratios with 95% CIs as measures of association.

RESULTS

Of an estimated 76.7 million delivery hospitalizations, 2.3 million (3.0%) were complicated by postpartum hemorrhage. From 2000 to 2019, the rate of postpartum hemorrhage increased from 2.7% to 4.3% (AAPC 2.6%, 94% CI 1.7-3.5%). Over the study period, the proportion of deliveries to individuals with at least one postpartum hemorrhage risk factor increased from 18.6% to 26.9% (AAPC 1.9%, 95% CI 1.7-2.0%). Among deliveries complicated by postpartum hemorrhage, blood transfusions increased from 5.4% to 16.7% from 2000 to 2011 and then decreased from 16.7% to 12.6% from 2011 to 2019. Peripartum hysterectomy among hospitalized individuals with postpartum hemorrhage increased from 1.4% to 2.4% from 2000 to 2009, did not change significantly from 2009 to 2016, and then decreased significantly from 2.1% to 0.9% from 2016 to 2019 (AAPC -27.0%, 95% CI -35.2% to -17.6%). Risk factors associated with postpartum hemorrhage and transfusion and hysterectomy in the setting of postpartum hemorrhage included prior cesarean delivery with previa or placenta accreta, placenta previa without prior cesarean delivery, and antepartum hemorrhage or placental abruption.

CONCLUSION

Postpartum hemorrhage and related risk factors increased over a 20-year period. Despite the increased postpartum hemorrhage rates, blood transfusions, and hysterectomy rates decreased in recent years.

Association of adverse pregnancy outcomes and multiple gestation with natural menopause: A population-based cohort study

OBJECTIVE

Adverse pregnancy outcomes (APOs) and early menopause are each associated with increased risk of cardiovascular disease (CVD); whether APOs are associated with age at menopause is unclear. We examined the association of gestational diabetes (GDM), hypertensive disorders of pregnancy (HDP), preterm birth, and multiple gestation with age at natural menopause.

STUDY DESIGN

Observational, prospective study within the Nurses' Health Study II cohort (1989-2019).

MAIN OUTCOMES MEASURES

Risk of early natural menopause, defined as occurring before the age of 45 years, and age at onset of natural menopause (hazard ratio (HR) >1 indicates younger age at menopause).

RESULTS

The mean [SD] baseline age of 69,880 parous participants was 34.5 [4.7] years. Compared with participants who had a term singleton first birth, those with a term multiple-gestation first birth had higher risk of early menopause (HR: 1.65, 95% CI: 1.05, 2.60) and younger age at natural menopause (HR: 1.46, 95% CI: 1.31, 1.63). Estimates for preterm multiple gestation were of similar magnitude. Menopause occurred at a younger age for those with a preterm birth with spontaneous labor (HR: 1.08, 95% CI: 1.03, 1.14) compared to those with a term birth with spontaneous labor. Conversely, estimates for GDM (HR: 0.95, 95% CI: 0.89, 1.02) and HDP (preeclampsia, HR: 0.93, 95% CI: 0.89, 0.97) suggested an association with older age at menopause.

CONCLUSIONS

In this large cohort study, several statistically significant associations between APOs and age at natural menopause were observed. A deeper understanding of the relationships among APOs, menopause, and CVD is needed to help identify people at higher risk for early menopause and later CVD.

Postpartum severe acute maternal morbidity according to gestational age at delivery in twin pregnancies: A prospective cohort study

OBJECTIVE

To assess the association between gestational age at delivery and postpartum severe acute maternal morbidity (SAMM) in twin pregnancies.

METHODS

Secondary analysis of the JUMODA cohort, a national, prospective, population-based study of twin pregnancies in France. We excluded women with delivery before 32 weeks of pregnancy, with a fetal death or medical termination, with antepartum SAMM, or with antepartum conditions responsible for postpartum SAMM. The primary outcome was a composite of postpartum SAMM. We assessed the association between gestational age at delivery and SAMM by using multivariable multilevel modified Poisson regression modeling.

RESULTS

Among the 7713 women included, 410 (5.3%) developed postpartum SAMM. Compared with the reference category of 37 weeks of pregnancy, the risk of postpartum SAMM was significantly lower for all categories of earlier gestational age at delivery (from an adjusted relative risk [RR] of 0.34, 95% confidence interval [CI] 0.17-0.68 at 32 weeks to an adjusted RR of 0.71, 95% CI 0.54-0.94 at 36 weeks), and did not differ for later gestational ages.

CONCLUSION

In twin pregnancies, compared with delivery at 37 weeks of pregnancy, delivery at earlier gestational ages was associated with a lower risk of postpartum SAMM. Continuing pregnancy beyond 37 weeks of pregnancy is not associated with an increased risk of postpartum SAMM.

Optimizing systems to manage postpartum hemorrhage

Systems to optimize the management of postpartum hemorrhage must ensure timely diagnosis, rapid hemodynamic and hemostatic resuscitation, and prompt interventions to control the source of bleeding. None of these objectives can be effectively completed by a single clinician, and the management of postpartum hemorrhage requires a carefully coordinated interprofessional team. This article reviews systems designed to standardize hemorrhage diagnosis and response.

Risk assessment tools to predict postpartum hemorrhage

Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality, and accurate risk assessments may allow providers to anticipate and prevent serious hemorrhage-related adverse events. Multiple category-based tools have been developed by national societies through expert consensus, and these tools assign low, medium, or high risk of hemorrhage based on a review of each patient's risk factors. Validation studies of these tools show varying performance, with a wide range of positive and negative predictive values. Risk prediction models for PPH have been developed and studied, and these models offer the advantage of more nuanced and individualized prediction. However, there are no published studies demonstrating external validation or successful clinical use of such models. Future work should include refinement of these models, study of best practices for implementation, and ultimately linkage of prediction to improved patient outcomes.

The role of fibrinogen in postpartum hemorrhage

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide (WHO), with almost 60000 deaths annually. Pregnancy is a prothrombotic state with increased levels of several coagulation factors to protect the parturient from bleeding problems during delivery. Fibrinogen has a significant role in coagulation and bleeding. Studies have pointed out that lower fibrinogen levels before delivery, but also at the initiation of PPH, are predictive of major hemorrhage. Early, the goal-directed fibrinogen concentrate therapy might be very useful in a subgroup of patients with serious PPH. This review aims to summarize the current literature on fibrinogen during PPH.