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Roy P, Ramirez A, Begum F. Contemporary Issues in Women's Health. Int J Gynaecol Obstet 2024; 165:531-534. [PMID: 38469600 DOI: 10.1002/ijgo.15444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Affiliation(s)
- Priyankur Roy
- Roy's Clinic and Multispecialty Hospital, West Bengal, India
| | - Atziri Ramirez
- Hospital Doctor Manuel Gea Gonzalez, Ciudad de México, Mexico
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Stensæth KH, Carlsen MIS, Løvvik TS, Uleberg O, Brede JR, Søvik E. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as adjunct treatment in life threatening postpartum hemorrhage: Fourteen years' experience from a single Norwegian center. Acta Obstet Gynecol Scand 2024; 103:965-969. [PMID: 38197478 PMCID: PMC11019522 DOI: 10.1111/aogs.14767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) remains a global health problem. The introduction of resuscitative endovascular balloon occlusion of the aorta (REBOA) in 2008 sought to enhance the management of hemorrhagic shock during PPH. In this study, we present a single Norwegian center's experience with REBOA as a supportive treatment in combating life threatening PPH. MATERIAL AND METHODS This is a historical cohort study from St Olav's University Hospital, with data from period 2008-2021. It includes all patients who underwent REBOA as an adjunct treatment due to life threatening PPH, analyzing the outcomes and trends over a 14-year period. RESULTS A total of 37 patients received REBOA as an adjunct treatment. All procedures were technically successful, achieving hemodynamic stability with an immediate average increase in systolic blood pressure of 36 ± 22 mmHg upon initial balloon inflation. Additionally, a downward trend was noted in the frequency of hysterectomies and the volume of blood transfusions required over time. No thromboembolic complications were observed. CONCLUSIONS Our 14 years of experience at St Olav's Hospital suggests that REBOA serves as a safe and effective adjunct interventional technique for managing life-threatening PPH. Furthermore, the findings indicate that incorporating a multidisciplinary approach to enable rapid aortic occlusion can potentially reduce the necessity for blood transfusions and hysterectomies.
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Affiliation(s)
- Knut Haakon Stensæth
- Department of Radiology and Nuclear MedicineSt Olav's University HospitalTrondheimNorway
- Department of Circulation and Medical ImagingNorwegian University of Science and TechnologyTrondheimNorway
| | - Marte Irene Skille Carlsen
- Department of Anesthesiology and Intensive Care MedicineSt Olav's University HospitalTrondheimNorway
- Department of TraumatologySt. Olav's University HospitalTrondheimNorway
| | - Tone Shetelig Løvvik
- Department of Obstetrics and GynecologySt Olav's University HospitalTrondheimNorway
| | - Oddvar Uleberg
- Department of Emergency Medicine and Pre‐hospital ServicesSt Olav's University HospitalTrondheimNorway
- Department of Research and Development, Division of Emergencies and Critical CareOslo University HospitalOsloNorway
| | - Jostein Rødseth Brede
- Department of Anesthesiology and Intensive Care MedicineSt Olav's University HospitalTrondheimNorway
- Department of Emergency Medicine and Pre‐hospital ServicesSt Olav's University HospitalTrondheimNorway
- Department of Research and DevelopmentNorwegian Air Ambulance FoundationOsloNorway
| | - Edmund Søvik
- Department of Radiology and Nuclear MedicineSt Olav's University HospitalTrondheimNorway
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Provinciatto H, Barbalho ME, da Câmara PM, Donadon IB, Fonseca LM, Bertani MS, Marinho AD, Sirena E, Provinciatto A, Amaral S. Prophylactic tranexamic acid in Cesarean delivery: an updated meta-analysis with a trial sequential analysis. Can J Anaesth 2024; 71:465-478. [PMID: 38453797 DOI: 10.1007/s12630-024-02715-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/29/2023] [Accepted: 11/04/2023] [Indexed: 03/09/2024] Open
Abstract
PURPOSE Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide. Although several studies on the prophylactic use of tranexamic acid (TXA) in parturients undergoing Cesarean delivery have been published, conflicting results raise questions regarding its use. Thus, we aimed to investigate the safety and efficacy of PPH prophylaxis with TXA. SOURCE We searched PubMed®, Embase, Cochrane Central, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing prophylactic TXA with placebo or no treatment in parturients undergoing Cesarean delivery. Our main outcomes were PPH, any blood transfusion, need for additional uterotonics, and adverse events. We performed a trial sequential analysis (TSA) of all outcomes to investigate the reliability and conclusiveness of findings. PRINCIPAL FINDINGS We included 38 RCTs including 22,940 parturients, 11,535 (50%) of whom were randomized to receive prophylactic TXA. Patients treated with TXA had significantly fewer cases of PPH (risk ratio [RR], 0.51; 95% confidence interval [CI], 0.38 to 0.69; P < 0.001); less blood transfusion (RR, 0.43; 95% CI, 0.30 to 0.61; P < 0.001), and less use of additional uterotonics (RR, 0.52; 95% CI, 0.40 to 0.68; P < 0.001). No significant differences were found between the groups in terms of adverse effects and thromboembolic events. CONCLUSION Prophylactic TXA administration for parturients undergoing Cesarean delivery significantly reduced blood loss, without increasing adverse events, supporting its use as a safe and effective strategy for reducing PPH in this population. STUDY REGISTRATION PROSPERO (CRD42023422188); first submitted 27 April 2023.
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Affiliation(s)
- Henrique Provinciatto
- Barao de Maua University Center, Avenida Portugal, 2433, Ribeirao Preto, SP, Brazil.
| | | | | | | | - Luiza M Fonseca
- Faculty of Medical Sciences of Minas Gerais, Belo Horizonte, Brazil
| | | | - Alice D Marinho
- Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Sara Amaral
- Regional Hospital Deputado Afonso Guizzo, Araranguá, Brazil
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Deniau B, Ricbourg A, Weiss E, Paugam-Burtz C, Bonnet MP, Goffinet F, Mignon A, Morel O, Le Guen M, Binczak M, Carbonnel M, Michelet D, Dahmani S, Pili-Floury S, Ducloy Bouthors AS, Mebazaa A, Gayat E. Association of severe postpartum hemorrhage and development of psychological disorders: Results from the prospective and multicentre HELP MOM study. Anaesth Crit Care Pain Med 2024; 43:101340. [PMID: 38128731 DOI: 10.1016/j.accpm.2023.101340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/10/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Post-partum hemorrhage (PPH) is the leading preventable cause of worldwide maternal morbidity and mortality. Risk factors for psychological disorders following PPH are currently unknown. HELP-MOM study aimed to determine the incidence and identify risk factors for psychological disorders following PPH. METHODS HELP-MOM study was a prospective, observational, national, and multicentre study including patients who experienced severe PPH requiring sulprostone. The primary endpoint was the occurrence of psychological disorders (anxiety and/or post-traumatic disorder and/or depression) following PPH, assessed at 1, 3, and 6 months after delivery using HADS, IES-R, and EPDS scales. RESULTS Between November 2014 and November 2016, 332 patients experienced a severe PPH and 236 (72%) answered self-questionnaires at 1, 3, and 6 months. A total of 161 (68%) patients declared a psychological disorder following severe PPH (146 (90.1%) were screened positive for anxiety, 96 (58.9%) were screened positive for post-traumatic stress disorder, and 94 (57.7%) were screened positive for post-partum depression). In multivariable analysis, the use of intra-uterine tamponnement balloon was associated with a lower risk to be screened positive for psychological disorder after severe PPH (OR = 0.33 [IC95% 0.15-0.69], p = 0.004, and after propensity score matching (OR=0.34 [IC95% 0.12-0.94], p = 0.04)). Low hemoglobin values during severe PPH management were associated with a higher risk of being screened positive for psychological disorders. Finally, we did not find differences in desire or pregnancy between patients without or with psychological disorders occurring in the year after severe PPH. DISCUSSION Severe PPH was associated with significant psychosocial morbidity including anxiety, post-traumatic disorder, and depression. This should engage a psychological follow-up. Large cohorts are urgently needed to confirm our results. REGISTRATION ClinicalTrials.gov under number NCT02118038.
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Affiliation(s)
- Benjamin Deniau
- Département d'Anesthésie-Réanimation et Centre de Traitement des Brûlés, Hôpitaux Universitaires Saint-Louis - Lariboisière, AP-HP, Paris, France; UMR-S 942, INSERM, MASCOT, Paris University, Paris, France; Université de Paris Cité, Paris, France; FHU PROMICE, France; Réseau INI-CRCT, France
| | - Aude Ricbourg
- Service de Gynécologie-Obstétrique, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Emmanuel Weiss
- Université de Paris Cité, Paris, France; Département d'Anesthésie-Réanimation, Hôpital Beaujon, APHP, Clichy, France
| | - Catherine Paugam-Burtz
- Université de Paris Cité, Paris, France; Département d'Anesthésie-Réanimation, Hôpital Beaujon, APHP, Clichy, France
| | - Marie-Pierre Bonnet
- Université de Paris Cité, Paris, France; Département d'Anesthésie Réanimation, Hôpital Armand Trousseau, DMU DREAM, APHP, Paris, France
| | - François Goffinet
- Université de Paris Cité, Paris, France; Maternité Cochin-Port Royal, APHP, Paris, France
| | - Alexandre Mignon
- Université de Paris Cité, Paris, France; Département d'Anesthésie-Réanimation, Hôpital Cochin-Port Royal, APHP, Paris, France; Maternité Cochin-Port Royal, APHP, Paris, France
| | - Olivier Morel
- Service de Gynécologie et Obstétrique, Centre Hospitalier Universitaire de Nancy, Nancy France
| | - Morgan Le Guen
- Université de Versailles Saint-Quentin, France; Département d'Anesthésie, Hôpital Foch, Suresnes, France
| | - Marie Binczak
- Service de Gynécologie et Obstétrique, Hôpital Foch, Suresnes, France
| | - Marie Carbonnel
- Service de Gynécologie et Obstétrique, Hôpital Foch, Suresnes, France
| | - Daphné Michelet
- Département d'Anesthésie et Réanimation, CHU de Reims, France; Université de Reins Champagne Ardenne, Reims, France
| | - Souhayl Dahmani
- Université de Paris Cité, Paris, France; Service d'Anesthésie, Hôpital Robert Debré, APHP, Paris, France; Service d'Anesthésie et Réanimation, Hôpital Robert Ballanger, Aulnay-sous-Bois, France
| | | | | | - Alexandre Mebazaa
- Département d'Anesthésie-Réanimation et Centre de Traitement des Brûlés, Hôpitaux Universitaires Saint-Louis - Lariboisière, AP-HP, Paris, France; UMR-S 942, INSERM, MASCOT, Paris University, Paris, France; Université de Paris Cité, Paris, France; FHU PROMICE, France; Réseau INI-CRCT, France
| | - Etienne Gayat
- Département d'Anesthésie-Réanimation et Centre de Traitement des Brûlés, Hôpitaux Universitaires Saint-Louis - Lariboisière, AP-HP, Paris, France; UMR-S 942, INSERM, MASCOT, Paris University, Paris, France; Université de Paris Cité, Paris, France; FHU PROMICE, France.
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Javitt MC, Madrazo BL. Invited Commentary: Obstetric Hemorrhage: Imaging for Prevention of Maternal and Perinatal Mortality. Radiographics 2024; 44:e230237. [PMID: 38547032 DOI: 10.1148/rg.230237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Marcia C Javitt
- From the Department of Radiology, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL 33136
| | - Beatrice L Madrazo
- From the Department of Radiology, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL 33136
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Hersh AR, Carroli G, Hofmeyr GJ, Garg B, Gülmezoglu M, Lumbiganon P, De Mucio B, Saleem S, Festin MPR, Mittal S, Rubio-Romero JA, Chipato T, Valencia C, Tolosa JE. Third stage of labor: evidence-based practice for prevention of adverse maternal and neonatal outcomes. Am J Obstet Gynecol 2024; 230:S1046-S1060.e1. [PMID: 38462248 DOI: 10.1016/j.ajog.2022.11.1298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 03/12/2024]
Abstract
The third stage of labor is defined as the time period between delivery of the fetus through delivery of the placenta. During a normal third stage, uterine contractions lead to separation and expulsion of the placenta from the uterus. Postpartum hemorrhage is a relatively common complication of the third stage of labor. Strategies have been studied to mitigate the risk of postpartum hemorrhage, leading to the widespread implementation of active management of the third stage of labor. Initially, active management of the third stage of labor consisted of a bundle of interventions including administration of a uterotonic agent, early cord clamping, controlled cord traction, and external uterine massage. However, the effectiveness of these interventions as a bundle has been questioned, leading to abandonment of some components in recent years. Despite this, upon review of selected international guidelines, we found that the term "active management of the third stage of labor" was still used, but recommendations for and against individual interventions were variable and not necessarily supported by current evidence. In this review, we: (1) examine the physiology of the third stage of labor, (2) present evidence related to interventions that prevent postpartum hemorrhage and promote maternal and neonatal health, (3) review current global guidelines and recommendations for practice, and (4) propose future areas of investigation. The interventions in this review include pharmacologic agents to prevent postpartum hemorrhage, cord clamping, cord milking, cord traction, cord drainage, early skin-to-skin contact, and nipple stimulation. Treatment of complications of the third stage of labor is outside of the scope of this review. We conclude that current evidence supports the use of effective pharmacologic postpartum hemorrhage prophylaxis, delayed cord clamping, early skin-to-skin contact, and controlled cord traction at delivery when feasible. The most effective uterotonic regimens for preventing postpartum hemorrhage after vaginal delivery include oxytocin plus ergometrine; oxytocin plus misoprostol; or carbetocin. After cesarean delivery, carbetocin or oxytocin as a bolus are the most effective regimens. There is inconsistent evidence regarding the use of tranexamic acid in addition to a uterotonic compared with a uterotonic alone for postpartum hemorrhage prevention after all deliveries. Because of differences in patient comorbidities, costs, and availability of resources and staff, decisions to use specific prevention strategies are dependent on patient- and system-level factors. We recommend that the term "active management of the third stage of labor" as a combined intervention no longer be used. Instead, we recommend that "third stage care" be adopted, which promotes the implementation of evidence-based interventions that incorporate practices that are safe and beneficial for both the woman and neonate.
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Affiliation(s)
- Alyssa R Hersh
- Oregon Health & Science University, Portland, OR; FUNDARED-MATERNA, Bogotá, Colombia.
| | | | - G Justus Hofmeyr
- University of Botswana, Gaborone, Botswana; University of the Witwatersrand, Johannesburg, Johannesburg, South Africa; Walter Sisulu University, Mthatha, South Africa
| | - Bharti Garg
- Oregon Health & Science University, Portland, OR
| | | | - Pisake Lumbiganon
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Bremen De Mucio
- Latin American Center for Perinatology, Women and Reproductive Health, Montevideo, Uruguay
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Mario Philip R Festin
- Department of Obstetrics and Gynecology, College of Medicine, University of the Philippines, Manila, Philippines
| | | | | | - Tsungai Chipato
- Faculty of Health Sciences, Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | - Catalina Valencia
- FUNDARED-MATERNA, Bogotá, Colombia; Medicina Fetal SAS, Medellin, Colombia
| | - Jorge E Tolosa
- Oregon Health & Science University, Portland, OR; FUNDARED-MATERNA, Bogotá, Colombia; St. Luke's University Health Network, Bethlehem, PA
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VanderMeulen H, Tang GH, Sholzberg M. Tranexamic acid for management of heavy vaginal bleeding: barriers to access and myths surrounding its use. Res Pract Thromb Haemost 2024; 8:102389. [PMID: 38623473 PMCID: PMC11017359 DOI: 10.1016/j.rpth.2024.102389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 04/17/2024] Open
Abstract
Tranexamic acid is safe and effective for the treatment of heavy vaginal bleeding during menstruation and childbirth. It improves the quality of life, facilitates participation in school and work, and reduces the risk of death from postpartum hemorrhage. Despite its well-established benefits, individual- and structural-level barriers preclude its widespread utilization, hindering effective patient care and perpetuating health inequities in women's health. We first describe the evidence for the use of tranexamic acid in treating heavy menstrual bleeding and postpartum hemorrhage. Barriers to tranexamic acid use, including structural sexism, period poverty, misinformation in product monograph labeling, stigmatization of vaginal blood loss, and drug access, are then discussed. Finally, we summarize relevant data presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- Heather VanderMeulen
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Grace H. Tang
- Department of Hematology, Hematology-Oncology Clinical Research Group, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Department of Medicine and Laboratory Medicine & Pathobiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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Simovic MO, Bynum J, Liu B, Dalle Lucca JJ, Li Y. Impact of Immunopathy and Coagulopathy on Multi-Organ Failure and Mortality in a Lethal Porcine Model of Controlled and Uncontrolled Hemorrhage. Int J Mol Sci 2024; 25:2500. [PMID: 38473750 DOI: 10.3390/ijms25052500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
Uncontrolled hemorrhage is a major preventable cause of death in patients with trauma. However, the majority of large animal models of hemorrhage have utilized controlled hemorrhage rather than uncontrolled hemorrhage to investigate the impact of immunopathy and coagulopathy on multi-organ failure (MOF) and mortality. This study evaluates these alterations in a severe porcine controlled and uncontrolled hemorrhagic shock (HS) model. Anesthetized female swine underwent controlled hemorrhage and uncontrolled hemorrhage by partial splenic resection followed with or without lactated Ringer solution (LR) or Voluven® resuscitation. Swine were surveyed 6 h after completion of splenic hemorrhage or until death. Blood chemistry, physiologic variables, systemic and tissue levels of complement proteins and cytokines, coagulation parameters, organ function, and damage were recorded and assessed. HS resulted in systemic and local complement activation, cytokine release, hypocoagulopathy, metabolic acidosis, MOF, and no animal survival. Resuscitation with LR and Voluven® after HS improved hemodynamic parameters (MAP and SI), metabolic acidosis, hyperkalemia, and survival but resulted in increased complement activation and worse coagulopathy. Compared with the LR group, the animals with hemorrhagic shock treated with Voluven® had worse dilutional anemia, coagulopathy, renal and hepatic dysfunction, increased myocardial complement activation and renal damage, and decreased survival rate. Hemorrhagic shock triggers early immunopathy and coagulopathy and appears associated with MOF and death. This study indicates that immunopathy and coagulopathy are therapeutic targets that may be addressed with a high-impact adjunctive treatment to conventional resuscitation.
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Affiliation(s)
- Milomir O Simovic
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - James Bynum
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Bin Liu
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | | | - Yansong Li
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
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Alonso-Burgos A, Díaz-Lorenzo I, Muñoz-Saá L, Gallardo G, Castellanos T, Cardenas R, Chiva de Agustín L. Primary and secondary postpartum haemorrhage: a review for a rationale endovascular approach. CVIR Endovasc 2024; 7:17. [PMID: 38349501 PMCID: PMC10864234 DOI: 10.1186/s42155-024-00429-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024] Open
Abstract
Postpartum haemorrhage (PPH) is a significant cause of maternal mortality globally, necessitating prompt and efficient management. This review provides a comprehensive exploration of endovascular treatment dimensions for both primary and secondary PPH, with a focus on uterine atony, trauma, placenta accreta spectrum (PAS), and retained products of conception (RPOC). Primary PPH, occurring within 24 h, often results from uterine atony in 70% of causes, but also from trauma, or PAS. Uterine atony involves inadequate myometrial contraction, addressed through uterine massage, oxytocin, and, if needed, mechanical modalities like balloon tamponade. Trauma-related PPH may stem from perineal injuries or pseudoaneurysm rupture, while PAS involves abnormal placental adherence. PAS demands early detection due to associated life-threatening bleeding during delivery. Secondary PPH, occurring within 24 h to 6 weeks postpartum, frequently arises from RPOC. Medical management may include uterine contraction drugs and hemostatic agents, but invasive procedures like dilation and curettage (D&C) or hysteroscopic resection may be required.Imaging assessments, particularly through ultrasound (US), play a crucial role in the diagnosis and treatment planning of postpartum haemorrhage (PPH), except for uterine atony, where imaging techniques prove to be of limited utility in its management. Computed tomography play an important role in evaluation of trauma related PPH cases and MRI is essential in diagnosing and treatment planning of PAS and RPOC.Uterine artery embolization (UAE) has become a standard intervention for refractory PPH, offering a rapid, effective, and safe alternative to surgery with a success rate exceeding 85% (Rand T. et al. CVIR Endovasc 3:1-12, 2020). The technical approach involves non-selective uterine artery embolization with resorbable gelatine sponge (GS) in semi-liquid or torpedo presentation as the most extended embolic or calibrated microspheres. Selective embolization is warranted in cases with identifiable bleeding points or RPOC with AVM-like angiographic patterns and liquid embolics could be a good option in this scenario. UAE in PAS requires a tailored approach, considering the degree of placental invasion. A thorough understanding of female pelvis vascular anatomy and collateral pathways is essential for accurate and safe UAE.In conclusion, integrating interventional radiology techniques into clinical guidelines for primary and secondary PPH management and co-working during labour is crucial.
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Affiliation(s)
- Alberto Alonso-Burgos
- Radiology Department, Vascular Surgery and Interventional Radiology Unit, University Clinic of Navarra, Clínica Universidad de Navarra, Marquesado de Santa Marta 1, 28027, Madrid, Spain.
| | - Ignacio Díaz-Lorenzo
- Radiology Department, Interventional Radiology Unit, University Hospital La Princesa, Madrid, Spain
| | - Laura Muñoz-Saá
- Gynaecology and Obstetrics, University Clinic of Navarra, Madrid, Spain
| | | | | | - Regina Cardenas
- Gynaecology and Obstetrics, University Clinic of Navarra, Madrid, Spain
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Vogel JP, Nguyen PY, Ramson J, De Silva MS, Pham MD, Sultana S, McDonald S, Adu-Bonsaffoh K, McDougall ARA. Effectiveness of care bundles for prevention and treatment of postpartum hemorrhage: a systematic review. Am J Obstet Gynecol 2024:S0002-9378(24)00042-5. [PMID: 38336124 DOI: 10.1016/j.ajog.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/13/2024] [Accepted: 01/17/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Care bundles are a promising approach to reducing postpartum hemorrhage-related morbidity and mortality. We assessed the effectiveness and safety of care bundles for postpartum hemorrhage prevention and/or treatment. DATA SOURCES We searched MEDLINE, Embase, Cochrane CENTRAL, Maternity and Infant Care Database, and Global Index Medicus (inception to June 9, 2023) and ClinicalTrials.gov and the International Clinical Trials Registry Platform (last 5 years) using a phased search strategy, combining terms for postpartum hemorrhage and care bundles. STUDY ELIGIBILITY CRITERIA Peer-reviewed studies evaluating postpartum hemorrhage-related care bundles were included. Care bundles were defined as interventions comprising ≥3 components implemented collectively, concurrently, or in rapid succession. Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies (controlled or uncontrolled) were eligible. METHODS Risk of bias was assessed using RoB 2 (randomized trials) and ROBINS-I (nonrandomized studies). For controlled studies, we reported risk ratios for dichotomous outcomes and mean differences for continuous outcomes, with certainty of evidence determined using GRADE. For uncontrolled studies, we used effect direction tables and summarized results narratively. RESULTS Twenty-two studies were included for analysis. For prevention-only bundles (2 studies), low-certainty evidence suggests possible benefits in reducing blood loss, duration of hospitalization, and intensive care unit stay, and maternal well-being. For treatment-only bundles (9 studies), high-certainty evidence shows that the E-MOTIVE intervention reduced risks of composite severe morbidity (risk ratio, 0.40; 95% confidence interval, 0.32-0.50) and blood transfusion for bleeding, postpartum hemorrhage, severe postpartum hemorrhage, and mean blood loss. One nonrandomized trial and 7 uncontrolled studies suggest that other postpartum hemorrhage treatment bundles might reduce blood loss and severe postpartum hemorrhage, but this is uncertain. For combined prevention/treatment bundles (11 studies), low-certainty evidence shows that the California Maternal Quality Care Collaborative care bundle may reduce severe maternal morbidity (risk ratio, 0.64; 95% confidence interval, 0.57-0.72). Ten uncontrolled studies variably showed possible benefits, no effects, or harms for other bundle types. Nearly all uncontrolled studies did not use suitable statistical methods for single-group pretest-posttest comparisons and should thus be interpreted with caution. CONCLUSION The E-MOTIVE intervention improves postpartum hemorrhage-related outcomes among women delivering vaginally, and the California Maternal Quality Care Collaborative bundle may reduce severe maternal morbidity. Other bundle designs warrant further effectiveness research before implementation is contemplated.
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Affiliation(s)
- Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Phi-Yen Nguyen
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jen Ramson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
| | - Manarangi S De Silva
- Department of Obstetrics, Gynaecology and Newborn Health, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Minh D Pham
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Saima Sultana
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Steve McDonald
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Kwame Adu-Bonsaffoh
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Accra, Ghana
| | - Annie R A McDougall
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
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11
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Abecassis A, Wainstock T, Sheiner E, Miodownik S, Pariente G. Risk factors for early postpartum hemorrhage: A retrospective, population-based, cohort analysis. Int J Gynaecol Obstet 2024. [PMID: 38321817 DOI: 10.1002/ijgo.15414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/16/2024] [Accepted: 01/25/2024] [Indexed: 02/08/2024]
Abstract
OBJECTIVE To identify risk factors for developing early postpartum hemorrhage (PPH) and to examine whether risk factors vary according to severity and mode of delivery. METHODS A population-based cohort study was conducted in which all deliveries at a tertiary medical center were included. Risk factors for developing early PPH were compared based on the severity of bleeding as well as the mode of delivery. Multiple logistic regression models were used to control for confounders. RESULTS Among 322 497 deliveries included in the analysis, early PPH complicated 1811 (0.56%) of all deliveries. Among all cases of early PPH, 505 deliveries (28%) were complicated with severe PPH. Using a logistic regression model, in vitro fertilization (IVF) pregnancy, previous cesarean delivery (CD), pre-eclampsia, placental abruption, and uterine rupture were independently associated only with severe early PPH, while non-progressive second stage of labor, induction of labor, and large for gestational age were independently associated with both severe and mild early PPH. When applying an additional logistic regression model, whereas IVF pregnancy, pre-eclampsia, and large for gestational age were independently associated with early PPH among vaginal deliveries only, placenta previa was independently associated with early PPH among CD only. CONCLUSIONS Independent risk factors for developing severe PPH solely include IVF pregnancy, previous CD, pre-eclampsia, placental abruption, and uterine rupture. IVF pregnancy, pre-eclampsia, and large for gestational age are independent risk factors for early PPH following vaginal delivery, while placenta previa is independently associated with early PPH after CD only. Due to the recognition of the importance of both the provider and institutional planning and preparation for PPH, the study's results should be viewed within the scope of its retrospective cohort design.
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Affiliation(s)
- Avishag Abecassis
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Tamar Wainstock
- Department of Epidemiology and Health Services Evaluation, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Shayna Miodownik
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Gali Pariente
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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12
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Madar H, Deneux-Tharaux C, Sentilhes L. Shock index as a predictor of postpartum haemorrhage after vaginal delivery: Secondary analysis of a multicentre randomised controlled trial. BJOG 2024; 131:343-352. [PMID: 37555480 DOI: 10.1111/1471-0528.17634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/09/2023] [Accepted: 07/22/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVE To describe the shock index (SI) distribution during the first 2 hours after delivery and to evaluate its performance when measured 15 and 30 minutes after delivery for predicting postpartum haemorrhage (PPH) occurrence in the general population of parturients after vaginal delivery. DESIGN Secondary analysis of a multicentre randomised controlled trial testing prophylactic administration of tranexamic acid versus placebo in addition to prophylactic oxytocin to prevent PPH. SETTING 15 French maternity units in 2015-2016. SAMPLE 3891 women with a singleton live fetus ≥35 weeks, born vaginally. METHODS For each PPH-related predicted outcome, we calculated the area under the receiver operating characteristic curve (AUROC) values of the SI at 15 and 30 minutes after delivery and its predictive performance for SI cut-off values of 0.7, 0.9 and 1.1. MAIN OUTCOME MEASURES Quantitative blood loss ≥1000 ml (QBL ≥1000 ml) measured in a graduated collector bag and provider-assessed clinically significant PPH (cPPH). RESULTS Prevalence of QBL ≥1000 ml and cPPH was respectively 2.7% (104/3839) and 9.1% (354/3891). The distributions of the SI at 15 and 30 minutes after delivery were similar with a median value of 0.73 and 97th percentile of 1.11 for both. The AUROC values of the 15-minute SI for discriminating QBL ≥1000 ml and cPPH were respectively 0.66 (lower limit of the 95% confidence interval [LCI] 0.60) and 0.56 (LCI 0.52); and for the 30-minute SI 0.68 (LCI 0.61) and 0.49 (LCI 0.43). CONCLUSIONS The shock index at 15 and 30 minutes after delivery did not satisfactorily predict either QBL ≥1000 ml or clinical PPH.
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Affiliation(s)
- Hugo Madar
- Université Paris Cité, Women's Health IHM, U1153, Centre of Research In Epidemiology and Statistics, Obstetrical, Perinatal and Paediatric Epidemiology EPOPé Research Team, INSERM, INRAE, Paris, France
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France
| | - Catherine Deneux-Tharaux
- Université Paris Cité, Women's Health IHM, U1153, Centre of Research In Epidemiology and Statistics, Obstetrical, Perinatal and Paediatric Epidemiology EPOPé Research Team, INSERM, INRAE, Paris, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France
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13
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Franchini M, Focosi D, Zaffanello M, Mannucci PM. Efficacy and safety of tranexamic acid in acute haemorrhage. BMJ 2024; 384:e075720. [PMID: 38176733 DOI: 10.1136/bmj-2023-075720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | - Marco Zaffanello
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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14
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Weeks AD. Reducing maternal deaths from haemorrhage: Seeking the low-hanging fruit. BJOG 2024. [PMID: 38177088 DOI: 10.1111/1471-0528.17753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/18/2023] [Accepted: 12/24/2023] [Indexed: 01/06/2024]
Affiliation(s)
- Andrew D Weeks
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
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15
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Nieto-Calvache AJ, Barona JS, Burgos-Luna JM, Muñoz-Córdoba L, Sarria-Ortiz D, Galindo-Velasco V, Meade Triviño P, Mondragón K, Messa-Byron A. The uterine tourniquet, a simple maneuver that may facilitate surgical management of postpartum hemorrhage. Int J Gynaecol Obstet 2024; 164:345-347. [PMID: 37776026 DOI: 10.1002/ijgo.15110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/13/2023] [Accepted: 08/22/2023] [Indexed: 10/01/2023]
Abstract
SynopsisThe uterine tourniquet is a temporary intervention that facilitates the application of other procedures for definitive control of postpartum hemorrhage.
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Affiliation(s)
| | | | | | - Laura Muñoz-Córdoba
- Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia
| | | | | | | | - Karen Mondragón
- Fundación Valle del Lili, Departamento de Urgencias, Cali, Colombia
| | - Adriana Messa-Byron
- Fundación Valle del Lili, Departamento de Ginecología y Obstetricia, Cali, Colombia
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16
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Vaid S, Gupta A, Houchens N. Quality and safety in the literature: January 2024. BMJ Qual Saf 2023; 33:66-70. [PMID: 38097250 DOI: 10.1136/bmjqs-2023-016782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 12/18/2023]
Affiliation(s)
| | - Ashwin Gupta
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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17
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Akter S, Forbes G, Vazquez Corona M, Miller S, Althabe F, Coomarasamy A, Gallos ID, Oladapo OT, Vogel JP, Lorencatto F, Bohren MA. Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis. Cochrane Database Syst Rev 2023; 11:CD013795. [PMID: 38009552 PMCID: PMC10680124 DOI: 10.1002/14651858.cd013795.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries. OBJECTIVES Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings. SEARCH METHODS We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies. SELECTION CRITERIA We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers. DATA COLLECTION AND ANALYSIS We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice. MAIN RESULTS We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence). AUTHORS' CONCLUSIONS Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.
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Affiliation(s)
- Shahinoor Akter
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Gillian Forbes
- Centre for Behaviour Change, University College London, London, UK
| | - Martha Vazquez Corona
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, and Safe Motherhood Program, Bixby Center for Global Reproductive Health and Policy, University of California, San Francisco, California, USA
| | - Fernando Althabe
- Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Joshua P Vogel
- Maternal and Child Health, Burnet Institute, Melbourne, Australia
| | | | - Meghan A Bohren
- Gender and Women's Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Australia
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18
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Abstract
Postpartum hemorrhage (PPH) affects about 4% of all deliveries in high-income countries and continues to rise, a trend attributable to the increase in caesarean section rates and maternal morbidity. Preventive measures such as the precautionary administration of uterotonics effectively reduce the risk of severe bleeding irrespective of birth mode. As a time-critical condition and a significant contributor to adverse maternal outcomes, PPH needs to be diagnosed early by measuring, not estimating, blood losses. Institutional treatment algorithms should be available to guide stage-based interdisciplinary management without delay. The main therapy goals are to identify the etiology and stop the bleeding by using uterotonics and mechanical and surgical interventions, to restore hemodynamic stability by volume and transfusion therapy and to optimize hemostasis by laboratory- and viscoelastic assay-guided factor replacement. This review highlights current recommendations for prevention, diagnosis and treatment of PPH.
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19
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Hofmeyr GJ. Novel concepts and improvisation for treating postpartum haemorrhage: a narrative review of emerging techniques. Reprod Health 2023; 20:116. [PMID: 37568196 PMCID: PMC10422815 DOI: 10.1186/s12978-023-01657-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Most treatments for postpartum haemorrhage (PPH) lack evidence of effectiveness. New innovations are ubiquitous but have not been synthesized for ready access. NARRATIVE REVIEW Pubmed 2020 to 2021 was searched on 'postpartum haemorrhage treatment', and novel reports among 755 citations were catalogued. New health care strategies included early diagnosis with a bundled first response and home-based treatment of PPH. A calibrated postpartum blood monitoring tray has been described. Oxytocin is more effective than misoprostol; addition of misoprostol to oxytocin does not improve treatment. Heat stable carbetocin has not been assessed for treatment. A thermostable microneedle oxytocin patch has been developed. Intravenous tranexamic acid reduces mortality but deaths have been reported from inadvertent intrathecal injection. New transvaginal uterine artery clamps have been described. Novel approaches to uterine balloon tamponade include improvised and purpose-designed free-flow (as opposed to fixed volume) devices and vaginal balloon tamponade. Uterine suction tamponade methods include purpose-designed and improvised devices. Restrictive fluid resuscitation, massive transfusion protocols, fibrinogen use, early cryopreciptate transfusion and point-of-care viscoelastic haemostatic assay-guided blood product transfusion have been reported. Pelvic artery embolization and endovascular balloon occlusion of the aorta and pelvic arteries are used where available. External aortic compression and direct compression of the aorta during laparotomy or aortic clamping (such as with the Paily clamp) are alternatives. Transvaginal haemostatic ligation and compression sutures, placental site sutures and a variety of novel compression sutures have been reported. These include Esike's technique, three vertical compression sutures, vertical plus horizontal compression sutures, parallel loop binding compression sutures, uterine isthmus vertical compression sutures, isthmic circumferential suture, circumferential compression sutures with intrauterine balloon, King's combined uterine suture and removable retropubic uterine compression suture. Innovative measures for placenta accreta spectrum include a lower uterine folding suture, a modified cervical inversion technique, bilateral uterine artery ligation with myometrial excision of the adherent placenta and cervico-isthmic sutures or a T-shaped lower segment repair. Technological advances include cell salvage, high frequency focussed ultrasound for placenta increta and extra-corporeal membrane oxygenation. CONCLUSIONS Knowledge of innovative methods can equip clinicians with last-resort options when faced with haemorrhage unresponsive to conventional methods.
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Affiliation(s)
- G J Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana, Notwane Rd, Gaborone, Botswana.
- Universities of the Witwatersrand and Walter Sisulu, East London, South Africa.
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20
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Wilkinson E. Simple intervention for severe blood loss after childbirth is found to save lives. BMJ 2023; 381:1055. [PMID: 37164378 DOI: 10.1136/bmj.p1055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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