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Overton E, D'Alton M, Goffman D. Intrauterine devices in the management of postpartum hemorrhage. Am J Obstet Gynecol 2024; 230:S1076-S1088. [PMID: 37690862 DOI: 10.1016/j.ajog.2023.08.015] [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: 05/31/2023] [Revised: 07/28/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023]
Abstract
Obstetrical hemorrhage is a relatively frequent obstetrical complication and a common cause of maternal morbidity and mortality worldwide. The majority of maternal deaths attributable to hemorrhage are preventable, thus, developing rapid and effective means of treating postpartum hemorrhage is of critical public health importance. Intrauterine devices are one option for managing refractory hemorrhage, with rapid expansion of available devices in recent years. Intrauterine packing was historically used for this purpose, with historical cohorts documenting high rates of success. Modern packing materials, including chitosan-covered gauze, have recently been explored with success rates comparable to uterine balloon tamponade in small trials. There are a variety of balloon tamponade devices, both commercial and improvised, available for use. Efficacy of 85.9% was cited in a recent meta-analysis in resolution of hemorrhage with the use of uterine balloon devices, with greatest success in the setting of atony. However, recent randomized trials have demonstrated potential harm associated with improvised balloon tamponade use In low resource settings and the World Health Organization recommends use be restricted to settings where monitoring is available and care escalation is possible. Recently, intrauterine vacuum devices have been introduced, which offer a new mechanism for achieving hemorrhage control by mechanically restoring uterine tone via vacuum suction. The Jada device, which is is FDA-cleared and commercially available in the US, found successful bleeding control in 94% of cases in an initial single-arm trial, with recent post marketing registry study described treatment success following hemorrhage in 95.8% of vaginal and 88.2% of cesarean births. Successful use of improvised vacuum devices has been described in several studies, including suction tube uterine tamponade via Levin tubing, and use of a modified Bakri balloon. Further research is needed with head-to-head comparisons of efficacy of devices and assessment of cost within the context of both device pricing and overall healthcare resource utilization.
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Affiliation(s)
- Eve Overton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY.
| | - Mary D'Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY
| | - Dena Goffman
- Department of Obstetrics and Gynecology, Columbia University, New York, NY
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Linde LE, Rasmussen S, Ebbing C. Response to risk of postpartum hemorrhage and fetal gender. Arch Gynecol Obstet 2023; 308:667-668. [PMID: 37119420 DOI: 10.1007/s00404-022-06738-3] [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: 05/01/2023]
Affiliation(s)
- Lorentz Erland Linde
- University of Bergen, Bergen, Norway.
- Haukeland University Hospital, Bergen, Norway.
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3
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Abstract
PURPOSE OF REVIEW Excessive bleeding during and following childbirth remains one of the leading causes of maternal mortality. RECENT FINDINGS Current guidelines differ in definitions and recommendations on managing transfusion and hemostasis in massive postpartum hemorrhage (PPH). Insights gained from trauma-induced coagulopathy are not directly transferable to the obstetric population due to gestational alterations and a differing pathophysiology. SUMMARY Factor deficiency is uncommon at the beginning of most etiologies of PPH but will eventually develop from consumption and depletion in the absence of bleeding control. The sensitivity of point-of-care tests for fibrinolysis is too low and may delay treatment, therefore tranexamic acid should be started early at diagnosis even without signs for hyperfibrinolysis. Transfusion management may be initiated empirically, but is best to be guided by laboratory and viscoelastic assay results as soon as possible. Hypofibrinogenemia is well detected by point-of-care tests, thus substitution may be tailored to individual needs, while reliable thresholds for fresh frozen plasma (FFP) and specific components are yet to be defined. In case of factor deficiency, prothrombin complex concentrate or lyophilized plasma allow for a more rapid restoration of coagulation than FFP. If bleeding and hemostasis are under control, a timely anticoagulation may be necessary.
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Affiliation(s)
- Christina Massoth
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster
| | - Manuel Wenk
- Department of Anesthesiology and Intensive Care, Clemenshospital Münster, Münster
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine University Hospital Wuerzburg, Wuerzburg, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine University Hospital Wuerzburg, Wuerzburg, Germany
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Liu LY, Nathan L, Sheen JJ, Goffman D. Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage. Int J Womens Health 2023; 15:905-926. [PMID: 37283995 PMCID: PMC10241213 DOI: 10.2147/ijwh.s366675] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/03/2023] [Indexed: 06/08/2023] Open
Abstract
Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.
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Affiliation(s)
- Lilly Y Liu
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Lisa Nathan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jean-Ju Sheen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Dena Goffman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
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Edwards RT, Ezeofor V, Bryning L, Anthony BF, Charles JM, Weeks A. Prevention of postpartum haemorrhage: Economic evaluation of the novel butterfly device in a UK setting. Eur J Obstet Gynecol Reprod Biol 2023; 283:149-157. [PMID: 36906411 DOI: 10.1016/j.ejogrb.2023.02.020] [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: 02/08/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVES To explore the cost-effectiveness of a novel PPH device as compared with usual care. DESIGN A decision analytical model was used to explore the cost-effectiveness of the PPH Butterfly device compared with usual care. This was part of a United Kingdom, UK, clinical trial ISRCTN15452399 using a matched historical cohort who had standard PPH management without the use of the PPH Butterfly device. The economic evaluation was conducted from a UK National Health Service (NHS) perspective. SETTING Liverpool Women's Hospital, UK. PARTICIPANTS 57 women with 113 matched controls. INTERVENTION The PPH Butterfly is a novel device that has been invented and developed in the UK to facilitate bimanual compression of the uterus in the treatment of PPH. MAIN OUTCOME MEASURES Main outcome measures included healthcare costs, blood loss, and maternal morbidity events. RESULTS Mean treatment costs in the Butterfly cohort were £3,459.66 as compared with standard care £3,223.93. Treatment with the Butterfly device resulted in decreased total blood loss in comparison with standard care. The Butterfly device had an incremental cost-effectiveness ratio of £3,795.78 per PPH progression avoided (defined as ≤ 1000 ml additional blood loss from device insertion point). If the NHS is prepared to pay £8,500 per PPH progression avoided, then the Butterfly device is cost-effective with a probability of 87 percent. In the PPH Butterfly treatment arm there were 9% fewer cases of massive obstetric haemorrhage (severe PPH of more than 2000mls or more than 4 units of blood transfusion required) recorded as compared with the standard care historical cohort. As a low-cost device, the PPH Butterfly device is cost-effective but can be cost-saving to the NHS. CONCLUSION The PPH pathway can result in high-cost resource use such as blood transfusion or high dependence unit hospital stays. The Butterfly device is a relative low-cost device in a UK NHS setting with a high probability of being cost-effective. The National Institute for Health and Care Excellence (NICE) can use this evidence in considering the adoption of innovative technologies such as the Butterfly device in the NHS. Extrapolation on an international scale to lower and middle-income countries could prevent mortality associated with PPH.
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Affiliation(s)
- Rhiannon T Edwards
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor, Gwynedd LL57 2PZ, UK.
| | - Victory Ezeofor
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor, Gwynedd LL57 2PZ, UK
| | - Lucy Bryning
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor, Gwynedd LL57 2PZ, UK
| | - Bethany F Anthony
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor, Gwynedd LL57 2PZ, UK
| | - Joanna M Charles
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor, Gwynedd LL57 2PZ, UK
| | - Andrew Weeks
- Department of Women's and Children's Health, University of Liverpool (a member of Liverpool Health Partners), Liverpool L69 3BX, UK
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Parker ME, Qureshi Z, Deganus S, Soki J, Cofie P, Dapaah P, Owusu R, Gwako G, Osoti A, Ogutu O, Opira J, Sunkwa-Mills G, Boamah M, Srofenyoh E, Aboagye P, Fofie C, Kaliti S, Morozoff C, Secor A, Metzler M, Abu-Haydar E. Introduction of the Ellavi uterine balloon tamponade into the Kenyan and Ghanaian maternal healthcare package for improved postpartum haemorrhage management: an implementation research study. BMJ Open 2023; 13:e066907. [PMID: 36737079 PMCID: PMC9900048 DOI: 10.1136/bmjopen-2022-066907] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Use of intrauterine balloon tamponades for refractory postpartum haemorrhage (PPH) management has triggered recent debate since effectiveness studies have yielded conflicting results. Implementation research is needed to identify factors influencing successful integration into maternal healthcare packages. The Ellavi uterine balloon tamponade (UBT) (Ellavi) is a new low-cost, preassembled device for treating refractory PPH. DESIGN A mixed-methods, prospective, implementation research study examining the adoption, sustainability, fidelity, acceptability and feasibility of introducing a newly registered UBT. Cross-sectional surveys were administered post-training and post-use over 10 months. SETTING Three Ghanaian (district, regional) and three Kenyan (levels 4-6) healthcare facilities. PARTICIPANTS Obstetric staff (n=451) working within participating facilities. INTERVENTION PPH management training courses were conducted with obstetric staff. PRIMARY AND SECONDARY OUTCOME MEASURES Facility measures of adoption, sustainability and fidelity and individual measures of acceptability and feasibility. RESULTS All participating hospitals adopted the device during the study period and the majority (52%-62%) of the employed obstetric staff were trained on the Ellavi; sustainability and fidelity to training content were moderate. The Ellavi was suited for this context due to high delivery and PPH burden. Dynamic training curriculums led by local UBT champions and clear instructions on the packaging yielded positive attitudes and perceptions, and high user confidence, resulting in overall high acceptability. Post-training and post-use, ≥79% of the trainees reported that the Ellavi was easy to use. Potential barriers to use included the lack of adjustable drip stands and difficulties calculating bag height according to blood pressure. Overall, the Ellavi can be feasibly integrated into PPH care and was preferred over condom catheters. CONCLUSIONS The training package and time saving Ellavi design facilitated its adoption, acceptability and feasibility. The Ellavi is appropriate and feasible for use among obstetric staff and can be successfully integrated into the Kenyan and Ghanaian maternal healthcare package. TRIAL REGISTRATION NUMBERS NCT04502173; NCT05340777.
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Affiliation(s)
| | - Zahida Qureshi
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Sylvia Deganus
- Department of Obstetrics and Gynecology, Tema General Hospital, Tema, Ghana
| | | | | | | | | | - George Gwako
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Alfred Osoti
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Omondi Ogutu
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Jacqueline Opira
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Gifty Sunkwa-Mills
- Awutu Senya East Municipal, Ghana Health Service, Kasoa, Central Region, Ghana
| | - Martin Boamah
- Department of Obstetrics and Gynaecology, Greater Accra Regional Hospital, Accra, Greater Accra, Ghana
| | - Emmanuel Srofenyoh
- Department of Obstetrics and Gynaecology, Greater Accra Regional Hospital, Accra, Greater Accra, Ghana
| | | | - Chris Fofie
- Ghana Health Service, Accra, Greater Accra, Ghana
| | - Stephen Kaliti
- Division of Reproductive and Maternal Health, Kenya Ministry of Health, Nairobi, Kenya
| | - Chloe Morozoff
- Global Health, University of Washington, Seattle, Washington, USA
| | | | - Mutsumi Metzler
- Medical Devices and Health Technologies, PATH, Seattle, Washington, USA
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Choodari-Oskooei B, Thwin SS, Blenkinsop A, Widmer M, Althabe F, Parmar MKB. Treatment selection in multi-arm multi-stage designs: With application to a postpartum haemorrhage trial. Clin Trials 2023; 20:71-80. [PMID: 36647713 PMCID: PMC9940121 DOI: 10.1177/17407745221136527] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Multi-arm multi-stage trials are an efficient, adaptive approach for testing many treatments simultaneously within one protocol. In settings where numbers of patients available to be entered into trials and resources might be limited, such as primary postpartum haemorrhage, it may be necessary to select a pre-specified subset of arms at interim stages even if they are all showing some promise against the control arm. This will put a limit on the maximum number of patients required and reduce the associated costs. Motivated by the World Health Organization Refractory HaEmorrhage Devices trial in postpartum haemorrhage, we explored the properties of such a selection design in a randomised phase III setting and compared it with other alternatives. The objectives are: (1) to investigate how the timing of treatment selection affects the operating characteristics; (2) to explore the use of an information-rich (continuous) intermediate outcome to select the best-performing arm, out of four treatment arms, compared with using the primary (binary) outcome for selection at the interim stage; and (3) to identify factors that can affect the efficiency of the design. METHODS We conducted simulations based on the refractory haemorrhage devices multi-arm multi-stage selection trial to investigate the impact of the timing of treatment selection and applying an adaptive allocation ratio on the probability of correct selection, overall power and familywise type I error rate. Simulations were also conducted to explore how other design parameters will affect both the maximum sample size and trial timelines. RESULTS The results indicate that the overall power of the trial is bounded by the probability of 'correct' selection at the selection stage. The results showed that good operating characteristics are achieved if the treatment selection is conducted at around 17% of information time. Our results also showed that although randomising more patients to research arms before selection will increase the probability of selecting correctly, this will not increase the overall efficiency of the (selection) design compared with the fixed allocation ratio of 1:1 to all arms throughout. CONCLUSIONS Multi-arm multi-stage selection designs are efficient and flexible with desirable operating characteristics. We give guidance on many aspects of these designs including selecting the intermediate outcome measure, the timing of treatment selection, and choosing the operating characteristics.
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Affiliation(s)
- Babak Choodari-Oskooei
- MRC Clinical Trials Unit at UCL,
Institute of Clinical Trials and Methodology, University College London (UCL),
London, UK
| | - Soe Soe Thwin
- Maternal and Perinatal Health Unit,
Department of Sexual and Reproductive Health and Research (SRH), World Health
Organization (WHO), Geneve, Switzerland
| | - Alexandra Blenkinsop
- MRC Clinical Trials Unit at UCL,
Institute of Clinical Trials and Methodology, University College London (UCL),
London, UK
- Amsterdam Institute for Global Health
and Development, Amsterdam, Netherlands
| | - Mariana Widmer
- Maternal and Perinatal Health Unit,
Department of Sexual and Reproductive Health and Research (SRH), World Health
Organization (WHO), Geneve, Switzerland
| | - Fernando Althabe
- Maternal and Perinatal Health Unit,
Department of Sexual and Reproductive Health and Research (SRH), World Health
Organization (WHO), Geneve, Switzerland
| | - Mahesh KB Parmar
- MRC Clinical Trials Unit at UCL,
Institute of Clinical Trials and Methodology, University College London (UCL),
London, UK
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Erickson EN, Myatt L, Danoff JS, Krol KM, Connelly JJ. Oxytocin receptor DNA methylation is associated with exogenous oxytocin needs during parturition and postpartum hemorrhage. Commun Med (Lond) 2023; 3:11. [PMID: 36707542 DOI: 10.1038/s43856-023-00244-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 01/12/2023] [Indexed: 01/29/2023] Open
Abstract
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.
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Erickson EN, Krol KM, Perkeybile AM, Connelly JJ, Myatt L. Oxytocin receptor single nucleotide polymorphism predicts atony-related postpartum hemorrhage. BMC Pregnancy Childbirth 2022; 22:884. [PMID: 36447139 PMCID: PMC9706912 DOI: 10.1186/s12884-022-05205-w] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/10/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Postpartum hemorrhage remains a key contributor to overall maternal morbidity in the United States. Current clinical assessment methods used to predict postpartum hemorrhage are unable to prospectively identify about 40% of hemorrhage cases. Oxytocin is a first-line pharmaceutical for preventing and treating postpartum hemorrhage, which acts through oxytocin receptors on uterine myocytes. Existing research indicates that oxytocin function is subject to variation, influenced in part by differences in the DNA sequence within the oxytocin receptor gene. One variant, rs53576, has been shown to be associated with variable responses to exogenous oxytocin when administered during psychological research studies. How this variant may influence myometrial oxytocin response in the setting of third stage labor has not been studied. We tested for differences in the frequency of the oxytocin receptor genotype at rs53576 in relationship to the severity of blood loss among a sample of individuals who experienced vaginal birth. METHODS A case-control prospective design was used to enroll 119 postpartum participants who underwent vaginal birth who were at least 37 weeks of gestation. Cases were defined by either a 1000 mL or greater blood loss or instances of heavier bleeding where parturients were given additional uterotonic treatment due to uterine atony. Controls were matched to cases on primiparity and labor induction status. Genotype was measured from a maternal blood sample obtained during the 2nd postpartum month from 95 participants. Statistical analysis included bivariate tests and generalized linear and Poisson regression modeling. RESULTS The distribution of the genotype across the sample of 95 participants was 40% GG (n = 38), 50.5% AG (n = 48) and 9.5% AA (n = 9). Blood loss of 1000 mL or greater occurred at a rate of 7.9% for GG, 12.5% for AG and 55.6% for AA participants (p = 0.005). Multivariable models demonstrated A-carriers (versus GG) had 275.2 mL higher blood loss (95% CI 96.9-453.4, p < 0.01) controlling for parity, intrapartum oxytocin, self-reported ancestry, active management of third stage or genital tract lacerations. Furthermore, A-carrier individuals had a 79% higher risk for needing at least one second-line treatment (RR = 1.79, 95% CI = 1.08-2.95) controlling for covariates. Interaction models revealed that A-carriers who required no oxytocin for labor stimulation experienced 371.4 mL greater blood loss (95% CI 196.6-546.2 mL). CONCLUSIONS We provide evidence of a risk allele in the oxytocin receptor gene that may be involved in the development of postpartum hemorrhage among participants undergoing vaginal birth, particularly among those with fewer risk factors. The findings, if reproducible, could be useful in studying pharmacogenomic strategies for predicting, preventing or treating postpartum hemorrhage.
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Affiliation(s)
- Elise N. Erickson
- grid.134563.60000 0001 2168 186XPresent Address: University of Arizona, Tucson, AZ USA ,grid.5288.70000 0000 9758 5690Oregon Health and Science University, OR Portland, USA
| | - Kathleen M. Krol
- grid.27755.320000 0000 9136 933XUniversity of Virginia, Charlottesville, VA USA
| | | | - Jessica J. Connelly
- grid.27755.320000 0000 9136 933XUniversity of Virginia, Charlottesville, VA USA
| | - Leslie Myatt
- grid.5288.70000 0000 9758 5690Oregon Health and Science University, OR Portland, USA
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Linde LE, Rasmussen S, Moster D, Kessler J, Baghestan E, Gissler M, Ebbing C. Risk factors and recurrence of cause-specific postpartum hemorrhage: A population-based study. PLoS One 2022; 17:e0275879. [PMID: 36240210 PMCID: PMC9565392 DOI: 10.1371/journal.pone.0275879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/23/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To explore risk profiles of the different types of postpartum hemorrhage (PPH >500ml or severe PPH >1500ml) and their recurrence risks in a subsequent delivery. METHODS With data from The Medical Birth Registry of Norway and Statistics Norway we performed a population-based cohort study including all singleton deliveries in Norway from 1967-2017. Multilevel logistic regression was used to calculate odds ratio (OR), with 95% confidence interval (CI), with different PPH types (PPH >500ml or PPH >1500ml (severe PPH) combined with retained placenta, uterine atony, obstetric trauma, dystocia, or undefined cause) as outcomes. RESULT We identified 277 746 PPH cases of a total of 3 003 025 births (9.3%) from 1967 to 2017. Retained placenta (and/or membranes) was most often registered as severe PPH (29.3%). Maternal, fetal, and obstetric characteristics showed different associations with the PPH types. Male sex of the neonate was associated with reduced risk of PPH. This effect was strongest on PPH due to retained placenta (adjusted OR, (aOR): 0.80, 95% CI 0.78-0.82), atony (aOR 0.92, 95% CI: 0.90-0.93) and PPH with undefined cause (aOR 0.96, 95% CI: 0.95-0.97). Previous cesarean section showed a strong association with PPH due to dystocia (aOR of 13.2, 95% CI: 12.5-13.9). Recurrence risks were highest for the same type: PPH associated with dystocia (aOR: 6.8, 95% CI: 6.3-7.4), retained placenta and/or membranes (aOR: 5.9, 95% CI: 5.5-6.4), atony (aOR: 4.0, 95% CI: 3.8-4.2), obstetric trauma (aOR: 3.9, 95% CI: 3.5-4.3) and PPH of undefined cause (aOR: 2.2, 95% CI: 2.1-2.3). CONCLUSION Maternal, fetal and obstetric characteristics had differential effects on types of PPH. Recurrence differed considerably between PPH types. Retained placenta was most frequently registered with severe PPH, and showed strongest effect of sex; delivery of a boy was associated with lower risk of PPH. Previous cesarean increased the risk of PPH due to dystocia.
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Affiliation(s)
| | - Svein Rasmussen
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Dag Moster
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Jörg Kessler
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
| | - Elham Baghestan
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
| | - Mika Gissler
- Finnish Institute for Health and Welfare, Department of Knowledge Brokers, Helsinki, Finland
- Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Cathrine Ebbing
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
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Lumbreras-Marquez MI, Villela-Franyutti D, Reale SC, Farber MK. Coagulation Management in Obstetric Anesthesia. Curr Anesthesiol Rep 2022. [DOI: 10.1007/s40140-022-00517-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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12
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Heesen M, Orbach-Zinger S. Optimal uterotonic management. Best Pract Res Clin Anaesthesiol 2022; 36:135-155. [DOI: 10.1016/j.bpa.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 11/28/2022]
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Dalmedico MM, Barbosa FM, Toledo CMD, Martins WA, Fedalto ADR, Ioshii SO. Tamponamento por balão intrauterino no tratamento da hemorragia pós-parto. Fisioter mov 2022. [DOI: 10.1590/fm.2022.35617.0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Resumo Introdução: A hemorragia pós-parto trata-se de uma emergência obstétrica com elevada prevalência e morbimortalidade significativa, sobretudo em contextos de baixa acessibilidade a serviços especializados de saúde. Objetivo: Avaliar a efetividade do tamponamento por balão intrauterino no controle da hemorragia pós-parto, redução da necessidade de intervenções cirúrgicas de emergência e redução da mortalidade materna. Métodos: Revisão sistemática de ensaios clínicos randomizados, orientada pelo Cochrane Handbook for Systematic Reviews of Interventions e relatada através do Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Foram considerados como critérios de elegibilidade ensaios clínicos randomizados que avaliaram o uso de diferentes tipos de balão para tamponamento intrauterino enquanto estratégia para a redução ou cessação da hemorragia pós-parto quando comparados a outras intervenções (farmacológicas ou cirúrgicas). Resultados: Quatro estudos avaliaram 498 pacientes para os desfechos preconizados. Em 80% dos casos relatados observou-se a cessação da hemorragia em um intervalo médio de 15 minutos, após a inserção dos dispositivos. O tempo de permanência dos dispositivos foi de 24 horas. Não foram relatados eventos adversos graves. Devido à heterogeneidade clínica entre os estudos, não foi possível realizar síntese quantitativa. Conclusão: Os achados obtidos não fornecem evidências suficientes para sustentar a utilização rotineira dos dispositivos de tamponamento uterino enquanto prática protocolar no controle da hemorragia pós-parto refratária. A utilização destes dispositivos, no entanto, parece ser promissora diante da falha das intervenções de primeira linha, podendo desempenhar um importante papel em termos de redução de morbimortalidade materna e preservação uterina.
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Dalmedico MM, Barbosa FM, Toledo CMD, Martins WA, Fedalto ADR, Ioshii SO. Intrauterine balloon tamponade for postpartum hemorrhage. Fisioter mov 2022. [DOI: 10.1590/fm.2022.35617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract Introduction: Postpartum hemorrhage is an obstetric emergency with high prevalence and significant morbidity and mortality, especially in areas with reduced access to specialized health services. Objective: To evaluate the effectiveness of intrauterine balloon tamponade in controlling postpartum hemorrhage, with the aim to reduce the need for emergency surgical interventions and decrease maternal mortality. Methods: A systematic review of randomized clinical trials, guided by the Cochrane Handbook for Systematic Reviews of Interventions and reported through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Randomized clinical trials that evaluated the use of different types of balloons for intrauterine tamponade as a strategy for reducing or stopping postpartum hemorrhage compared to other interventions (pharmacological or surgical) were considered for inclusion. Results: Four studies evaluated 498 patients. In 80% of the reported cases, hemorrhage cessation was observed within a mean interval of 15 min after device insertion. The device permanence time was 24 h. No serious adverse events were reported. Due to clinical heterogeneity between studies, it was not possible to perform a quantitative synthesis. Conclusion: We did not find enough evidence to support the routine use of uterine tamponade devices as a protocol practice in the control of refractory postpartum hemorrhage. However, the use of these devices seems to be promising in cases where first line interventions fail and may play an important role in decreasing maternal morbidity and mortality and in uterine preservation.
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Mendonça IM, Silva JBFD, Conceição JFFD, Fonseca SC, Boschi-Pinto C. Tendência da mortalidade materna no Estado do Rio de Janeiro, Brasil, entre 2006 e 2018, segundo a classificação CID-MM. CAD SAUDE PUBLICA 2022; 38:e00195821. [DOI: 10.1590/0102-311x00195821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/26/2021] [Indexed: 11/22/2022] Open
Abstract
O objetivo foi analisar a tendência da razão de mortalidade materna (RMM) segundo a classificação CID-Mortalidade Materna (CID-MM) no Estado do Rio de Janeiro, Brasil, no período de 2006 a 2018. Foi realizado estudo de tendência temporal da RMM no Rio de Janeiro segundo tipo de óbito - direto ou indireto - e grupos de causas da classificação CID-MM, da Organização Mundial da Saúde (OMS). A RMM foi calculada com dados do Sistema de Informações sobre Mortalidade (SIM) e do Sistema de Informações sobre Nascidos Vivos (SINASC). As tendências foram estimadas pelo Joinpoint Regression Program. Dos 2.192 óbitos maternos no estado, 61% foram por causas diretas, 34% indiretas e 5% não especificadas. A tendência da RMM total e por causas diretas foi de declínio: 1,2% (IC95%: -2,3; -0,1) ao ano e 3,8% (IC95%: -4,9; -2,6) entre 2006 e 2015, respectivamente. Para causas diretas, segundo a CID-MM, o grupo 2 (causas hipertensivas) foi preponderante, mas houve declínio da eclâmpsia. Seguiram-se o grupo 5 (outras complicações, das quais se destacaram a categoria O90 e a subcategoria O90.3 - cardiomiopatia no puerpério) e o grupo 1 (gravidez que termina em aborto). As causas indiretas apresentaram estabilidade e a maioria pertencia à categoria O99 e suas subcategorias, relacionadas a doenças cardiovasculares e respiratórias. A RMM no Rio de Janeiro apresentou tendência de declínio entre 2006 e 2018, porém distante do recomendado pela OMS e com diferentes comportamentos entre as causas. A classificação CID-MM foi útil para identificar grandes grupos de causas, mas é preciso desagregar por subcategorias, para o adequado conhecimento da etiologia da morte materna.
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Takaji R, Kiyosue H, Maruno M, Hongo N, Shimada R, Ide S, Tokuyama K, Okamoto M, Kawano Y, Asayama Y. Angiographic features and transarterial embolization of retained placenta with abnormal vaginal bleeding. CVIR Endovasc 2021; 4:77. [PMID: 34727271 PMCID: PMC8563979 DOI: 10.1186/s42155-021-00265-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 07/21/2021] [Accepted: 10/25/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives To clarify characteristic angiographic features and clinical efficacy of selective transarterial embolization (TAE) of retained placenta with abnormal vaginal bleeding. Methods The study cohort comprised 22 patients (mean age, 33.5 years; range, 22–24 years) who underwent selective TAE for retained placenta with abnormal bleeding between January 2018 and December 2020 at our institution. Angiographic images were reviewed by two certified radiologists with consensus. Medical records were reviewed to evaluate the efficacy of TAE. Angiographic features of retained placenta, technical success (disappearance of abnormal findings on angiography), complications, clinical outcomes (hemostatic effects and recurrent bleeding) were evaluated. Results Pelvic angiography showed a dilated vascular channel mimicking arteriovenous fistulas or an aneurysm contiguous with dilated uterine arteries in the mid-arterial–capillary phase in 20 patients; it showed contrast brush in the remaining two patients. TAE technical success was achieved in all patients. No major complications were observed in any patients. Fifteen patients were followed up with expectant management after TAE; all but one patient showed no re-bleeding during the follow-up period (mean follow-up interval, 3.4 months; range, 1–17 months). One patient showed minor rebleeding, which resolved spontaneously. Seven patients underwent scheduled hysteroscopic resection within 1 week after TAE, and no excessive bleeding was observed during or after the surgical procedure in all seven patients. Conclusions The characteristic angiographic feature of retained placenta is “dilated vascular channel that mimic low flow AVM.” TAE is a safe and effective treatment to manage retained placenta with abnormal bleeding.
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Affiliation(s)
- Ryo Takaji
- Departments of Radiology, Oita University Faculty of Medicine, Yufu City, Oita, 879-5593, Japan.
| | - Hiro Kiyosue
- Departments of Radiology, Oita University Faculty of Medicine, Yufu City, Oita, 879-5593, Japan
| | - Miyuki Maruno
- Departments of Radiology, Oita University Faculty of Medicine, Yufu City, Oita, 879-5593, Japan
| | - Norio Hongo
- Departments of Radiology, Oita University Faculty of Medicine, Yufu City, Oita, 879-5593, Japan
| | - Ryuichi Shimada
- Departments of Radiology, Oita University Faculty of Medicine, Yufu City, Oita, 879-5593, Japan
| | - Satomi Ide
- Departments of Radiology, Oita University Faculty of Medicine, Yufu City, Oita, 879-5593, Japan
| | - Kohei Tokuyama
- Departments of Radiology, Oita University Faculty of Medicine, Yufu City, Oita, 879-5593, Japan
| | - Mamiko Okamoto
- Department of Obstetrics and Gynecology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Yasushi Kawano
- Department of Obstetrics and Gynecology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Yoshiki Asayama
- Departments of Radiology, Oita University Faculty of Medicine, Yufu City, Oita, 879-5593, Japan
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Linde LE, Ebbing C, Moster D, Kessler J, Baghestan E, Gissler M, Rasmussen S. Recurrence of postpartum hemorrhage in relatives: A population-based cohort study. Acta Obstet Gynecol Scand 2021; 100:2278-2284. [PMID: 34622946 DOI: 10.1111/aogs.14262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 03/18/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Studies on the family aggregation of postpartum hemorrhage (PPH) are scarce and with inconsistent results, and to what extent current birthweight influences recurrence between relatives remains to be studied. Further, family aggregation of PPH has been studied from an individual, but not from a public heath perspective. We aimed to investigate family aggregation of PPH in Norway, how birthweight influences these effects, and to estimate the proportion of PPH cases attributable to a family history of PPH and current birthweight. MATERIAL AND METHODS Using data from the Medical Birth Registry of Norway, Statistics Norway, and Central Population Registry of Norway we identified individuals as newborns, parents, grandparents, and full and half-siblings, and studied 1 002 687 mother-offspring, 841 164 father-offspring, and 761 011 both-parents-offspring pairs. We used multilevel logistic regression to calculate odds ratios (OR) with 95% CI. RESULTS If the birth of the mother but not of the father involved PPH, then the OR of PPH (>500 mL) in the next generation was 1.44 (95% CI 1.39-1.49). If the birth of the father but not of the mother involved PPH, then OR was 1.12 (95% CI 1.08-1.16). These effects were stronger in severe PPH. Recurrence between siblings was highest between full sisters (OR 1.47, 95% CI 1.41-1.52), followed by maternal half-sisters, paternal half-sisters, and partners of full brothers. A family history of PPH or birthweight of 4000 g or more accounted for ≤5% and 15% of the total number of PPH cases, respectively. CONCLUSIONS A history of PPH in relatives influenced the recurrence risk of PPH in a dose-response pattern consistent with the anticipated proportion of shared genes. The recurrence was highest through the maternal line.
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Affiliation(s)
| | - Cathrine Ebbing
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Dag Moster
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Jørg Kessler
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Elham Baghestan
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Mika Gissler
- Department of Information and Service, Finnish Institute for Health and Welfare, Helsinki, Finland.,Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Svein Rasmussen
- Department of Clinical Science, University of Bergen, Bergen, Norway
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Ngene NC, Moodley J. Induction of labour in low-resource settings. Best Pract Res Clin Obstet Gynaecol 2021:S1521-6934(21)00118-8. [PMID: 34509391 DOI: 10.1016/j.bpobgyn.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/23/2022]
Abstract
Due to the disparity in resource availability between low- and high-resource settings, practice recommendations relevant to high-income countries are not always relevant and often need to be adapted to low-resource settings. The adaptation applies to induction of labour (IOL) which is an obstetric procedure that deserves special attention because it involves the initiation of a process that requires regular and frequent monitoring of the mother and foetus by experienced healthcare professionals. Lack of problem recognition and/or substandard care during IOL may result in harm with long-term sequelae. In this article, the authors discuss unique challenges such as insufficient resources (including staff, midwives, doctors, equipment, and medications) that result in occasional inadequate patient monitoring and/or delayed interventions during IOL in low-resource settings. We also discuss modifications in indications and methods for IOL, issues related to human immunodeficiency virus (HIV) infections, the feasibility of outpatient induction, clinical protocols and a minimum dataset for quality improvement projects. Overall, the desire to achieve a vaginal birth with IOL should not cloud the necessity to observe the required safety measures and implement necessary interventions; given that childbirth practices are the major determinants of pregnancy outcomes and patient satisfaction.
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19
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Pingray V, Widmer M, Ciapponi A, Hofmeyr GJ, Deneux C, Gülmezoglu M, Bloemenkamp K, Oladapo OT, Comandé D, Bardach A, Vázquez P, Cormick G, Althabe F. Effectiveness of uterine tamponade devices for refractory postpartum haemorrhage after vaginal birth: a systematic review. BJOG 2021; 128:1732-1743. [PMID: 34165867 PMCID: PMC9292664 DOI: 10.1111/1471-0528.16819] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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] [Accepted: 04/16/2021] [Indexed: 12/01/2022]
Abstract
Objectives To evaluate uterine tamponade devices’ effectiveness for atonic refractory postpartum haemorrhage (PPH) after vaginal birth and the effect of including them in institutional protocols. Search strategy PubMed, EMBASE, CINAHL, LILACS, POPLINE, from inception to January 2021. Study selection Randomised and non‐randomised comparative studies. Outcomes Composite outcome including surgical interventions (artery ligations, compressive sutures or hysterectomy) or maternal death, and hysterectomy. Results All included studies were at high risk of bias. The certainty of the evidence was rated as very low to low. One randomised study measured the effect of the condom‐catheter balloon compared with standard care and found unclear results for the composite outcome (relative risk [RR] 2.33, 95% CI 0.76–7.14) and hysterectomy (RR 4.14, 95% CI 0.48–35.93). Three comparative studies assessed the effect of including uterine balloon tamponade in institutional protocols. A stepped wedge cluster randomised controlled trial suggested an increase in the composite outcome (RR 4.08, 95% CI 1.07–15.58) and unclear results for hysterectomy (RR 4.38, 95% CI 0.47–41.09) with the use of the condom‐catheter or surgical glove balloon. One non‐randomised study showed unclear effects on the composite outcome (RR 0.33, 95% CI 0.11–1.03) and hysterectomy (RR 0.49, 95% CI 0.04–5.38) after the inclusion of the Bakri balloon. The second non‐randomised study found unclear effects on the composite outcome (RR 0.95, 95% CI 0.32–2.81) and hysterectomy (RR 1.84, 95% CI 0.44–7.69) after the inclusion of Ebb or Bakri balloon. Conclusions The effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting. Tweetable abstract Unclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery. Unclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery.
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Affiliation(s)
- V Pingray
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - M Widmer
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Program of Research, Development, and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - A Ciapponi
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - G J Hofmeyr
- University of Botswana, Gaborone, Botswana.,Effective Care Research Unit, University of the Witwatersrand/Walter Sisulu University, Mthatha, South Africa
| | - C Deneux
- Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, U1153 Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Université de Paris, Paris, France
| | - M Gülmezoglu
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Program of Research, Development, and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland.,Concept Foundation, Geneva, Switzerland
| | - K Bloemenkamp
- Department of Obstetrics, Birth Centre Wilhelmina's Children Hospital, Division Woman and Baby, University Medical Center Utrecht, Utrecht, The Netherlands
| | - O T Oladapo
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Program of Research, Development, and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - D Comandé
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - A Bardach
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - P Vázquez
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - G Cormick
- Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina
| | - F Althabe
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Program of Research, Development, and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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20
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Omotayo MO, Abioye AI, Kuyebi M, Eke AC. Prenatal anemia and postpartum hemorrhage risk: A systematic review and meta-analysis. J Obstet Gynaecol Res 2021; 47:2565-2576. [PMID: 34002432 DOI: 10.1111/jog.14834] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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: 03/05/2021] [Revised: 04/27/2021] [Accepted: 05/03/2021] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) has remained the leading cause of maternal mortality. While anemia is a leading contributor to maternal morbidity, molecular, cellular and anemia-induced hypoxia, clinical studies of the relationship between prenatal-anemia and PPH have reported conflicting results. Therefore, our objective was to investigate the outcomes of studies on the relationships between prenatal anemia and PPH-related mortality. MATERIALS AND METHODS Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE, and the Cochrane Central Register of Controlled Trials) were searched for studies published before August 2019. Keywords included "anemia," "hemoglobin," "postpartum hemorrhage," and "postpartum bleeding." Only studies involving the association between anemia and PPH were included in the meta-analysis. Our primary analysis used random effects models to synthesize odds-ratios (ORs) extracted from the studies. Heterogeneity was formally assessed with the Higgins' I2 statistics, and explored using meta-regression and subgroup analysis. RESULTS We found 13 eligible studies investigating the relationship between prenatal anemia and PPH. Our findings suggest that severe prenatal anemia increases PPH risk (OR = 3.54; 95% CI: 1.20, 10.4, p-value = 0.020). There was no statistical association with mild (OR = 0.60; 95% CI: 0.31, 1.17, p-value = 0.130), or moderate anemia (OR = 2.09; 95% CI: 0.40, 11.1, p-value = 0.390) and the risk of PPH. CONCLUSION Severe prenatal anemia is an important predictive factor of adverse outcomes, warranting intensive management during pregnancy. PROSPERO Registration Number: CRD42020149184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149184.
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Affiliation(s)
- Moshood O Omotayo
- Centre for Global Health and Division of Pediatric Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajibola I Abioye
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Population Health Sciences Program, Graduate School of Arts & Sciences, Harvard University, Cambridge, MA, USA
| | - Moshood Kuyebi
- Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Ahizechukwu C Eke
- Division of Maternal-Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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21
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Shi X, Wu H, Liu C, Zhu X. Circular suture of the uterine serosa and myometrium layer around placental attachment site for refractory postpartum hemorrhage. J Obstet Gynaecol Res 2021; 47:1735-1742. [PMID: 33590569 DOI: 10.1111/jog.14695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/19/2020] [Revised: 12/23/2020] [Accepted: 01/29/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the study was to analyze the clinical outcomes of circular suture at placental attachment site for refractory postpartum hemorrhage (PPH), which could block blood supply of the serosa and myometrium layer. METHODS Eighty cases of refractory PPH were enrolled and retrospective analyzed in this study for further analysis from a consecutive single center database between 2010 and 2018. After undergoing circular suture of the uterine serosa and myometrium layer around placental attachment site, surgical and perioperative outcomes were recorded and analyzed. RESULTS Among all the patients enrolled, 28 cases (35.0%) of refractory PPH were mainly caused by uterine inertia, 36 cases (45.0%) caused by ectopic placenta, and 2 cases (2.5%) caused by coagulation disorders. After circular suture of the uterine serosa and myometrium layer at placental attachment site, all the uterine active bleeding was controlled below 40 ml without recurrence. The perioperative results were similar between the vaginal and cesarean sections groups. CONCLUSIONS Circular suture of the uterine serosa and myometrium at the placental attachment site could control refractory PPH with few postoperative complications. Circular suture around placenta site could be applied in time to protect the endometrium even in primary hospital.
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Affiliation(s)
- Xueqin Shi
- Department of Obstetrics and Gynecology, Jianhu Hospital Affiliated to Nantong University, Jiangsu, P. R. China
| | - Han Wu
- Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, P. R. China
| | - Changyue Liu
- Department of General Surgery, Jianhu Hospital Affiliated to Nantong University, Jiangsu, P. R. China
| | - Xiaoyan Zhu
- Department of Obstetrics and Gynecology, Jianhu Hospital Affiliated to Nantong University, Jiangsu, P. R. China
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22
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Widmer M, Piaggio G, Hofmeyr GJ, Carroli G, Coomarasamy A, Gallos I, Goudar S, Gülmezoglu AM, Lin SL, Lumbiganon P, Mugerwa K, Owa O, Qureshi Z, Althabe F. Maternal characteristics and causes associated with refractory postpartum haemorrhage after vaginal birth: a secondary analysis of the WHO CHAMPION trial data. BJOG 2020; 127:628-634. [PMID: 31808245 PMCID: PMC7078998 DOI: 10.1111/1471-0528.16040] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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] [Accepted: 11/25/2019] [Indexed: 01/03/2023]
Abstract
Objective To assess the maternal characteristics and causes associated with refractory postpartum haemorrhage (PPH). Design Secondary analysis of the WHO CHAMPION trial data. Setting Twenty‐three hospitals in ten countries. Population Women from the CHAMPION trial who received uterotonics as first‐line treatment of PPH. Methods We assessed the association between sociodemographic, pregnancy and childbirth factors and refractory PPH, and compared the causes of PPH between women with refractory PPH and women responsive to first‐line PPH treatment. Main outcome measures Maternal characteristics; causes of PPH. Results Women with labour induced or augmented with uterotonics (adjusted odds ratio [aOR] 1.35; 95% CI 1.07–1.72), with episiotomy or tears requiring suturing (aOR 1.82; 95% CI 1.34–2.48) and who had babies with birthweights ≥3500 g (aOR 1.33; 95% CI 1.04–1.69) showed significantly higher odds of refractory PPH compared with the reference categories in the multivariate analysis adjusted by centre and trial arm. While atony was the sole PPH cause in 53.2% (116/218) of the women in the responsive PPH group, it accounted for only 31.5% (45/143) of the causes in the refractory PPH group. Conversely, tears were the sole cause in 12.8% (28/218) and 28% (40/143) of the responsive PPH and refractory PPH groups, respectively. Placental problems were the sole cause in 11 and 5.6% in the responsive and refractory PPH groups, respectively. Conclusion Women with refractory PPH showed a different pattern of maternal characteristics and PPH causes compared with those with first‐line treatment responsive PPH. Tweetable abstract Women with refractory postpartum haemorrhage are different from those with first‐line treatment responsive PPH. Women with refractory postpartum haemorrhage are different from those with first‐line treatment responsive PPH.
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Affiliation(s)
- M Widmer
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
| | - G Piaggio
- Statistika Consultoria, Campinas, Brazil
| | - G J Hofmeyr
- Effective Care Research Unit, Fort Hare and Walter Sisulu and Eastern Cape Department of Health, Universities of Witwatersrand, Witwatersrand, South Africa
| | - G Carroli
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina
| | - A Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - I Gallos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - S Goudar
- KLE Academy of Higher Education and Research, J N Medical College, Belagavi, Karnataka, India
| | - A M Gülmezoglu
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
| | - S L Lin
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - P Lumbiganon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - K Mugerwa
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - O Owa
- Department of Obstetrics and Gynaecology, Mother and Child Hospital, Akure, Nigeria
| | - Z Qureshi
- Department of Obstetrics and Gynaecology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - F Althabe
- Department of Reproductive Health and Research, World Health Organization, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland
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