1
|
Siefen AC, Kurte MS, Kron F. Economic effects of treating postpartum hemorrhage with vacuum-induced hemorrhage control devices - A budget impact analysis of the Jada® System in the German obstetrics setting. Eur J Obstet Gynecol Reprod Biol 2024; 294:222-230. [PMID: 38301501 DOI: 10.1016/j.ejogrb.2024.01.024] [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: 12/20/2023] [Accepted: 01/17/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE This study aimed to assess the budget impact of vacuum-induced hemorrhage control (VHC) devices for treating postpartum hemorrhage (PPH) from the perspective of the German statutory health insurance (SHI). STUDY DESIGN Evidence shows that treating PPH with VHC instead of uterine balloon tamponade (UBT) can reduce resource consumption (e.g., reduced number of blood transfusions and length of stay). A budget impact model combining aggregated German real-world reimbursement data of PPH cases with the assumption of resource reduction due to VHC usage was developed. Diagnosis-related groups (DRG) of PPH cases and their frequencies were collected using a publicly available database. A "downgrading mechanism" was performed, leading to a less resource-intensive DRG, i.e., resulting in a lower flat fee to be paid by SHI. Four subgroups were differentiated based on coded diagnoses and procedures: 1) PPH (O72.-) as main diagnosis, 2) PPH as secondary diagnosis, 3) UBT procedure coded, and 4) UBT or standard tamponade coded. Weighted averages of cost savings per case were calculated. RESULTS Data from 7,129 (subgroup 1), 49,523 (subgroup 2), 1,668 (subgroup 3), and 3,406 (subgroup 4) cases were retrieved. After applying the downgrading mechanism, cost savings (weighted average) resulted in 184.09 €, 210.50 €, 921.33 €, and 633.74 € for subgroups 1-4, respectively, CONCLUSION: This is the first German budget impact analysis of VHC for the treatment of PPH. Results showed the highest cost-saving potential for cases currently treated with UBT. Demonstrating not only clinical but also financial consequences of innovative treatments is crucial for the adoption into clinical practice.
Collapse
Affiliation(s)
| | - Melina S Kurte
- VITIS Healthcare Group, Cologne, Germany; Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Florian Kron
- VITIS Healthcare Group, Cologne, Germany; Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; Center for Integrated Oncology (CIO ABCD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany; FOM University of Applied Sciences, Essen, Germany.
| |
Collapse
|
2
|
Gruneberg D, Hofer S, Schöchl H, Zipperle J, Oberladstätter D, Decker SO, Von der Forst M, Tourelle KM, Dietrich M, Weigand MA, Schmitt FCF. Comparison of Two Viscoelastic Testing Devices in a Parturient Population. J Clin Med 2024; 13:692. [PMID: 38337386 PMCID: PMC10856714 DOI: 10.3390/jcm13030692] [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: 12/23/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Viscoelastic hemostatic assays (VHAs) have become an integral diagnostic tool in guiding hemostatic therapy, offering new opportunities in personalized hemostatic resuscitation. This study aims to assess the interchangeability of ClotPro® and ROTEM® delta in the unique context of parturient women. Methods: Blood samples from 217 parturient women were collected at three timepoints. A total of 631 data sets were eligible for our final analysis. The clotting times were analyzed via extrinsic and intrinsic assays, and the clot firmness parameters A5, A10, and MCF were analyzed via extrinsic, intrinsic, and fibrin polymerization assays. In parallel, the standard laboratory coagulation statuses were obtained. Device comparison was assessed using regression and Bland-Altman plots. The best cutoff calculations were used to determine the VHA values corresponding to the established standard laboratory cutoffs. Results: The clotting times in the extrinsic and intrinsic assays showed notable differences between the devices, while the extrinsic and intrinsic clot firmness results demonstrated interchangeability. The fibrinogen assays revealed higher values in ClotPro® compared to ROTEM®. An ROC analysis identified VHA parameters with high predictive values for coagulopathy exclusion and yet low specificity. Conclusions: In the obstetric setting, the ROTEM® and ClotPro® parameters demonstrate a significant variability. Device- and indication-specific transfusion algorithms are essential for the accurate interpretation of measurements and adequate hemostatic therapy.
Collapse
Affiliation(s)
- Daniel Gruneberg
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Stefan Hofer
- Department of Anesthesiology, Kaiserslautern Westpfalz Hospital, 67655 Kaiserslautern, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, 1200 Vienna, Austria
| | - Johannes Zipperle
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, 1200 Vienna, Austria
| | - Daniel Oberladstätter
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, 1200 Vienna, Austria
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria
| | - Sebastian O. Decker
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Maik Von der Forst
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Kevin Michel Tourelle
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Maximilian Dietrich
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Markus A. Weigand
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Felix C. F. Schmitt
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| |
Collapse
|
3
|
Ikuta S, Fujikawa M, Nakajima T, Kasai M, Aihara T, Yamanaka N. Machine learning approach to predict postpancreatectomy hemorrhage following pancreaticoduodenectomy: a retrospective study. Langenbecks Arch Surg 2024; 409:29. [PMID: 38183456 DOI: 10.1007/s00423-023-03223-6] [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: 08/18/2023] [Accepted: 12/29/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Postpancreatectomy hemorrhage (PPH) is a rare yet dreaded complication following pancreaticoduodenectomy (PD). This retrospective study aimed to explore a machine learning (ML) model for predicting PPH in PD patients. METHODS A total of 284 patients who underwent open PD at our institute were included in the analysis. To address the issue of imbalanced data, the adaptive synthetic sampling (ADASYN) technique was employed. The best-performing ML model was selected using the PyCaret library in Python and evaluated based on recall, precision, and F1 score metrics. In addition to assessing the model's performance on the test data, bootstrap validation (n = 1000) with the original dataset was conducted. RESULTS PPH occurred in 11 patients (3.9%), with a median onset time of 22 days postoperatively. These minority cases were oversampled to 85 using ADASYN. The extra trees classifier demonstrated superior performance with recall, precision, and F1 score of 0.967, 0.914, and 0.937, respectively. Both validation using the test data and bootstrap resampling consistently demonstrated recall, precision, and F1 score exceeding 0.9. The model identified the peak value of C-reactive protein during the first 7 postoperative days as the most significant feature, followed by the preoperative neutrophil-to-lymphocyte ratio. CONCLUSIONS This study highlights the potential of the ML approach to predict PPH occurrence following PD. Vigilance and early interventions guided by such model predictions could positively impact outcomes for high-risk patients.
Collapse
Affiliation(s)
- Shinichi Ikuta
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan.
| | - Masataka Fujikawa
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Takayoshi Nakajima
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Tsukasa Aihara
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| | - Naoki Yamanaka
- Department of Surgery, Meiwa Hospital, 4-31 Agenaruo, Nishinomiya, Hyogo, 663-8186, Japan
| |
Collapse
|
4
|
Maharjan M, Shrestha P, Ghimire S. A rare case of morbidly adherent placenta in a young Primigravida with RH negative pregnancy managed with peripartum subtotal hysterectomy. Int J Surg Case Rep 2024; 114:109121. [PMID: 38061086 PMCID: PMC10755056 DOI: 10.1016/j.ijscr.2023.109121] [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: 11/04/2023] [Revised: 11/21/2023] [Accepted: 12/02/2023] [Indexed: 01/01/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Postpartum hemorrhage (PPH) can be defined as excessive bleeding (>500 ml) from the genital tract after the delivery of baby upto 6 weeks. PPH accounts for major cause of maternal mortality rate. Prevention and early intervention can prevent this complication of delivery. However condition like placenta accreta leads to retention of placenta and makes PPH inevitable. CASE SUMMARY We present the case of massive postpartum hemorrhage secondary to Placenta accreta in young primigravida with RH negative pregnancy. Clinical findings and investigations were not significant during her admission. She delivered the baby via vaginal route but placenta was not expelled till 30 min. Due to failed manual removal of placenta patient was shifted to OT.Manual vacuum aspiration was done in OT setting and chunks of placenta along with blood clots were obtained.Uterine balloon tamponade was inserted. Due to persistent PV bleeding subtotal hysterectomy was carried out in line for placenta accreta. DISCUSSION Placenta accreta being one of the life threatening obstetric condition, it should be diagnosed as early as possible and need prompt management so as to prevent maternal mortality. Due to increasing number of cesarean delivery the cases of placenta accreta has been rising but rarely in some cases can it present in young primigravida with Rh negative pregnancy. CONCLUSION In the cases of morbidly adherent placenta it is necessary for obstetrician to early identify such conditions and timely intervene to save the mother's life. Moreover Rh negative could be a hidden risk factor.
Collapse
Affiliation(s)
- Meenu Maharjan
- Department of gynaecology and obstetrics, KIST medical college and teaching hospital, Gwarko, Lalitpur, Nepal
| | - Pratima Shrestha
- Department of gynaecology and obstetrics, KIST medical college and teaching hospital, Gwarko, Lalitpur, Nepal
| | - Sagun Ghimire
- Department of surgery, KIST medical college and Teaching Hospital, Gwarko, Lalitpur, Nepal.
| |
Collapse
|
5
|
Wei D, Jiang P, Gao R, Zhao Y. Prevention of Rectal Stenosis After Procedure for Prolapse and Hemorrhoids by Anastomotic Thread-Drawing and Anal Enlargement. Am Surg 2023; 89:5932-5939. [PMID: 37257493 DOI: 10.1177/00031348231180925] [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] [Indexed: 06/02/2023]
Abstract
PURPOSE to investigate preventive measures of rectal stricture after procedure for prolapse and hemorrhoids (PPH) and to intervene early. METHODS A total of 400 patients with severe mixed hemorrhoids hospitalized in the [anonymous hospital] from January 2018 to February 2022 were randomly divided into the experimental group and control group A, B, and C, with 100 patients in each group. Experimental group: Thread-drawing during operation and anal enlargement after PPH. Group A: Thread-drawing during PPH surgery, group B: Anal enlargement after PPH, and group C: PPH alone. The anastomotic sites of the 4 groups were observed for 1-2 months and followed up for 1-3 years. RESULTS The effective rate of mixed hemorrhoid treatment in the 4 groups was 100%. There was no rectal stenosis in the experimental group, 11% in group A, 7% in group B, and 14% in group C. CONCLUSION Multipoint thread-drawing and anal enlargement after PPH can avoid postoperative rectal stenosis and can strengthen anastomosis and reduce bleeding, while being a simple procedure that can be easily popularized.
Collapse
Affiliation(s)
- Dan Wei
- Department of General Surgery, Characteristic Medical Centre of Strategic Support Force, Beijing, China
| | - Peng Jiang
- Health Team of Comprehensive Training Brigade of Strategic Support Force, Beijing, China
| | - Ran Gao
- Department of General Surgery, Characteristic Medical Centre of Strategic Support Force, Beijing, China
| | - Yan Zhao
- Department of General Surgery, Characteristic Medical Centre of Strategic Support Force, Beijing, China
| |
Collapse
|
6
|
Gruneberg D, Braun P, Schöchl H, Nachtigall-Schmitt T, von der Forst M, Tourelle K, Dietrich M, Wallwiener M, Wallwiener S, Weigand MA, Fluhr H, Spratte J, Hofer S, Schmitt FCF. Fibrinolytic potential as a risk factor for postpartum hemorrhage. Front Med (Lausanne) 2023; 10:1208103. [PMID: 37746089 PMCID: PMC10516290 DOI: 10.3389/fmed.2023.1208103] [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: 04/18/2023] [Accepted: 07/27/2023] [Indexed: 09/26/2023] Open
Abstract
Background Postpartum hemorrhage (PPH) is still the leading cause of maternal morbidity and mortality worldwide. While impaired fibrin polymerization plays a crucial role in the development and progress of PPH, recent approaches using viscoelastic measurements have failed to sensitively detect early changes in fibrinolysis in PPH. This study aimed to evaluate whether women experiencing PPH show alterations in POC-VET fibrinolytic potential during childbirth and whether fibrinolytic potential offers benefits in the prediction and treatment of PPH. Methods Blood samples were collected at three different timepoints: T0 = hospital admission (19 h ± 18 h prepartum), T1 = 30-60 min after placental separation, and T2 = first day postpartum (19 h ± 6 h postpartum). In addition to standard laboratory tests, whole-blood impedance aggregometry (Multiplate) and viscoelastic testing (VET) were performed using the ClotPro system, which included the TPA-test lysis time, to assess the POC-VET fibrinolytic potential, and selected coagulation factors were measured. The results were correlated with blood loss and clinical outcome markers. Severe PPH was defined as a hemoglobin drop > 4g/dl and/or the occurrence of shock or the need for red blood cell transfusion. Results Blood samples of 217 parturient women were analyzed between June 2020 and December 2020 at Heidelberg University Women's Hospital, and 206 measurements were eligible for the final analysis. Women experiencing severe PPH showed increased fibrinolytic potential already at the time of hospital admission. When compared to non-PPH, the difference persisted 30-60 min after placental separation. A higher fibrinolytic potential was accompanied by a greater drop in fibrinogen and higher d-dimer values after placental separation. While 70% of women experiencing severe PPH showed fibrinolytic potential, 54% of those without PPH showed increased fibrinolytic potential as well. Conclusion We were able to show that antepartal and peripartal fibrinolytic potential was elevated in women experiencing severe PPH. However, several women showed high fibrinolytic potential but lacked clinical signs of PPH. The findings indicate that high fibrinolytic potential is a risk factor for the development of coagulopathy, but further conditions are required to cause PPH.
Collapse
Affiliation(s)
- Daniel Gruneberg
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Paula Braun
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with Allgemeine Unfallversicherungsanstalt, Vienna, Austria
| | | | - Maik von der Forst
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kevin Tourelle
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Maximilian Dietrich
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Wallwiener
- Department of Obstetrics and Gynecology, University of Heidelberg, Heidelberg, Germany
| | - Stephanie Wallwiener
- Department of Obstetrics and Gynecology, University of Heidelberg, Heidelberg, Germany
| | - Markus A. Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Herbert Fluhr
- Division of Obstetrics, Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Julia Spratte
- Department of Obstetrics and Gynecology, University of Heidelberg, Heidelberg, Germany
| | - Stefan Hofer
- Department of Anesthesiology, Kaiserslautern Westpfalz Hospital, Kaiserslautern, Germany
| | | |
Collapse
|
7
|
O'Neill S, Begg S, Spelten E. A five year descriptive analysis of potentially preventable hospitalisations for Ear, Nose, and Throat conditions in regional Victoria, Australia, from 2015 to 2020. BMC Public Health 2023; 23:1536. [PMID: 37568092 PMCID: PMC10422838 DOI: 10.1186/s12889-023-16448-3] [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: 07/05/2022] [Accepted: 08/03/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Potentially preventable hospitalisations of ear, nose, and throat conditions in the Murray Primary Health Network region have been found to be higher than the state average of Victoria, Australia. This study aimed to examine the association between selected patient-level characteristics and the likelihood of residing in a Murray PHN postcode with higher than expected numbers of potentially preventable ENT hospitalisations. METHODS Unit record hospital separation data were obtained from the Victorian Admitted Episodes Dataset. Postcodes were classified as having higher than expected numbers of potentially preventable hospitalisations across three subgroups of ENT using indirect standardisation techniques. Differences between patients from 'higher than expected' postcodes and 'other' postcodes with respect to the distribution of demographic and other patient characteristics were determined using chi-squared tests for each ENT subgroup. The results were confirmed by logistic regression analyses using resident of a postcode with higher than expected hospitalisations as the outcome variable. RESULTS Of the 169 postcodes located in the catchment area, 15 were identified as having higher than expected numbers of upper respiratory tract infection hospitalisations, 14 were identified for acute tonsillitis, and 12 were identified for otitis media. Patients from postcodes with 'higher than expected' hospitalisations for these conditions were more likely than others to be aged between 0 and 9 years, Indigenous, or from a culturally and linguistically diverse background. CONCLUSION Further investigation of the identified postcodes is warranted to determine access to and utilisation of primary healthcare services in the management of PPH ENT conditions in the region.
Collapse
Affiliation(s)
- Susan O'Neill
- Department of Community and Allied Health, La Trobe University, La Trobe Rural Health School, Bendigo, VIC, 3550, Australia.
| | - Stephen Begg
- Department of Community and Allied Health, La Trobe University, La Trobe Rural Health School, Bendigo, VIC, 3550, Australia
| | - Evelien Spelten
- Department of Community and Allied Health, La Trobe University, La Trobe Rural Health School, Bendigo, VIC, 3550, Australia
| |
Collapse
|
8
|
Khanna P, Sinha C, Singh AK, Kumar A, Sarkar S. The role of point of care thromboelastography (TEG) and thromboelastometry (ROTEM) in management of Primary postpartum haemorrhage: A meta-analysis and systematic review. Saudi J Anaesth 2023; 17:23-32. [PMID: 37032697 PMCID: PMC10077780 DOI: 10.4103/sja.sja_529_22] [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: 07/18/2022] [Revised: 09/07/2022] [Accepted: 09/11/2022] [Indexed: 12/24/2022] Open
Abstract
Background The utility of instantaneous evaluation of coagulation during primary postpartum haemorrhage (PPH) is paramount in the context of empirical blood product transfusion-related risk of dilutional and consumptive coagulopathy and circulatory overload. Methods A profound screening of electronic databases till August 15, 2022 was carried out after being enlisted in PROSPERO (CRD42021275514). Randomized control studies, comparative cohort studies, and cross-sectional studies comparing point-of-care viscoelastic test guided blood product transfusion with empirical transfusion in patients with PPH were included. Results We retrieved five studies, with a total of 1914 parturient with PPH. Patients receiving transfusion based upon point of care viscoelastic tests had lesser risk of having emergency hysterectomy (Odds ratio (OR) = 0.55, 95% CI 0.32-0.95, I2 = 7%), transfusion-associated circulatory overload (TACO) (OR = 0.03, 95% CI 0.00-0.50), reduced transfusion of fresh frozen plasma (OR = 0.07, 95% CI 0.04-0.14, I2 = 89%), platelets (OR = 0.51, 95% CI 0.28-0.91, I2 = 89%), packed red blood cell transfusion (OR = 0.70, 95% CI 0.55-0.88, I2 = 89%), and had better cost-effective treatment [Mean difference (MD) = -357.5, 95% CI - 567.75 to -147.25, I2 = 93%] than patient received empirical transfusion. However, there was no significant difference in the requirement of ICU admissions (OR = 0.77, 95% CI = 0.46-1.29, I2 = 82%). No mortality was detected across the studies. Conclusions Point of care viscoelastic assessment guided transfusion in PPH confederates with reduced morbidity. Nevertheless, more studies on the triggering values for transfusion, long-term survival, and cost-benefit in patients with PPH are warranted to establish its utility.
Collapse
Affiliation(s)
- Puneet Khanna
- Department of Anaesthesia, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Chandni Sinha
- Department of Anesthesia, AIIMS, Patna, Bihar, India
| | - Akhil K. Singh
- Department of Anaesthesia, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Ajeet Kumar
- Department of Anesthesia, AIIMS, Patna, Bihar, India
| | - Soumya Sarkar
- Department of Anesthesia, and Critical Care, AIIMS, Bhubaneswar, Odisha, India
| |
Collapse
|
9
|
Karlsson O. Protocol for postpartum haemorrhage including massive transfusion. Best Pract Res Clin Anaesthesiol 2022; 36:427-432. [PMID: 36513436 DOI: 10.1016/j.bpa.2022.09.003] [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: 05/21/2022] [Revised: 08/16/2022] [Accepted: 09/27/2022] [Indexed: 12/14/2022]
Abstract
Postpartum haemorrhage (PPH) is one of the most common causes of maternal mortality worldwide. Management of PPH depends on the severity of bleeding. If the bleeding is severe, aorta compression can reduce bleeding. It should be followed by insertion of two coarse needles for intravenous access and blood sampling for haemoglobin and haemostasis. Further on, monitoring of vital parameters, as well as provision of extra oxygen and warm crystalloids, should be performed. Uterine atony is the most common cause of PPH and local guidelines for uterotonic drug selection should be followed. Patients with ongoing bleeding should immediately receive surgical care for bleeding control. During severe ongoing bleeding, haemostasis care includes early tranexamic acid, transfusion in ratio 4:4:1 (blood:plasma:platelets), and extra fibrinogen intravenously. If not severe PPH, use goal-directed therapy. During general anaesthesia and uterine atony, stop volatile anaesthesia and change to intravenous anaesthesia.
Collapse
Affiliation(s)
- Ove Karlsson
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Anaesthesiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| |
Collapse
|
10
|
Ameh CA, Meka RJ, West F, Dickinson F, Allott H, Godia P. A synthesis of clinical and health system bottlenecks to implementing new WHO postpartum hemorrhage recommendations: Secondary data analysis of the Kenya Confidential Enquiry into Maternal Deaths 2014-2017. Int J Gynaecol Obstet 2022; 158 Suppl 1:14-22. [PMID: 35762810 PMCID: PMC9544179 DOI: 10.1002/ijgo.14270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 11/30/2022]
Abstract
Objective To describe maternal deaths from postpartum hemorrhage (PPH) in Kenya by secondary analysis of the Kenya Confidential Enquiry into Maternal Deaths (CEMD) database and clinical audit of a sample of those deaths, and to identify the perceived challenges to implementing country‐specific PPH guidelines. Methods A retrospective descriptive study using the Kenyan CEMD database and anonymized maternal death records from 2014–2017. Eight standards from the Kenya National Guidelines for Quality Obstetric and Perinatal Care were selected to perform clinical audit. The process of supporting eight Sub‐Saharan African countries to develop country‐specific PPH guidelines was described and perceived challenges implementing these were identified. Results In total, 725 women died from PPH. Most women attended at least one antenatal care visit (67.2%) and most did not receive iron and folate supplementation (35.7%). Only 39.0% of women received prophylactic uterotonics in the third stage of labor. Factors significantly associated with receiving prophylactic uterotonics were place of delivery (χ2 = 43.666, df = 4; P < 0.001), being reviewed by a medical doctor (χ2 = 16.905, df = 1; P < 0.001), and being reviewed by a specialist (χ2 = 49.244, df = 1; P < 0.001). Only three of eight standards had a greater percentage of met cases in comparison to unmet cases. Key concerns about implementation of the new WHO PPH guidance included use of misoprostol by unskilled health personnel, availability of misoprostol and tranexamic acid (TXA) at primary healthcare level, lack of availability of heat‐stable carbetocin (HSC) due to cost, lack of awareness and education about HSC and TXA, and lack of systems to ensure quality oxytocin is available at point of care. Conclusion There is a need for improved quality of care for women to minimize the risk of mortality from PPH, by implementing updated clinical guidelines combined with focused health system interventions. Improving quality of care for women with postpartum hemorrhage requires use of up‐to‐date clinical guidelines combined with focused health system interventions.
Collapse
Affiliation(s)
- Charles A Ameh
- Emergency Obstetric Care and Quality of Care Unit, WHO collaborating Centre for Research and Training in Maternal and Newborn Health, International Public Health Department, Liverpool School of Tropical Medicine, Liverpool, UK.,Department of Obstetrics and Gynecology, Kenya
| | - Ramya Jyothi Meka
- Emergency Obstetric Care and Quality of Care Unit, WHO collaborating Centre for Research and Training in Maternal and Newborn Health, International Public Health Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Fiona Dickinson
- Emergency Obstetric Care and Quality of Care Unit, WHO collaborating Centre for Research and Training in Maternal and Newborn Health, International Public Health Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Allott
- Emergency Obstetric Care and Quality of Care Unit, WHO collaborating Centre for Research and Training in Maternal and Newborn Health, International Public Health Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Pamela Godia
- Emergency Obstetric Care and Quality of Care Unit, WHO collaborating Centre for Research and Training in Maternal and Newborn Health, International Public Health Department, Liverpool School of Tropical Medicine, Liverpool, UK.,School of Public Health, University of Nairobi, Nairobi, Kenya.,Liverpool School of Tropical Medicine, Nairobi, Kenya
| |
Collapse
|
11
|
Jaffer D, Singh PM, Aslam A, Cahill AG, Palanisamy A, Monks DT. Preventing postpartum hemorrhage after cesarean delivery: a network meta-analysis of available pharmacologic agents. Am J Obstet Gynecol 2022; 226:347-365. [PMID: 34534498 DOI: 10.1016/j.ajog.2021.08.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/13/2021] [Accepted: 08/22/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postpartum hemorrhage causes a quarter of global maternal deaths. The World Health Organization recommends oxytocin as the first line agent to prevent hemorrhage during cesarean delivery. However, some randomized controlled trials suggest that other uterotonics are superior. OBJECTIVE We conducted a network meta-analysis comparing the ability of pharmacologic agents to reduce blood loss and minimize the need for additional uterotonics during cesarean delivery. DATA SOURCES We searched the Cochrane Central Register of Controlled Trials, Embase, and MEDLINE databases from inception to May 2020. STUDY ELIGIBILITY CRITERIA We included randomized controlled trials that compared oxytocin, carbetocin, misoprostol, ergometrine, carboprost, or combinations of these in the prevention of postpartum hemorrhage during cesarean delivery. METHODS We performed a systematic review followed by an NMA in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quality of the evidence was assessed with the Confidence in Network Meta-Analysis approach and Grading of Recommendations, Assessment, Development and Evaluations tool within the summary of findings table. Our primary outcomes were the estimated blood loss and need for additional uterotonics. Secondary outcomes included nausea and postpartum hemorrhage of >1000 mL. We performed sensitivity analyses to explore the influence of surgical context and oxytocin administration strategy. RESULTS A total of 46 studies with 7368 participants were included. Of those, 21 trials (6 agents and 3665 participants) formed the "estimated blood loss" network and, considering the treatment effects, certainty in the evidence, and surface under the cumulative ranking curve scores, carbetocin was assessed to probably be superior to oxytocin, but only in reducing the estimated blood loss by a clinically insignificant volume (54.83 mL; 95% confidence interval, 26.48-143.78). Misoprostol, ergometrine, and the combination of oxytocin and ergometrine were assessed to probably be inferior, whereas the combination of oxytocin and misoprostol was assessed to definitely be inferior to oxytocin. A total of 37 trials (8 agents and 6193 participants) formed the "additional uterotonic" network and, again, carbetocin was assessed to probably be superior to oxytocin, requiring additional uterotonics 185 (95% confidence interval, 130-218) fewer times per 1000 cases. Oxytocin plus misoprostol, oxytocin plus ergometrine, and misoprostol were assessed to probably be inferior, whereas carboprost, ergometrine, and the placebo were definitely inferior to oxytocin. For both primary outcomes, oxytocin administration strategies had a higher probability of being the best uterotonic, if initiated as a bolus. CONCLUSION Carbetocin is probably the most effective agent in reducing blood loss and the need for additional uterotonics. Oxytocin appears to be more effective when initiated as a bolus.
Collapse
|
12
|
Escobar MF, Nassar AH, Theron G, Barnea ER, Nicholson W, Ramasauskaite D, Lloyd I, Chandraharan E, Miller S, Burke T, Ossanan G, Andres Carvajal J, Ramos I, Hincapie MA, Loaiza S, Nasner D. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet 2022; 157 Suppl 1:3-50. [PMID: 35297039 PMCID: PMC9313855 DOI: 10.1002/ijgo.14116] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Maria Fernanda Escobar
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gerhard Theron
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.,Tygerberg Hospital, Cape Town, South Africa
| | - Eythan R Barnea
- Society for Investigation or Early Pregnancy (SIEP), New York, New York, USA
| | - Wanda Nicholson
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Diana Ramasauskaite
- Center of Obstetrics and Gynecology, Vilnius University Medical Faculty, Vilnius, Lithuania
| | - Isabel Lloyd
- Department of Obstetrics and Gynecology, Universidad de Panamá, Panama City, Panamá.,Hospital Santo Tomas, Panama City, Panamá
| | - Edwin Chandraharan
- Department of Obstetrics and Gynecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Thomas Burke
- Division of Global Health and Human Rights, Massachusetts General Hospital, Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, USA
| | - Gabriel Ossanan
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Javier Andres Carvajal
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Isabella Ramos
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Maria Antonia Hincapie
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Sara Loaiza
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Daniela Nasner
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | -
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia
| |
Collapse
|
13
|
Matthijsse S, Andersson FL, Gargano M, Yip Sonderegger YL. Cost-effectiveness analysis of carbetocin versus oxytocin for the prevention of postpartum hemorrhage following vaginal birth in the United Kingdom. J Med Econ 2022; 25:129-137. [PMID: 35007465 DOI: 10.1080/13696998.2022.2027669] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIMS To assess the cost-effectiveness of carbetocin versus oxytocin for the prevention of postpartum hemorrhage (PPH) following vaginal birth from the perspective of the UK National Health Service (NHS). MATERIALS AND METHODS A decision tree model was designed to analyze the cost per PPH event avoided associated with utilizing carbetocin versus oxytocin for prophylactic treatment of PPH in women following vaginal birth from a UK perspective. It modelled the potential for women to require an additional uterotonic after prophylaxis, and to still experience a PPH event and receive associated treatment. Inpatient recovery and follow-up periods post-PPH were also included in the model. Costs associated with drug acquisition and administration, PPH management (i.e. additional staffing and possible operating theater and high dependency unit utilization), inpatient hospitalization, and follow-up visits were all considered. Adverse event management costs were not included. Resource utilization varied depending on the severity of the PPH event (as defined by the amount of blood lost). PPH events avoided were estimated. In an exploratory analysis, quality adjusted life years (QALYs) were estimated as well. RESULTS In the deterministic base case, costs were £55 lower and PPH events were 0.0342 lower per woman with carbetocin use compared to oxytocin use. Across the cohort of 100 women the reduction in PPH events led to the largest cost savings (£4,233 saved) out of all cost categories, with total cost savings of £5,495. Carbetocin utilization amongst the entire cohort led to 3.42 avoided PPH events compared to oxytocin utilization, comprised of 3.03 fewer mild/moderate PPH events and 0.39 fewer severe PPH events. Carbetocin utilization led to 0.0001 additional QALYs per woman. CONCLUSION Carbetocin utilization leads to lower prophylactic treatment costs and less PPH events versus oxytocin when utilized for the prevention of PPH following vaginal birth in the UK.
Collapse
|
14
|
Jardine J, Gurol-Urganci I, Harris T, Hawdon J, Pasupathy D, van der Meulen J, Walker K. Risk of postpartum haemorrhage is associated with ethnicity: a cohort study of 981 801 births in England. BJOG 2021; 129:1269-1277. [PMID: 34889021 DOI: 10.1111/1471-0528.17051] [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: 07/05/2021] [Revised: 11/09/2021] [Accepted: 11/24/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the association between ethnic group and risk of postpartum haemorrhage in women giving birth. DESIGN Cohort study. SETTING Maternity units in England. POPULATION OR SAMPLE 981 801 records of births between 1st April 2015 and 31st March 2017 in a national clinical database. METHODS Multivariable logistic regression analyses with multiple imputation to account for missing data and robust standard errors to account for clustering within hospitals. MAIN OUTCOME MEASURES Postpartum haemorrhage of 1500ml or more (PPH). RESULTS 28 268 (2.9%) of births were complicated by PPH. Risks were higher in women from black (3.9%) and other (3.5%) ethnic backgrounds. Following adjustment for maternal and fetal characteristics, and care at birth, there was evidence of an increased risk of PPH in women from all ethnic minority groups, with the largest increase seen in black women (adjusted odds ratio 1.54 (1.45 to 1.63)). The increase in risk was robust to sensitivity analyses which included changing the outcome to PPH of 3000ml or more. CONCLUSIONS In England, women from ethnic minority backgrounds have an increased risk of PPH, when maternal, fetal and birth characteristics are taken into account. Factors contributing to this increased risk need further investigation. Perinatal care for women from ethnic minority backgrounds should focus on preventative measures to optimise maternal outcomes.
Collapse
Affiliation(s)
- Jennifer Jardine
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.,Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - Ipek Gurol-Urganci
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.,Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - Tina Harris
- Centre for Reproduction Research, Faculty of Health and Life Sciences, De Montfort University, The Gateway, Leicester, LE1 9BH, UK
| | - Jane Hawdon
- Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Dharmintra Pasupathy
- Department of Women and Children's Health, King's College London, 10th Floor, North Wing, St Thomas's Hospital London, SE1 7EH, UK.,Reproduction and Perinatal Centre, Faculty of Medicine and Health, University of Sydney NSW 2145, Australia
| | - Jan van der Meulen
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Kate Walker
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.,Clinical Effectiveness Unit, Royal College of Surgeons, 35-43 Lincoln's Inn Fields, Holborn, London, WC2A 3PE, UK
| | | |
Collapse
|
15
|
Das R, Farzana FD, Sultana Z, Mukherji K, Baayo A, Sultana M, Ali N, Chisti MJ, Sarker SA, Ahmed T, Faruque A. Evaluation of SIMESON, a training program to improve access to quality health care for pregnant women and newborn in different healthcare facilities of northern Bangladesh. Nurs Open 2021; 9:801-815. [PMID: 34784452 PMCID: PMC8685868 DOI: 10.1002/nop2.1131] [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: 04/29/2021] [Revised: 10/21/2021] [Accepted: 10/31/2021] [Indexed: 01/02/2023] Open
Abstract
Aim The study aims to explore the current knowledge and skills of healthcare providers already trained by SIMESON (simulation for essential skills for obstetrical and neonatal care), in reviewing perinatal health situations including current status of healthcare facilities and cost estimation. Design It was an observational study. Methods Cost estimation following both quantitative and qualitative approaches was also attempted. Result Knowledge and skills of 88 healthcare providers about the provision of normal delivery and immediate postpartum care, management of postpartum haemorrhage (PPH), retained placenta and use of bag and mask ventilation to help a baby breathe were found to be considerably strengthened following SIMESON training. During the 6 months after training, there were 477 PPH cases managed successfully with only one death; neonatal deaths observed were 6.6/1,000 live births; twice the number of facility deliveries; and 80% use rate of Ambu bag for helping baby breathe. The estimated cost per trainee was 395.68 USD, and 5.85 USD per beneficiary.
Collapse
Affiliation(s)
- Rina Das
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Fahmida Dil Farzana
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Zakia Sultana
- Terre des hommes foundation (Tdh), Dhaka, Bangladesh
| | | | - Adnan Baayo
- Terre des hommes foundation (Tdh), Dhaka, Bangladesh
| | - Marufa Sultana
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Nausad Ali
- Bangladesh Institute of Development Studies, Dhaka, Bangladesh
| | | | - Shafiqul Alam Sarker
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Asg Faruque
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| |
Collapse
|
16
|
D'Alton M, Rood K, Simhan H, Goffman D. Profile of the Jada® System: the vacuum-induced hemorrhage control device for treating abnormal postpartum uterine bleeding and postpartum hemorrhage. Expert Rev Med Devices 2021; 18:849-853. [PMID: 34355991 DOI: 10.1080/17434440.2021.1962288] [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] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Abnormal postpartum uterine bleeding occurs commonly after birth and can quickly become an obstetric emergency. With postpartum hemorrhage representing the leading cause of maternal mortality, accounting for 25% of maternal deaths due to obstetric complications, there is a critical need for effective and easy to use treatment options. AREAS COVERED This profile describes the Jada System, a novel intrauterine vacuum-induced hemorrhage control device that provides a rapid and effective treatment option for abnormal postpartum uterine bleeding and postpartum hemorrhage. In addition to explaining the mechanism of action of vacuum-induced hemorrhage control and reviewing the device's safety and effectiveness, this profile elucidates how the Jada System compares to currently available medications and devices for treatment of this obstetric emergency. EXPERT OPINION New therapies to address this life-threatening condition are needed to reduce the risk of maternal mortality and severe maternal morbidity. Data demonstrate that the Jada System provides rapid, effective control of abnormal postpartum uterine bleeding and postpartum hemorrhage, while offering reported ease of use and short treatment duration. These results suggest that use of the Jada System in treatment algorithms may improve outcomes.
Collapse
Affiliation(s)
- Mary D'Alton
- Department of Obstetrics and Gynecology, New York Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Kara Rood
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, USA
| | - Hyagriv Simhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
| | - Dena Goffman
- Department of Obstetrics and Gynecology, New York Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| |
Collapse
|
17
|
Mesfin S, Dheresa M, Fage SG, Tura AK. Assessment of Postpartum Hemorrhage in a University Hospital in Eastern Ethiopia: A Cross-Sectional Study. Int J Womens Health 2021; 13:663-669. [PMID: 34262356 PMCID: PMC8273907 DOI: 10.2147/ijwh.s300143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Received: 01/02/2021] [Accepted: 06/23/2021] [Indexed: 01/10/2023] Open
Abstract
Objective Despite implementation of different strategies, postpartum hemorrhage (PPH) continued to account for a substantial proportion of maternal deaths in Ethiopia. The objective of this study was to assess the magnitude of PPH and its associated factors among women who gave birth in a university hospital in eastern Ethiopia from 1 to 31 March 2020. Methods An institution-based cross-sectional study was conducted. A review of 653 randomly selected medical records of all deliveries from 1 March 2018 to 29 February 2020 in Hiwot Fana Specialized University Hospital (HFSUH), a university hospital in eastern Ethiopia, was conducted. Data were collected on sociodemographic characteristics, obstetric and reproductive health conditions, and presence of PPH. Data were coded, checked for completeness and entered using EpiData 3.1 and exported to SPSS 20 for analysis. Results were expressed using frequencies, tables and figures. Binary and multiple logistic regression were fitted to identify factors associated with PPH and associations were described using adjusted odds ratio (aOR) along with 95% confidence intervals (CI). Associations with p<0.05 in the multivariable logistic regression were declared as statistically significant. Results From a total of 642 (98.3%) women included in this study, 83 (12.9%; 95% CI 10.4–15.6) had PPH. Maternal age >35 years (aOR = 3.08; 95% CI 1.56, 6.07), no antenatal care (aOR = 3.65; 95% CI 1.97, 6.76), history of PPH (aOR = 4.18; 95% CI 1.99, 8.82), and being grand multigravida (aOR = 3.33; 95% CI 1.14, 9.74) were significantly associated with having PPH. Conclusion A high proportion of women who gave birth in HFSUH experienced PPH. Prevention and management of PPH should focus on improving antenatal care and prioritize grand multigravida, older women, and women with a previous history of PPH.
Collapse
Affiliation(s)
- Sinetibeb Mesfin
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Merga Dheresa
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Sagni Girma Fage
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.,Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| |
Collapse
|
18
|
Arribas M, Roberts I, Chaudhri R, Geer A, Prowse D, Lubeya MK, Kayani A, Javaid K, Grassin-Delyle S, Shakur-Still H. WOMAN-PharmacoTXA trial: Study protocol for a randomised controlled trial to assess the pharmacokinetics and pharmacodynamics of intramuscular, intravenous and oral administration of tranexamic acid in women giving birth by caesarean section. Wellcome Open Res 2021; 6:157. [PMID: 34250266 PMCID: PMC8264807 DOI: 10.12688/wellcomeopenres.16884.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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] [Accepted: 06/03/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Intravenous tranexamic acid (TXA) within 3 hours of birth significantly reduces death due to bleeding in women with postpartum haemorrhage (PPH). Most PPH deaths occur in the first hours after giving birth and treatment delay decreases survival. One barrier to rapid TXA treatment is the need for intravenous injection. Intramuscular injection and oral solution of TXA would be easier and faster to administer and would require less training. However, the pharmacokinetics (PK), pharmacodynamics and safety of TXA administered by different routes in pregnant women have not been established. The main aim of this study is to ascertain whether IM and oral solution of TXA will be absorbed at levels sufficient to inhibit fibrinolysis in pregnant women. Methods: WOMAN-PharmacoTXA is a prospective, randomised, open label trial to be conducted in Zambia and Pakistan. Adult women undergoing caesarean section with at least one risk factor for PPH will be included. Women will be randomised to receive one of the following about 1 hour prior to caesarean section: 1-gram TXA IV, 1-gram TXA IM, 4-grams TXA oral solution or no TXA. Randomisation will continue until 120 participants with at least six post randomisation PK samples are included. TXA concentration in maternal blood samples will be measured at baseline and at different time points during 24 hours after receipt of intervention. Blood TXA concentration will be measured from the umbilical cord and neonate. The primary endpoint is maternal blood TXA concentrations over time. Secondary outcomes include umbilical cord and neonate TXA concentration D-dimer concentration, blood loss and clinical diagnosis of PPH, injection site reactions and maternal and neonate adverse events. Discussion: The WOMAN-PharmacoTXA trial will provide important data on pharmacokinetics, pharmacodynamics and safety of TXA after IV, intramuscular and oral administration in women giving birth by caesarean section. Trial registration: ClincalTrials.gov,
NCT04274335 (18/02/2020).
Collapse
Affiliation(s)
- Monica Arribas
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Rizwana Chaudhri
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, H-8, Pakistan
| | - Amber Geer
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Danielle Prowse
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Mwansa Ketty Lubeya
- Women and Newborn Hospital, University Teaching Hospital, Nationalist Road, Lusaka, PB RW1X, Zambia.,Department of Obstetrics and Gynaecology, The University of Zambia-School of Medicine, Lusaka, Zambia
| | - Aasia Kayani
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, H-8, Pakistan
| | - Kiran Javaid
- Global Institute of Human Development, Shifa Tameer-e-Millat University, Islamabad, H-8, Pakistan
| | - Stanislas Grassin-Delyle
- Département de Biotechnologie de la Santé, Université Paris-Saclay, UVSQ, Inserm, Infection et inflammation, Montigny le Bretonneux, France.,Département des Maladies des Voies Respiratoires, Hôpital Foch, Suresnes, France
| | - Haleema Shakur-Still
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| |
Collapse
|
19
|
Puia IC, Puia A, Florea ML, Cristea PG, Stanca M, Fetti A, Moiş E. Stapled Hemorrhoidopexy: Technique and Long Term Results. Chirurgia (Bucur) 2021; 116:102-108. [PMID: 33638331 DOI: 10.21614/chirurgia.116.1.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/23/2022]
Abstract
Background: Stapled hemorrhoidopexy (Longo operation) is a infrequent technique in our area. A different concept from hemorrhoidectomy, a proportionally important raise in cost and a special training may have contributed to it. We report our long-term results with the standard technique. Methods: The data of 35 patients with symptomatic second- and third-degree hemorrhoids who had stapled hemorrhoidopexy using a PPH03 stapler, from 01 January 2012 to 04 December 2020, were retrospectively collected. The sex ratio male: female was 3:4 and the mean age 45 (range 28-60) years. The follow-up consisted in a rectal exam and evaluated anatomical recurrence or prolapse. Results: The mean operative time was 42 (30-70) min. The mean parenteral analgesic doses during the first 24 h were 1,52. The mean postoperative hospital stay was 1.55 (1-2) days. A single patient needed reoperation for a staple line bleeding, two patients had a thrombosis of internal hemorrhoids and in one patient a small prolapse was diagnosed at 3 months follow-up. No hematoma, anastomotic stenosis, persistent anal pain, tenesmus, or impaired anal continence was recorded. One patient mentioned discomfort related to the presence of staples. Patients were followed-up for 6 (1-9) years. Global satisfaction rate was 94%. Conclusion: Stapled hemorrhoidopexy procedure is a safe and feasible procedure, which necessitates few analgesics and allows an early discharge. A rigorous selection of cases and a correct surgical technique allow to obtain good long-term results and offer a high level of patients satisfaction.
Collapse
|
20
|
Helviz Y, Lasry M, Grisaru-Granovsky S, Bdolah-Abram T, Weiniger CF, Levin PD, Einav S. Severity of shock, rate of physiological stabilization and organ failure in healthy women admitted to the intensive care unit following major peripartum hemorrhage: A retrospective, descriptive study. J Crit Care 2021; 63:8-14. [PMID: 33549910 DOI: 10.1016/j.jcrc.2021.01.006] [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: 09/02/2020] [Revised: 12/09/2020] [Accepted: 01/16/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To describe shock severity, physiological stabilization and organ failure in healthy women admitted to the intensive care unit (ICU) after major peripartum hemorrhage (PPH). MATERIALS AND METHODS Retrospective, descriptive, single center study. RESULTS Twenty-nine women median age 33 years (interquartile range [IQR] 30-36) and gravidity 5 pregnancies (IQR 3-9) were studied. One woman died. The median maternal admission hematocrit was 28.8 (IQR 25.7-32.4). Median transfusion rates were nine units of packed red blood cells (IQR 7-12.25), eight fresh frozen plasma (IQR 6-12), 17 platelets (IQR 10-22) and 15 cryoprecipitate (IQR 9.75-20). Blood pressure dropped significantly in the six hours following ICU admission. Nonetheless, lactate decreased from 3.23 mmol/L to 1.54 mmol/L within 24 h of ICU admission, renal and pulmonary function were unaffected and coagulopathy was never observed. Two-thirds of the women underwent hysterectomy. One-third underwent repeated surgery. The median length of ICU stay was <48 h and that of mechanical ventilation was <24 h. Increased transfusion rates correlated with lengthier ICU admission (p ≤ 0.01 regardless of blood product). CONCLUSIONS Ongoing hemorrhage in women with severe PPH manifests subtly and often requires active intervention. Hemorrhage control is required to achieve physiological stabilization and minimize organ damage.
Collapse
Affiliation(s)
- Yigal Helviz
- Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel.
| | - Mor Lasry
- The Faculty of Medicine, Hebrew University and Hadassah, Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of obstetrics and gynecology, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Tali Bdolah-Abram
- The Faculty of Medicine, Hebrew University and Hadassah, Jerusalem, Israel
| | - Carolyn F Weiniger
- Obstetric Anesthesia Division of Anesthesiology & Critical Care & Pain, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Philip D Levin
- Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Sharon Einav
- Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel; Hebrew University Faculty of Medicine, Jerusalem, Israel
| |
Collapse
|
21
|
Theunissen F, Cleps I, Goudar S, Qureshi Z, Owa OO, Mugerwa K, Piaggio G, Gülmezoglu AM, Nakalembe M, Byamugisha J, Osoti A, Mandeep S, Poriot T, Gwako G, Vernekar S, Widmer M. Cost of hospital care of women with postpartum haemorrhage in India, Kenya, Nigeria and Uganda: a financial case for improved prevention. Reprod Health 2021; 18:18. [PMID: 33482858 PMCID: PMC7821537 DOI: 10.1186/s12978-020-01063-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 04/21/2020] [Accepted: 12/25/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Access to quality, effective lifesaving uterotonics in low and middle-income countries (LMICs) remains a major barrier to reducing maternal deaths from postpartum haemorrhage (PPH). Our objective was to assess the costs of care for women who receive different preventative uterotonics, and with PPH and no-PPH so that the differences, if significant, can inform better resource allocation for maternal health care. METHODS The costs of direct hospital care of women who received oxytocin or heat-stable carbetocin for prevention of PPH in selected tertiary care facilities in India, Kenya, Nigeria, and Uganda were assessed. We collected data from all women who had PPH, as well as a random sample of women without PPH. Cost data was collected for the cost of stay, PPH interventions, transfusions and medications for 2966 women. We analyzed the difference in cost of care at a facility level between women who experienced a PPH event and those who did not. Key findings The mean cost of care of a woman experiencing PPH in the study sites in India, Kenya, Nigeria, and Uganda exceeded the cost of care of a woman who did not experience PPH by between 21% and 309%. There was a large variation in cost across hospitals within a country and across countries. CONCLUSION Our results quantify the increased cost of PPH of up to 4.1 times that for a birth without PPH. PPH cost information can help countries to evaluate options across different conditions and in the formulation of appropriate guidelines for intrapartum care, including rational selection of quality-assured, effective medicines. This information can be applied to national assessment and adaptation of international recommendations such as the World Health Organization's recommendations on uterotonics for the prevention of PPH or other interventions used to treat PPH. Trial registration HRP Trial A65870; UTN U1111-1162-8519; ACTRN12614000870651; CTRI/2016/05/006969, EUDRACT 2014-004445-26. Date of registration 14 August 2014 Access to quality, effective lifesaving medicines in low and middle-income countries remains a major barrier to reducing maternal deaths from bleeding after childbirth. Information on to what extent treatments for bleeding increases the cost of care of women after childbirth is important for informed resource allocation. We collected data from all women who had bleeding after childbirth, as well as a random sample of women without bleeding in selected hospitals in India, Kenya, Nigeria, and Uganda. Cost data was collected for the cost of stay and interventions to manage bleeding for 2966 women. We compared the difference in cost of care between women who experienced a bleeding event and those who did not. The mean cost of care of a woman with bleeding in the study sites exceeded the cost of care of a woman who did not experience PPH by between 21% and 309%. There was a large variation in cost across hospitals within a country and across countries. Our results indicate an increased cost of bleeding of up to 4.1 times that for birth without bleeding. Effective prevention reduces the cost of care. Cost information can help countries to evaluate options across different conditions and in the formulation of appropriate guidelines for intrapartum care, including rational selection of quality-assured, effective medicines. This information can be applied to national assessment and adaptation of international recommendations such as the World Health Organization's recommendations on medications for the prevention of bleeding after childbirth or other interventions used to treat bleeding.
Collapse
Affiliation(s)
| | - Isotta Cleps
- Concept Foundation, Avenue de Sécheron 15, Geneva, Switzerland
| | - Shivaprasad Goudar
- KLE Academy of Higher Education and Research, J N Medical College, Belagavi, Karnataka, India
| | - Zahida Qureshi
- Department of Obstetrics and Gynaecology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | | | - Kidza Mugerwa
- Department of Obstetrics and Gynecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - Miriam Nakalembe
- Department of Obstetrics and Gynecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Alfred Osoti
- Department of Obstetrics and Gynaecology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Sura Mandeep
- Department of Obstetrics and Gynaecology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Teko Poriot
- Department of Obstetrics and Gynaecology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - George Gwako
- Department of Obstetrics and Gynaecology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Sunil Vernekar
- KLE Academy of Higher Education and Research, J N Medical College, Belagavi, Karnataka, India
| | - Mariana 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), Avenue Appia 20, 1201, Geneva, Switzerland
| |
Collapse
|
22
|
Almutairi WM. Incidences of Atonic Postpartum Hemorrhage and Related Risk Factors at a Tertiary Hospital in Saudi Arabia. Nurs Rep 2020; 10:164-71. [PMID: 34968361 DOI: 10.3390/nursrep10020020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/24/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022] Open
Abstract
Background: In 2017, there were 295,000 maternal deaths worldwide from preventable causes related to birth. The leading cause of maternal mortality is obstetric hemorrhage. In Saudi Arabia, a paucity of evidence about incidences of atonic Postpartum Hemorrhage (PPH) and related risk factors exists. Therefore, aims were to (a) identify incidences of atonic PPH from 2015 to 2018 (b) determine risk factors of atonic PPH in vaginal birth. Methods: Retrospective chart review with purposive sampling conducted revealed 386 charts, 220 (57%) vaginal birth and 166 (43%) caesarian section (CS). Logistic regression analysis was used. Results: Incidences of atonic PPH were 2.5% from 2015 to 2017, with the rate increasing by 12% from 2017 to 2018. In vaginal birth, significant associations between the severity of blood loss with epidural (F = 6.314, df = 1, p = 0.013), episiotomy (F = 4.38, df = 1, p = 0.038), induction of labor (IOL) (F = 1.224, df = 1, p = 0.004), and Interaction between IOL, AUG, and epidural (F = 7.24, df = 1, p = 0.041) found. Discussion: Increasing rate of atonic PPH confirmed. Epidural, episiotomy, induction of labor, and induction with augmentation are factors associated with severe atonic PPH in vaginal birth.
Collapse
|
23
|
Suganuma CA, Mano E. Patent Prosecution Highway program in Brazil and second medical indication patents challenges. Pharm Pat Anal 2020; 9:159-61. [PMID: 33275454 DOI: 10.4155/ppa-2020-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
24
|
Abstract
Worldwide, the incidence of postpartum haemorrhage (PPH) is ∼6% and it is the leading cause of maternal mortality. The present study introduces a non-invasive procedure called bilateral cervix apex clamping (BCAC) as a new treatment for refractory PPH. A total of 13 vaginal deliveries and 5 caesarean section patients received the BCAC procedure to stop bleeding. During the procedure, the anterior and posterior walls of the cervical apex were clamped using toothless ovum forceps from the left and right side. The procedure was terminated when the bleeding had nearly stopped without clamping. The success rate of the procedure was 94.4% (17/18) overall, and 92.3% for vaginal delivery and 100% in caesarean section patients. Only one case of vaginal delivery did we resort to exploratory laparotomy and hysterectomy as amniotic fluid embolism occurred. The time spent on the procedure was 2-4 min for vaginal delivery cases and 5-7 min for caesarean section patients. The blood loss reduced significantly after the procedure, before the BCAC and after it was 875(450) ml versus 100(80)ml (p < .0001). There was a reduction in the need for UAE (uterine artery embolisation) from 13 in 22,817 deliveries (2013-2015) to 0 in 18,212 deliveries (2016-2017 (p < .001). But no change in the rate of hysterectomy (5/22817 versus 5/18212) (p = .76). BCAC is a simple, easy, safe, effective and non-invasive procedure that can decrease bleeding in patients with PPH.Impact statementWhat is already known on this subject? The BCAC clamping procedure was first described in Russia 80 years ago as the Genkel-Tikanadze method. But a PUBMED search did not identify and previous studies published on use of the technique.What do the results of this study add? The results of this study show that the BCAC clamping procedure can reduce bleeding significantly in refractory postpartum haemorrhage, when the uterine body is well contracted. The procedure can be performed after both in vaginal delivery and caesarean section. It can also reduce the necessity for UAE and balloon tamponade.What are the implications of these findings for clinical practice and/or further research? BCAC can be used after the failure of regular first line therapy for postpartum haemorrhage.
Collapse
Affiliation(s)
- Li Jiang
- Department of Obstetrics and Gynecology, Shanghai Jiading Maternity & Infant Health Hospital, Tongji University Teaching Hospital, Shanghai, China
| | - Xiahong Wang
- Department of Obstetrics and Gynecology, Shanghai Jiading Maternity & Infant Health Hospital, Tongji University Teaching Hospital, Shanghai, China
| |
Collapse
|
25
|
Shen Z, Zhang J, Zhao S, Zhou Y, Wang W, Shen B. Preoperative biliary drainage of severely obstructive jaundiced patients decreases overall postoperative complications after pancreaticoduodenectomy: A retrospective and propensity score-matched analysis. Pancreatology 2020; 20:529-536. [PMID: 32107192 DOI: 10.1016/j.pan.2020.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/16/2020] [Accepted: 02/01/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The influence of preoperative biliary drainage (PBD) for obstructive jaundiced patients before pancreaticoduodenectomy is debated in the past decades. The aim of this study is to assess the impact of preoperative biliary drainage on intraoperative and postoperative outcomes in patients with severely obstructive jaundice. METHODS Data were collected retrospectively from severely obstructive jaundiced patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy from January 2012 to December 2017. The univariate and multivariate analyses were performed to assess independent risk factors for overall postoperative complications. A propensity score-matched (PSM) analysis was performed to adjust baseline characteristics between PBD and direct surgery (DS) groups. After PSM, intraoperative data and postoperative complications were compared between the two groups. RESULTS A total of 200 patients were included. The rate of overall postoperative complication occurred in 119 (59.5%) patients, with prealbumin <150 mg/L (OR = 3.03; 95%CI = [1.63-5.62]; p < 0.001), ASA (American Society of Anesthesiology score) classification II-III (OR = 2.27; 95%CI = [1.21-4.27]; p = 0.011), and direct surgery (OR = 3.88; 95%CI = [1.67-8.99]; p = 0.002) identified as independent risk factors in multivariate analysis. After PSM, there was similar operative time and intraoperative transfusion between PBD and DS group. However, DS group had a higher incidence of overall postoperative complication (p = 0.005), grades B and C of post-pancreatectomy hemorrhage (PPH) (p = 0.032), and grades B and C of postoperative pancreatic fistula (POPF) (p = 0.045) compared to PBD group. CONCLUSIONS In this retrospective study, in order to reduce overall postoperative complications, PBD should be performed routinely for those patients with serum total bilirubin level exceeding 250 μmol/L and undergoing pancreaticoduodenectomy.
Collapse
Affiliation(s)
- Ziyun Shen
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jun Zhang
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shiwei Zhao
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yiran Zhou
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Baiyong Shen
- Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China; Research Institute of Pancreatic Disease, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| |
Collapse
|
26
|
Sturiale A, Fabiani B, Menconi C, Cafaro D, Celedon Porzio F, Naldini G. Stapled Surgery for Hemorrhoidal Prolapse: From the Beginning to Modern Times. Rev Recent Clin Trials 2020; 16:39-53. [PMID: 32156241 DOI: 10.2174/1574887115666200310164519] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 08/16/2019] [Revised: 01/14/2020] [Accepted: 02/12/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Hemorrhoidal disease is the most common proctologic condition in adults. Among the different surgical procedures, one of the greatest innovations is represented by the stapled hemorrhoidopexy. The history of this technique started with a single stapler use passing through a double stapler technique to resect the adequate amount of prolapse, finally coming to the use of high volume devices. METHODS Nevertheless, each device has its own specific feature, the stapler is basically made up with one or more circular lines of titanium staples whose height may be variable. The procedure is based on different steps: Introduction of the CAD, evaluation of the prolapse, fashioning purse string or parachute suture, the introduction of the stapler head beyond the suture, pull the wires through the window, close the stapler and keep pulled the wires of the suture held together with forceps, fire using two hands, open the stapler and remove it and check the staple line and then check the specimen. One of the latest innovations in stapled surgery is Tissue Selective Therapy. It is a minimally invasive procedure in which there is a partial circular stapled hemorrhoidopexy focused on the prolapsing piles with bridges of normal mucosa left. RESULTS Several studies have reported that SH is a safe and effective procedure to treat hemorrhoidal prolapse. It is a quicker procedure with a shorter hospital stay and earlier return to work if compared with the conventional treatment. This is due to less postoperative pain, postoperative bleeding, wound complications and constipation. Furthermore, the first generation devices had worse outcomes if compared with those of the new generation stapler that showed lower postoperative complication rates with better anatomical and symptomatic results. CONCLUSION Stapled procedure for the treatment of symptomatic hemorrhoidal prolapse represents one of the most important innovations in proctology of the last century bringing with it the new revolutionary concept of the rectal intussusception as a determining factor involved in the natural history of the disease. Stapled hemorrhoidopexy marked an era in which the surgeon may offer the patients a safe, effective treatment with less pain and fast recovery.
Collapse
Affiliation(s)
- Alessandro Sturiale
- Proctology and Pelvic Floor Clinical Centre, Cisanello University Hospital, Pisa, Italy
| | - Bernardina Fabiani
- Proctology and Pelvic Floor Clinical Centre, Cisanello University Hospital, Pisa, Italy
| | - Claudia Menconi
- Proctology and Pelvic Floor Clinical Centre, Cisanello University Hospital, Pisa, Italy
| | - Danilo Cafaro
- Proctology and Pelvic Floor Clinical Centre, Cisanello University Hospital, Pisa, Italy
| | - Felipe Celedon Porzio
- Proctology and Pelvic Floor Clinical Centre, Cisanello University Hospital, Pisa, Italy
| | - Gabriele Naldini
- Proctology and Pelvic Floor Clinical Centre, Cisanello University Hospital, Pisa, Italy
| |
Collapse
|
27
|
Surbek D, Vial Y, Girard T, Breymann C, Bencaiova GA, Baud D, Hornung R, Taleghani BM, Hösli I. Patient blood management (PBM) in pregnancy and childbirth: literature review and expert opinion. Arch Gynecol Obstet 2020; 301:627-641. [PMID: 31728665 PMCID: PMC7033066 DOI: 10.1007/s00404-019-05374-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/31/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Patient blood management [PBM] has been acknowledged and successfully introduced in a wide range of medical specialities, where blood transfusions are an important issue, including anaesthesiology, orthopaedic surgery, cardiac surgery, or traumatology. Although pregnancy and obstetrics have been recognized as a major field of potential haemorrhage and necessity of blood transfusions, there is still little awareness among obstetricians regarding the importance of PBM in this area. This review, therefore, summarizes the importance of PBM in obstetrics and the current evidence on this topic. METHOD We review the current literature and summarize the current evidence of PBM in pregnant women and postpartum with a focus on postpartum haemorrhage (PPH) using PubMed as literature source. The literature was reviewed and analysed and conclusions were made by the Swiss PBM in obstetrics working group of experts in a consensus meeting. RESULTS PBM comprises a series of measures to maintain an adequate haemoglobin level, improve haemostasis and reduce bleeding, aiming to improve patient outcomes. Despite the fact that the WHO has recommended PBM early 2010, the majority of hospitals are in need of guidelines to apply PBM in daily practice. PBM demonstrated a reduction in morbidity, mortality, and costs for patients undergoing surgery or medical interventions with a high bleeding potential. All pregnant women have a significant risk for PPH. Risk factors do exist; however, 60% of women who experience PPH do not have a pre-existing risk factor. Patient blood management in obstetrics must, therefore, not only be focused on women with identified risk factor for PPH, but on all pregnant women. Due to the risk of PPH, which is inherent to every pregnancy, PBM is of particular importance in obstetrics. Although so far, there is no clear guideline how to implement PBM in obstetrics, there are some simple, effective measures to reduce anaemia and the necessity of transfusions in women giving birth and thereby improving clinical outcome and avoiding complications. CONCLUSION PBM in obstetrics is based on three main pillars: diagnostic and/or therapeutic interventions during pregnancy, during delivery and in the postpartum phase. These three main pillars should be kept in mind by all professionals taking care of pregnant women, including obstetricians, general practitioners, midwifes, and anaesthesiologists, to improve pregnancy outcome and optimize resources.
Collapse
Affiliation(s)
- Daniel Surbek
- Department of Obstetrics and Gynaecology, Bern University Hospital, Insel Hospital, University of Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland.
| | - Yvan Vial
- Service of Obstetrics, Department Woman-Mother-Child, University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Thierry Girard
- Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Christian Breymann
- Obstetric Research-Feto Maternal Haematology Unit, University Hospital Zurich, Zurich, Switzerland
| | | | - David Baud
- Service of Obstetrics, Department Woman-Mother-Child, University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - René Hornung
- Department of Obstetrics and Gynaecology, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | | | - Irene Hösli
- Clinic of Obstetrics and Gynaecology, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
28
|
Morris JL, Khatun S. Clinical guidelines-the challenges and opportunities: What we have learned from the case of misoprostol for postpartum hemorrhage. Int J Gynaecol Obstet 2018; 144:122-127. [PMID: 30387124 PMCID: PMC7379921 DOI: 10.1002/ijgo.12704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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] [Received: 06/26/2018] [Revised: 09/06/2018] [Accepted: 11/01/2018] [Indexed: 11/16/2022]
Abstract
Objective To establish whether national guidelines for postpartum hemorrhage (PPH) reflect new scientific evidence on misoprostol, and determine the challenges faced in their implementation. Methods A web‐based survey was sent by email to 130 national societies of obstetrics and gynecology (FIGO Member Associations) in 2016. The survey, composed of 18 questions, covered national guidelines on PPH with particular reference to misoprostol, the creation of national guidelines, and challenges to implementation. Results Completed surveys were received from 69 societies, for a 53% response rate. The key findings were that many countries lacked comprehensive, up‐to‐date, evidence‐based national guidelines providing guidance on misoprostol use; recommended regimens were very different in the national guidelines as well as between international and regional guidelines that are most often used as referencing documents; and there are a variety of challenges to implementation of guidelines. Conclusion There is a need, especially in countries with high maternal mortality, to establish mechanisms that ensure the existence of up‐to‐date, comprehensive, evidence‐based guidelines on PPH. This can be difficult given conflicting guidance at the international level. Regional and international societies should prioritize clinical updates and ensure their dissemination and implementation. A survey of 69 national societies of obstetrics and gynecology showed that many lacked comprehensive, up‐to‐date, evidence‐based national guidelines on postpartum hemorrhage, including misoprostol use.
Collapse
Affiliation(s)
- Jessica L Morris
- International Federation of Gynecology and Obstetrics (FIGO), London, UK
| | - Samia Khatun
- International Federation of Gynecology and Obstetrics (FIGO), London, UK
| |
Collapse
|
29
|
Alalfy M, Lasheen Y, Elshenoufy H, Elzahaby IM, Kaleem HW, El Sawah H, Azkalani A, Saber W, Rashwan ASSA. The efficacy of intrauterine misoprostol during cesarean section in prevention of primary PPH, a randomized controlled trial. J Matern Fetal Neonatal Med 2018; 33:1459-1465. [PMID: 30176758 DOI: 10.1080/14767058.2018.1519796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Postpartum hemorrhage is the leading cause of maternal mortality worldwide.Aim: To compare the incidence of postpartum hemorrhage in women eligible for elective cesarean section (CS) delivery when using intrauterine misoprostol added to oxytocin versus oxytocin alone.Design, Setting, Participants: This parallel randomized controlled trial study was conducted in two institutions in Egypt (Kasralainy and Aljazeerah hospital) 0.300 women eligible for elective CS delivery were enrolled in the study.Interventions: Before randomization, all women received the same preparations. After randomization; in the study group (N = 150), intrauterine misoprostol was used after placental delivery. In the control group (N = 150), the routine oxytocin alone was used.Results: Both groups were comparable (p-value >.05) with regard to the age, BMI, and gestational age as well as hemoglobin and hematocrit levels. The incidence of postpartum hemorrhage was significantly lower (p = .018) in the study group (1.33%) than the control group (6.67%). The absolute risk reduction was 5.3% (CI 95%: 0.8-10.6%) with a relative risk of 0.20 (CI 95%: 0.05-0.90) and number needed to treat (NNT) 19 (CI 95%: 125-9). Moreover, the needs for a blood transfusion, extra uterotonics or additional interventions were significantly lower in the study group than in the control group (p < .05). All the three parameters of blood loss ie the mean blood loss, and the mean reductions of hemoglobin and hematocrit levels were significantly (p-value <.05) lower in the study group (mean and SD) (442.59 and 151.33 mL,0.46 and 0.3 g/dL, and 0.84 and 0.56%), respectively than in the control group (591.01 and 287.97 mL,1.2 and 1.39 g/dL, and 3.47 and 3.52%), respectively. Adverse events were comparable between groups; these were fever, nausea, and vomiting and shivering.Conclusion: Intrauterine misoprostol (400 mg) when added to oxytocin is safe and effective in decreasing the incidence of postpartum hemorrhage (PPH) and reducing the amount of postpartum blood loss in case of elective CS delivery.
Collapse
Affiliation(s)
- Mahmoud Alalfy
- Reproductive health and family planning department, National Research Centre (Egypt), Giza, Egypt; Aljazeerah Hospital, CAIFM, Egypt
| | - Yossra Lasheen
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hossam Elshenoufy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - I M Elzahaby
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Heba W Kaleem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Heba El Sawah
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Azkalani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Waleed Saber
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed S S A Rashwan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| |
Collapse
|
30
|
Kahr MK, Brun R, Zimmermann R, Franke D, Haslinger C. Validation of a quantitative system for real-time measurement of postpartum blood loss. Arch Gynecol Obstet 2018; 298:1071-7. [PMID: 30225686 DOI: 10.1007/s00404-018-4896-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Reliable real-time estimation of blood loss is crucial for the prompt management of postpartum hemorrhage (PPH), which is one of the major obstetric complications worldwide. Our study aims at the validation of feasibility and precision of measured blood loss (MBL) with a quantitative real-time measurement system during (1) vaginal delivery and (2) cesarean section by comparison with a hemoglobin-based formula for blood loss as an objective control. This is the first study to include a reasonable number of patients in an everyday clinical setting. METHODS 921 patients were prospectively enrolled into this study (vaginal delivery: n = 461, cesarean delivery: n = 460) at a tertiary care hospital in Switzerland. Blood loss was measured by quantitative fluid collection bags. "Calculated blood loss" (CBL) was determined by modified Brecher`s formula based on the drop of hemoglobin after delivery. MBL based on our measurement system was compared to CBL by correlation analysis and stratified by the mode of delivery. RESULTS During vaginal delivery, MBL as determined by our quantitative measurement system highly correlated with CBL (p < 0.001, r = 0.683). This was also true for patients with cesarean deliveries (p < 0.001, r = 0.402), however, in a less linear amount. In women with cesarean deliveries, objectively low blood loss tended to be rather overestimated, while objectively high blood loss was more likely underestimated. CONCLUSIONS The technique of real-time measurement of postpartum blood loss after vaginal delivery as presented in this study is practicable, reliable and strongly correlated with the actual blood loss and, therefore, poses an actual improvement in the management of PPH.
Collapse
|
31
|
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is the leading cause of maternal mortality in low-income countries and is a significant contributor to severe maternal morbidity and long-term disability. Carbetocin may be an underused uterotonic for prevention of PPH. A number of studies are being conducted that may challenge the place of oxytocin as the first choice of uterotonics for prevention of PPH. This paper describes the current research into carbetocin and ranking of effectiveness of uterotonics that may provide important new information to assist healthcare decision makers to ensure that women receive an effective uterotonic for prevention of PPH. METHODS We searched the WHO International Clinical Trials Registry Platform for current studies on effectiveness of carbetocin for prevention of PPH following vaginal delivery with sample sizes large enough to provide quality evidence to support potential changes to international guidelines. We also searched the Cochrane Library for current systematic reviews including carbetocin used in prevention of PPH. RESULTS Susceptibility to degradation from exposure to heat is one of the key causes of reduced effectiveness of oxytocin in preventing PPH from uterine atony. Although heat stable and effective in preventing PPH, misoprostol is also subject to degradation due to exposure to moisture and produces some side-effects. Other uterotonics (including ergometrine and combinations of oxytocin, ergometrine and misoprostol) are also available and used with varying safety and effectiveness profiles and quality issues. Efforts to reduce maternal mortality from PPH include research studies seeking to identify safe, stable, effective uterotonics. Heat stable carbetocin is the subject of two major clinical studies into its effectiveness in preventing PPH following vaginal deliveries, information that could expand its application for prevention of PPH. CONCLUSION Heat stable carbetocin is being investigated as a potential alternative to oxytocin. This paper describes two current clinical trials on carbetocin and a network meta-analysis ranking of all uterotonic agents, including carbetocin, which combined may provide evidence supporting expansion of the use of the heat stable formulation of carbetocin in PPH prevention.
Collapse
Affiliation(s)
| | | | - Yeshita V. Pujar
- Department of Obstetrics & Gynaecology, KLE Academy of Higher Education and Research’s J. N. Medical College, Belagavi, Karnataka India
| |
Collapse
|
32
|
Abstract
BACKGROUND Severe secondary or delayed postpartum hemorrhage (PPH) is rare and affects 0.23-3% of all pregnancies. It happens between 24 hours to 12 weeks postdelivery. These PPHs occur more often during normal vaginal delivery; only a small subset of these PPHs occur after cesarean section. The top differential diagnoses of both primary and secondary PPH are different, and as a result, the management may be different. Although uterine atony causes 80% of primary PPHs, extensive literature review exposed the rarity of it in the setting of secondary PPH. CASE REPORT A 27-year-old woman presented to the emergency department 1 week after a cesarean section for severe vaginal bleeding that started an hour earlier. The patient required rigorous uterine massage for approximately 30 min along with oxytocin, carboprost, methergine, and misopristol before bleeding subsided. She required 1 unit of O- blood transfusion during resuscitation and still had a hemoglobin drop of 2.7 g/dL from arrival to after bleeding subsided. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PPH is a life-threatening condition that emergency physicians rarely encounter and may be uncomfortable managing. It is important to be familiar with the differential diagnosis of both primary and secondary PPH and the management of each of the causes.
Collapse
Affiliation(s)
- Nirav Patel
- Emergency Medicine Department, Coney Island Hospital, Brooklyn, New York
| | - Michael Radeos
- Emergency Medicine Department, Coney Island Hospital, Brooklyn, New York
| |
Collapse
|
33
|
Sirico A, Saccone G, Maruotti GM, Grandone E, Sarno L, Berghella V, Zullo F, Martinelli P. Low molecular weight heparin use during pregnancy and risk of postpartum hemorrhage: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2018; 32:1893-1900. [PMID: 29251025 DOI: 10.1080/14767058.2017.1419179] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide with a prevalence rate of approximately 6%. Although most cases of PPH have no identifiable risk factors, the incidence of PPH has been associated to the thromboprophylaxis in pregnancy with low molecular weight heparin (LMWH). Thus, the aim of the study is to evaluate the risk of PPH in cases of pregnant women exposed to LMWH. MATERIALS AND METHODS Electronic research was performed in OVID, Scopus, ClinicalTrials.gov, MEDLINE, the PROSPERO International Prospective Register of Systematic Reviews, EMBASE, and the Cochrane Central Register of Controlled Trials through April 2016. We included randomized controlled trials, cohort and case-control studies of women who underwent thromboprophylaxis with LMWH during pregnancy compared to a control group (either placebo or no treatment). The primary outcome was the incidence of PPH. The summary measures were reported as relative risk (RR) or as mean differences (MD) with 95% confidence interval (CI). RESULTS Eight studies including 22,162 women were analyzed. Of the 22,162 women, 1320 (6%) were administered LMWH, 20,842 (94%) women formed the nonexposed group (control group). Women treated with LMWH had a higher risk of PPH (RR 1.45, 95%CI 1.02-2.05) compared to controls; there was no difference in mean of blood loss at delivery (MD -32.90, 95%CI 68.72-2.93) and in risk of blood transfusion at delivery (RR 1.24, 95%CI 0.62-2.51), respectively. CONCLUSIONS Women who receive LMWH during pregnancy have a significantly higher risk of developing PPH. Women who receive LMWH during pregnancy have neither significantly higher mean blood loss at delivery nor higher risk of blood transfusion.
Collapse
Affiliation(s)
- Angelo Sirico
- a Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine , University of Naples "Federico II" , Naples , Italy
| | - Gabriele Saccone
- a Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine , University of Naples "Federico II" , Naples , Italy
| | - Giuseppe Maria Maruotti
- a Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine , University of Naples "Federico II" , Naples , Italy
| | - Elvira Grandone
- b Atherosclerosis and Thrombosis Unit , IRCCS "Casa Sollievo della Sofferenza" , S. Giovanni Rotondo , Italy
| | - Laura Sarno
- a Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine , University of Naples "Federico II" , Naples , Italy
| | - Vincenzo Berghella
- c Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine , Sidney Kimmel Medical College of Thomas Jefferson University , Philadelphia , PA , USA
| | - Fulvio Zullo
- a Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine , University of Naples "Federico II" , Naples , Italy
| | - Pasquale Martinelli
- a Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine , University of Naples "Federico II" , Naples , Italy
| |
Collapse
|
34
|
Wolk S, Grützmann R, Rahbari NN, Hoffmann RT, Plodeck V, Weitz J, Welsch T, Distler M. Management of clinically relevant postpancreatectomy hemorrhage ( PPH) over two decades - A comparative study of 1 450 consecutive patients undergoing pancreatic resection. Pancreatology 2017; 17:943-950. [PMID: 29111264 DOI: 10.1016/j.pan.2017.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/13/2017] [Accepted: 10/22/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES PPH is the main cause of mortality (up to 50%) after pancreatic resection. Due to differences in time of onset, localization and clinical impairment, there is no consistent management algorithm. METHODS Between 1994 and 2014 the occurrence of PPH in 115 out of 1 450 patients from a prospectively collected database was analyzed. The cohort was divided into two time periods: 1994-2009 and 2010-2014. The differences between the two groups were analyzed. RESULTS The overall incidence of PPH was 7.9%. The main causes of hemorrhage were the pancreatic anastomosis (31.1%) and the splanchnic arteries (23.5%). In the first period, there were more anastomotic hemorrhages (40.0% vs. 20.4%, p = 0.02), while in the second period more hemorrhages from the splanchnic arteries occurred (12.3% vs. 37%, p = 0.002). Bleeding control was achieved by relaparotomy (45.7%), noninterventionally (22.8%), endoscopically (19.7%) and angiographically (13.4%). In the second period, the relevance of interventional angiography significantly increased (24.6% vs. 4.3%, p = 0.001), whereas endoscopy lost importance (7% vs. 30%, p = 0.001). The in-hospital case fatality rate after PPH was 27.4%, with higher case fatality rate following extraluminal hemorrhage (23.9% vs. 3.4%, p < 0.001). CONCLUSIONS A shift in the management of PPH could be seen over the two periods. Interventional angiography has gained more importance in the treatment of severe extraluminal hemorrhage of the splanchnic arteries. Adequate treatment of PPH is crucial to improve the outcome.
Collapse
Affiliation(s)
- Steffen Wolk
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Robert Grützmann
- Department of Surgery, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Nuh N Rahbari
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Ralf T Hoffmann
- Institute of Radiology, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Verena Plodeck
- Institute of Radiology, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Marius Distler
- Department of General, Thoracic and Vascular Surgery, Medizinische Fakultät Carl Gustav Carus, TU Dresden, Dresden, Germany.
| |
Collapse
|
35
|
Khan T, Laul P, Laul A, Ramzan M. Prognostic factors of maternal near miss events and maternal deaths in a tertiary healthcare facility in India. Int J Gynaecol Obstet 2017; 138:171-176. [PMID: 28500780 DOI: 10.1002/ijgo.12208] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 08/25/2016] [Revised: 03/07/2017] [Accepted: 05/10/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To study maternal near miss (MNM) and maternal mortality to identify rectifiable risk factors. METHODS The present cross-sectional retrospective study included pregnant women who experienced acute life-threatening pregnancy-related adverse events at Deen Dayal Upadhyay hospital, New Delhi, India, between September 1, 2009, and August 31, 2011. Patient data were analyzed to investigate factors associated with MNM events and maternal deaths. RESULTS There were 369 patients included, and 302 MNM events and 67 maternal deaths were recorded. The recorded causes of MNM events included hemorrhage, hypertensive disorders, severe anemia with cardiac failure, organ failure, and infection in 192 (63.6%), 62 (20.5%), 13 (4.3%), 8 (2.6%), and 8 (2.6%) patients, respectively. Higher rates of anemia (P=0.007) and infection (P=0.007) were recorded among patients in the maternal death group than the MNMN group. CONCLUSION Hemorrhage and hypertension were major causes of MNM events and are likely major barriers to reducing maternal mortality in low-income countries. Anemia and infection were significant prognostic factors of maternal death in the present study. MNM could be used as surrogate for maternal death in the provision of standard obstetric care.
Collapse
Affiliation(s)
- Tabassum Khan
- Department of Obstetrics and Gynaecology, Deen Dayal Upadhyay Hospital, New Delhi, India
| | - Poonam Laul
- Department of Obstetrics and Gynaecology, Deen Dayal Upadhyay Hospital, New Delhi, India
| | - Anish Laul
- Maulana Azad Medical College, New Delhi, India
| | - Mohammed Ramzan
- Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
36
|
Gosain R. Update on Brazil's pharma patent landscape. Pharm Pat Anal 2016; 5:385-90. [PMID: 27804784 DOI: 10.4155/ppa-2016-0017] [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] [Indexed: 11/17/2022]
Abstract
Brazil's Pharma market is a dynamic and promising one. It ranks within the top ten market. There are peculiar hurdles that patentees have to overcome, such as, a two-tier examination, a serious backlog at the Brazilian Patent and Trademark Office. Several measures to accelerate examination have been adopted given the meager number of Examiners.
Collapse
|
37
|
Venkatesh S, Chinmayi, Ramkumar V, Sheela CN, Thomas A. Implementation of WHO Near-Miss Approach for Maternal Health at a Tertiary Care Hospital: An Audit. J Obstet Gynaecol India 2016; 66:259-62. [PMID: 27382220 PMCID: PMC4912489 DOI: 10.1007/s13224-015-0684-y] [Citation(s) in RCA: 2] [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: 04/28/2014] [Accepted: 02/19/2015] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate severe maternal outcomes (including maternal deaths and maternal near-miss cases). MATERIALS & METHODS A prospective study of severe maternal outcomes (including maternal deaths and maternal near-miss cases) from May 2012 to April 2013 was performed. For each woman, data were collected on the occurrence of selected severe pregnancy-related complications, the use of critical interventions, and admissions to intensive care unit. RESULTS The total number of deliveries were 2340. The number of maternal deaths was three. The natures of the near-miss cases during the study period were recorded. Prevalence of SAMM (severe acute maternal morbidity) was 2.025 %. CONCLUSION In areas where the maternal mortality is low, there is a need to shift focus to maternal near-miss cases or SAMM, which is a useful adjunct to maternal death enquiries.
Collapse
Affiliation(s)
| | - Chinmayi
- Department of OBG, St. John’s Medical College, Bangalore, India
| | - Vani Ramkumar
- Department of OBG, St. John’s Medical College, Bangalore, India
| | - C. N. Sheela
- Department of OBG, St. John’s Medical College, Bangalore, India
| | - Annamma Thomas
- Department of OBG, St. John’s Medical College, Bangalore, India
| |
Collapse
|
38
|
Long Q, Li Y, Li J, Wen Y, Du W, Wan C, Yue C. [Clinical observation on anal pendant expansion after PPH of mixed hemorrhoid treated with acupuncture at Xialiao (BL 34) and Changqiang (GV 1)]. Zhongguo Zhen Jiu 2016; 36:603-606. [PMID: 29231455 DOI: 10.13703/j.0255-2930.2016.06.013] [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] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare the difference in the clinical efficacy on anal pendant expansion after PPH (procedure for prolapse and hemorrhoids) of mixed hemorrhoid between acupuncture at Xialiao (BL 34) and Chang-qiang (GV 1) and oral administration of diosmin. METHODS Sixty cases of mixed hemorrhoids after PPH were randomized into an observation group and a control group, 30 cases in each one. In the observation group, since the 1st day, acupuncture had been applied to Xialiao (BL 34) and Changqiang (GV 1). The needles were retained for 30 min after qi arrival, and the treatment was given once a day, totally for 7 days. In the control group, diosmin tablets had been prescribed for oral administration since the 1st day, 0.9 g each time, twice a day, totally for 7 days. The degree, persistent time and the pain score of anal pendant expansion were compared on the 1st, 2nd, 3rd and 7th days after PPH between the two groups and the efficacy was evaluated. RESULTS On the 1st day after PPH, the diffe-rences in the scores of the degree and persistent time of anal pendant expansion were not significant statistically between the two groups (all P>0.05), but the pain score in the observation group was lower than that in the control group (P<0.05) and lower than that before treatment (P<0.05). On the 2nd, 3rd and 7th days after PPH, the degree and persistent time of anal pendant expansion and pain score in the two groups were all lower than those before treatment (all P<0.05). The results in the observation group were better than those in the control group (all P<0.05). At the end of treatment (on the 7th day after PPH), the total effective rate in the observation group was higher than that in the control group[90.0% (27/30) vs 83.3% (25/30),P<0.05]. CONCLUSIONS Acupuncture at Xialiao (BL 34) and Changqiang (GV 1) achieves the superior efficacy on anal pendant expansion after PPH of mixed hemorrhoids as compared with diosmin tablets.
Collapse
Affiliation(s)
- Qing Long
- Department of Chinese Medicine, Affiliated Hospital of Luzhou Medical University, Luzhou 646000, Sichuan Province, China
| | - Yan Li
- Department of Dermatology, Affiliated Chinese Medicine Hospital of Luzhou Medical University
| | - Jun Li
- Department of Chinese Medicine, Affiliated Hospital of Luzhou Medical University, Luzhou 646000, Sichuan Province, China
| | - Yong Wen
- Department of Chinese Medicine, Affiliated Hospital of Luzhou Medical University, Luzhou 646000, Sichuan Province, China
| | - Weiliang Du
- Department of Chinese Medicine, Affiliated Hospital of Luzhou Medical University, Luzhou 646000, Sichuan Province, China
| | - Chuan Wan
- Department of Chinese Medicine, Affiliated Hospital of Luzhou Medical University, Luzhou 646000, Sichuan Province, China
| | - Chaochi Yue
- Department of Chinese Medicine, Affiliated Hospital of Luzhou Medical University, Luzhou 646000, Sichuan Province, China
| |
Collapse
|
39
|
Khadilkar SS, Sood A, Ahire P. Quantification of Peri-partum Blood Loss: Training Module and Clot Conversion Factor. J Obstet Gynaecol India 2016; 66:307-14. [PMID: 27651622 DOI: 10.1007/s13224-016-0888-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 11/25/2015] [Accepted: 03/24/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To design an objective and accurate method to assess the peri-partum blood loss and to document the benefits of using this method on estimation of blood loss by healthcare professionals. MATERIALS AND METHODS This prospective study was conducted over 6 months at Cama Albless Hospital, Mumbai. To quantify the loss of liquid blood and clots, we made use of plastic drapes, measuring jars, gravimetric method and a training module along with novel clot conversion factor which was designed to validate the visual assessment of blood loss by healthcare professionals. RESULTS AND CONCLUSION The visual assessment of blood loss is unreliable. Training module should be on display in labor room and periodic training sessions on visual assessment by and for healthcare professionals are recommended, as we documented that training has definitely a beneficial impact on visual assessment. Clot conversion factor calculated in this study can prove to be a useful tool for objective assessment. Routine use of quantitative measurement rather than visual assessment of blood loss will go a long way to prevent hemorrhage-related maternal deaths.
Collapse
Affiliation(s)
- Suvarna Satish Khadilkar
- Bombay Hospital and Research Centre, Mumbai, India ; Grant Medical College, Cama and Albless Hospital, Mumbai, India
| | - Akanksha Sood
- Grant Medical College, Cama and Albless Hospital, Mumbai, India ; ESIC-PGIMSR, Andheri, Mumbai, India
| | - Prajakta Ahire
- Grant Medical College, Cama and Albless Hospital, Mumbai, India
| |
Collapse
|
40
|
Vlassoff M, Diallo A, Philbin J, Kost K, Bankole A. Cost-effectiveness of two interventions for the prevention of postpartum hemorrhage in Senegal. Int J Gynaecol Obstet 2016; 133:307-11. [PMID: 26952348 DOI: 10.1016/j.ijgo.2015.10.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 07/16/2015] [Revised: 10/27/2015] [Accepted: 01/29/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To compare, at the community level, the cost-effectiveness of oxytocin and misoprostol for the prevention of postpartum hemorrhage (PPH). METHODS The present cost-effectiveness study used data collected during a randomized trial that compared the prophylactic effectiveness of misoprostol and oxytocin for the prevention of PPH in a rural setting in Senegal between June 6 and September 21 2013. The two interventions were compared, with referral to a higher level facility owing to PPH being the outcome measure. The costs and effects were calculated for two hypothetical cohorts of patients delivering during a 1-year period, with each cohort receiving one intervention. A comparison with a third hypothetical cohort receiving the current standard of care was included. A sensitivity analysis was performed to estimate the impact of variations in model assumptions. RESULTS The cost per PPH referral averted was US$ 38.96 for misoprostol and US$ 119.15 for oxytocin. In all the scenarios modeled the misoprostol intervention dominated, except in the worst-case scenario, where the oxytocin intervention demonstrated slightly better cost-effectiveness. CONCLUSION The use of misoprostol for PPH prophylaxis could be cost effective and improve maternal outcomes in low-income settings.
Collapse
|
41
|
Xiang F, Feng JJ, Sun YQ, Gou YL. Tissue-selecting therapy stapler vs procedure for prolapse and hemorrhoids for treatment of mixed hemorrhoids. Shijie Huaren Xiaohua Zazhi 2014; 22:3753-3758. [DOI: 10.11569/wcjd.v22.i25.3753] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the efficacy and complications of tissue-selecting therapy stapler (TST) vs procedure for prolapse and hemorrhoids (PPH) in the treatment of mixed hemorrhoids.
METHODS: One hundred and eighty-two patients with mixed hemorrhoids were randomly divided into two groups to receive TST (study group, n = 91) and PPH (control group, n = 91), respectively. The efficacy, complications, hospital stay, hospitalization expenses, postoperative pain score, anal bulge score, and urinary retention were compared between the two groups.
RESULTS: After treatment, the two groups demonstrated no statistical differences in efficacy, hospital stay, hospitalization expenses, postoperative pain score, anal bulge score, urinary retention, postoperative anastomosis bleeding or fecal incontinence (P > 0.05). The study group was significantly better than the control group with regards to the number of stitches of suture for hemostasis, perioperative bleeding, operative time, fecal urgency, and rectostenosis (P < 0.05). During a follow-up period of 18 mo, the total effective rates for both groups were 100%. There were 5 cases of recurrence in the study group and 3 in the control group, which showed no statistical difference (P > 0.05).
CONCLUSION: TST and PPH for mixed hemorrhoids have similar therapeutic efficacy, but the former is associated with less postoperative complications, less operative bleeding, shorter operative time, and lower incidence of fecal urgency and rectostenosis.
Collapse
|
42
|
Saxton A, Fahy K, Hastie C. Effects of skin-to-skin contact and breastfeeding at birth on the incidence of PPH: A physiologically based theory. Women Birth 2014; 27:250-3. [PMID: 25113818 DOI: 10.1016/j.wombi.2014.06.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [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: 02/07/2014] [Revised: 05/31/2014] [Accepted: 06/10/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND The importance of optimising maternal/baby psychophysiology has been integrated into contemporary midwifery theories but not in the detail required to really understand the underpinning biological basis. METHOD The functioning of the autonomic nervous system, as it relates to the uterus is reviewed. The physiology of myometrial cell contraction and relaxation is outlined. The main focus is on the factors that affect the availability and uptake of oxytocin and adrenaline/noradrenaline in the myometrial cells. These are the two key neuro-hormones, active in the 3rd and 4th stages of labour, that affect uterine contraction and retraction and therefore determine whether the woman will have an atonic PPH or not. DISCUSSION The discussion explains and predicts the physiological functioning of the uterus during the 3rd and 4th stages of labour when skin-to-skin contact and breastfeeding occurs and when it does not. CONCLUSION This biologically based theory hypothesises that to achieve and maintain eutony and eulochia, midwives and birthing women should ensure early, prolonged and undisturbed skin-to-skin contact for mother and baby at birth including easy access for spontaneous breastfeeding.
Collapse
Affiliation(s)
- Anne Saxton
- Southern Cross University, Coolangatta, Queensland, Australia
| | - Kathleen Fahy
- Southern Cross University, Coolangatta, Queensland, Australia.
| | - Carolyn Hastie
- Southern Cross University, Coolangatta, Queensland, Australia
| |
Collapse
|
43
|
Abstract
BACKGROUND Postprandial hypotension (PPH) is an important clinical problem, which has received inappropriately little attention. METHODS A systematic search of the databases PubMed, Embase, Cochrane Library, and Web of Knowledge, from their inception to the present time, was conducted to identify studies relevant to the epidemiology, pathophysiology, and/or management of PPH. RESULTS A total of 417 full-text papers were retrieved from database searching and, following screening, 248 were retained. Of these, 167 papers were considered eligible for inclusion. CONCLUSIONS PPH occurs commonly in older people and represents a major cause of morbidity. Although the pathophysiology of PPH remains poorly defined, diverse factors, including impairments in sympathetic and baroreflex function, release of vasodilatory peptides, the rate of small intestinal nutrient delivery, gastric distension, and splanchnic blood pooling, appear important. Current pharmacologic and nonpharmacologic management is suboptimal. Research into the pathophysiology of PPH represents a priority so that management can be targeted more effectively.
Collapse
Affiliation(s)
- Laurence G Trahair
- Discipline of Medicine, University of Adelaide, Adelaide, Australia; NHMRC Center of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide, Adelaide, Australia; NHMRC Center of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - Karen L Jones
- Discipline of Medicine, University of Adelaide, Adelaide, Australia; NHMRC Center of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia.
| |
Collapse
|
44
|
Sharma M, Kaur P, Kaur K, Kaur A, Kaur PK, Kaur MM. A comparative study of oxytocin/misoprostol/methylergometrine for active management of the third stage of labor. J Obstet Gynaecol India 2014; 64:175-9. [PMID: 24966500 DOI: 10.1007/s13224-014-0512-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [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: 02/03/2013] [Accepted: 01/21/2014] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES To study oxytocin, misoprostol, and methylergometrine in active management of the third stage of labor and determine duration of the third stage of labor, blood loss, adverse effects, and need for additional uterotonics in each group. METHODS Clinical trial of 300 women with healthy singleton pregnancy allocated into three groups to receive either: 10 IU intravenous oxytocin infusion, 600 μg sublingual misoprostol, or 200 μg intravenous methylergometrine. Primary outcome measure was blood loss in the third stage of labor; secondary measures were duration of the third stage, side effects, and complications. RESULTS Subjects who received 600 μg of misoprostol had the least blood loss, followed by oxytocin, and methylergometrine. The shortest mean duration of the third stage was with misoprostol. Shivering and pyrexia were observed in misoprostol group, and raised blood pressure in methylergometrine group. CONCLUSIONS Misoprostol is as effective as oxytocin and both are more effective than methylergometrine in active management of the third stage of labor.
Collapse
Affiliation(s)
- Megha Sharma
- Department of Obstetrics and Gynaecology, GMC and Rajindra Hospital, 151 Punjabi Bagh, Patiala, 147001 Pb India
| | - Parneet Kaur
- Department of Obstetrics and Gynaecology, GMC and Rajindra Hospital, 151 Punjabi Bagh, Patiala, 147001 Pb India
| | - Khushpreet Kaur
- Department of Obstetrics and Gynaecology, GMC and Rajindra Hospital, 151 Punjabi Bagh, Patiala, 147001 Pb India
| | - Arvinder Kaur
- Department of Obstetrics and Gynaecology, GMC and Rajindra Hospital, 151 Punjabi Bagh, Patiala, 147001 Pb India
| | - Preet Kanwal Kaur
- Department of Obstetrics and Gynaecology, GMC and Rajindra Hospital, 151 Punjabi Bagh, Patiala, 147001 Pb India
| | - Mohi Manjit Kaur
- Department of Obstetrics and Gynaecology, GMC and Rajindra Hospital, 151 Punjabi Bagh, Patiala, 147001 Pb India
| |
Collapse
|
45
|
Jensen JR, White WM, Coddington CC. Maternal and neonatal complications of elective early-term deliveries. Mayo Clin Proc 2013; 88:1312-7. [PMID: 24182707 DOI: 10.1016/j.mayocp.2013.07.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 07/12/2013] [Accepted: 07/12/2013] [Indexed: 12/20/2022]
Abstract
Approximately 10% to 15% of all deliveries in the United States are performed before 39 completed weeks of gestation without a true medical indication for early delivery, despite long-standing recommendations against this practice. Early-term deliveries are those that occur between 3707 and 3867 weeks. It is now recognized that maternal and neonatal complications have increased for deliveries that occur at early- vs late-term gestation. The reasons for the increase in the rate of elective early-term deliveries are unclear but likely involve both patient and physician factors. Various strategies have been used to increase awareness of the morbidities associated with the practice of elective early-term delivery and to reduce its frequency. Insurers and quality accrediting agencies are increasingly holding hospitals accountable for their rates of elective early-term deliveries, and this pressure will likely continue to lead to widespread change in the practice of obstetrics. The interventions to increase adherence to evidence-based medicine guidelines that are described within this review may also be applicable to other areas of medicine.
Collapse
Affiliation(s)
- Jani R Jensen
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.
| | | | | |
Collapse
|
46
|
Rong H, Tang Y, Zhang H, Wu P, Chen Y, Li M, Wu G, Jiang H. The Stay-Green Rice like (SGRL) gene regulates chlorophyll degradation in rice. J Plant Physiol 2013; 170:1367-73. [PMID: 23816327 DOI: 10.1016/j.jplph.2013.05.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 05/07/2013] [Accepted: 05/08/2013] [Indexed: 05/24/2023]
Abstract
The Stay-Green Rice (SGR) protein is encoded by the SGR gene and has been shown to affect chlorophyll (Chl) degradation during natural and dark-induced leaf senescence. An SGR homologue, SGR-like (SGRL), has been detected in many plant species. We show that SGRL is primarily expressed in green tissues, and is significantly downregulated in rice leaves undergoing natural and dark-induced senescence. As the light intensity increases during the natural photoperiod, the intensity of SGRL expression declines while that of SGR expression increases. Overexpression of SGRL reduces the levels of Chl and Chl-binding proteins in leaves, and accelerates their degradation in dark-induced senescence leaves in rice. Our results suggest that the SGRL protein is also involved in Chl degradation. The relationship between SGRL and SGR and their effects on the degradation of the light-harvesting Chl a/b-binding protein are also discussed.
Collapse
Affiliation(s)
- Hong Rong
- Key Laboratory of Plant Resources Conservation and Sustainable Utilization, South China Botanical Garden, Chinese Academy of Sciences, Guangzhou 510650, PR China
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Austin ED, Menon S, Hemnes AR, Robinson LR, Talati M, Fox KL, Cogan JD, Hamid R, Hedges LK, Robbins I, Lane K, Newman JH, Loyd JE, West J. Idiopathic and heritable PAH perturb common molecular pathways, correlated with increased MSX1 expression. Pulm Circ 2012; 1:389-98. [PMID: 22140629 PMCID: PMC3224431 DOI: 10.4103/2045-8932.87308] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The majority of pulmonary arterial hypertension (PAH) is not associated with BMPR2 mutation, and major risk factors for idiopathic PAH are not known. The objective of this study was to identify a gene expression signature for IPAH. To accomplish this, we used Affymetrix arrays to probe expression levels in 86 patient samples, including 22 healthy controls, 20 IPAH patients, 20 heritable PAH patients (HPAH), and 24 BMPR2 mutation carriers that were as yet unaffected (UMC). Culturing the patient cells removes the signatures of drug effects and inflammation which have made interpretation of results from freshly isolated lymphocytes problematic. We found that gene expression signatures from IPAH patients clustered either with HPAH patients or in a single distinct group. There were no groups of genes changed in IPAH that were not also changed in HPAH. HPAH, IPAH, and UMC had common changes in metabolism, actin dynamics, adhesion, cytokines, metabolism, channels, differentiation, and transcription factors. Common to IPAH and HPAH but not UMC were an upregulation of vesicle trafficking, oxidative/nitrosative stress, and cell cycle genes. The transcription factor MSX1, which is known to regulate BMP signaling, was the most upregulated gene (4×) in IPAH patients. These results suggest that IPAH cases have a shared molecular origin, which is closely related to, but distinct from, HPAH. HPAH and IPAH share the majority of altered signaling pathways, suggesting that treatments developed to target the molecular etiology of HPAH will also be effective against IPAH.
Collapse
Affiliation(s)
- Eric D Austin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Jain D, Khuteta R, Chaturvedi V, Khuteta S. Effect of body mass index on pregnancy outcomes in nulliparous women delivering singleton babies: observational study. J Obstet Gynaecol India 2012; 62:429-31. [PMID: 23904704 DOI: 10.1007/s13224-012-0225-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 06/04/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To find out the effect of increasing body mass index (BMI) on pregnancy outcomes in nulliparous women delivering singleton babies. METHOD This was a hospital-based observation study, based on 300 nulliparous women delivering singleton babies in June 2009-Sept. 2010. Women were categorized into three groups. Underweight (BMI < 20 kg/m(2)), normal (BMI 20-24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)), and obese (BMI > 30 kg/m(2)) obstetric and perinatal outcomes were compared by univariate and multivariate analysis. RESULTS Maximum patients who underwent LSCS were having BMI > 30 kg/m(2) [OR 9.558 (95 % CI 5.82-17.27)]. As compared to women of normal BMI (20-24.9 kg/m(2)), morbidly obese women faced the higher risk of PIH [OR 8.045 (95 % CI 3.875-16.781)]. Obese women were more likely to have post partum hemorrhage [OR 5.11 (95 % CI 1.76-14.79)] compared with women of normal BMI. Birth weight <2,500 g was more common in women with BMI < 25 kg/m(2) (21.21 %), while highest incidence of birth weight >4,000 g (14.29 %) is seen in women of the obese group. CONCLUSIONS Increasing BMI is associated with increased incidence of cesarean delivery, PIH, post partum hemorrhage, and macrosomic babies.
Collapse
|
49
|
Singi SR, Fernandez E, Pandya ST, Badrinath HR. Recombinant factor VIIa: use in fatal post partum hemorrhage - Indian experience case series and review of literature. Indian J Hematol Blood Transfus 2009; 25:1-5. [PMID: 23100963 DOI: 10.1007/s12288-009-0001-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Accepted: 09/22/2008] [Indexed: 10/20/2022] Open
Abstract
Postpartum hemorrhage is leading cause of maternal mortality and still remains a challenging condition to treat and hysterectomy may be required to control the bleeding once medical interventions fail. These strategies are not always successful and a direct approach in activating the coagulation system can be more effective and life saving. We describe here the mechanism of action of rFVIIa, review of literature and its use in 10 cases with different causes for PPH with good response.
Collapse
|