Burden and outcomes of postpartum haemorrhage in Nigerian referral-level hospitals

OBJECTIVE

To determine the prevalence of primary postpartum haemorrhage (PPH), risk factors, and maternal and neonatal outcomes in a multicentre study across Nigeria.

DESIGN

A secondary data analysis using a cross-sectional design.

SETTING

Referral-level hospitals (48 public and six private facilities).

POPULATION

Women admitted for birth between 1 September 2019 and 31 August 2020.

METHODS

Data collected over a 1-year period from the Maternal and Perinatal Database for Quality, Equity and Dignity programme in Nigeria were analysed, stratified by mode of delivery (vaginal or caesarean), using a mixed-effects logistic regression model.

MAIN OUTCOME MEASURES

Prevalence of PPH and maternal and neonatal outcomes.

RESULTS

Of 68 754 women, 2169 (3.2%, 95% CI 3.07%-3.30%) had PPH, with a prevalence of 2.7% (95% CI 2.55%-2.85%) and 4.0% (95% CI 3.75%-4.25%) for vaginal and caesarean deliveries, respectively. Factors associated with PPH following vaginal delivery were: no formal education (aOR 2.2, 95% CI 1.8-2.6, P < 0.001); multiple pregnancy (aOR 2.7, 95% CI 2.1-3.5, P < 0.001); and antepartum haemorrhage (aOR 11.7, 95% CI 9.4-14.7, P < 0.001). Factors associated with PPH in a caesarean delivery were: maternal age of >35 years (aOR 1.7, 95% CI 1.5-2.0, P < 0.001); referral from informal setting (aOR 2.4, 95% CI 1.4-4.0, P = 0.002); and antepartum haemorrhage (aOR 3.7, 95% CI 2.8-4.7, P < 0.001). Maternal mortality occurred in 4.8% (104/2169) of deliveries overall, and in 8.5% (101/1182) of intensive care unit admissions. One-quarter of all infants were stillborn (570/2307), representing 23.9% (429/1796) of neonatal intensive care unit admissions.

CONCLUSIONS

A PPH prevalence of 3.2% can be reduced with improved access to skilled birth attendants.

Role of disruptions in O RhD negative donations in Colombia on increasing maternal mortality ratio from haemorrhage

OBJECTIVE

The aim of this work was to evaluate the relationship of the maternal mortality ratio due to obstetric haemorrhage (MMROH) with the national blood donations, particularly O RhD negative (Oneg) before and during COVID-19 pandemic.

BACKGROUND

The maternal mortality ratio is increasing in Colombia, yet little is known regarding the relationship between blood donations and maternal mortality due to obstetric haemorrhage.

MATERIALS AND METHODS

A retrospective cross-sectional study between January 1, 2018, and December 31, 2021, was performed, to assess MMROH compared to the blood donations notified to the Colombian National Haemovigilance System, through non-parametric methods. Because a relationship between blood donations and MMROH was identified, the analysis was expanded from 2009 to 2017.

RESULTS

In 2020, Colombia increased the MMROH by 32% compared to 2019 which coincided with the lockdown period to contain COVID-19. An inversed relationship (SumD2 = 631.0; rs = -0.7335; p 0.01) between blood donations, particularly Oneg (SumD2 = 652.0; rs = -0.7912; p 0.002) and MMROH was identified. For the years 2015-2019 and 2021, the annual mean MMROH was 8.5 ± 0.5 per 100 000 live births when the annual mean blood donations was 18.2 ± 0.4 donations per 1000 people and the Oneg was 1.0 ± 0.0 donations per 1000 people. In contrast, the years 2009-2014 and 2020 displayed an annual MMROH of 12.6 ± 0.8, when the annual collection of blood was 16.4 ± 0.8 donations and the Oneg was 0.9 ± 0.0, p < 0.001.

CONCLUSION

There was an inverse relationship between blood donation, mainly Oneg, and maternal mortality from obstetric haemorrhage. However, we recognise these deaths could be related to other reasons, especially when they occurred in rural areas with limited access to medical services.

Defining 'obstetric haemorrhage': Blood loss volume and severe morbidity

AIMS AND OBJECTIVES

Our goal is to describe the association between total quantitative blood loss (QBL) and risk of obstetric haemorrhage-related morbidity (OBH-M) to assess the utility of the current definition of obstetric haemorrhage (OBH).

METHODS

This was a retrospective cohort study completed of all patients who had a live delivery at the only urban safety-net hospital over a 2-year period from 2018 to 2019. We categorized deliveries into 10 equally sized deciles based on QBL and compared the proportion with OBH-M in each. Among the two deciles with the highest proportions of OBH-M, we stratified deliveries into seven groups of ascending intervals of 250cc QBL. Finally, we compared the positive predictive value (PPV) of the standard definition of OBH (QBL ≥ 1000cc) to a definition extrapolated from our stratified analysis. The primary outcome was proportion of deliveries within each QBL decile affected by OBH-M. The secondary outcome was PPV.

RESULTS

We found a significant increase in OBH-M from decile 9 (895-1201cc QBL) to decile 10 (1205-8325cc QBL) (p < 0.001). In our stratified analysis, we found QBL of 1500cc to be an inflection point for an increased proportion of OBH-M. Our secondary analysis showed an increased PPV for OBH-M using QBL of 1500cc (20.5%) compared with that of QBL 1000cc (9.8%).

CONCLUSIONS

Our findings suggest that a higher QBL threshold than the currently accepted definition of OBH is more predictive of OBH-M.

Concentration-effect relationship for tranexamic acid inhibition of tissue plasminogen activator-induced fibrinolysis in vitro using the viscoelastic ClotPro® TPA-test

BACKGROUND

Tranexamic acid is an antifibrinolytic drug that is commonly administered for obstetric haemorrhage. Conventional viscoelastic tests are not sensitive to tranexamic acid, but the novel ClotPro® TPA-test can measure tranexamic acid-induced inhibition of fibrinolysis. We aimed to evaluate the TPA-test in pregnant and non-pregnant women.

METHODS

We performed an in vitro study of whole blood samples spiked with tranexamic acid from pregnant women in the first, second, and third trimester (n=20 per group) and from non-pregnant women (n=20). We performed ClotPro TPA-tests of whole blood sample and ClotPro EX-tests, FIB-tests, and TPA-tests.

RESULTS

Clot lysis was inhibited in a concentration-dependent manner up to a tranexamic acid concentration of 6.25 mg L-1. At tranexamic acid concentrations of 12.5 mg L-1 and above, clot lysis was completely inhibited. The concentration-effect relationship of tranexamic acid did not differ in a clinically important manner in blood from pregnant women across all three trimesters or from non-pregnant controls. A median maximum lysis cut-off value of at9 least 16% (25-75th percentiles 15-18), a median clot lysis time of 3600 s (25-75th percentiles 3600-3600), or both was associated with a tranexamic acid concentration of least 12.5 mg L-1.

CONCLUSIONS

The ClotPro® TPA-test is sensitive in detecting inhibition of fibrinolysis by tranexamic acid in whole blood samples of pregnant and non-pregnant women. The concentration-effect relationship of tranexamic acid to inhibit fibrinolysis in whole blood did not differ for women in the first, second, and third trimester or for non-pregnant women.

The impact of a blended multidisciplinary training for the management of obstetric haemorrhage in Mbeya, Tanzania

Background

The Maternal Mortality Rate (MMR) in Tanzania is 78 times higher than that of the UK. Obstetric haemorrhage accounts for two-thirds of these deaths in Mbeya, Tanzania. A lack of healthcare providers' (HCPs') competencies has been the key attribute. This study measured the impact on HCP's competencies from a blended training programme on obstetric haemorrhage.

Methods

A "before and after" cohort study was undertaken with HCPs in 4 hospitals in the Mbeya region of Tanzania between August 2021 and April 2022. A multidisciplinary cohort of 34 HCPs (doctors, nurses, midwives, anaesthetists and radiologists) were enrolled on a blended face-to-face and virtual training course. The training was delivered by a multidisciplinary team (MDT) from London, UK, assisted by local multidisciplinary trainers from Mbeya, Tanzania and covered anaesthetic, obstetrics, haematology and sonographic use.

Results

There were 33 HCP in the cohort of trainees where 30/33 (90.9%) of HCPs improved their Anaesthesia skills with a mean score improvement of 26% i.e., 0.26 (-0.009 -0.50), 23 HCPs (69.7%) improved obstetric skills 18% i.e., 0.18 (-0.16 to 0.50), 19 (57.6%), (57.6%) improved competences in Haematology 15%.i.e., 0.15 (-0.33 to 0.87), 20 out of 29 HCPs with ultrasound access (68.8%) improved Sonographic skills 13%.i.e., 0.13 (-0.31 to 0.54). All 33 HCPs (100%) presented a combined change with the mean score improvement of difference of 25% i.e., 0.25 (0.05-0.66). The deaths attributed to obstetric haemorrhage, the mortality rate declined from 76/100,000 to 21/100,000 live births. Actual number of deaths due to obstetric haemorrhage declined from 8 before training to 3 after the completion of the training.

Conclusion

This comprehensive blended training on anaesthetic surgical, haematological, and sonographic management of obstetric haemorrhage delivers a significant positive impact on the detection, management and outcomes of obstetric haemorrhage.

Postpartum haemorrhage in high-resource settings: Variations in clinical management and future research directions based on a comparative study of national guidelines

OBJECTIVE

To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH.

DESIGN

Comparative study.

SETTING

High-resource countries.

POPULATION

Women with PPH.

METHODS

Systematic comparison of guidance on PPH from eight high-income countries.

MAIN OUTCOME MEASURES

Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour.

CONCLUSIONS

Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines.

RESULTS

Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.

Incidence and risk factors for severe postpartum haemorrhage in women with anterior low-lying or praevia placenta and prior caesarean: Prospective population-based study

OBJECTIVE

To assess the incidence and risk factors for severe postpartum haemorrhage (PPH) in women with an anterior low-lying or praevia placenta, prior caesarean and no prenatal suspicion of placenta accreta spectrum (PAS).

DESIGN

Population-based study in 176 maternity units in France.

POPULATION

All women with anterior low-lying (0-19 mm from the cervical internal os) or praevia placenta, diagnosed prospectively before birth, prior caesarean and no prenatal suspicion of PAS.

METHODS

Multivariable logistic regression to identify risk factors for severe PPH in the main population and after exclusion of women with PAS diagnosed only at birth.

MAIN OUTCOME MEASURES

Severe PPH defined by a composite criterion either estimated blood loss of ≥1500 ml, transfusion of ≥4 or more units of packed red blood cells, embolisation or surgical treatment.

RESULTS

Of the 520 114 women constituting the source population, 230 (0.44/1000 women; 95% confidence interval [CI] 0.38-0.50) met the inclusion criteria. Severe PPH rate was 24.8% (95% CI 19.2-30.4) overall, 27.5% (95% CI 21.8-33.3) in women with placenta praevia and 15.4% (95% CI 10.7-20.0) in women with low-lying placenta. PAS was diagnosed at birth in 22 women (9.9%; 95% CI 5.8-13.4), although previously unsuspected. After their exclusion, severe PPH incidence was 17.3% (95% CI 12.4-22.2). In multivariate analysis, the only factor associated with a higher severe PPH risk was placenta previa (aOR, 3.65; 95%CI, 1.20-15.8).

CONCLUSION

Severe PPH is frequent among women with anterior low-lying or praevia placenta and prior caesarean, even after exclusion of women with PAS. The risk of severe PPH for those with praevia is nearly twice that with low-lying placenta.

Changes in practice and management of placenta accreta spectrum disorder: A 20-year retrospective cohort study

BACKGROUND

Placenta accreta spectrum disorder is an increasingly prevalent cause of maternal morbidity in developed countries.

AIMS

This study aimed to review the management and outcomes of cases of placenta accreta spectrum, and compare blood loss and blood transfusion rates, over time after an institutional change in planned primary surgeon from gynaecological oncologists to experienced obstetricians.

METHODS

This retrospective cohort study included all cases of suspected or confirmed placenta accreta spectrum disorder (PASD) between 1999 and 2021 at Monash Health. Data were collected by reviewing medical records to obtain baseline characteristics, details of surgical planning and management and major maternal morbidity outcomes over a 20-year period. The primary surgical lead was recorded as either gynaecological oncologist or experienced obstetricians. The primary outcomes were estimated maternal blood loss and number of units of blood transfused.

RESULTS

A total of 88 patients were identified: 43 between 1999 and 2015 where gynaecological oncologists were the primary surgeon in 79% of cases and 45 between 2016 and 2021 where experienced obstetricians were the primary surgeon in 73.3% of cases. There was no statistically significant difference in the estimated blood loss between the two time periods (median: 2000 vs 2500 mL, P = 0.669). Hysterectomy rates were significantly reduced in the second time period, from 100 to 73.3%, P < 0.001.

CONCLUSION

Management of cases of PASDs has improved over time with changes in antenatal diagnosis and perioperative management, and management by experienced obstetricians has similar maternal outcomes compared to those whose management includes the presence of gynaecological oncologists.

Exploring the role of ex vivo metabolism on blood and plasma measurements of oxytocin among women in the third stage of labour: A post hoc study

AIMS

To examine the role of ex vivo oxytocin metabolism in post-dose peptide measurements.

METHODS

The stability of oxytocin (Study 1) and oxytocinase activity (Study 2) in late-stage pregnancy blood was quantified using liquid-chromatography tandem mass-spectrometry (LC-MS/MS) and a fluorogenic assay, respectively. Analyses were conducted using blood from pregnant women (>36 weeks gestation) evaluated in lithium heparin (LH), ethylenediaminetetraacetic acid (EDTA) and BD P100 blood collection tubes with or without protease inhibitors. In addition, plasma oxytocin concentrations following administration of oxytocin 240 IU inhaled, 5 IU intravenous or 10 IU intramuscular in women in third stage of labour (TSL) were analysed using enzyme-linked immunosorbent assay (ELISA) and LC-MS/MS to understand how quantified peptide concentrations differ between these analytical methods (Study 3).

RESULTS

Study 1: Oxytocin was stable in blood collected into EDTA tubes with or without protease inhibitors but not in LH tubes. Study 2: Blood collected into all EDTA-containing collection tubes led to near-complete inhibition of oxytocinase (≤100 min). In plasma, a 35% reduction in oxytocinase activity was observed in LH tubes with EDTA added. In plasma from late-stage pregnancy compared to nonpregnant participants, the oxytocinase activity was approximately 11-fold higher. Study 3: Plasma oxytocin concentrations from nonpregnant or women in TSL following exogenous oxytocin administration were ≤33 times higher when analysed using ELISA vs. LC-MS/MS methods.

CONCLUSIONS

Collection of blood from late-stage pregnant women into tubes containing EDTA inhibits oxytocinase effectively stabilizing oxytocin, suggesting low concentrations of oxytocin after dose administration reflect rapid in vivo metabolism.

Pharmacokinetics and safety of inhaled oxytocin compared with intramuscular oxytocin in women in the third stage of labour: A randomized open-label study

AIMS

To compare pharmacokinetics (PK) and safety of heat-stable inhaled (IH) oxytocin with intramuscular (IM) oxytocin in women in third stage of labour (TSL), the primary endpoint being PK profiles of oxytocin IH and secondary endpoint of safety.

METHODS

A phase 1, randomized, cross-over study was undertaken in 2 UK and 1 Australian centres. Subjects were recruited into 2 groups: Group 1, women in TSL; Group 2, nonpregnant women of childbearing potential (Cohort A, combined oral contraception; Cohort B, nonhormonal contraception). Participants were randomized 1:1 to: Group 1, oxytocin 10 IU (17 μg) IM or oxytocin 240 IU (400 μg) IH immediately after delivery; Group 2, oxytocin 5 IU (8.5 μg) intravenously and oxytocin 240 IU (400 μg) IH at 2 separate dosing sessions.

RESULTS

Participants were recruited between 23 November 2016 to 4 March 2019. In Group 1, 17 participants were randomized; received either IH (n = 9) or IM (n = 8) oxytocin. After IH and IM administration, most plasma oxytocin concentrations were below quantification limits (2 pg/mL). In Group 2 (n = 14), oxytocin IH concentrations remained quantifiable ≤3 h postdose. Adverse events were reported in both groups, with no deaths reported: Group 1, IH n = 3 (33%) and IM n = 2 (25%); Group 2, n = 14 (100%).

CONCLUSION

Safety profiles of oxytocin IH and IM were similar. However, PK profiles could not be established for oxytocin IH or IM in women in TSL, despite using a highly sensitive and specific assay.

Workshop on Blood Loss Quantification in Obstetrics: Improving Medical Student Learning through Clinical Simulation

PURPOSE

To assess whether a clinical simulation-based obstetric blood loss quantification workshop for medical undergraduate trainees improves theoretical-practical knowledge, along with self-assurance and self-confidence.

METHODS

This was a quasi-experimental pre-post learning study conducted at the Gynaecology and Obstetrics Unit of the Hospital Gregorio Marañón, Madrid, Spain. Participants were volunteer students in their fourth year of a 6-year degree course in Medicine. The study period was divided into the stages: pre-workshop, intra-workshop, 2 weeks post-workshop and 6 months post-workshop. In the pre-workshop stage, students completed a brief online course in preparation for the workshop. The effectiveness of the workshop was assessed through multiple choice tests and self-administered questionnaires. Data were compared between time-points using statistical tests for paired samples.

RESULTS

Of the 142 students invited (age 21.94 ± 3.12 years), 138 accepted the offer of the workshop (97.2%), and 85.4% had no experience in managing blood loss. Between the stages pre- and 2 weeks post-workshop, significant improvements were observed in theoretical-practical knowledge (μ = 1.109), self-assurance and self-confidence. At the 6 months post-workshop stage, theoretical-practical knowledge diminished compared with 2 weeks post-workshop, returning to pre-workshop levels, while self-assurance and confidence failed to vary significantly in the longer term.

CONCLUSIONS

The obstetric workshop improved theoretical-practical knowledge and the self-assurance and confidence of the medical students. Results 2 weeks post-workshop were maintained up until 6 months after the training intervention. The clinical simulation-based workshop was perceived by the students as useful and necessary.

Associations between ethnicity and admission to intensive care among women giving birth: a cohort study

OBJECTIVE

To determine the association between ethnic group and likelihood of admission to intensive care in pregnancy and the postnatal period.

DESIGN

Cohort study.

SETTING

Maternity and intensive care units in England and Wales.

POPULATION OR SAMPLE

A total of 631 851 women who had a record of a registerable birth between 1 April 2015 and 31 March 2016 in a database used for national audit.

METHODS

Logistic regression analyses of linked maternity and intensive care records, with multiple imputation to account for missing data.

MAIN OUTCOME MEASURES

Admission to intensive care in pregnancy or postnatal period to 6 weeks after birth.

RESULTS

In all, 2.24 per 1000 maternities were associated with intensive care admission. Black women were more than twice as likely as women from other ethnic groups to be admitted (odds ratio [OR] 2.21, 95% CI 1.82-2.68). This association was only partially explained by demographic, lifestyle, pregnancy and birth factors (adjusted OR 1.69, 95% CI 1.37-2.09). A higher proportion of intensive care admissions in Black women were for obstetric haemorrhage than in women from other ethnic groups.

CONCLUSIONS

Black women have an increased risk of intensive care admission that cannot be explained by demographic, health, lifestyle, pregnancy and birth factors. Clinical and policy intervention should focus on the early identification and management of severe illness, particularly obstetric haemorrhage, in Black women, in order to reduce inequalities in intensive care admission.

TWEETABLE ABSTRACT

Black women are almost twice as likely as White women to be admitted to intensive care during pregnancy and the postpartum period; this risk remains after accounting for demographic, health, lifestyle, pregnancy and birth factors.

The Recognition of Excessive blood loss At ChildbirTh (REACT) Study: a two-phase exploratory, sequential mixed methods inquiry using focus groups, interviews and a pilot, randomised crossover study

OBJECTIVES

To explore how childbirth-related blood loss is evaluated and excessive bleeding recognised; and to develop and test a theory of postpartum haemorrhage (PPH) diagnosis.

DESIGN

Two-phase, exploratory, sequential mixed methods design using focus groups, interviews and a pilot, randomised crossover study.

SETTING

Two hospitals in North West England.

SAMPLE

Women (following vaginal birth with and without PPH), birth partners, midwives and obstetricians.

METHODS

Phase 1 (qualitative): 8 focus groups and 20 one-to-one, semi-structured interviews were conducted with 15 women, 5 birth partners, 11 obstetricians, 1 obstetric anaesthetist and 19 midwives (n = 51). Phase 2 (quantitative): 11 obstetricians and ten midwives (n = 21) completed two simulations of fast and slow blood loss using a high-fidelity childbirth simulator.

RESULTS

Responses to blood loss were described as automatic, intuitive reactions to the speed, nature and visibility of blood flow. Health professionals reported that quantifying volume was most useful after a PPH diagnosis, to validate intuitive decisions and guide ongoing management. During simulations, PPH treatment was initiated at volumes at or below 200 ml (fast mean blood loss 79.6 ml, SD 41.1; slow mean blood loss 62.6 ml, SD 27.7). All participants treated fast, visible blood loss, but only half treated slow blood loss, despite there being no difference in volumes (difference 18.2 ml, 95% CI -5.6 to 42.2 ml, P = 0.124).

CONCLUSIONS

Experience and intuition, rather than blood loss volume, inform recognition of excessive blood loss after birth. Women and birth partners want more information and open communication about blood loss. Further research exploring clinical decision-making and how to support it is required.

TWEETABLE ABSTRACT

During a PPH, clinical decision-making is intuitive with clinicians treating as soon as excessive loss is recognised.

Experience of Bakri balloon tamponade at a single tertiary centre: a retrospective case series

Intrauterine balloon tamponade (IUBT) is an established fertility-sparing and life-saving treatment for postpartum haemorrhage. However, high-level evidence is lacking for specific aspects of its use. Our aim was to evaluate a large case series of IUBT to inform evidence-based clinical practice. 296 cases of IUBT over a three-year period at a tertiary obstetric referral centre were identified and reviewed. Demographic, clinical, and procedural outcome measures were collected; including rates of success and failure of IUBT, duration of tamponade, and complications. IUBT was successful in 265 (90%) of women and failed in 18 (6%). All failures occurred within six hours of balloon insertion. Once deemed stable and successful at six hours, no women required return to theatre or further intervention. The mean duration of intrauterine balloon tamponade was 18.5 hours. A large variance in clinical practice exists including duration of intrauterine balloon tamponade, and method and timing of removal. A number of changes informed by the results will be introduced and prospectively audited to improve IUBT use.Impact statementWhat is already known on this subject? Intrauterine balloon tamponade (IUBT) is an important second-line treatment option in severe postpartum haemorrhage (PPH). IUBT is easy to use, is effective especially in the setting of uterine atony, and is associated with minimal complications.What the results of this study add? This study confirms the high rate of success for IUBT in controlling PPH. We found that after six hours, if deemed successful, it is rare that further intervention is required. In addition, tamponade beyond 12 hours, gradual or incremental deflation of the balloon, and antibiotic cover beyond the duration of tamponade are unlikely to yield any further safety benefit.What the implications are of these findings for clinical practice and/or further research? Our findings suggest that women should not be required to fast for balloon removal; removal of the balloon should occur by 12 hours if deemed stable and adequately resuscitated; deflation and removal of the balloon can occur at once; and antibiotics should be ceased after balloon removal. These will allow women to mobilise and recover sooner, and improve flow and throughput in our high-acuity care areas.

Haematological features, transfusion management and outcomes of massive obstetric haemorrhage: findings from the Australian and New Zealand Massive Transfusion Registry

Massive obstetric haemorrhage (MOH) is a leading cause of maternal morbidity and mortality world-wide. Using the Australian and New Zealand Massive Transfusion Registry, we performed a bi-national cohort study of MOH defined as bleeding at ≥20 weeks' gestation or postpartum requiring ≥5 red blood cells (RBC) units within 4 h. Between 2008 and 2015, we identified 249 cases of MOH cases from 19 sites. Predominant causes of MOH were uterine atony (22%), placenta praevia (20%) and obstetric trauma (19%). Intensive care unit admission and/or hysterectomy occurred in 44% and 29% of cases, respectively. There were three deaths. Hypofibrinogenaemia (<2 g/l) occurred in 52% of cases in the first 24 h after massive transfusion commenced; of these cases, 74% received cryoprecipitate. Median values of other haemostatic tests were within accepted limits. Plasma, platelets or cryoprecipitate were transfused in 88%, 66% and 57% of cases, respectively. By multivariate regression, transfusion of ≥6 RBC units before the first cryoprecipitate (odds ratio [OR] 3·5, 95% CI: 1·7-7·2), placenta praevia (OR 7·2, 95% CI: 2·0-26·4) and emergency caesarean section (OR 4·9, 95% CI: 2·0-11·7) were independently associated with increased risk of hysterectomy. These findings confirm MOH as a major cause of maternal morbidity and mortality and indicate areas for practice improvement.

The effect of delayed umbilical cord clamping on cord blood gas analysis in vaginal and caesarean-delivered term newborns without fetal distress: a prospective observational study

OBJECTIVE

To determine variations in cord blood gas (CBG) parameters after 3-minute delayed cord clamping (DCC) in vaginal deliveries (VDs) and caesarean deliveries (CDs) at term without fetal distress.

DESIGN

Prospective observational study.

SETTING

University hospital.

SAMPLE

CBG from 97 VDs and 124 CDs without fetal distress.

METHODS

Comparison of paired arterial-venous CBG parameters drawn at birth from the unclamped cord and after 3-minutes DCC for VDs and CDs.

MAIN OUTCOME MEASURES

Base excess, bicarbonate, haematocrit and haemoglobin from both arterial and venous cord blood, lactate, neonatal outcomes, partial pressure of oxygen (pO₂ ), partial pressure of carbon dioxide (pCO₂ ), pH, and postpartum haemorrhage.

RESULTS

Arterial cord blood pH, bicarbonate ( HCO 3 - , mmol/l), and base excess (BE, mmol/l) decreased significantly after 3-minute DCC both in VDs (pH = 7.23 versus 7.27; P < 0.001; HCO 3 -  = 23.3 versus 24.3; P = 0.004; BE = -5.1 versus -2.9; P < 0.001) and CDs (pH = 7.28 versus 7.34; P < 0.001; HCO 3 -  = 26.2 versus 27.2; P < 0.001; BE = -1.5 versus 0.7; P < 0.001). After 3-minute DCC, pCO₂ increased in CDs only (57 versus 51; P < 0.001), whereas lactate increased more in CDs compared with VDs (lactate, +1.1 [0.9, 1.45] versus +0.5 [-0.65, 2.35]; P = 0.01). Postpartum maternal haemorrhage, neonatal maximum bilirubin concentration, and need for phototherapy were similar between the two groups. Newborns born by CD more frequently required postnatal clinical monitoring or admission to a neonatal intensive care unit.

CONCLUSIONS

After 3-minute DCC, the acid-base status shifted towards mixed acidosis in CDs and prevalent metabolic acidosis in VDs. CDs were associated with a more pronounced increase in arterial lactate, compared with VDs.

TWEETABLE ABSTRACT

By 3-minute DCC, acid-base status shifts towards mixed and metabolic acidosis in caesarean and vaginal delivery, respectively.

Risk of severe maternal morbidity associated with in vitro fertilisation: a population-based study

OBJECTIVE

To investigate the association between in vitro fertilisation IVF and severe maternal morbidity (SMM) and to explore the role of multiple pregnancy as an intermediate factor.

DESIGN

Population-based cohort-nested case-control study.

SETTING

Six French regions in 2012/13.

POPULATION

Cases were 2540 women with SMM according to the EPIMOMS definition; controls were 3651 randomly selected women who gave birth without SMM.

METHODS

Analysis of the associations between IVF and SMM with multivariable logistic regression models, differentiating IVF with autologous oocytes (IVF-AO) from IVF with oocyte donation (IVF-OD). The contribution of multiple pregnancy as an intermediate factor was assessed by path analysis.

MAIN OUTCOME MEASURES

Severe maternal morbidity overall and SMM according to its main underlying causal condition and by severity (near misses).

RESULTS

The risk of SMM was significantly higher in women with IVF (adjusted OR = 2.5, 95% CI 1.8-3.3). The risk of SMM was significantly higher with IVF-AO, for all-cause SMM (aOR = 2.0, 95% CI 1.5-2.7), for near misses (aOR = 1.9, 95% CI 1.3-2.8), and for intra/postpartum haemorrhages (aOR = 2.3, 95% CI 1.6-3.2). The risk of SMM was significantly higher with IVF-OD, for all-cause SMM (aOR = 18.6, 95% CI 4.4-78.5), for near misses (aOR = 18.1, 95% CI 4.0-82.3), for SMM due to hypertensive disorders (aOR = 16.7, 95% CI 3.3-85.4) and due to intra/postpartum haemorrhages (aOR = 18.0, 95% CI 4.2-77.8). Path-analysis estimated that 21.6% (95% CI 10.1-33.0) of the risk associated with IVF-OD was mediated by multiple pregnancy, and 49.6% (95% CI 24.0-75.1) of the SMM risk associated with IVF-AO.

CONCLUSION

The risk of SMM is higher in IVF pregnancies after adjustment for confounders. Exploratory results suggest higher risks among women with IVF-OD; however, confidence intervals were wide, so this finding needs to be confirmed. A large part of the association between IVF-AO and SMM appears to be mediated by multiple pregnancy.

TWEETABLE ABSTRACT

The risk of severe maternal morbidity is higher in IVF-conceived pregnancies than in pregnancies conceived by other means.

Maternal near-miss and death among women with postpartum haemorrhage: a secondary analysis of the Nigeria Near-miss and Maternal Death Survey

OBJECTIVE

To investigate the burden and health service events surrounding severe maternal outcomes (SMO) related to life-threatening postpartum haemorrhage (PPH) in Nigerian public tertiary hospitals.

DESIGN

Secondary analysis of a nationwide cross-sectional study.

SETTING

Forty-two tertiary hospitals.

POPULATION

Women admitted for pregnancy, childbirth or puerperal complications.

METHODS

All cases of SMO [maternal near miss (MNM) or maternal death (MD)] due to PPH were prospectively identified using WHO criteria over a 1-year period.

MAIN OUTCOME MEASURES

Incidence of SMO, health service events, case fatality rate (CFR) and mortality index (MI: % of death/SMO).

RESULTS

Postpartum haemorrhage occurred in 2087 (2.2%) of the 94 835 deliveries recorded during the study period. A total of 354 (0.3%) women had an SMO (103 MD; 251 MNM). It was the most frequent obstetric haemorrhagic complication across hospitals. PPH had the highest maternal mortality ratio (112/100 000 live births) and the recorded MI (29.1%) and CFR (4.9%) were second only to that of ruptured uterus. About 83% of women with SMO were admitted in a critical condition with over 50% being referred. MD was more likely when PPH led to neurological (80.8%), renal (73.5%) or respiratory (58.7%) organ dysfunction. Although the timing of life-saving interventions was not statistically different between the cases of MD and MNM, close to one-quarter of women who died received critical intervention at least 4 hours after diagnosis of life-threatening PPH.

CONCLUSIONS

Postpartum haemorrhage was a significant contributor to obstetric haemorrhage and SMO in Nigerian hospitals. Emergency obstetric services should be enhanced at the lower levels of healthcare delivery to reduce avoidable deaths from PPH.

FUNDING

The original research that generated the data for this secondary analysis, and the publication of this secondary analysis, was funded by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization. We have no other funding issue to declare for our study.

TWEETABLE ABSTRACT

One hundred and three maternal deaths and 251 near-misses resulted from PPH in 42 Nigerian tertiary facilities in 1 year.

Packed red cells versus whole blood transfusion for severe paediatric anaemia, pregnancy-related anaemia and obstetric bleeding: an analysis of clinical practice guidelines from sub-Saharan Africa and evidence underpinning recommendations

OBJECTIVE

Blood component transfusion is increasingly promoted in sub-Saharan Africa (SSA), but is resource-intensive so whole blood is often used. We examined SSA recommendations about whole blood and packed red cell transfusions for pregnancy-related bleeding or anaemia, and paediatric anaemia, and evaluated the evidence underpinning these recommendations.

METHOD

Relevant SSA guidelines were identified using five electronic databases, websites for SSA Ministries of Health, blood transfusion services and WHO. To facilitate comparisons, indications for transfusing packed red cells or whole blood within these guidelines and reasons given for these recommendations were recorded on a pre-designed matrix. The AGREE II tool was used to appraise guidelines that gave a reason for recommending either packed red cells or whole blood. We systematically searched MEDLINE, CINAHL, Global Health, Cochrane library and NHSBT Transfusion Evidence Library, using PRISMA guidelines, for clinical studies comparing whole blood with packed red cells or combined blood components in obstetric bleeding or anaemia, or paediatric anaemia. Characteristics and findings of included studies were extracted in a standardised format and narratively summarised.

RESULTS

32 English language guidelines from 15 SSA countries mentioned packed red cell or whole blood use for our conditions of interest. Only seven guidelines justified their recommendation for using packed red cells or whole blood. No recommendations or justifications had supporting citations to research evidence. 33 full-text papers, from 11 234 citations, were reviewed but only one study met our inclusion criteria. This was a single-centre study in post-partum haemorrhage.

CONCLUSION

Evidence comparing whole blood and packed red cell transfusion for common paediatric and maternal indications is virtually absent in SSA. Therefore, it is unclear whether policies promoting red cells over whole blood transfusion are clinically appropriate. Building a relevant evidence base will help develop effective policies promoting the most appropriate use of blood in African settings.

Management of major obstetric haemorrhage

One of the most important causes of maternal mortality is major obstetric haemorrhage. Major haemorrhage can occur in parturients either during the antepartum period, during delivery, or in the postpartum period. Early recognition and a multidisciplinary team approach in the management are the cornerstones of improving the outcome of such cases. The management consists of fluid resuscitation, administration of blood and blood products, conservative measures such as uterine cavity tamponade and sutures, and finally hysterectomy. Blood transfusion strategies have changed over the last decade with emphasis on use of fresh frozen plasma, platelets, and fibrinogen. Point-of-care testing for treating coagulopathies promptly and interventional radiological procedures have further revolutionized the management of such cases.

Implementation of an obstetric cell salvage service in a tertiary women's hospital

INTRODUCTION

Intraoperative cell salvage (ICS) is an important aspect of patient blood management programmes. An ICS service was introduced at KK Women's and Children's Hospital, Singapore, from 2 May 2011 to 30 April 2013 to aid in the management of massive obstetric haemorrhage.

METHODS

With support from the Ministry of Health's Healthcare Quality Improvement and Innovation Fund, a workgroup comprising obstetricians, anaesthetists and nursing staff was formed to develop training requirements, clinical guidelines and protocols for implementing ICS using the Haemonetics Cell Saver 5. Pregnant women with an anticipated blood loss of > 1,000 mL during Caesarean delivery, a baseline haemoglobin level of < 10 g/dL, rare blood types and who had refused donor blood were recruited to the service after obtaining informed consent.

RESULTS

A total of 11 women were recruited to the ICS service; the primary indications were placenta praevia and placenta accreta. Median blood loss in these 11 patients was 1,500 (range 400-3,000) mL. In four patients, adequate autologous blood was collected to initiate processing and salvaged, processed blood was successfully reinfused (mean 381.3 [range 223.0-700.0] mL). Median blood loss among these four patients was 2,000 (range 2,000-3,000) mL. No adverse event occurred following autologous transfusion. Mean immediate postoperative haemoglobin level was 8.0 (range 7.1-9.4) g/dL.

CONCLUSION

The implementation of an obstetric ICS service in our institution was successful. Future studies should seek to address the cost-effectiveness of ICS in reducing allogeneic blood utilisation.

Novel combined strategy of obstetric haemorrhage management during caesarean section using intrauterine balloon tamponade

OBJECTIVE

The aim of this trial was to evaluate the performance of a combined strategy of postpartum haemorrhage management, based upon thromboelastographic (TEG) assessment of coagulation, early surgical haemostasis and mechanical compression of the uterine wall combined with uterine cavity draining, via intrauterine balloon tamponade (BT).

METHODS

We carried out an open controlled trial, which included 119 women with obstetric haemorrhage (main group - combined strategy: n = 90, control group - conventional strategy: n = 29). The combined strategy included three essential components: (1) early surgical haemostasis, (2) mechanical pressure upon the uterine wall and draining of the uterine cavity via BT and (3) treatment of blood coagulation disorders identified via TEG.

RESULTS

The combined haemorrhage management strategy resulted in significantly lower number of peripartum hysterectomies compared with standard management (4.44% versus 31.03%, respectively, p = 0.02). Blood loss of >2000 ml occurred significantly less common in the main group compared with the control group (16.2% versus 27.6%, respectively, p = 0.03). Mean total blood loss after combined management was significantly lower than after the standard approach (2502 ± 203 ml versus 1836 ± 108 ml, p = 0.04).

CONCLUSIONS

The proposed combined strategy of obstetric haemorrhage management represents a powerful tool for fertility-sparing treatment of this life-threatening condition.

Iron deficiency anaemia in pregnancy: The role of parenteral iron

Maternal and perinatal morbidity and mortality remain major challenges in the delivery of safe maternity care worldwide. Anaemia in pregnancy is an important contributor to this dismal picture, especially where blood transfusion services are poorly developed. An early diagnosis and treatment of iron deficiency anaemia in pregnancy using the new generation dextran-free parenteral iron preparations can save lives and reduce morbidity in selected pregnancies. It is time to cast aside the fears associated with the use of the old parenteral iron preparations which were associated a high incidence of anaphylaxis, and embrace the use of new parenteral iron products which have better side effect profiles and can deliver total dose infusions without the need for test dosing. In selected women, the benefits of this treatment far outweigh any disadvantages.

[Scheduled hysterectomy vs. urgent hysterectomy in patients with placenta accreta in a high specialty medical unit]

BACKGROUND

Patients with placenta accreta have a high frequency of complications and death risk.

OBJECTIVE

The aim of this study was to compare the results of scheduled hysterectomy vs. urgent hysterectomy in patients with placenta accreta in a high specialty medical unit.

MATERIAL AND METHODS

An observational, comparative, cross-sectional study was conducted by reviewing patient records with confirmed diagnostic of placenta accreta, who attended in a one year period. They were divided into 2 groups based on the type of surgery, scheduled or urgent. Descriptive statistics were applied, with comparisons using Student t-test and chi squared tests. A value of P<.05 was considered significant.

RESULTS

There were 4,592 births in the period of study, and 125 obstetric hysterectomies were performed, with 40 confirmed cases of accreta (8.7 per thousand births) with 20 in scheduled and 20 in urgent surgeries, with the most frequent type being placenta accreta. The mean maternal age was 32 years, with a mean of 5 hours operating time, total bleeding 3135 ml, and 3.5 units of packed cells transfused. There was no statistical difference when comparing these variables with re-interventions, hypovolaemic shock, and intensive care unit admission. Caesarean-hysterectomy with hypogastric artery ligation was the most frequent surgery performed.

CONCLUSIONS

In this hospital, scheduled and urgent surgical treatment of patients with placenta accreta show similar results, probably because the constant availability of resources and the experience obtained by the multidisciplinary team in all shifts. Nevertheless, make absolutely sure to perform elective surgery while having all the necessary resources.

Blood transfusion practices in obstetric anaesthesia

Blood transfusion is an essential component of emergency obstetric care and appropriate blood transfusion significantly reduces maternal mortality. Obstetric haemorrhage, especially postpartum haemorrhage, remains one of the major causes of massive haemorrhage and a prime cause of maternal mortality. Blood loss and assessment of its correct requirement are difficult in pregnancy due to physiological changes and comorbid conditions. Many guidelines have been used to assess the requirement and transfusion of blood and its components. Infrastructural, economic, social and religious constraints in blood banking and donation are key issues to formulate practice guidelines. Available current guidelines for transfusion are mostly from the developed world; however, they can be used by developing countries keeping available resources in perspective.

Peripartum hysterectomy in a tertiary hospital in Western Sydney

The aim of this study was to review the incidence, indication, management and complications of peripartum hysterectomy (PH) in a tertiary level hospital over a decade. A retrospective review of all cases of PH performed at Westmead Hospital, Western Sydney, 2003-2012, was undertaken. PH was defined as hysterectomy performed after 20 weeks' gestation or any time after delivery but within 6 weeks' postpartum ( Awan et al. 2011 ). There were 56 cases of peripartum hysterectomy of 46,177 births, a rate of 1.22 per 1,000 births. The most common indication for PH was morbid adherence of the placenta (58.2%) followed by uterine atony. Having a history of both caesarean section and placenta praevia is highly associated with a morbidly adherent placenta in the index pregnancy (p = 0.002). The most common complication was coagulopathy followed by febrile illness and urinary tract injury. Our data showed previous caesarean section and placenta praevia to be associated with abnormal placentation, the leading indication for PH. Since there is an association between a planned caesarean hysterectomy and reduced amount of estimated blood loss and blood transfused, the knowledge of placentation and adequate preoperative planning and consideration for elective hysterectomy could be beneficial. The morbidity associated with PH is considerable.

A prospective surveillance of ruptured uterus in a rural tertiary health facility in northwest Nigeria

OBJECTIVE

To determine the frequency, cause and management outcome of ruptured uterus at a rural tertiary hospital.

METHODS

Cross sectional study which utilized a prospective surveillance of all cases of ruptured uterus that presented to the hospital from 1 April 2010 to 31 March 2013.

RESULTS

Frequency: Over the study period there were 3001 deliveries and 44 cases of ruptured uterus; however, three died before surgery and 41 cases had exploratory laparatomy giving a prevalence of 14.7/1000 deliveries or 1 in 68 deliveries. Their ages ranged from 18 to 45 with a mean of 28.3 ± 6.6 years and parity varied between 1 and 13 with majority (62.7%) being grand multiparous. Twenty-five (61.0%) lived over 50 km away from the hospital. Causes: Prolonged/obstructed labour accounted for 33 (80.5%) cases, 23 (56.1%) had previous caesarean sections, while injudicious use of oxytocin was observed in 17 (41.5%). Management outcome: All the women who had surgery survived but 16 (39.0%) had anaemia, 10 (24.4%) had wound infection, three (7.3%) developed burst abdomen and 11 (26.8%) had prolonged hospital stay. There were 40 (97.5%) stillbirths of which 25 (61.0%) were fresh.

CONCLUSION

The prevalence of ruptured uterus is high especially among women with prolonged/obstructed labour and previous caesarean section with associated high perinatal mortality.