Fibrinogen as a potential diagnostic marker for prediction and evaluation of postpartum hemorrhage: a retrospective study

OBJECTIVE

To investigate whether prenatal fibrinogen (FIB) or other related factors could be utilized to evaluate the risk of postpartum hemorrhage (PPH).

METHODS

A retrospective study was conducted in a database from January 2015 to December 2019. A total of 128 patients were enrolled and evaluated with FIB, in which 55 patients were assigned to low FIB and 73 in normal FIB.

RESULTS

According to the volume of blood loss, the mean of the low FIB group (<4 g/L) was markedly higher than that of the normal FIB group (≥4 g/L). Prenatal FIB was negatively correlated with PPH volume. The receiver operating characteristic (ROC) curve results indicated that the value of prenatal FIB was 0.701 to predict refractory PPH.

CONCLUSIONS

Prenatal FIB was significantly related to thrombin time (TT), which may be an independent factor to predict the coagulation state of prenatal pregnancy.

Vascular Subinvolution of the Placental Implantation Site as the Cause of Hysterectomy

Background. Vascular subinvolution of the placental bed is one of the uncommon but life-threatening forms of secondary postpartum hemorrhage. Studies on subinvolution of the implantation site are sparse and there is a scarcity of practice-based literature for this diagnosis. Case presentation. A 40-year-old woman with vaginal bleeding and light-headedness was admitted a few days after spontaneous abortion. Based on her unstable condition, hysterectomy was done. Pathologic gross evaluation of the uterus identified multiple large and dilated blood vessels, and microscopically, the myometrium showed thrombosis with scattered extravillous trophoblastic cells within the vessel walls. Conclusions. We described this rare case and explored the literature focusing on the pathophysiology and helpful ancillary studies for diagnosing this situation.

Accuracy testing of a novel obstetric blood loss quantifying device: A pilot study

The Stryker® system is accurate in detecting hemoglobin levels in fluid mixtures, which may assist professionals in assessing birth waste and diagnosing postpartum hemorrhage.

Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus

OBJECTIVE

There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth.

DESIGN

Systematic review and three-stage modified Delphi expert consensus.

SETTING

International.

POPULATION

Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance.

OUTCOME MEASURES

Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth.

RESULTS

Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman's haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman's haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach.

CONCLUSION

These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.

Ultrasonographic cervical length assessment in pregnancies with placenta previa and risk of perinatal adverse outcomes: a systematic review and meta-analysis

OBJECTIVE

This study aimed to examine the association between cervical length and the risk of adverse outcomes in placenta previa pregnancies. In addition, the diagnostic accuracy of cervical length in predicting emergency cesarean delivery due to hemorrhage was evaluated.

DATA SOURCES

PubMed, Web of Science, and Embase were systematically searched up to January 21, 2023.

STUDY ELIGIBILITY CRITERIA

Observational studies investigating the relationship between cervical length and maternal adverse outcomes in patients with placenta previa were considered eligible. The primary outcome was the diagnostic accuracy of cervical length measured at 28 to 34 weeks of gestation for the prediction of emergency cesarean delivery due to hemorrhage. The secondary outcomes were the probability of antenatal bleeding, preterm birth (both iatrogenic and spontaneous), and postpartum hemorrhage >2000 mL. Insufficient data were available on the transfusion procedure in cases where the cervical length was <30 mm.

METHODS

For prognostic analysis, the random-effects model was used to pool the odds ratios and the corresponding 95% confidence intervals. For the diagnostic part, we used a summary receiver-operating characteristic curve, pooled sensitivities and specificities, area under the curve, and summary likelihood ratios.

RESULTS

A total of 13 studies presenting data on 1462 pregnancies with placenta previa were included. Cervical length ≤30 mm at 28 to 34 weeks of gestation had a sensitivity of 61% (95% confidence interval, 43-77), specificity of 83% (95% confidence interval, 76-88), and area under the curve of 0.83 (95% confidence interval, 0.80-0.86) for the prediction of emergency cesarean delivery. Furthermore, cervical length ≤30 mm was associated with antenatal bleeding (odds ratio, 3.62; 95% confidence interval, 2.09-6.26; P<.001; I2=54.8%), preterm birth (odds ratio, 8.46; 95% confidence interval, 3.05-23.44; P<.001; I2=83.6%), and postpartum hemorrhage (odds ratio, 6.89; 95% confidence interval, 4.51-10.53; P<.001; I2=0.00%).

CONCLUSION

Short cervical length (≤30 mm) measured at 28 to 34 weeks of gestation can assist in predicting the risk of emergency cesarean delivery due to hemorrhage in pregnancies with placenta previa. Furthermore, short cervical length is significantly associated with the risk of antenatal bleeding, preterm birth, and postpartum hemorrhage in pregnancies with placenta previa.

Predictive performance of Shock Index for postpartum hemorrhage during cesarean delivery

BACKGROUND

The Shock Index (SI), defined as heart rate divided by systolic blood pressure, is reportedly an early surrogate indicator for postpartum hemorrhage (PPH). However, most previous studies have used clinical data of women who delivered vaginally. Therefore, we aimed to evaluate the SI pattern during cesarean delivery and determine its usefulness in detecting PPH.

METHODS

This was a single-center retrospective study using the clinical data of women (n = 331) who underwent cesarean delivery under spinal anesthesia at term between 2018 and 2021. We assessed the SI pattern stratified by total blood loss and evaluated the predictive performance of each vital sign in detecting PPH (total blood loss ≥1000 mL) based on the area under the receiver operating characteristic curve (AUROC).

RESULTS

At 10-15 min after delivery, the mean SI peaked between 0.84 and 0.90 and then decreased to a level between 0.72 and 0.77, which was similar to that upon entering the operating room. Among 331 women, 91 (27.5%) were diagnosed with PPH. There was no correlation between SI and total blood loss (rs = 0.02). The SI had low ability to detect PPH (AUROC 0.54, 95% confidence interval 0.47 to 0.61), which was similar to other vital signs (AUROCs 0.53-0.56).

CONCLUSION

We determined the pattern of SI during cesarean delivery. We found no correlation between SI and total blood loss. Unlike in vaginal delivery, the prognostic accuracy of SI for PPH detection in cesarean delivery was low.

Oxytocin at Elective Cesarean Delivery: A Dose-Finding Study in Pregnant People With Twin Pregnancy

BACKGROUND

Multiple pregnancy is associated with higher risk of uterine atony, postpartum hemorrhage (PPH), blood transfusion, hysterectomy, and death. The optimal dose of oxytocin at cesarean delivery in people with twin pregnancy is unknown. We sought to determine the effective bolus dose of oxytocin required to initiate adequate uterine tone in 90% of people (ED90) with twin pregnancy undergoing elective cesarean delivery. Our hypothesis was that the dose of oxytocin would be higher than 0.5 international units (IU) but lower than 5 IU.

METHODS

A double-blind dose-finding study using the biased coin up-down method was undertaken in people with twin pregnancy ≥36 weeks gestational age undergoing elective cesarean delivery under neuraxial anesthesia. Those with additional risk factors for PPH, apart from twin pregnancy, were excluded. Oxytocin was administered as an intravenous bolus over 1 minute on delivery of the second fetus. The first patient received 0.5 IU, and subsequent oxytocin doses were administered according to a sequential allocation scheme. The actual doses administered were 0.5, 1, 2, 3, 4, and 5 IU of oxytocin. The primary outcome was the response defined as the satisfactory uterine tone at 2 minutes after completion of administration of the oxytocin bolus, as assessed by the operating obstetrician. Secondary outcomes included need for rescue uterotonic drugs, adverse effects, and estimated blood loss. The ED90 was estimated using the Dixon-Mood and the isotonic regression methods.

RESULTS

Thirty patients were included in study. The estimated ED90 of oxytocin was 4.38 IU (95% confidence interval [CI], 3.68-4.86 IU) and 3.41 IU (95% CI, 2.83-3.98 IU) by the isotonic regression and Dixon-Mood methods, respectively. Seven patients had inadequate tone at the 2-minute evaluation point and required rescue uterotonic drugs. The median (interquartile range [IQR]) estimated blood loss was 1031 mL (732-1462 mL) calculated by the change in 24-hour hematocrit. Incidence of hypotension after oxytocin administration was 27%, nausea 30%, and vomiting 17%.

CONCLUSIONS

Our results demonstrated that people with twin pregnancy require a much higher dose of oxytocin than those with singleton pregnancies. We recommended people with twin pregnancies should receive an initial 5 IU bolus over at least 1 minute when undergoing elective cesarean delivery under neuraxial anesthesia.

The role of viscoelastic hemostatic assays for postpartum hemorrhage management and bedside intrapartum care

Viscoelastic hemostatic assays are point-of-care devices that assess coagulation and fibrinolysis in whole blood samples. These technologies provide numeric and visual information of clot initiation, clot strength, and clot lysis under low-shear conditions, and have been used in a variety of clinical settings and subpopulations, including trauma, cardiac surgery, and obstetrics. Emerging data indicate that these devices are useful for detecting important coagulation defects during major postpartum hemorrhage (especially low plasma fibrinogen concentration [hypofibrinogenemia]) and informing clinical decision-making for blood product use. Data from observational studies suggest that, compared with traditional formulaic approaches to transfusion management, targeted or goal-directed transfusion approaches using data from viscoelastic hemostatic assays are associated with reduced hemorrhage-related morbidity and lower blood product requirement. Viscoelastic hemostatic assays can also be used to identify and treat coagulation defects in patients with inherited or acquired coagulation disorders, such as factor XI deficiency or immune-mediated thrombocytopenia, and to assess hemostatic profiles of patients prescribed anticoagulant medications to mitigate the risk of epidural hematoma after neuraxial anesthesia and postpartum hemorrhage after delivery.

Detection of Postpartum Hemorrhage Using Compensatory Reserve Index in Patients Undergoing Cesarean Delivery

BACKGROUND

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. Early recognition and management are imperative for improved outcomes. The compensatory reserve index (CRI) is a novel physiological parameter that trends changes in intravascular volume, by continuously comparing extracted photoplethysmogram waveforms to a reference model that was derived from a human model of acute blood loss. This study sought to determine whether the CRI pattern was differential between those who do and do not experience PPH during cesarean delivery and compare these results to the American Society of Anesthesiologists (ASA) standards for noninvasive monitoring.

METHODS

Parturients undergoing cesarean delivery were enrolled between February 2020 and May 2021. A noninvasive CRI monitor was applied to collect continuous CRI values throughout the intraoperative and immediate postpartum periods. Patients were stratified based on blood loss into PPH versus non-PPH groups. PPH was defined as a quantitative blood loss >1000 mL. Function-on-scalar (FoS) regression was used to compare trends in CRI between groups (PPH versus non-PPH) during the 10 to 60-minute window after delivery. Two subanalyses excluding patients who received general anesthesia and preeclamptics were performed.

RESULTS

Fifty-one patients were enrolled in the study. Thirteen (25.5%) patients experienced PPH. Pregnant patients who experienced PPH had, on average, lower postdelivery CRI values (-0.13; 95% CI, -0.13 to -0.12; P < .001) than those who did not experience PPH. This persisted even when adjusting for preeclampsia and administration of uterotonics. The average mean arterial pressure (MAP) measurements were not statistically significant (-1.67; 95% CI, -3.57 to 0.22; P = .09). Similar trends were seen when excluding patients who underwent general anesthesia. When excluding preeclamptics, CRI values remained lower in those who hemorrhaged (-0.18; 95% CI, -0.19 to -0.17; P < .001).

CONCLUSIONS

CRI detects changes in central volume status not distinguished by MAP. It has the potential to serve as a continuous, informative metric, notifying providers of acute changes in central volume status due to PPH during cesarean delivery.

What do we know about why women bleed and what do we not know?

Women or people with a uterus are vulnerable to both normal and abnormal bleeding. During the reproductive years, the uterus is prepared physiologically to accept an embryo and support its growth and development during pregnancy, or in the absence of implantation of an embryo, recycle through the process of menstruation and accept an embryo a month or so later. If fertilization takes place and an embryo or embryos implant in the uterus, the fetal trophoblast, or outer cell layer of the embryo, invades and dilates the maternal spiral arteries and forms the placenta. No matter when in gestation a pregnancy ends, at the conclusion of pregnancy, the placenta should separate from the wall of the uterus and be expelled. Abnormal bleeding occurs during pregnancy or after delivery when the normal uteroplacental interface has not been established or is interrupted; during miscarriage; during ectopic pregnancy; during premature separation of the placenta; or during postpartum hemorrhage. Heavy menstrual bleeding, a subset of abnormal menstrual bleeding, can be quantitatively defined as >80 mL of blood loss per cycle. Unlike postpartum hemorrhage, heavy menstrual bleeding is significantly associated with an underlying bleeding disorder. While there is other reproductive tract bleeding in women, notably bleeding at the time of ovulation or with a life-threatening ruptured ectopic pregnancy, the unique bleeding that women experience is predominantly uterine in origin. Many of the unique aspects of uterine hemostasis, however, remain unknown.

Quality assessment of mobile applications on postpartum hemorrhage management

OBJECTIVE

To assess mobile application quality on the management of postpartum hemorrhage available in the digital stores of the main operating systems.

METHOD

A descriptive evaluative study, carried out from January to February 2023 on the App Store® and Google Play Store®. The Mobile Application Rating Scale was used to assess quality (engagement, functionality, aesthetics, information and subjective quality). Information extraction and assessment on postpartum hemorrhage was carried out using a table with information based on official documents, containing stratification, prevention, diagnosis and treatment.

RESULTS

Seven applications were included; of these, three were in English, six had an Android operating system. The quality mean was 3.88. The highest means were for functionality, reaching 5.0 (n = 6), and the lowest were for engagement, less than 3.0 (n = 4). The majority of applications presented less than 50% of the information on postpartum hemorrhage management.

CONCLUSION

The applications assessed achieved an acceptable quality mean and, according to health organizations' current protocols, did not contain the necessary information for complete postpartum hemorrhage management.

Abnormal obstetric shock index and associated factors among immediate postpartum women following vaginal delivery at a tertiary hospital in southwestern Uganda

BACKGROUND

Early recognition of haemodynamic instability after birth and prompt interventions are necessary to reduce adverse maternal outcomes due to postpartum haemorrhage. Obstetric shock Index (OSI) has been recommended as a simple, accurate, reliable, and low-cost early diagnostic measure that identifies hemodynamically unstable women.

OBJECTIVES

We determined the prevalence of abnormal obstetric shock index and associated factors among women in the immediate postpartum period following vaginal delivery at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda.

METHODS

We conducted a cross-sectional study at the labour suite and postnatal ward of MRRH from January 2022 to April 2022. We systematically sampled women who had delivered vaginally, and measured their blood pressures and pulse rates at 1 h postpartum. We excluded mothers with hypertensive disorders of pregnancy. Sociodemographic, medical and obstetric data were obtained through interviewer-administered questionnaires. The prevalence of abnormal OSI was the proportion of participants with an OSI ≥ 0.9 (calculated as the pulse rate divided by the systolic BP). Logistic regression analysis was used to determine associations between abnormal OSI and independent variables.

RESULTS

We enrolled 427 women with a mean age of 25.66 ± 5.30 years. Of these, 83 (19.44%), 95% CI (15.79-23.52) had an abnormal obstetric shock index. Being referred [aPR 1.94, 95% CI (1.31-2.88), p = 0.001], having had antepartum haemorrhage [aPR 2.63, 95% CI (1.26-5.73), p = 0.010] and having a visually estimated blood loss > 200 mls [aPR 1.59, 95% CI (1.08-2.33), p = 0.018] were significantly associated with abnormal OSI.

CONCLUSION

Approximately one in every five women who delivered vaginally at MRRH during the study period had an abnormal OSI. We recommend that clinicians have a high index of suspicion for haemodynamic instability among women in the immediate postpartum period. Mothers who are referred in from other facilities, those that get antepartum haemorrhage and those with estimated blood loss > 200mls should be prioritized for close monitoring. It should be noted that the study was not powered to study the factors associated with AOSI and therefore the analysis for factors associated should be considered exploratory.

Society for Maternal-Fetal Medicine Special Statement: Emergency checklist, planning worksheet, and system preparedness bundle for placenta accreta spectrum

Placenta accreta spectrum is a life-threatening complication of pregnancy that is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, massive transfusion, surgical injury, multisystem organ failure, and even death. Given the rarity and complexity, most obstetrical hospitals and providers do not have comprehensive expertise in the diagnosis and management of placenta accreta spectrum. Emergency management, antenatal interdisciplinary planning, and system preparedness are key pillars of care for this life-threatening disorder. We present an updated sample checklist for emergent and unplanned cases, an antenatal planning worksheet for known or suspected cases, and a bundle of activities to improve system and team preparedness for placenta accreta spectrum.

Implementing E-MOTIVE for detection and treatment of postpartum haemorrhage in South Africa

Postpartum haemorrhage is the leading cause of preventable maternal mortality in South Africa. In a significant breakthrough in the management of PPH, the E-MOTIVE trial found that a multifaceted health service intervention reduced severe PPH after vaginal delivery by 60% in 78 hospitals in Nigeria, Kenya, Tanzania and SA. The E-MOTIVE approach comprises objective blood loss measurement monitored every 15 minutes during the first hour after delivery to detect PPH early and trigger a bundle of first-line treatments, including massaging the uterus, oxytocin infusion, tranexamic acid infusion, intravenous crystalloid fluids, examination for the cause, emptying the bladder and, if necessary, escalation of care. E-MOTIVE was integrated into the existing Essential Steps in Managing Obstetric Emergencies algorithm. Certain research-related elements of the trial setting cannot be replicated in routine practice. Therefore, we need to develop local strategies to ensure the essential clinical elements of the intervention are implemented. Potential strategies include incorporating the E-MOTIVE principles into national guidelines, ongoing training strategies and ensuring all facilities are equipped with necessary medication, equipment and delegations. This breakthrough intervention provides hope for women in SA, and requires a purposeful, co-ordinated implementation strategy on a national scale to reach all levels of the health service.

Tranexamic acid by the intramuscular or intravenous route for the prevention of postpartum haemorrhage in women at increased risk: a randomised placebo-controlled trial (I'M WOMAN)

BACKGROUND

Postpartum haemorrhage (PPH) causes about 70,000 maternal deaths every year. Tranexamic acid (TXA) is a life-saving treatment for women with PPH. Intravenous (IV) TXA reduces deaths due to PPH by one-third when given within 3 h of childbirth. Because TXA is more effective when given early and PPH usually occurs soon after childbirth, giving TXA just before childbirth might prevent PPH. Although several randomised trials have examined TXA for PPH prevention, the results are inconclusive. Because PPH only affects a small proportion of births, we need good evidence on the balance of benefits and harms before using TXA to prevent PPH. TXA is usually given by slow IV injection. However, recent research shows that TXA is well tolerated and rapidly absorbed after intramuscular (IM) injection, achieving therapeutic blood levels within minutes of injection.

METHODS

The I'M WOMAN trial is an international, multicentre, three-arm, randomised, double-blind, placebo-controlled trial to assess the effects of IM and IV TXA for the prevention of PPH in women with one or more risk factors for PPH giving birth vaginally or by caesarean section.

DISCUSSION

The trial will provide evidence of the benefits and harms of TXA for PPH prevention and the effects of the IM and IV routes of administration. The IM route should be as effective as the IV route for preventing bleeding. There may be fewer side effects with IM TXA because peak blood concentrations are lower than with the IV route. IM TXA also has practical advantages as it is quicker and simpler to administer. By avoiding the need for IV line insertion and a slow IV injection, IM administration would free up overstretched midwives and doctors to focus on looking after the mother and baby and expand access to timely TXA treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05562609. Registered on 3 October 2022. ISRCTN Registry ISRCTN12590098. Registered on 20 January 2023. Pan African Clinical Trial Registry PACTR202305473136570. Registered on 18 May 2023.

Detection of postpartum uterine activity with electrohysterography

OBJECTIVE

Uterine contractions are essential for childbirth, but also for expulsion of the placenta and for limiting postpartum blood loss. Postpartum hemorrhage is associated with almost 25% of the maternal deaths worldwide and the leading cause of maternal death in most low-income countries. Little is known about the physiology of the uterus postpartum, particularly due to the lack of an accurate measurement tool. The primary objective of this pilot study is to explore the potential of using electrohysterography to detect postpartum uterine contractions. If postpartum uterine activity can be objectified, this could contribute to understanding the physiology of the uterus and improve diagnosis and treatment of postpartum hemorrhage.

STUDY DESIGN

In this observational study we included women aiming for a vaginal birth in two large maternity clinics in the Netherlands, Amphia Hospital Breda (group A, N2018-0161) and Máxima Medical Center Veldhoven (group B, N17.149). An electrode patch was placed on the maternal abdomen to record real-time electrical uterine activity until one hour postpartum continuously. In group A, the placement of the patch was lower than in group B. For analysis, tracings were divided into five different phases (1: dilatation until start pushing, 2: from start pushing until childbirth, 3: from childbirth until placental expulsion, 4: first hour after placental expulsion and 5: after one hour postpartum). Readability, signal quality and contraction frequency per hour were assessed. Additionally, patient satisfaction was evaluated through a survey.

RESULTS

In total 91 pregnant women were included of whom 45 in group A and 46 women in group B. Complete registrations were obtained throughout the five labor phases with very little artefacts or signal loss. The readability of the tracings decreased after childbirth. A significantly better readability was found in tracings where the patch placement was lower on the abdomen for phases 4 and 5. Contraction frequency was highest during phase 2 and decreased towards phase 5. Women rated the satisfaction with electrohysterography as high and mostly did not notice the patch.

CONCLUSION

It is possible to detect uterine activity postpartum with electrohysterography. Further investigation is recommended to improve diagnosis and treatment of postpartum hemorrhage.

Postpartum hemorrhage in Sub-Saharan Africa-a prospective study in metropolitan Mozambique

BACKGROUND

Estimates indicate approximately ≈500 to 1000 maternal deaths per 100,000 live births in Sub-Saharan Africa (SSA) (vs ≈5-20 in developed countries). Postpartum hemorrhage (PPH) seems a major contributor to maternal mortality (MM), but there are no comprehensive data for the region.

OBJECTIVES

Analyze MM, PPH, and associated risk factors.

METHODS

We collected prospective data on MM, PPH, and associated risk factors in metropolitan Mozambique. We recorded consecutive deliveries at the Maputo Central Hospital between February 2019 and January 2021. Data included age, HIV status, parity, delivery mode, notes, vital signs, laboratory values, and fetal parameters. PPH was determined by charted diagnosis, blood loss of >500 mL, transfusion, and/or notes indicating significant bleeding.

RESULTS

Of 8799 deliveries, ≈40% occurred in women residing outside Maputo City ("nonlocal"), with similar demographic characteristics between local and nonlocal women. However, compared with local women, nonlocal women had worse outcomes, including higher rates of MM (1.52% vs 0.78%; P =.0012) and PPH (16.51% vs 12.39%; P <.0001), whereby PPH was strongly associated with MM (adjusted odds ratio = 5.56; P <.0001). Almost all women with uterine atony (≈1%) experienced PPH. For women receiving laboratory tests on admission (drawn only if in distress; local, n = 561; nonlocal, n = 514), both cohorts revealed similar distributions of hemoglobin levels and platelet counts. Prepartum anemia (≈57%) and thrombocytopenia (≈21%) were prominent risk factors for PPH; risk increased with increasing severity and was additive in the presence of both.

CONCLUSIONS

PPH is a serious problem in Maputo province, a metropolitan area of SSA, portending high MM. Identification of correctable risk factors, including anemia, should catalyze the development of region-specific prevention protocols.

Unscarred uterine rupture with catastrophic hemorrhage immediately after vaginal delivery: diagnosis and management of six consecutive cases

BACKGROUND

To describe and explore the risk factors, clinical presentations, timely diagnostic approaches, and management in patients experiencing unscarred uterine rupture with catastrophic hemorrhage.

METHODS

We retrospectively analyzed clinical and imaging data from women who encountered postpartum hemorrhage (PPH) and were diagnosed with unscarred uterine rupture within a three-year timeframe (2018-2020). The data were extracted from medical records obtained from a multi-hospital 24-hour emergency PPH transfer system.

RESULTS

Six patients were identified as having unscarred uterine rupture after vaginal delivery. All six women were para 2, with four of them undergoing vacuum-assisted delivery. One patient experienced out-of-hospital cardiac arrest (OHCA), while five patients presented with hypovolemic shock. Abdominopelvic ultrasound revealed a boggy lower uterine segment. Initially, five patients underwent transarterial embolization (TAE) of the internal iliac arteries in an attempt to achieve hemostasis, but this approach proved unsuccessful. Abdominopelvic computed tomography (CT) confirmed the diagnosis of ruptured uterus by demonstrating disrupted myometrium and hemoperitoneum. Immediate exploratory laparotomy followed by life-saving hysterectomy was performed in all cases. The median estimated total blood loss was 2725 mL ± 900 mL (ranging from 1600 mL to 7100 mL). Lower segment lacerations were observed in all patients, with more extensive uterine damage noted in those who underwent vacuum extraction. The length of hospital stay varied between 9 and 38 days.

CONCLUSION

Instrument-assisted obstetric delivery is a possible contributing factor to unscarred uterine rupture in our study. In specific cases, the use of abdominopelvic CT prior to initiating transarterial embolization (TAE) offers valuable information to complement ultrasound findings. This comprehensive approach helps in accurately identifying the underlying cause of intractable postpartum hemorrhage (PPH). Immediate conversion to laparotomy is essential to explore the intra-abdominal factors causing PPH that cannot be controlled by TAE. The rational etiologies of uterine rupture must be clarified while generating practical guideline in the future.

Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis

BACKGROUND

Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries.

OBJECTIVES

Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings.

SEARCH METHODS

We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers.

DATA COLLECTION AND ANALYSIS

We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice.

MAIN RESULTS

We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence).

AUTHORS' CONCLUSIONS

Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.

Women with severe postpartum hemorrhage have a decreased endogenous thrombin potential before delivery

BACKGROUND

Severe postpartum hemorrhage (PPH), defined as a blood loss ≥1000 mL, is associated with maternal morbidity and mortality.

OBJECTIVES

We aimed at characterizing coagulation properties of predelivery plasmas from pregnant women with thrombin generation assay and hemostatic biomarkers (plasminogen activator inhibitor-1, tissue factor [TF], and thrombomodulin).

METHODS

A nested case-control study was conducted within the "Study of Biological Determinants of Bleeding Postpartum," a French prospective cohort study, in order to compare women with severe PPH (cases) and controls matched for age, body mass index, term, and mode of delivery. Plasma was collected at entry in the delivery room, and blood loss was measured objectively. The predelivery endogenous thrombin generation potential (ETP) was measured in plasma using calibrated automated thrombinography and low TF concentration. Hemostatic biomarkers were measured using ELISA kits.

RESULTS

A total of 142 women (71 cases and 71 controls) were investigated. There was no difference in the median lag phase, thrombin peak, and time to peak between cases and controls. However, median predelivery ETP was lower in cases than in controls (2170 vs 2408 nM.min, P < .0001), independently of mode of delivery and PPH etiology. Median plasminogen activator inhibitor-1 and TF levels were higher in cases compared with controls (107.4 vs 68.1 ng/mL, P = .0003; 34.4 vs 27.4 pg/mL, P = .007), whereas thrombomodulin levels did not differ between the 2 groups.

CONCLUSION

Among thrombin generation assay parameters, predelivery ETP levels may have a predictive value for severe PPH.

The AccuFlow sensor: a novel digital health tool to assess intrapartum blood loss at cesarean delivery

OBJECTIVES

During obstetric hemorrhage, peripheral vasoconstriction maintains heart rate and blood pressure until compensatory mechanisms are overwhelmed and patients deteriorate rapidly. Real-time perfusion measurements could quantify vasoconstriction, improving early recognition of hemorrhage and facilitating early intervention to reduce morbidity and mortality. The AccuFlow device makes rapid, non-invasive, quantitative measurements of perfusion, but has not been studied for hemorrhage detection or used in surgical settings. This study evaluated feasibility, tolerability, and preliminary efficacy of the AccuFlow for assessment of blood loss at cesarean delivery (CD).

METHODS

In this pilot study, sensors were applied to the wrist, forearm, bicep, and chest wall of 25 patients undergoing scheduled CD. Postoperatively, sensors were removed and patients rated the AccuFlow and the standard anesthesia monitoring equipment on a validated comfort rating scale for wearable computers (CRS). Blood loss was estimated by the surgical team (EBL) and calculated from change in hematocrit, weight, and height (CBL). CRS scores were compared via Wilcoxon signed ranks tests. Coefficients of correlation between sensor readings and CBL, and between EBL and CBL, were compared using Fisher's R-to-z transformation.

RESULTS

There were no safety events; no participants requested device removal. CRS ratings of the AccuFlow and the standard monitoring equipment were similar (7.2 vs. 8.8, p=0.25). Change in wrist perfusion from delivery to dressing placement was more strongly correlated with CBL than was EBL (R=-0.48 vs. R=0.087, p=0.03).

CONCLUSIONS

The AccuFlow sensor is well-tolerated and shows promise in detecting intrapartum hemorrhage, though larger studies are needed.

Hemostatic biomarkers associated with postpartum hemorrhage: a systematic review and meta-analysis

Postpartum hemorrhage (PPH) is a leading cause of maternal morbi-mortality. Although obstetric risk factors are well described, the impact of predelivery hematologic and hemostatic biomarkers remains incompletely understood. In this systematic review, we aimed to summarize the available literature on the association between predelivery hemostatic biomarkers and PPH/severe PPH. Searching MEDLINE, EMBASE, and CENTRAL databases from inception to October 2022, we included observational studies on unselected pregnant women without bleeding disorder reporting on PPH and on predelivery hemostatic biomarkers. Two review authors independently performed title, abstract and full-text screening, upon which quantitative syntheses of studies reporting on the same hemostatic biomarker were conducted, calculating the mean difference (MD) between women with PPH/severe PPH and controls. A search on 18 October 2022 yielded 81 articles fitting our inclusion criteria. The heterogeneity between studies was considerable. With regard to PPH, the estimated average MD in the investigated biomarkers (platelets, fibrinogen, hemoglobin, Ddimer, activated partial thromboplastin time, and prothrombin time) were not statistically significant. Women who developed severe PPH had lower predelivery platelets than controls (MD = -26.0 109/L; 95% confidence interval, -35.8 to -16.1), whereas differences in predelivery fibrinogen concentration (MD = -0.31 g/L; 95% confidence interval, -0.75 to 0.13) and levels of factor XIII or hemoglobin were not statistically significant in women with and without severe PPH. Predelivery platelet counts were, on average, lower in women with severe PPH compared with controls, suggesting the potential usefulness of this biomarker for predicting severe PPH. This trial was registered at the International Prospective Register of Systematic Reviews as CRD42022368075.

[Evolution of the obstetrical Shock Index in postpartum haemorrhage according to the use of sulprostone]

OBJECTIVES

The Shock Index (SI) is used in emergency medicine to assess the severity of active bleeding and in the postpartum context for postpartum haemorrhage (PPH). We investigated the diagnostic value of haemodynamic parameters (SI, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP)) in predicting subsequent use of uterotonic sulprostone treatment.

METHODS

This was a retrospective study including parturients with PPH ≥ 500mL between January 2017 and December 2018. Hemodynamic parameters at the diagnosis of PPH were compared according to whether the patient required subsequent sulprostone treatment (sulprostone(+) group) or not (sulprostone(-) group).

RESULTS

We included in the analysis 147 patients. The SI was significantly higher in the sulprostone(+) group (0.92±0.28 vs. 0.83±0.22; p=0.04). The SBP (107.2±17.5 vs. 113.8±17.7mmHg; p=0.03), DBP (56.8±12,2 vs. 61.5±13,2mmHg; p=0.04), MAP (73.6±12.6 vs. 78.5±13.4mmHg; p=0.03) were significantly lower in the same group. No difference between AUC of these parameters to predict the use of sulprostone was found (AUC between 0.59 and 0.61). No significant difference was found for the HR between the two groups.

CONCLUSION

The diagnostic value of SI appeared to be low and similar to other haemodynamic parameters in predicting the use of sulprostone.

[Postpartum Hemorrhage]

Postpartum hemorrhage (PPH) affects about 4% of all deliveries in high-income countries and continues to rise, a trend attributable to the increase in caesarean section rates and maternal morbidity. Preventive measures such as the precautionary administration of uterotonics effectively reduce the risk of severe bleeding irrespective of birth mode. As a time-critical condition and a significant contributor to adverse maternal outcomes, PPH needs to be diagnosed early by measuring, not estimating, blood losses. Institutional treatment algorithms should be available to guide stage-based interdisciplinary management without delay. The main therapy goals are to identify the etiology and stop the bleeding by using uterotonics and mechanical and surgical interventions, to restore hemodynamic stability by volume and transfusion therapy and to optimize hemostasis by laboratory- and viscoelastic assay-guided factor replacement. This review highlights current recommendations for prevention, diagnosis and treatment of PPH.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Comparison of quantitative and calculated postpartum blood loss after vaginal delivery

BACKGROUND

Because there is no consensus on the method of assessing postpartum blood loss, the comparability and relevance of the postpartum hemorrhage-related literature are questionable. Quantitative blood loss assessment using a volumetric technique with a graduated collector bag has been proposed to overcome limitations of intervention-based outcomes but remains partly subjective and potentially biased by amniotic fluid or missed out-of-bag losses. Calculated blood loss based on laboratory parameters has been studied and used as an objective method expected to reflect total blood loss. However, few studies have compared quantitative with calculated blood loss.

OBJECTIVE

This study aimed to compare the distribution of postpartum blood loss after vaginal delivery assessed by 2 methods-quantitative and calculated blood loss-and the incidence of abnormal blood loss with each method.

STUDY DESIGN

Data were obtained from the merged database of 3 multicenter, randomized controlled trials, all testing different interventions to prevent postpartum blood loss in individuals with a singleton live fetus at ≥35 weeks of gestation, born vaginally. All 3 trials measured blood loss volume by using a graduated collector bag. Hematocrit was measured in the eighth or ninth month of gestation and on day 2 postpartum. The 2 primary outcomes were: quantitative blood loss, defined by the total volume of blood loss measured in a graduated collector bag, and calculated blood loss, mathematically defined from the peripartum hematocrit change (estimated blood volume × [(antepartum hematocrit-postpartum hematocrit)/antepartum hematocrit], where estimated blood volume [mL]=booking weight [kg] × 85). We modeled the association between positive quantitative blood loss and positive calculated blood loss with polynomial regression and calculated the Spearman correlation coefficient.

RESULTS

Among the 8341 individuals included in this analysis, the median quantitative blood loss (100 mL; interquartile range, 50-275) was significantly lower than the median calculated blood loss (260 mL; interquartile range, 0-630) (P<.05). The incidence of abnormal blood loss was lower with quantitative blood loss than calculated blood loss for all 3 thresholds: for ≥500 mL, it was 9.6% (799/8341) and 32.3% (2691/8341), respectively; for ≥1000 mL, 2.1% (176/8341) and 11.5% (959/8341); and for ≥2000 mL, 0.1% (10/8341) and 1.4% (117/8341) (P<.05). Quantitative blood loss and calculated blood loss were significantly but moderately correlated (Spearman coefficient=0.44; P<.05). The association between them was not linear, and their difference tended to increase with blood loss. Negative calculated blood loss values occurred in 23% (1958/8341) of individuals; among them, >99% (1939/1958) had quantitative blood loss ≤500 mL.

CONCLUSION

Quantitative and calculated blood loss were significantly but moderately correlated after vaginal delivery. However, clinicians should be aware that quantitative blood loss is lower than calculated blood loss, with a difference that tended to rise as blood loss increased.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage

BACKGROUND

Delays in the detection or treatment of postpartum hemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and early diagnosis of postpartum hemorrhage, and delayed or inconsistent use of effective interventions may be able to be addressed by a treatment bundle.

METHODS

We conducted an international, cluster-randomized trial to assess a multicomponent clinical intervention for postpartum hemorrhage in patients having vaginal delivery. The intervention included a calibrated blood-collection drape for early detection of postpartum hemorrhage and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation), supported by an implementation strategy (intervention group). Hospitals in the control group provided usual care. The primary outcome was a composite of severe postpartum hemorrhage (blood loss, ≥1000 ml), laparotomy for bleeding, or maternal death from bleeding. Key secondary implementation outcomes were the detection of postpartum hemorrhage and adherence to the treatment bundle.

RESULTS

A total of 80 secondary-level hospitals across Kenya, Nigeria, South Africa, and Tanzania, in which 210,132 patients underwent vaginal delivery, were randomly assigned to the intervention group or the usual-care group. Among hospitals and patients with data, a primary-outcome event occurred in 1.6% of the patients in the intervention group, as compared with 4.3% of those in the usual-care group (risk ratio, 0.40; 95% confidence interval [CI], 0.32 to 0.50; P<0.001). Postpartum hemorrhage was detected in 93.1% of the patients in the intervention group and in 51.1% of those in the usual-care group (rate ratio, 1.58; 95% CI, 1.41 to 1.76), and the treatment bundle was used in 91.2% and 19.4%, respectively (rate ratio, 4.94; 95% CI, 3.88 to 6.28).

CONCLUSIONS

Early detection of postpartum hemorrhage and use of bundled treatment led to a lower risk of the primary outcome, a composite of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding, than usual care among patients having vaginal delivery. (Funded by the Bill and Melinda Gates Foundation; E-MOTIVE ClinicalTrials.gov number, NCT04341662.).

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Placenta Accreta Spectrum and Postpartum Hemorrhage

Placenta accreta spectrum is a group of disorders involving abnormal trophoblastic invasion to the deep layers of endometrium and myometrium. Placenta accrete spectrum is one of the major causes of severe maternal morbidity, with increasing incidence in the past decade mainly secondary to an increase in cesarean deliveries. Severity varies depending on the depth of invasion, with the most severe form, known as percreta, invading uterine serosa or surrounding pelvic organs. Diagnosis is usually achieved by ultrasound, and MRI is sometimes used to assess invasion. Management usually involves a hysterectomy at the time of delivery. Other strategies include delayed hysterectomy or expectant management.

Maternal Coagulation Disorders and Postpartum Hemorrhage

Coagulation disorders are rare causes of postpartum hemorrhage. Disturbances in coagulation should be suspected in patients with a family history of coagulopathy, those with a personal history of heavy menstrual bleeding, and those with persistent bleeding despite correction of other causes. The coagulopathic conditions discussed include disseminated intravascular coagulation, platelet disorders, and disturbances of coagulation factors. These should not be overlooked in the evaluation of obstetric hemorrhage, as diagnosis and appropriate treatment may prevent severe maternal morbidity and mortality.

Evaluation During Postpartum Hemorrhage

Postpartum hemorrhage is an obstetric emergency that is the leading and the most preventable cause of maternal death that occurs on the day of birth. The treatment of postpartum hemorrhage in a timely fashion is crucial to prevent morbidity and mortality. The accurate assessment of blood loss during delivery and the postpartum period remains a major challenge. Hence, it is imperative to have a standardized evaluation strategy for accurate assessment of blood loss, adequate classification of hemorrhage, and timely initiated interventions. The multidisciplinary evaluation strategy should be in place regardless of the delivery route.

Coagulation management and transfusion in massive postpartum hemorrhage

PURPOSE OF REVIEW

Excessive bleeding during and following childbirth remains one of the leading causes of maternal mortality.

RECENT FINDINGS

Current guidelines differ in definitions and recommendations on managing transfusion and hemostasis in massive postpartum hemorrhage (PPH). Insights gained from trauma-induced coagulopathy are not directly transferable to the obstetric population due to gestational alterations and a differing pathophysiology.

SUMMARY

Factor deficiency is uncommon at the beginning of most etiologies of PPH but will eventually develop from consumption and depletion in the absence of bleeding control. The sensitivity of point-of-care tests for fibrinolysis is too low and may delay treatment, therefore tranexamic acid should be started early at diagnosis even without signs for hyperfibrinolysis. Transfusion management may be initiated empirically, but is best to be guided by laboratory and viscoelastic assay results as soon as possible. Hypofibrinogenemia is well detected by point-of-care tests, thus substitution may be tailored to individual needs, while reliable thresholds for fresh frozen plasma (FFP) and specific components are yet to be defined. In case of factor deficiency, prothrombin complex concentrate or lyophilized plasma allow for a more rapid restoration of coagulation than FFP. If bleeding and hemostasis are under control, a timely anticoagulation may be necessary.

Interventions of Postpartum Hemorrhage

Postpartum hemorrhage is a common and potentially life-threatening obstetric complication, with successful management relying heavily on early identification of hemorrhage and prompt intervention. This article will review the management of postpartum hemorrhage, including initial steps, exam-specific interventions, medical therapy, minimally invasive, and surgical interventions.

Racial disparities in care escalation for postpartum hemorrhage requiring transfusion

BACKGROUND

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality in the United States and disproportionately affects pregnant persons of color.

OBJECTIVE

This study aimed to identify the demographic and obstetrical characteristics of those who received different levels of antihemorrhagic intervention in the setting of severe postpartum hemorrhage requiring blood transfusion.

STUDY DESIGN

This was a retrospective cohort study of patients with documented postpartum hemorrhage (estimated blood loss of ≥1000 mL) and blood product transfusion. Moreover, 3 levels of antihemorrhagic intervention were defined as follows: level 1, administration of uterotonics only; level 2, performance of a procedure (ie, B-Lynch suture, O'Leary stitch, Bakri balloon, dilation and curettage, laceration repair, or embolization); and level 3, hysterectomy. Maternal demographics, obstetrical characteristics, and comorbidities were extracted from electronic health records. Ordinal logistic regression was used to estimate the odds of higher intervention levels adjusting for maternal demographic and obstetrical characteristics.

RESULTS

Of note, 365 patients were included in this study, with a racial or ethnic composition of 30% White, 42% Black, 18% Hispanic, and 10% other. Moreover, 233 patients (64%) received level 1 intervention, 98 patients (27%) received level 2 intervention, and 34 patients (9%) received level 3 intervention. Patients receiving higher levels of intervention were more likely to have greater estimated blood loss (P<.001), have more transfusions (P<.001), and be of advanced maternal age (P=.004). Black and Hispanic patients were less likely to have received higher levels of intervention than White patients (P=.034). After adjusting for estimated blood loss, advanced maternal age, placenta accreta spectrum, and fibroids, Black patients remained significantly less likely to receive higher levels of intervention (adjusted odds ratio, 0.55; 95% confidence interval, 0.30-0.98). This difference persisted at an estimated blood loss of ≥3000 mL, with Black and Hispanic patients being significantly less likely to receive higher levels of intervention than White patients (odds ratio, 0.31 [95% confidence interval, 0.10-0.92] and 0.10 [95% confidence interval, 0.01-0.53], respectively).

CONCLUSION

Among patients experiencing postpartum hemorrhage and receiving transfusion, Black patients are less likely to receive higher levels of antihemorrhagic intervention. This disparity is concerning in this high-risk population and requires further attention and investigation.

Review of clinical practice guidelines for postpartum hemorrhage according to AGREE II

BACKGROUND

Clinical practice guidelines for postpartum hemorrhage (PPH) are available worldwide, but no review has assessed the quality of these guidelines. Poor-quality guidelines for PPH may lead clinicians to follow incorrect approaches.

OBJECTIVES

High-quality guidelines for PPH are important in guiding the clinical diagnosis and treatment of PPH and decreasing maternal mortality. The aim of this study was to assess the quality of clinical guidelines for PPH.

METHODS

We collected studies from different countries through a literature search including PubMed (MEDLINE), Web of Science, the Cochrane library, websites of health institutions from multiple countries, and search sites, according to the criterion of clinical guidelines for treatment of PPH published between inception and October 2022. Four independent reviewers assessed the eligible guidelines by using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Agreement among reviewers of the guidelines was measured with the intra-class correlation coefficient (ICC). The number of recommendations, strength of recommendations, and level of evidence were determined.

RESULTS

Seven sets of PPH guidelines published from 2007 to 2022 were identified. An overall high agreement among reviewers in each domain was observed (ICC 0.74 to 0.95). The median scores and ranges for each AGREE II domain were as follows: (i) scope and purpose (median = 86.51%, range: 61.11%-94.44%); (ii) stakeholder involvement (median = 73.02%, range: 52.78%-90.28%); (iii) rigor of development (median = 76.49%, range: 66.15%-97.92%); (iv) clarity and presentation (median = 88.49%, range: 68.06%-100.00%); (v) applicability (median = 73.36%, range: 53.13%-93.75%); and (vi) editorial independence (median = 84.52%, range: 60.42%-95.83%). Three sets of PPH guidelines scored high in all domains and were classified as recommended for clinical practice. The other guidelines were classified as recommended with modifications.

CONCLUSION

The methodological and reporting quality of the guidelines for PPH included in this review was generally good, but the strength of the recommendations and the quality of the evidence varied, thus potentially leading to confusion among clinicians applying the guidelines. An urgent need exists for rigorous studies to close important evidence gaps to support the development of guidelines for PPH.

Tranexamic Acid in the Prevention and Treatment of Postpartum Hemorrhage: A Review

Postpartum hemorrhage (PPH) continues to be one of the leading causes of maternal morbidity and mortality worldwide. The four main causes of PPH are uterine atony, lacerations, retained placenta, and bleeding diathesis. In the patient with PPH, immediate evaluation is needed to diagnose and treat the underlying cause of hemorrhage. Uterotonic agents such as oxytocin remain first line for prevention and treatment of uterine atony. Studies have evaluated the antifibrinolytic tranexamic acid (TXA) as an adjunctive therapy in the prevention and treatment of PPH. TXA has been shown to reduce blood loss, bleeding-associated mortality, and transfusion rates in a variety of clinical settings and thus may serve a role in treating PPH. Current studies have demonstrated that TXA is an effective treatment option with limited risk of adverse events in appropriately selected patients; however, additional studies are needed to further clarify the role of TXA in the prevention of PPH.

Machine learning approach to predict postpartum haemorrhage: a systematic review protocol

INTRODUCTION

Postpartum haemorrhage (PPH) is the most serious clinical problem of childbirth that contributes significantly to maternal mortality worldwide. This systematic review aims to identify predictors of PPH based on a machine learning (ML) approach.

METHODS AND ANALYSIS

This review adhered to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol. The review is scheduled to begin on 10 January 2023 and end on 20 March 2023. The main objective is to identify and summarise the predictive factors associated with PPH and propose an ML-based predictive algorithm. From inception to December 2022, a systematic search of the following electronic databases of peer-reviewed journal articles and online search records will be conducted: Cochrane Central Register, PubMed, EMBASE (via Ovid), Scopus, WOS, IEEE Xplore and the Google Scholar search engine. All studies that meet the following criteria will be considered: (1) they include the general population with a clear definition of the diagnosis of PPH; (2) they include ML models for predicting PPH with a clear description of the ML models; and (3) they demonstrate the performance of the ML models with metrics, including area under the receiver operating characteristic curve, accuracy, precision, sensitivity and specificity. Non-English language papers will be excluded. Data extraction will be performed independently by two investigators. The PROBAST, which includes a total of 20 signallings, will be used as a tool to assess the risk of bias and applicability of each included study.

ETHICS AND DISSEMINATION

Ethical approval is not required, as our review will include published and publicly accessible data. Findings from this review will be disseminated via publication in a peer-review journal.

PROSPERO REGISTRATION NUMBER

The protocol for this review was submitted at PROSPERO with ID number CRD42022354896.

Reproductive health and hemostatic issues in women and girls with congenital factor VII deficiency: A systematic review

BACKGROUND

Congenital factor VII (FVII) deficiency is an inherited bleeding disorder, with heterogenous bleeding symptoms. Women with FVII deficiency face hemostatic challenges during menstruation, ovulation, and childbirth. This systematic review evaluated prevalence and management of bleeding symptoms associated with gynecological and obstetric issues in women with FVII deficiency.

METHODS

Databases (BIOSIS Previews, Current Contents Search, Embase, and MEDLINE) were searched for studies reporting FVII deficiency and gynecological or obstetric issues in women. Articles were screened using Joanna Briggs Institute checklists and relevant data extracted.

RESULTS

One hundred fourteen women were identified from 62 publications. Forty-six women had severe deficiency (FVII:C < 5% or <5 IU/dl). Heavy menstrual bleeding (HMB) was the most common bleeding symptom (n = 94; 82%); hospitalization and urgent medical/surgical interventions for acute HMB episodes were required in 16 women (14%). Seven women reported ovarian bleeding (6%); other bleeding symptoms varied. Patient management was inconsistent and included hemostatic and hormonal treatments. Only four women (7%) reporting vaginal bleeding during pregnancy. Postpartum hemorrhage (PPH) occurred following 12/45 deliveries (27%; 5 [42%] requiring blood transfusion) and was not necessarily prevented by prophylaxis (8 women).

CONCLUSION

Women with congenital FVII deficiency have an increased risk of HMB, ovarian bleeding, and PPH, impacting quality of life. Recognition of a bleeding disorder as the cause is often delayed. Management of bleeding complications is heterogeneous due to lack of treatment guidelines. Harmonizing severity classification of FVII deficiency may help standardize treatment strategies and development of specific guidelines for these women.

Effect of implementation of a colorimetric quantitative blood loss system for postpartum hemorrhage

OBJECTIVE

To evaluate if the implementation of a colorimetric quantitative blood loss (QBL) system during cesarean delivery improves clinical outcomes.

METHODS

We conducted a retrospective cohort analysis after cesarean section before and after implementation of the Triton based colorimetric QBL system. Prevalence of postpartum hemorrhage, amount of blood products transfused, length of hospitalization, and rates of intensive care unit (ICU) admission were compared.

RESULTS

A total of 2221 patients were included. There were 1192 patients in the pre-intervention group and 1029 patients in the post-intervention group. There was no significant difference between groups in the prevalence of postpartum hemorrhage (8.6% vs 9.3%, P = 0.57), amount of packed red blood cells (pRBCs) transfused (45 vs 30, P = 0.41) or average length of hospital stay in days (3.0 vs 3.0, P = 0.37). There was a statistically significant decrease in ICU admissions between the pre- and post-intervention groups (2.2% vs 1.0%, P = 0.02).

CONCLUSION

There was no effect of implementation of the colorimetric QBL application system on diagnosis of postpartum hemorrhage, amount of blood products transfused, or length of hospital stay. Although a significant decrease in ICU admissions was observed, we could not determine if these transfers were hemorrhage related.

JTH in Clinic - Obstetric bleeding: VWD and other inherited bleeding disorders

Individuals with inherited bleeding disorders (IBDs) have higher bleeding risk during pregnancy, childbirth, and the postpartum period. Clinical management requires recognition of the IBD as high risk for postpartum hemorrhage and a personalized multidisciplinary approach that includes the patient in decision making. When the fetus is known or at risk to inherit a bleeding disorder, fetal and neonatal bleeding risk also need to be considered. In pregnant IBD patients, it is common for providers to need to make decisions in the absence of high level of certainty evidence. We here present the case of a pregnant von Willebrand disease patient that reached multiple decision points where there is currently clinical ambiguity due to a lack of high level of certainty evidence. For each stage of her care, from diagnosis to the postpartum period, we discuss current literature and describe our approach. This is followed by a brief overview of considerations in other IBDs and pregnancy.

Renal cyst mimicking hydronephrosis after uterine artery ligation for postpartum haemorrhage

BACKGROUND

The proximity of the uterus and the cervix to the urinary tract predisposes the latter to injury during obstetrical and gynaecological surgical procedures. Following a difficult surgical procedure on the lower uterine segment and or adnexa, urinary tract injury should be excluded.

METHODS

A booked 39-year-old G3P2 lady who suffered an ischaemic stroke in the index pregnancy had a caesarean delivery at 39 weeks of gestation and sustained an extensive tear that extended inferiorly on the left lateral aspect of the uterus and this resulted in postpartum haemorrhage. Following the repair of the tear, uterine artery ligation was performed to achieve haemostasis.

RESULTS

Postoperatively, conventional ultrasonography which was performed to exclude ureteric injury suggested left hydronephrosis and a preliminary report of computerized tomography (CT) showed the same finding. The patient subsequently had left ureteric stenting. The final report of the CT scan was delayed but showed a simple left renal cyst and no hydronephrosis.

CONCLUSION

Renal cyst is a differential diagnosis of hydronephrosis. Delayed availability of the final result of medical investigations jeopardises patients' safety. A preliminary imaging report is prone to error and its use to determine the indication for an invasive procedure should be limited to emergencies.

Scar Rupture in Early Puerperium: A Case Report

Uterine scar dehiscence or rupture is a rare but potentially life-threatening complication of caesarean delivery. It is the opening of the uterine incision line that can lead to postpartum haemorrhage, pelvic hematoma, pelvic abscess, endomyometritis, generalised or localised peritonitis and sepsis. Here we report a case of a 25 years old female who presented with puerperal pyrexia. Investigations revealed uterine scar rupture with a uterovesical collection. The case was managed conservatively with intravenous antibiotics, an intracervical Foley's catheter and a gonadotropin-releasing hormone agonist.