Society for Maternal-Fetal Medicine Special Statement: Checklist for initial management of amniotic fluid embolism

Amniotic fluid embolism is a rare syndrome characterized by sudden cardiorespiratory collapse during labor or soon after delivery. Because of its rarity, many obstetrical providers have no experience in managing amniotic fluid embolism and may therefore benefit from a cognitive aid such as a checklist. We present a sample checklist for the initial management of amniotic fluid embolism based on standard management guidelines. We also suggest steps that each facility can take to implement the checklist effectively.

Homelessness, housing instability, and abortion outcomes at an urban abortion clinic in the United States

BACKGROUND

Adverse reproductive health outcomes are well documented among people experiencing homelessness or housing instability. Little is known about abortion outcomes among this population.

OBJECTIVE

This study aimed to investigate the relationship between housing status and abortion outcomes and whether gestational age mediates this relationship.

STUDY DESIGN

Our sample comprised 1903 individuals who had abortions at an urban clinic in San Francisco, CA, from 2015 to 2017. We defined homelessness or housing instability as a binary exposure, which included staying outside, with friends and/or family, or in a tent, vehicle, shelter, transitional program, or hotel. We evaluated gestational duration of ≥20 weeks as a mediator variable. Our primary outcome was any abortion complication. Logistic regression models were adjusted for age, race, substance use, mental health diagnoses, and previous vaginal and cesarean deliveries.

RESULTS

Approximately 19% (n=356) of abortions were among people experiencing homelessness or housing instability. Compared with those with stable housing, people experiencing homelessness or housing instability presented later in pregnancy (mean gestational duration, 13.3 vs 9.5 weeks; P<.001) and had more frequent complications (6.5% vs 2.8%; P<.001; odds ratio, 2.2; 95% confidence interval, 1.2-3.9). Adjusting for race, substance use, mental health diagnoses, and previous cesarean deliveries, individuals experiencing homelessness or housing instability were more likely to have abortion complications (odds ratio, 2.3; 95% confidence interval, 1.3-4.0). However, the relationship was attenuated after adjusting for gestational duration (odds ratio, 1.4; 95% confidence interval, 0.7-2.6), suggesting that gestational duration mediates the relationship between housing status and abortion complications.

CONCLUSION

Patients experiencing homelessness or housing instability presented later in gestation, which seems to contribute to the increased frequency of abortion complications.

Excessive Primary Postpartum Hemorrhage

The diagnosis and treatment of excessive bleeding within the first 24 hours after delivery and its main causes, namely uterine atony, retained placental fragments, vascular lesions by local tissue rupture, and blood clotting disorder are presented. Of great interest is the iconography, which is suggestive and original.

Obstetric hemorrhage survey: Attitudes and practices of maternal-fetal medicine fellows

OBJECTIVE

To evaluate experiences related to obstetric hemorrhage and suspected abnormal placentation among first year maternal-fetal medicine fellows.

STUDY DESIGN

A cross-sectional anonymous survey was administered at the Society for Maternal-Fetal Medicine fellow retreat in March 2013. Fellows were asked about management strategies that reflected both their individual and institutional practices.

RESULTS

There was a 56% response rate (55/98). In cases of postpartum hemorrhage due to uterine atony, there was variable use of the uterine tamponade device. The median incremental time for balloon deflation was every 5 hours (IQR = 2-12). Compared to the east coast, fellows from the west coast performed more hysterectomies (mean±SD; 2.9±2.4 vs. 1.2±1.2, p = 0.004). During a peripartum hysterectomy, 29% of fellows used a handheld cautery device such as Ligasure® or Gyrus®. Fifty-six percent responded that their institution never recommend planned delayed hysterectomies for abnormal placental implantation.

CONCLUSION

There is wide variation in practice among first year maternal-fetal medicine fellows in management of peripartum hysterectomy and postpartum hemorrhage.

Intrauterine balloon tamponade for the control of postpartum haemorrhage

OBJECTIVE

To evaluate the effectiveness of balloon temponade in the management of postpartum haemorrhage.

METHODS

The study was conducted at the Dow University of Health Sciences and Civil Hospital Karachi from January to July 18, 2012, and comprised women aged 18-35 years, parity 1-6 and gestational age 31-41 weeks, who developed or were admitted with primary postpartum haemorrhage due to uterine atony in whom medical treatment had failed. SPSS 10 was used to analyse the data.

RESULTS

The mean age, parity, gestational age of 139 women was 26.4±4.2 years, 3.4±1.3, 37.81±1.67 respectively. Mean estimated blood loss was 1155.8±350.6 ml, mean systolic blood pressure 90.96±18.1 mmHg, diastolic blood pressure 55±7.5 mmHg and mean pulse was 108.3±10.89 bpm. Balloon tamponade was effective in 126(90.4%) cases.

CONCLUSIONS

Condom catheter balloon tamponade was an effective means of controlling postpartum haemorrhage. There should be a low threshold for use of balloon tamponade as it is effective, easy to use, easily available, has low complication rate, and an inexpensive modality to manage non-traumatic postpartum haemorrhage, especially in resource-limited settings, and still maintain reproductive ability.

Second-line uterotonics and the risk of hemorrhage-related morbidity

OBJECTIVE

Uterine atony is a leading cause of postpartum hemorrhage. Although most cases of postpartum hemorrhage respond to first-line therapy with uterine massage and oxytocin administration, second-line uterotonics including methylergonovine and carboprost are integral for the management of refractory uterine atony. Despite their ubiquitous use, it is uncertain whether the risk of hemorrhage-related morbidity differs in women exposed to methylergonovine or carboprost at cesarean delivery.

STUDY DESIGN

We performed a secondary analysis using the Maternal-Fetal Medicine Units Network Cesarean Registry. We identified women who underwent cesarean delivery and received either methylergonovine or carboprost for refractory uterine atony. The primary outcome was hemorrhage-related morbidity defined as intraoperative or postoperative red blood cell transfusion or the need for additional surgical interventions including uterine artery ligation, hypogastric artery ligation, or peripartum hysterectomy for atony. We compared the risk of hemorrhage-related morbidity in those exposed to methylergonovine vs carboprost. Propensity-score matching was used to account for potential confounders.

RESULTS

The study cohort comprised 1335 women; 870 (65.2%) women received methylergonovine and 465 (34.8%) women received carboprost. After accounting for potential confounders, the risk of hemorrhage-related morbidity was higher in the carboprost group than the methylergonovine group (relative risk, 1.7; 95% confidence interval, 1.2-2.6).

CONCLUSION

In this propensity score-matched analysis, methylergonovine was associated with reduced risk of hemorrhage-related morbidity during cesarean delivery compared to carboprost. Based on these results, methylergonovine may be a more effective second-line uterotonic.

Initial experience with a dual-balloon catheter for the management of postpartum hemorrhage

OBJECTIVE

When uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after delivery, tamponade of the uterus can be effective in decreasing hemorrhage secondary to uterine atony.

STUDY DESIGN

These data are from a postmarketing surveillance study of a novel dual-balloon catheter tamponade device, the Belfort-Dildy Obstetrical Tamponade System (ebb).

RESULTS

A total of 57 women were enrolled: 55 women had the diagnosis of postpartum hemorrhage, and 51 women had uterine balloon placement within the uterine cavity. This study reports the outcomes in the 51 women who had uterine balloon placement within the uterine cavity for treatment of postpartum hemorrhage, as defined by the "Instructions for Use." We further assessed 4 subgroups: uterine atony only (n = 28 women), placentation abnormalities (n = 8 women), both uterine atony and placentation abnormalities (n = 9 women), and neither uterine atony nor placentation abnormalities (n = 6 women). The median (range) time interval between delivery and balloon placement was 2.2 hours (0.3-210 hours) for the entire cohort (n = 51 women) and 1.3 hours (0.5-7.0 hours) for the uterine atony only group (n = 28 women). Bleeding decreased in 22/51 of cases (43%), stopped in 28/51 of cases (55%), thus decreased or stopped in 50/51 of the cases (98%) after balloon placement. Nearly one-half (23/51) of all women required uterine balloon volumes of >500 mL to control bleeding.

CONCLUSION

We conclude that uterine/vaginal balloon tamponade is very useful in the management of postpartum hemorrhage because of uterine atony and abnormal placentation.

The outcomes of surgical treatment modalities to decrease "near miss" maternal morbidity caused by peripartum hemorrhage

BACKGROUND

The treatment of patients with peripartum hemorrhage is unfortunately characterized by inadequate treatment that does not adhere to standard therapeutic measures.

AIM

Assessment of different management strategies among patients with severe hemorrhage, particularly the ones with "near-miss" maternal morbidity and mortality to establish clinically useful guidelines for the prevention and management of peripartum hemorrhage.

PATIENTS AND METHODS

In this study, the medical records of 458 patients who have experienced peripartum hemorrhage between March 2009 and March 2012 in a tertiary perinatal center were retrospectively reviewed. Specific surgical treatment modalities utilized to 61 patients with severe peripartum hemorrhage with respect to the procedure timing and effectivity were compared according to the outcomes and efficiency.

RESULTS

Sixty-one patients who have been diagnosed as severe peripartum hemorrhage have been included to the study. Six (75%) of the 8 patients who were treated with B-Lynch brace suture for uterine atony and 9 (60%) of the 15 patients who were treated with the Bakri balloon tamponade system for uterine atony or placenta accreta required hysterectomy following the initial therapeutic measures. The patients who have been treated with bilateral hypogastric artery ligation and B-Lynch brace suture or Bakri balloon uterine tamponade system were less likely to need a complementary hysterectomy for definitive treatment of peripartum hemorrhage when compared with patients treated with either B-Lynch brace suture or Bakri uterine tamponade balloon system alone.

CONCLUSIONS

The efficiency of B-Lynch compression brace sutures and the Bakri balloon uterine tamponade system is unpredictable in terms of the need for hysterectomy for peripartum hemorrhage patients diagnosed as either uterine atony or placenta previa. Regardless of the initial diagnosis, these modalities seem to be more effective in alleviating peripartum hemorrhage when accompanied by hypogastric artery ligation.

Intrauterine balloon tamponade as management of postpartum haemorrhage and prevention of haemorrhage related to low-lying placenta

The aim of the present study was to evaluate the effectiveness of Bakri balloon in preventing and treating postpartum haemorrhage (PPH). Intrauterine Bakri balloon was used in a total of 16 patients with two different purposes: prophylactic placement of the balloon after cesarean section (CS) in six patients with low-lying placenta and therapeutic placement in ten patients with persistent bleeding from uterine atony, after spontaneous delivery, and administration of uterotonics. Intrauterine Bakri balloon was a successful approach in controlling and preventing PPH in all 16 patients. The median nadir hematocrit was 26.6% in six patients who underwent CS and 25.6% in ten patients with persistent bleeding after spontaneous delivery. The intrauterine balloon was in place for a duration of 24 hours. The median balloon infusion volume was 345 ml (range 250-455). No complications were reported. Bakri balloon tamponade was a useful measure in treating PPH unresponsive to pharmacological therapy in patients who delivered vaginally. Moreover, it was able to prevent persistent bleeding in patients who underwent CS for central placenta previa.

Transfusion of blood and blood component therapy for postpartum haemorrhage at a tertiary referral center

OBJECTIVE

To determine the practice of transfusion of blood and blood products in cases of postpartum haemorrhage, at a tertiary referral center.

METHODS

A retrospective study was conducted where medical records were reviewed for women, who either delivered or were admitted in labour suite with diagnosis of postpartum haemorrhage. The study period extended from Jan 2008 to Oct 2009. During a period of 22 months, records were reviewed for transfusion of blood and blood products in above group of women. Data were analyzed for descriptive statistics.

RESULTS

During the study period, a total of 4744 patients were admitted in the labour suite. A total of 113 (2.36%) women were diagnosed with Post partum haemorrhage. Uterine atony was the commonest cause of PPH, followed by genital tract trauma. A total of 81 (71%) women received transfusion of blood and blood components (1.6%). The mean blood loss was 1088 ml (+/- 584 ml). Transfusion of blood and blood component therapy was significantly more in women who underwent caesarean section, compared to those women who delivered vaginally. There was one case of acute tubular necrosis due to PPH, and seven maternal deaths. The mean hospital stay was of +/- 3 days.

CONCLUSION

In this hospital based study, the prevalence of PPH was 2.36%, and the rate of transfusion of blood and blood products was 1.6%.

Vasa previa and postpartum hysterectomy in maternal Rh alloimmunization

Velamentous insertion of the cord, or vasa previa, is a malady where fetal vessels tranverse membranes ahead of the fetal part. The incidence of vasa previa is 1: 2000-3000 deliveries. Fetal mortality is over 50-75%. Early diagnosis is needed because these deliveries require emergency cesarean section; it is especially more common with placenta percreta, uterine atony and hemorrhage. Intravascular infusion of red blood cells (RBCs) into the fetus is one of the most successful means of in utero therapy for severe fetal anemia caused by RBC alloimmunization. We performed four fetal intrauterine intravascular transfusions (IVT) as therapy for severe fetal anemia. The patient underwent elective cesarean section. After delivery, profound uterine atony and vaginal hemorrhage were noted and the patient underwent hysterectomy. Pathological examination of the placenta and umbilical cord documented velamentous insertion of the cord. Before intrauterine IVT a detailed US examination is necessary to exclude vasa previa or placenta previa. Uterine atony may be result after a diagnosis of placenta previa or vasa previa. Intrauterine IVT is an irreplaceable diagnostic procedure in the treatment of severe fetal anemia.

[Use of acupuncture for labour augmentation]

INTRODUCTION

In Denmark, 45% of all primiparas and 12% of multiparas with uneventful pregnancies are augmented in order to treat dystocia. Augmentation using oxytocin is associated with uterine hyperstimulation, uterine rupture and foetal death. Currently, no studies show that acupuncture is effective for augmentation.

MATERIAL AND METHODS

A single-blinded randomized controlled trial with women diagnosed with dystocia. In the acupuncture group, the women had acupuncture in SP6, KI3, KI6, BL60, LI4 and acupressure on BL67. The control group received no treatment. The primary outcome was progression in cervical dilatation within two hours. The secondary outcomes were length of labour, length of second stage, use of augmentation, use of analgesia, caesarean section rate and number of instrumental deliveries.

RESULTS

A total of 84 women were randomised. There was no significant difference between the groups with regard to dilatation from randomization to effect assessment (p = 0.54). In the acupuncture group, the mean difference was 1.3 cm (0.69-1.91). In the control group, the mean difference was 1.56 (0.6-2.52). 27% of the women with dystocia delivered spontaneously without augmentation. No major side effects of acupuncture treatment were reported.

CONCLUSION

This study showed no effect of acupuncture treatment for primary or secondary inertia.

Diagnosis and treatment of peripartum bleeding

Severe peripartum hemorrhage (PPH) contributes to maternal morbidity and mortality and is one of the most frequent emergencies in obstetrics, occurring at a prevalence of 0.5-5.0%. Detection of antepartum risk factors is essential in order to implement preventive measures. Proper training of obstetric staff and publication of recommendations and guidelines can effectively reduce the frequency of PPH and its resulting morbidity and mortality. Therefore, an interdisciplinary expert committee was formed, with members from Germany, Austria, and Switzerland, to summarize recent scientific findings. An up-to-date presentation of the importance of embolization and of the diagnosis of coagulopathy in PPH is provided. Furthermore, the committee recommends changes in the management of PPH including new surgical options and the off-label use of recombinant factor VIIa.

Efficacy of selective arterial embolisation for the treatment of life-threatening post-partum haemorrhage in a large population

BACKGROUND

The objective of this study was to assess efficacy and determine the optimal indication of selective arterial embolisation (SAE) in patients with life-threatening post-partum haemorrhage (PPH).

METHODOLOGY/PRINCIPAL FINDINGS

One hundred and two patients with PPH underwent SAE and were included from January 1998 to January 2002 in our university care center. Embolisation was considered effective when no other surgical procedure was required. Univariate and multivariate statistical analysis were performed. SAE was effective for 73 patients (71.5%), while 29 required surgical procedures. SAE was effective in 88.6% of women with uterine atony that was associated with positive outcome (OR 4.13, 1.35-12.60), whereas caesarean deliveries (OR 0.16, 0.04-0.5) and haemodynamic shock (OR 0.21, 0.07-0.60) were associated with high failure rates, 47.6% and 39.1%, respectively.

CONCLUSIONS/SIGNIFICANCE

Success rate for SAE observed in a large population is lower than previously reported. It is most likely to succeed for uterine atony but not recommended in case of haemodynamic shock or after caesarean section.

Control of postpartum and post abortal haemorrhage with uterine packing

OBJECTIVE

To determine safety and effectiveness of uterine packing to stop hemorrhage in postpartum and post abortal cases.

METHODS

Patients who delivered either vaginally or via Caesarian section who developed primary post partum haemorrhage and post abortal patients developing primary post partum haemorrhage refractory to conventional medical treatment, were included in the study. Packing was done using 8-10 meters sterilized gauze from the fundus to cervix and was left for 12-24 hours or removed earlier in cases of failure to control hemorrhage. Morbidity and effectiveness was assessed.

RESULTS

Intractable primary hemorrhage was encountered in 20 patients of whom 2 had bleeding after caesarian section, 14 after vaginal delivery and 4 patients had post abortal haemorrhage. Uterine atony was the commonest cause. Failure of packing to control haemorrhage was seen in 3 cases. It was successful in 17 cases.

CONCLUSION

Whether used early or late in the management of post partum haemorrhage, uterine packing is a safe, quick and effective procedure.

Do prophylactic prostaglandins reduce the transfusion rate at cesarean section in high-order multiple pregnancies?

OBJECTIVE

Cesarean section is the more usual mode of delivery in high-order multiple pregnancy (> or =3). Excessive uterine distension increases the risk of bleeding and the need for transfusion. The aim of this study was to investigate if prophylactic use of prostaglandins at cesarean section for high-order multiple pregnancies reduces blood loss and transfusion requirement based on historic data.

STUDY DESIGN

We studied a prospective series of 28 parturients with high-order multiple pregnancy (group 2) who were treated, after clamping the last umbilical cord, with oxytocin (5IU intravenous then 35IU in a 24h infusion) combined with intravenous prostaglandin. A comparable retrospective series of 14 patients (group 1) had been given oxytocin alone at the same dose. Postoperative serum hemoglobin and transfusion rate as well as adverse effects were compared between the two groups. Student's t-test was used to compare continuous variables. Chi square test and Fisher exact test were used to compare categorical variables.

RESULTS

The two groups were comparable for anthropometric data and duration of pregnancy. None of the patients in group 2 required red cell transfusion while 21.4% of those in group 1 required transfusion. A significant lower decrease of postoperative haemoglobin is noted in group 2 (P=0.0006). Multivariate analysis using variables significant at univariate analysis and pre-eclampsia confirmed this difference. There were no adverse reactions to treatment.

CONCLUSION

In our experience, prophylactic prostaglandin infusion at cesarean section in high-order multiple pregnancy is associated with a lower need for per operative red cell transfusion and a higher postoperative hemoglobin level. This observation merits confirmation in larger studies.

[Percutaneous catheter embolization in life threatening obstetrical hemorrhage--a case report]

A case of life-threatening postpartum haemorrhage after Caesarean section is reported. The bleeding could finally be stopped by transcatheter embolisation of the internal iliac arteries. Our case and literature concerning management of obstetric haemorrhage by transcatheter embolisation reveals this method to be highly effective, but only slightly invasive and rarely associated with (usually minor) complications. The method is considered to be superior to arterial ligation.

[Uterine defibrillation in uterine inertia. Report of 2 cases]

The uterine atony are the most common cause of postpartum hemorrhage. Manual compression and pharmacologic methods are usually used with a successful result. When pharmacologic methods fail to control hemorrhage from atony, surgical measures should be undertaken to arrest the bleeding before it becomes life-threatening. We presents the utilization of electrical uterine defibrillation in two cases with acute hemorrhage confirming the effectivity of the proceeding.

[Reflex analgesia in the combined treatment of pregnant women with a pathological preliminary period]

The impact of reflex analgesia via transcutaneous electrical neurostimulation and electrical acupuncture was studied in 46 patients with an abnormal preliminary period by using tests of pain sensations and personal and reactive anxiety, ECG, hysterography, and computer-aided prediction of labor complications. Reflex analgesia was found to contribute to effective abolishment of preliminary pain sensations, to normalization of central nervous system function, autonomic reactions, uterine contractility, to reduction in pharmacological agent use and treatment duration, and to better delivery.

Nipple stimulation for labor augmentation

A randomized, prospective study was undertaken to evaluate the efficacy of nipple stimulation with a breast pump as compared to oxytocin for augmentation of labor. The average and maximal uterine activity achieved was significantly higher in the oxytocin-stimulated group, without significant differences in the length of labor stages, cesarean section rate, Apgar scores or umbilical artery pH. Fifty percent of the patients failed to respond to nipple stimulation after 30 minutes and were switched to oxytocin. These patients experienced a more rapid rate of cervical dilation in the active phase and reached higher maximal uterine activity with oxytocin stimulation; however, the cesarean section rate was highest in this group. Nipple stimulation with a breast pump appears to be a safe and effective alternative to oxytocin for the augmentation of labor.

[Electrostimulation of the uterus in uterine inertia]

The paper provides the results of electrostimulation application to the therapy for uterine inertia. Monopolarization current action on the cervix was shown to be beneficial in 83.34% females with abnormal labor. No negative effects of the method was found on the status of a fetus and a parturient.

[Changes in the biochemical indices of parturients with uterine inertia against the background of therapy]

A comparison was made of some biochemical parameters for energy metabolism, acid-base balance, blood gases and uterine contractility in parturients with uterine inertia who were on therapy with or without hyperbaric oxygenation. The presence of hypoxemia and metabolic acidosis in the parturients was found to intensify the processes of lipid peroxidation, to affect the functional status of myometrial biomembranes, to result in hyperenzymemia and disturbed tissue metabolism and lower myometrial contractility. The use of hyperbaric oxygenation in the multimodality therapy for uterine inertia was ascertained to eliminate oxygen deficiency, to increase tissue respiration, contributing to normal labor.

Postpartum hemorrhage

Postpartum hemorrhage is usually unexpected, and blood loss can be massive. Excessive bleeding after delivery may result from uterine atony, disruption of the genital tract, placental abnormalities, coagulation disorders and miscellaneous obstetric complications. Prompt treatment is imperative. Treatment options include oxytocics, prostaglandins, uterine exploration, uterine packing and, occasionally, surgery.

Neurology and behaviour of newborn infants delivered by vacuum extraction on maternal indication

23 full-term neonates delivered by vacuum extraction (VE) on maternal indication (primary or secondary uterine inertia) but with no sign of fetal asphyxia and a control group of 16 infants were studied. The infants were examined on the 1st and 5th days after birth with the Brazelton Neonatal Behavioural Assessment Scale and by a standardized neurological examination. On day 1 the VE-infants showed lower visual and auditory responsiveness in the behavioural assessment, and fewer optimal responses in the neurological examination than did the controls. Obstetrical factors such as abnormal presentation, long duration of the second stage of labour, and long duration of VE (greater than or equal to 15 minutes) may explain the differences. The differences between the groups had largely disappeared by day 5.

[Treatment with electric stimulation]

The author presents various electrostimulation techniques that have been applied with good results for triggering and stimulation of parturition, preventing secondary adynamia of pharmacologic analgesia at birth, for analgesia and sedation during childbirth, for the treatment of hypertensive dysgravida, for postoperative analgesia, and the prophylaxis of dynamic ileus, for the treatment of postoperative dynamic ileus and for the therapy of chronic pain. The electrostimulation technique is applied with several devices that deliver pulse currents of various form with a frequency between 1 and 250 Hz and intensities between 1 and 40 mA, through 2, 3 or 4 transcutaneous electrodes. The electrostimulation techniques can be applied as current therapeutical methods, or can be used as reserve therapy in various specialties. They are economical, easy to perform, and protect the patient against toxic, allergic, and genetic side effects of pharmacologic therapy.