Subsequent pregnancy outcomes and fertility rates in the case series that underwent bilateral hypogastric artery ligation(BHGAL)due to severe postpartum hemorrhage

Objective:To evaluate the effect of bilateral hypogastric artery ligation(BHGAL)on women's pregnancy outcomes and fertility rates in cases with severe postpartum hemorrhage.Methods:Patients hospitalized in a tertiary care center between 2007 and 2018 were included in the study.The records of cases were obtained from the hospital database,retrospectively.Maternal demographic data,morbidities or complications associated with BHGAL surgery,any additional haemostatic interventional or surgical procedures,preoperative admission and lowest postoperative haematocrit-hemoglobin values,blood products given,type of anaesthesia,intensive care unit(ICU)and length of hospital stay were recorded.In cases without surgical sterilization,future fertility and subsequent pregnancy outcomes were assessed for at least two years after operation.Information was obtained through face-to-face or telephone interviews with patients whose long-term fertility and subsequent pregnancy outcomes were assessed.Results:Sixty-eight patients with BHGAL surgery history were included in the study.26 Of 37 cases(70%)that did not undergo surgical sterilization had a desire for pregnancy after the surgery.Six of these cases(23%)were diagnosed with secondary infertility.The fertility rate of these cases was 77%,and subsequent pregnancy was detected in 20 women.A total of 25 pregnancies,including first and second pregnancies,developed,and 15 of these pregnancies resulted in term delivery,six preterm births,one stillbirth,and three abortions.Conclusions:The postoperative pregnancy rate was found to be higher than the rate of women with infertility problems,and this surgery does not seem to adversely affect pregnancy outcomes.This is a tertiary center experience and cohort studies with large patient series are needed.

Predictive model for postpartum hemorrhage requiring hysterectomy in a minority ethnic region

BACKGROUND Postpartum hemorrhage(PPH)is a leading cause of maternal mortality,and hysterectomy is an important intervention for managing intractable PPH.Accurately predicting the need for hysterectomy and taking proactive emergency measures is crucial for reducing mortality rates.AIM To develop a risk prediction model for PPH requiring hysterectomy in the ethnic minority regions of Qiandongnan,China,to help guide clinical decision-making.METHODS The study included 23490 patients,with 1050 having experienced PPH and 74 who underwent hysterectomies.The independent risk factors closely associated with the necessity for hysterectomy were analyzed to construct a risk prediction model,and its predictive efficacy was subsequently evaluated.RESULTS The proportion of hysterectomies among the included patients was 0.32%(74/23490),representing 7.05%(74/1050)of PPH cases.The number of deliveries,history of cesarean section,placenta previa,uterine atony,and placenta accreta were identified in this population as independent risk factors for requiring a hysterectomy.Receiver operating characteristic curve analysis of the prediction model showed an area under the curve of 0.953(95%confidence interval:0.928-0.978)with a sensitivity of 90.50%and a specificity of 90.70%.CONCLUSION The model demonstrates excellent predictive power and is effective in guiding clinical decisions regarding PPH in the ethnic minority regions of Qiandongnan,China.

D-Dimer: Predictor of Postpartum Hemorrhage among Pre-Eclampsia at Kilimanjaro Christian Medical Centre

Background: Postpartum hemorrhage (PPH) is the major contributor to maternal mortality and morbidity worldwide as well as in Tanzania. Studies have shown Pre-eclampsia as a risk indicator for Postpartum hemorrhage and D-dimer tends to rise in women with pre-eclampsia. Few studies that have shown the association between D-dimer and PPH have been controversial and differ according to ethnicity and lifestyle. Hence there is no suitable reference interval for D-dimer in predicting Postpartum hemorrhage among women with pre-eclampsia. Broad Objective: This study aimed to assess the association, sensitivity, and specificity of D-dimer as a laboratory predictor of postpartum hemorrhage among women with pre-eclampsia at KCMC hospital. Methodology: This was a hospital-based analytical cross-sectional study conducted at KCMC Hospital in Northern Tanzania from September 2022 to March 2023. A total of 195 women with pre-eclampsia were included in this study. Plasma D-dimer levels were taken from women with pre-eclampsia pre-delivery. Haematocrit was compared before and after delivery, and a fall of 10% was considered as Postpartum hemorrhage together with clinical assessment of the patient. Participants were divided among those who had severe features and those who did not have severe features and were further categorized into those who had PPH and those who did not have PPH. Logistic regression was used to determine the association between D-dimer and PPH adjusting for other factors. The Receiver Operating Curve (ROC) was used to evaluate the predictive value. Results: Higher median D-dimer levels were seen among women who had PPH compared to those who had no PPH. D-dimer was seen to be associated with PPH, thus for every unit increase of µg/ml of D-dimer among women who had pre-eclampsia without severe features there was a 14% significant increase in the odds of having postpartum hemorrhage and a 45% significant increase of having postpartum hemorrhage among those who had pre-eclampsia with severe features. Furthermore, the cut-off point of a D-dimer level of 0.66 µg/ml significantly predicts postpartum hemorrhage with a sensitivity of 75% and specificity of 55%. For those who had no severe features the cut-off point was 0.53 µg/ml with a sensitivity of 95% and specificity of 53%, and for those who had severe features the cut-off point was 3.58 µg/ml with a sensitivity of 50% and specificity of 96%. Conclusion: D-dimer can be used to predict postpartum hemorrhage among pre-eclampsia, especially among those who have severe features. This shows that D-dimer has specificity in predicting PPH in women with pre-eclampsia and can be applied in clinical services to save women from maternal morbidity and mortality. Blood products such as fresh frozen plasma, platelets, and whole blood together with tranexamic acid should be readily available in women with pre-eclampsia especially those with severe features with a D-dimer level of 3.58 µg/ml and above during delivery as they are at high risk of developing PPH.

Usefulness of transcatheter arterial embolization for eighty-three patients with secondary postpartum hemorrhage:Focusing on difference in angiographic findings

BACKGROUND Transcatheter arterial embolization(TAE)has been widely used as an effective and a safe treatment method and was often used as an alternative to the surgical management,but there are limited studies on the efficacy and the safety for patients undergoing their secondary postpartum hemorrhage(PPH).AIM To evaluate the usefulness of TAE for secondary PPH focusing on the angiographic findings.METHODS We conducted a research from January 2008 to July 2022 on all 83 patients(mean:32 years,range:24-43 years)presented with secondary PPH and they were treated with TAE in two university hospitals.The medical records and angiography were retrospective reviewed in order to evaluate the patients’characteristics,delivery details,clinical status and peri-embolization management,angiography and embolization details,technical/clinical success and complications.The group with active bleeding sign and the group without it were also compared and analyzed.RESULTS On angiography,46(55.4%)patients showed active bleeding signs such as contrast extravasation(n=37)or pseudoaneurysm(n=8)or both(n=1),and 37(44.6%)patients showed non-active bleeding signs such as only spastic uterine artery(n=2)or hyperemia(n=35).In the active bleeding sign group there were more multiparous patients,low platelet count,prothrombin time prolongation,and high transfusion requirements.The technical success rates were 97.8%(45/46)in active bleeding sign group and 91.9%(34/37)in non-active bleeding sign group,and the overall clinical success rates were 95.7%(44/46)and 97.3%(36/37).An uterine rupture with peritonitis and abscess formation occurred to one patient after the embolization,therefore hysterostomy and retained placenta removal were performed which was a major complication.CONCLUSION TAE is an effective and a safe treatment method for controlling secondary PPH regardless of angiographic findings.

Prevention and Control of Postpartum Hemorrhage: Validation of Rangel’s Technology for Huambo, Angola

In the immediate postpartum period, women need to be observed by the obstetric nurse so that measures can be taken to prevent hemorrhages and reduce its complications. Most maternal deaths from hemorrhage are preventable with support measures for clinical practice, such as: guiding protocols, training of professionals, organization and management of health services and provision of adequate conditions for the parturition process. Objective: To validate Rangel’s instrument with its application in the Maternity Ward of the General Hospital of Huambo, Angola. Methodology: This is a descriptive study with a quantitative approach. This is the sixth stage, called pre-test, of the Translation and Cultural Adaptation process. This instrument was sent for evaluation by the validators using the electronic data collection form named Google forms, with a seven-point Likert-type scale (from 7—totally agree to 1—totally disagree). The analysis was performed with the Cronbach’s Alpha coefficient index (>0.91) and the Content Validity Index (CVI > 0.98). Results: Of the 10 items of evaluation criteria of the instrument analyzed by the 20 validators, 100% of them obtained a Cronbach’s Alpha index rating of 0.91: clarity;coherence;scientific writing;relevance;sequence;uniqueness and updating. Coverage, item criticality and objectivity reached a Cronbach’s Alpha of 0.95. The Content Validity Index was 0.95 for coverage, coherence, item criticality, scientific writing, relevance and updating. Conclusion: Rangel’s instrument for nursing care aimed at preventing and controlling hemorrhage in the third period of birth, translated into Angolan Portuguese and validated by nurses, through the statistical results obtained in the validation, was considered reliable and necessary for clinical nursing practice in Huambo, Angola. .

Postpartum Hemorrhage: A Technical Essay

Background: Postpartum hemorrhage is one of the main causes of maternal mortality, mainly in underdeveloped countries. Deaths are mostly preventable, and are related to socioeconomic development, organization of health services and professional training. Objective: To systematize alerts for the prevention of postpartum hemorrhage. Method: This is a technical essay developed from reflections on previously produced and published texts about maternal mortality and has hemorrhage as the focus of this study. Results: It presents the concept, classification of hemorrhage, risk factors and their classification, prevention strategies, universal recommendations, pharmacological and non-pharmacological interventions when hemorrhage already exists, bleeding assessment techniques;clinical evaluation, by laboratory examination and by shock index. Conclusions: Hemorrhage is a preventable cause of maternal death through the accomplishment of multiple care. Hospital care must be conducted by qualified professionals and in adequate numbers. The risk diagnosis must be carried out during prenatal care with the recording of clinical data accessible in the health care network. All references studied are not specific to nursing, as hemorrhage prevention requires multidisciplinary action.

Postpartum Hemorrhage: Incidence, Causes and Maternal Outcomes at Muhimbili National Hospital, Tanzania—A Retrospective Descriptive Hospital-Based Study

Worldwide obstetric hemorrhage remains the leading cause of maternal mortality, accounting for over one quarter of maternal deaths. Over half of these deaths occur in Sub-Saharan Africa with mortality rates of 500 - 1000 per 100,000 births, compared to approximately 5 - 10 in developed countries. Over decades in Sub Saharan Africa preventive measures and treatment protocols have been made to reduce maternal mortality caused by PPH. While rates of postpartum hemorrhage have continued to rise, there is a need to evaluate if its etiology and patterns have changed over time. Broad Objective: This study aims at describing trends in incidence, causes and maternal outcomes of Postpartum Hemorrhage at Muhimbili National Hospital for a period of 7 years. Methodology: This is a retrospective descriptive hospital-based study that has included all cases of postpartum hemorrhage at Muhimbili National Hospital, a tertiary hospital in Tanzania from 2014 to 2020. The data was analyzed using SPSS Version 26 and presented using frequency tables, figures and percentages. The trends of postpartum hemorrhage over time were determined using chi-square test and P-value where less than 0.05 was considered statistically significant. Results: Overall, the incidence of postpartum hemorrhage has been fluctuating over the years with minimum of 1.78% and maximum of 2.87% with no statistical significance. Out of 1113 enrolled cases of PPH, 422 (37.9%) were attributed to genital tears followed by uterine atony 285 (25.6%). A statistically significant increase in linear trend was observed in the postpartum hemorrhage cases due to uterine atony, uterine rupture and sub analysis on genital tears (cervical tear). Overall, there was a statistically significant change in trend of maternal outcomes throughout the years, with a P-value < 0.001 and likelihood of complications increasing over time. Conclusion: The trend in the incidence of postpartum hemorrhage has been fluctuating over the years during the study period. The leading cause of postpartum hemorrhage was genital tears, followed by uterine atony with a significant increase in adverse maternal outcomes over the years. Continuous health education to medical personnel to improve timely and proper diagnosis of women in danger of PPH and timely referral, thus improve maternal morbidity and mortality.

Effect of Cesarean Section on the Severity of Postpartum Hemorrhage in Chinese Women： The Shanxi Study

Postpartum hemorrhage （PPH） is one of the most adverse obstetric outcomes. Our aim is to detect the risks of multilevel PPH in different cesarean section （CS） groups [including nulliparous CS with indications, nulliparous CS without indications, repeat cesarean （RC）, vaginal birth after cesarean （VBAC）, cesarean after vaginal birth （CAVB）]. We conducted a retrospective cohort study, and the data on 127 145 women collected from January 2014 to May 2016 and from 35 tertiary hospitals in Shanxi province, China, were reviewed. Based on the measuring results of PPH, an ordered logistic regression model was used to analyze the adjusted PPH risks for each of the CS groups, and comparisons were drawn between them. Finally, a total of 99 066 nulliparous （77.92%） and 28 079 multiparous （22.08%） women were observed. The number of CS cases was 61 117, and the rate for CS was 48.07%. A total of 10 029 women did not show indications for CS and accounted for 16.41% of the CS parturient, whereas 9103 women underwent a repeated cesarean, with a CS frequency of 14.89%. The number of VBAC cases was 989, whose rate was 9.88% in prior CS women. The number （proportions） of PPH was 3658 （2.88%） in L1 （PPH volume： ≥900 and 〈1500 mL）, 520 （0.41%） in L2 （PPH volume： ≥1500 and〈2100 mL）, and 201 （0.16%） in L3 （PPH volume： ≥2100 mL）. The Ln （n= 1, 2, 3, etc.） represented the increasing order of PPH severity. In the adjusted results, compared with spontaneous vaginal delivery （SVD） as the reference group, in the adjusted result for nulliparous, there was a decreased PPH risk in CS with indications （OR： 2.32; CI： 2.04-2.62）, which was lower than that of CS without indications （OR： 2.50; CI： 2.01-2.96）. The highest PPH risk in all subgroups （i.e. nulliparous and multiparous groups） was observed in the RC （OR： 3.61; CI： 3.16-4.17）, which was nearly twice higher than that of the VBAC （OR： 1.82; CI： 1.33-2.52）. CAVB （OR： 1.03; CI： 0.65-1.62） showed no significant difference with the reference group. Thus, we deemed that CS should be avoided in nulliparous pregnancies unless indicated, to prevent or reduce the rates for the use of RC or VBAC which are high risks of severe PPH to the parturient women.

Development of an assessment and intervention protocol for postpartum hemorrhage in the mainland of China: an evidence-based method and Delphi consult

Objective: Postpartum hemorrhage(PPH) is a leading cause of maternal death. Although guidelines have been updated, those with detailed protocols are limited for nursing practice. This study aims at establishing an early assessment and intervention protocol as a toolkit for PPH for midwives and obstetrical nurses.Methods: Employing the evidence-based method, a systematic Internet search of guidelines was conducted and appraisal of literatures was conducted with AGREE system and Oxman-Guyatt Overview Quality Assessment Questionnaire(OQAQ), according to which a protocol draft was therefore developed. Then, a two-round modified Delphi method was utilized to reach a consensus of the protocol built on best practices. Selection criteria for each intervention measure included consensus level with a threshold of 70%, mean of importance(M) >3.5, and coefficient of variation(CV) <0.25. Reliability of experts' opinion was calculated by positive coefficient and authoritative coefficient. Items without consistency were enlisted in the second-round consult. When all items met the selection criteria, the protocol would be finally formulated.Results: A 122-measure protocol was established, including prevention, assessment, and intervention of PPH. With a panel of 14 experts participated in the consult, the positivity coefficient was 0.93 and 1.00 for two rounds, respectively, and the authority coefficient was 0.88. After a two-round consult and revision of the draft, the final program was formulated, containing 5 first-level indexes and 14 second-level indexes with a total item of 120.Conclusions: The PPH protocol, based on high-quality evidences, was formulated with a two-round Delphi method, which can provide insight for midwives and obstetrical nurses to effectively deal with PPH.

Oxytocin Abuse and Postpartum Hemorrhage

Among the most consolidated dogmas in obstetrics, we have the essential role of oxytocin during: labor by regulating, consolidating uterine contractions, by supporting the expulsive efforts of the patient during childbirth and after childbirth by preventing postpartum hemorrhage. But what challenged us to conduct our study is the large and increasing number of surgical operations for postpartum hemorrhage in patients who received oxytocin during labor. We assumed that the generalization use of oxytocin in all patients during labor is probably responsible of this increasing rate of incidents. To verify this assumption, we carried out a prospective randomized comparative study, involving 3990 pregnant patients admitted at the start of labor at term, with no contraindication for giving birth by normal ways, during a period of 10 months (January-October 2022). The patients have been divided into 2 groups. The first group comprises 1991 patients who were placed on admission on a glucose serum infusion with 4 ampoules of a non-anticholinergic musculotropic antispasmodic: “Hydrated phloroglucinol + trimethylphloroglucinol” (Each ampoule contains 40 mg of hydrated phloroglucinol and 0.04 mg of trimethylphloroglucinol) instead of receiving oxytocin during the active phase of their labor and a second group consisting of 1999 patients who received oxytocin during the active phase of their labor. The results were very surprising and contrary to the already consolidated evidence in our specialty. Indeed, the rate of postpartum hemorrhages was 10 patients (0.5%) in the 1st group vs 30 patients (1.5%) in the 2nd group, 9 patients (0.4%) presented fetal heart rate abnormalities in the 1st group vs 90 (4.5%) in the 2nd group, 8 cases (0.4%) of dynamic dystocia in the 1st group vs 132 cases (6.6%) in the 2nd group and 99 caesareans (5%) in the 1st group vs 299 (15%) in the 2nd group. Against all expectations the results were very surprising, with more details in the article.

Effects of Misoprostol and Oxytocin Combined with Calcium Gluconate on Delivery Time of Parturient with High-risk Postpartum Hemorrhage and Neonatal Outcomes

Objective:To investigate the effect of misoprostol and oxytocin combined with calcium gluconate on parturient with high-risk postpartum hemorrhage.Methods:The clinical data of 80 parturient with high-risk postpartum hemorrhage who were treated in our hospital from July 2016 to July 2019 were retrospectively analyzed.According to different treatment methods,they were divided into control group(treated with misoprostol combined with oxytocin,40 cases)and observation group(treated with misoprostol and oxytocin combined with calcium gluconate,40 cases),compared the clinical efficacy,delivery time,postpartum hemorrhage 2 hour after delivery,postpartum hemorrhage 24 hours after delivery and Apgar score of the newborns at 1min after birth.Results:The total effective rate(95.00%)in the observation group was higher than that in the control group(77.50%),and the difference was statistically significant(P<0.05).The third delivery stage in the observation group was shorter than that in the control group,and the postpartum hemorrhage volume was less than that in the control group.The difference was statistically significant(P<0.05).There was no significant difference in Apgar score of the two groups of newborns(P>0.05).Conclusion:Misoprostol and oxytocin combined with calcium gluconate is effective in treating high-risk postpartum hemorrhage parturient,which not only can effectively reduce postpartum hemorrhage and shorten the delivery time,but also is beneficial for neonatal outcome and worthy of clinical application.

Balloon Tamponade in the Management of Postpartum Hemorrhage: Three Years of Experience in a Single Center

Introduction: Postpartum hemorrhage (PPH) is one of the leading causes of maternal death in the world and it is reported to occur in 5% - 8% of pregnancies. Objective: This study aimed to present a single centre’s experience in treating PPH by balloon tamponade. Methods: During the time period between January 2013 and March 2016, 50 patients who had undergone balloon tamponade for postpartum hemorrhage in our clinic were evaluated retrospectively. The patients’ age, parity, type of delivery, birth weight, hemoglobin and platelet values, total blood loss from catheter, balloon’s staying time, blood and platelet transfusion status, the presence of placenta anomalies and the Bakri balloon hemostasis success rate were evaluated. Results: During the study period, there were 27,249 deliveries. The frequency of massive postpartum hemorrhage was 0.61% (n = 168). Among the 168 patients with massive postpartum hemorrhage, there were 50 patients in whom the Bakri balloon catheter was used. Bakri balloons were placed via cesarean section incision in 19 patients and via vagina in 31 patients. The mean staying time of Bakri balloon was 18 hours. In 8 patients, balloon tamponade failed. Two patients underwent hysterectomy;other two patients had surgical ligation of the hypogastric artery. Four cases were referred to a tertiary center. Placental invasion abnormalities were observed in five patients. The overall Bakri balloon hemostasis successful rate was found to be as 84% in all cases. Conclusion: Bakri balloon tamponade is an effective, safe and practical approach in the treatment of postpartum hemorrhage.

Analysis of Influencing Factors of Preeclampsia on Postpartum Hemorrhage

Postpartum hemorrhage is a serious complication of preeclampsia.The main influencing factors of Preeclampsia on postpartum hemorrhage include vascular disease,trophoblast differentiation and infiltration disorder,the influence of antispasmodic,sedative and antihypertensive drugs,the incidence of hypertensive disorder complicating pregnancy related to calcium deficiency,coagulation dysfunction,and decreased blood volume during pregnancy.In recent years,postpartum hemorrhage has been the leading cause of maternal death in the world.Therefore,it is critical to understand the influencing factors of preeclampsia on postpartum hemorrhage.Based on the research and guidelines of preeclampsia and postpartum hemorrhage in recent years,this paper analyzes the influencing factors of preeclampsia on postpartum hemorrhage,and provides new ideas for clinical reduction of postpartum hemorrhage.

Assessment of Unmet Transfusion Needs in the Management of Immediate Postpartum Haemorrhage at the Kalaban Coro Reference Health Centre (MALI)

The aim was to assess transfusion needs in the management of immediate postpartum haemorrhage. Materials and Methods: this was a prospective, descriptive, analytical study from 01 January 2018 to 31 October 2018 in the gynecology and obstetrics department of the reference health center of Kalaban-Coro (Mali). Results: During the study period we recorded 32 cases of transfusion of the immediate postpartum out of 109 cases of hemorrhage or 29.35%;for a total of 2425 deliveries or a frequency of 1.31%. The main indications for blood transfusion were: postpartum haemorrhage due to tearing of the soft parts in 21.9%;retroplacental hematoma in 18.6%;uterine rupture in 12.5%;and placenta previa covering hemorrhagic in 12.5%. More than half of the transfused were evacuees, or 62.5%. Unmet transfusion requirements were 59.4%. The blood products requested were: whole blood in 99% of cases and fresh frozen plasma in only 1% of cases. Conclusion: the need for labile blood products remains a reality in obstetrics. The permanent availability of labile blood products improves the prognosis of immediate postpartum haemorrhages.

An old uterine rupture repaired 2 months postpartum using laparoscopy aided by hysteroscopy: A case report

With an incidence of 0.005%,unscarred uterine rupture is extremely rare.It is difficult to diagnose uterine rupture because of the absence of characteristic clinical symptoms.Here,we report a rare case of a 31-year-old woman with a uterine rupture that was accurately diagnosed and repaired by laparoscopy and hysteroscopy on postpartum day 69.The patient recovered uneventfully and was discharged on postoperative day 4.Three months after surgery,pelvic magnetic resonance imaging was performed,which confirmed wound repair.In women with a stable condition,laparoscopy with hysteroscopy could be an alternative choice for the diagnosis and treatment of suspected uterine rupture;however,more substantial studies are needed to confirm this surgical approach.

Factors Associated with Postpartum Haemorrhage amongst Primigravidae Women;the Case of Two Hospitals within the Bamenda Health District

Background: Approximately 830 women die from pregnancy-related conditions daily with 99% of these maternal deaths occurring in low resource countries. Primary postpartum haemorrhage (PPH) accounts for 25.7% of maternal deaths in Africa. In Cameroon, postpartum hemorrhage remains the leading cause of maternal death, with little information on the primigravidae population compared to multigravida or multiparity. Objective: The aim of this study was to assess the factors associated with postpartum haemorrhage amongst primigravidae women giving birth in two hospitals within the Bamenda Health District. Methods: This study was a multicentric, non-randomized cross-sectional descriptive and analytic study. Of the 221 women interviewed regarding their willingness to participate in the study, 197 consented. Quantification of blood loss was done by visual estimate and with the assistance of the pathfinder international wall chart for visual estimation of blood loss. Data was collected using a structured questionnaire and analyzed using SPSS version 23. A P-value of <0.05 used to determine association between variables was considered statistically significant. Results: The prevalence of postpartum hemorrhage in primigravidae was 7.1%. The risk factors of postpartum hemorrhage were: induction of labour (P-value < 0.01), duration of labour (P-value < 0.01), augmentation (P-value < 0.05), mode of delivery (P-value < 0.01), and macrosomia (P-value < 0.01). The main causes of PPH were uterine atony and obstetrical lacerations (P value < 0.01). Management was mostly by the use of non-pharmacological and pharmacological measures. The main adverse outcomes were shock and severe anaemia, with one case of nearmiss recorded. No maternal death was recorded. Conclusion: The prevalence of postpartum hemorrhage amongst primigravidae was high. The main causes of post-partum hemorrhage were uterine atony and obstetric lacerations. PPH was associated with uterine hypotonia, retained products and genital lacerations. No maternal mortality was recorded. These findings highlight the pressing need for good quality em ergency obstetric care and the availability of more accurate techniques of postpartum blood loss measurement. Secondly, hospitals need blood banks to manage patients with severe hemorrhage.

A Seven-Step Approach to Control Severe Hemorrhage in Cesarean Delivery with the Placenta Accreta Spectrum Disorders Avoiding Hysterectomy

Objectives: To describe a novel procedure to treat hemorrhage of placenta accreta spectrum disorders (PAS) or cesarean-scar pregnancy (CSP). Methods: This was a retrospective study of women under cesarean delivery with PAS or placenta previa. Patients’ information was acquired from hospital records. A novel procedure of surgery is developed with seven major steps, including avoiding placenta incised, elevating upward the uterine, clamping the uterine arteries with sponge forceps, removing the placenta, opening the vesicouterine space and suture techniques. Results: A total of 38 patients were reviewed. Twenty-one patients diagnosed with placenta accrete syndrome and 3 patients with CSP were underwent surgery with the novel procedure of surgery and all severe hemorrhage was controlled without hysterectomy. There were 2 women with bladder injuries needing primary repair. Fourteen patients with placenta previa underwent cesarean delivery and there was no intraoperative complication of the total 14 patients. Conclusion: The seven-step approach is more secure and effective to control severe hemorrhage without other invasive procedures in cesarean delivery with PAS. It is technically easier to maintain and improve surgical skills.

Tranexamic Acid and Ethamsylate for Reducing Blood Loss in Patient Undergoing Lower Segment Cesarean Section at High Risk for Post-Partum Hemorrhage: A Pilot Study

Objective: To assess the efficacy of intravenous tranexamic acid and ethamsylate in reducing blood loss during and after elective lower segment cesarean delivery in patients at high risk for postpartum hemorrhage. Methods: A double-blind, randomized placebo-controlled study was undertaken of women undergoing elective lower-segment cesarean delivery of a full-term pregnancy at high risk for postpartum hemorrhage at Ain Sham University Maternity Hospital in Cairo, Egypt, between January 2019 and October 2019. Patients were randomly assigned (1:1) using computer-generated random numbers to receive either 1 g tranexamic acid and 1 gm ethamsylate or 5% glucose (placebo) just after delivery of the fetus. Prophylactic oxytocin was administered to all women. Preoperative and postoperative complete blood count, hematocrit values, and maternal weight were used to calculate the estimated blood loss (EBL) during the cesarean, which was the primary outcome. Results: Analyses included 32 women in each group. Our results showed that tranexamic acid and ethamsylate significantly reduced bleeding during and after cesarean delivery. The study group’s total blood loss (149.22 ± 54.74 ml) was significantly less than the control group (353.75 ± 115.56 ml) (p < 0.001). In our study, postoperative hemoglobin and hematocrit were significantly higher in the study group than the control group (p < 0.001);Reduction in hemoglobin and hematocrit were significantly less in the study group than the control group (p < 0.001). Conclusion: The use of tranexamic acid and ethamsylate during cesarean delivery can significantly reduce blood loss during and after cesarean delivery.

The Active Management of Postpartum Uterine Atony—A Checklist Based Approach

Uterine atony remains the major cause of postpartum hemorrhage, and of death from postpartum hemorrhage in the United States. While existing guidelines outlining a general approach to postpartum hemorrhage are useful, recent data suggest that greater specificity may be necessary to significantly impact mortality. We present a highly specific and methodical approach to the management of uterine atony, which addresses what we believe to be the most common cause of preventable maternal hemorrhagic death in the US—lack of an intensive, focused approach to atony and perseverance with therapies that are not working. This protocol should result in cessation of hemorrhage by medical or surgical means within 1 hour of diagnosis. We then apply this protocol to a number of illustrative cases of maternal death due to atony. An approach involving the active management of uterine atony may assist clinicians in avoiding severe morbidity and mortality from uterine atony.

Low-dose aspirin in the prevention of pre-eclampsia in China: postpartum hemorrhage in subgroups of women according to their characteristics and potential bleeding risk

Background:The APPEC study is a large-population randomized controlled trial in China evaluating the role of low-dose aspirin prophylactic treatment for pre-eclampsia.There was no statistically significant difference in postpartum hemorrhage(PPH)incidence between the aspirin and control groups.This study aimed to evaluate the potential bleeding risk of 100 mg aspirin in high-risk pregnant women and the difference in the incidence of PPH according to maternal characteristics.Methods:This is a secondary data analysis of the APPEC study.Platelet counts and coagulation test results were collected at five follow-up visits.Subgroups defined by maternal age(<35 years and≥35 years),pre-pregnancy body mass index(pre-BMI,<28 kg/m 2 and≥28 kg/m 2),parity,gestational age at enrollment,and medical history,including pre-eclampsia,chronic hypertension,and diabetes mellitus,were analyzed.Logistic regression analysis was used to determine the statistical significance of the difference in the incidence of PPH after aspirin administration in pregnant women in each subgroup.Adjustment using multiple logistic regression models followed these analyses.Binary logistic regression was used to determine the relationship between pre-BMI and PPH.Results:There was no significant difference between the aspirin and control groups in bleeding risk(3.4%[16/464]vs.3.0%[13/434],T=0.147,P=0.701).No significant difference was found in the incidence of PPH in total(relative risk=1.220,95%confidence interval[CI]=0.720–2.067,P=0.459;aspirin group vs.control group,6.5%[30/464]vs.5.3%[23/434],P=0.459)or in subgroup analysis.A significant correlation between pre-BMI and PPH was found in the aspirin group,while in the control group there was no significant correlation(aspirin group,odds ratio[OR]=1.086,95%CI=1.004–1.175,P=0.040;control group,OR=1.060,95%CI=0.968–1.161,P=0.209).Conclusions:A dosage of 100 mg of aspirin per day,initiated from 12 to 20 gestational weeks until 34 weeks of gestation,did not increase the risk of potential bleeding and PPH regardless of the maternal characteristic.In the aspirin group,the positive correlation between BMI and PPH was significant.Trial Registration:ClinicalTrials.gov,NCT01979627.