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.

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.

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.

Predicting risk of postpartum hemorrhage using machine learning approach:A systematic review

Background Postpartum hemorrhage(PPH)could be avoided by identifying high-risk women.The objective of this systematic review is to determine PPH predictors using machine learning(ML)approaches.Method This strategy included searching for studies from inception through November 2022 through the database included:Cochrane Central Register,PubMed,MEDLINE,EMBASE,ProQuest,Scopus,WOS,IEEE Xplore,and the Google Scholar database.The search methodology employed the PICO framework(population,intervention,control,and outcomes).In this study,“P”represents PPH populations,“I”represents the ML approach as intervention,“C”represents the traditional statistical analysis approach as control,and“O”represents prediction and diagnosis outcomes.The quality assessment of each included study was performed using the PROBAST methodology.Results The initial search strategy resulted in 2048 citations,which were subsequently refined by removing duplicates and irrelevant studies.Ultimately,four studies were deemed eligible for inclusion in the review.Among these studies,three were classified as having a low risk of bias,while one was considered to have a low to moderate risk of bias.A total of 549 unique variables were identified as candidate predictors from the included studies.Nine distinct models were chosen as ML algorithms from the four studies.Each of the four studies employed different metrics,such as the area under the curve,false positive rate,false negative rate,and sensitivity,to report the accuracy of their models.The ML models exhibited varying accuracies,with the area under the curve(AUC)ranging from 0.706 to 0.979.Several weighted predictors were identified as significant factors in PPH risk prediction.These included pre-pregnancy maternal weight,maternal weight at the time of admission,fetal macrosomia,gestational age,level of hematocrit at the time of admission,shock index,frequency of contractions during labor,white blood cell count,pregnancy-induced hypertension,the weight of the newborn,duration of the second stage of labor,amniotic fluid index,body mass index,and cesarean delivery before labor.These factors were determined to have a notable influence on the prediction of PPH risk.Conclusion The findings from ML models used to predict PPH are highly encouraging.

Clinical Analysis of Postpartum Hemorrhage Requiring Massive Transfusions at a Tertiary Center

Background： The reports on massive transfusions （MTs） in obstetrics have recently been an increasing trend. We aimed to define the clinical features, risk factors, main causes, and outcomes of MTs due to severe postpartum hemorrhage （PPH） and the frequency trends over the past 10 years. Methods： We retrospectively analyzed the data of 3552 PPH patients who were at ≥28 weeks of gestation in the Obstetric Department of Peking University First Hospital from January 2006 to February 2015. The clinical records of patients receiving MT with ≥5 units （approximately 1000 ml） of red blood cells within 24 h of giving birth were included. The Pearson＇s Chi-square and Fisher＇s exact tests were used to compare the frequency distributions among the categorical variables of the clinical features. Results： One-hundred six women were identified with MT over the 10-year period. The MT percentage was stable between the first 5-year group （2006-2010） and the second 5-year group （2011-2015） （2.5‰ vs. 2.7‰, χ^2 = 154.85, P = 0.25）. Although uterine atony remained the main cause of MT, there was a rising trend for placental abnormalities （especially placenta accreta） in the second 5-year group compared with the first 5-year group （34% vs. 23%, χ^2 = 188.26, P = 0.03）. Twenty-four （23%） women underwent hysterectomy, and among all the causes of PPH, placenta accreta had the highest hysterectomy rate of 70% （17/24）. No maternal death was observed. Conclusions： There was a rising trend for placental abnormalities underlying the stable incidence of MT in the PPH cases. Placenta accreta accounted for the highest risk of hysterectomy. It is reasonable to have appropriate blood transfusion backup for high-risk patients, especially those with placenta accreta.

Postpartum Hemorrhage Following Cesarean Delivery in Women with a Scarred Uterus:A Retrospective Cohort Study

Objective:To develop a model to predict the risk of postpartum hemorrhage(PPH)following cesarean delivery in women with a scarred uterus.Methods:A total of 4,637 pregnant women with scarred uterus who underwent a cesarean delivery at a large hospital between January 2014 and December 2017 were enrolled.The women were divided into PPH(n=287)and non-PPH(n=4,350)groups.A model to predict PPH(blood loss≥1,000 mL within 24 h following cesarean delivery)was developed using multivariate logistic regression analysis.Receiver operating characteristic curve was drawn,and the area under curve(AUC)was calculated.Results:The incidence of PPH was 6.19%(287 of 4,637 women).Seven independent risk factors were associated with PPH:maternal age(odds ratio[OR]=1.42,95%confidence interval[CI]:1.02-1.97),previous gravidity(OR=1.24,95%CI:1.01-1.50),placental location(posterior wall of uterus,OR=0.69,95%CI:0.47-1.02;other locations,OR=1.21,95%CI:0.81-1.80),placenta previa(incomplete placenta previa,OR=10.51,95%CI:5.99-18.42;complete placenta previa,OR=31.65,95%CI:21.07-47.54),placenta accreta(OR=6.39,95%CI:4.02-10.16),hypertensive disorders of pregnancy(OR=2.27,95%CI:1.40-3.68),and fetal position(breech position,OR=2.07,95%CI:1.19-3.60;transverse position,OR=1.07,95%CI:0.48-2.41).A predictive model with AUC of 0.89 was developed(95%CI:0.86-0.91,P<0.001).Conclusions:A model was developed to predict PPH following cesarean delivery in women with a scarred uterus.

Intravenous Administration of Carbetocin Versus Oxytocin for Preventing Postpartum Hemorrhage After Vaginal Delivery in High Risk Women:A Double-blind,Randomized Controlled Trial

Objective::To compare the effects between carbetocin and oxytocin on reducing postpartum hemorrhage(PPH)after vaginal delivery in high risk pregnant women.Methods::A prospective double-blinded randomized study was conducted in the Nanjing Drum Tower Hospital from March to May 2018.Women at or beyond 28 gestational weeks,cephalic presentation,18-45 years old,and with at least one risk factor for PPH,were enrolled.Using a computer-generated randomization sequence,women were randomized to carbetocin group or oxytocin group which receive 100μg intravenous infusion carbetocin or 10 IU intravenous infusion of oxytocin after anterior shoulder and before placental delivery.The primary outcome was the incidence of blood loss≥500 mL within 24 hours postpartum.The secondary outcomes were amount of total blood loss,blood loss within 2 hours after delivery,the rate of blood loss≥1000 mL postpartum,need for a second-line uterotonics and interventions,blood transfusion,difference between hemoglobin before and 48 hours after delivery,adverse maternal events attributed to the trial medication.Hemodynamic status(blood pressure and pulse)was measured at 0 minutes,30 minutes,60 minutes,and 120 minutes after delivery.Results::A total of 314 and 310 participants constituted the carbetocin and oxytocin groups,respectively.The baseline characteristics were comparable between the groups.The carbetocin group had similar rates of PPH(blood loss≥500 mL)and rates of≥1000 mL PPH,(29.6%vs.26.8%,P=0.48)and(3.2%vs.3.5%,P=0.83),to the oxytocin group.The average amount of bleeding was(422.9±241.4)mL in carbetocin group and(406.0±257.5)mL in oxytocin group,which was no statistically significant difference(P=0.40).Either the amount of blood loss within 2 hours((55.5±33.9)mL vs.(59.9±48.7)mL)was no statistically significant difference(P=0.19).The need for therapeutic uterotonics was 23.9%in carbetocin group and 23.5%in oxytocin group,which was also no statistically difference(P=0.93).The rate of blood transfusion(P=0.62)and hemoglobin change(P=0.07)were not differ between the carbetocin and oxytocin groups.However,the rate of manually removing placenta was significantly different between two groups regarding the need for manually remove of placenta because of uterine bleeding in the third stage of labor(4 cases in carbetocin group vs.13 cases in oxygen group),especially in those after oxytocin-induced or augmented labor(relative risk:3.39,95%confidence interval:1.09-10.52).After delivery,the blood pressure in the carbetocin group tend to be lower than that in the oxytocin group(P>0.05),especially at 30 minutes postpartum(P<0.05),while pulse tend to be simultaneously higher(P>0.05).Conclusion::Among women with high risk of PPH,intravenous carbetocin infusion did not better than oxytocin in the prevention of blood loss≥500 mL after vaginal delivery.

Influences of dopamine and norepinephrine on hemodynamic parameters in patients with postpartum hemorrhage

Background Postpartum hemorrhage, a severe complication during delivery, is one of the leading causes of maternal death. Dopamine and norepinephrine are widely used as first-line therapy. This study aimed at comparing their effects on hemodynamics. Methods A perspective, randomized, parallel-group study was performed. The patients were randomly divided into a dopamine group （maximum dose ≤ 0.2 μg·kg^-1· min^-1） and a norepi-nephrine group （maximum dose ≤ 0.2 μg·kg^-1· min^-1）. Both treatments increased the mean arterial pressure （MAP） to more than 70 mmHg. PiCCO was used for monitoring hemodynamic parameters, lactic acid and urine output. Results A total of 73 patients were enrolled in this study. Thirty seven patients were assigned to the dopamine group, 36 patients to the norepinephrine group. Average MAP was increased from 55.2±5.22 mmHg to 71.4±4.67 in dopamine group, and from 54.8±5.87 mmHg to 72.2±4.67 in norepinephrine group. MAP showed a significant increase before and after treatment in both groups （P〈0.001）, but no significant difference was found between the two groups （P=0.425）. After 6 hours of treatment, the average heart rate （ 101±9.81 ） and cardiac output index （CI, 2.40±0.40 L. min^-1· m^-2） in the norepinephrine group were lower than those of the dopamine group （ 120±16.7 and 3.01±0.38 L· min^-1· m^-2, P〈0.001） The global ejection fraction （GEF, 43.9±3.32% ） and systemic vascular resistance index （SVRI, 3763±229.9 dynes, s·m^-2· cm^-5） of the norepinephrine were higher than those in the dopamine group （37.4±4.77%, 2613±235.6 dynes, s·m^-2· cm^-5, P〈0.001 ）. There was a significant difference in urine output between the norepinephrine group （117±17.4 mL/h） and dopamine group （70.7±11.8 mL/h）. Conclusions In patients with postpartum hemorrhage, norepinephrine improves the MAP mainly by increasing the myocardial contraction force and the renal perfusion. Therefore, it is recommended as the first choice for the treatment of these patients.

Analysis of risk factors related to severe postpartum hemorrhage of twin pregnancies delivered by cesarean section

Objective:To investigate the risk factors of severe postpartum hemorrhage(PPH)in cesarean section of twin pregnancy,and to provide clinical basis for pregnancy management and perioperative obstetric management of twin pregnancy.Methods:The clinical data of 631 twin pregnancies with gestational age
28 weeks delivered by cesarean section at Peking University People's Hospital(PKUPH)from January 2004 to January 2017 were retrospectively analyzed.Methods of conception,the combined weight of twins,serum albumin level before cesarean section,operation time and other factors on the amount of blood loss during cesarean section were analyzed.Results:The proportion of severe PPH was significantly higher in in vitro fertilization-embryo transfer(IVF-ET)group,the combined weight of twins>6000g group,serum albumin before cesarean section<30 g/dl group than in the natural pregnancy group,4000–6000g group,<4000g group and serum albumin
30 g/dl group respectively(P<0.05).The proportion of severe PPH in the elective surgery group of twin pregnancy was higher than that in the emergency surgery group,but the difference was not statistically significant(P>0.05).Moreover,according to the surgical indications,the emergency surgery group was divided into premature rupture of membranes(PROM),labor,fetal distress and others groups,no significant difference were detected among these groups(P>0.05).Conclusion:IVF-ET,the combined weight of twins,serum albumin before operation were significantly correlated with severe PPH of twin pregnancies delivered by cesarean section,revealing that it is necessary to strengthen pregnancy management of twin pregnancy.

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.