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Klippel-Trènaunay syndrome is a rare congenital disorder characterised by vascular malformations, which may be exacerbated during pregnancy and pose considerable thromboembolic and haemorrhagic risk for obstetric patients. We report on a patient with this syndrome who underwent elective caesarean section which was indicated due to previous obstetric anal sphincter injury. We describe her multidisciplinary preoperative planning and successful management of major postpartum haemorrhage with uterine compression sutures and intrauterine balloon tamponade (‘uterine sandwich’).

Postpartum haemorrhage (PPH) due to multiple vaginal lacerations is difficult to manage and tamponade is used as a life-saving measure. Condom catheter with stay sutures at the vaginal introitus for this purpose has not been reported. We describe successfully managing PPH due to multiple vaginal lacerations following a forceps delivery using a condom tied to an 18 FG Foley catheter. The device was introduced to the vagina, inflated with 700 mL of normal saline and was held in situ by sealing the vaginal introitus with interrupted nylon stitches running between the labia minora. Condom catheter is cheap and freely available in low-resource settings. The preparation and application can be done by a less experienced operator.

Item does not contain fulltext BACKGROUND: Women with rare bleeding disorders (RBDs), including coagulation factor deficiencies and fibrinolytic disorders, may have a higher risk of postpartum hemorrhage (PPH). Information on this patient category is lacking in the existing PPH guidelines because data on PPH in patients with RBDs are scarce. OBJECTIVE: To describe the prevalence of PPH in women with an RBD and evaluate the use of peripartum hemostatic prophylaxis. METHODS: In the Rare Bleeding Disorders in the Netherlands (RBiN) study, patients with RBDs (n = 263) were included from all 6 Dutch hemophilia treatment centers. Patient-reported information on delivery, peripartum hemostatic prophylaxis, and occurrence of PPH was collected retrospectively. If available, information about the precise volume of postpartum blood loss was extracted from electronic patient files. PPH was defined as blood loss ≥500 mL (World Health Organization guideline). RESULTS: A total of 244 pregnancies, including 193 livebirths, were reported by 85 women. A considerable proportion of these women experienced PPH, ranging from 30% in factor V deficiency to 100% in hyperfibrinolysis. Overall, PPH was reported in 44% of deliveries performed with and 53% of deliveries performed without administration of peripartum hemostatic prophylaxis. Blood loss was significantly higher in deliveries without administration of hemostatic prophylaxis (median 1000 mL) compared to deliveries with administration of prophylaxis (median 400 mL) (p = 0.011). Patients with relatively mild deficiencies also frequently experienced PPH when peripartum hemostatic prophylaxis was omitted. CONCLUSION: PPH is common in rare coagulation factor deficiencies, both severe and mild, and fibrinolytic disorders, especially when peripartum prophylactic hemostatic treatment was not administered. The use of prophylactic hemostatic treatment was associated with less postpartum blood loss.

Postpartum hemorrhage can occur unexpectedly and with high dynamics. The mother's life often depends on quick action and good communication within an interdisciplinary team. Knowledge of each other's therapeutic options plays a major role. Treatment procedures include obstetric, surgical, and radiologic techniques. In addition to availability and experience with the techniques, two important aspects must be considered in the selection process: the type of delivery and the cause of the hemorrhage. In particular, the distinction between pregnancies with or without disturbed placentation from the placenta accreta spectrum is crucial. From these two points of view, we discuss here different uterus-preserving and uterus-removing techniques. We describe in detail the advantages and disadvantages of each procedure. Because most therapeutic options are based on small case series and uncontrolled studies, local circumstances and physician experience are critical in setting internal standards.

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide (WHO), with almost 60000 deaths annually. Pregnancy is a prothrombotic state with increased levels of several coagulation factors to protect the parturient from bleeding problems during delivery. Fibrinogen has a significant role in coagulation and bleeding. Studies have pointed out that lower fibrinogen levels before delivery, but also at the initiation of PPH, are predictive of major hemorrhage. Early, the goal-directed fibrinogen concentrate therapy might be very useful in a subgroup of patients with serious PPH. This review aims to summarize the current literature on fibrinogen during PPH.

Congenital factor VII (FVII) deficiency is an inherited bleeding disorder, with heterogenous bleeding symptoms. Women with FVII deficiency face hemostatic challenges during menstruation, ovulation, and childbirth. This systematic review evaluated prevalence and management of bleeding symptoms associated with gynecological and obstetric issues in women with FVII deficiency.Databases (BIOSIS Previews, Current Contents Search, Embase, and MEDLINE) were searched for studies reporting FVII deficiency and gynecological or obstetric issues in women. Articles were screened using Joanna Briggs Institute checklists and relevant data extracted.One hundred fourteen women were identified from 62 publications. Forty-six women had severe deficiency (FVII:C 5% or5 IU/dl). Heavy menstrual bleeding (HMB) was the most common bleeding symptom (n = 94; 82%); hospitalization and urgent medical/surgical interventions for acute HMB episodes were required in 16 women (14%). Seven women reported ovarian bleeding (6%); other bleeding symptoms varied. Patient management was inconsistent and included hemostatic and hormonal treatments. Only four women (7%) reporting vaginal bleeding during pregnancy. Postpartum hemorrhage (PPH) occurred following 12/45 deliveries (27%; 5 [42%] requiring blood transfusion) and was not necessarily prevented by prophylaxis (8 women).Women with congenital FVII deficiency have an increased risk of HMB, ovarian bleeding, and PPH, impacting quality of life. Recognition of a bleeding disorder as the cause is often delayed. Management of bleeding complications is heterogeneous due to lack of treatment guidelines. Harmonizing severity classification of FVII deficiency may help standardize treatment strategies and development of specific guidelines for these women.

Systems to optimize the management of postpartum hemorrhage must ensure timely diagnosis, rapid hemodynamic and hemostatic resuscitation, and prompt interventions to control the source of bleeding. None of these objectives can be effectively completed by a single clinician, and the management of postpartum hemorrhage requires a carefully coordinated interprofessional team. This article reviews systems designed to standardize hemorrhage diagnosis and response.

International audience; BackgroundThe optimal dose of tranexamic acid to inhibit hyperfibrinolysis in postpartum haemorrhage is unclear. Tranexamic Acid to Reduce Blood Loss in Hemorrhagic Cesarean Delivery (TRACES) was a double-blind, placebo-controlled, randomised, multicentre dose-ranging study to determine the dose–effect relationship for two regimens of intravenous tranexamic acid vs placebo.MethodsWomen experiencing postpartum haemorrhage during Caesarean delivery were randomised to receive placebo (n=60), tranexamic acid 0.5 g (n=57), or tranexamic acid 1 g i.v. (n=58). Biomarkers of fibrinolytic activation were assayed at five time points, with inhibition of hyperfibrinolysis defined as reductions in the increase over baseline in D-dimer and plasmin–antiplasmin levels and in the plasmin peak time.ResultsIn the placebo group, hyperfibrinolysis was evidenced by a mean increase over baseline [95% confidence interval] of 93% [68–118] for D-dimer level at 120 min and 56% [25–87] for the plasmin–antiplasmin level at 30 min. A dose of tranexamic acid 1 g was associated with smaller increases over baseline (D-dimers: 38% [13–63] [P=0.003 vs placebo]; plasmin–antiplasmin: –2% [–32 to 28] [P=0.009 vs placebo]). A dose of tranexamic acid 0.5 g was less potent, with non-significant reductions (D-dimers: 58% [32–84] [P=0.06 vs placebo]; plasmin–antiplasmin: 13% [18–43] [P=0.051]). Although both tranexamic acid doses reduced the plasmin peak, reduction in plasmin peak time was significant only for the 1 g dose of tranexamic acid.ConclusionsFibrinolytic activation was significantly inhibited by a dose of intravenous tranexamic acid 1 g but not 0.5 g. Pharmacokinetic–pharmacodynamic modelling of these data might identify the best pharmacodynamic monitoring criteria and the optimal tranexamic acid dosing regimen for treatment of postpartum haemorrhage.

Accurate noninvasive prenatal diagnosis of placenta accreta spectrum (PAS) disorder is critical for delivery management.To evaluate the diagnostic ability of MRI features in predicting the PAS, invasive depth and postpartum hemorrhage (PPH) in high-risk gravid patients.Between February 2019 and November 2020, women with ultrasound (US)-suspected PAS were enrolled. With the exclusion criteria, 80 women were included in the study. Two experienced genitourinary radiologists reviewed and recorded the MRI features. The chi square test was used to compare the effectiveness of MRI features. Relative risk ratios were computed to test the association of intraplacental T2-hypointense bands with poor outcomes of cesarean section. Receiver operating characteristic (ROC) analyses based on the number and area of intraplacental T2-hypointense bands were used to predict PAS, invasion depth, and PPH.PAS was diagnosed in 56 of 80 women (70%). At delivery, 24 of 80 women (30%) experienced PPH (≥1000 mL). Intraplacental T2-hypointense bands were detected at MRI in 28 of 56 women with PAS (50%). The relative risk ratio of intraplacental T2-hypointense bands was 1.51 for PAS, 3.17 for depth of PAS invasiveness and 4.74 for PPH. The largest areas of intraplacental T2-hypointense bands for predicting PAS, invasion depth and PPH were 0.66 cmThe appearance of intraplacental T2-hypointense bands has important diagnostic value for PAS, its invasion depth and PPH. The area of the largest T2-hypointense band in the placenta can predict poor outcomes of cesarean section.

The use of viscoelastic haemostatic assays (VHAs) to guide blood product replacement during postpartum haemorrhage is expanding. Rotem and TEG devices can be used to detect and treat clinically significant hypofibrinogenaemia, although evidence to support the role of VHAs for guiding fresh frozen plasma and platelet transfusion is less clear. If Rotem/TEG traces are normal, clinicians should investigate for another cause of bleeding, and haemostatic support is not required. Guidelines support the use of VHAs during postpartum haemorrhage as part of locally agreed algorithms. There is a wide consensus that fibrinogen replacement is needed if the Fibtem A5 is12 mm and if there is ongoing bleeding. Guidelines recommend against using VHAs to guide tranexamic acid infusion, and this drug should be given as soon as bleeding is recognised, irrespective of the Rotem/TEG traces. The cost-effectiveness of VHAs during postpartum haemorrhage needs to be addressed.

Reproductive tract bleeding is an underappreciated health care problem among adolescent and young adult (AYA) females with inherited bleeding disorders (IBDs) comprising von Willebrand disease, platelet disorders, hemophilia carriership, and rare factor deficiencies. IBDs are prevalent in women of all ages and have been detected in about 50% of women with menorrhagia or heavy menstrual bleeding (HMB) and about 20% of women with postpartum hemorrhage (PPH). The clinical spectrum of gynecologic and obstetric bleeding in AYA with IBDs ranges from HMB, ovulation bleeding, and surgical bleeding to miscarriages and life-threatening PPH. Reproductive tract bleeding adversely affects the quality of life of this patient population, in addition to causing substantial morbidity and mortality. Early diagnosis of IBDs offers the opportunity for timely intervention with hormones, hemostatic agents, and prophylaxis with factor concentrates, thereby improving outcomes. This review summarizes the epidemiology, pathophysiology, clinical manifestations, diagnostic approach, management, and prophylaxis for reproductive tract bleeding in AYA with IBDs. This review provides a multidisciplinary approach to the problem, which is critical to improve the outcomes of this patient population.

The use of tranexamic acid for postpartum hemorrhage has entered obstetric practice globally with the evidence-based expectation of saving lives. This improvement in the care of women with postpartum hemorrhage has come at a price. For the anesthetist, having tranexamic acid ampoules close at hand would seem an obvious strategy to facilitate its use during caesarean delivery, an important setting for severe hemorrhage. Tragically, we have identified a number of recent instances of inadvertent intrathecal administration of tranexamic acid instead of local anesthetic for spinal anesthesia. Reported cases of this catastrophic error appear to be increasing. The profound neurotoxicity of tranexamic acid causes rapid-onset convulsions, with mortality of 50%. How can these tragic errors be averted? Drug safety alerts have been issued by the US Food and Drug Administration and the World Health Organization, but that is not enough. We recommend extensive dissemination of information to raise awareness of this potential hazard; and local hospital protocols to ensure that tranexamic acid is stored separately from anesthetic drugs, preferably outside the operating room and with an auxiliary warning label. Implementation of safety strategies on a very large scale will be needed to ensure that the life-saving potential of tranexamic acid is not eclipsed by drug error mortality.

Patients with a bleeding tendency with normal laboratory tests have been described as having an unclassified bleeding disorder or bleeding disorder of unknown cause (BDUC). There are very little data available on how to manage pregnancy.To study management and outcomes of these patients at four United Kingdom hemophilia comprehensive care centers.Retrospective case note review from 2010-2020.Sixty deliveries in 36 patients were recorded. The median International Society on Thrombosis and Haemostasis bleeding assessment tool score was 9. In 54 cases for which data were available, the odds ratio for post partum hemorrhage (PPH) was 6.3 for no primary hemostatic prophylaxis versus prophylaxis (95% confidence interval 1.2-34.2, p .05); 7/9 (78%) versus 16/45 (36%) PPH incidence for the groups, respectively. Hemostatic prophylaxis was with tranexamic acid but some patients received desmopressin or platelet infusions. Secondary PPH was seen in 5/60 (8%) of cases. No neonatal bleeding complications or maternal thromboembolic complications were noted. Avoidance of regional anesthesia and fetal delivery precautions were commonly advised, but in the small number of cases in which they occurred no complications were noted.Despite hemostatic prophylaxis PPH was commonly seen. Further prospective studies of BDUC patients are required to determine optimal management in pregnancy as well as determine the pathophysiological basis of bleeding.

Background Clinical judgment is one of the crucial skills necessary for nurses to practice safely and support positive patient outcomes. Inpatient nurse educators often seek engaging and meaningful methods of providing important learning to bedside nurses. Method A game-based learning (GBL) activity, originally created to enhance clinical judgment in the management of post-partum hemorrhage (PPH) for undergraduate nursing students, was replicated for RNs' continuing education on an obstetric unit. Results Although less remarkable than undergraduate students' scores, RNs' scores improved significantly ( p < .05) for every aspect of the clinical judgment model applied to PPH (recognition, analysis, action, evaluation) from pre- to posttest after using the GBL activity. Conclusion GBL is effective for enhancing the clinical judgment ability of RNs for specific topics such as PPH and can be utilized to support education across a continuum of expertise for those in, or preparing for, direct patient care. [ J Contin Educ Nurs . 2022;53(11):500–504.]

To reproduce the absence of postpartum hemorrhage (PPH) experienced by all mammals except humans, in humans, by implementation of the 1, 2, 3 min expedient squatting protocol www.youtube.com/watch?v=AAJPW4p6rzU. The protocol prevents postpartum hemorrhage ≥ 500 mL after vaginal birth. It only requires a digital watch to precisely time 2 min.Mean blood loss and PPH rate are reported for 2,149 consecutive planned, attended vaginal births using the 1, 2, 3 min squatting third stage protocol.Blood loss; PPH ≥ 1000 mL.Expedient delivery of the placenta in squatting within 3-5 min postpartum resulted in an average blood loss of 100 mL in the first 2 h after birth and no cases of PPH ≥ 500 mL in the first 24 h after birth. The lowest previously published PPH ≥ 1000 mL rate at vaginal birth is 4 %. The PPH ≥ 1000 mL using Active Management is 5 %.Less bleeding occurs when women expediently push out the placenta within 3 min of the birth of the newborn, in squatting, taking advantage of the still open cervix, gravity, and the increased effectiveness of their diaphragm and abdominal muscles.

© 2022 Elsevier B.V. All rights reserved., Introduction: Postpartum hemorrhage (PPH) is mostly caused by uterine atony and is the leading cause of maternal death. Hysterectomy may be necessary in severe cases, but uterine compressive sutures are an uterine-sparing alternative. In 2005, Alcides Pereira proposed a technique with serial superficial stiches around the uterus. To date, there were no further reports on its clinical use. Objective: To evaluate a tertiary center's experience with Alcides-Pereira's compressive uterine sutures for severe PPH due to uterine atony, reviewing its efficacy, morbidity, and impact on reproductive outcomes. Study design: An 11-year retrospective cohort study of Alcides-Pereira's sutures for PPH at a single tertiary hospital. Demographic and obstetric data were collected. Details of subsequent pregnancies and fertility plans were collected through a telephonic interview. Comparison between women in which the sutures were effective and ineffective to prevent hysterectomy was made. Results: Alcides-Pereira's sutures were applied in 23 patients with PPH due to uterine atony. The technique was successful in controlling the hemorrhage and avoiding hysterectomy in 20 patients (87%). When successful, the sutures avoided the need for any blood therapy in 55% (RR 0.45, 95% CI 0.28-0.73) of patients, intensive care unit admission in 80% (RR 0.2, 95% CI 0.08-0.48) and significantly shortened the length of hospital stay. All patients with preserved uterus resumed their usual menstrual pattern. One had a subsequent term vaginal delivery; one had three first trimester miscarriages. All other patients did not try to conceive. Conclusion: Alcides-Pereira's sutures are a feasible, uterine-sparing technique, providing an effective and safe option for PPH.

We analysed whether immediate skin-to-skin contact between the healthy newborn and the mother after a caesarean section has a modulatory role on postpartum haemorrhage and uterine contraction. Unblinded, randomized clinical trial, simple random sampling, conducted in women undergoing caesarean sections. Of the population identified, the caesarean section total (N = 359), 23.2% (N = 83) met the inclusion criteria: scheduled caesarean section, accepting skin-to-skin contact, good level of consciousness. They were randomly allocated to the intervention group, skin-to-skin contact (N = 40), and to the control group, usual procedure (N = 40). There were three losses. Clinical variables: plasma haemoglobin, uterine contraction, breastfeeding, postoperative pain, were measured, and subjective variables: maternal satisfaction, comfort, comparison with previous caesarean section and newborn crying. Women with skin-to-skin contact had greater uterine contraction after caesarean section. The maternal plasma haemoglobin levels at discharge were significantly higher. It was associated with higher breastfeeding rate, satisfaction, comfort levels and with less maternal pain and less crying in the newborn.

Major haemorrhage is a leading cause of morbidity and mortality worldwide. Successful treatment requires early recognition, planned responses, readily available resources (such as blood products) and rapid access to surgery or interventional radiology. Major haemorrhage is often accompanied by volume loss, haemodilution, acidaemia, hypothermia and coagulopathy (factor consumption and fibrinolysis). Management of major haemorrhage over the past decade has evolved to now deliver a 'package' of haemostatic resuscitation including: surgical or radiological control of bleeding; regular monitoring of haemostasis; advanced critical care support; and avoidance of the lethal triad of hypothermia, acidaemia and coagulopathy. Recent trial data advocate for a more personalised approach depending on the clinical scenario. Fresh frozen plasma should be given as early as possible in major trauma in a 1:1 ratio with red blood cells until the results of coagulation tests are available. Tranexamic acid is a cheap, life-saving drug and is advocated in major trauma, postpartum haemorrhage and surgery, but not in patients with gastrointestinal bleeding. Fibrinogen levels should be maintained 2 g.l

Uterine contraction is crucial for a successful labor and the prevention of postpartum hemorrhage. It is enhanced by hypoxia; however, its underlying mechanisms are yet to be elucidated. In this study, transcriptomes revealed that hypoxia-inducible factor-1alpha was upregulated in laboring myometrial biopsies, while blockade of hypoxia-inducible factor-1alpha decreased the contractility of the myometrium and myocytes in vitro via small interfering RNA and the inhibitor, 2-methoxyestradiol. Chromatin immunoprecipitation sequencing revealed that hypoxia-inducible factor-1alpha directly binds to the genome of contraction-associated proteins: the promoter of Gja1 and Ptgs2, and the intron of Oxtr. Silencing the hypoxia-inducible factor-1alpha reduced the expression of Ptgs2, Gja1, and Oxtr. Furthermore, blockade of Gja1 or Ptgs2 led to a significant decrease in myometrial contractions in the hypoxic tissue model, whereas atosiban did not remarkably influence contractility. Our study demonstrates that hypoxia-inducible factor-1alpha is essential for promoting myometrial contractility under hypoxia by directly targeting Gja1 and Ptgs2, but not Oxtr. These findings help us to better understand the regulation of myometrial contractions under hypoxia and provide a promising strategy for labor management and postpartum hemorrhage treatment.

We aimed to evaluate the clinical outcomes and adverse events of preventive B-Lynch suture performed during cesarean section in patients at a high risk of postpartum hemorrhage.This retrospective observational study included patients who underwent a cesarean section and the B-Lynch suture at a tertiary perinatal medical center between January 2019 and May 2021. The B-Lynch sutures were placed preventively before excessive blood loss occurred in patients with uterine atony, placental position abnormality (placenta previa and low-lying placenta), placenta accreta, thrombocytopenia, coagulopathy, and other risk factors of bleeding. Partial compression sutures for bleeding points and vaginal gauze packing were placed if required.The B-Lynch suture was performed in 38 patients, and hysterectomy was avoided in all patients. Only one patient required intrauterine balloon tamponade as an additional treatment 5 days after the cesarean section. No apparent postoperative bleeding occurred within 2 h after the cesarean section in 35 patients (92%), and blood transfusion was avoided in 14 patients (37%). Thirty-three adverse events occurred in 23 patients; these included an inflammatory response, hematomas, retained products of conception, and ileus in one, two, and two patients, respectively. In most cases, the events were not severe and were unrelated to the procedure. In one patient, a second-look operation was performed and no complications were observed in the uterus and abdominal cavity.Preventive B-Lynch suture seemed effective and safe after a short-term observation. When excessive bleeding is expected during a cesarean section, an early introduction of this procedure is recommended.

Low molecular weight heparin (LMWH) has been given to reproductive-age women with various indications. This study aims to assess the benefits and risks of such use.We retrospectively reviewed data (n = 204) between Jan 2016 and May 2019. Logistic regression analysis was conducted to evaluate the correlation between indications and reproductive outcomes.LMWH use had higher odds of live birth in women less than 30 years of age (OR: 4.98; 95% CI = 1.13-21.98; p = 0.034) and with protein S deficiency (OR: 3.90; 95% CI = 1.77-8.59; p = 0.001). For the subgroup of recurrent pregnant loss, LMWH use was only advantageous to women with protein S deficiency (OR: 2.45; 95%:1.01-5.97; p = 0.048). Risks such as preterm delivery, small-for-gestational-age, placental abruption, antepartum/postpartum hemorrhage were not significantly increased among subgroups. Women treated with LMWH and who had successful live births (n = 171) had a slightly increased risk of postpartum hemorrhage compared to controls (n = 8058) during this period in our institution (2.9% vs 1.2%, p 0.001).LMWH administration produces a higher chance of live-birth to women younger than 30 years of age or with protein S deficiency. However, risk of postpartum hemorrhage is increased.

Higher rates of postpartum hemorrhage (PPH) have been reported for women with von Willebrand disease (VWD). Comprehensive multidisciplinary care reduces these rates; thus PPH may not be secondary to VWD.We conducted a retrospective review for the period of 2009-2018, including all VWD pregnancies at 2 tertiary care academic hospitals to determine rates, etiology, and timing of PPH.A total of 63 women with 80 pregnancies were included. Three women had twin pregnancies. Sixty-six pregnancies (82.5%) involved type 1 VWD; 4 (5.0%), type 2 (unclear subtype); 3 (3.8%) type 2A; 3 (3.8%) type 2B; and 2 (2.5%), type 2M. Median age of patients was 32.9 years (range 19-43 y). Most patients were blood type O (65%), and 33 of 80 pregnancies (41.3%) were nulliparous. The mean bleeding assessment score was 8 (range 0-16). Thirty-seven pregnancies (46.3%) received prophylactic hemostatic treatment prior to delivery. Seventy-four percent of pregnancies were delivered vaginally, and 88% received epidural anaesthesia. The majority of pregnancies (78.8%) had von Willebrand factor (VWF) levels assessed during the third trimester, with most (71.3%) achieving VWF levels above 1.00 IU/mL. Four pregnancies (5.2%) were complicated by primary PPH; uterine atony in 2 and placenta previa in 1. Delayed postpartum bleeding occurred in 5 pregnancies (6.3%).Multidisciplinary care of pregnancies with VWD improves outcomes. Rates of primary and delayed PPH in this study are lower than previously described and are similar to those of women without VWD. In women with VWD, uterine etiologies for primary PPH need to be considered, in a manner similar to the assessment of women without VWD, to ensure hemostasis is achieved.

Objective: To develop and validate (both internally and externally) a prediction model examining a combination of risk factors in order to predict postpartum haemorrhage (PPH) in a general obstetric Irish population of singleton pregnancies. Study design: We used data from the National Maternal and Newborn Clinical Management System (MN-CMS), including all singleton deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019. We defined PPH as an estimated blood loss of = 1000 ml following the birth of the baby. Multivariable logistic regression with backward stepwise selection was used to develop the prediction model. Candidate predictors included maternal age, maternal body mass index, parity, previous caesarean section, assisted fertility, gestational age, fetal macrosomia, mode of delivery and history of PPH. Discrimination was assessed using the area under the receiver operating characteristic curve (ROC) C-statistic. We used bootstrapping for internal validation to assess overfitting, and conducted a temporal external validation using data from all singleton deliveries at CUMH during 2020. Results: Out of 6,077 women, 5,807 with complete data were included in the analyses, and there were 270 (4.65%) cases of PPH. Four variables were considered the best combined predictors of PPH, including parity (specifically nulliparous), macrosomia, mode of delivery (specifically operative vaginal delivery, emergency caesarean section and prelabour caesarean section), and history of PPH. These predictors were used to develop a nomogram to provide individualised risk assessment for PPH. The original apparent C-statistic was 0.751 (95% CI: 0.721, 0.779) suggesting good discriminative performance. There was minimal optimism adjustment to the C-statistic after bootstrapping, indicating good internal performance (optimism adjusted C-statistic: 0.748). Results of external validation were comparable with the development model suggesting good reproducibility. Conclusions: Four routinely collected variables (parity, fetal macrosomia, mode of delivery and history of PPH) were identified when predicting PPH in a general obstetric Irish population of singleton pregnancies. Use of our nomogram could potentially assist with individualised risk assessment of PPH and inform clinical decision-making allowing those at highest risk of PPH be actively managed.

Background Postpartum Hemorrhage (PPH) is one of the main causes of maternal mortality, mainly in the poorest regions of the world, drawing attention to the need for strategies for preventing it. This study aims to evaluate the efficacy of prophylactic administration of Tranexamic Acid (TXA) in decreasing blood loss in pregnant women in delivery, preventing PPH. Methods Systematic review of randomized clinical trials. We searched for publications in PubMed, EMBASE and Cochrane Library databases, with the uniterms “postpartum, puerperal hemorrhage” and “tranexamic acid”, published between January of 2004 and January of 2020. The eligibility criteria were trials published in English with pregnant women assessed during and after vaginal or cesarean delivery about the effect of prophylactic use of TXA on bleeding volume. The random-effects model was applied with the DerSimonian-Laird test and the Mean Difference (MD) was calculated for continuous variables together with each 95% CI. This systematic review was previously registered in the PROSPERO platform under the registration n° CRD42020187393. Results Of the 630 results, 16 trials were selected, including one with two different doses, performing a total of 6731 patients. The intervention group received a TXA dose that varied between 10 mg.kg−1 and 1g (no weight calculation). The TXA use was considered a protective factor for bleeding (MD: -131.07; 95% CI: -170.00 to -92.78; p= 0.000) and hemoglobin variation (MD: -0.417; 95% CI: -0.633 to -0.202; p= 0.000). In the subgroup analysis related to the cesarean pathway, the effect of TXA was even greater. Conclusion The prophylactic use of tranexamic acid is effective in reducing the post-partum bleeding volume. PROSPERO registration ID CRD42020187393.

Although the rates of adolescent pregnancies appear to have dropped according to the World Health Organization (WHO), the decrease in the age of the first menarche and better nutrition seems to contribute to the otherwise high rate of adolescent pregnancy worldwide, despite the efforts of different organizations to improve upon this trend. We conducted a population-based retrospective cohort study from January 2015 to December 2021 using our hospitals’ database. We totaled 2.954 adolescent and 6.802 adult pregnancies. First, we compared younger adolescents’ outcomes with those of older adolescents, as well as with adolescents aged between 18 and 19 years old; secondly, we compared adolescent pregnancies with adult ones. We detected higher percentages of cephalo-pelvic disproportion (43.2%), cervical dystocia (20.7%), and twin pregnancy (2.7%) in underage adolescents compared with 32%, 14.1%, and 1% in older underage adolescents, respectively, and 15.3%, 3.1%, and 0.6% in older ones. As teens became older, the likelihood of malpresentations and previous C-sections rose, whereas the likelihood of vaginal lacerations declined. When comparing adolescents with adult women, we found more cases that required episiotomy (48.1% compared with 34.6%), instrumental delivery (2.1% compared with 1%), and cervical laceration (10.7% compared with 8.4%) in the adolescent group, but the rates of malpresentation (11.4% compared with 13.5%), previous C-section (13.9% compared with 17.7%), and placenta and vasa praevia (4.5.6% compared with 14%) were higher in the adult women group. Adolescent pregnancy is prone to being associated with higher risks and complications and continues to represent a challenge for our medical system.

Sheehan’s syndrome (SS) is ischaemic necrosis of the pituitary gland due to massive postpartum haemorrhage. The clinical manifestations may vary from subtle to life-threatening and may present immediately after delivery or many years later. We present a case history of a 58-year-old non-diabetic woman who had undetected SS and presented with two unusual manifestations, including recurrent hypoglycaemia and dilated cardiomyopathy 34 years after delivery. The dilated cardiomyopathy reversed partially after treatment.

Background and Objectives: Postpartum hemorrhage (PPH) is an obstetrical emergency and although the mortality rate from PPH has decreased, it is still considered a challenge in obstetrics. This study aimed to estimate the rate of primary PPH, as well as to investigate the potential risk factors and management options. Material and methods: This was a retrospective case-control study of all cases with PPH (blood loss > 500 mL, irrespective of the mode of delivery) managed in the Third Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Greece, from 2015 to 2021. The ratio of cases to controls was estimated to be 1:1. The chi-squared test was used to examine if there was any relationship between several variables and PPH, while subgroup multivariate logistic regression analyses of certain causes of PPH were also conducted. Results: During the study period, from a total of 8545 births, 219 (2.5%) pregnancies were complicated with PPH. A maternal age > 35 years (OR: 2.172; 95% CI: 1.206–3.912; p = 0.010), preterm delivery (

Objective: Tranexamic acid (TXA) is a cost-effective intervention for the prevention of postpartum hemorrhage (PPH) in women undergoing cesarean section but the evidence to support its use is conflicting. We conducted this meta-analysis to evaluate the efficacy and safety of TXA in low- and high-risk cesarean deliveries. Data sources: We searched MEDLINE (via PubMed), Embase, the Cochrane Library, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform (ICTRP) portal from inception to April 2022 (updated October 2022 and February 2023) with no language restrictions. Additionally, grey literature sources were also explored. Study eligibility criteria: All randomized controlled trials (RCTs) investigating the prophylactic use of intravenous TXA in addition to standard uterotonic agents in women undergoing cesarean deliveries as compared to placebo, standard treatment, or prostaglandins were included in this meta-analysis. Methods: We used the revised Cochrane "Risk of Bias" tool (RoB 2.0) to assess the quality of included RCTs. RevMan 5.4 was used to conduct all statistical analyses under a random-effects model. Results: We included 50 RCTs (6 in only high-risk patients and 2 with prostaglandins as the comparator) evaluating TXA in our meta-analysis. TXA reduced the risk of blood loss >1000 mL, mean total blood loss, and the need for blood transfusion in both low- and high-risk patients. TXA was associated with a beneficial effect in our secondary outcomes including decline in hemoglobin levels and the need for additional uterotonic agents. TXA increased the risk of non-thromboembolic adverse events but, based on limited data, did not increase the incidence of thromboembolic events. The administration of TXA before skin incision, but not after cord clamping, was associated with a large benefit. The quality of evidence was rated as low to very low for outcomes in the low-risk population and moderate for most outcomes in the high-risk subgroup. Conclusions: TXA may reduce the risk of blood loss in cesarean deliveries with a higher benefit observed in high-risk patients but the lack of high-quality evidence precludes any strong conclusions. Additional studies, especially in the high-risk population and evaluating the timing of TXA administration, are needed to confirm or refute these findings.

Postpartum haemorrhage is a common complication of pregnancy, most commonly due to uterine atony. Uterotonics have a vital role in preventing postpartum haemorrhage but the choice of the most effective agent with the fewest adverse effects is a subject of debate. Carbetocin, a synthetic analogue of oxytocin has been available in the UK since 2007 but is not currently widely used. It has a longer duration of action than oxytocin, which avoids the need for an infusion and as it is heat-stable it can be stored at room temperature. Current UK clinical guidelines, based on the results of older meta-analyses, do not recommend carbetocin as a first-line agent. ACochranereview, published in 2018, ranked carbetocin in the top three drug regimens for preventing postpartum haemorrhage and an international consensus statement on uterotonic use for caesarean birth concluded that carbetocin may become the preferred drug for caesarean birth, by reducing the need for additional uterotonics. The higher cost of carbetocin when compared with oxytocin is a limiting factor, but the significant healthcare costs of a postpartum haemorrhage and the physiological impact of this event suggests it a reasonable alternative to consider, especially if ergometrine is contraindicated or in those who are undergoing a caesarean birth or are at high risk of bleeding.

Postpartum hemorrhage is an obstetric emergency with a rising incidence. The aim of this study was to identify trends in the specific contribution of various risk factors for postpartum hemorrhage by observing their odds ratios throughout different time periods.In this population-based retrospective cohort study trends of change in odds ratios for known risk factors for postpartum hemorrhage occurring in three consecutive eight-year intervals between 1988 and 2014 were compared. Two multivariable logistic regression models were used in order to identify independent risk factors for postpartum hemorrhage in our population. Trends of various risk factors were compared along the time period of the study.The incidence of postpartum hemorrhage increased from 0.5% to 1988 to 0.6%. Using logistic regression models, preeclampsia, vacuum extraction delivery, retained placenta, perineal or vaginal tears and delivery of a large for gestational age neonate were recognized as independent risk factors for postpartum hemorrhage. While the odds ratios for perineal or vaginal tears significantly increased, odds ratios for delivery of a large for gestational age neonate significantly decreased. Odds ratios for the other risk factors did not change significantly.In our study, not only did the rates of statistically significant risk factors for postpartum hemorrhage change during the study period, the specific contribution of each risk factor changed as well. Having a better understanding of these trends might augment our ability to predict this grave obstetric complication and improve maternal outcomes in the future.

The aim of this before and after study was to evaluate the efficacy of a complex operative obstetrics course in improving practitioner confidence. The course covered rotational instrumental vaginal delivery, vaginal breech delivery, cervical cerclage, management of postpartum haemorrhage, and complex caesarean section. Participants filled in a pre- and postcourse questionnaire using a Likert scale to rate confidence from 1 (not confident) to 5 (very confident) in 15 key skills. Data were analysed using a two-sample

To examine the extent of hospital-level variation in risk-adjusted rates of postpartum hemorrhage (PPH).We performed a cross-sectional study examining live births in 257 California hospitals between 2011 and 2015 using linked birth certificate and maternal discharge data. PPH was measured using International Classification of Diseases Codes version 9. Mixed-effects logistic regression models were used to examine the presence and extent of hospital-level variation in PPH before and after adjustment for patient-level risk factors and select hospital characteristics (teaching status and annual delivery volume). Risk-adjusted rates of PPH were estimated for each hospital. The extent of hospital variation was evaluated using the median odds ratio (MOR) and intraclass correlation coefficient (ICC).Our study cohort comprised 1,904,479 women who had a live birth delivery hospitalization at 247 hospitals. The median, lowest, and highest hospital-specific rates of PPH were 3.48%, 0.54%, and 12.0%, respectively. Similar rates were observed after adjustment for patient and hospital factors (3.44%, 0.60%, and 11.48%). After adjustment, the proportion of the total variation in PPH rates attributable to the hospital was low, with a MOR of 2.02 (95% confidence interval [CI]: 1.89-2.15) and ICC of 14.3% (95% CI: 11.9%-16.3%).Wide variability exists in the rate of PPH across hospitals in California, not attributable to patient factors, hospital teaching status, and hospital annual delivery volume. Determining whether differences in hospital quality of care explain the unaccounted-for variation in hospital-level PPH rates should be a public health priority.

This study aims to identify whether placental thickness and cervical length measured by MRI correlate with postpartum hemorrhage (PPH) in patients at high risk for placenta accreta spectrum (PAS) disorders.The placental thickness and cervical length of 200 patients from October 2017 to October 2021 were retrospectively measured. The mid-sagittal plane of the placentas was measured by 2 independent radiologists using MRI. Partial correlation analysis was used to characterize the correlation between placental thickness, cervical length and estimated blood loss during surgery. The correlation between clinical features, placental thickness, cervical length and PPH was evaluated with univariate and multivariate analyses. A nomogram was constructed based on the logistic regression.Placental thickness was positively correlated with the estimated blood loss during delivery, while cervical length had a negative correlation with it, based on the adjustment for gestational age. Multivariate analyses revealed that prior cesarean section, placenta previa, increased placental thickness(≧4.35 cm) and short cervical length（3.05 cm） were independent risk factors for PPH. When the 4 risk factors were combined together, the AUC was the highest, 0.773 (95%CI 0.707-0.840).Placental thickness and cervical length correlated with PPH. The nomogram constructed based on prior cesarean section, placenta previa, placental thickness and cervical length can be used to recognize patients with a higher risk of PPH.

Placenta previa greatly contributes to severe antenatal and post-partum hemorrhage. Previous studies have mainly focused on the risk factors of placenta previa, with very few studies reporting which factors may affect the potential resolution of 28th-week previa. This study aimed to investigate the impact of maternal characteristics on potential resolution of placenta previa from the 28th-to the 36th-week of pregnancy.A retrospective longitudinal sub-cohort investigation was carried out among 368 pregnant women with 28th-week previa from the Longitudinal Placenta Previa Study (LoPPS). Logistic regression analysis was used to discover the connections between maternal covariates and the placental potential resolution. Multivariable linear regression analysis was used to detect the associations between perioperative characteristics and volume of intraoperative bleeding.Among pregnant women whose placenta completely or partially covered the internal os at the 28th-week of pregnancy, 37.5% were without placenta previa at the 36th-week and 25.8% converted into marginal placenta previa. There were significant correlation between placenta previa type and GHD (Beta: 2.808, 95% CI: 1.642, 7.138; p = 0.041), type of 28th-week previa (Beta: 6.767, 95% CI: 1.592, 18.767; p 0.001), and number of prior cesarean sections (Beta: 3.326, 95% CI: 1.580, 9.081; p 0.001).62.5% of the pregnant women with 28th-week placenta previa were still with previa at the 36 weeks of gestation (25.8% with marginal and 36.7% with partial/complete placenta previa). This proportion is even higher for 28th-week complete placenta previa.Chinese Clinical Trial Registry ChiCTR2100054068, December 8, 2021.

Background: Pregnancy-related acute kidney injury (PRAKI) is a common problem in the developing world. Materials and methods: In this retrospective observational study at a tertiary care hospital in South India we evaluated records for the maternal, fetal, and renal outcomes in women with PRAKI. Results: Over a 10-year period, 395 patients of PRAKI were seen constituting 8.1% of all acute kidney injury (AKI). The mean age of patients was 27 ± 3 years. A total of 176 (44.5%) had pre-eclampsia, 132 (33.4%) had puerperal sepsis, 76 (19.2%) had antepartum hemorrhage or postpartum hemorrhage (APH 30/PPH 46), nine (2.2%) had hemolytic uremic syndrome (HUS). Obstruction was seen in two patients. Eleven had underlying glomerulonephritis out of three had lupus nephritis. Forty-five of 395 (11.39%) had hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, that is, 25.5% of those with pre-eclampsia. Sixteen (4.0%) had placental abruption. A total of 288 (72.9%) presented postpartum. Renal biopsy done in 103 (26%) showed patchy cortical necrosis (PCN) in 25 (22.3%), diffuse cortical necrosis (DCN) in 23 (20.3%), acute tubular necrosis (ATN) in 20 (19.4%), acute interstitial nephritis (AIN) in 10 (9.7%), while nine (8.7%) had thrombotic microangiopathy (TMA). Glomerular disease was seen in 11. Cortical necrosis (CN) was seen in 48 patients of which 10 (20.83%) had abruption placenta, 25 (52%) had puerperal sepsis, 11 (22.9%) had postpartum hemorrhage (PPH), and two (4.1%) had TMA. A total of 290 (73.4%) required dialysis. About 76% improved while 8.3% progressed to end-stage renal disease (ESRD). Maternal mortality (MM) was 5%. There were 42 intrauterine deaths and 30 deaths in the neonatal period. Discussion: Pregnancy-related acute kidney injury in developing countries is more common as compared to the West. Only 49% patients had booked pregnancy, that is, received regular antenatal care. Apart from pre-eclampsia which is also the major cause in the West and was the etiology in 44% of patients with PRAKI in our study, sepsis (33%) and maternal hemorrhage (19%) were also significant. Immediate recovery from PRAKI was 75% however about 8% develop end-stage kidney disease (ESKD) while in the west ESKD occurred in only about 2%. Conclusion: Pregnancy-related acute kidney injury is an important cause of maternal and fetal morbidity and mortality. Pre-eclampsia emerged as the most common cause of PRAKI and CN was the most common histological lesion. Proper antenatal care and management may improve pregnancy outcomes.

Objective. This study was aimed at investigating the correlation of platelet function with postpartum hemorrhage and venous thromboembolism (VTE) in gestational hypertension patients with diabetes mellitus. Methods. A total of 93 patients with gestational hypertension complicated with diabetes treated from March 2020 to June 2021 were selected as the research group, and 56 healthy pregnant women during the same period were selected as the control group. Platelet function-related indicators (platelet count (PLT), platelet volume distribution width (PDW), and mean platelet volume (MPV)) were compared between the two groups. The patients were divided into a severe group ( n = 13 ), mild group ( n = 28 ), and nonbleeding group ( n = 52 ) according to the severity of postpartum hemorrhage, and the value of combined detection of platelet function-related indicators on the severity of postpartum hemorrhage was evaluated and analyzed. According to the occurrence of VTE, the patients were divided into a VTE group and non-VTE group to analyze the predictive value of combined detection of platelet function-related indicators for VTE occurrence in patients. Results. The PLT value of the study group was lower than that of the control group, while the PDW and MPV values were higher than those of the control group (all P < 0.05 ). The PLT value increased with the aggravation of postpartum hemorrhage, while the PDW and MPV values decreased with the aggravation of postpartum hemorrhage among the three groups with different severities of postpartum hemorrhage (all P < 0.05 ). The area under the curve (AUC) of PLT, PDW, and MPV combination to evaluate the severity of postpartum hemorrhage in patients with gestational hypertension combined with diabetes was greater than that of PLT alone and PDW alone (both P < 0.05 ). The PLT value was negatively correlated with the severity of postpartum hemorrhage, while PDW and MPV values were positively correlated with the severity of postpartum hemorrhage (both P < 0.05 ). According to the occurrence of VTE, patients were divided into the VTE group ( n = 10 ) and non-VTE group ( n = 83 ). The PLT value of the VTE group was higher than that of the non-VTE group, while the PDW and MPV values were lower than those of the non-VTE group (all P < 0.05 ). The AUC of PLT, PDW, and MPV combination to predict the occurrence of VTE in patients with gestational hypertension combined with diabetes was greater than that of each index alone (all P < 0.05 ). Conclusion. Patients with gestational hypertension complicated with diabetes had abnormal platelet function, and the platelet function was related to postpartum hemorrhage and VTE.

Postpartum hemorrhage (PPH) represents total cumulative blood loss in excess of 1,000 ml or blood loss accompanied by signs and/or symptoms of hypovolemia within 24 hr following birth (The American College of Obstetricians and Gynecologists [ACOG], 2017). As a large number of PPHs occur in low-risk women (ACOG, 2019), the emergency nurse practitioner must be prepared to identify and manage this uncommon but life-threatening condition. The etiology, pharmacological management strategies, and other interventions are reviewed in an algorithmic approach. This organized approach not only supports maternal survival during PPH but is also applicable to postprocedural bleeding of obstetric and gynecological etiologies.

Aim: To reassess the normal duration of each stage of labor in a contemporary Japanese cohort, and to determine whether prolongation of each stage of labor increases the rate of postpartum hemorrhage (PPH) in vaginal deliveries. Methods: Clinical data of women who delivered at term at 12 facilities between 2012 and 2018 were retrospectively collected. A total of 31 758 women were subdivided into three or four subgroups according to the duration of each stage of labor and parity. Univariate and multivariate logistic regression analyses were performed to estimate crude and adjusted odds ratios (ORs) of PPH (blood loss ≥ 1000 mL) in each subgroup, with women with the shortest durations in each subgroup used as the reference group. Results: The reference range of each stage of labor was found to be shorter than that previously reported. Women with prolonged second (primiparity, adjusted OR: 1.15–1.78; multiparity, adjusted OR: 1.14–1.74) and third (primiparity, adjusted OR: 1.39–4.95; multiparity, adjusted OR: 1.46–3.80) stages of labor showed an increased risk of PPH, whereas those with prolonged first stage did not. A significantly increased risk of PPH was found both in primiparous and multiparous women with third stages of labor ≥ 5 min. Conclusions: The normal duration of each stage of labor in the Japanese population needs to be revised and well-recognized by obstetric care providers. A prolonged third stage of labor was a more important contributing factor to PPH than prolonged first or second stages.

Objectives Placenta previa is diagnosed in up to 15% of pregnancies at the anatomy ultrasound and 0.5% persist to term. There is limited data regarding pregnancy outcomes with resolved previa. We aimed to examine patients with resolved placenta previa to determine if abnormal placentation at any time during pregnancy is associated with adverse events during labor. Study Design Patients with placenta previa were identified after second trimester ultrasound, included if placenta previa resolved with the placental edge greater than 2 cm from the internal cervical os, and excluded if placenta previa persisted to term, resolution occurred prior to 20 weeks, patients underwent a prior cesarean delivery, or delivered at an outside institution. Time-matched controls were identified among patients with normal placental location. Demographic data and outcomes were collected. Student's t-test, Wilcoxon's rank-sum test, Chi-square, Fisher's exact test, and univariable and multivariable logistic regression were used as appropriate Results Overall, 560 patients had placenta previa, 275 had resolved placenta previa, 285 were excluded. Resolved placenta previa patients were significantly older with lower prepregnancy body mass index (BMI), were significantly more likely to be a current smoker, have used assisted reproductive technology, and have had previous uterine surgeries. Overall, 10.2% of patients with resolved placenta previa experienced postpartum hemorrhage, compared with 2.1% in the normal placentation group. Patients with resolved placenta previa were 5.2 times more likely to have a postpartum hemorrhage (odds ratio [OR] = 5.2, 95% confidence interval [CI]: 2.1–12.7; p Conclusion Patients with resolved placenta previa had a higher rate of postpartum hemorrhage and use of uterotonic agents. This information might have important clinical implications and could be incorporated into the hemorrhage risk assessment during labor. Key Points

At a population level, there is a poor understanding of the incidence and pre-disposing risk factors of postpartum haemorrhage (PPH) among women with inherited bleeding disorders (IBD).To determine the incidence of PPH, and identify maternal factors associated with risk of PPH among women with IBD.We conducted a retrospective cohort study using data housed within ICES (formerly known as the Institute for Clinical Evaluative Sciences). The cohort included women with an in-hospital, live or stillborn delivery, between January 2014 and December 2019. The primary outcome was PPH (identified by ICD-10 code O72). PPH incidence and risk factors were compared between women with and without IBD. Temporal trends were assessed using the Cochrane-Armitage test. Between group differences were assessed using standardised differences (std. difference).Total 601,773 women were included; 2002 (.33%) had an IBD diagnosis. PPH incidence was 1.5 times higher (7.3 vs. 4.9 cases/100 deliveries, std. difference .1) among women with IBD compared to women without. Women with IBD were slightly older (31.7 vs. 30.7 years), had higher rates of hypertension, previous PPH, and induction of labour. Women with IBD were more frequently diagnosed with anaemia (4.8% vs. 1.8%; std difference .17) and had lower haemoglobin levels at admission for delivery compared to women without IBD.This study contributes to the literature regarding obstetric bleeding among women with IBD, showing that anaemia at delivery may be an important risk factor for PPH. Given their predisposition to anaemia, clarifying this relationship will optimise management and outcomes.

To evaluate the efficacy of misoprostol to minimized blood loss during and after cesarean delivery (CD).Screening of MEDLINE, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials from inception to February 2021 using the keywords related to misoprostol, CD, postpartum hemorrhage, and intraoperative blood loss and their MeSH terms.Only RCTs were included. Participants included women undergoing CD whether elective or selective. Thirty studies including 6593 women, 26 in English, 2 in Thai, 1 in French, and 1 in Chinese.Data from all selected studies were extracted independently by two authors. Data extracted included location of the trial, sample size, inclusion and exclusion criteria, participants characteristics, intervention details including timing, dose, and route of drug administration. Outcomes assessed included estimated intraoperative and postoperative blood loss, occurrence of postpartum hemorrhage, the need for additional uterotonics, and hemoglobin difference.Four studies (968 women) compared preoperative to postoperative misoprostol and found a mean difference in intraoperative blood loss of -205.00 (-339.22, -70.77), p = 0.003 and in postoperative blood loss -216.27 (-347.08, -85.46), p 0.001 and a significantly lower need for additional uterotonics with a risk ratio of 0.54 (0.46, 0.64), p 0.00001. Twenty-two studies (4701 participants) compared misoprostol to oxytocin. There was a mean difference in intraoperative blood loss of -108.43 (-156.04, -60.82), p 0.0001. Nine of these trials with 1978 participants evaluated postoperative blood loss. These found a mean difference of -64.12 (-116.19, -12.04) with a p = 0.02. Fourteen trials with 3166 participants measured the difference between preoperative and postoperative hemoglobin. These found a mean difference of -0.25 (-0.35, -0.15) with a p 0.001. Twenty trials with 4416 participants measured the need for administration of additional uterotonics. These found a risk ratio of 0.62 (0.49, 0.78) with a p value of0.001.The combined use of misoprostol and oxytocin during CD is effective in reducing blood loss during and after CD.

Abnormal postpartum hemorrhage is a common problem, complicating 3-5% of vaginal and operative deliveries. In a majority of cases (98%) uterine atony, retained placenta or genital tract lacerations are responsible for excessive blood loss. However, occasionally, serious coagulopathy may occur early after delivery or in specific circumstances such as with placental abruption. Also, when bleeding is caused by uterine atony, retained placenta or vaginal lacerations, a dilutional coagulopathy may develop. Hence correcting coagulation abnormalities is often required. Crucial to manage postpartum coagulopathy is the use of tranexamic acid to reduce hyperfibrinolysis. In the present narrative review, we will discuss the use of tranexamic acid for the prevention and management of major postpartum hemorrhage by reviewing the available literature.

A significant barrier to improving prevention and treatment of postpartum hemorrhage (PPH) is a lack of innovative medicines that meet the needs of women and providers, particularly those in low-and middle-income countries (LMICs). The Accelerating Innovation for Mothers (AIM) project established a new database of candidate medicines under development for five pregnancy-related conditions between 2000 and 2021.To systematically identify and rank candidates for prevention and treatment of PPH.Adis Insight, Pharmaprojects, WHO ICTRP, PubMed, and grant databases were searched to develop the AIM database.AIM database was searched for candidates being evaluated for PPH prevention and treatment, regardless of phase.Candidates were ranked as high, medium, or low potential based on prespecified criteria. Analysis was primarily descriptive, describing candidates and development potential.Of the 444 unique candidates, only 39 pertained to PPH. One was high potential (heat-stable/inhaled oxytocin) and three were medium potential (melatonin, vasopressin and dofetilide via nanoparticle delivery).The pipeline for new PPH medicines is concerningly limited, lacking diversity, and showing little evidence of novel technologies. Without significant investment in early-phase research, it is unlikely that new products will emerge.

To describe maternal deaths from postpartum hemorrhage (PPH) in Kenya by secondary analysis of the Kenya Confidential Enquiry into Maternal Deaths (CEMD) database and clinical audit of a sample of those deaths, and to identify the perceived challenges to implementing country-specific PPH guidelines.A retrospective descriptive study using the Kenyan CEMD database and anonymized maternal death records from 2014-2017. Eight standards from the Kenya National Guidelines for Quality Obstetric and Perinatal Care were selected to perform clinical audit. The process of supporting eight Sub-Saharan African countries to develop country-specific PPH guidelines was described and perceived challenges implementing these were identified.In total, 725 women died from PPH. Most women attended at least one antenatal care visit (67.2%) and most did not receive iron and folate supplementation (35.7%). Only 39.0% of women received prophylactic uterotonics in the third stage of labor. Factors significantly associated with receiving prophylactic uterotonics were place of delivery (χThere is a need for improved quality of care for women to minimize the risk of mortality from PPH, by implementing updated clinical guidelines combined with focused health system interventions.

To explore differences in obstetric practices and clinical outcomes of postpartum hemorrhage (PPH) in Nigerian facilities.A descriptive cross-sectional study of public health facilities providing maternal healthcare services in Nigeria. Surveys were conducted across 38 purposively sampled facilities (January 2020-March 2021) to collect information on obstetric practices related to the management of the third stage of labor, treatment of postpartum hemorrhage, and clinical outcomes related to postpartum hemorrhage in the preceding 12 months.The median number of annual births per facility was 2230 (IQR, 1952-3283). The cesarean section rate was 21.6% (range 2.1%-52.6%). There was large variability in PPH rate (median 3%, range 0.4%-16.8%) and blood transfusions for PPH (median 2.8%, range 0.4%-48.6%) after vaginal birth. There was less variability for laparotomies (median 0.25%, range 0%-2.8%) and maternal deaths (median 0.11%, range 0%-0.64%) due to PPH after vaginal birth. The number of maternal deaths from all causes varied (median 0.27%, range 0%-3.5%). The rates of PPH and adverse maternal outcomes did not vary substantially between state or federal facilities, region, type of facility, and the number of clinical staff.Across the Nigerian facilities surveyed there was large variation in PPH rates and adverse maternal outcomes due to PPH. This variability remains largely unexplained and requires further insights and detailed data to gain a deeper understanding of the root causes and challenges to implement customized solutions to improve maternal outcomes.

Objective: To identify the lessons learned from women who died during pregnancy or childbirth in Lebanon between 2018 and 2020. Method: This is a case series and synthesis of maternal deaths between 2018 and 2020 that were reported by healthcare facilities to the Ministry of Public Health in Lebanon. The notes recorded from the maternal mortality review reports were analyzed using the “Three Delays” model to identify preventable causes and lessons learned. Results: A total of 49 women died before, during, or after childbirth, with hemorrhage being the most frequent cause (n = 16). The possible factors that would have prevented maternal deaths included a prompt recognition of clinical severity, availability of blood for transfusion and magnesium sulfate for eclampsia, adequate transfer to tertiary care hospitals comprising specialist care, and involvement of skilled medical staff in obstetric emergencies. Conclusion: Many maternal deaths in Lebanon are preventable. Better risk assessment, use of an obstetric warning system, access to adequately skilled human resources and medications, and improved communication and transfer mechanisms between private and tertiary care hospitals may avoid future maternal deaths.

Introdução:A Hemorragia Pós-Parto (HPP) é a principal causa direta de morte materna em todo o mundo. Sua principal etiologia consiste na perda dos mecanismos de hemostasia após o parto, sendo que todas as pacientes são suscetíveis a esta complicação. A HPP é uma condição prevalente que necessita de preparo adequado das equipes para que haja intervenção eficaz, oportuna e, consequentemente, menores desfechos negativos.Objetivo:Avaliar o panorama de mortalidadematerna por HPP no Brasil entre os anos de 2016 – 2020, de acordo com raça e faixa etária.Metodologia:Trata-se de um estudo epidemiológico descritivo, de caráter transversal, realizado com coleta de dados de janeiro de 2016 até dezembro 2020 dos casos de mortalidade por HPP no Brasil disponibilizado no banco de dados doDepartamento de Informática do Sistema Único de Saúde do Brasil (DATASUS).Resultados e Discussão:Foi evidenciado uma maior incidência de mortalidade materna por causas obstétricas diretas em pacientes pretas e pardas em comparação a pacientes brancas no Brasil, o que se pode associar a questões demográficas e socioeconômicas. O índice de mortalidade materna foi maior na faixa etária dos 30- 39 anos, quando comparada a dos 20-29 anos, tanto na raça branca quanto na raça preta e parda. A idade materna avançada, por si só, aumenta o risco de morte materna, pois tem maior chance de se associar a : pré-natal inadequado,comorbidades médicas, complicações em gestação anterior e tabagismo.Conclusões:a prevalência de HPP é diretamente proporcional à idade materna. Além disso, foi visto que as raças preta e parda são mais vulneráveis a doenças, já que se encontram sob maiores condições de insalubridade e negligência. Assim, é necessário que as equipes multidisciplinares estejam atentas e bem treinadas, tendo em vista que a prevenção da HPP e condução adequada da mesma em cenários de emergência, de modo que hajam desfechos maternos e fetais positivos.&nbsp

Objectives Postpartum hemorrhage (PPH) is still one of the leading causes of maternal mortality worldwide. Recently effective PPH therapy with uterine packing with the chitosan-covered gauze was shown. This databased retrospective case–control study compares the therapy success of the chitosan tamponade with that of the balloon tamponade and medical therapy only. Methods All women who delivered at a university hospital between May 2016 and May 2019 with PPH were included. Based on the applied therapy, women were divided into three groups: medical therapy only, balloon tamponade and chitosan tamponade. The groups were compared in terms of therapy success, side-effects and reasons for PPH. Primary outcome was the need for surgical/radiological measures including hysterectomy, secondary outcomes were differences in hemoglobin levels, duration of inpatient stay, admission to intensive care unit, number of administered blood products and inflammation parameters. Results A total of 666 women were included in the study. 530 received medical therapy only, 51 the balloon tamponade and 85 the chitosan tamponade. There were no significant differences in the need for surgical therapy, but a significantly lower number of hysterectomies in the chitosan tamponade group than in the balloon tamponade group. There were no relevant differences in secondary outcomes and no adverse events related to the chitosan tamponade. Since the introduction of chitosan tamponade, the number of PPH related hysterectomies dropped significantly by 77.8%. Conclusions The chitosan tamponade is a promising treatment option for PPH. It reduces the postpartum hysterectomy rate without increased side effects compared to the balloon tamponade.