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Objective Methods Results Conclusion To elucidate the demographics, clinical characteristics, and outcomes of patients with postpartum hemorrhage (PPH) who underwent transcatheter arterial embolization (TAE).We conducted a retrospective observational study using the Japanese Diagnosis Procedure Combination inpatient database, which covers roughly 90% of all tertiary emergency hospitals in Japan, between April 2012 to March 2020. We identified patients with PPH who underwent TAE using the Japanese medical procedure status and code, and the device or drug code. We examined the patient characteristics, interventions administered, and clinical outcomes.Among 64 893 patients diagnosed with PPH, we identified 2705 (4.2%) patients with PPH who underwent TAE. The most common cause of PPH was uterine atony (68.7%), followed by disseminated intravascular coagulation after labor (30.0%) and placenta accreta spectrum disorders (23.4%). The proportion of patients who underwent repeat TAE and a hysterectomy was 64 (2.4%) and 188 (7.0%), respectively. Among hysterectomies (n = 188), 26 (13.8%) had the procedure performed before TAE, 73 (38.8%) underwent hysterectomy on the same day as TAE, and 89 (47.4%) had the procedure conducted after TAE. Of those who underwent a hysterectomy after TAE (n = 89), 33 (37%) were performed more than 1‐week after initial TAE. Overall in‐hospital mortality was 14/2705 (0.5%).Even if hemostasis is achieved through TAE, one must be mindful that a hysterectomy may become necessary more than 1 week after the procedure. These results could be helpful in clinical decision making and providing patients with additional treatment options for PPH that preserve patient fertility. [ABSTRACT FROM AUTHOR]

Introduction Material and Methods Results Conclusions In recent decades, centralization of health care has resulted in a number of obstetric unit closures. While studies support better infant outcomes in larger facilities, few have investigated maternal outcomes. We investigated obstetric unit closures over time and whether obstetric volume is associated with onset of labor, postpartum hemorrhage (PPH) and obstetric anal sphincter injury (OASIS).All births registered in Sweden between 1992 and 2019 (Medical Birth Register, N = 2 931 140), linked with data on sociodemographic characteristics and maternal/infant diagnoses, were used to describe obstetric unit closures. After excluding congenital malformations, obstetric volume was categorized (low: 0–1999, medium: 2000–3999, high: ≥4000 births per year). Restricting to 2004 onwards (after most closures), the association between volume and onset of labor (spontaneous as reference) was estimated. Restricting to spontaneous, full‐term (≥37 weeks gestation) cephalic births, we then investigated the association between volume and PPH and, after excluding planned cesarean sections, OASIS. Odds ratios from multilevel (logistic) models clustered by hospital were estimated.The 20 dissolved obstetric units (1992–2019) had relatively stable volume until their closure. Compared to the average, women birthing in the highest volume hospitals were older (31.3 years vs. 30.4) and a higher proportion had >12 years of education (57 vs. 51%). Compared to high‐volume hospitals, there was no significant difference in labor starting by elective cesarean section or induction, rather than spontaneously, among low (OR 0.88, 95% CI: 0.73–1.06) and medium (OR 0.84, 95% CI 0.71–1.01) volume hospitals. There were lower odds of PPH among low (OR 0.72, 95% CI 0.63–0.85) and medium (OR 0.83, 95% CI 0.72–0.97) volume hospitals. No significant association was found between obstetric volume and OASIS (low: OR 0.98, 95% CI 0.82–1.18; medium: OR 0.90, 95% CI 0.77–1.05).There was not a strong relationship between obstetric volume and maternal outcomes. Reduced odds of PPH for women birthing in smaller units may be due to triaging high‐risk pregnancies to larger hospitals. While there was no significant association between obstetric volume and onset of labor or OASIS, other important factors related to closures, such as workload and overcrowding, should be investigated. [ABSTRACT FROM AUTHOR]

Introduction Material and Methods Results Conclusions Cesarean sections are increasing worldwide and are associated with altered risks of complications for both mother and child. Vaginal birth after cesarean section is associated with lower maternal and neonatal morbidity than in repeat cesarean section. Only a few studies have considered the indication for the previous cesarean section to be of importance for the outcome of subsequent labor. The aim of this study was to evaluate whether the indication for a previous cesarean section affects the outcomes at a subsequent delivery in women with induction of labor.This retrospective cohort study of the four largest delivery units in Stockholm during 2012–2015 included 1150 women with one previous cesarean section with induction of labor. Inclusion criteria: women with induced labor and a previous cesarean section, singleton pregnancy, cephalic presentation, gestational age of ≥34 weeks. The women were grouped by indication for the previous cesarean section. Primary outcome: mode of delivery (vaginal birth after previous cesarean section or repeat cesarean section). Secondary outcomes: induction to delivery time, postpartum hemorrhage, uterine rupture. Neonatal outcomes: birth weight, Apgar score <7, arterial umbilical cord blood gas pH <7.0.Our study found that the indication of labor dystocia at the previous cesarean section, increased the risk of repeat cesarean section (aOR 5.35; 95% CI: 1.64–17.50) in women with induction of labor. Other risk factors for repeat cesarean section were birth weight >4000 g, maternal BMI ≥30 or if vaginal prostaglandin was used as the method for induction of labor. A previous vaginal delivery and use of oxytocin increased the chance of a vaginal delivery in this group of women.Our study showed that the indication for the previous cesarean section affects the outcome in the subsequent delivery in women with induction of labor. If the indication for the previous cesarean section was labor dystocia, the risk of repeat cesarean section was increased. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Methods Results Conclusion It is unclear if a history of cesarean birth (CB) is a risk factor for postpartum hemorrhage (PPH) even after a successful planned vaginal birth.A historical retrospective cohort study from all deliveries (42,456) between 2004 and 2019. Inclusion criteria were as follows: (i) women with only one previous CB; (ii) liveborn cephalic singleton pregnancy and term spontaneous labor; (iii) successful planned vaginal birth; (iv) no operative vaginal delivery; and (v) no history of PPH. Women who experienced intrapartum uterine rupture leading to CB were excluded. Those who experienced uterine rupture diagnosed after vaginal birth were not excluded. The labor after cesarean (LAC) group (109 women with previous CB and current vaginal birth) were compared with 2 control groups to consider the parity: control group 1 (1633 nulliparous women) and control group 2 (4197 parous women). The main outcome was the rate of PPH (> 500 mL). Multivariate analysis was performed to investigate whether previous CB was an independent risk factor for PPH. Bivariate analysis and causal framework was used to determine the relation between variables of clinical interest.The PPH rates in the LAC group, control group 1, and control group 2 were 12.8%, 5.3%, and 6.4%, respectively. Irrespective of the group control (1 or 2), a history of CB was associated with an increased risk of PPH: adjusted odds ratio (aOR) 2.38 [95% confidence interval (CI) 1.28–4.44] (adjusted with maternal age, overweight, hyperthermia, and use of oxytocin) and aOR 2.16 [95% CI 1.20–3.87] (adjusted with maternal age and overweight) for Groups 1 (parous) and 2 (nulliparous), respectively.A history of cesarean birth could be a risk factor for PPH even after successful planned vaginal delivery. [ABSTRACT FROM AUTHOR]

Objective To investigate the prenatal diagnosis and perinatal outcomes between anterior placenta accreta and non-anterior placenta. Methods A retrospective analysis was done for 560 pregnant women who were diagnosed with placenta accreta and delivered in the Third Affiliated Hospital of Guangzhou Medical University .According to the location of the placenta, the group was dividing into anterior placenta accreta group (319 cases) and non-anterior placenta accreta group (241 cases). The general characteristics, maternal and infant outcomes of the two groups were analyzed. The non-anterior placenta accrete group (241 cases) then were dividing into two groups according to the time of clear diagnosis. Those who were firstly diagnosed with placenta accrete during or after the operation was the intrapartum diagnosis group (missed diagnosis) (70 cases), and those who were diagnosed with clear placenta accreta before the delivery was prenatal diagnosis group (171 cases). The general characteristics, maternal and infant outcomes of the two groups were also analyzed. Results There were statistically significant differences in the parity, history of cesarean section, delivery mode, degree of placenta accreta, missed diagnosis rate, neonatal birth weight, and hysterectomy rate between the non-anterior placenta accrete group and the anterior placenta accreta group. In the case of prenatal diagnosis of different degrees of placenta accreta, the prenatal diagnosis rate of placental adhesion in the non-anterior placenta accreta group was lower than that of the anterior placenta accreta group, which was statistically significant. In the non-anterior placenta accrete group, there were statistically significant differences in the age, cesarean section history, placenta previa status, mode of delivery, degree of implantation, 24-hour bleeding volume, blood transfusions, NICU transfer rate, uterine loss rate between the intrapartum diagnosis group (missed diagnosis) and the prenatal diagnosis group. Conclusions The high-risk factors of patients with non-anterior placenta accreta are different from those of patients with anterior placenta accreta. Multiple births and a history of cesarean section are high-risk factors for anterior placenta accreta patients. Non-anterior placenta accreta are more likely to be missed diagnosed, especially the placental adhesion. For pregnant women with non-anterior placenta accreta missed diagnosis, there is a high rate of adverse birth outcomes, especially in the rate of neonatal transfer to the NICU. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion To investigate whether induction/augmentation of labor in pregnant women with anemia increases the risk of postpartum hemorrhage (PPH) and whether this risk varied by indications for labor induction/augmentation and by anemia severity in pregnancy.In a prospective cohort study of 9420 pregnant women from 13 hospitals across India, we measured hemoglobin concentrations at recruitment (≥28 weeks of gestation) and blood loss after childbirth during follow‐up and collected clinical information about PPH. Clinical obstetric and childbirth information at both visits were extracted from medical records. Anemia severity in the third trimester was categorized using hemoglobin concentrations (no/mild anemia: hemoglobin ≥10 g/dL; moderate: hemoglobin 7 to 9.9 g/dL; severe: hemoglobin <7 g/dL), while PPH was defined based on blood loss volume (vaginal births: ≥500 mL or cesarean sections: ≥1000 mL) and clinical diagnosis. Indications for labor induction/augmentation were classified as clinically indicated and elective as per guidelines. We performed multivariable modified Poisson regression analyses to investigate the associations of anemia severity and indications for labor induction/augmentation, including their interaction, with PPH, adjusted for potential confounders.PPH was associated with anemia but not with indications for labor induction/augmentation. However, there was a significant interaction between the two factors in relation to PPH (P = 0.003). Among pregnant women with severe anemia, a higher risk of PPH was associated with elective (adjusted risk ratio, 3.44 [95% confidence interval, 1.29–9.18]) but not with clinically indicated (adjusted risk ratio, 1.22 [95% confidence interval, 0.42–3.55]) labor induction/augmentation. No associations were observed among pregnant women with no/mild and moderate anemia.The risk of PPH is higher in women who have moderate–severe anemia in late pregnancy. Induction/augmentation of labor is generally safe for women with anemia, but it can increase the risk of PPH in women with severe anemia if performed electively. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective Design Setting Sample Methods Results Conclusions To understand the experiences of women, birth partners and health professionals of verbal followed by retrospective written consent in a prospective cohort study of a device to manage postpartum haemorrhage (PPH).Grounded Theory.Tertiary facility in North‐West England, UK.We used purposive and theoretical sampling to recruit 51 participants; 12 women, 12 birth partners, 16 obstetricians and 11 midwives.Semi‐structured interviews were conducted, using a topic guide for focus, until data saturation was achieved. Data were analysed using framework analysis technique.Most women wanted sufficient information to make a decision at the time of the event, rather than in advance, and preferred not to be overwhelmed with detail. A key factor in making the decision to participate was a positive and trusting relationship with the attending obstetrician. Obtaining consent for research in emergencies was viewed by obstetricians as requiring a different approach and more challenging than consent for standard procedures in an emergency.This is one of the first studies to explore verbal followed by retrospective written consent processes with women, clinicians and observers. This was acceptable to all, however information needs to be appropriate, and those discussing consent require adequate training (199/200). [ABSTRACT FROM AUTHOR]

Background and Objectives: To develop key performance indicators (KPI) for use in quality assessment of our institutional goal‐directed massive transfusion (GDMT). Materials and Methods: A team comprising our transfusion and emergency medicine departments carried out a cross‐sectional data analysis of GDMT in adult patients from January 2021 to December 2022. The study was rooted in the Define, Measure, Analyse, Improve, Control (DMAIC) approach. Features of KPIs were (a) importance, (b) scientific soundness and (c) feasibility. Study parameters were defined and analysed using measures of central tendencies and benchmark comparison. Results: Ninety‐two massive transfusion events occurred and 1405 blood components were used. Trauma was the leading cause, followed by postpartum haemorrhage and upper gastrointestinal bleeding. Appropriate GDMT activation was observed only in 43.47% of events. The turnaround time (TAT) was within the benchmark in 85.8% of events with an average of 16 ± 10 min. The average utilization of blood components was 20.5 (interquartile range [IQR] = 11.3) in the appropriate group and 5.5 (IQR = 4.25) in the inappropriate group with a wastage rate of 3.5%. Duration of activation was 6.19 ± 4.59 h, and the adherence to thromboelastography was 66.3%. Overall mortality was 45.65%, and the average duration of hospital stay was 6.1 ± 5.9 days. Conclusion: The KPIs developed were easy to capture, and the analysis provided a comprehensive approach to the quality improvement of the GDMT protocol. [ABSTRACT FROM AUTHOR]

Background: Placenta previa is an obstetric complication related to severe maternal morbidity and mortality. Magnetic resonance imaging (MRI) can be used for the preoperative evaluation of postpartum hemorrhage. Purpose: To investigate the value of MRI-based radiomics analysis in predicting postpartum hemorrhage among pregnant women with placenta previa. Material and Methods: Preoperative T2-weighted MRI and related clinical data of 371 patients were retrospectively collected, and these patients were randomly allocated into two subsets: the training dataset (n = 260) and the validation dataset (n = 111). The logistic regression (LR) classifier was used for the development of the radiomics model and the calculation of the radiomics score (Radscore). Results: A total of eight radiomics features and five clinical features were selected for model development. The area under the receiver operating characteristic curve (AUC) of the radiomics model in the training and validation datasets were 0.929 (95% confidence interval [CI] = 0.891–0.957) and 0.914 (95% CI = 0.846–0.959), respectively. Combined with clinical factors, nomograms demonstrated improved diagnostic efficacy, with an AUC of 0.968 (95% CI = 0.939–0.986) in the training dataset and 0.947 (95% CI = 0.888–0.981) in the validation dataset. Conclusion: The MRI-based model has certain value in predicting postpartum hemorrhage in pregnant women with placenta previa. [ABSTRACT FROM AUTHOR]

Background: Deranged antepartum laboratory parameters may be risk factors for postpartum hemorrhage (PPH). However, whether this is also valid in women who give birth prematurely is currently unknown. Methods: We performed a retrospective single-center study to assess the role of antepartum hemoglobin, platelet count, fibrinogen, activated partial thromboplastin time, and prothrombin time as risk factors for PPH following caesarean section. We defined PPH as documented blood loss of at least 1 L and/or transfusion of red blood cell concentrates. We stratified the included patients according to gestational age: extremely preterm (gestational age < 28 weeks), very preterm (gestational age between 28 and 32 weeks), late and moderate preterm (gestational age between 32 and 37 weeks), and term (gestational age ≥ 37 weeks). Results: We included 1734 patients, 112 (6%) of whom had PPH. In total, 19 patients (10%) were in the extremely preterm group, 13 patients (10%) were in the very preterm group, 44 patients (9%) were in the late and moderate preterm group, and 36 patients (4%) were in the term group. Hemoglobin predicted PPH in all gestational age groups. Platelet count was associated with PPH in term, but not in preterm patients. Fibrinogen was associated with PPH in late prematurity but not in term patients and not in patients with early or extreme prematurity. Conclusions: Antepartum hemoglobin was the only factor predicting PPH in preterm and term caesarean sections. Platelet count and fibrinogen concentration were associated with PPH in term and late prematurity, respectively, but not in earlier stages of prematurity. [ABSTRACT FROM AUTHOR]

Aim: To compare the effectiveness of 50 and 100 μg of carbetocin with 10 IU of oxytocin for the prevention of postpartum hemorrhage (PPH). Methods: This was a triple‐blind, non‐inferiority trial involving pregnant women recruited at term. We compared two doses of carbetocin (50 and 100 μg) with 10 IU of oxytocin administered as uterotonic agent after vaginal or cesarean delivery. Uterine contractility was assessed at 2‐ and 5‐min after uterotonic administration. The association between adequate uterine tone and PPH with the patients' characteristics were examined using the chi‐square test. Effect of the drugs on the odds of developing PPH was examined using logistics regressions. All analyses were conducted using STATA (StataCorp L.L.C.) with a significance level set at 0.05. Results: In total, 324 women (50 μg carbetocin group‐111, 100 μg carbetocin group‐106, and oxytocin group‐107) participated in the study. There was a significantly higher proportion of women with adequate uterine tone in those that had 100 μg carbetocin relative to 50 μg and 10 IU oxytocin at 5 min (p < 0.001). Patients who received oxytocin had a higher average blood loss than women that had either 50 or 100 μg carbetocin (p = 0.128). There was a significant difference in the need for additional uterotonic, with a higher proportion of participants among those who received 10 IU of oxytocin (p < 0.001). Conclusion: Patients that had 100 μg of carbetocin had a better adequate uterine tone at the fifth minute compared to those who had 50 μg and 10 IU of oxytocin. Generally, carbetocin use was less likely associated with risk of PPH and use of additional intervention. [ABSTRACT FROM AUTHOR]

The article examines various approaches to managing obstetric hemorrhage through the use of haemostatic agents. Topics include the role of fibrinogen in addressing bleeding complications during childbirth; the application of tranexamic acid to reduce blood loss in postpartum hemorrhage; and strategies to improve patient outcomes with prompt administration of these agents.

Objective We aimed to determine the composite maternal hemorrhagic outcome (CMHO) among individuals with and without hypertensive disorders of pregnancy (HDP), stratified by disease severity. Additionally, we investigated the composite neonatal adverse outcome (CNAO) among individuals with HDP who had postpartum hemorrhage (PPH) versus did not have PPH. Study Design Our retrospective cohort study included all singletons who delivered at a Level IV center over two consecutive years. The primary outcome was the rate of CMHO, defined as blood loss ≥1,000 mL, use of uterotonics, mechanical tamponade, surgical techniques for atony, transfusion, venous thromboembolism, intensive care unit admission, hysterectomy, or maternal death. A subgroup analysis was performed to investigate the primary outcome stratified by (1) chronic hypertension, (2) gestational hypertension and preeclampsia without severe features, and (3) preeclampsia with severe features. A multivariable regression analysis was performed to investigate the association of HDP with and without PPH on a CNAO which included APGAR <7 at 5 minutes, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, seizures, neonatal sepsis, meconium aspiration syndrome, ventilation >6 hours, hypoxic–ischemic encephalopathy, or neonatal death. Results Of 8,357 singletons, 2,827 (34%) had HDP. Preterm delivery <37 weeks, induction of labor, prolonged oxytocin use, and magnesium sulfate usage were more common in those with versus without HDP (p < 0.001). CMHO was higher among individuals with HDP than those without HDP (26 vs. 19%; adjusted relative risk [aRR] = 1.11, 95% CI: 1.01–1.22). In the subgroup analysis, only individuals with preeclampsia with severe features were associated with higher CMHO (n = 802; aRR = 1.52, 95% CI: 1.32–1.75). There was a higher likelihood of CNAO in individuals with both HDP and PPH compared to those with HDP without PPH (aRR = 1.49, 95% CI: 1.06–2.09). Conclusion CMHO was higher among those with HDP. After stratification, only those with preeclampsia with severe features had an increased risk of CMHO. Among individuals with HDP, those who also had a PPH had worse neonatal outcomes than those without hemorrhage. Key Points Individuals with HDP had an 11% higher likelihood of CMHO. After stratification, increased CMHO was limited to those with preeclampsia with severe features. There was a higher likelihood of CNAO in those with both HDP and PPH compared to HDP without PPH. [ABSTRACT FROM AUTHOR]

Objective: To study neonatal and maternal outcomes associated with routine maneuvers in breech vaginal delivery at term. Methods: This was a secondary analysis of the multicenter PREMODA observational prospective study in France and Belgium. We included women with vaginal breech delivery, excluding those who underwent maneuvers to resolve a dystocic delivery. Maternal data and characteristics of labor, in addition to neonatal and maternal outcomes, were recorded. We defined two groups according to mode of delivery; breech vaginal delivery with or without routine maneuvers, and we compared the variables between the groups. To assess the factors associated with adverse perinatal outcomes, a multivariate logistic regression with adjustment for confounders was performed. Results: Of the 2502 women with planned vaginal deliveries, 1794 were delivered vaginally, 606 of whom were excluded from the study due to maneuvers performed for dystocia. A total of 25 other patients were excluded as a result of missing data. A total of 537 women were included in the routine maneuvers group and 626 women in the no maneuvers group. Adverse perinatal outcome was similar for the two groups (4.5% vs 5.0%, P = 0.65) and no neonatal deaths were reported. Third degree perineal tear and postpartum hemorrhage >1 L rates were comparable for the two groups. After adjustment, the factors associated with adverse perinatal outcomes were primiparity and birth weight <2500 g. Conclusion: Routine maneuvers were not associated with an increase in neonatal morbidity in our population. Synopsis: Performing vaginal breech delivery with routine maneuvers appears safe, with no associated neonatal or maternal morbidity. These maneuvers may be included in training programs to further obstetrician skills. [ABSTRACT FROM AUTHOR]

Uterine necrosis is a rare complication of uterine artery embolization for postpartum hemorrhage and most patients end up having a hysterectomy. Here we report a case in which the patient experienced a recurrent fever 28 days after uterine artery embolization as treatment for postpartum hemorrhage and had no response to antibiotics. Magnetic resonance imaging of the pelvis revealed a mass which was approximately 12‐cm in size with air bubbles in the uterus, suggesting necrosis with infection. Transvaginal clamping of the uterine mass was performed and necrotic tissue removed under laparoscopic monitoring, which successfully spared the necessity for a hysterectomy. The patient's subsequent progress was favorable. In the present study we review the high‐risk factors of uterine necrosis following uterine artery embolization and summarize the key points of early diagnosis. In addition, we propose a strategy to successfully spare the necessity for a hysterectomy without the spread of infection or uterine perforation. Synopsis: Uterine necrosis should be considered when consistent fever appears after uterine artery embolization. Earlier diagnosis and timely removal of necrotic tissue could be helpful for hysterectomy sparing. [ABSTRACT FROM AUTHOR]

Objective: This study examines maternal mortality among Brazilian indigenous women from 2015 to 2021, contrasting their causes of death with non‐indigenous women. Methods: An observational study utilizing Ministry of Health data analyzed maternal deaths' characteristics, comparing indigenous and non‐indigenous groups based on death certificates and live‐birth records. Variables included age, region, location, time, and cause of death. Maternal mortality ratios (MMR) were calculated with linear regression and outliers identified with Grubbs test. Prevalence ratios compared MMR and causes of death. Results: Between 2015 to 2021, Brazil recorded 13 023 maternal deaths. Among these, with 205 among indigenous women (1.60% of total). Indigenous women had higher MMR (115.14/100 000), than non‐ indigenous women (66.92/100 000), consistently across years. Hemorrhagic causes notably contributed to the indigenous women's elevated MMR. Conclusion: Indigenous Brazilian women face elevated maternal mortality rates across all causes, primarily due to hemorrhage, contrasting wih national trends. Synopsis: IBrazilian indigenous women exhibit a heightened maternal mortality risk, primarily attributed to hemorrhage, distinguishing them from the non‐indigenous population. [ABSTRACT FROM AUTHOR]

• New approaches to maternal blood loss quantification should be investigated. • A novel device was more accurate than volumetry and is highly usable. • The device my address limitations of current blood loss quantification practices. • The device may impact PPH related morbidity and needs further testing. To study the accuracy and usability of a novel obstetric blood loss quantifying tool in clinical settings. A mixed-methods study was conducted in an Irish tertiary maternity unit. The accuracy of measuring the blood content (hemoglobin concentration) of elective Caesarean section birth waste with a novel obstetric blood loss quantifying device was compared, using Bland-Altman and correlation analysis, with staff volumetry and a reference hemoglobinometer. Hospital staff (nurses, midwives and doctors) opinion of the usability of the device was studied by an anonymous questionnaire which generated a System Usability Scale (SUS) score. SUS scores range from 0 to 100 with higher scores reflecting greater usability. The device was used by 19 different hospital staff members (nine nurses, four midwives and six doctors) in 19 elective Caesarean deliveries that had varying levels of PPH risk. Bland-Altman analysis produced mean biases of −0.7 ± 1.5 g/dL and 0.2 ± 1.2 g/dL for the device and staff measurements respectively. The width of the limits of agreement was narrower for device measurements than for staff measurements (4.5 g/dL and 5.7 g/dL respectively). The device's measurements of hemoglobin content correlated more strongly with the hemoglobinometer rather than with hospital staff measurements (Spearman correlation coefficients of 0.9 and 0.6 respectively). This suggests that the device is more accurate in determining the blood content of the birth waste than hospital staff volumetric measurements. Hospital staff members assigned the device a mean SUS score of 82 which suggests that the device is highly usable. An early feasibility study in clinical settings suggests that a novel device for quantifying obstetric blood loss was more accurate than volumetry in measuring the hemoglobin content of birth waste. Health professionals also found the device highly usable. This data suggests that there is much potential in transitioning from a "human-made" to a "machine-made" assessment of blood loss. Future studies will entail additional testing of the device to assess its impact on the morbidities associated with postpartum hemorrhage. [ABSTRACT FROM AUTHOR]

• Limited evidence on best strategy with unfavorable cervix 24 h after first vaginal dinoprostone. • Efficacy, maternal and neonatal morbidity after repeated methods questioned. • Similar vaginal delivery and neonatal morbidity between vaginal dinoprostone and cervical ripening balloon. • Cervical ripening balloon more efficient with more favourable cervix or labor within 24 h. To compare dinoprostone vaginal insert (PG) with cervical ripening balloon (CRB) as second line of cervical ripening in women at term with a persistent unfavorable cervix after first PG. This retrospective cohort study comprised all women with singleton fetus in cephalic presentation who required cervical ripening at term (≥37 weeks) for maternal and/or fetal disease using repeated PG or CRB for a persistent unfavorable cervix (Bishop score <6) 24 h after first PG. Primary outcome was vaginal delivery rate. Secondary outcomes were favorable cervix (Bishop score ≥6) or labor within 24 h after second device placement, postpartum hemorrhage (PPH) and neonatal morbidity. 180 women were analyzed (127 repeated PG (70.6 %) and 53 CRB after first PG (29.4 %)). After second device, 93.3 % of women had a favorable cervix (Bishop score ≥6) or were in labor within 24 h, and the rate was significantly higher after CRB, compared to repeated PG (98.1 % vs. 91.3 %; p = 0.048). Vaginal deliveries were similar between groups (62.2 % after repeated PG vs. 54.7 % after CRB; p = 0.36). PPH was observed in 22.2 % of included women, and no difference was observed between groups (21.3 % vs. 21.4 %; p = 0.63). Neonatal morbidity was similar between groups (13.4 % vs. 9.4 %; p = 0.48). Vaginal delivery rate and neonatal morbidity were similar when using PG or CRB as second line in women at term with a persistent unfavorable cervix after first PG. CRB seemed to be more efficient on the cervix status, compared to repeated PG, in these women. [ABSTRACT FROM AUTHOR]

• Ultrasound accurately identified invasive placentation in 86.1% of women with placenta previa and prior cesarean delivery. • Disruption of the bladder-myometrial interface was the most reliable ultrasound sign. • All confirmed cases of placenta accreta had at least one ultrasound sign of invasive placentation. • Accurate antenatal ultrasound improves management, unnecessary hysterectomies and maternal and perinatal outcomes. To evaluate the performance of ultrasound for antenatal identification of invasive placentation in women with placenta previa in the setting of prior cesarean delivery. This was a multicenter, retrospective, cohort study. Singleton pregnancies at risk of placenta accreta because of persistent placenta previa in the setting of prior cesarean delivery who delivered at four centers, from January 2010 to May 2020, were included in the study. For this study, pregnancies with diagnosis of accreta, increta, or percreta were considered under the umbrella term of placenta accreta. All women with placenta previa identified in the second trimester had a follow-up ultrasound at 32–34 weeks. Only those with prior cesarean delivery were considered at risk of placenta accreta. Women were considered with suspected accreta in case of suspected prenatal ultrasound. Women with suspected placenta accreta had delivery planned via cesarean hysterectomy at 34+0 – 35+6 weeks, without any attempt to remove the placenta. The primary endpoint of the study was the performance of ultrasound for antenatal identification of invasive placentation. The following ultrasound signs were evaluated: placenta lacunae; loss of clear space; increased vascularity between myometrium and placenta; intracervical lake; rail sign; uterovesical hypervascularity; increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region; and disruption of bladder-myometrial interface. 180 singleton pregnancies with placenta previa in the setting of prior cesarean delivery were identified. Of them, 155 (86.1%) had antenatal suspected placenta accreta based on ultrasound, having at least one sign of invasive placentation. Of the 155 suspected cases, 99 had confirmed placenta accreta at the time of delivery. Among the 99 cases of confirmed placenta accreta, all of them had at least one sign of invasive placentation at ultrasound. Among the 81 cases with placenta previa, prior cesarean delivery, without placenta accreta, 25/81 (30.9%) had ultrasound scan negative for sign of invasive placentation, and 56/81 (69.1%) had at least one sign of invasive placentation). In particular, 12/81 (14.8%) had placenta lacunae, 16/81 (19.8%) had loss of clear space, 20/81 (24.7%) had increased vascularity between myometrium and placenta, 9/81 (11.1%) had intracervical lake, 14/81 (17.3%) had rail sign, 14 (17.3%) had uterovesical hypervascularity, 5/81 (6.2%) had increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region, 8/81 (9.9%) had disruption of bladder-myometrial interface. In the group of women with confirmed placenta accreta, the most common sign recorded was the disruption of bladder-myometrial interface, being recorded in 88/99 women. Disruption of bladder-myometrial interface had the highest sensitivity in detection placenta accreta. Women with disruption of bladder-myometrial interface at ultrasound had 73-fold increase in the risk of placenta accreta compared to those who did not. Prenatal ultrasound has an excellent diagnostic accuracy in identifying invasive placentation in women with placenta previa and prior cesarean delivery. [ABSTRACT FROM AUTHOR]

Summary: Background: Re‐exploration following caesarean birth and the associated maternal morbidity has not been investigated in the UK. Our aims were to determine the national incidence and identify the associated risk factors. Methods: We conducted a prospective observational case–control study across 194 UK consultant‐led maternity units in women whose caesarean birth was complicated by a re‐exploration. Independent factors for re‐exploration were analysed using multivariable multi‐level mixed effects logistic regression. Results: Over the study period (1 June 2021 and 31 May 2022) 238,423 caesarean births were recorded across the UK of which 187 women underwent re‐exploration, giving an incidence of one re‐exploration per 1282 caesarean births (95%CI 1:1099–1:1471). Haemorrhage (124/187, 66.3%) and sepsis (31/187, 16.6%) were the most common findings at re‐exploration. Median (IQR [range]) time interval to re‐exploration following the caesarean birth was 1 (0–4 [0–28]) day. Mechanical ventilation was required in 34 (18.6%) women, cardiac arrest was reported in 5 (2.7%) and 3 (1.6%) women died. Independent preceding factors associated with a re‐exploration included: receipt of blood transfusion (adjusted OR (95%CI) 8.25 (2.66–25.61)); use of a general anaesthetic (adjusted OR (95%CI) 3.33 (1.61–6.88)); pre‐eclampsia (adjusted OR (95%CI) 3.27 (1.55–6.91)); black ethnicity (adjusted OR (95%CI) 3.14 (1.39–7.11)); postpartum haemorrhage (adjusted OR (95%CI) 2.82 (1.81–4.37)); use of anticoagulants or antiplatelet drugs pre‐caesarean birth (adjusted OR (95%CI) 2.26 (1.35–3.81)); and emergency caesarean birth (adjusted OR (95%CI) 1.89 (1.01–3.57)). Conclusion: Re‐exploration following caesarean birth in the UK is uncommon but is associated with significant maternal morbidity and mortality. These study findings will help guide informed consent and encourage appropriate surveillance of high‐risk women postpartum. [ABSTRACT FROM AUTHOR]

Objective: To assess the postpartum depression (PPD) risk in women with postpartum hemorrhage (PPH) and moderators. Methods: We identified observational studies of PPD rates in women with versus without PPH in Embase/Medline/PsychInfo/Cinhail in 09/2022. Study quality was evaluated using the Newcastle‐Ottawa‐Scale. Our primary outcome was the odds ratio (OR, 95% confidence intervals [95%CI]) of PPD in women with versus without PPH. Meta‐regression analyses included the effects of age, body mass index, marital status, education, history of depression/anxiety, preeclampsia, antenatal anemia and C‐section; subgroup analyses were based on PPH and PPD assessment methods, samples with versus without history of depression/anxiety, from low‐/middle‐ versus high‐income countries. We performed sensitivity analyses after excluding poor‐quality studies, cross‐sectional studies and sequentially each study. Results: One, five and three studies were rated as good‐, fair‐ and poor‐quality respectively. In nine studies (k = 10 cohorts, n = 934,432), women with PPH were at increased PPD risk compared to women without PPH (OR = 1.28, 95% CI = 1.13 to 1.44, p < 0.001), with substantial heterogeneity (I2 = 98.9%). Higher PPH‐related PPD ORs were estimated in samples with versus without history of depression/anxiety or antidepressant exposure (OR = 1.37, 95%CI = 1.18 to 1.60, k = 6, n = 55,212, versus 1.06, 95%CI = 1.04 to 1.09, k = 3, n = 879,220, p < 0.001) and in cohorts from low‐/middle‐ versus high‐income countries (OR = 1.49, 95%CI = 1.37 to 1.61, k = 4, n = 9197, versus 1.13, 95%CI = 1.04 to 1.23, k = 6, n = 925,235, p < 0.001). After excluding low‐quality studies the PPD OR dropped (1.14, 95%CI = 1.02 to 1.29, k = 6, n = 929,671, p = 0.02). Conclusions: Women with PPH had increased PPD risk amplified by history of depression/anxiety, whereas more data from low‐/middle‐income countries are required. [ABSTRACT FROM AUTHOR]

Background: The prostaglandin E1 analog "misoprostol" is a drug that has powerful ecbolic effects and can be beneficial in the prevention and treatment of postpartum hemorrhage, which is the leading cause of maternal mortality worldwide. Objectives: To assess the value of adding intrauterine misoprostol together with intravenous oxytocin injection compared with sublingual misoprostol together with intravenous oxytocin injection during elective cesarean section to reduce blood loss intraoperatively and prevent postpartum hemorrhage. Methods: A total of 192 pregnant women were counseled and recruited from the labor and delivery unit at Kasr Al Aini Hospital, Cairo University, and equally randomized into two groups. Group (A) included 96 women who received intrauterine misoprostol (400 mg) + oxytocin. Group (B) included 96 women who received sublingual misoprostol (400 mg) + oxytocin. The primary outcome of our study was estimation of the amount of blood loss during and after cesarean delivery. The secondary outcomes were the incidence of PPH within the first 6 h after labor, the need for blood transfusion, the need for any supplementary ecbolic drugs, the need for additional surgical intervention for PPH, changes in hematocrit and hemoglobin in both groups after delivery, and the incidence of side effects of the study medications. Results: We observed a significant discrepancy between the two groups in terms of postoperative Hb and Hct, postoperative differences (pre- and post-Hb and post-Hct) and EBL favoring the intrauterine group. However, no significant difference was observed between the groups with respect to excessive blood loss > 1000 ml in the 1st six hours, the need for supplementary ecbolics, the necessity for blood or blood prod, the need for additional surgical intervention (for PPH) or side effects. Conclusion: Intrauterine misoprostol combined with oxytocin intravenous infusion is more effective than sublingual misoprostol combined with oxytocin intravenous infusion in lowering intraoperative blood loss and preventing postpartum hemorrhage in elective cesarean section. Trial registration: This trial was retrospectively registered with the ClinicalTrials.gov Registry on 12-April-2024 (registration number: NCT06364098). [ABSTRACT FROM AUTHOR]

Background: Bilateral adrenal hemorrhage is a rare but often a fatal cause of primary adrenal insufficiency that can result in adrenal crisis if not identified and managed appropriately. Case presentation: We present a case of a 27-year-old Caucasian female who was admitted to the hospital 17 days postpartum with pleuritic chest and flank pain, shortness of breath and nausea. Computed tomography imaging confirmed multiple thromboemboli including pulmonary emboli and noted bilateral bulky adrenal glands. She was managed for infection and pulmonary emboli; however, she complained of persistent headaches, nausea, and vomiting despite appropriate management. Radiology re-review found the computed tomography imaging was consistent with bilateral adrenal hemorrhage in hindsight. Subsequent endocrine evaluation with hypothalamic–pituitary–adrenal axis interrogation and adrenocorticotropic hormone (Synacthen) stimulation testing confirmed resultant primary adrenal insufficiency. She required urgent intravenous hydrocortisone and was subsequently discharged on oral adrenal replacement therapy and anticoagulation. Conclusions: Delay in identification and treatment of adrenal insufficiency can lead to catastrophic outcomes. This case highlights the challenge of diagnosing bilateral adrenal hemorrhage and resultant adrenal insufficiency as patients may not present with the classic risk factors, signs, symptoms, and electrolyte derangements. [ABSTRACT FROM AUTHOR]

Tranexamic acid is a recommended treatment for women with a clinical diagnosis of postpartum haemorrhage, but whether it can prevent bleeding is unclear. We conducted a systematic review and individual patient data (IPD) meta-analysis of randomised controlled trials to assess the effects of tranexamic acid in women giving birth. In this systematic review and IPD meta-analysis, we searched the WHO International Clinical Trials Registry Platform from database inception to Aug 4, 2024 for randomised trials that assessed the effects of tranexamic acid in women giving birth. Trials were eligible if they were prospectively registered, placebo-controlled, included more than 500 women, and had a low risk of bias for random sequence generation and allocation concealment. IPD were requested from the trial investigators. The primary outcomes were the numbers of women with life-threatening bleeding and thromboembolic events. We used a one-stage model to analyse the data and explored whether the effect of tranexamic acid varied by the underlying risk of life-threatening bleeding, type of birth, presence of moderate or severe anaemia, or timing of administration (before or after a diagnosis of postpartum haemorrhage). This study is registered with PROSPERO, CRD42022345775. We analysed data on 54 404 women from five trials. We obtained IPD for 43 409 women from four trials and aggregate data on 10 995 women from one trial. All trials had a low risk of bias. Life-threatening bleeding occurred in 178 (0·65%) of 27 300 women in the tranexamic acid group versus 230 (0·85%) of 27 093 women in the placebo group (pooled odds ratio [OR] 0·77 [95% CI 0·63–0·93]; p=0·008). There was no evidence that the effect of tranexamic acid varied by the underlying risk of life-threatening bleeding, type of birth, presence of moderate or severe anaemia or timing of administration. No significant difference was identified between tranexamic acid and placebo groups with regard to thromboembolic events: 50 (0·2%) of 26 571 women in the tranexamic acid group had fatal or non-fatal thromboembolic events versus 52 (0·2%) of 26 373 women in the placebo group (pooled OR 0·96 [0·65–1·41]; p=0·82) with no significant heterogeneity identified in the subgroup analyses. Tranexamic acid reduces the risk of life-threatening postpartum bleeding. We found no evidence that tranexamic acid increases the risk of thrombosis. Although we do not recommend the use of tranexamic acid in all women giving birth, consideration should be given to its use before a diagnosis of postpartum haemorrhage in women at high risk of death. The Bill & Melinda Gates Foundation. [ABSTRACT FROM AUTHOR]

Tranexamic acid, given within 3 h of birth, reduces bleeding deaths in women with postpartum haemorrhage. We examined whether giving tranexamic acid shortly after birth can prevent postpartum haemorrhage in women with moderate or severe anaemia. This international, randomised, double-blind, placebo-controlled trial was done in 34 hospitals across four countries (Nigeria, Pakistan, Tanzania, and Zambia). We recruited women of any age in active labour with moderate or severe anaemia (haemoglobin <100 g/L). We randomly assigned women (1:1) who had given birth vaginally to receive 1 g of tranexamic acid or matching placebo by slow intravenous injection (over 10 min) within 15 min of the umbilical cord being cut or clamped. Women were randomly assigned by selection of the lowest numbered treatment pack from a box containing 20 packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to group assignment. The primary outcome was a clinical diagnosis of primary postpartum haemorrhage, which might be an estimated blood loss of more than 500 mL or any blood loss sufficient to compromise haemodynamic stability within 24 h of randomisation, analysed on an intention-to-treat basis. Safety analyses were performed in all participants included in the intention-to-treat population. This trial was registered on ISRCTN (ISRCTN62396133), ClinicalTrials.gov (NCT03475342), and the Pan African Clinical Trial Registry (PACTR201909735842379) and is closed to recruitment. From Aug 24, 2019, to Sept 19, 2023, 16 586 women aged 14–50 years were invited to take part and 1518 were excluded. 7580 women were randomly assigned to receive tranexamic acid and 7488 to receive placebo. Primary outcome data were unavailable for one woman in each group. The median time interval from the start of the administration of the trial treatment to the diagnosis of postpartum haemorrhage was 18·5 min (IQR 5–58); 20 min (8–64) in women with moderate anaemia and 13 min (7–44) in women with severe anaemia. 358 (35%) of 1024 with postpartum haemorrhage for whom time data were available were diagnosed before the trial treatment had been fully administered. Clinically diagnosed postpartum haemorrhage occurred in 530 (7·0%) of 7579 in the tranexamic acid group and in 497 (6·6%) of 7487 in the placebo group (risk ratio [RR] 1·05, 95% CI 0·94–1·19). There was no strong evidence against the null hypothesis of homogeneity of effects for any of the prespecified subgroup analyses: severity of anaemia (p=0·44), antepartum haemorrhage (p=0·044), birth canal trauma (p=0·37), use of pain control (p=0·37), and baseline risk of postpartum haemorrhage (p=0·31). There were no vascular occlusive events (pulmonary embolism, deep vein thrombosis, stroke, and myocardial infarction) reported in either group. There were no adverse events related to the treatment and no treatment-related deaths. In women with moderate and severe anaemia, giving tranexamic acid within 15 min of the umbilical cord being clamped did not reduce the risk of clinically diagnosed postpartum haemorrhage. The Bill & Melinda Gates Foundation and the Wellcome Trust. [ABSTRACT FROM AUTHOR]

Background: Postpartum hemorrhage is one of the leading causes of maternal mortality and morbidity. The etiology of postpartum hemorrhage exhibits variations in relation to the mode of birth; consequently, risk factors for massive transfusion in elective cesarean section might diverge from those encountered in vaginal birth or emergency cesarean section. The main purpose of this study was to investigate antepartum risk factors of massive transfusion for elective cesarean section. Methods: We conducted a retrospective cohort study based on data from a nationwide system that collected inpatient medical records from tertiary hospitals in mainland China. We included women who had undergone elective cesarean section from January 2013 to August 2018. Primary outcome was massive transfusion defined as transfusion of more than eight units of red blood cells on the day of childbirth. Candidate risk factors were identified by the 10th revision of International Classification of Diseases Codes of admission diagnoses. The relationship between each factor and massive transfusion was assessed using multivariable logistic regression. Results: A total of 294,695 women were included and 572 of them received massive transfusion (incidence: 194 per 100,000 elective cesarean sections). Maternal age [adjusted odds ratio (aOR) 1.22; 95% confidence interval (CI) 1.10–1.48], anemia (aOR 1.66; 95% CI 1.34–2.05), thrombocytopenia (aOR 3.54; 95% CI 2.39–5.05), coagulopathy (aOR 25.92; 95% CI 8.59–69.50), hypoalbuminemia (aOR 2.97; 95% CI 1.86–4.53), hepatic dysfunction (aOR 1.65; 95% CI 1.04–2.47), uterine scar (aOR 1.39; 95% CI 1.15–1.67), multiple pregnancy (aOR 2.84; 95% CI 1.74–4.38), polyhydramnios (aOR 2.52; 95% CI 1.19–4.68) and placenta previa (aOR 25.03; 95% CI 21.04–29.77) were associated with massive blood transfusion for elective cesarean section. Among the women receiving massive blood transfusion, 7 (1.2%) died during hospitalization, 126 (22.0%) needed hysterectomy, 25 (4.4%) uterine packing and 57 (10.0%) uterine artery ligation. Conclusions: Ten risk factors of massive transfusion were identified in women undergoing elective cesarean section. Our findings may facilitate blood products preparation and provide opportunities for applying prophylactic strategies prior to cesarean section for women at high risk of massive transfusion. [ABSTRACT FROM AUTHOR]

Introduction Material and Methods Results Conclusions Melatonin has been suggested to have a biological role in the onset and progress of labor. We tested the hypothesis that the addition of melatonin during an induction of labor will reduce the need for a cesarean birth.This trial underwent protocol amendments that are detailed in the main text of the article. This trial is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12616000311459). At a multi‐center health service including secondary and tertiary obstetric hospitals, we performed a randomized, double‐blind, placebo‐controlled trial in women with a singleton cephalic pregnancy, free of significant maternal or perinatal complications who were undergoing induction of labor (with or without cervical ripening). Women were randomized to 10 mg melatonin vs placebo, with cervical ripening as required, and then 6‐h during their induction of labor to a maximum of four doses or until birth. The primary outcome was cesarean birth. Secondary outcomes included labor, maternal, and neonatal outcomes. Data were analyzed using intention to treat. Sub‐group analyses based on mode of ripening and parity were also performed.Between 2019 and 2021 we randomized 189 women (103 to melatonin and 86 to placebo). The study was prematurely terminated due to logistical complications resulting from the COVID‐19 pandemic. Cesarean rates were 28/103 (27.2%) in the melatonin group versus 20/84 (23.3%) in the placebo group (RR 1.17 95% CI 0.71–1.92). There were no significant differences in rate of cesarean birth between the melatonin and placebo groups for failure to progress (13.4% and 9.3%, respectively, RR 1.46; 95% CI 0.64–3.32) or suspected fetal distress (10.7% and 10.5%, respectively, RR 1.02; 95% CI 0.44–2.34). The melatonin group had significantly lower rates of spontaneous vaginal birth within 24 h (35.0% vs. 50.0%; RR 0.70 95% CI 0.50–0.98). The rates of secondary outcomes such as total length of labor, rate of postpartum hemorrhage, and instrumental birth were comparable. Babies born in the melatonin group were more likely to need admission to the special care nursery, namely for hypoglycemic monitoring (18.5% vs. 8.1% RR 2.26; 95% CI 1.00–5.10).In women undergoing induction of labor, melatonin does not reduce the cesarean section rate. Melatonin use intrapartum may also be associated with neonatal hypoglycemia. [ABSTRACT FROM AUTHOR]

Postpartum hemorrhage (PPH) remains a significant complication of pregnancy globally, with uterine atony accounting for the great majority of cases. Second‐line hemostatic strategies such as uterine balloon tamponade play a crucial role in managing refractory hemorrhage. Despite its effectiveness, the phenomenon of balloon displacement poses a challenge to PPH management, often leading to treatment failure. Various techniques have been proposed to address this issue, including vaginal packing, cervical cerclage, fixation to the abdominal wall, holding the cervix with ring forceps, and suspending the balloon with cervical sutures. Each method has its advantages and limitations, influencing its suitability in different clinical scenarios. Understanding these techniques may be useful to optimize and improve the management of PPH and maternal outcomes. This review provides a comprehensive summary of these strategies, their mechanisms, and their clinical implications, aiming to guide healthcare providers in choosing the most appropriate approach for individual cases of PPH. [ABSTRACT FROM AUTHOR]

Introduction Material and Methods Results Conclusions Although Omega‐3 is thought to have anticoagulative properties, the potential untoward effects of Omega‐3 during pregnancy have not been investigated. No previous studies have been made to specifically assess its effect on postpartum hemorrhage (PPH). Our aim was to determine if an association exists between Omega‐3 intake during pregnancy and profuse PPH or massive PPH.Data on all deliveries that occurred at Karolinska University Hospital during the years 2007–2011 (n = 41 139) was collected from the medical record of Obstetrix, maternal health and delivery chart system. Women with reported Omega‐3 use in early pregnancy were considered exposed and all other as unexposed. Bivariate and adjusted multivariate analysis was performed on main outcomes.Omega‐3 use was associated with 25% increased odds of PPH (adjusted odds ratio (aOR) 1.25, 95% confidence interval [CI] (1.06–1.47)) and a more than doubled odds of massive PPH (aOR 2.36, 95% CI 1.26–4.44). In addition, there was a minor increase in the amount of blood loss. Although few, women on low‐dose discontinued terminated at 36th week showed no significant association to blood loss measurements.Our observational findings showed 25% higher odds of PPH and two times higher odds of massive PPH in women who reported using Omega‐3 in early pregnancy. Our findings give some support to advocate discontinued use of Omega‐3 in late pregnancy. [ABSTRACT FROM AUTHOR]

Background: Cesarean section poses a fourfold risk for postpartum hemorrhage (PPH), necessitating accurate blood loss estimation to enable timely interventions. However, the conventional visual estimation method often leads to underestimation, resulting in undiagnosed PPH even in our setting, Uganda. Yet, the quantitative standard techniques remain underutilized. Objective: We compared visual and calculated blood loss among women undergoing cesarean delivery at Gulu Regional Referral Hospital in northern Uganda. Design: We employed a cross-sectional study design. Methods: We enrolled pregnant women scheduled for cesarean section and determined both calculated and visually estimated blood loss. Data analysis involved using Pearson's moment correlation coefficient to compare the two methods and logistic regression to determine the factors associated with PPH. Results: We included 105 participants, most were primigravida (n = 100, 43%), aged 15–24 years (n = 100, 52%), with term gestation (n = 100, 75%). The mean visual estimated blood loss (vEBL) was 235.3 ± 123.7 ml (interquartile range (IQR) 50–600 ml), while the calculated estimated blood loss (cEBL) was 435.0 ± 1328.2 ml (IQR −11,182.1–2226.7 ml). Visual estimation underestimated blood loss in 90% of cases (n = 100), and 21% (n = 21) had undiagnosed PPH (>1000 ml blood loss). None of the respondents had PPH (>1000 ml blood loss) following vEBL. There was a small positive correlation between both methods (vEBL and cEBL; r = 0.1165; p = 0.2482). Women aged >35 years were 1.60 times more likely to experience PPH than their counterparts aged 25–34 years (adjusted odds ratio (AOR): 1.60; 95% CI: 1.11–2.30, p < 0.011). Chorioamnionitis increased the risk of PPH by 2.2 times (AOR: 2.20; 95% CI: 1.20–4.05, p < 0.012). Conclusion: The visual estimation technique significantly underestimated blood loss in up to 90% of cases, particularly during emergency cesarean sections. Among the 21% of cases diagnosed with PPH based on calculated blood loss, advanced maternal age and chorioamnionitis were notable contributing factors. Routine hemoglobin and hematocrit testing in obstetric care can be effectively utilized to objectively assess blood loss, aiding in the accurate diagnosis and management of PPH. Implementing these measures, even in resource-constrained settings, can significantly reduce the morbidity and mortality associated with PPH. Trial registration: Not applicable. [ABSTRACT FROM AUTHOR]

Cesarean section for breech presentation is often recommended. However, cesarean section affects future reproduction. The aim of this study was to assess the effect of mode of the first birth in breech on outcomes of the second birth and the two births together. This is a register-based nationwide cohort study including 23 062 women with a first singleton birth in breech ≥ 34 gestational weeks and a subsequent singleton birth in Sweden 2000–2019. Exposure was mode of first delivery. Main maternal outcome was a composite of fourth-degree perineal injury, postpartum hemorrhage requiring blood transfusion, hysterectomy, or death. Main infant outcome was a composite of stillbirth, extremely preterm birth (< 28 weeks), moderate to severe hypoxic ischemic encephalopathy, therapeutic hypothermia, or death. Outcomes were analyzed using multivariable logistic regression. In the first birth, the infant composite outcome affected < 1% in both groups but the risk was higher in the vaginal breech group (13/1525), compared with the breech CS group (27/21 537), aOR 7.06, 95% CI 2.91–17.1. In the second birth, the infant composite outcome affected < 1% in both groups but the risk was lower for the first vaginal breech group (3/1525) compared with the first breech CS group (152/21 537), aOR 0.26, 95% CI 0.08–0.84. There was no significant difference between the groups in risk of composite infant outcome in the two births assessed together, or in risk of composite maternal outcome. In total, the chance of a two-children family without maternal or infant severe adverse composite outcome was high and similar regardless mode of the breech first birth. [ABSTRACT FROM AUTHOR]

Oxytocin is the principal drug and the primary choice for labor induction and postpartum hemorrhage prevention and treatment. The problems associated with oxytocin are not usually from its effectiveness, but they are from its compromised quality which may occur at the point of manufacturing, transportation, and storage. The main objective of this study was to assess the status of oxytocin injection quality and associated factors in the health facilities located in Addis Ababa city, Ethiopia. A laboratory based instrumental quality testing alongside a cross sectional study design was used to evaluate oxytocin injection quality in Addis Ababa city administration from January to June, 2022 according to United States Pharmacopeia (USP 20), and the World Health Organization guideline of post-market medicine quality assessment. Binary logistic regression and cross tabulation analysis were conducted using SPSS 26. Significance was considered at p ≤ 0.05. Out of 107 tested oxytocin injection samples, 92.5% met the limit for oxytocin content, 81.3% for sterility test, and 91.6% for pH value. Overall, quality failure rate was 23.4%, while sterility test failure rate was 18.7%. Lack of reliable refrigerated storage condition [(AOR = 5.62, 95% CI: (1.87, 16.88)], lack of effective cold chain system during distribution [(AOR = 5.5, 95% CI: (1.53, 19.74)], and weak national medicine regulatory system [(AOR = 3.23, 95% CI: (1.13, 9.23)] were among the significantly associated factors for the failure of some of the brands. The study demonstrated that oxytocin injection quality failure rate, failing to meet at least one quality test requirement, is demonstrated in the health facilities of Addis Ababa. The determinant factors for the reported failures are related to storage, distribution, and regulatory system. Hence, these should be addressed by strictly adhering in to the national regulation and providing a comprehensive health promotion on rational use of oxytocin injection should be implemented to assure its quality and safety. [ABSTRACT FROM AUTHOR]

Background: The severe postpartum hemorrhage (SPPH) leads to dangerous maternal conditions, and its rate is still increasing and the trend in related risk factors is changing. Placenta-related problems remain the high-risk factor for SPPH. The object is to investigate the prevalence and the risk factors of the severe postpartum hemorrhage in pregnant women with placenta previa or low-lying placenta. Method: A retrospective analysis of pregnant women with placenta previa or low-lying placenta after 28 weeks gestation from May 2018 to May 2023 in the Peking Union Medical College Hospital was conducted. The primary outcome was severe postpartum hemorrhage defined as blood loss ≥ 1000 mL within 24 h of childbirth, or with signs or symptoms of low blood volume requiring transfusion of ≥ 4U of red blood cells. Univariate and multivariate logistic regression were used to identify potential risk factors of severe postpartum hemorrhage and receiver operating curve to evaluate the prediction performance. Results: Of the 14,964 women, 201 met the inclusive criteria. SPPH rate was 1.3% overall and 18.9% in women with placenta previa or low-lying placenta. Weight (aOR = 0.93, 95%CI 0.87–0.99), increta or percreta placenta (aOR = 7.93, 95%CI 2.53–24.77) were the risk factors. The area under the ROC curve was 0.69(95%CI 0.59–0.80) for increta or percreta placenta alone, and 0.72(95%CI 0.62–0.82) for the combination of times of cesarean sections and anterior placenta. Conclusions: Placenta accreta spectrum was the key independent risk factor of SPPH in women with placenta previa or low-lying placenta. Antenatal risk assessment of SPPH in these population is highly desirable and optimal intervention could be planned. [ABSTRACT FROM AUTHOR]

Objective Postpartum hemorrhage (PPH) protocols improve patient safety and reduce utilization of blood products; however, few data exist on sustainability of PPH checklist use, how use affects care delivery, and variation of use among patient subgroups. This study aimed to (1) examine compliance with PPH checklist use during vaginal deliveries, (2) evaluate whether checklist use varied by patient and/or care team characteristics, and (3) evaluate whether checklist use was associated with increased use of recommended medications/interventions. Study Design This was a quality improvement study performed from April 2021 through June 2023. A multidisciplinary team developed a revised PPH checklist and used quality improvement methodology to increase checklist use following vaginal birth. Data were collected from medical records and clinician survey. Control charts were generated to track checklist use and evaluate special cause variation. Chi-square tests and logistic regression were used to evaluate variation in medications/interventions and across subgroups. Results During the study period, there were 342 cases of PPH at the time of vaginal birth. The checklist was used in 67% of PPH cases during the 20-month period after implementation in a setting where no checklist was previously being used. We found no statistically significant differences in checklist use by patient or health care team characteristics. Use of tranexamic acid, carboprost, and misoprostol were significantly associated with checklist use. Conclusion This study demonstrated successful implementation of a checklist protocol where no checklist was previously being used, with sustained use in an average of 67% of PPH cases over 20 months. Checklist use was consistent across subgroups and was associated with higher use of interventions shown to lower blood loss. Key Points Our study showed sustainability of PPH checklist use over a 20-month period. PPH checklist use was associated with increased use of interventions known to reduce blood loss. Checklist was used consistently across patient subgroups; may help address inequities in obstetric outcomes. [ABSTRACT FROM AUTHOR]

Background: Oxytocin is a widely used uterotonic agent to prevent postpartum hemorrhage in cesarean sections. However, its administration method can influence hemodynamic stability. This study compares the hemodynamic effects of low dose Bolus followed by continuous Intravenous (IV) infusion versus Continuous IV Infusion during cesarean sections. Methodology: Sixty participants undergoing elective cesarean delivery were divided into two groups: Group IB (2 IU IV bolus with 8 IU infusion) and Group I (10 IU IV infusion). Hemodynamic parameters, including systolic (SBP) and diastolic blood pressure (DBP), pulse rate (HR), and mean arterial pressure (MAP) were measured at different time intervals. Linear analogue scale (LAS) scores were used to assess uterine contractions, and surgeon satisfaction was evaluated. Results: There was no statistically significant difference between the SBP or DBP between the two groups. The fall in MAP in Group IB (bolus group) was higher than that in the Group I (Infusion group) at all time intervals but was not statistically significant. The linear increase in Heart rate was significantly higher in Group IB compared to Group I at 5 minutes and 15 minutes of administration of oxytocin. While Group IB exhibited a better Uterine contraction as assessed by LAS scoring at 5 and 10 minutes of Oxytocin administration which was statistically significant. There was no statistically significant difference in Blood loss between the two groups. Conclusion: While both administration methods of oxytocin in cesarean sections induce hemodynamic changes, low dose bolus-continuous injection of oxytocin resulted in slightly more hemodynamic changes than the continuous injection but had a greater effect on uterine contraction. [ABSTRACT FROM AUTHOR]

The article focuses on developments related to the "Journal of Obstetrics & Gynecology Research," highlights its 50th anniversary in 2024.

Objective: To investigate the incidence of severe postpartum haemorrhage among nulliparous women with a spontaneous onset of labour at term from 2000 to 2020. Design: Population‐based cohort study. Setting: National, using the Medical Birth Registry of Norway. Population: Women (n = 330 244) who gave birth to their first singleton child in a cephalic presentation after a spontaneous onset of labour at term. Methods: Cross‐tabulations and regression analysis with generalised linear models were used to assess time trends and adjust for potential confounding factors. We also stratified the analyses by maternal age groups, obstetric interventions, mode of delivery and institution size. Time trends were analysed using periods of 5 or 6 years as a unit, and the period from 2000 to 2004 was used as the reference. Main outcome measures: Severe postpartum haemorrhage (PPH) was defined as blood loss of >1500 mL within 24 h and/or in combination with blood transfusion. Results: Severe PPH occurred in 7601/330 244 (2.30%) women. The incidence increased from 1.24% in 2000–2004 to 3.83% in 2015–2020 (adjusted relative risk, aRR 2.90; 95% CI 2.70–3.12). Changes in maternal characteristics or obstetric interventions did not explain the increase, and we found similar increases across institutions of all sizes. Conclusions: The incidence of severe PPH among nulliparous women increased almost threefold over 21 years. The current high incidence warrants urgent efforts to assess unknown risk factors, the health care provided and health system factors that may contribute to the increase, to inform improvements in care. [ABSTRACT FROM AUTHOR]

Aim: To map the commonly used quantitative blood loss measurement methods in clinical practice and provide a solid foundation for future studies. Design and Method: This study adhered to the JBI methodology for scoping reviews and preferred reporting items for systematic reviews and meta‐analyses extension for scoping reviews. We conducted a literature search using five databases to retrieve articles published between January 2012 and September 2022. The search was repeated on 29 February 2024. Data extraction and verification were carried out by two independent researchers using a self‐designed data extraction form. Results: Ultimately, 26 studies published between 2012 and 2024 were considered eligible for inclusion. Six categories of methods were identified from the 26 articles. Among the included studies, only two involved randomized controlled trials, with the majority being observational studies. The World Health Organization (2012) version of the postpartum haemorrhage diagnostic criteria was predominantly used in most studies. Gravimetric and volumetric methods emerged as the most commonly used methods for quantifying postpartum haemorrhages. The timing of blood collection was inconsistent among the included studies. Only 12 studies mentioned measures for the management of amniotic fluid. Conclusions: This scoping review supports the replacement of the visual estimation of blood loss with quantitative assessment methods. Supporting a specific assessment approach is not feasible due to the variability of the study. Future research should focus on establishing the best practices for specific quantitative methods to standardize the management of postpartum haemorrhage and reduce the incidence of postpartum haemorrhage‐related adverse outcomes. Relevance to Clinical Practice: Healthcare professionals need to acknowledge the low accuracy of visual estimation methods and implement quantitative methods to assess postpartum blood loss. Given the limitations inherent in each assessment method, quantification of blood loss should be combined with assessment of maternal vital signs, physiologic indicators and other factors. [ABSTRACT FROM AUTHOR]

Placenta previa-accreta spectrum disorders are a cause of obstetric hemorrhage that can lead to maternal fetal mortality and morbidity. We aimed to describe the use of a uterine isthmic tourniquet left in situ as a new uterus-preserving approach for patients with placenta previa-accreta. In this retrospective comparative study, the patients who underwent surgery for placenta previa between 2017 and 2024 at our tertiary hospital were reviewed. Primary outcome of the study is to evaluate feasibility of uterine isthmic tourniquet left in situ for uterine preserving by preventing postpartum hemorrhage for patients with placenta previa-accreta. As a secondary outcome, group 1 (n=28) patients who were managed with uterine isthmic tourniquet left in place were compared with patients in group 2 (n=32) who were managed with only bilateral uterine artery ligation. This new approach uterine isthmic tourniquet technique prevented postpartum hemorrhage with a rate of 100 percent in group 1 patients, while uterine artery ligation prevented postpartum hemorrhage with a rate of 75 % in group 2. Postoperative additional interventions (relaparotomy hysterectomy, balloon tamponade application, uterine or vaginal packing) were performed for eight patients in group 2 (25 %) but not in group 1 (0 %) (p=0.015). The haemoglobin levels before caesarean section were similar in both groups (p=0.235), while the postoperative haemoglobin levels were lower in group 2 (9.69 ± 1.37 vs. 8.15 ± 1.32) (p=0.004). Erythrocyte suspension was given to two patients in group 1 and 12 patients in group 2 (2/28 7 % vs. 12/32 37 %, p=0.018). The uterine isthmic tourniquet left in situ technique is a safe, simple and effective for preventing postpartum hemorrhage and preserving uterus during placenta previa accreta surgery as superior to uterine artery ligation alone. [ABSTRACT FROM AUTHOR]

Hemorrhage risk assessment tools have been studied using estimated blood loss. We study the association between peripartum hemorrhage risk assessment score and peripartum quantified blood loss (QBL) in term vaginal and cesarean deliveries. This is a retrospective analysis conducted on 3,657 patients who underwent term vaginal and cesarean deliveries at a public hospital in New York City. Utilizing the risk assessment tool developed by the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), patients were categorized into low-, medium-, or high-risk groups for postpartum hemorrhage. Medium-risk (B=0.08, SE=0.01, p<0.001) and high-risk (B=0.12, SE=0.02, p<0.001) AWHONN scores were associated with significantly higher QBL as compared to low-risk AWHONN score. Medium-risk approached significance (OR: 1.67, 95 % CI: 1.00, 2.79, p=0.050) and high-risk AWHONN score was significantly associated (OR: 1.95, 95 % CI: 1.09, 3.48, p=0.02) with increased odds for postpartum hemorrhage (≥1,000 mL). Each individual factor comprising the AWHONN score whose percentage in our sample was seen in greater than 2.7 % of patients was independently significantly associated with increased QBL (six of nine factors) and postpartum hemorrhage (four of nine factors). The AWHONN measure previously validated with estimated blood loss predicted obstetric blood loss with QBL. Although not on the basis of the data shown in our study, we believe that QBL should be routinely used to measure obstetric blood loss. [ABSTRACT FROM AUTHOR]

Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that affects the peripheral nervous system. The purpose of our study was to evaluate maternal and fetal/neonatal outcomes among pregnancies complicated by GBS. We performed a retrospective cohort study using the Healthcare Cost and Utilization Project – National Inpatient Sample from the United States. ICD-9 codes were used to identify all pregnant women who delivered between 1999 and 2015 and had a diagnosis of GBS. The remaining women without GBS who delivered during that time period constituted the comparison group. The associations between maternal GBS and obstetrical and fetal/neonatal outcomes were evaluated using multivariate logistic regression, while adjusting for the confounding effects of maternal characteristics. Of 13,792,544 births included in our study, 291 were to women with GBS, for an overall incidence of 2.1/100,000 births. A steady increase in maternal GBS was observed over the study period (from 1.26 to 3.8/100,000 births, p=0.02). Further, women with GBS were more likely to have pregnancies complicated by preeclampsia, OR 1.69 (95 % CI 1.06–2.69), sepsis, 9.30 (2.33–37.17), postpartum hemorrhage, 1.83 (1.07–3.14), and to require a transfusion, 4.39 (2.39–8.05). They were also at greater risk of caesarean delivery, 2.07 (1.58–2.72) and increased length of hospital stay, 4.48 (3.00–6.69). Newborns of women with GBS were more likely to be growth restricted, 2.50 (1.48–4.23). GBS in pregnancy is associated with maternal and newborn adverse outcomes. These patients would benefit from close follow-up throughout their pregnancy and in the postpartum period. [ABSTRACT FROM AUTHOR]

Aims: Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide. To prevent PPH, the WHO recommends administration of oxytocin (OT) immediately after birth, i.e. during the third stage of labour (TSL). Previous studies demonstrate that methods to quantify OT in biological matrices, e.g. enzyme‐linked immunosorbent assays (ELISA), radioimmunoassays (RIA) and liquid chromatography–tandem mass spectrometry (LC–MS/MS) lack the specificity and/or sensitivity to accurately quantify OT in plasma from women administered OT during TSL. This is due to increased metabolic clearance of OT in late‐stage pregnancy and at the time of childbirth, resulting in extremely low OT plasma concentrations. This study describes the development of an ultra‐sensitive bioanalytical method that overcomes the issues previously reported and enables accurate pharmacokinetic analyses of exogenously administered OT in TSL. Methods: A selective and sensitive assay to quantify OT in TSL plasma was developed. Immunoprecipitation (IP) was applied to selectively extract OT from the TSL plasma, thereby generating clean extracts compatible with nanoflow LC (nLC). nLC–MS/MS was chosen for its high sensitivity and ability to differentiate between OT and potentially co‐captured OT‐like immunoreactive products. Results: The presented methodology is accurate and precise, with a good linear fit between 100–10 000 fg mL−1 OT. TSL plasma samples from a clinical phase 1 study (NCT02999100) were analysed successfully, enabling OT quantification down to 100 fg mL−1. Conclusions: The presented IP–nLC–MS/MS method succeeded in overcoming the sensitivity challenge related to the assay of OT in TSL plasma and thereby revealing the PK profiles of OT in TSL plasma clinical study samples. [ABSTRACT FROM AUTHOR]

Postpartum hemorrhage, or excessive bleeding after birth, is a leading cause of maternal morbidity. A major cause of postpartum hemorrhage is uterine atony, tiring of the uterus which leads to ineffective contractions. Uterine contractions depend on oxytocin signaling in the myometrium, which in turn depends on expression of the oxytocin receptor (OXTR). Both genetic and epigenetic factors related to the oxytocin receptor are associated with risk of postpartum hemorrhage, but a mechanism relating these factors to oxytocin receptor activity in myometrium remains unclear. We report a genetic by epigenetic interaction whereby the relationship between DNA hydroxymethylation and OXTR gene expression depends on a common OXTR gene variant (rs53576). We also provide evidence that a similar genetic by epigenetic interaction using blood-derived DNA methylation is associated with relevant clinical outcomes: quantity of oxytocin administration and odds for postpartum hemorrhage. These results provide new avenues for predicting how women will respond to pharmacological agents in the prevention and treatment of postpartum hemorrhage. [ABSTRACT FROM AUTHOR]

To determine whether obstetric outcomes differ between women with endometriosis and those without, where all women undergo first-trimester screening for endometriosis. A prospective observational cohort study. The Early Pregnancy Unit at University College London Hospital, United Kingdom. Women with a live pregnancy progressing beyond 12 weeks' gestation and concurrent endometriosis (n = 110) or no endometriosis (n = 393). All women underwent a pelvic ultrasound examination in early pregnancy to examine for the presence of endometriosis and uterine abnormalities. The primary outcome of interest was preterm birth, defined as delivery before 37 completed weeks' gestation. Secondary outcomes included late miscarriage, antepartum hemorrhage, placental site disorders, gestational diabetes, hypertensive disorders of pregnancy, neonates small for gestational age, mode of delivery, intrapartum sepsis, postpartum hemorrhage, and admission to the neonatal unit. Women with a diagnosis of endometriosis did not have statistically significantly higher odds of preterm delivery (adjusted odds ratio [aOR] 1.85 [95% confidence interval {CI} 0.50–6.90]), but they did have higher odds of postpartum hemorrhage during cesarean section (aOR 3.64 [95% CI 2.07–6.35]) and admission of their newborn infant to the neonatal unit (aOR 3.24 [95% CI 1.08−9.73]). Women with persistent or recurrent deep endometriosis after surgery also had higher odds of placental site disorders (aOR 8.65 [95% CI 1.17–63.71]) and intrapartum sepsis (aOR 3.47 [95% CI 1.02–11.75]). We observed that women with endometriosis do not have higher odds of preterm delivery, irrespective of their disease subtype. However, they do have higher odds of postpartum hemorrhage during the cesarean section and newborn admission to the neonatal unit. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the association between adenomyosis and placenta accreta spectrum (PAS) and to evaluate the effect of assisted reproductive technology (ART) in mediating this association. Methods: We retrieved data for singleton women from the Japanese nationwide perinatal registry between 2013 and 2019, excluding women with a history of adenomyomectomy. To investigate the association between adenomyosis and PAS among women, we used a multivariable logistic regression model with multiple imputation for missing data. We evaluated mediation effect of ART including in vitro fertilization and intracytoplasmic sperm injection on the association between adenomyosis and PAS using causal mediation analysis based on the counterfactual approach. Results: Of 1 500 173 pregnant women, 1539 (0.10%) had adenomyosis. The number receiving ART was 489/1539 (31.8%) and 117 482/1 498 634 (7.8%) in women with and without adenomyosis, respectively. The proportion of women who developed PAS was 21/1539 (1.4%) in women with adenomyosis and 7530/1 498 634 (0.5%) in women without adenomyosis. Adenomyosis was significantly associated with PAS (odds ratio [OR] 1.95; 95% confidence interval [CI] 1.26–3.00; P = 0.002). Mediation analysis showed that OR of the total effect of adenomyosis on PAS was 1.98 (95% CI 1.13–3.04), OR of natural indirect effect (effect explained by ART) was 1.15 (95% CI 1.01–1.41), and OR of natural direct effect (effect unexplained by ART) was 1.72 (95% CI 0.86–2.82). The proportion mediated (natural indirect effect/total effect) was 26.5%. Adenomyosis was also significantly associated with PAS without previa (OR 1.96; 95% CI 1.23–3.13, P = 0.005). Conclusion: Adenomyosis was significantly associated with PAS. ART mediated 26.5% of the association between adenomyosis and PAS. Synopsis: Adenomyosis was associated with placenta accreta development. Assisted reproductive technology partially mediated the association between adenomyosis and placenta accreta. [ABSTRACT FROM AUTHOR]

Objective: The study aims to evaluate the long‐term impact of internal iliac artery ligation (IIAL) on ovarian hormonal and functional changes in women. The procedure is often used for postpartum hemorrhage and is considered uterus‐sparing. However, its effects on ovarian reserve and fertility preservation remain controversial. Methods: This is a retrospective, case–control study involving consecutive female patients aged 17–47 years. These patients underwent successful bilateral IIAL due to severe postpartum hemorrhage between January 2022 and December 2022. The control group included women of matching age, parity, and body mass index (BMI) who did not undergo IIAL. Both groups were followed for 6 months to measure follicle‐stimulating hormone (FSH) and luteinizing hormone (LH) levels, antral follicle counts, and ovarian volume. Results: The study comprised 62 patients in the IIAL group and 86 in the control group. No significant differences were found in FSH and LH levels between the two groups (P > 0.05). However, the numbers of antral follicles in both the right and left ovaries were significantly lower in the IIAL group than in the control group (P < 0.05). Ovarian volume did not show a significant difference between the groups (P > 0.05). Conclusion: The findings suggest that IIAL leads to a significant decrease in the number of ovarian follicles at 6 months post‐operation. However, it does not significantly impact FSH and LH levels or ovarian volume. Synopsis: The study reveals that IIAL significantly decreases ovarian follicle counts at 6 months but does not impact FSH, LH levels, or ovarian volume. [ABSTRACT FROM AUTHOR]

Purpose: This study retrospectively assessed blood loss during cesarean deliveries for twin and singleton pregnancies using two distinct methods, quantitative estimation measured during cesarean sections and hematocrit-based calculated estimation. Methods: We included scheduled cesarean deliveries for twin or singleton pregnancies at ≥ 34 weeks of gestation. Quantitative blood loss was recorded based on the blood volume in the graduated collector bottle and by weighing the blood-soaked textiles during cesarean sections. The blood loss was calculated using the change in hematocrit levels before and after the cesarean delivery. Results: We evaluated 403 cases including 44 twins and 359 singletons. Quantitative blood loss during cesarean section was significantly higher in twin pregnancies than that in singleton pregnancies (1117 [440] vs 698 [378] mL; p < 0.001). However, no significant differences were observed in the calculated blood loss between the two groups on the day after delivery (487 mL [692 mL] vs 507 mL [522 mL]; p = 0.861). On post-delivery days 4–5, twin pregnancies were associated with a significantly higher calculated blood loss than singleton pregnancies (725 [868] mL vs 444 [565] mL, p = 0.041). Although a significant moderate correlation between quantitative and calculated blood loss was observed in singleton pregnancies (r = 0.473, p < 0.001), no significant correlation was observed between twin pregnancies (r = 0.053, p = 0.735). Conclusion: Quantitative blood loss measurements during cesarean section may be clinically insufficient in twin pregnancies. Incorporating blood tests and continuous assessments are warranted for enhanced blood loss evaluation, especially in twin pregnancies, owing to the risk of persistent bleeding. [ABSTRACT FROM AUTHOR]

Purpose: Combined spinal-epidural analgesia (CSEA) is effective but not sufficient for labor pain. This study was conducted to assess the real-time analgesic efficacy, side effects of anesthetic drug dosage, and maternal satisfaction in labor to provide reference for the optimization of labor analgesia. Methods: This was a prospective, cohort, single-center study that included 3020 women who received CSEA for labor analgesia. The visual analogue scale (VAS) for labor pain, real-time anesthetic drug dosage, side effects, adverse labor outcomes, factors influencing average drug dosage, and maternal satisfaction with CSEA were assessed. Results: Overall, the VAS labor pain score was lowest at the first hour after the anesthesia was given. After 4 h for primiparas and 3 h for multiparas, the VAS score was greater than 3 but the anesthetic drug dosage did not reach the maximum allowed dosage at the same time. The average anesthetic drug dosage was positively correlated with fever, urinary retention, uterine atony, prolonged active phase, prolonged second stage, assisted vaginal delivery, and postpartum hemorrhage. The average anesthetic drug dosage was the highest in women ≤ 20 years old, those with a body mass index (BMI) ≥ 24.9 kg/m2, and those with a primary or secondary education level. Conclusion: Appropriate age guidance and emphasis on education of labor analgesia, weight management during pregnancy, and real-time anesthetic dosage adjustment during labor based on VAS pain score may have positive effects on the satisfaction of labor analgesia. Clinical trial number and registry: Clinicaltrials.gov (ChiCTR2100051809). [ABSTRACT FROM AUTHOR]

• Improvement in detection and anticipation of placental complications may be effective in addressing the increasing trend of PPH • Increasing C-sections trends and other interventions may also need to be addressed while quality improvement projects will have a role to play. • Further staff education to upskill to reduce the incidence of unintentional cutting during caesarean section and episiotomies. To analyse temporal trends for primary Postpartum Haemorrhage (PPH), Major Obstetric Haemorrhage (MOH) between 2005 and 2021 and to examine the causes and factors contributing to the risk of PPH during 2017–2021. International ICD-10-AM diagnostic codes from hospital discharge records were used to identify cases of PPH. Temporal trends in PPH and MOH incidence were illustrated graphically. Poisson regression was used to assess the time trends and to examine factors associated with the risk of PPH during 2017–2021. A total of 1,003,799 childbirth hospitalisations were recorded; 5.6% included a diagnosis of primary PPH. Risk increased almost fourfold from 2.5% in 2005 to 9.6% in 2021. The ICD-10 AM code for other immediate primary PPH was recorded for 85% of PPH cases in 2017–2021 whereas a diagnosis of uterine inertia/atony was associated with just 3.6% of the cases. Respectively, trauma-related, tissue-related and thrombin-related causes were associated with one third, 4.2% and 0.5% of cases. A wide range of factors relating to the woman including comorbidities, mode of delivery, labour-related interventions and associated traumas increased risk of PPH but placental complications, especially morbidly adherent placenta, were strong risk factors. Improvement in detection and anticipation of placental complications may be effective in addressing the increasing trend of PPH, however, the trends of increasing C-sections and other interventions may also need to be addressed while staff education and quality improvement projects will have a role to play. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic and associated lockdowns disrupted health care worldwide. High-income countries observed a decrease in preterm births during lockdowns, but maternal pregnancy–related outcomes were also likely affected. This study investigates the effect of the first COVID-19 lockdown (March–June 2020) on provision of maternity care and maternal pregnancy–related outcomes in the Netherlands. National quasi-experimental study. Multiple linked national registries were used, and all births from a gestational age of 24+0 weeks in 2010–2020 were included. In births starting in midwife-led primary care, we assessed the effect of lockdown on provision of care. In the general pregnant population, the impact on characteristics of labour and maternal morbidity was assessed. A difference-in-regression-discontinuity design was used to derive causal estimates for the year 2020. A total of 1,039,728 births were included. During the lockdown, births to women who started labour in midwife-led primary care (49%) more often ended at home (27% pre-lockdown, +10% [95% confidence interval: +7%, +13%]). A small decrease was seen in referrals towards obstetrician-led care during labour (46%, −3% [−5%,−0%]). In the overall group, no significant change was seen in induction of labour (27%, +1% [−1%, +3%]). We found no significant changes in the incidence of emergency caesarean section (9%, −1% [−2%, +0%]), obstetric anal sphincter injury (2%, +0% [−0%, +1%]), episiotomy (21%, −0% [−2%, +1%]), or post-partum haemorrhage: >1000 ml (6%, −0% [−1%, +1%]). During the first COVID-19 lockdown in the Netherlands, a substantial increase in homebirths was seen. There was no evidence for changed available maternal outcomes, suggesting that a maternity care system with a strong midwife-led primary care system may flexibly and safely adapt to external disruptions. [ABSTRACT FROM AUTHOR]