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Objective: To determine the prevalence of primary postpartum haemorrhage (PPH), risk factors, and maternal and neonatal outcomes in a multicentre study across Nigeria. Design: A secondary data analysis using a cross‐sectional design. Setting: Referral‐level hospitals (48 public and six private facilities). Population: Women admitted for birth between 1 September 2019 and 31 August 2020. Methods: Data collected over a 1‐year period from the Maternal and Perinatal Database for Quality, Equity and Dignity programme in Nigeria were analysed, stratified by mode of delivery (vaginal or caesarean), using a mixed‐effects logistic regression model. Main outcome measures: Prevalence of PPH and maternal and neonatal outcomes. Results: Of 68 754 women, 2169 (3.2%, 95% CI 3.07%–3.30%) had PPH, with a prevalence of 2.7% (95% CI 2.55%–2.85%) and 4.0% (95% CI 3.75%–4.25%) for vaginal and caesarean deliveries, respectively. Factors associated with PPH following vaginal delivery were: no formal education (aOR 2.2, 95% CI 1.8–2.6, P < 0.001); multiple pregnancy (aOR 2.7, 95% CI 2.1–3.5, P < 0.001); and antepartum haemorrhage (aOR 11.7, 95% CI 9.4–14.7, P < 0.001). Factors associated with PPH in a caesarean delivery were: maternal age of >35 years (aOR 1.7, 95% CI 1.5–2.0, P < 0.001); referral from informal setting (aOR 2.4, 95% CI 1.4–4.0, P = 0.002); and antepartum haemorrhage (aOR 3.7, 95% CI 2.8–4.7, P < 0.001). Maternal mortality occurred in 4.8% (104/2169) of deliveries overall, and in 8.5% (101/1182) of intensive care unit admissions. One‐quarter of all infants were stillborn (570/2307), representing 23.9% (429/1796) of neonatal intensive care unit admissions. Conclusions: A PPH prevalence of 3.2% can be reduced with improved access to skilled birth attendants. [ABSTRACT FROM AUTHOR]

Abnormal invasion of the placenta into the uterine tissue during pregnancy is one of the most common causes of peripartum hysterectomy, as well as morbidity and mortality. A multidisciplinary approach is the best way to manage such cases in order to maintain perioperative haemodynamic stability, which leads to lower rates of complications and shorter hospital stays for both the parturient and the newborn. The authors hereby report the case of a 27-year-old female {Gravidity and Parity (G1P2)} at 36 weeks of gestation, diagnosed with central placenta accreta with bladder invasion. In the present case, authors performed a balloon-assisted caesarean delivery under general anaesthesia while avoiding hysterectomy. The patient had a history of a previous caesarean delivery 1.5 years prior. Placenta accreta was diagnosed during her ultrasound. All routine laboratory results were within the normal range, except for haemoglobin, which was 10.1 g/dL. An elective caesarean section with a consented hysterectomy under general anaesthesia was planned. Adequate blood and blood products (4 units of packed red blood cells and 2 units of fresh frozen plasma) were arranged before surgery. Bilateral internal iliac artery embolisation was performed to reduce perioperative bleeding. Flexible cystoscopy was conducted prior to surgery to confirm the extent of bladder invasion. The caesarean section was successfully carried out with the multidisciplinary team approach under general anaesthesia, and hysterectomy was not performed, allowing for a successful fertility-sparing caesarean delivery by our team. The patient was transferred to the Intensive Care Unit (ICU) after the surgery for proper vital monitoring and adequate pain management. She was moved to the ward on day 2 and discharged on day 3. In conclusion, balloon occlusion of the internal iliac artery is effective for haemostasis in most cases of patients with placenta previa.

Background and Objectives: Obstetric haemorrhage is the leading cause of maternal morbidity and mortality worldwide. We aimed to estimate the economic cost of Major Obstetric Haemorrhage (MOH) and the cost of therapeutic blood components used in the management of MOH in Ireland. Materials and Methods: We performed a nationwide cross‐sectional study utilising top‐down and bottom‐up costing methods on women who experienced MOH during the years 2011–2013. Women with MOH were allocated to Diagnostic Related Groups (DRGs) based on the approach to MOH management (MOH group). The total number of blood components used for MOH treatment and the corresponding costs were recorded. A control group representative of a MOH‐free maternity population was designed with predicted costs. All costs were expressed in Euro (€) using 2022 prices and the incremental cost of MOH to maternity costs was calculated. Cost contributions are expressed as percentages from the estimated total cost. Results: A total of 447 MOH cases were suitable for sorting into DRGs. The estimated total cost of managing women who experienced MOH is approximately €3.2 million. The incremental cost of MOH is estimated as €1.87 million. The estimated total cost of blood components used in MOH management was €1.08 million and was based on an estimated total of 3997 products transfused. Red blood cell transfusions accounted for the highest contribution (20.22%) to MOH total cost estimates compared to other blood components. Conclusions: The total cost of caring for women with MOH in Ireland was approximately €3.2 million with blood component transfusions accounting for between one third and one half of the cost. [ABSTRACT FROM AUTHOR]

Introduction: The United Nations has set a target to reduce global maternal deaths to less than 70 per 100,000 live births by 2030. However, despite high rates of institutional deliveries in Karnataka, a state in southern India, maternal mortality remains a significant challenge. This study aims to analyse a 10-year period of pregnancy-related deaths in a healthcare centre in Karnataka to identify the causes and avoidable factors contributing to maternal mortality. Material and Methods: A comprehensive review of records from 2009 to 2018 was conducted, gathering data on socio-demographic features, obstetric and medical history, referral details, duration of hospital stay until death, cause of death, organ dysfunction at admission and avoidable factors contributing to maternal death by inputs from expert committee. The percentages of incidences of causes were determined and analysed using binary logistic regression. Results:One hundred nine maternal deaths were reported during the study period. The majority of these deaths occurred in rural areas, with infections and obstetric haemorrhage being the primary causes. A significant number of deaths occurred within 24 hours of admission, including during the postpartum period, with approximately one-fourth of cases being critically ill and nearly half of the cases had multiorgan dysfunction. Delay in seeking health services (42.8%) and failure to recognize early features of infection (36.3%) emerged as a common contributing factor tomaternal deathss. The presence of any delay in receiving obstetric care (odds ratio [OD]= 3.31), referral status (OD= 3.20), and rural residence (OD=3.06) were significant factors contributing to instability at the time of admission. Conclusions: This study underscores the urgent need to address preventable factors contributing to maternal deaths in Karnataka. Strategies should focus on reducing delays in seeking care, improving recognition and management of infection during pregnancy and enhancing access to emergency obstetric services, particularly for women in rural areas. [ABSTRACT FROM AUTHOR]

Introduction: Many complications can occur during pregnancy, delivery, and the immediate post-partum period that necessitate admission to the Intensive Care Unit (ICU). As maternal mortality is declining in many areas of the developing world, studying it alone may not be sufficient to provide information on the quality of care given. Therefore, the emphasis is more on Severe Acute Maternal Morbidity (SAMM) or Maternal Near Miss (MNM), which has emerged as a promising alternative to maternal mortality reviews. This approach has an advantage over maternal mortality as it draws attention to the reproductive health of surviving women. Aim: To determine the clinical profile, predisposing clinical conditions, and outcomes of SAMM. Materials and Methods: A descriptive study was conducted at Bangalore Baptist Hospital, Bangalore, Karnataka, India, from November 2020 to June 2022. Data were collected on all pregnant women and postpartum women up to 42 days after delivery who were admitted to the high-risk labour room, High Dependency Unit (HDU), and ICU. A total of 191 patients were enrolled, and various variables were studied, including demographic details, gestational age, co-morbidities, intensive care management, and neonatal outcomes. Women with Life-Threatening Conditions (WLTC), SAMM, and Maternal Deaths (MD) were noted, and using these parameters, the Severe Maternal Outcome Ratio (SMOR), MNM incidence ratio, and mortality index were calculated. Results: Among the 191 women with life-threatening conditions, 187 had SAMM, and four patients succumbed to death. The majority of SAMM cases were due to obstetric haemorrhage, observed in 73 patients (46.2%). This was followed by hypertensive disorders in pregnancy, seen in 65 patients (41.1%), and sepsis, seen in 15 patients (15.24%). The SMOR was calculated to be 44.05%. The MNM ratio was 43.13%, and the MNM mortality ratio was 46.75:1. A mortality index of 20.94% was reported in the study. Out of 155 births, 128 were live births, 14 were intrauterine deaths, 10 were fresh still-births, and three were early neonatal deaths. Conclusion: Screening for high-risk pregnancies and timely detection of severe maternal morbidity are important steps toward promoting safe obstetric care. A multi-disciplinary team with good ICU care and availability of blood and blood products will help decrease maternal mortality.

Abnormal invasion of the placenta into the uterine tissue during pregnancy is one of the most common causes of peripartum hysterectomy, as well as morbidity and mortality. A multidisciplinary approach is the best way to manage such cases in order to maintain perioperative haemodynamic stability, which leads to lower rates of complications and shorter hospital stays for both the parturient and the newborn. The authors hereby report the case of a 27-year-old female {Gravidity and Parity (G1P2)} at 36 weeks of gestation, diagnosed with central placenta accreta with bladder invasion. In the present case, authors performed a balloon-assisted caesarean delivery under general anaesthesia while avoiding hysterectomy. The patient had a history of a previous caesarean delivery 1.5 years prior. Placenta accreta was diagnosed during her ultrasound. All routine laboratory results were within the normal range, except for haemoglobin, which was 10.1 g/dL. An elective caesarean section with a consented hysterectomy under general anaesthesia was planned. Adequate blood and blood products (4 units of packed red blood cells and 2 units of fresh frozen plasma) were arranged before surgery. Bilateral internal iliac artery embolisation was performed to reduce perioperative bleeding. Flexible cystoscopy was conducted prior to surgery to confirm the extent of bladder invasion. The caesarean section was successfully carried out with the multidisciplinary team approach under general anaesthesia, and hysterectomy was not performed, allowing for a successful fertilitysparing caesarean delivery by our team. The patient was transferred to the Intensive Care Unit (ICU) after the surgery for proper vital monitoring and adequate pain management. She was moved to the ward on day 2 and discharged on day 3. In conclusion, balloon occlusion of the internal iliac artery is effective for haemostasis in most cases of patients with placenta previa. [ABSTRACT FROM AUTHOR]

The article focuses on uterine inversion, a condition where the placenta remains attached to the uterine wall and pulls the uterus inside out during delivery. It is discussed that treatment options vary depending on the severity of the inversion and may involve manual reinsertion of the uterus, abdominal surgery, or emergency hysterectomy.

Objective: The aim of this work was to evaluate the relationship of the maternal mortality ratio due to obstetric haemorrhage (MMROH) with the national blood donations, particularly O RhD negative (Oneg) before and during COVID‐19 pandemic. Background: The maternal mortality ratio is increasing in Colombia, yet little is known regarding the relationship between blood donations and maternal mortality due to obstetric haemorrhage. Materials and Methods: A retrospective cross‐sectional study between January 1, 2018, and December 31, 2021, was performed, to assess MMROH compared to the blood donations notified to the Colombian National Haemovigilance System, through non‐parametric methods. Because a relationship between blood donations and MMROH was identified, the analysis was expanded from 2009 to 2017. Results: In 2020, Colombia increased the MMROH by 32% compared to 2019 which coincided with the lockdown period to contain COVID‐19. An inversed relationship (SumD2 = 631.0; rs = −0.7335; p 0.01) between blood donations, particularly Oneg (SumD2 = 652.0; rs = −0.7912; p 0.002) and MMROH was identified. For the years 2015–2019 and 2021, the annual mean MMROH was 8.5 ± 0.5 per 100 000 live births when the annual mean blood donations was 18.2 ± 0.4 donations per 1000 people and the Oneg was 1.0 ± 0.0 donations per 1000 people. In contrast, the years 2009–2014 and 2020 displayed an annual MMROH of 12.6 ± 0.8, when the annual collection of blood was 16.4 ± 0.8 donations and the Oneg was 0.9 ± 0.0, p < 0.001. Conclusion: There was an inverse relationship between blood donation, mainly Oneg, and maternal mortality from obstetric haemorrhage. However, we recognise these deaths could be related to other reasons, especially when they occurred in rural areas with limited access to medical services. [ABSTRACT FROM AUTHOR]

Aims and Objectives: Our goal is to describe the association between total quantitative blood loss (QBL) and risk of obstetric haemorrhage‐related morbidity (OBH‐M) to assess the utility of the current definition of obstetric haemorrhage (OBH). Methods: This was a retrospective cohort study completed of all patients who had a live delivery at the only urban safety‐net hospital over a 2‐year period from 2018 to 2019. We categorized deliveries into 10 equally sized deciles based on QBL and compared the proportion with OBH‐M in each. Among the two deciles with the highest proportions of OBH‐M, we stratified deliveries into seven groups of ascending intervals of 250cc QBL. Finally, we compared the positive predictive value (PPV) of the standard definition of OBH (QBL ≥ 1000cc) to a definition extrapolated from our stratified analysis. The primary outcome was proportion of deliveries within each QBL decile affected by OBH‐M. The secondary outcome was PPV. Results: We found a significant increase in OBH‐M from decile 9 (895–1201cc QBL) to decile 10 (1205–8325cc QBL) (p < 0.001). In our stratified analysis, we found QBL of 1500cc to be an inflection point for an increased proportion of OBH‐M. Our secondary analysis showed an increased PPV for OBH‐M using QBL of 1500cc (20.5%) compared with that of QBL 1000cc (9.8%). Conclusions: Our findings suggest that a higher QBL threshold than the currently accepted definition of OBH is more predictive of OBH‐M. [ABSTRACT FROM AUTHOR]

Tranexamic acid is an antifibrinolytic drug that is commonly administered for obstetric haemorrhage. Conventional viscoelastic tests are not sensitive to tranexamic acid, but the novel ClotPro® TPA-test can measure tranexamic acid-induced inhibition of fibrinolysis. We aimed to evaluate the TPA-test in pregnant and non-pregnant women. We performed an in vitro study of whole blood samples spiked with tranexamic acid from pregnant women in the first, second, and third trimester (n =20 per group) and from non-pregnant women (n =20). We performed ClotPro TPA-tests of whole blood sample and ClotPro EX-tests, FIB-tests, and TPA-tests. Clot lysis was inhibited in a concentration-dependent manner up to a tranexamic acid concentration of 6.25 mg L−1. At tranexamic acid concentrations of 12.5 mg L−1 and above, clot lysis was completely inhibited. The concentration–effect relationship of tranexamic acid did not differ in a clinically important manner in blood from pregnant women across all three trimesters or from non-pregnant controls. A median maximum lysis cut-off value of at9 least 16% (25–75th percentiles 15–18), a median clot lysis time of 3600 s (25–75th percentiles 3600–3600), or both was associated with a tranexamic acid concentration of least 12.5 mg L−1. The ClotPro® TPA-test is sensitive in detecting inhibition of fibrinolysis by tranexamic acid in whole blood samples of pregnant and non-pregnant women. The concentration–effect relationship of tranexamic acid to inhibit fibrinolysis in whole blood did not differ for women in the first, second, and third trimester or for non-pregnant women. [ABSTRACT FROM AUTHOR]

Aims: To examine the role of ex vivo oxytocin metabolism in post‐dose peptide measurements. Methods: The stability of oxytocin (Study 1) and oxytocinase activity (Study 2) in late‐stage pregnancy blood was quantified using liquid‐chromatography tandem mass‐spectrometry (LC–MS/MS) and a fluorogenic assay, respectively. Analyses were conducted using blood from pregnant women (>36 weeks gestation) evaluated in lithium heparin (LH), ethylenediaminetetraacetic acid (EDTA) and BD P100 blood collection tubes with or without protease inhibitors. In addition, plasma oxytocin concentrations following administration of oxytocin 240 IU inhaled, 5 IU intravenous or 10 IU intramuscular in women in third stage of labour (TSL) were analysed using enzyme‐linked immunosorbent assay (ELISA) and LC–MS/MS to understand how quantified peptide concentrations differ between these analytical methods (Study 3). Results: Study 1: Oxytocin was stable in blood collected into EDTA tubes with or without protease inhibitors but not in LH tubes. Study 2: Blood collected into all EDTA‐containing collection tubes led to near‐complete inhibition of oxytocinase (≤100 min). In plasma, a 35% reduction in oxytocinase activity was observed in LH tubes with EDTA added. In plasma from late‐stage pregnancy compared to nonpregnant participants, the oxytocinase activity was approximately 11‐fold higher. Study 3: Plasma oxytocin concentrations from nonpregnant or women in TSL following exogenous oxytocin administration were ≤33 times higher when analysed using ELISA vs. LC–MS/MS methods. Conclusions: Collection of blood from late‐stage pregnant women into tubes containing EDTA inhibits oxytocinase effectively stabilizing oxytocin, suggesting low concentrations of oxytocin after dose administration reflect rapid in vivo metabolism. [ABSTRACT FROM AUTHOR]

Aims: To compare pharmacokinetics (PK) and safety of heat‐stable inhaled (IH) oxytocin with intramuscular (IM) oxytocin in women in third stage of labour (TSL), the primary endpoint being PK profiles of oxytocin IH and secondary endpoint of safety. Methods: A phase 1, randomized, cross‐over study was undertaken in 2 UK and 1 Australian centres. Subjects were recruited into 2 groups: Group 1, women in TSL; Group 2, nonpregnant women of childbearing potential (Cohort A, combined oral contraception; Cohort B, nonhormonal contraception). Participants were randomized 1:1 to: Group 1, oxytocin 10 IU (17 μg) IM or oxytocin 240 IU (400 μg) IH immediately after delivery; Group 2, oxytocin 5 IU (8.5 μg) intravenously and oxytocin 240 IU (400 μg) IH at 2 separate dosing sessions. Results: Participants were recruited between 23 November 2016 to 4 March 2019. In Group 1, 17 participants were randomized; received either IH (n = 9) or IM (n = 8) oxytocin. After IH and IM administration, most plasma oxytocin concentrations were below quantification limits (2 pg/mL). In Group 2 (n = 14), oxytocin IH concentrations remained quantifiable ≤3 h postdose. Adverse events were reported in both groups, with no deaths reported: Group 1, IH n = 3 (33%) and IM n = 2 (25%); Group 2, n = 14 (100%). Conclusion: Safety profiles of oxytocin IH and IM were similar. However, PK profiles could not be established for oxytocin IH or IM in women in TSL, despite using a highly sensitive and specific assay. [ABSTRACT FROM AUTHOR]

Background: Placenta accreta spectrum disorder is an increasingly prevalent cause of maternal morbidity in developed countries. Aims: This study aimed to review the management and outcomes of cases of placenta accreta spectrum, and compare blood loss and blood transfusion rates, over time after an institutional change in planned primary surgeon from gynaecological oncologists to experienced obstetricians. Methods: This retrospective cohort study included all cases of suspected or confirmed placenta accreta spectrum disorder (PASD) between 1999 and 2021 at Monash Health. Data were collected by reviewing medical records to obtain baseline characteristics, details of surgical planning and management and major maternal morbidity outcomes over a 20‐year period. The primary surgical lead was recorded as either gynaecological oncologist or experienced obstetricians. The primary outcomes were estimated maternal blood loss and number of units of blood transfused. Results: A total of 88 patients were identified: 43 between 1999 and 2015 where gynaecological oncologists were the primary surgeon in 79% of cases and 45 between 2016 and 2021 where experienced obstetricians were the primary surgeon in 73.3% of cases. There was no statistically significant difference in the estimated blood loss between the two time periods (median: 2000 vs 2500 mL, P = 0.669). Hysterectomy rates were significantly reduced in the second time period, from 100 to 73.3%, P < 0.001. Conclusion: Management of cases of PASDs has improved over time with changes in antenatal diagnosis and perioperative management, and management by experienced obstetricians has similar maternal outcomes compared to those whose management includes the presence of gynaecological oncologists. [ABSTRACT FROM AUTHOR]

Objective: To assess the incidence and risk factors for severe postpartum haemorrhage (PPH) in women with an anterior low‐lying or praevia placenta, prior caesarean and no prenatal suspicion of placenta accreta spectrum (PAS). Design: Population‐based study in 176 maternity units in France. Population: All women with anterior low‐lying (0–19 mm from the cervical internal os) or praevia placenta, diagnosed prospectively before birth, prior caesarean and no prenatal suspicion of PAS. Methods: Multivariable logistic regression to identify risk factors for severe PPH in the main population and after exclusion of women with PAS diagnosed only at birth. Main outcome measures: Severe PPH defined by a composite criterion either estimated blood loss of ≥1500 ml, transfusion of ≥4 or more units of packed red blood cells, embolisation or surgical treatment. Results: Of the 520 114 women constituting the source population, 230 (0.44/1000 women; 95% confidence interval [CI] 0.38–0.50) met the inclusion criteria. Severe PPH rate was 24.8% (95% CI 19.2–30.4) overall, 27.5% (95% CI 21.8–33.3) in women with placenta praevia and 15.4% (95% CI 10.7–20.0) in women with low‐lying placenta. PAS was diagnosed at birth in 22 women (9.9%; 95% CI 5.8–13.4), although previously unsuspected. After their exclusion, severe PPH incidence was 17.3% (95% CI 12.4–22.2). In multivariate analysis, the only factor associated with a higher severe PPH risk was placenta previa (aOR, 3.65; 95%CI, 1.20–15.8). Conclusion: Severe PPH is frequent among women with anterior low‐lying or praevia placenta and prior caesarean, even after exclusion of women with PAS. The risk of severe PPH for those with praevia is nearly twice that with low‐lying placenta. [ABSTRACT FROM AUTHOR]

Objective: To compare guidelines from eight high‐income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH. Design: Comparative study. Setting: High‐resource countries. Population: Women with PPH. Methods: Systematic comparison of guidance on PPH from eight high‐income countries. Main outcome measures: Definition of PPH, prophylactic management, measurement of blood loss, initial PPH‐management, second‐line uterotonics, non‐pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour. Conclusions: Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second‐line uterotonics and non‐pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion‐protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence‐based PPH guidelines. Results: Definitions of (severe) PPH varied as to the applied cut‐off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second‐line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably. [ABSTRACT FROM AUTHOR]

BackgroundThe Maternal Mortality Rate (MMR) in Tanzania is 78 times higher than that of the UK. Obstetric haemorrhage accounts for two-thirds of these deaths in Mbeya, Tanzania. A lack of healthcare providers' (HCPs') competencies has been the key attribute. This study measured the impact on HCP's competencies from a blended training programme on obstetric haemorrhage.MethodsA “before and after” cohort study was undertaken with HCPs in 4 hospitals in the Mbeya region of Tanzania between August 2021 and April 2022. A multidisciplinary cohort of 34 HCPs (doctors, nurses, midwives, anaesthetists and radiologists) were enrolled on a blended face-to-face and virtual training course. The training was delivered by a multidisciplinary team (MDT) from London, UK, assisted by local multidisciplinary trainers from Mbeya, Tanzania and covered anaesthetic, obstetrics, haematology and sonographic use.ResultsThere were 33 HCP in the cohort of trainees where 30/33 (90.9%) of HCPs improved their Anaesthesia skills with a mean score improvement of 26% i.e., 0.26 (−0.009 −0.50), 23 HCPs (69.7%) improved obstetric skills 18% i.e., 0.18 (−0.16 to 0.50), 19 (57.6%), (57.6%) improved competences in Haematology 15%.i.e., 0.15 (−0.33 to 0.87), 20 out of 29 HCPs with ultrasound access (68.8%) improved Sonographic skills 13%.i.e., 0.13 (−0.31 to 0.54). All 33 HCPs (100%) presented a combined change with the mean score improvement of difference of 25% i.e., 0.25 (0.05–0.66). The deaths attributed to obstetric haemorrhage, the mortality rate declined from 76/100,000 to 21/100,000 live births. Actual number of deaths due to obstetric haemorrhage declined from 8 before training to 3 after the completion of the training.ConclusionThis comprehensive blended training on anaesthetic surgical, haematological, and sonographic management of obstetric haemorrhage delivers a significant positive impact on the detection, management and outcomes of obstetric haemorrhage.

In the case of progression of obstetric haemorrhage (OH) and non-effective preventive and therapeutic measures during childbirth and after delivery, the volume of blood loss can increase and exceed > 1.5% of body weight (25–30% of circulating blood volume – CBV). In such cases that we are talking about massive obstetric haemorrhage (MOH), which leads to an increase in the frequency of maternal morbidity and mortality. The objective: determine the effectiveness of various approaches to the restoration of blood loss in the cases of MOH development, which occurred to various etiological factors, with the introduction of the modern concept of damage control resuscitation (DCR) and innovative methods of surgical hemostasis. Materials and methods. During 2015–2023 years at five clinical bases of the Department of Obstetrics and Gynecology N1 of Shupyk National Healthcare University of Ukraine we analyzed 165 cases of MOH. In all MOH cases, an integrated approach was used to stop haemorrhage using both drug therapy and modern methods of surgical hemostasis in accordance with the regulatory documents of the Ukrainian Ministry of Healthcare. In main group of 59 women in labor with the MOH (2020–2023 years) an integrated approach to stop haemorrhage and restore the blood loss according to DCR concept with the priority of high-quality and rapid CBV restoration with blood products and minimization of infusion therapy was used. The comparison group consisted of 106 women in labor with MOH (2015–2019 years) and similar methods of haemorrhage termination to restore blood loss in accordance with the order N 205 of the Ukrainian Ministry of Healthcare «Obstetric haemorrhage» with the priority of rapid restoration of blood loss by crystalloids (during 2015–2019 years). Results. The mean blood loss, time till haemorrhage is stopped, and the duration of surgery in the main group were significantly lower than in the comparison group (p<0.05). In the postpartum period the number of cases with severe anemia was significantly more often in the comparison group – 47.2% versus 11.9% in the main group (OR 6.6 CI 2.7–15.9; p<0.01), as well as the frequency of hysterectomy – 50.9% versus 28.8% (OR 2.6 CI 1.3–5.1; p<0.01). An early onset and a significantly higher rate of transfusions of fresh frozen plasma and erythrocyte mass were found in the main group – respectively 88.1% versus 38.7% in the comparison group (OR 11.7, CI: 4.8–28.4; p<0.001). This resulted in a significantly lower volume of blood loss, duration of surgical intervention, and average time for haemorrhage stop in the main group compared to the comparison group (p<0.05). Conclusions. The use of modern uterotonic agents (carbetocin), tranexamic acid preparations, innovative surgical technologies and early initiation of transfusion therapy with blood preparations with minimization of crystalloid infusion and according to the DCR concept for the development of MOH allows to reduce the volume of blood loss, the frequency of severe postpartum complications, and to prevent maternal morbidity and death. [ABSTRACT FROM AUTHOR]

Objective: To compare the effect of a non-pneumatic anti-shock garment (NASG) on blood loss from obstetric haemorrhage with standard management of obstetric haemorrhage. Methods: This is an observational study of consecutive obstetric haemorrhage cases before and after the introduction of the non-pneumatic anti-shock garment conducted in a tertiary care centre in Southern India. A total of 122 women were included in the study out of which, 48 women were in the pre-intervention group and 74 in the post-intervention group. Blood loss was measured and recorded before and after the introduction of NASG. Results: The number of patients with significant blood loss (>750 ml) decreased from 81.3% to 50% after the use of NASG. The number of women with shock index >0.7 also reduced significantly from 81.3% to 56.8% thus reflecting the lower number of women requiring blood transfusion in the post-intervention group (56.2% v/s 14.9%). There was also a decrease in the number of cases requiring surgical management in the post NASG intervention group with a significant p-value of

Objective: To test the equivalence of two doses of intravenous iron (ferric carboxymaltose) in pregnancy. Design: Parallel, two‐arm equivalence randomised controlled trial with an equivalence margin of 5%. Setting: Single centre in Australia. Population 278 pregnant women with iron deficiency. Methods: Participants received either 500 mg (n = 152) or 1000 mg (n = 126) of intravenous ferric carboxymaltose in the second or third trimester. Main outcome measures: The proportion of participants requiring additional intravenous iron (500 mg) to achieve and maintain ferritin >30 microg/L (diagnostic threshold for iron deficiency) at 4 weeks post‐infusion, and at 6 weeks, and 3‐, 6‐ and 12‐months postpartum. Secondary endpoints included repeat infusion rate, iron status, birth and safety outcomes. Results: The two doses were not equivalent within a 5% margin at any time point. At 4 weeks post infusion, 26/73 (36%) participants required a repeat infusion in the 500‐mg group compared with 5/67 (8%) in the 1000‐mg group: difference in proportions, 0.283 (95% confidence interval [CI] 0.177–0.389). Overall, participants in the 500‐mg arm received twice the repeat infusion rate (0.81 [SD = 0.824] versus 0.40 [SD = 0.69], rate ratio 2.05, 95% CI 1.45–2.91). Conclusions: Administration of 1000 mg ferric carboxymaltose in pregnancy maintains iron stores and reduces the need for repeat infusions. A 500‐ mg dose requires ongoing monitoring to ensure adequate iron stores are reached and sustained. [ABSTRACT FROM AUTHOR]

Spontaneous uterine vein rupture in pregnancy is rare. This current case report presents a case of broad ligament vein rupture in spontaneous twin pregnancy that is even rarer. A female in her early 30s at the third trimester of a twin pregnancy presented with headache and left upper abdominal pain for 2 days. After admission, her blood pressure was 158/112 mmHg accompanied with increased blood lipids and proteinuria. Ultrasonography did not show any abnormalities. The main diagnoses included twin pregnancy with abdominal pain of unknown aetiology, preeclampsia and hyperlipidaemia. Her blood pressure and symptoms did not improve after administration of medications. An emergency caesarean section and laparotomy were then performed. Intraoperatively, bright red non-coagulated blood was observed within the pelvis and removed. After two healthy female babies were delivered, pelvic exploration revealed haematomas in the broad ligaments bilaterally and haemostatic sutures and clips were applied to successfully treat the ruptured vein. In cases of unexplained abdominal pain accompanied with fetal distress and haemodynamic instability, especially in twin pregnancy that can cause uterus over-expansion and broad ligament over-stretch, the possibility of spontaneous uterine vein rupture should be considered. Rapid diagnosis, immediate fluid replacement and prompt surgical intervention are essential for the safety of the mother and child., Competing Interests: Declaration of conflicting interestThe authors declare that there are no conflicts of interest.

Due to the increase in injury rate and increased social activity in pregnant women, there is an increase in the number of abdominal injuries as a result of accidents, domestic conflicts, and abuse. The absence of systematic reviews and meta-analyses related to the algorithmization of treatment tactics for multisystem abdominal trauma leads to a large percentage of treatment and diagnostic errors and complications, high maternal and perinatal mortality, which, in turn, dictates the need to develop a standardized interdisciplinary approach to the management of this category of patients.Aim of study. Standardization of the therapeutic and diagnostic approach to the treatment of pregnant women with multisystem closed abdominal trauma.Material and methods. This literature review presents data from Russian and foreign publications from January 2015 to December 2020 from the electronic databases of PubMed, Cochrane Library, Scopus, eLibrary using the primary search strategy: trauma of pregnant women, multisystem closed abdominal trauma, damage control surgical treatment, emergency caesarean section, post-mortem caesarean section, treatment and diagnostic algorithm, obstetric bleeding, uterine rupture, placental abruption (total 571 publications), with the following exception from the request for non–full-text articles, publications not in Russian or English, manuscripts, dedicated to open trauma and obstetric complications of non-traumatic origin. The data extraction method was performed by two researchers independently of each other. We analyzed multicenter studies, large series of cases, original articles (11 retrospective studies with the selection of patients from 2001 to 2015; all 988 pregnant women with blunt abdominal trauma) and clinical recommendations; systematic reviews, meta-analyses, and randomized clinical studies for this period on multisystem closed trauma in pregnant women were not found. The levels of evidence and strength of recommendations in the review are derived from Russian and foreign clinical recommendations based on meta-analyses and systematic reviews prior to 2015.Results. The treatment and diagnostic algorithm for multisystem abdominal trauma in pregnant women was standardized based on their hemodynamic status, and indications for minimally invasive and open interventions in this category of patients were clarified.Conclusion. Timely diagnosing and multidisciplinary approach contribute to reducing both maternal and perinatal mortality.

The article presents the discussion on endovascular interventions in obstetric haemorrhage. Topics include previous uterine surgery, fibromas, anticoagulant use, fertility treatment, anaemia, severe preeclampsia, HELLP syndrome, and multiple pregnancy; and bleeding being difficult to control due to the uterus's rich blood supply, particularly to the placenta.

Obstetric haemorrhage remains a significant cause of maternal morbidity and mortality. It is the leading obstetric cause for admission to intensive care units. Knowledge of risk factors and early recognition of haemorrhage enables rapid activation of a coordinated multidisciplinary team response. Clear unit protocols for the management of massive haemorrhage that are reinforced by team drills help to increase awareness in the multidisciplinary team, improve performance and thus can improve patient outcome. Pharmacological agents and surgical manoeuvres are reviewed in the article, as are blood conservation techniques. [ABSTRACT FROM AUTHOR]

The article presents the discussion on Major obstetric haemorrhage (MOH) having a challenge for anaesthetists and obstetricians. Topics include physiological changes of normal pregnancy masking the clinical presentation of hypovolaemia; and clinical evidence of maternal cardiovascular compromise representing significant blood loss irrespective of estimates.

Abstract Background Obstetric haemorrhage is the leading cause of maternal death worldwide, 99% of which occur in low and middle income countries. The majority of deaths and adverse events are associated with delays in identifying compromise and escalating care. Management of severely compromised pregnant women may require transfer to tertiary centres for specialised treatment, therefore early recognition is vital for efficient management. The CRADLE vital signs alert device accurately measures blood pressure and heart rate, calculates the shock index (heart rate divided by systolic blood pressure) and alerts the user to compromise through a traffic light system reflecting previously validated shock index thresholds. Methods This is a planned secondary analysis of data from the CRADLE-3 trial from ten clusters across Africa, India and Haiti where the device and training package were randomly introduced. Referral data were prospectively collected for a 4-week period before, and a 4-week period 3 months after implementation. Referrals from primary or secondary care facilities to higher level care for any cause were recorded. The denominator was the number of women seen for maternity care in these facilities. Results Between April 1 2016 and Nov 30th, 2017 536,223 women attended maternity care facilities. Overall, 3.7% (n = 2784/74,828) of women seen in peripheral maternity facilities were referred to higher level care in the control period compared to 4.4% (n = 3212/73,371) in the intervention period (OR 0.89; 0.39–2.05) (data for nine sites that were able to collect denominator). Of these 0.29% (n = 212) pre-intervention and 0.16% (n = 120) post-intervention were referred to higher-level facilities for maternal haemorrhage. Although overall referrals did not significantly reduce there was a significant reduction in referrals for obstetric haemorrhage (OR 0.56 (0.39–0.65) following introduction of the device with homogeneity (i-squared 26.1) between sites. There was no increase in any bleeding-related morbidity (maternal death or emergency hysterectomy). Conclusions Referrals for obstetric haemorrhage reduced following implementation of the CRADLE Vital Signs Alert Device, occurring without an increase in maternal death or emergency hysterectomy. This demonstrates the potential benefit of shock index in management pathways for obstetric haemorrhage and targeting limited resources in low- middle- income settings. Trial registration This study is registered with the ISRCTN registry, number ISRCTN41244132 (02/02/2016).

Objective: To determine the association between ethnic group and likelihood of admission to intensive care in pregnancy and the postnatal period. Design: Cohort study. Setting: Maternity and intensive care units in England and Wales. Population or sample: A total of 631 851 women who had a record of a registerable birth between 1 April 2015 and 31 March 2016 in a database used for national audit. Methods: Logistic regression analyses of linked maternity and intensive care records, with multiple imputation to account for missing data. Main outcome measures: Admission to intensive care in pregnancy or postnatal period to 6 weeks after birth. Results: In all, 2.24 per 1000 maternities were associated with intensive care admission. Black women were more than twice as likely as women from other ethnic groups to be admitted (odds ratio [OR] 2.21, 95% CI 1.82–2.68). This association was only partially explained by demographic, lifestyle, pregnancy and birth factors (adjusted OR 1.69, 95% CI 1.37–2.09). A higher proportion of intensive care admissions in Black women were for obstetric haemorrhage than in women from other ethnic groups. Conclusions: Black women have an increased risk of intensive care admission that cannot be explained by demographic, health, lifestyle, pregnancy and birth factors. Clinical and policy intervention should focus on the early identification and management of severe illness, particularly obstetric haemorrhage, in Black women, in order to reduce inequalities in intensive care admission. Black women are almost twice as likely as White women to be admitted to intensive care during pregnancy and the postpartum period; this risk remains after accounting for demographic, health, lifestyle, pregnancy and birth factors. Black women are almost twice as likely as White women to be admitted to intensive care during pregnancy and the postpartum period; this risk remains after accounting for demographic, health, lifestyle, pregnancy and birth factors. [ABSTRACT FROM AUTHOR]

Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality worldwide, particularly in low-resource settings. Despite advances in obstetric care, PPH continues to pose significant challenges, especially when conservative management fails. In such cases, more aggressive surgical interventions become necessary to control hemorrhage and preserve the patient's fertility. The bilateral ligation of the anterior division of the internal iliac arteries (IIAL) is a fertility-preserving procedure. This procedure has been widely adopted in obstetric practice, particularly for managing cases of uterine atony, placenta previa, and other conditions associated with massive hemorrhage. However, despite its proven efficacy, IIAL remains underutilized due to the technical expertise required and the limited exposure among obstetricians during training. This study aims to advocate for increased training and awareness to enhance its adoption in clinical practice., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Naga Rachana et al.)

Background: Maternal near-miss (MNM) is a risk stratification for maternal morbidity. The purpose of this study was to describe the perioperative care given in the management of this particular population of women who have undergone a caesarean section (CS). Methods: This was a retrospective, descriptive study at a single tertiary institute over a one-year period (1 January to 31 December 2018) at the Chris Hani Baragwanath Academic Hospital. The aim of this study was to describe the anaesthetic and surgical management of CS-related haemorrhage in an MNM population. The primary objectives were to determine the MNM rate from CS-related obstetric haemorrhage during the study period and to describe the intervention strategies employed in perioperative management for women with CS-related obstetric haemorrhage. The secondary objectives were to determine factors associated with massive transfusion and major estimated blood loss. The primary outcome was the MNM rate for CS deliveries. Results: A total of 8 306 women had CS of whom 105 (1.26%) were classified as MNM due to bleeding during and after the procedure. The median age was 28, with a median parity of 2 (44%), and overall estimated median (IQR) blood loss volume of 1 800 (1 200-2 100) ml. The leading cause of haemorrhage was postpartum haemorrhage (87%). Eighteen (17%) of the women had relook surgery for postpartum CS sepsis. Age and parity of ≥ 3 had a univariate association with major estimated blood loss. The use of general anaesthesia and parity of ≥ 3 had an adjusted association with the institution of massive transfusion protocol (adjusted odds ratio [aOR] 5.28, 95% confidence interval [CI] 1.03--27.01 and aOR 3.88, 95% CI 1.47--10.25, respectively). Conclusion: MNM from bleeding during or after a CS occurred in approximately 1 in 80 women who delivered by CS. These women required multiple interventions to arrest the haemorrhage and to achieve haemodynamic stability. Women with a higher parity and undergoing general anaesthesia were associated with severe bleeding. Approximately 1 in 4 women required an exploratory laparotomy and less than 7% required a hysterectomy. [ABSTRACT FROM AUTHOR]

Objectives: To explore how childbirth-related blood loss is evaluated and excessive bleeding recognised; and to develop and test a theory of postpartum haemorrhage (PPH) diagnosis.Design: Two-phase, exploratory, sequential mixed methods design using focus groups, interviews and a pilot, randomised crossover study.Setting: Two hospitals in North West England.Sample: Women (following vaginal birth with and without PPH), birth partners, midwives and obstetricians.Methods: Phase 1 (qualitative): 8 focus groups and 20 one-to-one, semi-structured interviews were conducted with 15 women, 5 birth partners, 11 obstetricians, 1 obstetric anaesthetist and 19 midwives (n = 51). Phase 2 (quantitative): 11 obstetricians and ten midwives (n = 21) completed two simulations of fast and slow blood loss using a high-fidelity childbirth simulator.Results: Responses to blood loss were described as automatic, intuitive reactions to the speed, nature and visibility of blood flow. Health professionals reported that quantifying volume was most useful after a PPH diagnosis, to validate intuitive decisions and guide ongoing management. During simulations, PPH treatment was initiated at volumes at or below 200 ml (fast mean blood loss 79.6 ml, SD 41.1; slow mean blood loss 62.6 ml, SD 27.7). All participants treated fast, visible blood loss, but only half treated slow blood loss, despite there being no difference in volumes (difference 18.2 ml, 95% CI -5.6 to 42.2 ml, P = 0.124).Conclusions: Experience and intuition, rather than blood loss volume, inform recognition of excessive blood loss after birth. Women and birth partners want more information and open communication about blood loss. Further research exploring clinical decision-making and how to support it is required.Tweetable Abstract: During a PPH, clinical decision-making is intuitive with clinicians treating as soon as excessive loss is recognised. [ABSTRACT FROM AUTHOR]

Intrauterine balloon tamponade (IUBT) is an established fertility-sparing and life-saving treatment for postpartum haemorrhage. However, high-level evidence is lacking for specific aspects of its use. Our aim was to evaluate a large case series of IUBT to inform evidence-based clinical practice. 296 cases of IUBT over a three-year period at a tertiary obstetric referral centre were identified and reviewed. Demographic, clinical, and procedural outcome measures were collected; including rates of success and failure of IUBT, duration of tamponade, and complications. IUBT was successful in 265 (90%) of women and failed in 18 (6%). All failures occurred within six hours of balloon insertion. Once deemed stable and successful at six hours, no women required return to theatre or further intervention. The mean duration of intrauterine balloon tamponade was 18.5 hours. A large variance in clinical practice exists including duration of intrauterine balloon tamponade, and method and timing of removal. A number of changes informed by the results will be introduced and prospectively audited to improve IUBT use. What is already known on this subject? Intrauterine balloon tamponade (IUBT) is an important second-line treatment option in severe postpartum haemorrhage (PPH). IUBT is easy to use, is effective especially in the setting of uterine atony, and is associated with minimal complications. What the results of this study add? This study confirms the high rate of success for IUBT in controlling PPH. We found that after six hours, if deemed successful, it is rare that further intervention is required. In addition, tamponade beyond 12 hours, gradual or incremental deflation of the balloon, and antibiotic cover beyond the duration of tamponade are unlikely to yield any further safety benefit. What the implications are of these findings for clinical practice and/or further research? Our findings suggest that women should not be required to fast for balloon removal; removal of the balloon should occur by 12 hours if deemed stable and adequately resuscitated; deflation and removal of the balloon can occur at once; and antibiotics should be ceased after balloon removal. These will allow women to mobilise and recover sooner, and improve flow and throughput in our high-acuity care areas. [ABSTRACT FROM AUTHOR]

Background: In recent years, different international and national campaigns have been implemented to combat obstetric haemorrhage. Maternal mortality (MM) is one of the main concerns of public health and represents a good indicator to measure the quality of care, an indicator that also allows to establish the socioeconomic differences between countries. There are still many activities to be carried out and achieve the objective set by the World Health Organization (WHO) and the Latin American Federation of Societies in Obstetrics and Gynaecology (FLASOG) "Zero deaths due to haemorrhage". Objective: Based on the scientific evidence available, deepen the knowledge of the role of obstetric haemorrhage as the main avoidable cause of maternal morbidity and mortality. Methodology: retrospective study through the search of original articles and systematic reviews in: Elsevier, Lancet, Intramed, PubMed, EMBASE, ScienceDirect and Cochrane Library. The following keywords were used for all sites: "Obstetric haemorrhage", "Maternal mortality and obstetric haemorrhage", "Maternal morbidity and obstetric haemorrhage", "Postpartum, late, secondary haemorrhage". The items with the highest level of evidence were selected. Conclusions: Obstetric haemorrhage is still a potential cause of maternal and fetal morbidity and mortality. Its appearance at any time of pregnancy is a cause for concern and alarm. Despite advances in obstetric and anesthetic care, its treatment remains a challenge for the surgical team, anesthesiologist, gynaecologist and Pediatrician.

Background: Obstetric haemorrhage is the leading cause of maternal death worldwide, 99% of which occur in low and middle income countries. The majority of deaths and adverse events are associated with delays in identifying compromise and escalating care. Management of severely compromised pregnant women may require transfer to tertiary centres for specialised treatment, therefore early recognition is vital for efficient management. The CRADLE vital signs alert device accurately measures blood pressure and heart rate, calculates the shock index (heart rate divided by systolic blood pressure) and alerts the user to compromise through a traffic light system reflecting previously validated shock index thresholds.Methods: This is a planned secondary analysis of data from the CRADLE-3 trial from ten clusters across Africa, India and Haiti where the device and training package were randomly introduced. Referral data were prospectively collected for a 4-week period before, and a 4-week period 3 months after implementation. Referrals from primary or secondary care facilities to higher level care for any cause were recorded. The denominator was the number of women seen for maternity care in these facilities.Results: Between April 1 2016 and Nov 30th, 2017 536,223 women attended maternity care facilities. Overall, 3.7% (n = 2784/74,828) of women seen in peripheral maternity facilities were referred to higher level care in the control period compared to 4.4% (n = 3212/73,371) in the intervention period (OR 0.89; 0.39-2.05) (data for nine sites that were able to collect denominator). Of these 0.29% (n = 212) pre-intervention and 0.16% (n = 120) post-intervention were referred to higher-level facilities for maternal haemorrhage. Although overall referrals did not significantly reduce there was a significant reduction in referrals for obstetric haemorrhage (OR 0.56 (0.39-0.65) following introduction of the device with homogeneity (i-squared 26.1) between sites. There was no increase in any bleeding-related morbidity (maternal death or emergency hysterectomy).Conclusions: Referrals for obstetric haemorrhage reduced following implementation of the CRADLE Vital Signs Alert Device, occurring without an increase in maternal death or emergency hysterectomy. This demonstrates the potential benefit of shock index in management pathways for obstetric haemorrhage and targeting limited resources in low- middle- income settings.Trial Registration: This study is registered with the ISRCTN registry, number ISRCTN41244132 (02/02/2016). [ABSTRACT FROM AUTHOR]

Obstetric haemorrhage is a leading cause of maternal morbidity and mortality and is a common reason for intensive care unit (ICU) admission in the postpartum. Primary postpartum obstetric haemorrhage is associated with four main causes: tone, thrombin, trauma, and tissue. Regarding the last one, placenta accreta is an abnormal invasion of the placenta into the myometrium. Early diagnosis of placenta accreta allows for better perioperative management; however, it is sometimes only identified during caesarean delivery when the placenta cannot be removed. We report a case of a 37-year-old woman with a history of caesarean section due to placenta previa, who was admitted at 36 weeks and 1 day for an urgent caesarean section (c-section) due to cord presentation. A subarachnoid block (SAB) was used for anaesthesia. It was chosen over general anaesthesia because it allows the patient to experience the birth of her children, enhances pain control, and avoids complications associated with general anaesthesia. Besides our centre has expertise in neuraxial anaesthesia. During the procedure, placental accretism and massive haemorrhage occurred, and a life-saving abdominal hysterectomy was needed. The patient experienced hypotension, partially responsive to volume replacement and vasopressors, leading to norepinephrine infusion and conversion to general anaesthesia. The surgery lasted 2.5 hours with a blood loss of 3500 ml. The patient was extubated without complications and transferred to the post anaesthesia care unit (PACU). Risk factors for placenta accreta spectrum (PAS) include previous surgery and placenta previa with a prior c-section. Antenatal diagnosis is crucial, and women with risk factors should undergo imaging at experienced centres. Delivery centres must have protocols for unexpected PAS and major obstetric haemorrhage. Both general and neuraxial anaesthesia can be suitable for managing PAS, and caesarean hysterectomy is often required to control haemorrhage. Postoperatively, adequate monitoring and care is essential. PAS management should involve excellent communication between a multidisciplinary team in specialised centres., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Laranjo et al.)

Objectives: To study the efficacy and safety of emergency bilateral internal iliac artery ligation (BIAL) in arresting massive obstetric haemorrahge. Study Design: Retrospective study. Setting: Department of Obstetrics and Gynaecology Unit-I, Allied Hospital, Faisalabad. Period: January 2014 to December 2018. Material & Methods: Fifty eight (58) patients with obstetric haemorrhage were included in this retrospective study. Bilateral internal iliac artery ligation was performed to control massive postpartum haemorrhage, post-operative internal haemorrhage. Results: The fifty eight (58) women underwent BIAl. Booked cases were onlhy (27%) and (73%) were unbooked. Out of 58 women 16(27%) women were with morbid adherent placenta, 14(24%) with uterine atony, 11(19%) uterine rupture, 9(17%) post-operative internal haemorrhage and 8(13%) coagulopathy were underwent BIAL. Out of 58 women 15(36%) ended in hysterectomy because of failure to control bleeding and uterus preserved in (64%). Overall efficacy in term of saving maternal life was 90%. One women had ureteric injury that was managed by Urologist. One another patient required re-laparotomy for persistant internal haemorrahge. Conclusion: Bilateral internal iliac artery ligation is safe and effective technique to control massive obstetric haemorrhage. Timely decision is also important to prevent hysterectomy. BIAL should include in algorithm to control intractable obstetric haemorrhage and consultant obstetricians and gynaecologist should learn that technique. [ABSTRACT FROM AUTHOR]

Summary: Massive obstetric haemorrhage (MOH) is a leading cause of maternal morbidity and mortality world‐wide. Using the Australian and New Zealand Massive Transfusion Registry, we performed a bi‐national cohort study of MOH defined as bleeding at ≥20 weeks' gestation or postpartum requiring ≥5 red blood cells (RBC) units within 4 h. Between 2008 and 2015, we identified 249 cases of MOH cases from 19 sites. Predominant causes of MOH were uterine atony (22%), placenta praevia (20%) and obstetric trauma (19%). Intensive care unit admission and/or hysterectomy occurred in 44% and 29% of cases, respectively. There were three deaths. Hypofibrinogenaemia (<2 g/l) occurred in 52% of cases in the first 24 h after massive transfusion commenced; of these cases, 74% received cryoprecipitate. Median values of other haemostatic tests were within accepted limits. Plasma, platelets or cryoprecipitate were transfused in 88%, 66% and 57% of cases, respectively. By multivariate regression, transfusion of ≥6 RBC units before the first cryoprecipitate (odds ratio [OR] 3·5, 95% CI: 1·7–7·2), placenta praevia (OR 7·2, 95% CI: 2·0–26·4) and emergency caesarean section (OR 4·9, 95% CI: 2·0–11·7) were independently associated with increased risk of hysterectomy. These findings confirm MOH as a major cause of maternal morbidity and mortality and indicate areas for practice improvement. [ABSTRACT FROM AUTHOR]

Introduction: A diagnostic accuracy study assessing the reliability and validity of a novel plasma fibrinogen point-of-care (F-Point) device compared with the von Clauss method of assay.Methods: Forty-one women presenting for elective caesarean delivery and 43 non-pregnant female patients presenting for elective gynaecological surgery were recruited to assess agreement at normal fibrinogen levels (elective gynaecological cohort) and high fibrinogen levels (elective caesarean section cohort). Validity was assessed by comparing the F-Point results with the gold standard of von Clauss fibrinogen assay performed on the ACL Top 500. Reliability (test-retest) and validity were assessed using the intraclass correlation to control for operator variance (two-way random absolute agreement method), presented as intra class correlation coefficients (ICCs) and 95% confidence interval, and Bland-Altman analysis, presented as mean bias and 95% limits of agreement and coefficient of variation (COV).Results: The results demonstrated a high test-retest reliability demonstrated in the paired F-Point measurements with an intraclass correlation coefficient (ICC) of 0.95, a bias of 0 (-00.69 to 0.69) and a COV of 9%. Similarly, there was acceptable agreement demonstrated between F-Point and von Clauss assay with an ICC of 0.91, a bias of -0.1 (-0.96 to 0.75) and a COV of 11%.Conclusions: Our novel plasma fibrinogen point-of-care device has been shown to be reliable and valid when testing fibrinogen levels as low as 2 g/L. Future studies investigating the correlation at lower fibrinogen levels, for example during haemorrhage and in patients with coagulopathies, are required. [ABSTRACT FROM AUTHOR]

Obstetric haemorrhage, and in particular PPH, remains the leading cause of maternal morbidity and mortality worldwide. Historically the impact of PPH has been most significant in low resource settings, however recent data suggests both the rate of PPH and number of maternal deaths due to haemorrhage are on the rise in the UK. Prevention and rapid recognition and management of PPH by clinicians, is key to mitigate the ensuing maternal morbidity and mortality. This article aims to provide an overview of important conservative, medical and surgical strategies for the prevention and management of PPH and to highlight the existing gaps in current literature to direct future work. [ABSTRACT FROM AUTHOR]

Background: Haemorrhagic morbidity is more common in women with abnormal placentation, that is placenta praevia or morbidly adherent placenta. The incidence of abnormal placentation is increasing due to rising caesarean section rates. Concerns regarding blood safety, blood shortages and soaring costs of blood processing have generated growing enthusiasm for blood conservation strategies. The aim of our study was to look at intraoperative cell salvage (IOCS) use and allogeneic transfusion patterns in patients with abnormal placentation. Methods: Patients with abnormal placentation were identified from the hospital database over a 2-year period between 2015 and 2016. Information collected for those that had IOCS setup included estimated blood loss, volume of blood collected and returned, pre- and postoperative haemoglobin levels and use of allogeneic blood. Results: A total of 139 cases of abnormal placentation were identified. Abnormal placentation accounted for 62% of all cases of IOCS usage and was established for 53 patients with abnormal placentation. The re-transfusion rate was 18.5%. Five patients received IOCS blood only. The allogeneic transfusion rate was 7.5% in patients who had IOCS setup compared with 6.9% in those who did not (p = 1.00). Median blood loss was greater for patients who had IOCS blood returned compared with patients who had not (p = 0.004). The median volume of blood returned was 520 (114–608) mL. Preoperative haemoglobin levels were lower for patients who received a combination of cell salvage and allogeneic blood (p = 0.006). Conclusions: IOCS contributed to a reduction or elimination of allogeneic transfusion for a proportion of this high-risk cohort and should be an integral component of a hospitals' blood conservation strategy. [ABSTRACT FROM AUTHOR]

Objective: To determine variations in cord blood gas (CBG) parameters after 3-minute delayed cord clamping (DCC) in vaginal deliveries (VDs) and caesarean deliveries (CDs) at term without fetal distress.Design: Prospective observational study.Setting: University hospital.Sample: CBG from 97 VDs and 124 CDs without fetal distress.Methods: Comparison of paired arterial-venous CBG parameters drawn at birth from the unclamped cord and after 3-minutes DCC for VDs and CDs.Main Outcome Measures: Base excess, bicarbonate, haematocrit and haemoglobin from both arterial and venous cord blood, lactate, neonatal outcomes, partial pressure of oxygen (pO2 ), partial pressure of carbon dioxide (pCO2 ), pH, and postpartum haemorrhage.Results: Arterial cord blood pH, bicarbonate ( HCO3- , mmol/l), and base excess (BE, mmol/l) decreased significantly after 3-minute DCC both in VDs (pH = 7.23 versus 7.27; P < 0.001; HCO3-  = 23.3 versus 24.3; P = 0.004; BE = -5.1 versus -2.9; P < 0.001) and CDs (pH = 7.28 versus 7.34; P < 0.001; HCO3-  = 26.2 versus 27.2; P < 0.001; BE = -1.5 versus 0.7; P < 0.001). After 3-minute DCC, pCO2 increased in CDs only (57 versus 51; P < 0.001), whereas lactate increased more in CDs compared with VDs (lactate, +1.1 [0.9, 1.45] versus +0.5 [-0.65, 2.35]; P = 0.01). Postpartum maternal haemorrhage, neonatal maximum bilirubin concentration, and need for phototherapy were similar between the two groups. Newborns born by CD more frequently required postnatal clinical monitoring or admission to a neonatal intensive care unit.Conclusions: After 3-minute DCC, the acid-base status shifted towards mixed acidosis in CDs and prevalent metabolic acidosis in VDs. CDs were associated with a more pronounced increase in arterial lactate, compared with VDs.Tweetable Abstract: By 3-minute DCC, acid-base status shifts towards mixed and metabolic acidosis in caesarean and vaginal delivery, respectively. [ABSTRACT FROM AUTHOR]

One of the most important causes of maternal mortality is major obstetric haemorrhage. Major haemorrhage can occur in parturients either during the antepartum period, during delivery, or in the postpartum period. Early recognition and a multidisciplinary team approach in the management are the cornerstones of improving the outcome of such cases. The management consists of fluid resuscitation, administration of blood and blood products, conservative measures such as uterine cavity tamponade and sutures, and finally hysterectomy. Blood transfusion strategies have changed over the last decade with emphasis on use of fresh frozen plasma, platelets, and fibrinogen. Point-of-care testing for treating coagulopathies promptly and interventional radiological procedures have further revolutionized the management of such cases.

Post-partum obstetric haemorrhage is a leading cause of mortality among Japanese women, generally treated with haemostatic measures followed by supplementary transfusion. Commonly used in the setting of severe trauma, massive transfusion protocols (MTPs), preparations of red blood cell concentrate (RBC) and fresh frozen plasma (FFP) with additional supplements, have proved effective in decreasing patient mortality following major obstetric bleeding events. Although promising, the optimal configuration of RBC and FFP utilized for obstetric bleeding needs to be verified. Here, we conducted a systematic literature review to define the optimal ratio of RBC to FFP for transfusion therapy during instances of obstetric bleeding. Our analysis extracted four retrospective, observational studies, all demonstrating that an FFP/RBC ratio of ≥1 was associated with improved patient outcomes following obstetric haemorrhage. We therefore conclude that, from the standpoint of haemostatic resuscitation, an FFP/RBC ratio of ≥1 is a necessary condition for optimal clinical management during MTP administration in the field of obstetrics. Hence, we further propose an optimized MTP strategy to be utilized in the setting of severe obstetric bleeding.

Objective: To understand the elements influencing the maternal deaths in the Limpopo province, South Africa. Methods: A retrospective review of all maternal deaths which occurred at the Pietersburg Hospital, Limpopo province was done over a five-year period (January 2011 to December 2015). The hospital death register was used to collate a list of maternal deaths occurring during the study period. The medical records of maternal deaths were reviewed. The total deliveries and live births for each year were obtained from the delivery registers. The data collected included maternal age, parity, referring facility, date of admission, date and time of death, ward where death occurred, and cause of death. Results: There were 14 685 live births and 232 maternal deaths between 2011 and 2015, resulting in an institutional Maternal Mortality Ratio (iMMR) of 1579/100 000 live births. The mean age of the patients was 29 years. Forty-three per cent of deaths occurred within 24 hours of admission, 35% died in ICU and 89% were referred from regional and district hospitals and community health centres. Of the referred patients, 83% were from district hospitals. Obstetric haemorrhage and pre-eclampsia, or eclampsia, were the main causes of death. Conclusion: The iMMR at Pietersburg Hospital remains unacceptably high. Most of the maternal deaths are due to obstetric haemorrhage, pre-eclampsia or eclampsia, medical and surgical disorder and non-pregnancy related infections.

Background. Obstetric haemorrhage (OH) is the leading cause of maternal mortality worldwide, although, indirectly, HIV is also a leading cause of maternal mortality in some settings with a high HIV seroprevalence. Objective. To determine the possible association between increasing rates of OH and HIV or its treatment. Methods. We conducted a retrospective chart review of women with OH at King Edward VIII Hospital, Durban, South Africa, over a 3-year period (2009 - 2011), during which the drug regimen for the prevention of mother-to-child transmission was evolving from single-dose nevirapine to antenatal zidovudine combined with intrapartum nevirapine (also referred to as dual therapy), and finally to a combination or highly active antiretroviral therapy (cART or HAART). Cases of OH (including abruptio placentae, placenta praevia, unspecified antepartum haemorrhage (APH), and postpartum haemorrhage (PPH)) were identified from maternity delivery records, and the relevant data extracted. Results. We analysed the records of 448 women diagnosed with OH. Even though the incidence of OH was low, the study found an increasing number of cases during the 3-year period. PPH – not APH – was associated with HIV seropositivity (odds ratio 1.84, 95% confi­dence interval 1.14 - 2.95). cART was not associated with an increased risk of haemorrhage. Conclusion. HIV was associated with a high risk of PPH, and its possible association with HIV treatment needs further research.

Objectives: To investigate the indications, interventions and clinical outcomes of pregnant and newly delivered women admitted to the multidisciplinary intensive care unit. Study Design: Retrospective review / observational study. Setting and Duration: Critical care unit of Pakistan Navy Ship Shifa hospital Karachi from 1st August 2017 to 31st July 2018. Materials and Methods: This study was carried out in 13 bedded Intensive care units of PNS Shifa hospital Karachi, over a period of one year. All obstetrics admissions to ICU up to 42 days postpartum were included in the study, while those patients admitted after 42 days of delivery were excluded. Results: During the study period, 2688 women delivered and 66 obstetric patients were admitted to ICU, which was 7.5% of all ICU admission and it accounted for 2.4% of all deliveries. The most common indication for admission to ICU was hypertension disorders of pregnancy 45.4% followed by obstetric haemorrhage in 42.4% cases. 75% of the cases belonged to the age group of 21-35 years. The parity of 60% of patients was in the range of P2-P4. During the stay in ICU, 9% of patients were put on ventilator support, 40.9% had blood product transfusion, while 45% received antihypertensive and anticonvulsant therapy. Maternal mortality was 4.5%. Conclusion: Hypertensive disorder of pregnancy and obstetric hemorrhage were the main indications for admission to ICU. A multidisciplinary team approach and timely recognition of complications development can lead to a better maternal outcome. Universal availability of antenatal care can help in reducing serious complications and admissions to ICU. [ABSTRACT FROM AUTHOR]

Postpartum haemorrhages (PPHs) account for around 200 deaths per year in the developed regions of the world. However, the efficacy of pharmacological and clinical interventions to prevent or manage PPHs is well established. Our objective was to determine the effectiveness of non-clinical interventions targeting healthcare professionals, organisations or facilities in preventing PPH or improving its management. We conducted a systematic review using the PRISMA four-step model. The MEDLINE and Cochrane databases were searched up to March 2019. Inclusion criteria were interventional studies, published in English of French language, aiming to reduce PPH outcomes for women in hospitals, regardless of study design. The studies' methodological quality was assessed according to the Cochrane EPOC criteria. We found 32 studies that met the inclusion criteria. None met all the methodological quality criteria. Six types of non-clinical interventions were identified: guideline dissemination, audit with feedback, simulation, training, clinical pathway and multifaceted interventions. Eleven studies reported a significant reduction in PPH rates and/or its complications, five studies reported a significant increase and 16 studies no significant results. The heterogeneity of the studies prevents us from identifying an effective non-clinical intervention in reducing PPH rates. [ABSTRACT FROM AUTHOR]