Twin pregnancy and postpartum haemorrhage: a systematic review and meta-analysis.

BACKGROUND: Postpartum haemorrhage (PPH) continues to stand as the primary cause of maternal morbidity and mortality post-delivery, with twin pregnancies carrying a heightened risk of PPH compared to singleton deliveries. OBJECTIVES: To investigate the incidence of primary PPH among twin pregnancies and report on maternal and peripartum characteristics within this population. METHODS: A literature search was conducted using data from PubMed, EMBASE, Cochrane, Scopus, and Web of Science. The search aimed to identify studies concerning mothers with twin pregnancies and postpartum haemorrhage (PPH) from the inception of each respective database to June 8th, 2023. Pooled means and proportions were analyzed using the generic inverse variance method. This review was registered prospectively with PROSPERO (CRD42023427192). RESULTS: A total of 21 studies involving 23,330 twin pregnant patients were included. Incidence of PPH for vaginal delivery and Caesarean delivery (CS) was found to be 10.9% (95% CI: -0.017, 0.235, I2 = 96%) and 27.0% (95% CI: 0.180, 0.359, I2 = 99%) respectively. In vitro fertilization (IVF) was the most common conception method at 62.0% (95% CI: 0.448, 0.792, I2 = 100%) with 81.1% (95% CI: 0.708, 0.915, I2 = 100%) of twins being dichorionic diamniotic. CONCLUSION: This meta-analysis demonstrated more than one in ten vaginal deliveries and over one in four cesarean sections result in PPH for twin pregnancies. IVF is the predominant method of conception in this patient group and seems to contribute to subsequent PPH risk in specific mothers. While preliminary, these findings underscore the necessity for further well-designed and high-quality studies to validate these results.

Use of Prophylactic Parenteral Tranexamic Acid for Reduction of Blood Loss During and After Caesarean Section: A Double-Blind Randomized Controlled Study.

BACKGROUND: Haemorrhage is a leading cause of maternal mortality. The prophylactic use of tranexamic acid during vaginal delivery or caesarean section has the potential to reduce blood loss and postpartum anaemia. OBJECTIVE: To determine the effectiveness and safety of tranexamic acid in reducing blood loss during and within twenty-four hours after a caesarean section. METHODS: This was a randomised controlled study of two hundred and eighty-four (284) pregnant women booked for caesarean section at the University of Nigeria Teaching Hospital (UNTH), Ituku Ozalla, Enugu, Nigeria. The women were randomised into two groups: the intervention group (n = 142) that received intraoperative tranexamic acid with routine post-delivery oxytocin injection and the control group (n =142) that received placebo with routine post-delivery oxytocin. Blood loss was assessed both intra and post-operatively using a standard technique. RESULTS: The mean intraoperative blood loss was significantly lower in the intervention group compared to the control group (435.9±34 vs. 918±258.7, P=0.036). Similarly, the postoperative blood loss within twenty-four hours of surgery was significantly less in the intervention compared to the control group (232.71±67.4 vs. 717±317.6, P=0.031). The incidences of postoperative anaemia and blood transfusion intra or postoperatively were also significantly less in the intervention group compared to the control group (33.2% vs. 48.6; RR = 0.623; 95% CI = 0.46-0.84; p = 0.002, and 6.3% vs 24.6%: RR = 0.257; 95%CI = 0.13-0.52; P= < 0.001, respectively). There were no differences in the incidences of maternal and neonatal complications. CONCLUSION: The use of prophylactic parenteral tranexamic acid significantly reduces blood loss during and after caesarean section. It is therefore recommended in our obstetric practice as it has the potential to reduce the incidence of postpartum anaemia.

CONTEXTE: L'hémorragie est l'une des principales causes de mortalité maternelle. L'utilisation prophylactique de l'acide tranexamique lors d'un accouchement par voie basse ou d'une césarienne a le potentiel de réduire la perte de sang et l'anémie post-partum. OBJECTIF: Déterminer l'efficacité et la sécurité de l'acide tranexamique dans la réduction de la perte de sang pendant et dans les vingt-quatre heures suivant une césarienne. MÉTHODES: Cette étude contrôlée randomisée a inclus deux cent quatre-vingt-quatre (284) femmes enceintes prévues pour une césarienne à l'Hôpital Universitaire du Nigeria (UNTH), Ituku Ozalla, Enugu, Nigéria. Les femmes ont été randomisées en deux groupes : le groupe d'intervention (n = 142) qui a reçu de l'acide tranexamique en peropératoire avec une injection d'oxytocine post-accouchement de routine et le groupe témoin (n = 142) qui a reçu un placebo avec l'oxytocine de routine post-accouchement. La perte de sang a été évaluée pendant l'opération et après l'opération à l'aide d'une technique standard. RÉSULTATS: La perte de sang moyenne peropératoire était significativement plus faible dans le groupe d'intervention par rapport au groupe témoin (435,9±34 vs. 918±258,7, P=0,036). De même, la perte de sang postopératoire dans les vingt-quatre heures suivant l'opération était significativement plus faible dans le groupe d'intervention par rapport au groupe témoin (232,71±67,4 vs. 717±317,6, P=0,031). Les incidences d'anémie postopératoire et de transfusion sanguine pendant ou après l'opération étaient également significativement plus faibles dans le groupe d'intervention par rapport au groupe témoin (33,2% vs. 48,6%; RR = 0,623; IC 95% = 0,46-0,84; p = 0,002, et 6,3% vs. 24,6%: RR = 0,257; IC 95% = 0,13-0,52; P= < 0,001, respectivement). Il n'y avait pas de différences dans les incidences de complications maternelles et néonatales. CONCLUSION: L'utilisation prophylactique d'acide tranexamique parentéral réduit significativement la perte de sang pendant et après une césarienne. Il est donc recommandé dans notre pratique obstétricale, car il a le potentiel de réduire l'incidence de l'anémie post-partum. MOTS-CLÉS: Acide tranexamique, Perte de sang intrapartum, Hémorragie post-partum, Anémie.

Pregnancy, childbirth and neonatal outcomes of women with rare inherited coagulation disorders.

Background: We aimed to describe the characteristics and the pregnancy outcomes of women with rare inherited coagulation factor disorders managed at a tertiary obstetric-haematology unit in the United Kingdom. Methods: A retrospective service evaluation was conducted using routinely collected medical records. Descriptive analyses were applied to investigate pregnancy, childbirth and neonatal management and outcomes. Results: Overall, 20 patients with rare inherited coagulation disorders were included who birthed 30 live infants from 29 pregnancies. Regarding maternal bleeding outcomes, 3% experienced antepartum haemorrhage, 38% of pregnancies experienced primary post-partum haemorrhage, and none experienced secondary post-partum haemorrhage. Five (17%) neonates had cranial ultrasound scans for imaging to investigate for a neonatal haemorrhage, which were all normal. Conclusions: Although women with rare inherited coagulation disorders may be more susceptible to complications in pregnancy, within this cohort there was no evidence that the condition led to increased morbidity or mortality when best practices were observed.

Sella Turcica Size in Women with Sheehan Syndrome-A Case-Control Study.

Introduction: Sheehan syndrome is a common cause of hypopituitarism in developing countries. Among risk factors, in addition to post-partum haemorrhage, a smaller sellar volume is also believed to predispose to pituitary necrosis. Some earlier studies have reported smaller sellar volume in these patients but involved a small number of patients and lacked matched controls. The main of the present study was to study the sellar volume in a large cohort of patients with Sheehan syndrome and compare it with age- and parity-matched controls. Methods: Fifty women with Sheehan syndrome and an equal number of age- and parity-matched controls were studied. Baseline investigations, relevant hormonal assay, and MRI of pituitary were studied in all. Results: Sellar volume was significantly lower in patients with Sheehan syndrome (334.50 ± 129.08 mm3 in patients as against 456.64 ± 169.25 mm3 in controls, P = 0.000). Far more women with Sheehan syndrome than controls had decreased sellar volume (40% vs. 12%). Conclusions: Patients with Sheehan syndrome have a smaller sellar volume that may be a non-modifiable risk factor for the development of post-partum pituitary necrosis.

A Case Report of Secondary Postpartum Hemorrhage in a Pregnant Woman With a Mechanical Mitral Valve: Challenges of Anticoagulation.

A pregnant woman with rheumatic heart disease always runs the risk of developing both thromboembolic and hemorrhagic symptoms, necessitating careful monitoring of her anticoagulation treatments both throughout pregnancy and after delivery. Postpartum haemorrhage, a hemorrhagic manifestation, can be challenging to control and presents a significant challenge when it comes to beginning anticoagulation after delivery. Thus, pregnancy in these patients is an extremely risky endeavour. Given that these women take anticoagulants, managing these women with artificial heart valves throughout pregnancy can be difficult. The diminished clotting ability in these women may be the cause of postpartum haemorrhage, and a multidisciplinary approach is necessary for a successful treatment. To manage this potentially fatal illness, a well-equipped institution with proper support systems is essential. We present a 23-year-old primigravida who was 39 weeks and three days pregnant and had a repaired aortic valve as well as a prosthetic mitral valve. She was taking warfarin to prevent clotting when she was pregnant.

Obstetrics Outcomes in Women Undergoing Second-Stage Cesarean Section: A Cross-Sectional Study.

Background Cesarean section (CS) involves the delivery of the fetus through incisions in the abdomen or uterine walls which is an alternative to vaginal delivery. In the majority of women, second-stage CS is performed without even attempting assisted vaginal delivery. This leads to difficulty for obstetricians for whether to perform an immediate CS or attempt a difficult vaginal birth as the effective method of delivery as CS are linked with higher morbidities which further increase when a CS is performed in the second stage. Hence, the present study was performed to find out obstetrics results in women undergoing second-stage CS. Method A cross-sectional study was conducted in the Department of Obstetrics and Gynecology of a tertiary care center attached to a medical college to study obstetric outcomes in women undergoing second-stage CS from January 2021 to December 2022 on 54 postnatal women who underwent second-stage CS. Results The mean age was 26.7 ± 3.9 years ranging between 19 and 35 years involving a majority of primiparity women. Maximum patients were having gestational age between 39 and 40 weeks and had spontaneous labor. The main indication of second-stage CS was non-reassuring fetal status and the method of delivery mainly involved for the deeply impacted head was the modified patwardhan technique in which if the head is embedded deeply in the pelvis in the OP position the anterior shoulder is delivered first followed by the same side leg then opposite side leg followed by the arm is gently delivered. Baby's trunk, legs, and buttocks are moved out by pulling them carefully and gently. And lastly, the head of the infant is finally moved out. The intra-operative complications mainly found were an extension of uterine angle and the post-operative complication was post-partum hemorrhage (PPH). The most common neonatal complication was the requirement for neonatal intensive care unit (NICU) admission. In conclusion, the present study reported a hospital range between seven and 14 days in comparison to other studies that reported hospital stays between three and 15 days. Conclusion In conclusion, higher maternal and fetal morbidities were associated with CS performed at full dilation of the cervix. The most common maternal complication seen was an injury to uterine vessels along with PPH however neonatal complications included the requirement of NICU monitoring. As there are no appropriate guidelines for the same, formulation of guidelines for performing CS at full dilation is required.

Trends and regional variations in prescriptions dispensed to stimulate uterine contractions at the end of pregnancy in Belgium: A community-based study from 2003 to 2018.

PURPOSE: To investigate trends and regional variations in uterotonics dispensed around birth between 2003 and 2018 in Belgium. METHODS: Data, including outpatient and inpatient prescriptions were extracted from a nationally representative prescription database. The prevalence of uterotonics dispensed during a period including the 7 days before birth, the delivery day and the 7 days after birth was computed over three 4-year-long study periods from 2003 to 2018. The trends between periods and associations between the use of at least one uterotonic and maternal age, region of residence, delivery type and social status were assessed using logistic regression. RESULTS: In total, 31 675 pregnancies were included in the study. The proportion of pregnancies exposed to at least one uterotonic decreased significantly from 92.9% (95%CI, 92.3-93.4) in 2003-2006 to 91.4% (95%CI, 90.7-92.0) in 2015-2018 for vaginal births and from 95.5% (95%CI, 94.5-96.4) to 93.7% (95%CI, 92.6-94.7) for caesarean sections. However, for vaginal births, the proportion of oxytocin increased from 84.5% (95%CI, 83.7-85.2) to 89% (95%CI 88.3-89.7). A significant association was found between uterotonic agent use and maternal age, region of residence, and delivery type. The dispensation of some uterotonic agents differed significantly between the regions. CONCLUSIONS: The proportion of pregnancies exposed to at least one uterotonic was high across the study period but decreased slightly between 2003 and 2018. Important variations in uterotonic use between regions highlight the need for improved national guidance.

Does antenatal cholecalciferol supplementation affect the mode or timing of delivery? Post hoc analyses of the MAVIDOS randomized controlled trial.

BACKGROUND: Observational studies relating maternal 25-hydroxyvitamin D status to timing and mode of delivery have reported inconsistent results. We assessed the effect of antenatal cholecalciferol supplementation on the incidence of preterm birth, delivery mode and post-partum haemorrhage (PPH). METHODS: MAVIDOS was a randomized, double-blind, placebo-controlled trial of 1000 IU/day cholecalciferol from 14 weeks' gestation until delivery. Gestational age, mode of delivery [categorized as spontaneous vaginal delivery (SVD), instrumental (including forceps and vacuum extraction) or Caesarean section] and PPH (>500 ml estimated blood loss) were determined from medical records. RESULTS: A total of 965 women participated in the study until delivery. Gestation at birth and incidence of preterm birth (cholecalciferol 5.7%, placebo 4.5%, P = 0.43) were similar between the two treatment groups. SVD (versus instrumental or Caesarean delivery) was more likely in women randomized to cholecalciferol [Relative Risk (RR) 1.13, 95% confidence interval (CI) 1.02,1.25] due to lower instrumental (RR 0.68, 95%CI 0.51,0.91) but similar risk of Caesarean delivery (RR 0.94, 95%CI 0.74,1.19). PPH was less common in women randomized to cholecalciferol [32.1% compared with placebo (38.1%, P = 0.054) overall], but similar when stratified by delivery mode. CONCLUSIONS: Antenatal cholecalciferol supplementation did not alter timing of birth or prevalence of preterm birth but demonstrated a possible effect on the likelihood of SVD.

A relational approach to improving interprofessional teamwork in post-partum haemorrhage (PPH).

BACKGROUND: Post-partum haemorrhage (PPH) is an obstetric emergency that requires effective teamwork under complex conditions. We explored healthcare team performance for women who suffered a PPH, focusing on relationships and culture as critical influences on teamwork behaviours and outcomes. METHODS: In collaboration with clinical teams, we implemented structural, process and relational interventions to improve teamwork in PPH cases. We were guided by the conceptual framework of Relational Coordination and used a mixed methods approach to data collection and analysis. We employed translational simulation as a central, but not singular, technique for enabling exploration and improvement. Key themes were identified from surveys, focus groups, simulation sessions, interviews, and personal communications over a 12-month period. RESULTS: Four overarching themes were identified: 1) Teamwork, clear roles and identified leadership are critical. 2) Relational factors powerfully underpin teamwork behaviours-shared goals, shared knowledge, and mutual respect. 3) Conflict and poor relationships can and should be actively explored and addressed to improve performance. 4) Simulation supports improved team performance through multifaceted mechanisms. One year after the project commenced, significant progress had been made in relationships and systems. Clinical outcomes have improved; despite unprecedented increase in labour ward activity, there has not been any increase in large PPHs. CONCLUSIONS: Teamwork, relationships, and the context of care can be actively shaped in partnership with clinicians to support high performance in maternity care. We present our multifaceted approach as a guide for leaders and clinicians in maternity teams, and as an exemplar for others enacting quality improvement in healthcare.

Assessment of post-partum haemorrhage risk among women with moderate thrombocytopenia.

It is unknown whether moderate thrombocytopenia represents a risk factor for post-partum haemorrhage (PPH). We assessed PPH risk among women with a platelet count of between 100 and 50 × 109 /l and stratified the risk for O/non-O blood group. We included consecutive women undergoing vaginal delivery or caesarean section with moderate thrombocytopenia. Women with >150 × 109 /l platelets at delivery were selected as controls and matched for age, type of birth and ethnicity. Odds ratios (ORs) with their 95% confidence intervals (95% CIs) were calculated as risk estimates. A total of 94 thrombocytopenic women and 94 controls were included in the study. The rate of PPH was significantly higher in thrombocytopenic women than in controls (37% vs. 10%, p < 0.001); there was a higher risk of PPH in the thrombocytopenic group when compared to the control group (adjusted OR 4.7, 95% CI 2.1-10.8, p < 0.01) and this association was stronger in blood group O carriers (adjusted OR 11.0, 95% CI 2.4-49.6, p < 0.01). In conclusion, our study shows that a moderate thrombocytopenia is a risk factor for PPH, especially in blood group O carriers.

Arresting post-partum hemorrhage using the novel trans-vaginal uterine artery clamp.

OBJECTIVES: Post-partum hemorrhage (PPH) continues to be the leading cause of maternal mortality in low-resource settings. The commonest variant - Atonic PPH, is managed by additional pharmacological measures which may fail. Additional surgical interventions for hemostasis take time and are not universally available. Immediate arrest of bleeding was deemed essential and a novel Transvaginal Uterine Artery Clamp (TVUAC) was explored for its effectiveness in achieving immediate hemostasis in atonic and mixed post-partum hemorrhage. STUDY DESIGN: A retrospective chart review was performed for all patients, who underwent vaginal delivery and developed immediate post-partum atonic PPH, in a tertiary care center in South India, between 1st April 2015 and 31st December 2020. As soon as excess bleeding was observed, two TVUACs were applied trans-vaginally at 3' and 9'o clock position of the cervix to occlude the uterine arteries where it joins the isthmus of the uterus. RESULTS: Of 3999 vaginal deliveries, there were 251 patients who developed primary atonic PPH during the study period, of which 89 were managed by medical measures alone. Out of the remaining 162 patients, in 153 (94.4%) TVUAC helped to achieve hemostasis; with TVUAC alone in 120 patients (78.43%) and with an additional second line surgical intervention in 33 patients. In nine patients, TVUAC was not readily available and hence second line interventions alone were used. None required any third line surgical interventions (laparotomies) for hemostasis nor were there any incident of maternal mortality or consumptive coagulopathy. TVUAC was applied for a mean duration of 25 ± 10 min. Only 11.6% (29/251, 95% C.I 7.9-16.1%) of the patients required a blood transfusion with a median of 2 (1-4) units of packed RBC. No procedure related complications were reported up to a scheduled 6th week in-person follow-up. CONCLUSION: The novel TVUAC shows potential in limiting third line interventions, maternal morbidity and mortality. Its effectiveness and safety may be further explored as a first line surgical adjunct to medical measures, in PPH protocols in low-resource settings.

Context specific realities and experiences of nurses and midwives in basic emergency obstetric and newborn care services in two district hospitals in Rwanda: a qualitative study.

BACKGROUND: In low and middle-income countries, nurses and midwives are the frontline healthcare workers in obstetric care. Insights into experiences of these healthcare workers in managing obstetric emergencies are critical for improving the quality of care. This article presents such insights, from the nurses and midwives working in Rwandan district hospitals, who reflected on their experiences of managing the most common birth-related complications; postpartum hemorrhage (PPH) and newborn asphyxia. Rwanda has made remarkable progress in obstetric care. However, challenges remain in the provision of high-quality basic emergency obstetric and newborn care (BEmONC). This study is a qualitative part of a broader research project about implementation of an mLearning and mHealth decision support tool in BEmONC services in Rwanda. METHODS: In this exploratory qualitative aspect of the research, four focus group discussions (FGDs) with 26 nurses and midwives from two district hospitals in Rwanda were conducted. Each FGD was made up of two parts. The first part focused on the participants' reflections on the research results (from the previous study), while the second part explored their experiences of delivering obstetric care services. The research results included: survey results reflecting their knowledge and skills of PPH management and of neonatal resuscitation (NR); and findings from a six-month record review of PPH management and NR outcomes, from the district hospitals under study. Data were analyzed using hybrid thematic analysis. RESULTS: The analysis revealed three main themes: (1) reflections to the baseline research results, (2) self-reflection on the current practices, and (3) contextual factors influencing the delivery of BEmONC services. Nurses and midwives felt that the presented findings were a true reflection of the reality and offered diverse explanations for the results. The participants' narratives of lived experiences of providing BEmONC services are also presented. CONCLUSION: The insights of nurses and midwives regarding the management of birth-related complications revealed multi-faceted factors that influence the quality of their obstetric care. Even though the study was focused on PPH management and NR, the resulting recommendations to improve quality of care could benefit the broader field of maternal and child health, particularly in low and middle-income countries.

Utilization of red cell concentrate from storage centers of South Gujarat.

INTRODUCTION: Blood storage centres in remote areas of the country was started to serve the patients in those locations. Present study analyses the the utilisation of blood from such storage centres under one regional transfusion centre in south Gujrat. MATERIALS AND METHODS: In this retrospective study amount of blood requested, utilised, major reasons for utilisation were studied from available records and analysed. RESULTS: 20 storage centres serving almost 2 million population per year was studied. 2197 - 3089 units of blood were requested from these centres per year with utilisation rates of 100 - 134 units/centre/year. Severe anaemia, Antenatalcare, operations and postpartum. Haemorrhage were important causes for red cell transfusion. DISCUSSION AND CONCLUSION: The storage centres are functioning reasonably well but utilisation of around 2500 - 3500 units packed red cell per year for 2 million population suggests under utlisation of the facility.

Obstetric neonatal emergency simulation workshops in remote and regional South India: a qualitative evaluation.

BACKGROUND: Healthcare facilities in remote locations with poor access to a referral centre have a high likelihood of health workers needing to manage emergencies with limited support. Obstetric and neonatal clinical training opportunities to manage childbirth emergencies are scant in these locations, especially in low- and middle-income countries. OBJECTIVES: This study aimed to explore the factors, which influenced healthcare worker experience of attending birth emergencies in remote and regional areas of South India, and the perceived impact of attending the Obstetric and Neonatal Emergency Simulation (ONE-Sim) workshop on these factors. DESIGN: Qualitative descriptive study using pre- and post-workshop qualitative surveys. SETTINGS: Primary healthcare facilities in remote/regional settings in three states of South India. PARTICIPANTS: A total of 125 healthcare workers attended the workshops, with 85 participants completing the pre- and post-workshop surveys included in this study. Participants consisted of medical and nursing staff and other health professionals involved in care at childbirth. METHODS: ONE-Sim workshops (with a learner-centred approach) were conducted across three different locations for interprofessional teams caring for birthing women and their newborns, using simulation equipment and immersive scenarios. Thematic analysis was employed to the free-text responses obtained from the surveys consisting of open-ended questions. RESULTS: Participants identified their relationship with the patient, the support provided by other health professionals, identifying their gaps in knowledge and experience, and the scarcity of resources as factors that influenced their experience of birth emergencies. Following the workshops, participant learning centred on improving team and personal performance and approaching future emergencies with greater confidence. CONCLUSIONS: Challenges experienced by healthcare workers across sites in remote and regional South India were generally around patient experience, senior health professional support and resources. The technical and interpersonal skills introduced through the ONE-Sim workshop may help to address some of these factors in practice.

A mixed methods evaluation of Advanced Life Support in Obstetrics (ALSO) and Basic Life Support in Obstetrics (BLSO) in a resource-limited setting on the Thailand-Myanmar border.

Background: Short emergency obstetric care (EmOC) courses have demonstrated improved provider confidence, knowledge and skills but impact on indicators such as maternal mortality and stillbirth is less substantial. This manuscript evaluates Advanced Life Support in Obstetrics (ALSO) and Basic Life Support (BLSO) as an adult education tool, in a protracted, post-conflict and resource-limited setting. Methods: A mixed methods evaluation was used. Basic characteristics of ALSO and BLSO participants and their course results were summarized. Kirkpatrick's framework for assessment of education effectiveness included: qualitative data on participants' reactions to training (level 1); and quantitative health indicator data on change in the availability and quality of EmOC and in maternal and/or neonatal health outcomes (level 4), by evaluation of the post-partum haemorrhage (PPH) related maternal mortality ratio (MMR) and stillbirth rate in the eight years prior and following implementation of ALSO and BLSO. Results: 561 Thailand-Myanmar border health workers participated in ALSO (n=355) and BLSO (n=206) courses 2008-2020. Pass rates on skills exceeded 90% for both courses while 50% passed the written ALSO test. Perceived confidence significantly improved for all items assessed. In the eight-year block preceding the implementation of ALSO and BLSO (2000-07) the PPH related MMR per 100,000 live births was 57.0 (95%CI 30.06-108.3)(9/15797) compared to 25.4 (95%CI 11.6-55.4)(6/23620) eight years following (2009-16), p=0.109. After adjustment, PPH related maternal mortality was associated with birth before ALSO/BLSO implementation aOR 3.825 (95%CI 1.1233-11.870), migrant (not refugee) status aOR 3.814 (95%CI 1.241-11.718) and attending ≤four antenatal consultations aOR 3.648 (95%CI 1.189-11.191). Stillbirth rate per 1,000 total births was 18.2 (95%CI 16.2-20.4)(291/16016) before the courses, and 11.1 (95%CI 9.8-12.5)(264/23884) after, p=0.038. Birth before ALSO/ BLSO implementation was associated with stillbirth aoR 1.235 (95%CI 1.018-1.500). Conclusions: This evaluation suggests ALSO and BLSO are sustainable, beneficial, EmOC trainings for adult education in protracted, post-conflict, resource-limited settings.

Complement activation and blockade in massive post-partum haemorrhage, thrombotic microangiopathy and acute kidney injury: a case report.

BACKGROUND: Thrombotic microangiopathy (TMA)-mediated acute kidney injury (AKI) following massive haemorrhage is a rare but severe complication of the post-partum period. It is associated with a poor renal prognosis and a high risk of end-stage kidney disease. Complement activation may occur in this picture. However, whether complement activation, and thus complement blockade, may be critically relevant in this setting is unknown. CASE PRESENTATION: A 50 year-old woman presented with massive delayed post-partum haemorrhage (PPH). Despite bleeding control and normalization of coagulation parameters, she rapidly developed AKI stage 3 associated with dysmorphic microhematuria and proteinuria up to 2 g/day with the need of renal replacement therapy. Blood tests showed signs of TMA associated with markedly increased sC5b-9 and factor Bb plasma levels, respectively markers of terminal and alternative complement pathway over-activation. This clinical picture prompted us to initiate anti-C5 therapy. sC5b-9 normalized within 12 h after the first dose of eculizumab, factor Bb and C3 after seven days, platelet count after nine days and haptoglobin after 3 weeks. The clinical picture improved rapidly with blood pressure control within 48 h. Diuresis resumed after three days, kidney function rapidly improved and haemodialysis could be discontinued after the sixth and last dose. Serum creatinine returned to normal two years after presentation. CONCLUSIONS: We suggest that massive PPH induced major activation of complement pathways, which ultimately lead to TMA-induced AKI. Various causes, such as oocyte-donation, the potential retention of placental material and the use of tranexamic acid may have contributed to complement activation due to PPH. The prompt administration of anti-C5 therapy may have rapidly restored kidney microcirculation patency, thus reversing signs of TMA and AKI. We propose that complement activation may represent a major pathophysiological player of this complication and may provide a novel therapeutic avenue to improve renal prognosis in TMA-induced AKI following massive PPH.

A case series of post-partum haemorrhage managed using Ellavi uterine balloon tamponade in a rural regional hospital.

Uterine balloon tamponade (UBT) should be attempted once emergency measures have been applied and medical treatment for post-partum haemorrhage (PPH) resulting from an atonic uterus has failed. Sinapi Biomedical (Pty) Ltd developed the Ellavi UBT, a free-flow pressure-controlled UBT unit. The device is affordable for use in lesser-resourced countries. A case series of Ellavi UBT used by medical officers in a rural regional hospital without specialist supervision was conducted. This case series was conducted in St Elizabeth's Hospital in Lusikisiki, South Africa. The hospital serves as the regional hospital for the Ingquza Hill Subdistrict in the Eastern Cape Province. The Nelson Mandela Academic Hospital (NMAH) in Mthatha is the tertiary referral hospital. Workshops were conducted on the use of Ellavi UBT, and devices were made freely available to the hospital. The case series included 10 patients. Six patients delivered by caesarean section, and four had normal vertex deliveries. All patients had additional oxytocin infusions, and eight patients received misoprostol. Following the insertion and inflation of the Ellavi UBT, the PPH stopped in seven patients, was much reduced in one patient and reduced in one patient. In one case, the Ellavi UBT had no effect on the bleeding. All 10 patients were referred to the NMAH. All patients in the case series had good outcomes. The insertion of the Ellavi UBT and subsequent referral proved to be feasible in a rural regional hospital. All patients included in the case series arrived at the referral hospital and had a good outcome.

Risk of major labour-related complications for pregnancies progressing to 42 weeks or beyond.

BACKGROUND: Post-term gestation beyond 41+6 completed weeks of gestation is known to be associated with a sharp increase in the risk of stillbirth and perinatal mortality. However, the risk of common adverse outcomes related to labour, such as shoulder dystocia and post-partum haemorrhage for those delivering at this advanced gestation, remains poorly characterised. The objective of this study was to examine the risk of adverse, labour-related outcomes for women progressing to 42 weeks gestation or beyond, compared with those giving birth at 39 completed weeks. METHODS: We performed a state-wide cohort study using routinely collected perinatal data in Australia. Comparing the two gestation cohorts, we examined the adjusted relative risk of clinically significant labour-related adverse outcomes, including macrosomia (≥ 4500 at birth), post-partum haemorrhage (≥1000 ml), shoulder dystocia, 3rd or 4th degree perineal tear and unplanned caesarean section. Parity, maternal age and mode of birth were adjusted for using logistic regression. RESULTS: The study cohort included 91,314 women who birthed at 39 completed weeks and 4317 at ≥42 completed weeks. Compared to 39 weeks gestation, those giving birth ≥42 weeks gestation had an adjusted relative risk (aRR) of 1.85 (95% CI 1.55-2.20) for post-partum haemorrhage following vaginal birth, 2.29 (95% CI 1.89-2.78) following instrumental birth and 1.44 (95% CI 1.17-1.78) following emergency caesarean section; 1.43 (95% CI 1.16-1.77) for shoulder dystocia (for non-macrosomic babies); and 1.22 (95% CI 1.03-1.45) for 3rd or 4th degree perineal tear (all women). The adjusted relative risk of giving birth to a macrosomic baby was 10.19 (95% CI 8.26-12.57) among nulliparous women and 4.71 (95% CI 3.90-5.68) among multiparous women. The risk of unplanned caesarean section was 1.96 (95% CI 1.86-2.06) following any labour and 1.47 (95% CI 1.38-1.56) following induction of labour. CONCLUSIONS: Giving birth at ≥42 weeks gestation may be an under-recognised risk factor for several important, labour-related adverse outcomes. Clinicians should be aware that labour at this advanced gestation incurs a higher risk of adverse outcomes. In addition to known perinatal risks, the risk of obstetric complications should be considered in the counselling of women labouring at post-term gestation.

Repeated pregnancies in uncorrected double outlet right ventricle: a rare occurrence.

Pregnancy in a woman with double outlet right ventricle, ventricular septal defect, and pulmonary stenosis is presented. Her previous two pregnancies ended in fetal losses. In the current pregnancy, she had thrombocytopenia, placenta previa, and severe fetal growth restriction. She underwent an emergency caesarean section followed by post-partum haemorrhage and COVID-19 infection. Literature review has been performed.