Blood flow changes in pelvic vessels associated with the application of an abdominal compression belt in healthy postpartum women

Introduction: Postpartum haemorrhage (PPH) accounts for a high proportion of maternal mortality and morbidity throughout the world. A uterine compression belt which has been developed recently represents a very low tech, low cost solution in managing postpartum haemorrhage. Objectives: To evaluate the blood flow changes in pelvic vessels following application of the postpartum haemorrhage compression belt (Laerdal Global Health, Stavanger, Norway). Methods: The sample included healthy postpartum women within 6 hours of vaginal delivery. The study was performed at Teaching Hospital, Ragama, Sri Lanka. PPH compression belt was applied on the lower abdomen in a supine position with a slight lateral tilt. Patient's pulse, blood pressure and Doppler indices (RI, PI and PFV) of the uterine, internal iliac and femoral arteries were measured using transabdominal Doppler ultrasonography. Lower limb oxygen saturation was also measured. Measurements were obtained by connecting the subjects to a multimonitor throughout the study period of 20 minutes. Median RI, PI and PFV was calculated and comparisons were made between the baseline and after belt application at 10 and 20 minutes. Results: A total of 20 healthy women were included and the mean time from delivery to study inclusion was 2.5 (range 0.5­5.0) hours. There were no adverse outcomes or altered vital signs noted among participants. Overall there were no significant changes in the internal iliac, uterine and femoral artery blood flow after application of the compression belt. Conclusions: There were no significant changes in the internal iliac, uterine and femoral artery blood flow after application of the compression belt. This preliminary study only shows that the application of the PPH compression belt has no apparent adverse changes in the iliac, uterine and femoral artery blood flow in postpartum mothers.

Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure.

OBJECTIVES: To evaluate patient outcomes and need for further interventions in women with a morbidly adherent placenta (MAP), before and after introduction of the Triple-P procedure involving placental non-separation, myometrial excision and reconstruction of the uterine wall. METHODS: Between December 2007 and February 2014, 30 patients with MAP were treated at our center. In 2007, we instituted a policy of bilateral prophylactic occlusion balloon catheter placement in both internal iliac arteries followed by Cesarean section with non-placental separation and preservation of the uterus. In 2010, the surgical technique was modified and the Triple-P procedure introduced. As a result, 19 women in our study received the Triple-P protocol (study group) and 11 did not (control group). The quantity of blood replacement products, estimated blood loss, and necessity for uterine arterial embolization and/or hysterectomy were recorded retrospectively and compared between the two groups. RESULTS: Placenta percreta was confirmed in six (54.5%) patients in the control group and 13 (68.4%) in the study group. Estimated mean blood loss during the procedure was lower in the study group than in the control group (1.70 L vs 2.17 L, respectively), but the difference was not statistically significant (P = 0.445). The risks of postpartum hemorrhage (PPH) and hysterectomy were statistically significantly lower in the study group (PPH, 54.5% vs 15.8%; P = 0.035; hysterectomy, 27.3% vs 0.0%; P = 0.045). As a consequence, there was a significant decrease in duration of inpatient stay in the study group (P = 0.044). CONCLUSION: Introduction of the Triple-P procedure conveyed a significantly reduced rate of hysterectomy, PPH and duration of hospital stay in patients with MAP. .

Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review.

BACKGROUND: Uterine-sparing surgical interventions have long been practiced as an alternative to hysterectomy in the management of severe postpartum haemorrhage (PPH); however, the risks of impairment of subsequent fertility from such procedures are unclear. OBJECTIVE: To evaluate the menstrual and fertility outcomes following radiological or conservative surgical interventions for severe PPH. SEARCH STRATEGY: A systematic review of English and non-English articles using the Cochrane Library 2012, PubMed (1950-2012), Embase (1980-2012), and the National Research Register. The keywords used for our search included 'fertility', 'reproductive outcome', 'postpartum haemorrhage', 'embolisation', 'hypogastric artery ligation', 'B-Lynch suture', 'stepwise uterine devascularisation', 'tamponade', and 'uterine compression sutures'. SELECTION CRITERIA: Studies including human female subjects with at least five cases. DATA COLLECTION AND ANALYSIS: Independent extraction of articles by two authors using predefined data fields, including study quality indicators. MAIN RESULTS: We identified 402 publications and after exclusions, 28 studies were included in the systematic review. Seventeen studies (675 women) reported on the fertility outcomes after uterine artery embolisation, five studies (195 women) reported on the fertility outcomes after uterine devascularisation, and six studies (125 women) reported on the fertility outcomes following uterine compression sutures. Overall, 553 out of 606 (91.25%) women resumed menstruation within 6 months of delivery. One hundred and eighty-three out of 235 (77.87%) women who desired another pregnancy achieved conception. AUTHOR'S CONCLUSIONS: Uterine-sparing radiological and surgical techniques for the management of severe PPH do not appear to adversely affect the menstrual and fertility outcomes in most women; however, the number of studies and the quality of the available evidence is of concern.

A Uniform Description of Perioperative Brain MRI Findings in Infants with Severe Congenital Heart Disease: Results of a European Collaboration.

BACKGROUND AND PURPOSE: A uniform description of brain MR imaging findings in infants with severe congenital heart disease to assess risk factors, predict outcome, and compare centers is lacking. Our objective was to uniformly describe the spectrum of perioperative brain MR imaging findings in infants with congenital heart disease. MATERIALS AND METHODS: Prospective observational studies were performed at 3 European centers between 2009 and 2019. Brain MR imaging was performed preoperatively and/or postoperatively in infants with transposition of the great arteries, single-ventricle physiology, or left ventricular outflow tract obstruction undergoing cardiac surgery within the first 6 weeks of life. Brain injury was assessed on T1, T2, DWI, SWI, and MRV. A subsample of images was assessed jointly to reach a consensus. RESULTS: A total of 348 MR imaging scans (180 preoperatively, 168 postoperatively, 146 pre- and postoperatively) were obtained in 202 infants. Preoperative, new postoperative, and cumulative postoperative white matter injury was identified in 25%, 30%, and 36%; arterial ischemic stroke, in 6%, 10%, and 14%; hypoxic-ischemic watershed injury in 2%, 1%, and 1%; intraparenchymal cerebral hemorrhage, in 0%, 4%, and 5%; cerebellar hemorrhage, in 6%, 2%, and 6%; intraventricular hemorrhage, in 14%, 6%, and 13%; subdural hemorrhage, in 29%, 17%, and 29%; and cerebral sinovenous thrombosis, in 0%, 10%, and 10%, respectively. CONCLUSIONS: A broad spectrum of perioperative brain MR imaging findings was found in infants with severe congenital heart disease. We propose an MR imaging protocol including T1-, T2-, diffusion-, and susceptibility-weighted imaging, and MRV to identify ischemic, hemorrhagic, and thrombotic lesions observed in this patient group.

MRI Findings at Term-Corrected Age and Neurodevelopmental Outcomes in a Large Cohort of Very Preterm Infants.

BACKGROUND AND PURPOSE: Brain MR imaging at term-equivalent age is a useful tool to define brain injury in preterm infants. We report pragmatic clinical radiological assessment of images from a large unselected cohort of preterm infants imaged at term and document the spectrum and frequency of acquired brain lesions and their relation to outcomes at 20 months. MATERIALS AND METHODS: Infants born at <33 weeks' gestation were recruited from South and North West London neonatal units and imaged in a single center at 3T at term-equivalent age. At 20 months' corrected age, they were invited for neurodevelopmental assessment. The frequency of acquired brain lesions and the sensitivity, specificity, and negative and positive predictive values for motor, cognitive, and language outcomes were calculated, and corpus callosal thinning and ventricular dilation were qualitatively assessed. RESULTS: Five hundred four infants underwent 3T MR imaging at term-equivalent age; 477 attended for assessment. Seventy-six percent of infants had acquired lesions, which included periventricular leukomalacia, hemorrhagic parenchymal infarction, germinal matrix-intraventricular hemorrhage, punctate white matter lesions, cerebellar hemorrhage, and subependymal cysts. All infants with periventricular leukomalacia, and 60% of those with hemorrhagic parenchymal infarction had abnormal motor outcomes. Routine 3T MR imaging of the brain at term-equivalent age in an unselected preterm population that demonstrates no focal lesion is 45% sensitive and 61% specific for normal neurodevelopment at 20 months and 17% sensitive and 94% specific for a normal motor outcome. CONCLUSIONS: Acquired brain lesions are common in preterm infants routinely imaged at term-equivalent age, but not all predict an adverse neurodevelopmental outcome.

Fetal electrocardiogram: ST waveform analysis in intrapartum surveillance.

ST waveform analysis of fetal electrocardiogram (ECG) for intrapartum surveillance (STAN) is a newly introduced method for fetal surveillance. The purpose of this commentary is to assist in the proper use of fetal ECG in combination with cardiotocography (CTG) during labour. Guidelines and recommendations concerning CTG and ST waveform interpretation and classification are stated that were agreed on by the European experts on ST waveform analysis for intrapartum surveillance during a meeting in Utretcht, The Netherlands in January 2007.

Review of the first 1502 cases of ECG-ST waveform analysis during labour in a teaching hospital.

OBJECTIVE: To assess the impact of introduction of the STAN monitoring system. STUDY DESIGN: Prospective observational study. SETTING: Tertiary referral labour ward, St George's Hospital, London. POPULATION: High-risk term pregnancies. METHODS: We report all consecutive cases of intrapartum monitoring using the STAN S 21 fetal heart monitor. Cases with adverse neonatal outcome were evaluated in relation to the ST waveform analysis and cardiotocography (CTG). MAIN OUTCOME MEASURES: Cord artery metabolic acidosis, neonatal encephalopathy (NNE) and reasons behind cases with poor outcome. RESULTS: Between 2002 and 2005, there were 1502 women monitored by STAN. Based on combined STAN analysis in the 1502 women, action was indicated in 358 women (23.8%), while in 1108 women (73.8%) no action was indicated. Traces were not interpretable in 36 women (2.4%). Of the 836 cases (55.7%) where cord blood gases were available, there were 23 cases (2.8%) of metabolic acidosis and 16 of these (70%) were identified by STAN. Overall, there were 14 cases of NNE monitored by STAN. Retrospective analysis of these highlights human errors, such as poor CTG interpretation, delay in taking appropriate action and not following the guidelines. CONCLUSIONS: Our experience suggests the need for more intense training on interpretation of CTG and strict adherence to guidelines.

Delivery of the posterior arm reduces shoulder dimensions in shoulder dystocia.

OBJECTIVE: To evaluate a possible reduction in shoulder diameter and circumference by extending the posterior arm during delivery, for an easier birth in cases of shoulder dystocia. METHODS: In this study of 33 neonates the bisacromial diameter and axilloacromial circumference were measured within 72 h of birth, first with the neonate's arms by its chest and then with 1 arm extended above its head. Reductions in diameter and circumference were evaluated. RESULTS: The mean +/- SD differences in bisacromial diameter and axilloacromial circumference were 1.9 +/- 0.69 cm and 2.52 +/- 1.18 cm, respectively. A greater reduction was observed in neonates with a greater shoulder diameter. CONCLUSION: In cases of shoulder dystocia, delivery of the posterior arm should significantly reduce shoulder dimensions, especially in larger fetuses, and prevent a need for excessive traction.

Validation of traction force indicator in ventouse devices.

OBJECTIVE: To evaluate whether the traction force indicator in a ventouse device gave an accurate estimation of the force applied. METHODS: The study was carried out at the Derby City Hospital. An estimate of measurement errors was made by analyzing the standard deviation of the residuals for 30 Kiwi OmniCup devices (Clinical Innovations, Abingdon, Oxfordshire, England) and a standard industrial spring balance. RESULTS: The measurement errors for the traction forces were very small and acceptable for the OmniCup. The overall estimate of measurement errors was 0.45 kg (1.35 lb). CONCLUSION: The overall measurement error for the traction force indicator of the OmniCup was found to be very small. Injuries associated the ventouse, such as cephalohematomas and subgaleal hemorrhages, may be minimized if the recommended limits for a safe traction force are not exceeded.

Uterine compression sutures: surgical management of postpartum hemorrhage.

BACKGROUND: It has been estimated that worldwide, over 125,000 women die of postpartum hemorrhage each year. The traditional management of this condition includes the use of oxytocics, such as oxytocin, ergometrine, and prostaglandins, before proceeding to ligation of the internal iliac arteries and even hysterectomy. The B-Lynch technique is a surgical procedure that may be used to arrest postpartum hemorrhage resulting from uterine atony. CASES: This paper describes simple modifications of this technique that make this procedure less complex to perform. Three clinical case scenarios illustrate the context in which the sutures may be used. CONCLUSION: Compression sutures placed into the postpartum uterus may provide a simple first surgical step to control bleeding when routine oxytocic measures have failed. We suggest that the technique we have described is a simple procedure and should be tried before more complex interventions are used.

Reliability of intrauterine pressure measurements.

The reliability of intrauterine pressure measurements was studied by placing two catheters in the same uterus in women in labor. Nineteen parturients were studied, five with two Intran I catheters in different pockets of amniotic fluid, five with two Intran II catheters in different pockets, and nine with two Intran II catheters in the same pocket of amniotic fluid. Among 1429 contractions studied, the catheters showed differences of pressure of less than 5 mmHg in 86% of contractions and of less than 10 mmHg in 94%. When cumulative uterine activity was calculated for each labor, the difference in the total active pressures shown by the two catheters was less than 5% in 17 cases and 5% or more in two cases. These differences are unlikely to be of any importance in the management of labor.

Premature rupture of membranes in nulliparas at term with unfavorable cervices: a double-blind randomized trial of prostaglandin and placebo.

OBJECTIVE: To determine whether the use of a prostaglandin (PG) E2 3-mg pessary followed by a delay of 12 hours before stimulation of labor with oxytocin improves obstetric outcome compared with the use of a placebo pessary. METHODS: One hundred fifty-five nulliparas at term with poor cervical scores (modified Bishop score below 6 of 10) and premature rupture of membranes (PROM) were recruited for this double-blind, placebo-controlled randomized trial. On admission to the study, either a PGE2 pessary or an identical-appearing placebo pessary was inserted into the posterior fornix. If labor did not start in the next 12 hours or if symptoms and signs of infection were evident, labor was induced with oxytocin infusion. Assignment was unblinded at the end of the study, and details of the labor and maternal and neonatal outcome in women who received a PG pessary were compared with those who received a placebo pessary. RESULTS: Women receiving a PG pessary were significantly less likely to require stimulation of labor at the end of 12 hours than were those given a placebo pessary (37 versus 58%, P = .002). The mean time between admission to study and delivery was significantly shorter in the PG group compared with the placebo group (15 versus 19 hours, P = .01). The rate of cesarean delivery was not statistically different in the two groups (13.9% with PG versus 15.8% with placebo). CONCLUSION: In nulliparas with poor cervical scores who present with PROM at term and no evidence of infection or obstetric complications, use of a PGE2 pessary resulted in more women establishing labor earlier, with a resultant reduction in the admission-to-delivery interval, compared with the use of a placebo pessary. The cesarean delivery rates in the two groups were similar, and there were no significant differences in neonatal outcome.

Augmentation of labor: does internal tocography result in better obstetric outcome than external tocography?

Labor was augmented in 250 patients for slow progress. These women were randomized to have uterine contractions recorded by either an external tocotransducer or an intrauterine catheter. Oxytocin was titrated to achieve an optimal frequency of contractions of six to seven every 15 minutes in each group; additional information on active contraction area profiles was available for those patients who had an intrauterine catheter. There was no statistically significant difference between the groups in the length of the post-augmentation period. The mean maximum dose of oxytocin was 11.1 mU/minute in the external tocography group and 11.0 mU/minute in the internal tocography group. Evidence of uterine hyperstimulation requiring temporary reduction of the oxytocin dose occurred in 19 and 20.2% of the patients in the external and internal tocography groups, respectively. Cesarean delivery was necessary in 12.6 and 16.9% of patients in the external and internal tocography groups, respectively, which is a nonsignificant difference. The incidence of low Apgar scores in the neonates and admission to neonatal intensive care was similar in both groups. The incidence of poor Apgar scores was not different between those who had transient hyperstimulation and those who had no hyperstimulation. In the management of augmented labor, monitoring of uterine contractions by intrauterine pressure catheters did not confer any advantage over tocography by external transducers.

Evaluation of maternal perception of sound-provoked fetal movement as a test of antenatal fetal health.

Maternal perception of sound-provoked fetal movement was correlated with the results of nonstress cardiotocography in 1097 women with obstetric or medical antenatal risk factors. Ninety-two percent of the mothers felt fetal movements with the stimulus; all but three had a reactive non-stress test (NST). These three women were taking multiple antihypertensive drugs and were less than 33 weeks' gestation. Of 88 patients with no maternal perception of sound-provoked fetal movement, ten had nonreactive NSTs. Ultrasound confirmed the absence of fetal movement to the stimulus. The outcome in nine of these ten cases suggested some evidence of fetal compromise. Maternal perception of sound-provoked fetal movement correlated well with the results of the NST; the sensitivity (76.9%), specificity (92.8%), and negative predictive value (99.7%) were all high, although the positive predictive value was only 11.4%. Maternal perception of sound-provoked fetal movement may suffice as an inexpensive and simple method of evaluating antenatal fetal well-being in risk situations. When the mother is doubtful or does not feel the sound-provoked fetal movement, NST is indicated to evaluate the fetal health.

Does prostaglandin confer significant advantage over oxytocin infusion for nulliparas with pre-labor rupture of membranes at term?

Ninety-four nulliparous women with a poor cervical score (less than 6) who had premature rupture of membranes at term were randomized by sealed envelope into two groups. One group received immediate stimulation of labor with oxytocin infusion. The second group received two prostaglandin E2 (PGE2) 3-mg pessaries 4 hours apart, followed by oxytocin infusion, if necessary. The interval between initiation of therapy to onset of labor was significantly longer in the PG group, but the length of labor was similar in both groups. The maximum dose of oxytocin needed was significantly higher in the oxytocin group. The cesarean delivery rate in the oxytocin group was 14.9%, compared with 19.1% in the PG group (not significantly different). All seven cesareans in the oxytocin group and seven of nine in the PG group were for failed stimulation of labor. Neonatal Apgar scores at 1 and 5 minutes and admission to the neonatal intensive care unit were similar in the two groups. The incidence of maternal and neonatal infection was small and was not different in the two groups. The use of PGE2 3-mg pessaries 4 hours apart, followed by oxytocin infusion if necessary, did not confer any benefit over the use of intravenous oxytocin in obstetric or neonatal outcome when both agents were started a few hours after admission.

No evidence of hearing loss due to fetal acoustic stimulation test.

The fetal acoustic stimulation test is used increasingly for fetal assessment. To evaluate the possibility of acoustic trauma, 465 children who had been exposed to vibroacoustic stimulation in utero were screened at 4 years of age for high-frequency hearing loss. A hand-held audiometer with test tones at 25 dB for 1000 and 4000 Hz was used because responses at this level indicate hearing within normal limits for middle and high frequencies. Thirty-one children failed the test. Failure to respond was followed by inspection of the ear canal for wax, tympanometry, and reflex measurement to assess the tympanic membrane, middle ear, and eustachian tube. Hearing was retested across the full frequency range using conventional audiometric technique, and referral for otolaryngologic examination and treatment was made if necessary. The causes of hearing loss were impacted wax in 12, current or recent upper respiratory tract infection with eustachian tube dysfunction and middle ear effusion in 15, and unresolved middle ear effusion after treatment with antibiotics for otitis media in two. Profound bilateral sensorineural hearing loss of unknown origin was found in one and slight bilateral gently sloping hearing loss in another. Retesting of all children with conductive hearing loss indicated that hearing had returned to normal after treatment. None of the children showed evidence of hearing loss.

Vibroacoustic stimulation and intrauterine sound pressure levels.

The sound pressure level in amniotic fluid generated by vibroacoustic stimulation, assessed with a hydrophone placed close to the fetal head, was studied in 16 subjects. The mean recorded sound pressure level was 115 dB and the highest level was 129 dB. The range of the background noise was 63.5-80.5 dB. There was no obvious relationship between the distance from the stimulator to the hydrophone and the intrauterine sound pressure level. Although sound pressure levels are high, they are probably reduced before reaching the cochlea of the fetus because of the surrounding amniotic fluid and the fluid in the middle ear.