Weight-based oxytocin infusion for preventing uterine atony during caesarean delivery in non-labouring patients: A dose-response study.

Postpartum haemorrhage remains a significant cause of maternal morbidity and mortality with the commonest reason being uterine atony. For prevention of uterine atony during caesarean delivery, oxytocin is advocated as a first line drug. There is however no published data regarding utility of a weight-based oxytocin infusion. The present study evaluated dose-response relationship for oxytocin infusion when used as weight-based regimen. A total of 55 non-labouring patients without risk factors for uterine atony and scheduled for caesarean delivery under spinal anaesthesia were enrolled. Randomization was done to receive oxytocin infusion in a dose of 0.1, 0.15, 0.2, 0.25 or 0.3 IU kg-1  h-1 (n = 11 each), initiated at the time of cord clamping and continued until the end of surgery. Successful outcome was defined as attaining an adequate uterine response at 4 min of initiation of infusion and maintained till end of surgery. Oxytocin associated hypotension, tachycardia, ST-T changes, nausea/vomiting, flushing and chest pain were also observed. A significant linear trend for adequate intraoperative uterine tone was seen with increasing dose of weight-based oxytocin infusion (P < 0.001). The effective dose in 90% population (ED90) was 0.29 IU kg-1  h-1 (95% CI = 0.25-0.42). Amongst the oxytocin associated side effects, a significant linear trend was seen between increasing dose of oxytocin infusion and hypotension as well as nausea/vomiting (p = 0.016 and 0.023 respectively). Thus, oxytocin infusion during caesarean delivery may be used as per the patient's body weight.

Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis.

OBJECTIVE: To assess the efficacy, effectiveness, and safety of uterine balloon tamponade for treating postpartum hemorrhage. STUDY DESIGN: We searched electronic databases (from their inception to August 2019) and bibliographies. We included randomized controlled trials, nonrandomized studies, and case series that reported on the efficacy, effectiveness, and/or safety of uterine balloon tamponade in women with postpartum hemorrhage. The primary outcome was the success rate of uterine balloon tamponade for treating postpartum hemorrhage (number of uterine balloon tamponade success cases/total number of women treated with uterine balloon tamponade). For meta-analyses, we calculated pooled success rate for all studies, and relative risk with 95% confidence intervals for studies that included a comparative arm. RESULTS: Ninety-one studies, including 4729 women, met inclusion criteria (6 randomized trials, 1 cluster randomized trial, 15 nonrandomized studies, and 69 case series). The overall pooled uterine balloon tamponade success rate was 85.9% (95% confidence interval, 83.9-87.9%). The highest success rates corresponded to uterine atony (87.1%) and placenta previa (86.8%), and the lowest to placenta accreta spectrum (66.7%) and retained products of conception (76.8%). The uterine balloon tamponade success rate was lower in cesarean deliveries (81.7%) than in vaginal deliveries (87.0%). A meta-analysis of 2 randomized trials that compared uterine balloon tamponade vs no uterine balloon tamponade in postpartum hemorrhage due to uterine atony after vaginal delivery showed no significant differences between the study groups in the risk of surgical interventions or maternal death (relative risk, 0.59; 95% confidence interval, 0.02-16.69). A meta-analysis of 2 nonrandomized before-and-after studies showed that introduction of uterine balloon tamponade in protocols for managing severe postpartum hemorrhage significantly decreased the use of arterial embolization (relative risk, 0.29; 95% confidence interval, 0.14-0.63). A nonrandomized cluster study reported that use of invasive procedures was significantly lower in the perinatal network that routinely used uterine balloon tamponade than that which did not use uterine balloon tamponade (3.0/1000 vs 5.1/1000; P < .01). A cluster randomized trial reported that the frequency of postpartum hemorrhage-related invasive procedures and/or maternal death was significantly higher after uterine balloon tamponade introduction than before uterine balloon tamponade introduction (11.6/10,000 vs 6.7/10,000; P = .04). Overall, the frequency of complications attributed to uterine balloon tamponade use was low (≤6.5%). CONCLUSION: Uterine balloon tamponade has a high success rate for treating severe postpartum hemorrhage and appears to be safe. The evidence on uterine balloon tamponade efficacy and effectiveness from randomized and nonrandomized studies is conflicting, with experimental studies suggesting no beneficial effect, in contrast with observational studies. Further research is needed to determine the most effective programmatic and healthcare delivery strategies on uterine balloon tamponade introduction and use.

Risk of Emergency Operations, Adverse Maternal and Neonatal Outcomes according to the Planned Gestational Age for Cesarean Delivery.

BACKGROUND: The objective of this study was to assess the risk of emergency cesarean deliveries (CDs) and adverse neonatal/maternal outcomes according to the planned gestational age at delivery (GAD) for elective CD. METHODS: The study population consisted of term singleton pregnant women who were booked for elective CD and were subsequently delivered at term by CD, after excluding cases with a trial of labor. The relationship between the planned GAD, risk of emergency CD prior to planned date, and adverse neonatal/maternal outcomes were determined. RESULTS: The frequency of emergency CD, adverse neonatal and maternal outcomes were 9.5%, 4.5%, and 5.9%, respectively. The risk of emergency CD prior to the planned delivery date increased significantly according to the planned GAD (5.8% at 37 weeks, 8.2% at 38 weeks, 13.6% at 39 weeks, and 26.7% at 40 weeks or more of planned GAD, P = 0.005). Emergency CD was associated with an increased risk of adverse maternal outcomes, whereas the risk of adverse neonatal outcomes did not differ. In the total study population including both cases with elective and emergency CD, the risk of adverse maternal outcomes did not increase according to the planned GAD, and the risk of adverse neonatal outcomes decreased significantly according to the planned GAD. CONCLUSION: The risk of emergency CD increased as the planned GAD increased, but the risk of adverse maternal outcomes did not increase and the risk of adverse neonatal outcomes decreased significantly according to the planned GAD in the total study population including elective/emergency CD.

Risk factors for severe postpartum hemorrhage: a case-control study.

BACKGROUND: In high-income countries, the incidence of severe postpartum hemorrhage (PPH) has increased. This has important public health relevance because severe PPH is a leading cause of major maternal morbidity. However, few studies have identified risk factors for severe PPH within a contemporary obstetric cohort. METHODS: We performed a case-control study to identify risk factors for severe PPH among a cohort of women who delivered at one of three hospitals in Norway between 2008 and 2011. A case (severe PPH) was classified by an estimated blood loss ≥1500 mL or the need for blood transfusion for excessive postpartum bleeding. Using logistic regression, we applied a pragmatic strategy to identify independent risk factors for severe PPH. RESULTS: Among a total of 43,105 deliveries occurring between 2008 and 2011, we identified 1064 cases and 2059 random controls. The frequency of severe PPH was 2.5% (95% confidence interval (CI): 2.32-2.62). The most common etiologies for severe PPH were uterine atony (60%) and placental complications (36%). The strongest risk factors were a history of severe PPH (adjusted OR (aOR) = 8.97, 95% CI: 5.25-15.33), anticoagulant medication (aOR = 4.79, 95% CI: 2.72-8.41), anemia at booking (aOR = 4.27, 95% CI: 2.79-6.54), severe pre-eclampsia or HELLP syndrome (aOR = 3.03, 95% CI: 1.74-5.27), uterine fibromas (aOR = 2.71, 95% CI: 1.69-4.35), multiple pregnancy (aOR = 2.11, 95% CI: 1.39-3.22) and assisted reproductive technologies (aOR = 1.88, 95% CI: 1.33-2.65). CONCLUSIONS: Based on our findings, women with a history of severe PPH are at highest risk of severe PPH. As well as other established clinical risk factors for PPH, a history of severe PPH should be included as a risk factor in the development and validation of prediction models for PPH.

Incidence of immediate postpartum hemorrhages in French maternity units: a prospective observational study (HERA study).

BACKGROUND: Most estimates of postpartum hemorrhage (PPH) are calculated from studies that use administrative or medical birth databases, and only a few from prospective observational studies. Our principal objective was to estimate the incidence of PPH according to their severity (mild or severe) in vaginal deliveries (>500 mL, ≥1000 mL) and cesareans (>1000 mL and ≥1500 mL). The secondary objectives were to describe the incidence of PPH according to maternity unit characteristics, causes, and types of PPH management. METHODS: This prospective observational study took place in French maternity wards. Women who gave birth at a term ≥ 22 weeks were eligible for the study. 182 maternity units participated in a study with prospective data collection from 1 February, 2011, to 31 July, 2011. The main outcome measure was PPH incidence. RESULTS: PPH incidence after vaginal delivery was 3.36 % [95 % CI: 3.25-3.47 %] and after cesareans 2.83 % [95 % CI: 2.63-3.04 %]. The incidence of severe PPH after vaginal delivery was 1.11 % [95 % CI: 1.05-1.18 %] and after cesareans 1.00 % [95 % CI: 0.88-1.13 %]. This incidence rate varied according to maternity unit characteristics. The principal cause of PPH for both modes of delivery was uterine atony (57.7 % for vaginal births and 66.3 % for cesareans). Vascular embolization was more frequent among women with cesareans (10.0 vs. 2.9 %), who also required transfusions more often (44.4 vs 12.7 %). CONCLUSIONS: The incidence of PPH was lower than the rate expected from the literature. Effective treatment of uterine atony and optimizing the identification of blood loss remain important priorities.

Case records of the Massachusetts General Hospital: Case 34-2012: a 27-year-old woman in Ethiopia with severe pain, bleeding, and shock during labor.

A 27-year-old woman was admitted to a hospital in Ethiopia because of severe abdominal pain during labor, with cessation of contractions. She had been in labor at home, pushing for 24 hours. On arrival at the hospital 3 hours later, she was in shock. A procedure was performed.

The ED90 of prophylactic oxytocin infusion after delivery of the placenta during cesarean delivery in laboring compared with nonlaboring women: an up-down sequential allocation dose-response study.

BACKGROUND: Prophylactic administration of oxytocin as a part of active management of the third stage of labor reduces the risk of postpartum hemorrhage. Prophylactic oxytocin is often administered as an infusion rather than a bolus. The aim of the current up-down sequential allocation dose-response study was to test the hypothesis that parturients who receive intrapartum exogenous oxytocin therapy, and who subsequently undergo cesarean delivery for labor dystocia, will have a higher estimated effective dose in 90% of paturients (ED90) for oxytocin infusion in the third stage of labor compared with nonlaboring parturients. METHODS: The study design was a single-blinded, dual-arm, dose-response study using a 9:1 biased-coin sequential allocation method to estimate the ED90 of an infusion of prophylactic oxytocin in women undergoing cesarean delivery with neuraxial anesthesia. The experimental (laboring) group included women scheduled for intrapartum cesarean delivery after prior exposure to exogenous oxytocin, and the control (nonlaboring) group included women scheduled for elective cesarean delivery. The starting infusion rate was 18 IU/h, with an incremental dose of 2 IU/h. The outcome was satisfactory uterine tone 4 minutes after delivery as judged by the obstetrician. Secondary outcomes included requirement for additional uterotonic agents and maternal side effects (e.g., nausea and vomiting, ST-segment depression). Dose-response data for each group were evaluated by a log-logistic function and ED90 estimates derived from the fitted equations using the delta method. RESULTS: Thirty-eight and 32 subjects participated in the nonlaboring and laboring groups, respectively. The oxytocin ED90 was significantly greater for the laboring group (44.2 IU/h [95% confidence interval (CI), 33.8-55.6]) compared with that for the nonlaboring group (16.2 IU/h [95% CI, 13.1-19.3]; difference in dose 28 IU/h [95% CI of difference, 26-29, P < 0.001]). Significantly more women in the laboring group (34%) than in the nonlaboring group (8%) required supplemental uterotonic agents (difference 26% [95% CI of the difference, 7%-44%, P = 0.008]). The overall incidence of side effects was greater in the laboring group (69%) than in the nonlaboring group (34%; difference 25% [95% CI of the difference, 10%-59%, P = 0.004]). CONCLUSIONS: Women with prior exposure to exogenous oxytocin require a higher initial infusion rate of oxytocin to prevent uterine atony after cesarean delivery than women without prior exposure.

Success factors for Bakri™ balloon usage secondary to uterine atony: a retrospective, multicentre study.

BACKGROUND: Post-partum haemorrhage (PPH) is one of the major obstetric complications and remains a cause of avoidable maternal mortality and morbidity. AIMS: The aims of this study were to assess the success and practicability of a Bakri™ balloon intrauterine tamponade for PPH and evaluate the predictive factors for success. MATERIALS AND METHODS: Women who received the Bakri™ balloon secondary to uterine atony and subsequent failure of routine drug treatment were identified at 6 hospital sites. Demographic, obstetric and specific factors in regard to the Bakri™ balloon use were recorded. Factors predictive of Bakri™ balloon success were evaluated. RESULTS: Intrauterine Bakri™ balloon tamponade was used in 36 women with uterine atony of which 28 received the balloon treatment after vaginal delivery: more than 50% of women (16/28) presented with PPH with blood loss > 1000 mL (mean blood loss: 1130 mL). Two balloon insertions failures were identified. Bakri balloon success was 100% for women with bleeding < 1000 mL. Twenty-five women (69%) did not require invasive treatment; seven (19%) required arterial embolisation and four (11%) surgical management. No short-term complication was observed after balloon insertion. CONCLUSION: The use of the Bakri™ balloon method, if undertaken early, is effective for the management of PPH with uterine atony (100% success compared to 69% overall success rate). Intrauterine balloon tamponade should included in PPH management guidelines.

Amniotic fluid embolism induces uterine anaphylaxis and atony following cervical laceration.

Amniotic fluid embolism (AFE) is a rare, high-risk obstetric complication primarily found in the lungs and potentially related to anaphylaxis. Tryptase release from the mast cell reflects anaphylaxis. Case report and findings: A female, aged over 40 years, presented with uterine atony and lethal hemorrhage after induced vaginal labor. Cervical laceration was accompanied by severe hemorrhage. Stromal edema and myometrial swelling were consistent with uterine atony. Alcian blue staining and zinc coproporphyrin immunostaining disclosed AFE, which was more prominent in the uterus than in the lungs. Tryptase immunostaining was diffuse and prominent around the activated mast cells (halos) in the uterus, including the cervix. Similar distribution of findings on the AFE markers, tryptase halos, complement receptor C5aR, and atony in the uterus suggested the causality of AFE to anaphylaxis, complement activation and atony. It is probable that disseminated intravascular coagulation (DIC), induced by AFE, uterine atony and cervical laceration, caused the lethal hemorrhage. It is likely that AFE, in association with cervical laceration, induces uterine anaphylaxis, complement activation, atony, DIC and lethal hemorrhage.

Weight-based versus fixed dose oxytocin infusion for preventing uterine atony during cesarean section in laboring patients: A randomized trial.

OBJECTIVE: We compared efficacy of weight-based (0.4 IU/kg/h) versus fixed-dose (34 IU/h) oxytocin infusion during cesarean section. METHODS: The oxytocin infusion in either group (n = 32 each) was initiated upon cord clamping. Primary outcome measure was adequacy of uterine tone at 4 min after initiating oxytocin infusion. Oxytocin associated side effects were also observed. RESULTS: Significantly less oxytocin was used with the weight-based versus fixed-dose regimen (16.3 [11.2-22.4] IU vs 20.4 [15.8-26.9] IU; P = 0.036). Incidence of adequate uterine tone was clinically greater but not significantly different with the weight-based versus fixed-dose regimen (81.3% vs 71.9%; P = 0.376). The weight-based regimen was associated with clinically lesser, although not statistically significant need for rescue oxytocin (25% vs 46.9%; P = 0.068) and additional uterotonic (9.4% vs 15.6%; P = 0.708); as well as oxytocin associated side effects (hypotension [34.4% vs 46.9%; P = 0.309], nausea/vomiting [18.8% vs 40.6%; P = 0.055], and ST-T changes [0% vs 3.1%; P = 1.000]). CONCLUSION: Weight-based oxytocin was not significantly different from the fixed-dose regimen in terms of uterotonic efficacy or associated side-effects, despite significantly lower doses being used. Use of weight-based oxytocin infusion (0.4 IU/kg/h) can be considered in clinical practice. TRIAL REGISTRATION: Clinical Trial Registry of India (ctri.nic.in, number. CTRI/2021/01/030642).

Risk factors for uterine atony/postpartum hemorrhage requiring treatment after vaginal delivery.

OBJECTIVE: We sought to identify risk factors for uterine atony or hemorrhage. STUDY DESIGN: We conducted a secondary analysis of a 3-arm double-blind randomized trial of different dose regimens of oxytocin to prevent uterine atony after vaginal delivery. The primary outcome was uterine atony or hemorrhage requiring treatment. In all, 21 potential risk factors were evaluated. Logistic regression was used to identify independent risk factors using 2 complementary predefined model selection strategies. RESULTS: Among 1798 women randomized to 10, 40, or 80 U of prophylactic oxytocin after vaginal delivery, treated uterine atony occurred in 7%. Hispanic (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3-3.4), non-Hispanic white (OR, 1.6; 95% CI, 1.0-2.5), preeclampsia (OR, 3.2; 95% CI, 2.0-4.9), and chorioamnionitis (OR, 2.8; 95% CI, 1.6-5.0) were consistent independent risk factors. Other risk factors based on the specified selection strategies were obesity, induction/augmentation of labor, twins, hydramnios, anemia, and arrest of descent. Amnioinfusion appeared to be protective against uterine atony (OR, 0.53; 95% CI, 0.29-0.98). CONCLUSION: Independent risk factors for uterine atony requiring treatment include Hispanic and non-Hispanic white ethnicity, preeclampsia, and chorioamnionitis.

Carbetocin in comparison with oxytocin in several dosing regimens for the prevention of uterine atony after elective caesarean section in the Netherlands.

PURPOSE: The aim of the study was to compare the prophylactic effects of carbetocin with those of oxytocin for the prevention of uterine atony in patients undergoing elective caesarean section (CS) in the Netherlands. The primary endpoint was the need for additional uterotonic medication. METHODS: Each of the five participating Dutch hospitals treated 50-100 term patients with 100 µg of intravenous carbetocin on prescription. Each centre retrieved charts of 250 patients treated with oxytocin according to the hospital's policy for the prevention of uterine atony (oxytocin bolus 5 IU, bolus 10 IU or bolus 5 IU followed by 10 IU in 2 h). RESULTS: In the carbetocin group 462 subjects were included and in the oxytocin group 1,122. The proportion of subjects needing additional uterotonic treatment was 3.1 % (95 % CI 1.7-5.1 %) after carbetocin and 7.2 % (5.8-8.9 %) after oxytocin; relative risk 0.41 (0.19-0.85); p = 0.0110. Carbetocin was most effective compared with the oxytocin 5 IU bolus subgroup with less need for additional uterotonic medication (3.1 vs. 9.3 %, p = 0.0067) and blood transfusions (2.2 vs. 3.6 %, p = 0.0357). CONCLUSIONS: Compared with oxytocin, prophylaxis of uterine atony with carbetocin after an elective CS diminished the need for additional uterotonics by more than 50 %.

Outcome Of B-Lynch Application In Patients With Post-Partum Hemorrhage Following Cesarean Section.

BACKGROUND: The most common cause of post partum hemorrhage after a cesarean section is uterine atony. Aims and Objective: The main aim of this study was to examine the outcomes of the B-Lynch procedure in patients who experienced primary PPH after cesarean section. METHODS: This study spanned one year, from August 2020 to August 2021, at Ayub Teaching Hospital. Patients who developed post-partum hemorrhage after a cesarean section were enrolled in this study and a thorough review of their records was conducted to identify those who received B-Lynch sutures and assess the resulting outcomes. RESULTS: Out of the 87 patients who experienced PPH, 24 (27.6%) patients received the B-Lynch procedure. Among these 24 patients, only two (8.3%) needed hysterectomy, while the remaining 22 successfully recovered after receiving the B-Lynch procedure. CONCLUSIONS: The B-Lynch technique proves to be a safe, effective, and easily applicable method for stopping hemorrhage in patients who experienced significant initial postpartum hemorrhage due to uterine atony.

Successful treatment of two patients with postpartum disseminated intravascular coagulation complicated by abdominal compartment syndrome.

Disseminated intravascular coagulation (DIC) and abdominal compartment syndrome (ACS) are rare complications of pregnancy, and even more rare are cases with both complications occurring concomitantly. Obstetricians are relatively unfamiliar with these types of cases, the majority of which are fatal. We describe here a primigravida with acute fatty liver of pregnancy and a multipara with placental abruption who each developed uterine inertia complicated by postpartum DIC that required total hysterectomy. They developed ACS postoperatively and required decompressive laparotomy to alleviate increased intra-abdominal pressure and end-organ dysfunction. After timely decompressive laparotomy, both patients recovered without any additional complications and were discharged within 4 weeks of their initial admission. These 2 cases serve to remind obstetricians to consider the possibility of ACS whenever there is a fresh wound in the abdominal cavity of a patient with postpartum DIC. However, even when there is severe deterioration in the condition of a patient with ACS, immediate decompressive laparotomy may not be appropriate; the timing of the procedure is very important.

Primary uterine inertia in four labrador bitches.

Uterine inertia is a common cause of dystocia in the bitch and is designated as primary (i.e., uterine contractions fail to ever be initiated) or secondary (i.e., uterine contractions cease after a period of time but before labor is completed). The etiology of primary uterine inertia is not well understood. The accurate diagnosis of primary uterine inertia requires the use of tocodynamometry (uterine monitoring). Primary uterine inertia has been postulated to result from a failure of luteolysis resulting in persistently elevated progesterone concentrations. In this study, primary uterine inertia was diagnosed in a series of four bitches in which luteolysis was documented suggesting some other etiopathogenesis for primary uterine inertia.

Five unit bolus oxytocin at cesarean delivery in women at risk of atony: a randomized, double-blind, controlled trial.

BACKGROUND: I.v. bolus oxytocin is used routinely during cesarean delivery to prevent postpartum hemorrhage. Its adverse hemodynamic effects are well known, resulting in a recent change in dose from 10 IU to 5. Whether a 5 IU bolus has any advantages over infusion alone is unclear. We tested the hypothesis that a 5 IU i.v. bolus of oxytocin before the initiation of a continuous infusion decreases the need for additional uterotonic drugs in the first 24 hours after delivery in women with risk factors for uterine atony undergoing cesarean delivery, compared with infusion alone. METHODS: A prospective, randomized, double-blind, controlled trial was conducted in 143 subjects undergoing cesarean delivery with at least 1 risk factor for uterine atony. Subjects received 5 IU bolus of oxytocin or normal saline i.v. over 30 seconds after umbilical cord clamping. All subjects received an infusion of 40 IU oxytocin in 500 mL normal saline over 30 minutes, followed by 20 IU in 1 L over 8 hours. The primary outcome was the need for additional uterotonics in the first 24 hours after delivery. Secondary outcomes included uterine tone as assessed by the surgeon (5-point Likert scale: 0 = "floppy," 4 = "rock hard"), estimated blood loss, side effects of bolus administration, and the oxytocin bolus-placental delivery interval. RESULTS: There was no difference in the need for additional uterotonic drugs in the first 24 hours between groups. There was a significant difference in uterine tone immediately after placental delivery (P < 0.01) (2.8 in the oxytocin group [95% confidence interval 2.6-3.0] vs 2.2 in the saline group [95% confidence interval 1.8-2.5]), which disappeared after 5 minutes. There were no differences in observed or reported side effects between groups. CONCLUSIONS: We found that a 5 IU i.v. bolus of oxytocin added to an infusion did not alter the need for additional uterotonic drugs to prevent or treat postpartum hemorrhage in the first 24 hours in women undergoing cesarean delivery with risk factors for uterine atony, despite causing an initial stronger uterine contraction. Our study was not powered to find a difference in side effects between groups. These results suggest that an oxytocin infusion may be adequate without the need for a bolus, even in high-risk patients.

Incidence, trends, risk factors, indications for, and complications associated with cesarean hysterectomy: a 17-year experience from a single institution.

PURPOSE: To review the incidence, trends, risk factors, indications for, and complications associated with cesarean hysterectomy (CH) in our institution. MATERIALS AND METHODS: Retrospective study of 158 women who had CH at the Detroit Medical Center during a 17 period. RESULTS: During the study period, 158 of 202,356 deliveries were CH, giving an overall incidence of 0.78 per 1,000 deliveries. Of the 158 cases, 14 were elective while 144 were emergently performed due to complications encountered at cesarean section. Analysis of the eligible 144 cases showed that the commonest risk factors were previous cesarean delivery (76%) and placenta previa (35%). Abnormal placenta adherence was the indication for CH in 50.7%, followed by uterine atony in 34.7% and uterine rupture in 16.7% of the cases. Febrile morbidity (44.4%) and disseminated intravascular coagulopathy (22.9%) were the most common postoperative complications. Most complications occurred in patients with parity greater than two. Compared to the last decade, CH performed more recently were less likely to be complicated by bowel injury or disseminated intravascular coagulopathy. CONCLUSION: Morbidly adherent placenta has replaced uterine atony as the leading indication for emergent CH in our institution. High parity remains a risk factor for complications; however, we recorded a reduction in bowel injury and disseminated intravascular coagulopathy in recent years.

Postpartum Cardiogenic Shock Diagnosed by Focused Cardiac Ultrasound and Treated With Venoarterial Extracorporeal Membrane Oxygenation: A Case Report.

We present the case of a primigravid patient, who developed cardiogenic shock during the early postpartum period in the setting of retained placenta, uterine atony, and hemorrhage. Focused cardiac ultrasound played a central role in identifying the cause of hemodynamic instability. The decision to initiate venoarterial extracorporeal membrane oxygenation was instrumental in the successful outcome for our patient, characterized by a full recovery without major neurological and cardiovascular sequelae.

[Air embolism during elective cesarean section, and uterine atony due to fetal macrosomia]. / Embolia aérea durante cesáirea electiva y atonía uterina por feto macrosómico.

We report the case of a paradoxical air embolism during a scheduled cesarean section for fetal macrosomia (7.010 kg) in a 38-year-old woman with a history of gestational diabetes and preeclampsia. Spinal anesthesia was satisfactory and well tolerated. After approximately 30 minutes (coinciding with uterine exteriorization), the patient presented a sudden episode of dyspnea, confusion, hypotension, and ST segment depression. The episode lasted approximately 10 minutes and resolved spontaneously with no sequelae. Neurological status and the electrocardiogram were normal at the end of surgery and no postoperative lesions were observed. In the immediate postoperative period, the patient presented a massive hemorrhage due to uterine atony. Echocardiography revealed a patent foramen ovale. The clinical signs in this patient are highly suggestive of a paradoxical cerebral and coronary air embolism.

Uterine torsion of 720 degrees in the third trimester of pregnancy and accompanying bladder torsion: a case report.

Partial rotation of the uterus not more than 45 degrees to the right is considered to be normal. Since all cases are not reported, the incidence of uterine torsion in pregnancy is not known exactly. In the literature, there have been reports of cases with uterine torsion ranging from 45 to 720 degrees. This is a case report of uterine torsion of 720 degrees with accompanying bladder torsion, developing after two caesarean sections, and developing of uterine atony after the operation.