Determinants of postpartum uterine atony in urban South Ethiopia: a community-based unmatched nested case-control study.

BACKGROUND: Uterine atony is the most common cause of postpartum hemorrhage, which is the leading preventable cause of maternal morbidity and mortality. Despite several interventions uterine atony-related postpartum hemorrhage remains a global challenge. Identifying risk factors of uterine atony helps to reduce the risk of postpartum hemorrhage and subsequent maternal death. However, evidence about risk factors of uterine atony is limited in the study areas to suggest interventions. This study aimed to assess determinants of postpartum uterine atony in urban South Ethiopia. METHODS: A community-based unmatched nested case-control study was conducted from a cohort of 2548 pregnant women who were followed-up until delivery. All women with postpartum uterine atony (n = 93) were taken as cases. Women who were randomly selected from those without postpartum uterine atony (n = 372) were taken as controls. Using a case to control ratio of 1:4, the total sample size was 465. An unconditional logistic regression analysis was done using R version 4.2.2 software. In the binary unconditional logistic regression model variables that have shown association at p < 0.20 were recruited for multivariable model adjustment. In the multivariable unconditional logistic regression model, statistically significant association was declared using 95% CI and p < 0.05. Adjusted odds ratio (AOR) used to measure the strength of association. Attributable fraction (AF) and population attributable fraction (PAF) were used to interpret the public health impacts of the determinants of uterine atony. RESULTS: In this study, short inter-pregnancy interval < 24 months (AOR = 2.13, 95% CI: 1.26, 3.61), prolonged labor (AOR = 2.35, 95% CI: 1.15, 4.83), and multiple birth (AOR = 3.46, 95% CI: 1.25, 9.56) were determinants of postpartum uterine atony. The findings suggest that 38%, 14%, and 6% of uterine atony in the study population was attributed to short inter-pregnancy interval, prolonged labor, and multiple birth, respectively, which could be prevented if those factors did not exist in the study population. CONCLUSIONS: Postpartum uterine atony was related to mostly modifiable conditions that could be improved by increasing the utilization of maternal health services such as modern contraceptive methods, antenatal care and skilled birth attendance in the community.

Peripartum Hysterectomy among Patients Admitted to the Department of Obstetrics and Gynaecology in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Emergency peripartum hysterectomy is a life-saving procedure performed as an emergency procedure to control torrential bleeding and it is associated with significant maternal morbidity and mortality. There are only a few studies regarding this topic so this study guides us to monitor the trend and start appropriate policies to reduce unnecessary caesarean deliveries. The aim of this study was to find out the prevalence of peripartum hysterectomy among patients admitted to the Department of Obstetrics and Gynaecology in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted in the Department of Obstetrics and Gynaecology of the tertiary care centre. Data from 1 January 2015 to 31 December 2022 were collected between 25 January 2023 and 28 February 2023 from the hospital records. Ethical approval was obtained from the Institutional Review Committee of the same institute (Reference number: 2301241700). Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Among 54,045 deliveries, peripartum hysterectomy was seen in 40 (0.074%) (0.05-0.10, 95% Confidence Interval). The major indication of emergency peripartum hysterectomy was abnormal placentation (placenta accreta spectrum) which was 25 (62.50%) followed by uterine atony in 13 (32.50%) of patients and uterine rupture in 2 (5%). Conclusions: The prevalence of peripartum hysterectomy was lower than in other studies done in similar settings. The indication for Emergency peripartum hysterectomy has changed in recent years from uterine atonicity to the morbidly adherent placenta which is due to a rise in the caesarean section rate. Keywords: caesarean section; hysterectomy; placenta accreta.

Risk factors for postpartum haemorrhage in the Northern Province of Rwanda: A case control study.

BACKGROUND: Postpartum haemorrhage (PPH) remains a major global burden contributing to high maternal mortality and morbidity rates. Assessment of PPH risk factors should be undertaken during antenatal, intrapartum and postpartum periods for timely prevention of maternal morbidity and mortality associated with PPH. The aim of this study is to investigate and model risk factors for primary PPH in Rwanda. METHODS: We conducted an observational case-control study of 430 (108 cases: 322 controls) pregnant women with gestational age of 32 weeks and above who gave birth in five selected health facilities of Rwanda between January and June 2020. By visual estimation of blood loss, cases of Primary PPH were women who changed the blood-soaked vaginal pads 2 times or more within the first hour after birth, or women requiring a blood transfusion for excessive bleeding after birth. Controls were randomly selected from all deliveries without primary PPH from the same source population. Poisson regression, a generalized linear model with a log link and a Poisson distribution was used to estimate the risk ratio of factors associated with PPH. RESULTS: The overall prevalence of primary PPH was 25.2%. Our findings for the following risk factors were: antepartum haemorrhage (RR 3.36, 95% CI 1.80-6.26, P<0.001); multiple pregnancy (RR 1.83; 95% CI 1.11-3.01, P = 0.02) and haemoglobin level <11 gr/dL (RR 1.51, 95% CI 1.00-2.30, P = 0.05). During the intrapartum and immediate postpartum period, the main causes of primary PPH were: uterine atony (RR 6.70, 95% CI 4.78-9.38, P<0.001), retained tissues (RR 4.32, 95% CI 2.87-6.51, P<0.001); and lacerations of genital organs after birth (RR 2.14, 95% CI 1.49-3.09, P<0.001). Coagulopathy was not prevalent in primary PPH. CONCLUSION: Based on our findings, uterine atony remains the foremost cause of primary PPH. As well as other established risk factors for PPH, antepartum haemorrhage and intra uterine fetal death should be included as risk factors in the development and validation of prediction models for PPH. Large scale studies are needed to investigate further potential PPH risk factors.

What is new in peripartum hysterectomy? A seventeen year experience in a tertiary hospital.

OBJECTIVE: To identify changing trends in peripartum hysterectomy (PH), both elective. cesarean hysterectomy and emergency cesarean hysterectomy, at a single training and research hospital over the last 17 years in Istanbul, Turkey. MATERIALS AND METHODS: A retrospective cohort study was performed between January 2001 and September 2017. The records of all patients who had PH at Kanuni Sultan Süleyman Training and Research Hospital were analyzed. RESULTS: There were 243 cases of PH during the study period. A total of 266,386 births occurred, of which 60.1% were vaginal deliveries and 39.8% were cesarean sections. The incidence of PH increased from 0.67 per 1000 deliveries to 1.14 per 1000 deliveries during 2001-2008 and 2009-2017, respectively, with an overall incidence of 0.91 per 1000 deliveries during the 17 years. The main indication for PH changed significantly during this time from uterine atony (57.1%) to placenta accreta spectrum (85%). About 37% of women who underwent PH had at least one previous cesarean delivery during 2001-2008, whereas that percentage increased to 95.4% during 2009-2017. CONCLUSION: Placenta accreta spectrum was the leading cause of PH and was associated with significant maternal morbidity and mortality.

New approach to the risk variables for administration of fibrinogen in patients with postpartum hemorrhage by using cluster analysis.

OBJECTIVE: To analyze all the variables in women who received fibrinogen for postpartum hemorrhage (PPH) using hierarchical cluster analysis, to provide greater insight into the risk variables involved in these women. METHODS: This retrospective study of women with at least 500 mL of bleeding at birth or during the postpartum period and treated with fibrinogen was conducted at the Department of Obstetrics and Gynecology, Atatürk University School of Medicine from January 2013 to January 2018. Data on the women were obtained from medical records and various risk variables were recorded and analyzed using hierarchical cluster analysis. RESULTS: A total of 114 women with PPH were included in the study. Based on a dendrogram, three main clusters of similar quality variables were created: 1) gravida, parity, age, cervical/vaginal hematoma, laparotomy, hypogastric artery ligation, uterine artery embolization, uterine artery ligation, uterine atony, distance from outer center, lowest hemoglobin, preoperative platelets, endometritis, preoperative white blood cells; 2) lowest fibrinogen, highest fibrinogen, type of birth, placenta invasion anomaly, Bakri balloon tamponade, postpartum hysterectomy, preoperative activated partial thromboplastin time (APTT), preoperative international normalized ratio (INR), placental abruption, in-utero ex fetus; 3) postoperative APTT, postoperative INR, maternal mortality, erythrocyte transfusion, plasma transfusion, hospital stay time, disseminated intravascular coagulation/HELLP syndrome, highest hemoglobin, blood group, postoperative platelets, platelet transfusion, pre-eclampsia/eclampsia, fibrinogen extract. CONCLUSION: According to the cluster analysis, we should keep fibrinogen extract in the foreground especially in the treatment of hemorrhage in patients with variable conditions. As a result, we can determine whether fibrinogen extract, which has a high economic cost, should be kept at each center. We can also direct which patient will be referred in accordance with the referral steps.

Prevalence, related factors and maternal outcomes of primary postpartum haemorrhage in governmental hospitals in Kabul-Afghanistan.

BACKGROUND: To determine the prevalence, related factors and maternal outcomes of primary PPH in governmental hospitals in Kabul Afghanistan. METHODS: An observational study was designed to determine the prevalence, related factors and maternal outcomes of primary PPH in governmental hospitals in Kabul-Afghanistan. The population of this study consisted of all women who gave birth to a child between August and October 2018. The structured checklist was used to collect the data from patients who were suffering from primary PPH. RESULTS: Among the 8652 women who were observed, 215 (2.5%) of them suffered from primary PPH and 2 (0.9%) of them died under caesarean section. The most common related factors of primary PPH were uterine atonia (65.6%), previous PPH (34.9%), prolonged labor (27%), genital tract trauma (26.5%), and induction of labor (20.5%). The most common maternal outcomes of primary PPH were respiratory failure (7%), hysterectomy (6%), and hypovolaemic shock (5.1%). CONCLUSIONS: According to our findings, the major cause of postpartum bleeding was uterine atonia. Therefore, postpartum care of women is essential, especially for those with previous PPH and prolonged labor that require more attention.

Homelessness, housing instability, and abortion outcomes at an urban abortion clinic in the United States.

BACKGROUND: Adverse reproductive health outcomes are well documented among people experiencing homelessness or housing instability. Little is known about abortion outcomes among this population. OBJECTIVE: This study aimed to investigate the relationship between housing status and abortion outcomes and whether gestational age mediates this relationship. STUDY DESIGN: Our sample comprised 1903 individuals who had abortions at an urban clinic in San Francisco, CA, from 2015 to 2017. We defined homelessness or housing instability as a binary exposure, which included staying outside, with friends and/or family, or in a tent, vehicle, shelter, transitional program, or hotel. We evaluated gestational duration of ≥20 weeks as a mediator variable. Our primary outcome was any abortion complication. Logistic regression models were adjusted for age, race, substance use, mental health diagnoses, and previous vaginal and cesarean deliveries. RESULTS: Approximately 19% (n=356) of abortions were among people experiencing homelessness or housing instability. Compared with those with stable housing, people experiencing homelessness or housing instability presented later in pregnancy (mean gestational duration, 13.3 vs 9.5 weeks; P<.001) and had more frequent complications (6.5% vs 2.8%; P<.001; odds ratio, 2.2; 95% confidence interval, 1.2-3.9). Adjusting for race, substance use, mental health diagnoses, and previous cesarean deliveries, individuals experiencing homelessness or housing instability were more likely to have abortion complications (odds ratio, 2.3; 95% confidence interval, 1.3-4.0). However, the relationship was attenuated after adjusting for gestational duration (odds ratio, 1.4; 95% confidence interval, 0.7-2.6), suggesting that gestational duration mediates the relationship between housing status and abortion complications. CONCLUSION: Patients experiencing homelessness or housing instability presented later in gestation, which seems to contribute to the increased frequency of abortion complications.

Epidemiological analysis of peripartum hysterectomy across nine European countries.

INTRODUCTION: Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries. MATERIAL AND METHODS: We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section. RESULTS: A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (ρ = 0.67, P < .05). CONCLUSIONS: Prevalence of peripartum hysterectomy may vary considerably between high-income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine-fold increased risk of peripartum hysterectomy.

Haematological features, transfusion management and outcomes of massive obstetric haemorrhage: findings from the Australian and New Zealand Massive Transfusion Registry.

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.

Major obstetric haemorrhage in Metro East, Cape Town, South Africa: a population-based cohort study using the maternal near-miss approach.

BACKGROUND: Major obstetric haemorrhage is a leading cause of maternal mortality and accounts for one-third of maternal deaths in of Africa. This study aimed to assess the population-based incidence, causes, management and outcomes of major obstetric haemorrhage and risk factors associated with poor maternal outcome. METHODS: Women with major obstetric haemorrhage who met the WHO maternal near-miss criteria or died in the Metro East region, Cape Town, South Africa, were evaluated from November 2014-November 2015. Major obstetric haemorrhage was defined as haemorrhage in pregnancies of at least 20 weeks' gestation or occurring up to 42 days after birth, and leading to hysterectomy, hypovolaemic shock or blood transfusion of ≥5 units of Packed Red Blood Cells. A logistic regression model was used to analyse associations with poor outcome, defined as major obstetric haemorrhage leading to massive transfusion of ≥8 units of packed red blood cells, hysterectomy or death. RESULTS: The incidence of major obstetric haemorrhage was 3/1000 births, and the incidence of massive transfusion was 4/10.000 births in the Metro East region (32.862 births occurred during the studied time period). Leading causes of haemorrhage were placental abruption 45/119 (37.8%), complications of caesarean section 29/119 (24.4%) and uterine atony 13/119 (10.9%). Therapeutic oxytocin was administered in 98/119 (82.4%) women and hysterectomy performed in 33/119 (27.7%). The median numbers of packed red blood cells and units of Fresh Frozen Plasma transfused were 6 (interquartile range 4-7) and 3 (interquartile range 2-4), ratio 1.7:1. Caesarean section was independently associated with poor maternal outcome: adjusted OR 4.01 [95% CI 1.58, 10.14]. CONCLUSIONS: Assessment of major obstetric haemorrhage using the Maternal Near Miss approach revealed that placental abruption and complications of caesarean section were the major causes of major obstetric haemorrhage. Caesarean section was associated with poor outcome.

Maternal characteristics and causes associated with refractory postpartum haemorrhage after vaginal birth: a secondary analysis of the WHO CHAMPION trial data.

OBJECTIVE: To assess the maternal characteristics and causes associated with refractory postpartum haemorrhage (PPH). DESIGN: Secondary analysis of the WHO CHAMPION trial data. SETTING: Twenty-three hospitals in ten countries. POPULATION: Women from the CHAMPION trial who received uterotonics as first-line treatment of PPH. METHODS: We assessed the association between sociodemographic, pregnancy and childbirth factors and refractory PPH, and compared the causes of PPH between women with refractory PPH and women responsive to first-line PPH treatment. MAIN OUTCOME MEASURES: Maternal characteristics; causes of PPH. RESULTS: Women with labour induced or augmented with uterotonics (adjusted odds ratio [aOR] 1.35; 95% CI 1.07-1.72), with episiotomy or tears requiring suturing (aOR 1.82; 95% CI 1.34-2.48) and who had babies with birthweights ≥3500 g (aOR 1.33; 95% CI 1.04-1.69) showed significantly higher odds of refractory PPH compared with the reference categories in the multivariate analysis adjusted by centre and trial arm. While atony was the sole PPH cause in 53.2% (116/218) of the women in the responsive PPH group, it accounted for only 31.5% (45/143) of the causes in the refractory PPH group. Conversely, tears were the sole cause in 12.8% (28/218) and 28% (40/143) of the responsive PPH and refractory PPH groups, respectively. Placental problems were the sole cause in 11 and 5.6% in the responsive and refractory PPH groups, respectively. CONCLUSION: Women with refractory PPH showed a different pattern of maternal characteristics and PPH causes compared with those with first-line treatment responsive PPH. TWEETABLE ABSTRACT: Women with refractory postpartum haemorrhage are different from those with first-line treatment responsive PPH.

Massive blood transfusion in relation to delivery: incidence, trends and risk factors: a population-based cohort study.

OBJECTIVE: To estimate incidence, trends over time, and risk factors for massive blood transfusions in obstetric patients. A secondary aim was to evaluate transfusion ratios in relation to massive transfusion. DESIGN: Population-based cohort. SETTING: Five hospitals, in the Stockholm County, Sweden, from 1990 to 2011. POPULATION: All women that gave birth in Stockholm county, Sweden, and who received blood transfusions postpartum between 1990 and 2011. METHODS: Data on pregnancies and deliveries from the Swedish National Medical Birth Registry was cross-linked to the Stockholm transfusion database. Massive blood transfusion was defined as the transfusion of ≥10 units of red blood cells from partus through the next day. MAIN OUTCOME MEASURES: Main primary outcome was massive blood transfusion postpartum. RESULTS: Our cohort comprised 517 874 deliveries. Massive blood transfusion occurred in 277 women, for an incidence of 5.3 per 10 000 deliveries, and increased by 30% (P < 0.001) between the first and the second half of the study period. Major risk factors apparent before delivery were abnormal placentation (odds ratio [OR] 41; 95% CI 29.3-58.1), pre-eclampsia/placental abruption (OR 4; 95% CI 2.8-5.6), and previous caesarean delivery (OR 4; 95% CI 3.1-6.0). Risk factors at time of delivery were uterine rupture, atonic uterus, and caesarean delivery (OR 38, 17, and 3, respectively). CONCLUSION: We found an increasing trend in the postpartum rate of massive transfusion. Women with abnormal placentation were found to have the highest increased risk. Improved antenatal awareness of these women at risk might improve management and reduce the rate of massive transfusion. TWEETABLE ABSTRACT: Risk of massive blood transfusion in obstetric patients increases with placental complications and prior caesarean section.

Maternal near miss determinants at a maternity hospital for high-risk pregnancy in northeastern Brazil: a prospective study.

BACKGROUND: To investigate the association between sociodemographic and obstetric variables and delays in care with maternal near misses (MNMs) and their health indicators. METHODS: A prospective cohort study was conducted at a high-risk maternity hospital in northeastern Brazil from June 2015 to May 2016 that included all pregnant women seen at the maternity hospital during the data collection period and excluded those who had not been discharged at the end of the study or whom we were unable to contact after the 42nd postpartum day for MNM control. We used the MNM criteria recommended by the WHO. Risk ratios (RRs) and their 95% confidence intervals (CIs) were calculated. Hierarchical multiple logistic regression analysis was performed. The p values of all tests were two-tailed, and the significance level was set to 5%. RESULTS: A total of 1094 pregnant women were studied. We identified 682 (62.4%) women without adverse maternal outcomes (WOAMOs) and 412 (37.6%) with adverse maternal outcomes (WAMOs), of whom 352 had potentially life-threatening conditions (PLTCs) (85.4%), including 55 MNM cases (13.3%) and five maternal deaths (1.2%). During the study period, 1002 live births (LBs) were recorded at the maternity hospital, resulting in an MNM ratio of 54.8/1000 LB. The MNM distribution by clinical condition identified hypertension in pregnancy (67.2%), hemorrhage (42.2%) and sepsis (12.7%). In the multivariate analysis, the factors significantly associated with an increased risk of MNM were fewer than six prenatal visits (OR: 3.13; 95% CI: 1.74-5.64) and cesarean section in the current pregnancy (OR: 2.91; 95% CI: 1.45-5.82). CONCLUSIONS: The factors significantly associated with the occurrence of MNM were fewer than six prenatal visits and cesarean section in the current pregnancy. These findings highlight the need for improved quality, an increased number of prenatal visits and the identification of innovative and viable models of labor and delivery care that value normal delivery and decrease the percentage of unnecessary cesarean sections.

Women receiving massive transfusion due to postpartum hemorrhage: A comparison over time between two nationwide cohort studies.

INTRODUCTION: Incidence of massive transfusion after birth was high in the Netherlands between 2004 and 2006 compared with other high-income countries. This study investigated incidence, causes, management and outcome of women receiving massive transfusion due to postpartum hemorrhage in the Netherlands in more recent years. MATERIAL AND METHODS: Data for all pregnant women who received eight or more units of packed red blood cells from a gestational age of 20 weeks and within the first 24 hours after childbirth, during 2011 and 2012, were obtained from a nationwide retrospective cohort study, including 61 hospitals with a maternity unit in the Netherlands. RESULTS: Incidence of massive transfusion due to postpartum hemorrhage decreased to 65 per 100 000 births (95% CI 56-75) between 2011 and 2012, from 91 per 100 000 births (95% CI 81-101) between 2004 and 2006, while median blood loss increased from 4500 mL (interquartile range 3250-6000) to 6000 mL (interquartile range 4500-8000). Uterine atony remained the leading cause of hemorrhage. Thirty percent (53/176) underwent peripartum hysterectomy between 2011 and 2012, compared with 25% (83/327) between 2004 and 2006. Case fatality rate for women who received massive transfusion due to postpartum hemorrhage was 2.3% (4/176) between 2011 and 2012, compared with 0.9% (3/327) between 2004 and 2006. CONCLUSIONS: The incidence of postpartum hemorrhage with massive transfusion decreased in the Netherlands between both time frames, but remained an important cause of maternal mortality and morbidity, including peripartum hysterectomy. National surveillance of maternal morbidity and mortality due to postpartum hemorrhage through an improved and continuous registration with confidential enquiries may lead to the identification of clear improvements of maternal care.

Emergency peripartal hysterectomy - a single-center analysis of the last 13 years at a tertiary perinatal care unit.

Background Peripartal hysterectomy (PH) is a challenging surgical procedure with elevated maternal morbidity. Methods From 2004 to 2016, 41 emergency PHs were performed at the tertiary care center of the Department of Gynecology and Obstetrics at University Hospital Ulm. In our retrospective analysis, the incidence of PH in our hospital was 12.8 per 10,000 deliveries with a maternal mortality of 2.4%. PH followed in 80.5% after cesarean section (c-section). Underlying causes/indications for PH were abnormal placentation (53.7%; n=22), uterine atony (26.8%; n=11), uterine lacerations (14.6%; n=6) and in rare cases uterine infection (4.9%; n=2). The median number of transfused products was 11 packed red blood cells (range 0-55 products), 10 fresh frozen plasma units (range 1-43) and two platelet concentrates (0-16). Results Loss of blood as estimated by surgeons was significantly correlated with actual transfused blood volume (P<0.001). Clinically relevant intra- and/or postoperative complications occurred in 53.7% of patients (n=22). Abnormal placentation was the leading cause for PH with an increased incidence during the last 10 years presumptively representing the elevated rate of c-sections. Conclusion PH goes along with increased rates of blood product transfusions independently of indication for surgery and has a high morbidity with a major complication rate of more than 50%. Prepartal assessment of risk factors like abnormal invasive placenta are crucial for reducing maternal morbidity.

The Effect of Tranexamic Acid on Preventing Post-partum Hemorrhage Due to Uterine Atony: A Triple-blind Randomized Clinical Trial.

BACKGROUND: Postpartum haemorrhage (PPH) is an important cause of early maternal death which needs to be controlled. OBJECTIVE: This study was designed to compare the effect of intravenous tranexamic acid (TXA) and prostaglandin analogue on reducing PPH resulted from uterine atony in women undergoing C section or vaginal delivery. METHOD: A randomized, triple-blind, placebo-controlled study was conducted on 248 pregnant women with PPH due to uterine atony who were randomly assigned into two groups of TXA as the intervention group (n=124) and prostaglandin analogue as the control group (n=124). The intervention group received 4 g TXA for an hour and then 1 g over 6 hours infusion intravenously and the control group received prostaglandin analogue. RESULTS: Postoperative bleeding did not significantly differ between the two groups (68.2±6.1 ml and 69.1±175.73 ml, respectively, P =0.6). Moreover, hemoglobin declines were 1±0.4 g/dl and 1.2±0.5 g/dL in TXA and prostaglandin group respectively, indicating that the difference was not statistically significant (P =0.7). CONCLUSION: The results of the present study showed that administrating intravenous TXA had comparable effects with prostaglandin analogue on reducing PPH in women with uterine atony and in those undergoing C section or vaginal delivery. Therefore, TXA can be used instead of prostaglandin in managing such patients.

Maternal morbidity after implementation of a postpartum hemorrhage protocol including use of misoprostol.

OBJECTIVE: To compare maternal morbidity before and after implementation of a postpartum hemorrhage (PPH) protocol that included misoprostol. METHODS: A retrospective analysis was performed using data from 34 631 deliveries recorded at a Spanish hospital between January 1, 2007, and December 31, 2014. The PPH protocol was implemented in 2009 and included use of misoprostol and the Bakri balloon. RESULTS: The pre-implementation and post-implementation groups comprised 9394 and 25 237 women, respectively. Women in the pre-implementation group tended to have lower hemoglobin levels than did those in the post-implementation group: 811 (8.6%) versus 1349 (5.3%) for levels less than 90 g/L, and 272 (2.9%) versus 497 (2.0%) for levels less than 80 g/L (both P<0.001). Implementation of the PPH protocol was also associated with a decrease in the frequency of postpartum hysterectomies owing to uterine atony (0.11 cases per 1000 deliveries vs 0.53 cases per 1000 deliveries for the pre-implementation group; P=0.063). Pregnancy length, maternal age, neonatal weight at delivery, multiple pregnancy, previous cesarean delivery, parity, operative vaginal delivery, induced labor, cesarean delivery, and not using the PPH protocol were found to predict postpartum anemia in the multivariate analysis (all P<0.001). CONCLUSION: Implementation of the PPH protocol decreased rates of postpartum anemia and postpartum hysterectomy owing to uterine atony.

A nationwide population-based cohort study of peripartum hysterectomy and arterial embolisation in Belgium: results from the Belgian Obstetric Surveillance System.

OBJECTIVES: To assess the prevalence of major obstetric haemorrhage managed with peripartum hysterectomy and/or interventional radiology (IR) in Belgium. To describe women characteristics, the circumstances in which the interventions took place, the management of the obstetric haemorrhage, the outcome and additional morbidity of these women. DESIGN: Nationwide population-based prospective cohort study. SETTING: Emergency obstetric care. Participation of 97% of maternities covering 98.6% of deliveries in Belgium. PARTICIPANTS: All women who underwent peripartum hysterectomy and/or IR procedures in Belgium between January 2012 and December 2013. RESULTS: We obtained data on 166 women who underwent peripartum hysterectomy (n=84) and/or IR procedures (n=102), corresponding to 1 in 3030 women undergoing a peripartum hysterectomy and another 1 in 3030 women being managed by IR, thereby preserving the uterus. Seventeen women underwent hysterectomy following IR and three women needed further IR despite hysterectomy. Abnormal placentation and/or uterine atony were the reported causes of haemorrhage in 83.7%. Abnormally invasive placenta was not detected antenatally in 34% of cases. The interventions were planned in 15 women. Three women were transferred antenatally and 17 women postnatally to a hospital with emergency IR service. Urgent peripartum hysterectomy was averted in 72% of the women who were transferred, with no significant difference in need for transfusion. IR procedures were able to stop the bleeding in 87.8% of the attempts. Disseminated intravascular coagulation secondary to major haemorrhage was reported in 32 women (19%). CONCLUSION: The prevalence in Belgium of major obstetric haemorrhage requiring peripartum hysterectomy and/or IR is estimated at 6.6 (95% CI 5.7 to 7.7) per 10 000 deliveries. Increased clinician awareness of the risk factors of abnormal placentation could further improve the management and outcome of major obstetric haemorrhage. A case-by-case in-depth analysis is necessary to reveal whether the hysterectomies and arterial embolisations performed in this study were appropriate or preventable.

[Maternal deaths due to haemorrhage: Results from the French confidential enquiry into maternal deaths, 2010-2012]. / Mortalité maternelle par hémorragie, résultats de l'ENCMM, France 2010­2012.

Haemorrhage is the first cause of maternal mortality and morbidity in France and a quality of care marker. Haemorrhage rate in France is around 5 to 10% of deliveries. PPH is defined as a post-partum blood loss≥500mL whatever the delivery route and sometime blood can be concealed inside the pelvis. Between 2010 and 2012 in France, 29 deaths were related to haemorrhage giving a maternal mortality ratio of 1.2/100,000 live births (CI 95% 0.8-1.7). Haemorrhage cases decreased from last triennium (2007-2009) especially for uterine atony cases (12/29) but remains the first leading cause of direct maternal death. Patients with previous cesarean birth were more represented than in general obstetrical population (11/23). Substandard care were mainly due to delays in diagnosis of hemoperitoneum, delays in adequate resuscitation because of reassuring vital signs (normal blood pressure or normal hematocrite at the initial stage of bleeding) or organisational mistakes.

Incidence, management and outcome of women requiring massive transfusion after childbirth in the Netherlands: secondary analysis of a nationwide cohort study between 2004 and 2006.

BACKGROUND: Postpartum hemorrhage remains the leading cause of maternal morbidity and mortality worldwide. Few population-based studies have examined the epidemiology of massive transfusion for postpartum hemorrhage. The aim of this study was to determine the incidence, management, and outcomes of women with postpartum hemorrhage who required massive transfusion in the Netherlands between 2004 and 2006. METHODS: Data for all women from a gestational age of 20 weeks onwards who had postpartum hemorrhage requiring eight or more red blood cell concentrates were obtained from a nationwide population-based cohort study including all 98 hospitals with a maternity unit in the Netherlands. RESULTS: Three hundred twenty-seven women who had postpartum hemorrhage requiring massive transfusion were identified (massive transfusion rate 91 per 100,000 deliveries (95% confidence interval: 81-101)). The median blood loss was 4500 mL (interquartile range 3250-6000 mL) and the median number of red blood cell concentrates transfused was 11 units (interquartile range 9-16 units). Among women receiving massive transfusion, the most common cause of hemorrhage was uterine atony. Eighty-three women (25%) underwent hysterectomy, 227 (69%) were admitted to an intensive care unit, and three women died (case fatality rate 0,9%). CONCLUSION: The number of women in the Netherlands who had postpartum hemorrhage treated with massive transfusion was relatively high compared to other comparable settings. Evidence-based uniform management guidelines are necessary.