Conservative Surgical Management of Early Postpartum Hemorrhage: A 12-Year Experience in a Tertiary Care Center in the South of Thailand.

Background/Purpose of the Study: To evaluate the success rate and predictive factors of success in conservative surgical management of early postpartum hemorrhage (PPH). Methods: A retrospective study was conducted at a tertiary care hospital in the south of Thailand, from January 2006 to December 2017. PPH with conservative surgical management including Bakri balloon tamponade, B-Lynch uterine compression sutures, arterial embolization, vessel ligations, and combined surgical procedures was reviewed. The procedures were considered successful if bleeding could be controlled without subsequent hysterectomy. Multivariate logistic regression analysis was used to identify predictive factors for success of conservative surgical treatment. Results: Among 39,327 deliveries, 1461 (3.7%) patients had early PPH, and 92 cases received conservative surgical management. Most patients (92.4%) underwent cesarean section. Median (IQR) blood loss before conservative surgery was 1800 (1100, 2575) mL, and median (IQR) time from early PPH to conservative surgical management was 41 (25.5, 60.0) minutes. The overall success rate of conservative surgical management was 80.4%, meanwhile the postoperative complication rate was 27.2%. The predictive factors significantly associated with success were maternal age < 35 years (odds ratio [OR] 4.53, 95% confidence interval [CI] 1.27-16.23; p = 0.02), blood loss before conservative surgery < 1800 mL (OR 5.82, 95% CI 1.45-23.33; p = 0.01), and time to start conservative surgery ≤ 40 min (OR 4.76, 95% CI 1.13-20.12; p = 0.03). Conclusion: The overall success rate of conservative surgical procedures was high. Maternal age < 35 years, blood loss before conservative management < 1800 mL, and time to conservative surgery ≤ 40 min were predictive factors of success.

Reference ranges of fetal mandible measurements: Inferior facial angle, jaw index, mandible width/maxilla width ratio and mandible length in Thai fetuses at 15 to 23 weeks of gestation.

OBJECTIVES: To determine the normal distribution of 1) inferior facial angles (IFA), 2) jaw index, 3) mandible width/maxilla width ratio (MD/MX ratio), and 4) mandible length (ML) in second trimester Thai fetuses. METHODS: A prospective study was performed between April 1 and October 31, 2020, at the Maternal-Fetal Medicine Unit of Songklanagarind Hospital. Transabdominal ultrasonography was performed on Thai singleton pregnant women at 150/7 to 236/7 weeks of gestation to measure IFA, jaw index, MD/MX ratio and ML. All women received standard antenatal care and were followed up until delivery. The exclusion criteria were multifetal gestation, congenital anomaly, chromosomal abnormality, fetal growth restriction, abnormal amniotic fluid volume, suspected abnormality of fetal mandible, maxilla or jaws based on the proposed criteria from previous studies and suspected neonatal structural or genetic abnormalities postnatally. Quantile regression was used to estimate changes in the median, 5th and 95th percentiles of each parameter across gestational ages and to generate formulas for predicting the 5th percentile value for each parameter. RESULTS: The results of 291 women were analyzed. Scatter plots and reference ranges of each parameter were generated. IFA, jaw index and ML values significantly increased, while the MD/MX ratio value significantly decreased, with increasing gestational age. The formulas calculated for predicting the 5th percentile value for each parameter were IFA = 55.12 + 0.045*(GA in days-136) jaw index = 37.272 + 0.01693*(GA in days-136) MD/MX ratio = exp(0.027-0.00110*(GA in days-136)) ML = 20.83 + 0.243*(GA in days-136). CONCLUSIONS: The reference ranges and formulas to calculate the 5th percentile values of mandible parameters in Thai fetuses were developed. TRIAL REGISTRATION: This study has been reviewed and approved by the Thai Clinical Trials Registry with identification number TCTR20210602003.

Reliability of measurements of facial profile parameters by operators with different levels of experience at 15 to 23 weeks of gestation.

PURPOSE: To compare the reliability of measurements of five fetal facial profile parameters by operators with different levels of experience, at 15 to 23 weeks of gestation in Thai fetuses. METHODS: An observational study was conducted. The inferior facial angle, anteroposterior mandibular diameter, mandible width, maxilla width, and mandible length were measured in 123 normal fetuses, using 2D ultrasonography, by three operators with different levels of experience. Each participant was examined by two operators. Each operator performed three independent measurements for each parameter and was blinded to the results of the other. Reliability of measurement was evaluated using intraclass correlation coefficient. Bland-Altman analysis was used to evaluate agreement. RESULTS: The ability to obtain a mandible length measurement was highest (100%) among the five parameters. Intraobserver variabilities of anteroposterior mandibular diameter, mandible width, maxilla width, and mandible length measurements were excellent for all operators (ICC 0.958-0.986), while those of inferior facial angle measurements were moderate to excellent (ICC 0.560-0.923), depending on the operators' experience. Interobserver variabilities varied between pairs of operators; only two parameters, anteroposterior mandibular diameter and mandible length, showed excellent interobserver variabilities (ICC >0.9), with good agreement. CONCLUSIONS: The mandible length measurement was the best parameter in terms of feasibility and reliability.