Uterine packing with chitosan-covered tamponade to treat postpartum hemorrhage.

Postpartum hemorrhage remains a major cause of maternal mortality and morbidity worldwide with higher rates found in resource-challenged countries. Conventional use of uterotonics such as oxytocin, prostaglandins, and medications to support coagulation, such as fibrinogen and tranexamic acid, are helpful but may not be sufficient to arrest life-threatening postpartum hemorrhage. Severe postpartum hemorrhage leads to an increased need for blood transfusions and the use of invasive techniques, such as intrauterine balloon tamponade, compression sutures, and arterial ligation, as advanced steps in the management cascade. In extreme cases where hemorrhage is resistant to these therapies, a hysterectomy may be necessary to avoid possible maternal death. Uterine packing with a chitosan-covered tamponade is an emerging tool in the armamentarium of the obstetrical team, especially when resources for advance surgical and other invasive options may be limited. Modified chitosan-impregnated gauze was originally described in the management of acute hemorrhage in the field of military medicine, combining the physiological antihemorrhaging effect of modified chitosan with a compression tamponade for the acute treatment of wound bleeding. The first described use in obstetrics was in 2012, showing that the chitosan-covered tamponade is an effective intervention to arrest ongoing therapy-resistant postpartum hemorrhage. Further studies showed a reduction in hysterectomies and blood transfusions. The method is, however, underreported and is not yet an established method used worldwide. To demonstrate the step-by-step application of the intrauterine chitosan-covered tamponade in the management of therapy-resistant postpartum hemorrhage, we have produced a teaching video to illustrate the important steps and techniques to optimize the effectiveness and safety of this novel intervention.

Meta-analysis of the effect of duration of labour on postpartum haemorrhage.

OBJECTIVES: To evaluate the relationship between stages of labour and the risk of postpartum haemorrhage (PPH) and provide evidence for clinical application. MATERIAL AND METHODS: Manual searches were undertaken, and computer searches of PubMed, MEDLINE, Web of Science, CNKI, Wanfang and Wipu databases with a search window from database creation to April 2022 were conducted to procure relevant studies on the relationship between labour phase and PPH. The articles included in this study were evaluated for quality, and RevMan 5.3 software was used for meta-analysis. RESULTS: Meta-analysis showed that the incidence of PPH in women with weak uterine contractions was 27.5%, compared with 18.1% in women with normal contractions [relative risk (RR) = 1.60; 95% confidence interval (CI) 1.38, 1.85; p < 0.01]. There was a statistically significant difference in the incidence of PPH in pregnant women with a prolonged second stage of labour (≥ 2 h) (34.5%) compared with those whose second stage of labour was normal in duration (15.9%) (RR = 0.20; 95% CI 0.15, 0.25; p < 0.01). The incidence of PPH was 52.1% in pregnant women with a prolonged third stage of labour (≥ 15 min) compared with 20.9% in those whose third stage of labour was of normal duration (RR = 3.53; 95% CI 2.75, 4.52; p < 0.01). The difference in the incidence of a prolonged third stage of labour in pregnant women with weak contractions compared with those with normal contractions was statistically significant (72.3% vs 15.5%) (RR = 0.47; 95% CI 0.35, 0.60; p < 0.01). CONCLUSIONS: Duration of labour is associated with the development of PPH, and the risk of PPH is increased in women with weak contractions or with a prolonged second or third stage of labour.

Intravenous versus intramuscular oxytocin injection for preventing uterine atonic primary postpartum haemorrhage in third stage of labour: A double-blind randomised controlled trial.

Objectives: To compare the efficacy and safety of intravenous and intramuscular oxytocin in preventing atonic primary postpartum haemorrhage in the third stage of labour. Methods: A double-blind randomised clinical study on consenting women without risk factors for primary postpartum haemorrhage in labour at term. Two hundred and thirty-two women were randomly allotted into intravenous (n = 115) and intramuscular (n = 117) oxytocin groups in the active management of the third stage of labour. All participants received 10 IU of oxytocin, either IV or IM, and 1 ml of water for injection as a placebo via a route alternate to that of administration of oxytocin within 1 min of the baby's delivery. The primary outcome measures were mean postpartum blood loss and haematocrit change. Trial Registration No.: PACTR201902721929705. Results: The baseline socio-demographic and clinical characteristics were similar between the two groups (p > 0.05). There was no statistically significant difference between the two groups with regards to the mean postpartum blood loss (254.17 ± 34.85 ml versus 249.4 ± 39.88 ml; p = 0.210), haematocrit change (2.4 (0.8%) versus 2.1 (0.6%); p = 0.412) or adverse effects (p > 0.05). However, the use of additional uterotonics was significantly higher in the intravenous group (25 (21.73%) versus 17 (14.53%); p = 0.032). Conclusion: Although oxytocin in both study groups showed similar efficacy in terms of preventing atonic primary postpartum haemorrhage, participants who received intravenous oxytocin were more likely to require additional uterotonics to reduce their likelihood of having an atonic primary postpartum haemorrhage. However, both routes have similar side effect profiles.

A new step-wise surgical technique of knapsack-like uterine compression sutures for intractable postpartum hemorrhage in cesarean section.

BACKGROUND: Intractable postpartum hemorrhage (PPH) during cesarean section has been a significant concern for obstetricians. We aimed to explore the effectiveness and safety of a new type of uterine compression suture, the step-wise surgical technique of knapsack-like sutures for treating intractable PPH caused by uterine atony and placenta factors in cesarean section. METHODS: The step-wise surgical technique of knapsack-like sutures was established on the basis of the artful combination of vertical strap-like sutures and an annular suture-ligation technique. This novel surgical technique was applied to 34 patients diagnosed with PPH during cesarean section due to severe uterine atony and placental factors in our department. The hemostatic effects, clinical outcomes and follow-up visit results were all reviewed and analyzed. RESULTS: This new uterine compression suture successfully stopped bleeding in 33 patients, and the effective rate was 97.06%. Only 1 patient failed and was changed to use bilateral uterine arterial embolization and internal iliac artery embolization. The follow-up visits indicated that 33 patients restored menstruation except for 1 who was diagnosed with amenorrhea. The gynecological ultrasound tests of all the patients suggested good uterine involutions, and they had no obvious complaints such as hypogastralgia. CONCLUSIONS: This step-wise surgical technique of knapsack-like uterine compression sutures can compress the uterus completely. It is a technique that can conserve the uterus and fertility function without special equipment in caesarean section for PPH, with the characteristics of being safe, simple and stable (3 S) with rapid surgery, reliable hemostasis and resident doctor to operation (3R).

Peripartum hysterectomy: A 9-year population-based study in Slovakia.

OBJECTIVE: To assess the incidence of peripartum hysterectomy (PH) in Slovakia. Additionally, we wanted to describe reasons for the procedure, associated clinical circumstances, and complications. METHODS: This was a descriptive, population-based study among women who underwent PH in Slovakia between January 2012 and December 2020. Peripartum hysterectomy was defined as surgical removal of the uterus from the peripartum period up to 42 days postpartum. Data were obtained retrospectively from the standardized questionnaires that are completed in Slovakia for any case of PH. The background population consisted of all other women who delivered during the study period. RESULTS: Of the 436 136 births, there were 397 cases of PH, giving an incidence of 0.91 per 1000 births. It was higher with advanced maternal age, multiparity, multiple pregnancies, and cesarean deliveries. The main reasons for the procedure were placental pathologies and uterine atony in 52.9% and 33.0%, respectively. A total of 150 (37.8%) women required admission to an intensive care unit. The mortality rate was 1.5%. CONCLUSION: The incidence of PH is relatively high in Slovakia when compared with other European countries, highlighting the need to improve prenatal diagnosis of morbidly adherent placenta and the management of peripartum hemorrhage.

Peripartum Hysterectomy Outcomes: Our Eleven-Year Experience at a Tertiary Care Hospital.

Aim: To investigate the outcomes of peripartum hysterectomies (PHs) conducted to prevent maternal morbidity and mortality at a tertiary care hospital with 15,000 deliveries per year. Method: Patients who underwent PHs during delivery and/or within 24 h of delivery between the years 2011-2022 were retrospectively evaluated. Hysterectomies not performed in the peripartum period, cases that were managed by methods such as balloon tamponade, compression suture, or arterial ligation rather than hysterectomy, and hysterectomies performed before 20 weeks were excluded. Obstetric and demographic characteristics of the cases, as well as indications and outcomes of PH, were investigated. Results: Among the 130 patients who underwent PH, 4 (3.04%) patients delivered vaginally, 1 (0.7%) patient delivered vaginally after cesarean section, 12 (9.2%) patients delivered by primary cesarean section, and 113 (86.9%) patients delivered by secondary cesarean section. Placenta accreta spectrum disorder was the reason for PH in 54.6% (n = 71) of the cases while 16.1% (n = 21) underwent PH due to uterine atony. The PH rate was 0.75 per 1000 births, and the maternal mortality rate was 7.6 per 1000 hysterectomies in this study. Conclusion: Obstetricians in developed/ing countries support the active management of the third stage of labor mainly to mitigate the preventable risk factors of post-/peri-partum hemorrhage. The current study suggests that obstetricians need to focus on the placenta in order to reduce PH.

Reflections on peripartum hysterectomy: A 10-year retrospective observational study in Northeast China.

OBJECTIVE: To explore the change trends in incidence and leading factors to peripartum hysterectomy (PH) at a regional tertiary medical center in northeast China. METHODS: This was a retrospective observational study of all PH cases conducted at Shengjing Hospital between January 1, 2012 and December 31, 2021. Information on maternal characteristics of pregnancy and delivery, indications of PH, inventions before hysterectomy, complications, and maternal and neonatal outcomes obtained from the Shengjing Hospital Information System were analyzed. RESULTS: Among a total of 157 553 deliveries, there were 127 cases of PH (overall PH incidence: 0.85/1000 deliveries); 120 patients (94.49%) underwent hysterectomy after cesarean section, and seven (5.51%) underwent vaginal delivery (P < 0.001). Abnormal placentation was the leading indication for PH (101, 79.53%), including placenta previa (PP) with placenta accreta spectrum (PAS) (93, 73.23%), PP alone (5, 3.94%), and PAS alone (3, 2.36%). Among the patients who underwent PH with abnormal placentation, 92.08% had at least one cesarean section (P < 0.001) and 20.19% had bladder injury (P = 0.044). All maternal deaths (n = 2) occurred in referral patients, and the maternal mortality rate was 1.57/100 hysterectomies. CONCLUSION: Abnormal placentation was the primary indication for PH. For such patients, adequate assessment of their condition and complete communication are strongly recommended. The identification of high-risk groups for postpartum hemorrhage, timely and effective rescue, and referral are equally important for avoiding PH.

Intra-uterine packing: an effective and affordable tool in the management of post-partum hemorrhage - cohort study.

Introduction: postpartum hemorrhage is the main cause of maternal death worldwide. Uterine balloon packing has shown promising outcomes in PPH management. Nevertheless, its usage is limited in low- and middle-income countries due to associated costs. Uterine packing using gauzes presents a potentially efficient and cost-effective alternative. This study aims to assess the safety and efficacy of intra-uterine packing with gauzes in managing postpartum hemorrhage. Methods: this was a retrospective study over a period of two years and six months. All patients who experienced PPH due to uterine atony during vaginal delivery, with no response to medical first-line treatment, were included. IUP using gauze was employed as a second-line intervention. The primary outcome was the success of postpartum hemorrhage management. Secondary outcomes included patient vitals, the need for blood transfusion, change in hemoglobin levels (delta Hemoglobin), and maternal morbidity (post-partum infection, Sheehan syndrome, and retained gauzes). Results: the study included 63 patients. The mean age was 30.06 ± 5.6, the mean gravida was 2.65 ± 1.9 and the mean para was 2.12 ± 1.31. None of these patients experienced major complications following gauze insertion. Three patients underwent laparotomy and conservative surgical management was performed. Hysterectomy was not required for any participant, and no maternal deaths were recorded.

Abnormal Uterine Involution May Lead to Atony and Postpartum Hemorrhage: A Hypothesis, With Review of the Evidence.

Uterine involution has 2 major components-(1) involution of vessels; and (2) involution of myometrium. Involution of vessels was addressed by Rutherford and Hertig in 1945; however, involution of myometrium has received little attention in the modern literature. We suggest that the pathophysiology of myometrial involution may lead to uterine atony and postpartum hemorrhage. The myometrium dramatically enlarges due to gestational hyperplasia and hypertrophy of myocytes, caused by hormonal influences of the fetal adrenal cortex and the placenta. After delivery, uterine weight drops rapidly, with physiologic involution of myometrium associated with massive destruction of myometrial tissue. The resulting histopathology, supported by scientific evidence, may be termed "postpartum metropathy," and may explain the delay of postpartum menstrual periods until the completion of involution. When uterine atony causes uncontrolled hemorrhage, postpartum hysterectomy examination may be the responsibility of the perinatal pathologist.Postpartum metropathy may be initiated when delivery of the baby terminates exposure to the hormonal influence of the fetal adrenal cortex, and may be accelerated when placental delivery terminates exposure to human chorionic gonadotrophin (HCG). This hypothesis may explain why a prolonged third stage of labor, and delays in management, are risk factors for severe hemorrhage due to uterine atony.

Intrauterine devices in the management of postpartum hemorrhage.

Obstetrical hemorrhage is a relatively frequent obstetrical complication and a common cause of maternal morbidity and mortality worldwide. The majority of maternal deaths attributable to hemorrhage are preventable, thus, developing rapid and effective means of treating postpartum hemorrhage is of critical public health importance. A uterine balloon tamponade is one option for the management of refractory postpartum hemorrhage in the setting of uterine atony. However, recently, intrauterine vacuum devices have been introduced, which offer a new mechanism for achieving hemorrhage control by mechanically restoring uterine tone. This review discusses currently available devices and data supporting their use.

Minimum effective dose of oxytocin bolus during the caesarean section for patients at high vs low risk of uterine atony: A non-randomized, dual-arm, dose-finding prospective trial.

Background and Aims: There are scanty data for oxytocin dose in patients at high risk of uterine atony. We aimed to compare the effective dose (ED) 90 of oxytocin for adequate uterine tone during the caesarean section in patients at high-risk vs low-risk uterine atony. Methods: This dose-finding study was undertaken after ethical approval in non-labouring women aged >18 years with pre-defined risk factors for uterine atony (high-risk group) vs those without such factors (low-risk group) (n = 39 each). Starting dose of oxytocin in the first patient of low-risk and high-risk groups was 1 and 3 IU, respectively. Achieving adequate uterine tone at 3 min of oxytocin bolus was designated 'success', while inadequate tone constituted 'failure'. If the response was 'failure', the dose of oxytocin was increased for the next patient by 0.5 or 0.2 IU (high- and low-risk groups, respectively). In case of a successful response, the dose for the next patient was decreased with a probability of 1/9 using the same dosing intervals or otherwise kept unchanged. Results: The ED90 (95% CI) of oxytocin bolus was 4.7 (3.3-6.0) IU for the high-risk group and 2.2 (1.3-3.2) IU for the low-risk group (P = 0.044). Oxytocin-associated tachycardia (P = 0.247) and hypotension (P = 0.675) were clinically greater for the high-risk vs low-risk group but statistically similar. Conclusion: Non-labouring patients with high-risk factors for uterine atony require a greater dose of initial oxytocin bolus to achieve adequate uterine tone during the caesarean section compared to those without risk factors.

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.

Postpartum Hemorrhage and Tranexamic Acid: A Literature Review.

This review aims to explore the postpartum hemorrhage (PPH) burden and the efficacy of prophylactic tranexamic acid (TXA) in PPH and recent indications of TXA. A comprehensive review of the literature was conducted using a combination of Medical Subject Headings keywords including "Postpartum haemorrhage," "Tranexamic acid," and "Cesarean section." PPH has been explored for epidemiology, risk factors, and pathophysiology in the first part of the article. Recent indications of TXA, obstetric indications, and the role of TXA as prophylaxis for PPH are discussed in the second part of this article. TXA has many indications apart from obstetric indications and shows a significant effect in controlling bleeding. Furthermore, TXA is more efficient in preventing PPH if administered during the final stage of labor and is a valuable option for managing obstetric bleeding.

Clinical outcome analysis of modified B-Lynch sutures in the fundus uteri and part of the corpus uteri for the prevention of intraoperative haemorrhage during caesarean delivery in women with twin pregnancy: a retrospective study.

OBJECTIVE: To explore the efficacy of modified B-Lynch sutures in the fundus uteri and part of the corpus uteri for the prevention of intraoperative haemorrhage during caesarean delivery in women with twin pregnancy. METHODS: This retrospective analysis covers the clinical data of 40 women with postpartum haemorrhage caused by uterine inertia during caesarean section in women with twin pregnancy in our hospital from January 2018 to May 2022. These women were divided into the group with modified B-Lynch sutures at the fundus and part of the corpus uteri (Group A, 20 patients) and the group with classic B-Lynch sutures (Group B, 20 patients) according to the treatment received. The treatment effect and safety of the two uterine compression sutures were compared. RESULTS: In this study, no statistically significant differences were found in the outcomes of haemostasis or intraoperative and 24-h postoperative blood loss between the two uterine compression suture groups (P > 0.05). Compared to Group B, Group A showed a significantly reduced operative time, postoperative hospital stay, puerperal morbidity rate, pain score and duration of lochia. CONCLUSION: Modified B-Lynch sutures at the fundus and part of the corpus uteri can achieve a haemostatic effect similar to that of the classic B-Lynch suture, while it allows for a shortened operative time and reduced postoperative complications. Modified B-Lynch sutures can serve as a safe, rapid and effective haemostatic method for the prevention and treatment of postpartum haemorrhage during caesarean section in women with twin pregnancy, showing certain validity for promotion in clinics.

Vacuum-Induced Hemorrhage Control versus Uterine Balloon Tamponade for Postpartum Hemorrhage.

OBJECTIVE: To compare maternal outcomes of uterine balloon tamponade (UBT) versus an intrauterine vacuum-induced hemorrhage control device (VHD) for the management of primary postpartum hemorrhage (PPH). METHODS: Retrospective cohort of all patients with PPH due to uterine atony treated with an intrauterine device within a university health system from January 2019 to June 2021. The primary outcome of massive transfusion, defined as PPH requiring transfusion of ≥4 units of packed red blood cells (PRBC), was compared between 2 groups: UBT (n = 78) versus VHD (n = 36). Statistical analysis included the use of chi-squared and Wilcoxon rank sum tests with statistical significance set at P < 0.05. RESULTS: Baseline characteristics were similar between the 2 groups. The proportion of patients who received ≥4 units of PRBC was significantly lower in the VHD group compared to the UBT group (2.8% vs. 20.5%, P = <0.01). The proportion of patients who were transfused ≥2 units of PRBC and median estimated blood loss (EBL) were also both significantly lower in the VHD group compared to the UBT group (36.1% vs. 57.7%, P = < 0.01, and 1 500 mL vs. 1 875 mL, P = 0.02, respectively). Rates of other secondary outcomes were similar between the 2 groups. CONCLUSION: Our data suggest that the use of intrauterine VHD in the management of PPH is associated with a lower number of massive transfusions and EBL compared to UBT. Randomized controlled trials are needed before drawing definitive conclusions on which device is more effective in this setting.

Uterine tamponade in postpartum hemorrhage with handmade balloons: Comparison of manufacturing, infusion, and total times.

OBJECTIVE: To compare the manufacturing, infusion, and total times of handmade balloons for uterine tamponade using the El Hennawy and Alves techniques, given the failure of initial measures and uterotonic therapy to control postpartum hemorrhage. METHODS: An open clinical trial (clinical article) was conducted among 30 physicians, residents, and assistants in an Obstetrics Department. Each participant manufactured and infused one of two different balloons compared in the study, in a randomly predefined sequence. The manufacturing and infusion times were timed by the researchers and their medians were compared using the t test or Mann-Whitney U test. RESULTS: The manufacturing time of the El Hennawy balloon was 72 s lower in relation to the Alves balloon (P < 0.010). Regarding the infusion time, the Alves balloon was filled faster than the El Hennawy balloon (P < 0.010). The total time (manufacturing and infusion) of Alves balloon was also lower than the El Hennawy device (P < 0.010). CONCLUSIONS: Although the El Hennawy balloon was manufactured more quickly, the total time of manufacturing and infusing the Alves balloon was much faster, which makes it the most suitable device to be used in critical situations of postpartum hemorrhage.

Hysteroscopy after conservative surgical treatment of severe postpartum hemorrhage due to uterine atony: A systematic literature review.

OBJECTIVE: To assess the prevalence of intrauterine anomalies, primarily intrauterine adhesions (IUAd), after conservative surgical treatment of severe postpartum hemorrhage with uterine atony (SPPH-UA) and determine patient eligibility for hysteroscopy. METHODS: PubMed and the Cochrane Library were searched by combining keywords "postpartum hemorrhage", "uterine atony", and "hysteroscopy" to perform a literature review. Articles in French and English with more than five cases of hysteroscopy following SPPH-UA were selected. All cases that had hysteroscopy after conservative surgical treatment of SPPH-UA were collected. A blinded statistical analysis revealed IUAd risk factors. RESULTS: In all, 83% of patients agreed to hysteroscopy and 38% of 71 cases had an IUAd. Age was not a risk factor (P = 0.950). Other factors included multiparity (odds ratio [OR] 1.93, P = 0.039), cesarean delivery (OR 3.58, P = 0.584) and postpartum infection (OR 3.33, P = 0.04). Risk was at 57% after uterine padding with multiple transfixing square stitches (Cho-technique) (P = 0.001), 6% after non-transfixing uterine folding brace suture (B-Lynch technique) when used alone, 29% after uterine artery embolization and after internal iliac artery ligation (OR 0.98, P = 0.645); uterine vascular ligation (OR 0.69, P = 0.253) and more than two procedures (OR 0.69, P = 2.53). Disparity between authors was observed (P = 0.015) and concerned only the surgical techniques used. CONCLUSION: A classification is proposed for deciding post-SPPH hysteroscopy. Further studies are required to determine appropriateness.