Postpartum menstrual equity: Video and audio analysis of vaginal bleeding counseling during postpartum inpatient care at a southeastern US tertiary hospital.

BACKGROUND: Despite the universal nature of postpartum vaginal bleeding after childbirth and the importance of managing vaginal bleeding in the postpartum period to monitor health status, little is known about the information or products that birthing individuals are provided. Investigating current practices may offer insights to enacting more supportive and equitable postpartum care. OBJECTIVE: To evaluate the patterns and content of vaginal bleeding counseling provided to birthing parents while on a postnatal inpatient unit. DESIGN: Observational study of inpatient postpartum care. Birthing parents and their companions consented to video and audio recording of themselves, their infants, and healthcare team members during their postnatal unit stay. METHODS: Following IRB approval and in coordination with clinicians at a tertiary hospital in the southeastern United States, data were collected with 15 families from August to December 2020. A multidisciplinary team coded video and audio data from each family from 12 h before hospital discharge. This analysis evaluates patterns of vaginal bleeding counseling timing, content, and language concordance and thematic content of this communication. RESULTS: Birthing parent participants were self-identified Hispanic White (n = 6), non-Hispanic Black (n = 5), non-Hispanic White (n = 3), and non-Hispanic multi-race (n = 1). Six were Spanish-speaking and eight had cesarean section births. The timing, content, and language concordance of vaginal bleeding communication varied, with these topics mainly addressed in the hour preceding discharge. Twelve of the 15 birthing parents had communication on these topics between 2 and 5 times, 2 had one exchange, and 1 had no counseling on postpartum bleeding observed. Four of the six Spanish-speaking birthing parents had counseling on these topics that was not language concordant. Postpartum vaginal bleeding management involved the themes of access to products, patient safety, and meaningful counseling. There was a lack of adequate access, variation in accurate and respectful care, and a busy clinical environment with differences in information provided. CONCLUSION: Findings suggest that there are opportunities to strengthen clinical practices for more consistent, proactive, and language concordant vaginal bleeding and subsequent menstrual care postpartum. Menstrual equity is an important part of dignified and safe care.

Video analysis of when and what information on vaginal bleeding was shared between people who just gave birth and their healthcare team at the hospital.Why did we do the study? After birth, people must take care of vaginal bleeding. It is important for people in the hospital to recognize warning signs for too much bleeding, have access to pads, and feel supported by their healthcare team before discharging to home. There has been little research on experiences with inpatient counseling on postpartum vaginal bleeding­a part of the reproductive life cycle­for new parents. We wanted to watch and listen in hospital rooms so we could think about the best ways for healthcare providers to talk about vaginal bleeding. What did we do? We asked 15 people who just gave birth, people staying with them at the hospital, and their healthcare team if we could video and sound record in their hospital rooms. They could start and stop recording anytime. We only recorded people who agreed to be in the study. What did we learn? We watched recordings of the last 12 hours at the hospital before each family went home. We found that most of the time, the healthcare workers did not talk about vaginal bleeding. People who spoke Spanish did not always have someone interpreting into their language. Sometimes family members had to translate and ask for pads. Some people did not have enough pads or underwear and had to wait after asking for more. What does it mean? We found ways to improve teaching about vaginal bleeding after birth. We recommend always having an interpreter when needed, giving people enough pads and underwear in their rooms, including companions in the teaching, and having enough healthcare workers to answer requests. These ideas would improve the counseling and give everyone the support needed after giving birth.

En kvinne i 30-årene med brystsmerter og sirkulatorisk sjokk etter fødsel.

Background: Bleeding is a serious cause of hypotension and tachycardia after childbirth and should always be considered. Case presentation: A healthy woman in her thirties who had previously undergone caesarean section, underwent induction and operative vaginal delivery. Postpartum, she experienced chest pain, hypotension and tachycardia, and had signs of ischaemia on electrocardiogram. A CT scan showed a large intraperitoneal haematoma. The patient underwent immediate laparotomy and received a massive blood transfusion. However, no large haematoma was found. The chest pain was attributed to a myocardial infarction caused by hypovolaemic shock. After discharge, the patient experienced significant vaginal bleeding and was transferred to a different university hospital. A CT scan revealed a large retroperitoneal haematoma. Emergency surgery was performed based on the suspicion of active bleeding, but only an older haematoma was found. Re-evaluation of the initial CT scan revealed that the haematoma was in fact located retroperitoneally and was thereby not found in the first operation. Interpretation: This case highlights the importance of bleeding as an important cause in unstable postpartum patients. Additionally, it is a reminder that retroperitoneal haematomas can occur in obstetric patients and can mask typical symptoms of uterine rupture such as abdominal pain. also hindering perioperative diagnosis.

Postpartum hemoperitoneum - A rare case of uterine artery pseudoaneurysm rupture after uncomplicated vaginal delivery.

OBJECTIVE: Our aim is to demonstrate a rare cause of hemoperitoneum without vaginal bleeding resulting from the rupture of a uterine artery pseudoaneurysm after uncomplicated vaginal delivery. CASE REPORT: A 39-year-old woman who had experienced a normal vaginal delivery 8 days previously to being seen in our hospital, was presented to the emergency room with hypovolemic shock. Computed tomography angiography (CTA) showed massive internal bleeding and a ruptured pseudoaneurysm arising from the left uterine artery. The patient was successfully treated through transcatheter arterial embolization (TAE). CONCLUSION: A pseudoaneurysm is a rare disease which can occur during an uncomplicated vaginal delivery. The clinical presentation can vary from asymptomatic, vaginal bleeding or hemoperitoneum. The diagnosis can be made by using Doppler sonography, CTA or Magnetic Resonance Imaging. The use of TAE is now the most common treatment option and possesses a high success rate.

A case with rare complication of chronic puerperal uterine inversion and underwent operation reduction.

OBJECTIVE: Puerperal uterine inversion is a rare and severe complication and is associated with short cord, uncontrolled cord traction, placenta accreta, or uterine atony. CASE REPORT: A primigravida woman gave birth a 2770 gm newborn at term at our hospital, and clinically presented postpartum hemorrhage, hypovolemic shock, postpartum preeclampsia and urinary retention. She discharged 3 days postpartum, but she complained persist vaginal bleeding and lower abdominal pain for more than 1 month. Uterine inversion was diagnosed and laparoscope surgery for reduction was done. CONCLUSION: The non-specific clinical presentation made diagnosis of uterine inversion more difficult. Except pelvic examination, sonographic and hysteroscopic images were record in this article. Surgical intervention was performed. A fundus incision was effective for reduction and had low risk of bladder and bowel injury.

Comparison of two labor induction regimens with intravaginal misoprostol 25 µg and adverse perinatal outcomes.

OBJECTIVE: The aim of the study was to compare two labor induction regimens (4 and 6 h), to determine predictors of successful labor induction with intravaginal misoprostol 25 µg tablets, and to evaluate the association with adverse perinatal outcomes. METHODS: This was a retrospective cohort study that included singleton pregnancies undergoing induction of labor with an intravaginal misoprostol 25 µg tablet between 37 and 42 weeks of gestation. The pregnant women were divided into two groups: Group 1-intravaginal misoprostol 25 µg every 4 h and Group 2-intravaginal misoprostol 25 µg every 6 h. RESULTS: Pregnant women were divided into Group 1 (n=289) and Group 2 (n=278). Group 1 had a higher median number of intravaginal misoprostol 25 µg tablets (3.0 vs. 2.0 tablets, p<0.001), a lower prevalence of postpartum hemorrhage (7.6 vs. 32.7%, p<0.001), and a higher need for oxytocin (odds ratio [OR]: 2.1, 95%CI: 1.47-2.98, p<0.001) than Group 2. Models including intravaginal misoprostol 25 µg tablets every 4 and 6 h [x2(1)=23.7, OR: 4.35, p<0.0001], parity [x2(3)=39.4, OR: 0.59, p=0.031], and Bishop's score [x2(4)=10.8, OR: 0.77, p=0.019] were the best predictors of failure of labor induction. A statistically significant difference between groups was observed between the use of the first intravaginal misoprostol 25 µg tablet at the beginning (Breslow p<0.001) and the end of the active labor phase (Long Hank p=0.002). CONCLUSION: Pregnant women who used intravaginal misoprostol 25 µg every 4 h had a longer time from the labor induction to the beginning of the active phase of labor and higher rates of adverse perinatal outcomes than women who used intravaginal misoprostol 25 µg every 6 h.

Dengue Infection During Pregnancy and Adverse Birth Outcomes: A Systematic Review and Meta-Analysis.

Dengue is a rapidly spreading mosquito-borne viral disease, posing significant public health challenges in tropical and subtropical regions. This systematic review and meta-analysis aimed to evaluate the relationship between maternal dengue virus infection and adverse birth outcomes. A literature search was conducted in PubMed, Embase, and web of science databases until April 2024. Observational studies examining the association between laboratory-confirmed maternal dengue infection and adverse birth outcomes such as preterm birth, low birth weight (LBW), small for gestational age (SGA), stillbirth, and postpartum haemorrhage were included. Data were extracted, and risk of bias was assessed using the Newcastle-Ottawa Scale. Random-effects meta-analysis models were used to pool data in R software (V 4.3). Twenty studies met the inclusion criteria. The pooled prevalence of preterm birth among dengue-affected pregnancies was 18.3% (95% CI: 12.6%-25.8%), with an OR of 1.21 (95% CI: 0.78-1.89). For LBW, the pooled prevalence was 17.1% (95% CI: 10.4%-26.6%), with an OR of 1.00 (95% CI: 0.69-1.41). SGA had a pooled prevalence of 11.2% (95% CI: 2.7%-36.9%) and an OR of 0.93 (95% CI: 0.41-2.14). The prevalence of stillbirth was 3.3% (95% CI: 1.6%-6.8%), with significant associations found in some studies (RR: 2.67; 95% CI: 1.09-6.57). Postpartum haemorrhage had an OR of 1.97 (95% CI: 0.53-2.69). While maternal dengue infection was associated with a higher prevalence of preterm birth and LBW, the associations were not statistically significant. Significant associations were observed for stillbirth in specific studies. Further research with standardized methodologies is needed to clarify these relationships and identify potential mechanisms.

Thromboelastography as an early prediction method for hypofibrinogenemia in emergency department patients with primary postpartum hemorrhage.

BACKGROUND: Timely and accurate assessment of coagulopathy is crucial for the management of primary postpartum hemorrhage (PPH). Thromboelastography (TEG) provides a comprehensive assessment of coagulation status and is useful for guiding the treatment of hemorrhagic events in various diseases. This study aimed to evaluate the role of TEG in predicting hypofibrinogenemia in emergency department (ED) patients with primary PPH. METHODS: We conducted a retrospective observational study in the ED of a university-affiliated tertiary hospital between November 2015 and August 2023. TEG was performed upon admission. The cutoff value for hypofibrinogenemia was 200 mg/dL. The primary outcome was the presence of hypofibrinogenemia. RESULTS: Among the 174 patients, 73 (42.0%) had hypofibrinogenemia. The need for massive transfusion was higher in the hypofibrinogenemia group (37.0% vs. 5.0%, p < 0.001). Among the TEG parameters, all values were significantly different between the groups, except for lysis after 30 min, suggesting a tendency toward hypocoagulability. Multivariable analysis revealed that the alpha angle (odds ratio (OR) 0.924, 95% confidence interval (CI) 0.876-0.978) and maximum amplitude (MA) (OR 0.867, 95% CI 0.801-0.938) were independently associated with hypofibrinogenemia. The optimal cutoff values for the alpha angle and maximum amplitude (MA) for hypofibrinogenemia were 63.8 degrees and 56.1 mm, respectively. CONCLUSION: Point-of-care TEG could be a valuable tool for the early identification of hypofibrinogenemia in ED patients with primary PPH.

Emergency and prophylactic uterine artery embolization in gynecology and obstetrics - a retrospective analysis.

BACKGROUND: This study aimed to evaluate the safety and efficacy of emergency and prophylactic uterine artery embolization (UAE) in our clinical practice, including technical success, clinical success, and associated complications. PATIENTS AND METHODS: In this retrospective study, we analyzed 64 women who underwent emergency (n =18) and prophylactic (n = 46) UAE. Indications for emergency UAE included postpartum hemorrhage or severe hemorrhage during pregnancy termination, while prophylactic UAE was performed prior to surgical removal of retained products of conception (RPOC), delivery with abnormal placental implantation, or pregnancy termination (cervical pregnancy or fetal anomalies accompanied by abnormal placental implantation). Technical success of UAE was defined as complete exclusion of the vascular lesion and contrast stasis on the final angiogram, while clinical success was defined as cessation of bleeding after UAE Termination without a hysterectomy. RESULTS: The overall clinical success of UAE in our study was 97% (62/64). All embolization procedures were technically and clinically successful in the prophylactic group without life-threatening hemorrhages or hysterectomies (100% success rate, 46/46). However, while 100% technical success was similarly attained in the emergency group, bleeding was successfully controlled in 89% of cases (16/18). In two patients with significant blood loss (over 2000 mL), embolization failed to achieve hemostasis, resulting in persistent bleeding and subsequent hysterectomy. CONCLUSIONS: UAE is a safe and effective procedure for managing primary postpartum hemorrhage or severe hemorrhage during pregnancy termination and for decreasing the risk of severe hemorrhage during surgical removal of RPOC, delivery with abnormal placental implantation, or pregnancy.

Temporary clamping of the uterine arteries versus coventional technique for the prevention of postpartum hemorrage during cesarean section: a randomized controlled trial study.

BACKGROUND: Cesarean sections are the most common abdominal surgical interventions worldwide, with increasing rates in both developed and developing countries. Postpartum (hemorrhage PPH) during cesarean sections can lead to maternal morbidity, prolonged hospital stays, and increased mortality rates. Although various non-surgical measures have been recommended for PPH prevention, surgical techniques such as uterine artery ligation and embolization have been used to manage PPH effectively. OBJECTIVE: This study aimed to evaluate the effectiveness of a surgical technique based on the temporary bilateral clamping of uterine arteries to reduce blood loss during cesarean sections. METHODS: A longitudinal prospective, randomized, controlled study was conducted with a preliminary population group of 180 patients at the University Hospital Regional de Málaga from November 2023 to January 2024. The study protocol was approved by the Ethics Committee of the Regional University Hospital of Malaga (protocol 1729-N-23 and registred with ISRCTN15307819|| http://www.isrctn.org/ , Date submitted 12 June 2023 ISRCTN 15307819). The patients were divided into two groups based on whether the clamping technique was applied during their cesarean sections. The study assessed hemoglobin levels before and after surgery, hospitalization durations, and the prevalence of anemia at discharge as the primary outcomes. RESULTS: The patients who underwent the clamping technique demonstrated significant reductions in hemoglobin differences (0.80 g/dL) compared to the control group (1.42 g/dL). The technique also resulted in shorter hospital stays (3.02 days vs. 3.90 days) and a lower prevalence of anemia at discharge (76.2% vs. 60%). CONCLUSION: Temporary clamping of uterine arteries during cesarean sections appears to be an effective measure for preventing postpartum hemorrhaging, reducing hospital stays, and decreasing the prevalence of anemia at discharge. Further research with larger sample sizes and standardized indications is warranted to confirm the benefits and potential broader applications of this technique. TRIAL REGISTRATION: ISRCTN 15,307,819.

New zeolite-based composite pads with high-volume blood absorption for early warning of postpartum hemorrhage.

Medical treatment of severe blood loss during labor is crucial, and the early warning indicator of postpartum hemorrhage (PPH) is essential for labor medical treatment. Measurement of blood loss conventionally looks dirty, reluctant, and less hygienic since some of the blood might be spilled out in the maternity bed, while commercially existing pads have low blood absorption capacity. A new design composite pad composed of absorbent materials, including cellulose rayon, super absorbent polymer (SAP), and zeolite was fabricated and characterized. The SAP and zeolite show properties as crystalline and amorphous materials, respectively. The surface area of natural zeolite was 19.79 (m2/g). The newly fabricated composite pad showed a high blood absorption capacity (>500-600 mL) with a blood absorption rate of 55.56-85.84 mL/min (depending on the blood volume), showing better performance as compared to the commercial pads. These characteristics suggest that the new composite pad could function not only as a sanitary pad but also as an early warning indicator for PPH if the rate and blood volume reach the dangerous category (≥600 mL or at ≥13 mL/min rate).

Cell salvage techniques and obstetric haemorrhage.

Over the last decade, the incidence of postpartum haemorrhage has risen because of increasing maternal age at time of delivery, multiple births, obesity and increased obstetric interventions, resulting in most of these women requiring blood transfusions. While lifesaving, blood transfusion is not without risk. Recipients may rarely develop transfusion-transmitted infections or suffer immunological sequelae. Intraoperative cell salvage is recommended by several national policy making organisations as a safe cost-effective alternative to autologous blood transfusion in both emergency and elective settings. Moreover, emerging data has also revealed that autotransfusion of vaginally shed blood is both feasible and safe. These techniques are useful in patients who decline blood transfusions for both personal and religious reasons and should therefore be taken into consideration when planning place of birth.

Trends, causes and factors associated with primary Postpartum Haemorrhage (PPH) in Ireland: A review of one million hospital childbirths.

OBJECTIVE: To analyse temporal trends for primary Postpartum Haemorrhage (PPH), Major Obstetric Haemorrhage (MOH) between 2005 and 2021 and to examine the causes and factors contributing to the risk of PPH during 2017-2021. METHODS: International ICD-10-AM diagnostic codes from hospital discharge records were used to identify cases of PPH. Temporal trends in PPH and MOH incidence were illustrated graphically. Poisson regression was used to assess the time trends and to examine factors associated with the risk of PPH during 2017-2021. RESULTS: A total of 1,003,799 childbirth hospitalisations were recorded; 5.6% included a diagnosis of primary PPH. Risk increased almost fourfold from 2.5% in 2005 to 9.6% in 2021. The ICD-10 AM code for other immediate primary PPH was recorded for 85% of PPH cases in 2017-2021 whereas a diagnosis of uterine inertia/atony was associated with just 3.6% of the cases. Respectively, trauma-related, tissue-related and thrombin-related causes were associated with one third, 4.2% and 0.5% of cases. A wide range of factors relating to the woman including comorbidities, mode of delivery, labour-related interventions and associated traumas increased risk of PPH but placental complications, especially morbidly adherent placenta, were strong risk factors. CONCLUSIONS: Improvement in detection and anticipation of placental complications may be effective in addressing the increasing trend of PPH, however, the trends of increasing C-sections and other interventions may also need to be addressed while staff education and quality improvement projects will have a role to play.

Fetal major anomalies and related maternal, obstetrical, and neonatal outcomes.

PURPOSE: To examine maternal, obstetrical, and neonatal outcomes of pregnancies complicated by major fetal anomalies. METHODS: A 10 year retrospective cohort study at a tertiary university hospital compared maternal and obstetrical outcomes between women with singleton pregnancies complicated by major fetal anomalies, and a control group with non-anomalous fetuses. RESULTS: For the study compared to the control group, the median gestational age at delivery was lower: 37.0 vs. 39.4 weeks (p < 0.001); and the preterm delivery rates were higher, both at < 37 weeks (46.2 vs. 6.2%, p < 0.001) and < 32 weeks (15.4 vs. 1.2%, p < 0.001). For the study compared to the control group, the placental abruption rate was higher (6.8 vs. 0.9%, p = 0.002); 87.5 vs. 100% occurred before labor. For the respective groups, the mean gestational ages at abruption were 32.8 ± 1.3 and 39.9 ± 1.7 weeks (p = 0.024); and cesarean section and postpartum hemorrhage rates were: 53.8 vs. 28.3% (p < 0.001) and 11.3 vs. 2.8% (p = 0.001), respectively. For the respective groups, hypertensive disorders of pregnancy rates were 9.5 vs. 2.1% (p = 0.004), stillbirth rates were 17.1 vs. 0.3% (p < 0.001), and neonatal death rates 12.5 vs. 0.0% (p < 0.001). Major fetal anomalies were found to be associated with adverse maternal outcomes (OR = 2.47, 95% CI 1.50-4.09, p < 0.001). Polyhydramnios was identified as an independent risk factor in a multivariate analysis that adjusted for fetal anomalies, conception by IVF, and primiparity for adverse maternal outcomes (OR = 4.7, 95% CI 1.7-13.6, p < 0.001). CONCLUSIONS: Pregnancies with major fetal anomalies should be treated as high-risk due to the increased likelihood of adverse maternal and neonatal outcomes.

Tranexamic acid in preventing postpartum blood loss in vaginal delivery: a double-blinded randomized controlled trial.

BACKGROUND: Postpartum hemorrhage (PPH) is an obstetrical emergency that occurs in 1% to 10% of all deliveries and contributes to nearly one-quarter of all maternal deaths worldwide. Tranexamic acid has been established as an adjunct in the treatment of PPH but its role in its prevention of PPH following vaginal delivery has not been widely studied. OBJECTIVE: This study aimed to assess the effect of prophylactic tranexamic acid (1 g) along with active management of the third stage of labor in reducing postpartum blood loss and the incidence of postpartum hemorrhage after vaginal delivery. STUDY DESIGN: In this randomized controlled trial, 650 women with singleton pregnancies at ≥34 weeks of gestation who were undergoing vaginal delivery were included. Eligible women were randomly assigned to receive either 1 g of tranexamic acid or placebo intravenously along with active management of the third stage of labor. Calibrated blood collection bags were used to measure postpartum blood loss during the third and fourth stages of labor. RESULTS: Of 886 women approached for the study, 650 who met the inclusion criteria were enrolled, and 320 in group A and 321 in group B were analyzed. The maternal characteristics were similar between the groups. The mean blood loss did not differ significantly between the intervention and placebo groups (378.5±261.2 mL vs 383.0±258.9 mL; P=.93). The incidence of primary postpartum hemorrhage was comparable in both groups (15.9% in group A and 15.3% in group B; P=.814). The median quantitative decreases in hemoglobin levels within 12 to 24 hours after delivery were 0.60 g% (interquartile range, 0.40-0.90) in group A and 0.60 g% (interquartile range, 0.40-0.80) in group B, which were comparable in both groups (P=.95). The most common adverse effect reported was dizziness, and there was no thromboembolic event at 3 months follow-up in either group. CONCLUSION: The use of tranexamic acid as a prophylactic measure along with active management of the third stage of labor does not provide additional benefit in reducing the postpartum blood loss and incidence of postpartum hemorrhage after vaginal delivery. El resumen está disponible en Español al final del artículo.

Nonpneumatic anti-shock garment utilization for obstetric hemorrhage management and its predictors among obstetric care providers in Ethiopia: a systematic review and meta-analysis.

INTRODUCTION: Non-pneumatic Anti-Shock Garment (NASG) is a lightweight, reusable first aid compression device that squeezes blood from the lower extremities and centralizes blood circulation to vital organs of the body. Postpartum hemorrhage followed by severe preeclampsia/eclampsia is the leading primary cause of maternal death (A reduction in extreme maternal adverse outcomes and faster recovery from shock are more likely to occur with earlier NASG intervention. The median blood loss reduced by half when the NASG was used for obstetric hemorrhage management, which was associated with significantly reduced maternal mortality among the most severe cases. OBJECTIVE: To estimate the pooled prevalence of NASG utilization and its predictors in Ethiopia. METHODS: Appropriate and comprehensive searches of PubMed, MEDLINE, EMBASE, Google Scholar, HINARI, and Scopus were performed. The electronic literature search was last performed on November 18/2023. All observational study designs were eligible for this SRMA. All cross sectional studies reporting the prevalence/proportion of NASG utilization for obstetric hemorrhage management among obstetric care providers and associated factors were included in this SRMA. Primary studies lacking the outcome of interest were excluded from the SRMA. The extracted Microsoft Excel spreadsheet data were imported into STATA software version 17 (STATA Corporation, Texas, USA) for analysis. A random-effects model was used to estimate the pooled prevalence of NASG utilization among obstetric care providers in Ethiopia. The Cochrane Q-test and I2 statistics were computed to assess the heterogeneity among the studies included in the SRMA. RESULT: A total of 1623 articles were found by using our search strategies and seven studies comprising 2335 participants were ultimately included in the SRMA. The pooled prevalence of NASG utilization for obstetric hemorrhage in Ethiopia was 43.34% (95% CI: 35.25, 51.42%). The findings of this subgroup analysis by sample size showed that the pooled prevalence of NASG utilization for obstetric hemorrhage was greater in studies with sample sizes of less than the mean sample size (48.6%; 95% CI: 32.34, 64.86%). Receiving training (AOR = 3.88, 95% CI: 2.08-5.37), having good knowledge (AOR = 1.99, 95% CI: 1.28-3.16), positive attitude (AOR = 2.16, 95% CI: 1.62-2.75) and having available NASGs in the facility (AOR = 4.89, 95%CI: 2.88-8.32) were significantly associated with the use of NASGs for obstetric hemorrhage management. CONCLUSION: The level of NASG utilization for obstetric hemorrhage in Ethiopia is low. Receiving training, good knowledge, positive attitudes and availability of NASG were significantly associated with the utilization of NASG. Therefore, policy makers and other stakeholders should emphasize enhancing the knowledge and attitudes of obstetric care providers through continuous support and training. At the same time, they should work strictly in providing devices for all the health facilities.

Outcomes and prognosis of postpartum hemorrhage according to management protocol: an 11-year retrospective study from two referral centers.

BACKGROUND: No standard treatment guidelines have been established for postpartum hemorrhage (PPH). We aimed to assess the differences in outcomes and prognoses between patients with PPH who underwent surgical and non-surgical treatment. METHODS: This retrospective study included 230 patients diagnosed with PPH at two referral hospitals between August 2013 and October 2023. The patients were divided into non-surgical (group 1, n = 159) and surgical intervention groups (group 2, n = 71). A subgroup analysis was performed by dividing the surgical intervention group into immediate (n = 45) and delayed surgical intervention groups (n = 26). RESULTS: Initial lactic acid levels and shock index were significantly higher in group 2 (2.85 ± 1.37 vs. 4.54 ± 3.63 mmol/L, p = 0.001, and 0.83 ± 0.26 vs. 1.10 ± 0.51, p < 0.001, respectively). Conversely, initial heart rate and body temperature were significantly lower in group 2 (92.5 ± 21.0 vs. 109.0 ± 28.1 beat/min, p < 0.001, and 37.3 ± 0.8 °C vs. 37.0 ± 0.9 °C, p = 0.011, respectively). Logistic regression analysis identified low initial body temperature, high lactic acid level, and shock index as independent predictors of surgical intervention (p = 0.029, p = 0.027, and p = 0.049, respectively). Regarding the causes of PPH, tone was significantly more prevalent in group 1 (57.2% vs. 35.2%, p = 0.002), whereas trauma was significantly more prevalent in group 2 (24.5% vs. 39.4%, p = 0.030). Group 2 had worse overall outcomes and prognoses than group 1. The subgroup analysis showed significantly higher rates of uterine atony combined with other causes, hysterectomy, and disseminated intravascular coagulopathy in the delayed surgical intervention group than the immediate surgical intervention group (42.2% vs. 69.2%, p = 0.027; 51.1% vs. 73.1%, p = 0.049; and 17.8% vs. 46.2%, p = 0.018, respectively). CONCLUSIONS: Patients with PPH presenting with increased lactic acid levels and shock index and decreased body temperature may be surgical candidates. Additionally, immediate surgical intervention in patients with uterine atony combined with other causes of PPH could improve prognosis and reduce postoperative complications.

Early identification and conservative treatment of postpartum hemorrhage in the lower uterine segment after vaginal delivery.

OBJECTIVE: This study examined the efficacy of pulling down the cervix and packing it in the vaginal fornix (PC-PVF) on postpartum hemorrhage in the lower uterine segment (PPH-LUS). METHODS: All cases of PPH-LUS after vaginal delivery at two tertiary hospitals between January 2019 and December 2022 were retrospectively investigated. Patients treated successfully with conservative measures were divided into routine treatment only (40 patients), routine treatment + early PC-PVF (33 patients), and routine treatment + late PC-PVF (51 patients) groups. Routine treatment consisted of uterine massage, uterotonics, and tranexamic acid administration. The therapeutic effect was evaluated by comparing the volume and rate of bleeding within 24 h after delivery. RESULTS: A total of 124 patients were treated conservatively, except for three patients who underwent laparotomy for hemostasis after PC-PVF failed for incomplete rupture of the lower uterine segment. The efficacy of treatment was 44% (40/91) for routine treatment only and 100% when combined with PC-PVF for PPH-LUS. There was no significant difference in maternal age, gestational week, neonatal weight, and Apgar score. But the total blood loss in the conventional treatment + early PC-PVF group (657.27 ml ± 131.61 ml) was significantly lower than that in the other two groups, which was 847.13 ml ± 250.37 ml(p < .01) and 1040.78 ml ± 242.70 ml (p < .01), respectively. The bleeding rate in the routine treatment + early PC-PVF group decreased significantly after tamponade. CONCLUSIONS: PC-PVF is a safe and effective treatment for PPH-LUS. Early identification of PPH-LUS and prompt application of PC-PVF can effectively reduce blood loss after vaginal delivery.

Postpartum hemorrhage is a serious threat to maternal safety and remains to be the leading cause of maternal death. At present, there is a lack of early identification and targeted conservative treatment of PPH-LUS after vaginal delivery. Innovations for the treatment of PPH-LUS are still greatly needed because, with currently available management strategies, there is still inconsistency in outcomes, increased risk of complications, and limited access in primary hospitals. Based on clinical data statistics and comparison, it is proved that PC-PVF is a simple, rapid, and noninvasive method for the treatment of PPH-LUS after vaginal delivery in this study. Because of its simple technical requirements, easily accessible materials, and low cost, PC-PVF is suitable for hospitals at all levels.

Effects of tranexamic acid preconditioning on the incidence of postpartum haemorrhage in vaginal deliveries with identified risk factors in China: a prospective, randomized, open-label, blinded endpoint trial.

OBJECTIVE: This study aimed to evaluate the effects of tranexamic acid (TXA) in preventing postpartum haemorrhage (PPH) among women with identified risk factors for PPH undergoing vaginal delivery in China. METHODS: This prospective, randomized, open-label, blinded endpoint (PROBE) trial enrolled 2258 women with one or more risk factors for PPH who underwent vaginal delivery. Participants were randomly assigned in a 1:1 ratio to receive an intravascular infusion of 1 g TXA or a placebo immediately after the delivery of the infant. The primary outcome assessed was the incidence of PPH, defined as blood loss ≥500 mL within 24 h after delivery, while severe PPH was considered as a secondary outcome and defined by total blood loss ≥1000 mL within 24 h. RESULTS: 2245 individuals (99.4%) could be followed up to their primary outcome. PPH occurred in 186 of 1128 women in the TXA group and in 215 of 1117 women in the placebo group (16.5% vs. 19.2%; RR, 0.86; 95% CI, 0.72 to 1.02; p = 0.088). Regarding secondary outcomes related to efficacy, women in the TXA group had a significant lower rate of severe PPH than those in the placebo group (2.7% vs. 5.6%; RR, 0.49; 95% CI, 0.32 to 0.74; p = 0.001; adjusted p = 0.002). Similarly, there was a significant reduction in the use of additional uterotonic agents (7.8% vs. 15.6%; RR, 0.50; 95% CI, 0.39 to 0.63; p < 0.001; adjusted p = 0.001). No occurrence of thromboembolic events and maternal deaths were reported in both groups within 30 days after delivery. CONCLUSIONS: In total population with risk factors for PPH, the administration of TXA following vaginal delivery did not result in a statistically significant reduction in the incidence of PPH compared to placebo; however, it was associated with a significantly lower incidence of severe PPH.

Prophylactic administration of TXA did not yield a statistically significant reduction in the incidence of PPH among women with risk factors in vaginal deliveries.Prophylactic use of TXA may help to reduce the incidence of severe PPH.

Nomogram based on clinical characteristics and ultrasound indicators for predicting severe postpartum hemorrhage in patients with anterior placenta previa combined with previous cesarean section: a retrospective case-control study.

BACKGROUND: Placental accreta spectrum disorders (PAS) are a high-risk group for severe postpartum hemorrhage (SPPH), with the incidence of PAS increasing annually. Given that cesarean section and anterior placenta previa are the primary risk factors for PAS, therefore, our study aims to investigate the predictive value of clinical characteristics and ultrasound indicators for SPPH in patients with anterior placenta previa combined with previous cesarean section, providing a theoretical basis for early prediction of SPPH. METHODS: A total of 450 patients with anterior placenta previa combined with previous cesarean section were retrospectively analyzed at Shengjing Hospital affiliated with China Medical University between January 2018 and March 2022. Clinical data and ultrasound indicators were collected. Patients were categorized into SPPH (blood loss >2000mL, 182 cases) and non-SPPH (blood loss ≤ 2000mL, 268 cases) groups based on the blood loss within 24 h postpartum. The population was randomly divided into training and validation cohorts at a 7:3 ratio. LASSO and multifactorial logistic regression analyses were utilized to identify independent risk factors for SPPH. Accordingly, a nomogram prediction model was constructed, the predictive performance was assessed using receiver operating characteristic (ROC) curves, calibration curves and decision curve analysis (DCA). RESULTS: Among the 450 patients, 182 experienced SPPH (incidence rate, 40.44%). Preoperative systemic immune-inflammatory index, preoperative D-dimer level, preoperative placenta accreta spectrum ultrasound scoring system (PASUSS) score, and one-step-conservative surgery were identified as independent risk factors for SPPH in patients with anterior placenta previa combined with previous cesarean section. A nomogram was constructed based on these factors. The areas under the ROC curves for the training and validation cohorts were 0.844 (95%CI: 0.801-0.888) and 0.863 (95%CI: 0.803-0.923), respectively. Calibration curves and DCA indicated that this nomogram demonstrated good predictive accuracy. CONCLUSIONS: This nomogram presents an effective and convenient prediction model for identifying SPPH in patients with anterior placenta previa combined with previous cesarean section. It can guide surgical planning and improve prognosis.