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Current Opinion in Anaesthesiology Jun 2024The worldwide leading cause of maternal death is severe maternal hemorrhage. Maternal hemorrhage can be profound leading to an entire loss of blood volume. In the past... (Review)
Review
PURPOSE OF REVIEW
The worldwide leading cause of maternal death is severe maternal hemorrhage. Maternal hemorrhage can be profound leading to an entire loss of blood volume. In the past two decades, Patient Blood Management has evolved to improve patient's care and safety. In surgeries with increased blood loss exceeding 500 ml, the use of cell salvage is strongly recommended in order to preserve the patient's own blood volume and to minimize the need for allogeneic red blood cell (RBC) transfusion. In this review, recent evidence and controversies of the use of cell salvage in obstetrics are discussed.
RECENT FINDINGS
Numerous medical societies as well as national and international guidelines recommend the use of cell salvage during maternal hemorrhage.
SUMMARY
Intraoperative cell salvage is a strategy to maintain the patient's own blood volume and decrease the need for allogeneic RBC transfusion. Historically, cell salvage has been avoided in the obstetric population due to concerns of iatrogenic amniotic fluid embolism (AFE) or induction of maternal alloimmunization. However, no definite case of AFE has been reported so far. Cell salvage is strongly recommended and cost-effective in patients with predictably high rates of blood loss and RBC transfusion, such as women with placenta accreta spectrum disorder. However, in order to ensure sufficient practical experience in a multiprofessional obstetric setting, liberal use of cell salvage appears advisable.
Topics: Humans; Pregnancy; Female; Operative Blood Salvage; Postpartum Hemorrhage; Erythrocyte Transfusion; Blood Transfusion, Autologous; Blood Loss, Surgical; Embolism, Amniotic Fluid; Obstetrics
PubMed: 38391030
DOI: 10.1097/ACO.0000000000001337 -
Gynecologie, Obstetrique, Fertilite &... Apr 2024Between 2016 and 2018, 20 maternal deaths were related to obstetric haemorrhage, excluding haemorrhage in the first trimester of pregnancy, representing a mortality...
Between 2016 and 2018, 20 maternal deaths were related to obstetric haemorrhage, excluding haemorrhage in the first trimester of pregnancy, representing a mortality ratio of 0.87 per 100,000 live births (95% CI 0.5 -1.3). Obstetric haemorrhage is the cause of 7.4% of all maternal deaths up to 1 year, 10% of maternal deaths within 42days, and 21% of deaths directly related to pregnancy (direct causes). Between 2001 and 2018, maternal mortality from obstetric haemorrhage has been considerably reduced, from 2.2deaths per 100,000 live births in 2001-2003 to 0.87 in the period presented here. Nevertheless, obstetric haemorrhage is still one of the main direct causes of maternal death, and remains the cause with the highest proportion of deaths considered probably (53%) or possibly (42%) preventable according to the CNEMM's collegial assessment (see chapter 3). The preventable factors reported are related to inadequate content of care in 94% of cases and/or organisation of care in 44% of cases. In this triennium, maternal death due to haemorrhage occurred mainly in the context of caesarean delivery (65% of cases, i.e. 13/20), and mostly in the context of emergency care (12/13). The main causes of obstetric haemorrhage were uterine rupture (6/20) in unscarred uterus or in association with placenta accreta, and surgical injury during the caesarean delivery (5/20). Every maternity hospital, whatever its resources and/or technical facilities, must be able to plan any obstetric haemorrhage situation that threatens the mother's vital prognosis. Intraperitoneal occult haemorrhage following caesarean section and uterine rupture require immediate surgery with the help of skilled surgeon resources with early and appropriate administration of blood products.
Topics: Pregnancy; Female; Humans; Maternal Mortality; Maternal Death; Cesarean Section; Postpartum Hemorrhage; Uterine Rupture
PubMed: 38373487
DOI: 10.1016/j.gofs.2024.02.016 -
Japanese Journal of Radiology Jun 2024This study aimed to clarify associations between subacute hematoma on placental magnetic resonance imaging (MRI), antenatal bleeding, and preterm deliveries in patients...
PURPOSE
This study aimed to clarify associations between subacute hematoma on placental magnetic resonance imaging (MRI), antenatal bleeding, and preterm deliveries in patients with placenta previa (PP) without placenta accreta spectrum (PAS).
MATERIALS AND METHODS
This retrospective study investigated 78 consecutive patients with PP (median age, 34.5 years; interquartile range [IQR], 31-37 years) who underwent placental MRI in the third trimester. Patients with PAS detected intraoperatively or pathologically were excluded. Two radiologists evaluated the presence of subacute hematomas and their locations on placental MRI. We examined associations between presence of subacute hematoma and antenatal bleeding, emergency cesarean section (CS), hysterectomy, gestational age (GA) at delivery, birth weight, and amount of blood loss at CS. We also examined the association between perinatal outcome and subacute hematoma location: marginal, retro-placental, or intra-placental. Inter-observer agreement for the detection of subacute hematoma was calculated using kappa analysis.
RESULTS
Subacute hematomas were identified on MRI in 39 of the 78 patients (50.0%). Antenatal bleeding and emergency CS were more prevalent in patients with subacute hematoma on MRI (20 patients [51.3%] and 18 patients [46.2%], respectively) than in patients without (7 patients [17.9%], Fisher's exact test, p = 0.004 and 7 patients [17.9%], p = 0.014, respectively). GA at delivery was significantly lower in patients with subacute hematoma (median 36w3d, IQR 35w4d-37w1d) than in patients without (median 37w1d, IQR 36w4d-37w2d; Mann-Whitney test: p = 0.048). Marginal hematoma was significantly associated with antenatal bleeding and emergency CS. Inter-observer agreement for the presence of subacute hematoma was moderate (κ = 0.573).
CONCLUSION
Subacute hematoma on placental MRI was associated with antenatal bleeding, emergency CS and shorter GA at delivery in patients with PP. Marginal hematoma was also associated with antenatal bleeding and emergency CS. Placental MRI appears useful for predicting antenatal bleeding and preterm delivery in patients with PP.
Topics: Humans; Female; Pregnancy; Placenta Previa; Magnetic Resonance Imaging; Adult; Retrospective Studies; Premature Birth; Hematoma; Placenta; Predictive Value of Tests; Uterine Hemorrhage
PubMed: 38369566
DOI: 10.1007/s11604-024-01541-3 -
Journal of Family Medicine and Primary... Dec 2023Antepartum hemorrhage (APH) is one of the deadliest complications in obstetrics. It can complicate about 2-5% of pregnancies. It contributes significantly to maternal...
INTRODUCTION AND AIM
Antepartum hemorrhage (APH) is one of the deadliest complications in obstetrics. It can complicate about 2-5% of pregnancies. It contributes significantly to maternal and perinatal mortality and morbidity during pregnancy and childbearing worldwide. The aim of this study was to determine maternal and fetal outcomes in patients presenting with APH.
MATERIALS AND METHODS
This was a retrospective study. Pregnant women with >28 weeks gestation reporting to the Department of Obstetrics and Gynecology from May 2021 to April 2022 were included in the study. Ethical approval from the institutional ethical committee was taken.
RESULT
This study included 76 patients of APH. Most patients in the analysis were found to be second gravida (30%). Anemia was the most common associated morbidity (51.31%). 58% of these patients were of placenta previa, 14% were of abruption, and 10% were of accreta. Among all patients, 94.74% recovered well. 2.63% of cases could not be saved and resulted in maternal mortality. The proportions of babies alive, intra-uterine death (IUD), and intubated were 86.84%, 11.84%, and 1.32%, respectively. 17.1% of patients required a lifesaving cesarean hysterectomy.
CONCLUSION
APH is an obstetrical emergency that requires timely diagnosis and early intervention. Swift management is required to improve maternal and fetal outcomes.
PubMed: 38361908
DOI: 10.4103/jfmpc.jfmpc_692_23 -
Journal of Family Medicine and Primary... Dec 2023Recent researches have indicated that pregnancies with frozen embryo transfer are associated with the increment of risk of maternal and neonatal complications,...
INTRODUCTION
Recent researches have indicated that pregnancies with frozen embryo transfer are associated with the increment of risk of maternal and neonatal complications, especially hypertension during pregnancy. The present study aimed to compare the occurrence rate of gestational hypertension in pregnancy with frozen embryo transfer and normal pregnancy.
MATERIALS AND METHODS
This research, as a retrospective cross-sectional study, was performed on pregnant women with frozen embryo transfer ( = 97) and women with normal pregnancies ( = 164) referring to medical centers under the supervision of Ahvaz University of Medical Sciences in 2021. Women aged 18-35 were included in the study after week 20 of pregnancy. Maternal and neonatal outcomes including hypertensive disorders of pregnancy (including gestational hypertension and preeclampsia), preterm birth (before the week 37), low birth weight (lower than 2500 g), neonatal asphyxia (Apgar score >7 in minute 5), intrauterine growth restriction (IUGR) and bleeding in the first trimester of pregnancy were evaluated. The association between frozen embryo transfer and pregnancy outcomes was evaluated using multiple logistic regressions.
RESULTS
The findings of this study indicated that pregnancy hypertension was observed in 23 people (23.7%) from the frozen embryo transfer group vs. 18 people (11.0%) from the normal pregnancy group ( = 0.006). Frozen embryo transfer pregnancy has a higher risk of gestational hypertension (OR = 2.521, 95% CI: 1.281-4.962; = 0.007), preterm birth (OR = 2.264, 95% CI: 1.335-3.840; = 0.002), and low birth weight (OR = 2.017, 95% CI: 1.178-3.455; = 0.011). However, the incidence of birth asphyxia ( = 0.850), intrauterine growth restriction ( = 0.068), first-trimester bleeding ( = 0.809), and placenta accreta ( = 0.143) did not show a significant difference between two types of normal pregnancy and frozen embryo transfer pregnancy.
CONCLUSION
Frozen embryo transfer pregnancy was associated with a higher risk of maternal and neonatal complications, hypertension, preterm birth, and low birth weight compared to natural and spontaneous pregnancies.
PubMed: 38361845
DOI: 10.4103/jfmpc.jfmpc_2429_22 -
Pakistan Journal of Medical Sciences 2024The study aimed to demonstrate the efficacy and safety of an innovative hemostatic technique in managing Placenta Previa and Accreta Spectrum by S. Rao Spiral Suturing...
OBJECTIVE
The study aimed to demonstrate the efficacy and safety of an innovative hemostatic technique in managing Placenta Previa and Accreta Spectrum by S. Rao Spiral Suturing (SRSS) of a lower uterine segment.
METHOD
In this retrospective study conducted at Department of Obstetrics & Gynecology Unit-II of Nishtar Medical University, Multan between December 2018 to January 2021, one hundred and thirty consenting patients' clinical records were reviewed with major degree placenta previa/placenta accrete spectrum, either operated electively or presented in an emergency, with or without a history of previous cesarean section. The enrolled patients underwent SRSS, procedure's efficacy and safety were measured by the number of obstetrical hysterectomies, the time required for the procedure, estimated blood loss, blood transfusion volume, need for any other hemostatic technique, bladder trauma, pelvic infection, scar site hematoma or abscess, sepsis, duration of hospital stay and maternal mortality.
RESULTS
Out of 130 patients, 17(12.6%) had Placenta Accreta, 86(66.3%) Increta, and 27(21%) Percreta. The Placenta location was anterior dominant in 102(78.4%) cases and posterior in 17(8.4%). Of the patients who underwent surgery, only two required obstetrical hysterectomy due to uncontrolled bleeding. The procedure took three to five minutes in 127 patients and five to seven minutes in three patients. Regarding intraoperative blood transfusion, 54.6% of patients were transfused 1000-2000 ml blood, and 5.38% required > 3000 ml. No blood transfusion was required postoperatively in any patient. Postpartum hemorrhage, infection, fever, and sepsis were not observed in any patient postoperatively. None of the patients suffered bladder injury. All patients were discharged as per routine.
CONCLUSION
SRSS is an innovative, safe, effective, and simple suturing technique for patients with Placenta Previa and Accreta spectrum.
PubMed: 38356810
DOI: 10.12669/pjms.40.3.7747 -
European Journal of Obstetrics &... Mar 2024To investigate the feasibility, safety, and efficiency after application of a cervical tourniquet during caesarian hysterectomy owing to placenta accreta.
OBJECTIVES
To investigate the feasibility, safety, and efficiency after application of a cervical tourniquet during caesarian hysterectomy owing to placenta accreta.
STUDY DESIGN
It was a monocentric prospective observational study for 3 years. Patients were allocated into two group: Group Tourniquet: (TG) in which a cervical tourniquet was systematically applied during hysterectomy, control group (CG) when the caesarian hysterectomy was performed without.
RESULTS
20 patients in the TG and 23 patients in the CG. Tourniquet application significantly reduced per operative estimated blood loss volume (TG: 530 ± 135 vs 940 ± 120 ml in the CG, p = 0.0074), ΔHB (0.6 [0.3-1.9] vs 2.5[2.5-3.6] g/dl in the CG, p = 0.006) RBC transfusion requirements' (TG: 2 ± 1.7 vs 4.3 ± 2.1 units in the CG, p = 0.046) procedure duration (TG: 98 ± 21 vs 137 ± 33 min in the CG, p = 0.015), clotting disorders (TG: 1 (5%) vs 6 (26,1%) in the CG, p = 0.013) and the incidence of bladder wounds (TG: 1 (5%) vs 5 (21,7%) in the CG, p = 0.048). There was no significant difference regarding ICU transfer rate (TG: 16 (80%) vs 20 (86.9%) in the CG, p = 0.53) or length of stay (TG: 1.4 [2,3] vs 2.3 [1-4] days in the CG, p = 0.615) and digestive wound (TG: 0 vs 2 (8,7%) in the CG, p = 0.641).
CONCLUSION
In case of a radical management of placenta accreta. A strategy that involves the application of a cervical Tourniquet should be considered as a feasible, safe and above all efficient alternative to prevent blood spoliation.
PubMed: 38351966
DOI: 10.1016/j.eurox.2024.100285 -
CVIR Endovascular Feb 2024Postpartum haemorrhage (PPH) is a significant cause of maternal mortality globally, necessitating prompt and efficient management. This review provides a comprehensive... (Review)
Review
Postpartum haemorrhage (PPH) is a significant cause of maternal mortality globally, necessitating prompt and efficient management. This review provides a comprehensive exploration of endovascular treatment dimensions for both primary and secondary PPH, with a focus on uterine atony, trauma, placenta accreta spectrum (PAS), and retained products of conception (RPOC). Primary PPH, occurring within 24 h, often results from uterine atony in 70% of causes, but also from trauma, or PAS. Uterine atony involves inadequate myometrial contraction, addressed through uterine massage, oxytocin, and, if needed, mechanical modalities like balloon tamponade. Trauma-related PPH may stem from perineal injuries or pseudoaneurysm rupture, while PAS involves abnormal placental adherence. PAS demands early detection due to associated life-threatening bleeding during delivery. Secondary PPH, occurring within 24 h to 6 weeks postpartum, frequently arises from RPOC. Medical management may include uterine contraction drugs and hemostatic agents, but invasive procedures like dilation and curettage (D&C) or hysteroscopic resection may be required.Imaging assessments, particularly through ultrasound (US), play a crucial role in the diagnosis and treatment planning of postpartum haemorrhage (PPH), except for uterine atony, where imaging techniques prove to be of limited utility in its management. Computed tomography play an important role in evaluation of trauma related PPH cases and MRI is essential in diagnosing and treatment planning of PAS and RPOC.Uterine artery embolization (UAE) has become a standard intervention for refractory PPH, offering a rapid, effective, and safe alternative to surgery with a success rate exceeding 85% (Rand T. et al. CVIR Endovasc 3:1-12, 2020). The technical approach involves non-selective uterine artery embolization with resorbable gelatine sponge (GS) in semi-liquid or torpedo presentation as the most extended embolic or calibrated microspheres. Selective embolization is warranted in cases with identifiable bleeding points or RPOC with AVM-like angiographic patterns and liquid embolics could be a good option in this scenario. UAE in PAS requires a tailored approach, considering the degree of placental invasion. A thorough understanding of female pelvis vascular anatomy and collateral pathways is essential for accurate and safe UAE.In conclusion, integrating interventional radiology techniques into clinical guidelines for primary and secondary PPH management and co-working during labour is crucial.
PubMed: 38349501
DOI: 10.1186/s42155-024-00429-7 -
Diagnostics (Basel, Switzerland) Feb 2024We previously reported that T2 dark bands and placental bulges observed in magnetic resonance imaging (MRI) can predict adverse maternal outcomes in patients with...
PURPOSE
We previously reported that T2 dark bands and placental bulges observed in magnetic resonance imaging (MRI) can predict adverse maternal outcomes in patients with placenta accreta spectrum (PAS) and placenta previa undergoing prophylactic balloon occlusion of the internal iliac artery. On the other hand, the risk factors associated with the use of prophylactic aortic balloon occlusion (PABO) have not been sufficiently investigated. This retrospective study aimed to identify MRI-based risk factors associated with adverse maternal outcomes in the context of PABO during a cesarean section (CS) for PAS and placenta previa.
MATERIALS AND METHODS
Ethical approval was obtained for a data analysis of 40 patients diagnosed with PAS and placenta previa undergoing PABO during a CS. Clinical records, MRI features, and procedural details were examined. The inclusion criteria for the massive bleeding group were as follows: an estimated blood loss (EBL) > 2500 mL, packed red blood cell (pRBC) transfusion (>4 units), and the need for a hysterectomy or transcatheter arterial embolization after delivery. The massive and nonmassive bleeding groups were compared.
RESULTS
Among the 22 patients, those in the massive bleeding group showed significantly longer operative durations, a higher EBL ( < 0.001), an increased number of pRBC transfusions ( < 0.001), and prolonged postoperative hospital stays ( < 0.05). T2 dark bands on MRI were significant predictors of adverse outcomes ( < 0.05).
CONCLUSION
T2 dark bands on MRI were crucial predictors of adverse maternal outcomes in patients undergoing PABO for PAS or placenta previa during a CS. Recognizing these MRI features proactively indicates the need for effective management strategies during childbirth and emphasizes the importance of further prospective studies to validate and enhance these findings.
PubMed: 38337849
DOI: 10.3390/diagnostics14030333 -
Journal of Clinical Medicine Jan 2024We investigated the association between placental location and pregnancy outcomes in placenta previa. This multi-center retrospective study enrolled 781 women who...
We investigated the association between placental location and pregnancy outcomes in placenta previa. This multi-center retrospective study enrolled 781 women who delivered between May 1999 and February 2020. We divided the dataset into anterior ( = 209) and posterior ( = 572) groups and compared the baseline characteristics and obstetric and neonatal outcomes. The adverse obstetric outcomes associated with placenta location were evaluated using a multivariate logistic analysis. Gestational age at delivery in the anterior group (253.0 ± 21.6) was significantly lower than that in the posterior group (257.6 ± 19.1) ( = 0.008). The anterior group showed significantly higher parity, rates of previous cesarean section, non-vertex fetal positions, admissions for bleeding, emergency cesarean sections, transfusions, estimated blood loss, and combined placenta accrete spectrum ( < 0.05). In the multivariate analysis, the anterior group had higher rates of transfusion (OR 2.23; 95% CI 1.50-3.30), placenta accreta spectrum (OR 2.16; 95% CI 1.21-3.97), and non-vertex fetal positions (OR 2.47; 95% CI 1.09-5.88). These findings suggest that more caution is required in the treatment of patients with anterior placenta previa. Therefore, if placenta previa is diagnosed prenatally, it is important to determine the location of the body and prepare for massive bleeding in the anterior group.
PubMed: 38337369
DOI: 10.3390/jcm13030675