antepartum hemorrhage [keywords]
- Population-Based Risk for Peripartum Hysterectomy during Low and Moderate Risk Delivery Hospitalizations. [JOURNAL ARTICLE]
- Am J Obstet Gynecol 2016 Jun 24.
Postpartum hysterectomy is an obstetric procedure that carries significant maternal risk that is not well characterized by hospital volume.The objective of this study was to determine risk for peripartum hysterectomy for women at low and moderate risk for the procedure.This population-based study used data from the Nationwide Inpatient Sample to characterize risk for peripartum hysterectomy. Women with a diagnosis of placenta accreta or prior cesarean and placenta previa were excluded. Obstetrical risk factors along with demographic and hospital factors were evaluated. Multivariable mixed-effects log-linear regression models were developed to determine adjusted risk. Based on these models receiver operating characteristic curves were plotted, and the area under the curve was determined to assess discrimination.Cesarean hysterectomy occurred in 1 in 1913 deliveries. Risk factors associated with significant risk for hysterectomy included mode of delivery, stillbirth, placental abruption, fibroids, and antepartum hemorrhage. These factors retained their significance in adjusted models: The risk ratio for stillbirth was 3.44 (95% confidence interval (CI) 2.94-4.02), abruption 2.98 (95% CI 2.52-3.20), fibroids 3.63 (95% CI 3.22-4.08), and antepartum hemorrhage 7.15 (95% CI 6.16-8.32). The area under the curve (AUC) for the model was 0.833.Cesarean hysterectomy is a relatively common event that hospitals providing routine obstetric care should be prepared to manage. That specific risk factors are highly associated with risk for hysterectomy supports routine use of hemorrhage risk-assessment tools. However, given that a significant proportion of hysterectomies will be unpredictable, the availability of rapid transfusion protocols may be necessary for hospitals to safely manage these cases.
- ASSOCIATION BETWEEN PLACENTAL ABRUPTION AND CAESAREAN SECTION AMONG PATIENTS AT KHYBER TEACHING HOSPITAL PESHAWAR. [Journal Article]
- J Ayub Med Coll Abbottabad 2016 Jan-Mar; 28(1):172-4.
Ante partum haemorrhage remains to be a major cause of morbidity and mortality.30% of this haemorrhage is attributed to placental abruption. Along with other adverse maternal outcomes, it increases the risk of Caesarean sections in patients, which is a public health concern. This study was conducted to find out whether any significant association exists between placental abruption and C-section in our set up.A cross-sectional study was conducted from July 26th, 2011 to May 1st, 2013 (i.e., 21 months) in the Department of Obstetrics and Gynaecology, Khyber Teaching Hospital Peshawar on a sample of 334 patients who presented with antepartum haemorrhage after 28 weeks of gestation. All those patients with and without placental abruption were followed throughout pregnancy and labour to detect the risk of caesarean section.Among study participants, parity had the highest dispersion while gestational age had the lowest. Caesarean section was performed on 26.3% (95% CI) of the study participants. Proportion of placental abruption among patients presenting with ante partum haemorrhage was 20.6%, (95% CI) out of which 7.5% underwent C-section. Association between placental abruption and C-section was found significant at α = 0.05 (p = 0.03).Risk of caesarean section is increased in pregnancies complicated by placental abruption as compared to pregnancies complicated by other causes of ante partum haemorrhage.
- Complications of external cephalic version: a retrospective analysis of 1121 patients at a tertiary hospital in Sydney. [JOURNAL ARTICLE]
- BJOG 2016 Jun 16.
To report the complication rate associated with external cephalic version (ECV) at term.Single-centre retrospective study.A major tertiary hospital in Sydney, Australia.All women who underwent an ECV at Royal Prince Alfred Hospital from 1995-2013 were included.ECV was attempted on all consenting women with a breech presentation at term in the absence of contraindications. Complications were classified as minor (transient cardiotocography abnormalities, ruptured membranes, small antepartum haemorrhage) or serious (fetal death, placental abruption, fetal distress requiring emergency caesarean section, fetal bone injury, cord prolapse). ECV success rates and rate of reversion to breech were recorded.The primary outcome was the incidence of serious complications. Secondary outcome measures were the rate of minor complications and reversion to breech.Of 1121 patients that underwent ECV, five (0.45%) experienced a serious complication. There was one placental abruption, one emergency caesarean section for fetal distress and two cord prolapses. There was one fetal death attributable to a successful ECV. Forty-eight women (4.28%) experienced a minor complication. Reversion to the breech occurred in sixteen patients (3.32%).ECV at term is associated with a low rate of serious complications.Study of 1121 consecutive ECV attempts shows low rate of complications although one fetal death reported.
- Rigorous Simulation Training Protocol Does Not Improve Maternal and Neonatal Outcomes From Shoulder Dystocia . [Journal Article]
- Obstet Gynecol 2016 May.:3S.
Simulation models are widespread educational tools for training for rare clinical scenarios. This study compared maternal and neonatal outcomes before and after implementation of a shoulder dystocia simulation protocol.Vaginal deliveries at a single institution from September 2008 to December 2014 were reviewed. Mandatory shoulder dystocia simulation training was implemented for obstetric providers at the end of 2009. Incidence of shoulder dystocia and delivery outcome was compared pre and post simulation. Chi-squared and Fisher Exact tests along with multivariate logistic regression models were conducted to adjust for potential confounding.9401 vaginal deliveries were identified. 304 deliveries were associated with a shoulder dystocia (3.2%). The rate of any shoulder dystocia was approximately two times higher post-simulation (1.8% versus 3.7%; P<.0001). This remained significant after adjustment for maternal age, race, diabetes status, body mass index, Pitocin, delivery method, sex and birth weight (OR 2.19, 95% CI [1.45-3.12]; P=.0002). The rate of severe shoulder dystocia was higher post intervention as well (0.6% versus 1.4%; P=.005). There was no decrease from pre to post simulation in birth injury (7.5% versus 11.4%; P=.59), postpartum hemorrhage (10.0% versus 12.9%; P=.80), third or fourth degree lacerations (10.0% versus 6.8%; P=.51), or episiotomies (5.0% versus 5.3%; P=1.00).Simulation training was associated with increased identification of shoulder dystocia events without decrease in adverse maternal or neonatal outcomes. Antepartum and intrapartum risk categorization, counseling, and individualized delivery planning must be considered as provider training alone does not impact adverse maternal and neonatal outcomes.
- Omission of fetal sampling in treatment of subsequent pregnancies in fetal-neonatal alloimmune thrombocytopenia. [JOURNAL ARTICLE]
- Am J Obstet Gynecol 2016 Apr 27.
Fetal-neonatal alloimmune thrombocytopenia affects approximately 1 of 1000 live births, most of which are not severely thrombocytopenic. Despite effective treatment with intravenous gammaglobulin and/or prednisone, antenatal management of a subsequent affected pregnancy is complicated by the risks associated with fetal blood sampling. Furthermore, there are no biomarker(s) of high risk other than the occurrence of intracranial hemorrhage in a previous sibling. Management of these high-risk pregnancies requires intensive treatment initiated at 12 weeks of gestation.The objective of the study was to evaluate whether empiric escalation of therapy at 32 weeks allows the omission of fetal blood sampling in all fetal-neonatal alloimmune thrombocytopenia-affected patients. Specifically, we sought to determine whether intensive intravenous gammaglobulin-based regimens for the treatment of a subsequent fetal-neonatal alloimmune thrombocytopenia-affected pregnancy followed by empirically escalated intravenous gammaglobulin and prednisone treatment would increase the fetal platelet count and thus safely allow omission of fetal blood sampling in the antepartum management of these patients.In this prospective, multicenter, randomized controlled study, 99 women with fetal-neonatal alloimmune thrombocytopenia whose prior affected child did not have an intracranial hemorrhage were randomized to receive an intensive intravenous gammaglobulin-based regimen: 2 g/kg per week or intravenous gammaglobulin 1 g/kg per week plus prednisone 0.5 mg/kg per day, starting at 20-30 weeks of gestation. Escalated therapy (intravenous gammaglobulin 2 g/kg per week plus prednisone 0.5 mg/kg per day) was recommended and usually initiated at 32 weeks when fetal counts were <50,000/mL(3) or when fetal blood sampling was not performed. The preliminary report of this study from 2007 demonstrated the efficacy of both intravenous gammaglobulin-based regimens in most patients. Most patients who underwent fetal sampling had adequate fetal counts and therefore did not have their treatment escalated. This post hoc analysis describes the 29 fetuses who had their treatment escalated either because they had low counts at 32 weeks or when sampling was not performed. This study explored whether the empiric escalation of treatment at 32 weeks was sufficiently effective in increasing fetal platelet counts in these patients.Mean fetal and birth counts of fetuses randomized to each of the 2 initial treatment groups were all >100,000/mL(3). Three neonates had an intracranial hemorrhage; all 3 were grade 1 and all had birth platelet counts >130,000/mL(3). In a post hoc analysis, 19 fetuses undergoing fetal blood sampling at 32 weeks had fetal platelet counts <50,000/mL(3) despite their initial treatment. Of these 19, birth platelet counts were >50,000/mL(3) in 11 of 13 fetuses who received escalated treatment compared with only 1 of 6 of those who did not (P = .01); only 3 fetuses that received initial therapy followed by escalated treatment had birth platelet counts <50,000/mL(3) and none had an intracranial hemorrhage. The platelet counts of 14 of 15 fetuses that received empirically escalated treatment without sampling were >50,000/mL(3) at birth. In addition, none of these had an intracranial hemorrhage.The 2 recommended protocols of intensive initial treatment followed by empiric escalation of therapy at 32 weeks of gestation are reasonably safe, effective in increasing fetal platelet counts, and allow omission of fetal blood sampling by increasing the fetal platelet count in almost all cases.
- Midwife-led continuity models versus other models of care for childbearing women. [Journal Article, Research Support, Non-U.S. Gov't, Review]
- Cochrane Database Syst Rev 2016.:CD004667.
Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led continuity models and other models of care.To compare midwife-led continuity models of care with other models of care for childbearing women and their infants.We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (25 January 2016) and reference lists of retrieved studies.All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth.Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e. regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and all fetal loss before and after 24 weeks plus neonatal death using the GRADE methodology: all primary outcomes were graded as of high quality.For the primary outcomes, women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = eight; high quality) and less all fetal loss before and after 24 weeks plus neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife-led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.For the secondary outcomes, women who had midwife-led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = four), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss less than 24 weeks and neonatal death (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife-led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = seven), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = three) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = seven). There were no differences between groups for fetal loss equal to/after 24 weeks and neonatal death, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five-minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in midwife-led continuity models of care. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care.Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and all fetal loss/neonatal death associated with midwife-led continuity models of care.
- Do women with recurrent miscarriage constitute a high-risk obstetric population? [Journal Article]
- Hum Fertil (Camb) 2016 Apr; 19(1):9-15.
The aim of this study was to examine if women with history of recurrent miscarriage have a higher risk of maternal and foetal complications in future pregnancies. This was a retrospective case control study that analysed data collected prospectively between 2001 and 2007 from 400 women with history of recurrent miscarriage who achieved pregnancies progressing beyond 24 weeks gestation compared to 39,860 deliveries from the general obstetric database within the same time period. Results showed that women with recurrent miscarriage had significantly increased odds of low Apgar scores at one (odds ratios (OR) 1.57, 95% CI 1.20-2.05) and five minutes (OR 2.0, 95% CI 1.23-3.27), small for gestational age (OR 1.96, 95% CI 1.12-3.43), preterm delivery (OR 1.64, 95% CI 1.22-2.19) and antepartum haemorrhage (OR 7.67, 95% CI 4.23-13.91). The risks were increased in the presence of a male foetus but no difference was observed between primary and secondary miscarriage patients. In conclusion, women with recurrent miscarriage have an increased risk of several maternal and foetal complications and therefore may require closer monitoring during the antenatal period particularly when pregnant with a male foetus.
- Analytical study of intrauterine fetal death cases and associated maternal conditions. [Journal Article]
- Int J Appl Basic Med Res 2016 Jan-Mar; 6(1):11-3.
Intrauterine fetal death is an important indicator of maternal and perinatal health of a given population. This study was undertaken to study the maternal and fetal factors associated with intrauterine fetal death.This was a retrospective single center study. The details were entered in a preformed proforma. The details of complaints at admission, obstetrics history, menstrual history, examination findings, per vaginal examination findings, mode of delivery and fetal outcomes, placental examination, condition of cord and investigation reports were recorded.A total of 250 intrauterine fetal deaths were reported amongst 6942 deliveries conducted during the study period. The incidence rate of intrauterine fetal death was 36/1000 live births. Two hundred and twenty-two deliveries were unbooked and unsupervised. The other observations were rural population (58%), low socioeconomic group (71.2%), previous stillbirth (9.2%), gestational hypertension (32.8%), anemia (74.4%), antepartum hemorrhage (18.8%), and congenital malformations (CMFs) (8.8%).The incidence of intrauterine fetal deaths in our population is higher than that reported from developed countries. This is associated with anemia, pregnancy-induced hypertension, illiteracy, low socioeconomic status, and higher incidence of undiagnosed CMFs.
- Verbal/social autopsy study helps explain the lack of decrease in neonatal mortality in Niger, 2007-2010. [Journal Article, Research Support, Non-U.S. Gov't]
- J Glob Health 2016 Jun; 6(1):010604.
This study was one of a set of verbal/social autopsy (VASA) investigations undertaken by the WHO/UNICEF-supported Child Health Epidemiology Reference Group to estimate the causes and determinants of neonatal and child deaths in high priority countries. The study objective was to help explain the lack of decrease in neonatal mortality in Niger from 2007 to 2010, a period during which child mortality was decreasing.VASA interviews were conducted of a random sample of 453 neonatal deaths identified by the 2010 Niger National Mortality Survey (NNMS). Causes of death were determined by expert algorithm analysis, and the prevalence of household, community and health system determinants were examined along the continuum of maternal and newborn care, the Pathway to Survival for newborn illnesses, and an extended pathway for maternal complications. The social autopsy findings were compared to available data for survivors from the same cohort collected by the NNMS and the 2012 Niger Demographic and Health Survey.Severe neonatal infection and birth asphyxia were the leading causes of early neonatal death in the community and facilities. Death in the community after delayed careseeking for severe infection predominated during the late neonatal period. The levels of nearly all demographic, antenatal and delivery care factors were in the direction of risk for the VASA study decedents. They more often resided rurally (P < 0.001) and their mothers were less educated (P = 0.03) and gave birth when younger (P = 0.03) than survivors' mothers. Their mothers also were less likely to receive quality antenatal care (P < 0.001), skilled attendance at birth (P = 0.03) or to deliver in an institution (P < 0.001). Nearly half suffered an obstetric complication, with more maternal infection (17.9% vs 0.2%), antepartum hemorrhage (12.5% vs 0.5%) and eclampsia/preeclampsia (9.5% vs 1.6%) than for all births in Niger. Their mothers also were unlikely to seek health care for their own complications (37% to 42%) as well as for the newborn's illness (30.6%).Niger should scale up its recently implemented package of high-impact interventions to additional integrated health facilities and expand the package to provide antenatal care and management of labor and delivery, with support to reach a higher level facility when required. Community interventions are needed to improve illness recognition and careseeking for severe neonatal infection.
- Vasa previa: diagnosis and management. [JOURNAL ARTICLE]
- Am J Obstet Gynecol 2016 Mar 2.
Vasa previa is a rare condition that is associated with a high rate of fetal or neonatal death when not diagnosed antenatally. The majority of available studies are either small, do not include antepartum data, limited to single institutions, or are biased by inclusion of patients from registries and online vasa previa support groups.The purpose of this study was to investigate the diagnostic and management strategies for this potentially catastrophic entity and to describe further maternal and placental risk factors that may aid in the establishment of a screening protocol for vasa previa.This was a retrospective multicenter descriptive study that included all pregnancies that were complicated by vasa previa that delivered between January 1, 2000, and December 31, 2012. Nine maternal fetal medicine practices and the hospitals in which they practice participated in data collection of diagnosis, treatment, and maternal-neonatal outcomes.Sixty-eight pregnancies were identified that included the diagnosis of vasa previa or "possible vasa previa" either in the ultrasound record or in the hospital record at the time of delivery. Four cases (5.8%) appeared to resolve on repeat ultrasound examination. Fifteen of the 64 cases that were suspected of having vasa previa could not be verified or were not documented at delivery. Of the remaining 49 cases, where vasa previa was documented, 47 cases (96%) were diagnosed by ultrasound scanning antenatally. Known risk factors for vasa previa were present in 41 of 47 cases (87%). Of the 49 cases, 41 were delivered by planned cesarean delivery at a mean gestational age of 34.7 weeks, and 8 cases required emergent cesarean delivery at a mean gestational age of 34.6 weeks (range, 32.4-36.0 weeks gestation). Seven of these emergent cesarean deliveries had been diagnosed previously; 1 case had not. All of the emergent cesarean deliveries were for vaginal bleeding; 1 case was also for a concerning fetal heart rate, but only 1 of the known cases had a documented ruptured fetal vessel. None of these cases were found to have cervical shortening before the onset of bleeding. One of the undiagnosed cases resulted in a ruptured fetal vessel and a baby with no heart beat at birth who survived but had periventricular leukomalacia at 1 month of age with mild white-matter atrophy. Of the remaining neonates in this group, there were no deaths and no major complications beyond mild respiratory distress syndrome in 9 cases. There were no other major neonatal complications, which included no cases of periventricular leukomalacia, neonatal sepsis, necrotizing enterocolitis, or any grade of intraventricular hemorrhage in the confirmed cases of vasa previa.This study confirms most current recommendations that include risk-based ultrasound screening, early hospitalization at 30-34 weeks gestation, antenatal corticosteroids at 30-32 weeks gestation, and elective delivery at 33-34 weeks gestation. Thus, with these recommendations for current identification and management of vasa previa in this series of geographically diverse mostly private practice maternal fetal medicine practices, we have confirmed recent reports that show a dramatic improvement in neonatal survival and complications compared with earlier reports.