antepartum hemorrhage [keywords]
- Pregnancy outcomes of antiphospholipid syndrome: In a low resource South Asian setting. [Journal Article]
- Obstet Med 2016 Jun; 9(2):83-9.
Antiphospholipid syndrome is associated with recurrent pregnancy loss, and specific treatment improves pregnancy outcome. Laboratory diagnosis is limited in South Asia. We assessed management outcomes of definite/probable antiphospholipid syndrome treated at a tertiary centre in Sri Lanka.Descriptive cross-sectional study of pregnancy outcomes with heparin and aspirin therapy.miscarriage, intrauterine death and live birth when compared to previous untreated pregnancies.Of 646 gestations in 145 women, 146 (22.6%) received specific treatment. In the preceding pregnancies without specific treatment, the rates of miscarriage, late fetal loss, stillbirth and live birth were 60%, 26%, 8% and 7%, respectively. Following specific treatment with low-dose aspirin ± low-molecular weight heparin in 146 pregnancies (145 women), the rates of miscarriage, late fetal loss, stillbirth and live birth were 14%, 10%, 3% and 74%, respectively. Mean birth weight was 2.54 ± 0.62 kg, preterm births complicated 32 (29.6%) with a mean gestational age at delivery 33.7 ± 2.6 weeks, with three neonatal deaths. Maternal complications were: pre-eclampsia 16 (10.9%), gestational diabetes 28 (19.2%), antepartum haemorrhage in 1 patient. Only 73/145 (50.3%) women had laboratory confirmation of antiphospholipid syndrome, while others were treated empirically. Live births in diagnosed vs. empiric treatment - 80.8% vs. 67.1%.Pregnant women with clinical antiphospholipid syndrome when treated with low-dose aspirin and heparin, the live birth rate of 7% in the previous pregnancy resulted in live births of 74% in a resource limited South Asian setting.
- Prevalence and risk factors associated with the patency of ductus arteriosus in premature neonates: a prospective observational study from Iran. [JOURNAL ARTICLE]
- J Matern Fetal Neonatal Med 2016 Aug 25.:1-5.
Patent ductus arteriosus (PDA) is a common problem in the preterm infants. The frequency of PDA varies with the time of study, and the characteristics of the population included in the trial.To determine the prevalence and prenatal risk factor associated with PDA.This prospective cross-sectional observational study was carried out on neonates who had gestational age below 37 weeks during the period of February 2014 to September 2014. Echocardiography was done at 4-7 days of postnatal age. The association between prenatal risk factors of the infants and the PDA was studied.From a total population of 200 enrolled infants 22.5% had PDA. The mean gestational age and birth weight were 32.1 ± 2.65 (weeks) and 1741 ± 622.85 (g), respectively. Maternal antepartum hemorrhage, respiratory distress syndrome (RDS), need for surfactant, birth weights, female gender, gestational age, Apgar scores at 1 and 5 min of the infants were found to be associated with the prevalence of PDA.Several prenatal factors make preterm newborns susceptible to PDA. These risk factors should be identified as soon as possible for early commencement of PDA management.
- Preventing deaths due to haemorrhage. [REVIEW, JOURNAL ARTICLE]
- Best Pract Res Clin Obstet Gynaecol 2016 Jun 23.
Prevention of deaths from obstetric haemorrhage requires effective health systems including family planning, commodities, personnel, infrastructure and ultimately universal access to comprehensive obstetric care for women giving birth. The main causes of death associated with antepartum haemorrhage are placental abruption, placenta praevia and uterine rupture. Preventive measures include preconceptual folate supplementation, management of hypertensive disorders, early diagnosis of placenta praevia and use of uterine stimulants cautiously, particularly misoprostol. Preventive measures for post-partum haemorrhage include routine active management of the third stage of labour. Treatment involves a cascade of increasingly invasive interventions in rapid sequence until the bleeding is stopped. These interventions include fluid resuscitation, removal of the placenta, bimanual uterine compression, uterotonics, tranexamic acid, suturing of lower genital tract injury, blood product replacement, balloon tamponade, laparotomy, stepwise uterine devascularization, uterine compression sutures and hysterectomy. Emergency temporizing measures include application of the non-pneumatic anti-shock garment, and at laparotomy, aortic compression and uterine tourniquet application. The effectiveness of treatment methods and the optimal dosage of misoprostol are research priorities. Interesting new approaches include transvaginal uterine artery clamping and suction uterine tamponade.
- Pregnancy outcomes in women with osteogenesis imperfecta: a retrospective cohort study. [JOURNAL ARTICLE]
- J Perinatol 2016 Jul 21.
Osteogenesis imperfecta (OI) is a rare genetic disorder characterized by defects in type I collagen that can pose serious complications during pregnancy. The aim was to evaluate maternal and fetal outcomes in pregnant women with OI.This was a retrospective cohort study, using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. We examined the records of pregnant women with OI during the period 2003 to 2011. We evaluated antenatal complications and method of delivery among 295 women with OI, using unconditional logistic regression.Of the total 7 287 994 births in our cohort, we encountered 295 deliveries among women with OI. The prevalence was 4 per 1 00 000 deliveries per year over the study period. Births to women with OI were more likely to be complicated by antepartum hemorrhage (odds ratio (OR) 2.01, 95% confidence interval (CI) 1.04 to 3.91), placenta abruption (OR 2.50, 95% CI 1.24 to 5.03), intrauterine growth restriction and small-for-gestational-age infants (OR 2.42, 95% CI 1.42 to 4.14), congenital malformation (OR 7.33, 95% CI 4.20 to 12.78) and preterm birth (OR 2.24, 95% CI 1.63 to 3.06). Seventy-five percent of women with OI delivered by cesarean section, and they had an increased rate of tubal sterilization at delivery (OR 1.67, 95% CI 1.18 to 2.36). No differences in rates of stress fracture and maternal death were found.These findings suggest that there are increased risks to both mother and fetus in pregnancies complicated by OI.Journal of Perinatology advance online publication, 21 July 2016; doi:10.1038/jp.2016.111.
- Gestational age specific stillbirth risk among Indigenous and non-Indigenous women in Queensland, Australia: a population based study. [Journal Article]
- BMC Pregnancy Childbirth 2016; 16(1):159.
In Australia, significant disparity persists in stillbirth rates between Aboriginal and Torres Strait Islander (Indigenous Australian) and non-Indigenous women. Diabetes, hypertension, antepartum haemorrhage and small-for-gestational age (SGA) have been identified as important contributors to higher rates among Indigenous women. The objective of this study was to examine gestational age specific risk of stillbirth associated with these conditions among Indigenous and non-Indigenous women.Retrospective population-based study of all singleton births of at least 20 weeks gestation or at least 400 grams birthweight in Queensland between July 2005 and December 2011 using data from the Queensland Perinatal Data Collection, which is a routinely-maintained database that collects data on all births in Queensland. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95 % confidence intervals, adjusting for maternal demographic and pregnancy factors.Of 360987 births analysed, 20273 (5.6 %) were to Indigenous women and 340714 (94.4 %) were to non-Indigenous women. Stillbirth rates were 7.9 (95 % CI 6.8-9.2) and 4.1 (95 % CI 3.9-4.3) per 1000 births, respectively. For both Indigenous and non-Indigenous women across most gestational age groups, antepartum haemorrhage, SGA, pre-existing diabetes and pre-existing hypertension were associated with increased risk of stillbirth. There were mixed results for pre-eclampsia and eclampsia and a consistently raised risk of stillbirth was not seen for gestational diabetes.This study highlights gestational age specific stillbirth risk for Indigenous and non-Indigenous women; and disparity in risk at term gestations. Improving access to and utilisation of appropriate and responsive healthcare may help to address disparities in stillbirth risk for Indigenous women.
- Pregnancy at 65, risks and complications. [Journal Article]
- J Hum Reprod Sci 2016 Apr-Jun; 9(2):119-20.
A 65-year-old postmenopausal pregnant woman was referred with antepartum hemorrhage at 29 weeks of gestation. Postadmission diagnosed with chronic hypertension, gestational diabetes mellitus, valvular heart disease, and placenta previa. Her pregnancy was terminated by cesarean delivery at 32 weeks as she had a bout of bleeding per vaginum. Most of the placenta was adherent with no plane of cleavage; therefore, cesarean hysterectomy was performed. Baby birth weight was 1650 g and was shifted to nursery for observation and mother needed Intensive Care Unit care postcesarean. On the 15(th) day, both healthy mother and baby were discharged. Although pregnancy is possible in postmenopausal women with hormone support but the incidence of complications remain very high. It raises a need for developing well-laid guidelines for performing in vitro fertilization in older age group women.
- 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.Peripartum 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, 2.94-4.02), abruption 2.98 (95% confidence interval, 2.52-3.20), fibroids 3.63 (95% confidence interval, 3.22-4.08), and antepartum hemorrhage 7.15 (95% confidence interval, 6.16-8.32). The area under the curve for the model was 0.833.Peripartum 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.