Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus.

OBJECTIVE: There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth. DESIGN: Systematic review and three-stage modified Delphi expert consensus. SETTING: International. POPULATION: Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance. OUTCOME MEASURES: Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth. RESULTS: Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman's haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman's haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach. CONCLUSION: These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.

Diagnostic accuracy of endometrial sampling tests for detecting endometrial cancer: a systematic review and meta-analysis.

OBJECTIVES: To determine the diagnostic accuracy of different endometrial sampling tests for detecting endometrial carcinoma. DESIGN: Systematic review and meta-analysis of studies of diagnostic accuracy. DATA SOURCES: Cochrane Library, MEDLINE/PubMed, CINAHL, Web of Science and Scopus, from the date of inception of the databases to 18 January 2023. Additionally, the reference lists of included studies and other systematic reviews were thoroughly searched. ELIGIBILITY CRITERIA: We included published cross-sectional studies that evaluated any endometrial sampling test (index tests) in women (participants) with clinical suspicion of endometrial carcinoma (target condition) in comparison with histopathology of hysterectomy specimens (reference standard). We excluded case-control and case series studies. No restrictions on language or date of publication were applied. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted study data and assessed study quality using the revised quality assessment tool for diagnostic accuracy studies (QUADAS-2). We used bivariate diagnostic random-effects meta-analysis and presented the results in a summary receiver operating characteristic curve. We assessed the certainty of evidence as recommended by the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach. RESULTS: Twelve studies (1607 participants), published between 1986 and 2022, contributed data to the meta-analysis results. Seven studies were judged to be at a low risk of bias in all domains and all studies had low applicability concerns. The most studied index tests were Pipelle and conventional dilation and curettage (D&C). The sensitivity, specificity, positive likelihood ratio and negative likelihood ratio (95% CIs) for Pipelle were 0.774 (0.565 to 0.900), 0.985 (0.927 to 0.997), 97.000 (14.000 to 349.000) and 0.241 (0.101 to 0.442) and for conventional D&C were 0.880 (0.281 to 0.993), 0.984 (0.956 to 0.995), 59.300 (14.200 to 153.000) and 0.194 (0.007 to 0.732), respectively. CONCLUSION: High certainty evidence indicates that endometrial sampling using Pipelle or conventional D&C is accurate in diagnosing endometrial cancer. Studies assessing other endometrial sampling tests were sparse. TRIAL REGISTRATION NUMBER: https://osf.io/h8e9z.

Impact of intrapartum factors on oxidative stress in newborns.

OBJECTIVE: To determine the impact of the method of delivery and type of obstetric anesthesia on oxidative stress in neonates. METHODS: The trial included 164 women in two groups of elective cesarean delivery (CD) and uncomplicated vaginal delivery (VD) at term. The CD group was randomized to either a spinal or general anesthesia and the VD group was randomized to either a local or a spinal saddle block. The main outcome measures were the umbilical venous blood glutathione and malondialdhyde (MDA). RESULTS: Neonates of CD had significantly higher levels of MDA and pO(2) and lower glutathione levels than VD. However, in regression analysis, the mode of delivery and type of anesthesia were independent factors that determine the level of MDA but not the level of glutathione. Gestational age was a significant predictor of the glutathione level while birth weight was a significant predictor of the MDA level. CONCLUSION: The oxidative status of the newborn is not simply a reflection of the mode of delivery and type of anesthesia. The impact of gestational age and birth weight appears to be crucial. This must be considered when planning elective delivery.