The Management of Uterine Arteriovenous Malformations in Obstetrics.

Uterine arteriovenous malformation (AVM) is a rare but serious condition that can cause heavy uterine bleeding. It occurs when abnormal connections form between the arteries and veins in the uterus, leading to significant health complications. Accurate identification and diagnosis are crucial because overlooking or mishandling them can lead to severe, life-threatening bleeding. We present the case of a 30-year-old patient presenting with abnormal uterine bleeding 15 days after she gave birth to her second child. The ultrasound examination showed images suggestive of retained ovuloplacental remnants, so a uterine aspiration was performed, but the patient presented severe vaginal bleeding. Subsequently, magnetic resonance imaging (MRI) was performed, demonstrating the presence of a prominent lesion in the posterior wall of the uterine body with multiple serpentine-like pathways and a signal void suggestive of aberrant vessels corresponding to AVMs. Ergotrate and misoprostol were administered to control the bleeding, and a Bakri balloon was inserted and maintained until the bleeding stopped. We are highlighting this case to emphasize the importance of considering uterine AVM (UAVM) when dealing with abnormal uterine bleeding, even in the postpartum period. Due to its rarity, there is a lack of substantial evidence to guide clinicians in managing this condition.

Changes in use and outcomes after fibrinogen concentrate insurance coverage for critical obstetrical hemorrhage: a nationwide questionnaire survey in Japan.

Fibrinogen concentrate (FC) for acquired hypofibrinogenemia associated with critical obstetrical hemorrhage (COH) was covered by public medical insurance in September 2021 in Japan. We aimed to investigate changes in the policy of FC use and its effect on COH after insurance coverage. A primary survey covering September 2020 to August 2021 and a secondary survey covering September 2021 to August 2022 were conducted at 428 higher-level medical facilities. We investigated the policy of FC use in transfusion strategy and the maternal outcomes in COH. Among the hospitals that responded to both surveys, the number of facilities that use FC increased from 51.5 (101/196) to 78.6% (154/196) (P < 0.0001). The number of COH cases treated using FC increased from 14.3 to 24.3% (P < 0.0001) and that transfused with ≥ 10 units of red blood cells (RBCs) decreased from 36.8 to 29.8% (P = 0.001). The incidence of pulmonary edema reduced by 3.7-2.0% (P = 0.021), and transfusion-induced allergy by 1.9-0.7% (P = 0.008). No changes were observed in the incidence of thromboembolism, arterial embolization, or hysterectomy. The increased use of FC after insurance coverage led to changes in the transfusion strategy, which may be associated with decreases in transfusions of RBCs, pulmonary edema, and transfusion-induced allergies.

Intrauterine devices in the management of postpartum hemorrhage.

Obstetrical hemorrhage is a relatively frequent obstetrical complication and a common cause of maternal morbidity and mortality worldwide. The majority of maternal deaths attributable to hemorrhage are preventable, thus, developing rapid and effective means of treating postpartum hemorrhage is of critical public health importance. Intrauterine devices are one option for managing refractory hemorrhage, with rapid expansion of available devices in recent years. Intrauterine packing was historically used for this purpose, with historical cohorts documenting high rates of success. Modern packing materials, including chitosan-covered gauze, have recently been explored with success rates comparable to uterine balloon tamponade in small trials. There are a variety of balloon tamponade devices, both commercial and improvised, available for use. Efficacy of 85.9% was cited in a recent meta-analysis in resolution of hemorrhage with the use of uterine balloon devices, with greatest success in the setting of atony. However, recent randomized trials have demonstrated potential harm associated with improvised balloon tamponade use In low resource settings and the World Health Organization recommends use be restricted to settings where monitoring is available and care escalation is possible. Recently, intrauterine vacuum devices have been introduced, which offer a new mechanism for achieving hemorrhage control by mechanically restoring uterine tone via vacuum suction. The Jada device, which is is FDA-cleared and commercially available in the US, found successful bleeding control in 94% of cases in an initial single-arm trial, with recent post marketing registry study described treatment success following hemorrhage in 95.8% of vaginal and 88.2% of cesarean births. Successful use of improvised vacuum devices has been described in several studies, including suction tube uterine tamponade via Levin tubing, and use of a modified Bakri balloon. Further research is needed with head-to-head comparisons of efficacy of devices and assessment of cost within the context of both device pricing and overall healthcare resource utilization.

Prenatal hypertension as the risk of eclampsia, HELLP syndrome, and critical obstetric hemorrhage.

Critical bleeding is a common cause of maternal mortality in obstetric patients. However, the non-obstetric factors underlying critical obstetric bleeding remain uncertain. Therefore, this study aimed to clarify the impact of chronic hypertension on obstetric hemorrhage by evaluating a nationwide administrative database in Japan. Women who gave birth between 2018 and 2022 were enrolled. The primary outcome was critical hemorrhage requiring massive red blood cell (RBC) transfusion during childbirth. In total, 354, 299 eligible women were selected from the database. The maternal mortality rate was >1.0% among those who received a massive RBC transfusion (≥4000 cc), and this amount was used as the cutoff of the outcome. Critical hemorrhage was less frequent with elective Caesarean section (CS) compared with vaginal childbirth or emergent CS (odds ratio [OR], 0.38; 95% confidence interval, 0.30-0.47). Multiple logistic regression analysis adjusting for these obstetric risks revealed that a higher maternal age (adjusted OR [aOR] per 1 year, 1.07 [1.05-1.09]); oral medications with prednisolone (aOR, 2.5 [1.4-4.4]), anti-coagulants (aOR, 10 [5.4-19]), and anti-platelets (aOR, 2.9 [1.3-6.4]); and a prenatal history of hypertension (aOR, 2.5 [1.5-4.4]) and hypoproteinemia (aOR, 5.8 [1.7-20]) are the risks underlying critical obstetric hemorrhage. Prenatal history of hypertension was significantly associated with obstetric disseminated intravascular coagulation (OR, 1.9 [1.5-2.4]); Hemolysis, Elevated Liver enzymes, and Low platelet count (HELLP) syndrome (OR, 3.3 [2.7-4.2]); and eclampsia (OR, 6.1 [4.6-8.1]). In conclusion, a maternal prenatal history of hypertension is associated with the development of HELLP syndrome, eclampsia, and resultant critical hemorrhage. The incidence of HELLP syndrome and eclampsia increased more than fivefold in the presence of prenatal hypertension. However, the likelihood of subsequently developing DIC or experiencing critical bleeding did not change by the presence of prenatal hypertension.

Adrenal Crisis in a Delayed Diagnosis of Sheehan Syndrome.

Sheehan syndrome is a well-documented endocrinological disorder that appears to be closely associated as a secondary sequela to postpartum hemorrhage. Due to pregnancy-related physiological adaptations, namely the increase in blood volume but lack of hypertrophic or hyperplastic growth within the pituitary, pregnancy increases the likelihood of infarction of the pituitary. This, coupled with other complications, such as postpartum hemorrhage, can lead to ischemia and permanent damage to the pituitary, and thus, all the downstream endocrinological pathways regulated by the pituitary. Namely, this can include, but is not limited to, adrenal crisis from improper stimulation of steroid secretion. Individuals who have been diagnosed with Sheehan syndrome require lifelong steroid supplementation for appropriate regulation of multiple systems, specifically circulatory. Without appropriate steroid supplementation exogenously, patients can rapidly decline with adverse hypotension, altered mental status, and loss of vascular tone. This case presents a case of a patient who, after extensive chart review and history taking, was found to have had a complicated pregnancy many years ago with multiple transfusions needed to stabilize her and was placed on exogenous steroid management, presenting for adrenal crisis, hypotension, and altered mental status after not taking her home steroid medication.

Investigation of Intrapartum Parenteral Magnesium Sulfate as an Independent Risk Factor for Postpartum Hemorrhage Using Quantitative Blood Loss Assessment.

BACKGROUND: Magnesium sulfate is used for seizure prophylaxis in preeclampsia and for fetal neuroprotection when delivery is anticipated before 32 weeks of gestation. Existing risk assessment tools for postpartum hemorrhage often identify the use of magnesium sulfate as an intrapartum risk factor. Previous studies examining the association between the use of magnesium sulfate and postpartum hemorrhage have relied largely on qualitative estimates of blood loss rather than quantitative estimates of blood loss. OBJECTIVE: This study aimed to determine whether intrapartum administration of magnesium sulfate is associated with an increased risk of postpartum hemorrhage using a quantitative blood loss assessment via the use of graduated drapes and weight differences in surgical supplies. STUDY DESIGN: This case-control study was conducted to test the hypothesis that intrapartum parenteral administration of magnesium sulfate is not independently associated with postpartum hemorrhage. All deliveries at our tertiary-level academic medical center between July 2017 and June 2018 were reviewed. Of note, 2 categories of postpartum hemorrhage were defined: the traditional definition (>500 mL for vaginal delivery and >1000 mL for cesarean delivery) and the contemporary definition (>1000 mL regardless of delivery mode). Statistical analyses using the chi-square test, Fisher exact test, t test, or Wilcoxon rank-sum test were performed to compare the patients who did and did not receive magnesium sulfate concerning the rates of postpartum hemorrhage, pre- and postdelivery hemoglobin level, and rates of blood transfusion. RESULTS: A total of 1318 deliveries were included, with postpartum hemorrhage rates of 12.2% (traditional definition) and 6.2% (contemporary definition). Multivariate logistic regression did not find the use of magnesium sulfate as an independent risk factor by either definition (odds ratio, 1.44 [95% confidence interval, 0.87-2.38] and 1.34 [95% confidence interval, 0.71-2.54]). The only significant independent risk factor was cesarean delivery, by both definitions (odds ratio, 2.71 [95% confidence interval, 1.85-3.98] and 19.34 [95% confidence interval, 8.55-43.72]). CONCLUSION: In our study population, intrapartum administration of magnesium sulfate was not found to be an independent risk factor for postpartum hemorrhage. Cesarean delivery was determined as an independent risk factor, consistent with previous reports.

Traditional uterine tamponade and vacuum-induced uterine tamponade devices in obstetrical hemorrhage management.

Obstetrical hemorrhage is the leading cause of maternal morbidity and mortality worldwide, and the rates of severe hemorrhage are increasing. There is a crucial need to expand treatment options for hemorrhage to address this global crisis. Over the last decade, the evolution of hemorrhage control devices has contributed to advancements in obstetrical hemorrhage management. The number of existing hemorrhage control devices and techniques has increased markedly in recent years, and new devices are in development. The current evidence for established and investigational hemorrhage control devices has been summarized in this review. Of note, 2 main categories of devices exist: traditional uterine tamponade and vacuum-induced uterine tamponade. Although traditional intrauterine balloon tamponade devices are currently used widely in postpartum hemorrhage management, novel hemorrhage control devices and techniques have been developed. These include the minisponge tamponade device, the Jada System, a modified Bakri balloon technique, and a suction tube uterine tamponade technique. Reassuring safety data and preliminary efficacy data from pilot studies of these novel techniques support the powerful role intrauterine devices can play in obstetrical hemorrhage management. This review aimed to improve awareness of device options so that continued efforts can be made to integrate new technology into hemorrhage management protocols. Well-designed studies inclusive of new hemorrhage control devices are essential to understanding where new technology fits into preexisting obstetrical hemorrhage algorithms. In addition, access to new tamponade technology remains limited on a global scale. Programs aimed at both increasing access to devices and expanding educational initiatives are essential to make new technology a standard component for hemorrhage management.

Recognizing who is at risk for postpartum hemorrhage: targeting anemic women and scoring systems for clinical use.

Iron deficiency anemia during pregnancy is a common concern, affecting 38% of women worldwide and up to 50% in developing countries. It is defined differently throughout all 3 trimesters. It has several detrimental effects on pregnancy outcomes for both the mother and the fetus, such as increasing the risk for postpartum depression, preterm delivery, cesarean delivery, preeclampsia, and low birthweight. Management of iron deficiency anemia is done classically via oral iron supplementation. However, recent evidence has shown that intravenous iron is a good alternative to oral iron if patients are unable to tolerate it, not responding, or present with a new diagnosis very late in pregnancy. Management of iron deficiency anemia was demonstrated to be protective against postpartum hemorrhage. Other ways to prevent postpartum hemorrhage include improving prediction tools that can identify those at risk. Several risk assessment kits have been developed to estimate the risk for postpartum hemorrhage among patients and have been proven useful in the prediction of patients at high risk for postpartum hemorrhage despite limitations among low-risk groups. More comprehensive tools are also being explored by determining clinically relevant factors through nomograms, with some proving their efficacy after implementation. Machine learning is also being used to develop more complete tools by including risk factors previously not accounted for. These newer tools, however, still require external validation before being adopted despite promising results under testing conditions.

Bilateral ligation of the anterior trunk of the internal iliac artery in uterine atony secondary to uterine inversion: case report.

Postpartum hemorrhage is one of the leading causes of maternal mortality worldwide. Uterine atony is the main cause, representing up to 90% of cases, and is a risk factor for uterine inversion. Morbidity and mortality occur in 41% of uterine inversion cases, including massive obstetric hemorrhage. Massive obstetric hemorrhage is a medical emergency that puts life and reproductive function at risk, and therefore, its treatment must be timely and immediate. If there is no favorable response with the initial measures, surgical intervention proceeds. When choosing the surgical procedure, priority should be given to the technique with the easiest access and which is the least invasive, the safest, and in which the surgeon has more experience. We present a case report with our technique of bilateral ligation of the anterior trunk of the hypogastric artery, after a uterine compression suture failed, with excellent results and preserved fertility in an adolescent patient. We describe the technique and the result. The response time of the uterus with normal tone was 5 minutes, and postligation bleeding was only 50 mL after the patient had bled 1200 mL without complications; thus, it is an adequate and cost-effective technique. The bilateral ligation of the anterior trunk of the hypogastric artery technique in the case of postpartum hemorrhage is an effective, safe, and fertility-preserving surgical procedure that constitutes an alternative to emergency obstetrical hysterectomy when other, less invasive methods have failed.

Prophylactic endovascular internal iliac balloon placement during cesarean hysterectomy for placenta accreta spectrum.

BACKGROUND: The utility of prophylactic endovascular internal iliac balloon placement in the surgical management of placenta accreta spectrum is debated. OBJECTIVE: In this study, we review outcomes of surgical management of placenta accreta spectrum with and without prophylactic endovascular internal iliac balloon catheter use at a single institution. STUDY DESIGN: This is a retrospective cohort study of consecutive viable singleton pregnancies with a confirmed pathologic diagnosis of placenta accreta spectrum undergoing scheduled delivery from October 2018 through November 2020. In the T1 period (October 2018-August 2019), prophylactic endovascular internal iliac balloon catheters were placed in the operating room before the start of surgery. Balloons were inflated after neonatal delivery and deflated after hysterectomy completion. In the T2 period (September 2019-November 2020), endovascular catheters were not used. In both time periods, all surgeries were performed by a dedicated multidisciplinary team using a standardized surgical approach. The outcomes compared included the estimated blood loss, anesthesia duration, operating room time, surgical duration, and a composite of surgical complications. Comparisons were made using the Wilcoxon rank-sum test and the Fisher exact test. RESULTS: A total of 30 patients were included in the study (T1=10; T2=20). The proportion of patients with placenta increta or percreta was 80% in both groups, as defined by surgical pathology. The median estimated blood loss was 875 mL in T1 and 1000 mL in T2 (P=.84). The proportion of patients requiring any packed red blood cell transfusion was 60% in T1 and 40% in T2 (P=.44). The proportion of patients requiring >4 units of packed red blood cells was 20% in T1 and 5% in T2 (P=.25). Surgical complications were observed in 1 patient in each group. Median operative anesthesia duration was 497 minutes in T1 and 296 minutes in T2 (P<.001). Median duration of operating room time was 498 minutes in T1 and 205 minutes in T2 (P<.001). Median surgical duration was 227 minutes in T1 and 182 minutes in T2 (P<.05). The median duration of time for prophylactic balloon catheter placement was 74 minutes (range, 46-109 minutes). The median postoperative length of stay was similar in both groups (6 days in T1 and 5.5 days in T2; P=.36). CONCLUSION: The use of prophylactic endovascular internal iliac balloon catheters was not associated with decreased blood loss, packed red blood cell transfusion, or surgical complications. Catheter use was associated with increased duration of anesthesia, operating room time, and surgical time.

Severe maternal morbidity in pregnant patients with SARS-CoV-2 infection.

BACKGROUND: Although the increased risk for severe illness and adverse pregnancy outcomes associated with SARS-CoV-2 infection during pregnancy is well described, the association of infection with severe maternal morbidity has not been well characterized. OBJECTIVE: This study aimed to evaluate the risk for severe maternal morbidity associated with SARS-CoV-2 infection during pregnancy. STUDY DESIGN: This was a multicenter retrospective cohort study of all pregnant patients who had a SARS-CoV-2 test done and who delivered in a New York health system between March 1, 2020 and March 1, 2021. Patients with missing test results were excluded. The primary outcome of severe maternal morbidity, derived from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine example list of diagnoses and complications, was compared between the following 2 groups: patients who tested positive for SARS-CoV-2 during pregnancy and patients who tested negative. Secondary outcomes included subgroups of severe maternal morbidity. Multivariable logistic regression was used to adjust for potential confounders such as maternal demographics, neighborhood socioeconomic status, hospital location, and pregnancy-related complications. A subanalysis was performed to determine if the risk for severe obstetrical hemorrhage and hypertension-associated or neurologic morbidity differed based on the timing of SARS-CoV-2 infection between those who tested positive for SARS-CoV-2 at their delivery hospitalization (ie, active infection) and those who tested positive during pregnancy but negative at their delivery hospitalization (ie, resolved infection). RESULTS: Of the 22,483 patients included, 1653 (7.4%) tested positive for SARS-CoV-2 infection. Patients with SARS-CoV-2 infection were more commonly Black, multiracial, Hispanic, non-English speaking, used Medicaid insurance, were multiparous, and from neighborhoods with a lower socioeconomic status. Patients with SARS-CoV-2 infection were at an increased risk for severe maternal morbidity when compared with those without infection (9.3 vs 6.5%; adjusted odds ratio, 1.52; 95% confidence interval, 1.21-1.88). Patients with SARS-CoV-2 infection were also at an increased risk for severe obstetrical hemorrhage (1.1% vs 0.5%; adjusted odds ratio, 1.78; 95% confidence interval, 1.04-2.88), pulmonary morbidity (2.0% vs 0.5%; adjusted odds ratio, 3.90; 95% confidence interval, 2.52-5.89), and intensive care unit admission (1.8% vs 0.5%; adjusted odds ratio, 3.29; 95% confidence interval, 2.09-5.04) when compared with those without infection. The risk for hypertension-associated or neurologic morbidity was similar between the 2 groups. The timing of SARS-CoV-2 infection (whether active or resolved at time of delivery) was not associated with the risk for severe obstetrical hemorrhage or hypertension-associated or neurologic morbidity when compared with those without infection. CONCLUSION: SARS-CoV-2 infection during pregnancy was associated with an increased risk for severe maternal morbidity, severe obstetrical hemorrhage, pulmonary morbidity, and intensive care unit admission. These data highlight the need for obstetrical unit preparedness in caring for patients with SARS-CoV-2 infection, continued public health efforts aimed at minimizing the risk for infection, and support in including this select population in investigational therapy and vaccine trials.

Management of Acquired Factor VIII Inhibitors With NovoSeven and Obizur.

Acquired hemophilia A (AHA) is a rare hemorrhagic disorder caused by the production of autoantibodies against coagulation factor VIII (FVIII). AHA is associated with significant morbidity and mortality primarily as a result of bleeding. Although many disorders are associated with the development of these inhibitors, up to 50% of cases remain idiopathic. The approach to therapy involves an initial strategy often to control acute bleeding episodes followed by definitive treatment to eradicate the inhibitor with immunosuppressive agents. We present the case of a 63-year-old Caucasian male hospitalized for severe Covid-19 who developed bleeding due to an acquired FVIII inhibitor that had never been treated definitively. Our case presentation focuses on in-hospital management of this patient's acute bleeding episodes with by-passing agents and recombinant porcine factor VIII.

Placenta Percreta Complications.

Placenta percreta is the most severe form of placenta accreta and is characterized by placental invasion through the entirety of the myometrium and possibly into extrauterine tissues. It is associated with prior cesarean deliveries and placenta previa. Herein, we present the case of a patient who developed placenta percreta and experienced massive blood loss of 27 liters. She developed many complications over the next 11 months, including deep vein thrombosis, pulmonary embolism, preeclampsia after pregnancy, hematoma, blood clots in the bladder, lactation failure, ileus, vesicovaginal fistula, excessive scar tissue requiring surgery, loss of an ovary, and recurrent bladder perforation. We analyze the mechanisms of these complications and the most common complications associated with placenta percreta.

Anesthetic Management of a Patient With a Ruptured Heterotopic Pregnancy for Emergency Exploratory Laparotomy.

Heterotopic pregnancy (HP) is an uncommon clinical condition characterized by the coexistence of intrauterine and extra-uterine pregnancies. HP is a diagnostic challenge as the typical methods for the early diagnosis of ectopic pregnancy are confounded by the simultaneous presence of intrauterine pregnancy (IUP). Ruptured HP is a potentially life-threatening obstetric emergency and can result in significant morbidity and mortality. Early diagnosis is the key to a favorable outcome. With the increasing number of patients undergoing artificial reproductive technology (ART), which is an important risk factor for HP, the odds of encountering HP patients are also growing. Anesthesiologists are challenged by the need to manage a bleeding obstetric patient while simultaneously ensuring the safety of the IUP. We present perioperative management of a patient with bleeding ruptured HP for emergency laparotomy who went on to have a successful twin delivery 37w3d via cesarean section.

Correlation between hemorrhage risk prediction score and severe maternal morbidity.

BACKGROUND: Obstetrical hemorrhage is a leading cause of severe maternal morbidity, a key indicator of a nation's healthcare delivery system and often associated with a high rate of preventability. Limited data suggest that a patient's hemorrhage risk score may be associated with risk for maternal morbidity such as severe hemorrhage, intensive care unit admission, or transfusion. Little is known regarding the relationship between hemorrhage risk score and nontransfusion-related morbidity. OBJECTIVE: We sought to evaluate the association between a patient's California Maternal Quality Care Collaborative admission hemorrhage risk score and severe maternal morbidity. STUDY DESIGN: This was a retrospective cohort of delivery admissions from 2018 to 2019 in a single healthcare network. Admission risk scores were assigned to each patient using the California Maternal Quality Care Collaborative criteria. Rates of transfusion- and nontransfusion-associated severe maternal morbidity were compared across low-, medium-, and high-risk strata. We defined severe maternal morbidity as the presence of any International Classification of Diseases diagnosis or procedure codes outlined by the Centers for Disease Control and Prevention, need for intensive care unit admission, or prolonged postpartum hospital length of stay. A multivariable logistic regression was used to assess the association between hemorrhage risk score and severe maternal morbidity. RESULTS: In the overall cohort, severe maternal morbidity occurred in 2.4% (n=517) of all deliveries. Excluding cases requiring transfusion, 0.6% (n=131) of cases still had a severe maternal morbidity event. The incidence of severe maternal morbidity was 1.6% (n=264) in patients categorized as low risk for hemorrhage compared with 2.5% (n=118) and 13.6% (n=135) in patients who were categorized as medium or high risk for hemorrhage, respectively (P<.001). Patients classified as high risk had a significant association with both severe maternal morbidity (adjusted odds ratio, 8.8; 95% confidence interval, 7.0-11) and nontransfusion-associated severe maternal morbidity (adjusted odds ratio, 3.6; 95% confidence interval, 2.2-5.9). CONCLUSION: In addition to predicting the risk for obstetrical hemorrhage and transfusion, our findings indicate that the California Maternal Quality Care Collaborative admission hemorrhage risk tool predicts risk for transfusion- and nontransfusion-associated severe maternal morbidity. Our findings imply that despite awareness and the identification of patients at high risk for obstetrical hemorrhage on admission, significant hemorrhage-associated morbidity persisted. Our data indicate that the identification of risk alone may be insufficient to reduce morbidity and imply that further work is needed to investigate and implement new practices in response to a patient's score stratum.

Prevention of postpartum hemorrhage.

Postpartum hemorrhage is a leading cause of severe maternal morbidity and mortality worldwide and the United States. While the rates of maternal mortality attributable to hemorrhage are declining, severe maternal morbidity continues to be a growing problem. Efforts in recent years to more appropriately identify patients at risk, define significant hemorrhage, quantify blood loss, and standardize approaches to care in pregnancy and postpartum have led to an increasing preventability of PPH. We aim to review the most current recommendation for the prevention and effective management of obstetric hemorrhage.

Prophylactic internal iliac artery ligation versus balloon occlusion for placenta accreta spectrum disorders: A retrospective cohort study.

OBJECTIVE: To compare surgical outcomes between women undergoing prophylactic internal iliac artery ligation or preoperative placement of balloon-occlusive devices at cesarean hysterectomy for placenta accreta spectrum (PAS) disorders. METHODS: A retrospective cohort study was conducted at a tertiary-care referral center for PAS disorders in Ontario, Canada. Eligible electronic records were reviewed of women undergoing cesarean hysterectomy for PAS disorders between November 2012 and June 2018. Outcomes for the ligation and balloon groups were compared primarily on procedure-related complications and secondarily on total procedure time, bleeding and transfusion metrics, and intraoperative and postoperative complications. RESULTS: Of the 79 cases of cesarean hysterectomy, 47 underwent balloon placement and 32 underwent ligation. Baseline characteristics between the groups were similar except for more emergency procedures in the ligation group (37.5% vs 12.8%, P=0.014). The balloon-related complication rate was 5/47 (10.6%), with no reported complications in the ligation group (P=0.077). Procedural time was longer in the balloon group (353 ± 14 vs 227 ± 13 minutes, P<0.001). Estimated blood loss was similar (1874 ± 245 mL vs 1713 ± 181 mL, P=0.590). CONCLUSION: Women undergoing prophylactic placement of endovascular balloons at caesarean hysterectomy for PAS disorders had a 10.6% procedure-related complication rate and increased total procedure time, with no decrease in blood loss compared to those undergoing surgical ligation.

Fibrinogen for the management of critical obstetric hemorrhage.

AIM: In cases of critical obstetric hemorrhage leading to extreme hypofibrinogenemia, fibrinogen is the marker that indicates the critical severity, and early fibrinogen supplementation centering on hemostatic resuscitation is a vital treatment to stabilize a catastrophic condition. In this review, we investigated the effect of fibrinogen level on hemostasis and what we can do to treat hypofibrinogenemia efficiently and improve patients' outcome. METHODS: We reviewed numerous articles related to hypofibrinogenemia in critical obstetric hemorrhage. Especially, we performed a systematic review on target value of fibrinogen for hemostasis and effectiveness of fibrinogen concentrate. We also reviewed the articles about the methods for early normalization of fibrinogen level such as tranexamic acid, massive transfusion protocol, and point-of-care testing. RESULTS: The target value of fibrinogen calculated by needs for massive transfusion was 200 mg/dL or 10 mm of A5FIBTEM . Although fibrinogen concentrate worked poorly on fibrinogen levels within the normal range, it improved the blood fibrinogen levels rapidly when it was administered to critical obstetric hemorrhage patients with serious hypofibrinogenemia. Hence, the volume of FFP transfused could be reduced along with a reduction in the frequency of pulmonary edema due to volume overload. CONCLUSION: The patient group for which fibrinogen concentrate works most effectively is cases with severe hypofibrinogenemia. Further research is required in the light of evidence. The essence of the transfusion algorithm in critical obstetric hemorrhage is to approach the target value for obtaining hemostasis, ensure an accurate and prompt grasp of the severity using point-of-care testing, introduce a massive transfusion protocol and use tranexamic acid.

Abnormal placentation.

The term "morbidly adherent placenta" has recently been introduced to describe the spectrum of disorders including placenta accreta, increta and percreta. Due to excessive invasion of the placenta into the uterus there is associated significant maternal morbidity and mortality. Most significant risk factors for morbidly adherent placenta include history of prior cesarean delivery as well as placenta previa in the current pregnancy. Ultrasound remains the gold standard for antenatal diagnosis, however, in recent years MRI has assisted in identifying complex parametrial involvement. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multi-disciplinary team-based approach, and referral to an experienced center.

James Blundell, Obstetrical Hemorrhage, and the Origins of Transfusion Medicine.

Although James Blundell is rightly acknowledged as the father of modern transfusion therapy, a review of the events surrounding the initial human-to-human transfusions in the first decades of the 19th century reveals substantial contributions by Blundell's collaborators. Bundell's uncle John Haighton provided substantial support for animal experimentation in the growing field of physiology studies. John Leacock of Barbados provided the essential original experiments that focused the path of investigation on within-species transfusions. London instrument makers such as Laundy and Lloyd provided precision-made syringes without risk of air embolism. Fellow obstetricians Charles Waller and Edward Doubleday became ardent supporters of the new therapy and brought case referrals to Blundell's attention and care. British medical journals, such as The Lancet, provided much needed dissemination of early successes to curious medical practitioners. This 200th anniversary year of the first successful attempts at human-to-human transfusion presents an opportunity to review the failures and successes which occurred during the first days of what would ultimately become a life-saving treatment for millions worldwide.