Preventing Maternal Morbidity from Obstetric Hemorrhage: Implications of a Provider Training Initiative (Podcast)

CONTEXT AND OBJECTIVE: Evaluation of severe maternal morbidity has been used in monitoring of maternal health. The objective of this study was to estimate its incidence and main causes in São Luís, Maranhão, Brazil. DESIGN AND SETTING: Prospective longitudinal study, carried out in two public high-risk maternity hospitals and two public intensive care units (ICUs) for referral of obstetric cases from the municipality. METHODS: Between March 1, 2009, and February 28, 2010, all cases of severe maternal morbidity according to the Mantel and Waterstone criteria were identified. The sociodemographic and healthcare characteristics of the extremely severe cases were compared with the less severe cases, using the Fisher, Χ2, Student t and Mann-Whitney tests, with a significance level of < 0.05. RESULTS: 127 cases of severe maternal morbidity were identified among 8,493 deliveries, i.e. an incidence of 15.0/1000 deliveries. Out of 122 cases interviewed, 121 cases were within the Waterstone criteria and 29 were within the Mantel criteria, corresponding to incidences of 14.1/1000 and 3.4/1000 deliveries, respectively. These rates were lower than those described in the literature, possibly due to case loss. The main causes were hypertension during pregnancy, which was more frequent in less severe cases (P = 0.001) and obstetric hemorrhage, which was more common among extremely severe cases (P = 0.01). CONCLUSIONS: Direct obstetric disorders were the main causes of severe maternal morbidity in São Luís, Maranhão. Investigation and monitoring of severe morbidity may contribute towards improving obstetric care in the municipality.

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Obstetric Hemorrhage Management and Maternal Morbidity Among Non-Hispanic Black Women [34L]

Obstetrics and Gynecology ◽

10.1097/01.aog.0000533573.11755.b6 ◽

2018 ◽

Vol 131 ◽

pp. 138S

Author(s):

Pooja Jayaprakash ◽

Tierra Curry ◽

Alyssa Brown ◽

Judette Louis

Keyword(s):

Black Women ◽

Maternal Morbidity ◽

Obstetric Hemorrhage

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Prediction of severe adverse maternal outcome in women admitted in obstetric ward using physiological and biochemical parameters

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20191960 ◽

2019 ◽

Vol 8 (5) ◽

pp. 2019

Author(s):

Reena Rani ◽

Sunita Bai Meena ◽

C. P. Yadav ◽

Deepti Goswami ◽

Reva Tripathi ◽

...

Keyword(s):

Multivariate Analysis ◽

Risk Score ◽

Biochemical Parameters ◽

Maternal Morbidity ◽

Near Miss ◽

Maternal Outcomes ◽

Obstetric Hemorrhage ◽

Common Cause ◽

Physiological And Biochemical ◽

Near Miss Maternal Morbidity

Background: To study physiological and biochemical parameters to predict serious adverse maternal outcomes and to develop risk score using above parameters.Methods: This prospective study was conducted in 500 high risk pregnant women attending tertiary care teaching hospital. We noted physiological and biochemical parameters as soon as they were available .The primary outcome measures was “severe adverse maternal outcome(SAMO)” in form of one or more among mortality, near miss morbidity and ICU admissions.Results: Out-off 500 women, severe adverse maternal outcomes were seen in 158 (31.6%) women. Most common cause of near miss maternal morbidity was hypertensive disease of pregnancy (62.7%) followed by major obstetric hemorrhage (18.9%). There were 33(6.6%) ICU admission, 23 (4.6%) maternal death and 153 (30.6%) near miss maternal morbidity. The most common cause of maternal death in our study was obstetric hemorrhage. The significant variables after multivariate analysis [temp, pulse, urine protein] were used to devise a Maternal early warning score (MEWS) based on physiological parameters at score value of ≥1/6 was found to have sensitivity of 70% and specificity of 82% in predicting SAMO with AUROC of 0.76. The significant laboratory parameters after multivariate analysis were blood urea, serum creatinine, serum bilirubin and liver enzymes. The obstetric risk score (Maternal risk prediction score MRPS) which incorporated of these laboratory parameters in addition to physiological parameters has sensitivity of 82% and specificity of 75% with AUROC 0.79 value ≥ 2/18.Conclusions: The addition of laboratotory parameters to physiological variables improves performance of risk score to predict SAMO.

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Postpartum hemorrhage: a continuing challenge

Hematology ◽

10.1182/asheducation-2015.1.132 ◽

2015 ◽

Vol 2015 (1) ◽

pp. 132-137 ◽

Cited By ~ 10

Author(s):

Evelyn Lockhart

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Replacement Therapy ◽

Postpartum Hemorrhage ◽

Maternal Morbidity ◽

Morbidity And Mortality ◽

Obstetric Hemorrhage ◽

Antifibrinolytic Therapy ◽

Maternal Morbidity And Mortality ◽

Fibrinogen Replacement Therapy

Abstract Obstetric hemorrhage remains a leading cause of maternal morbidity and mortality worldwide. Many postpartum hemorrhages (PPHs) do not have identifiable risk factors; maternity units should therefore have obstetric hemorrhageprotocols in place for all parturients as every pregnancy has the potential to be complicated by hemorrhage. This review will examine the epidemiology of PPH as well as current recommendations for key elements in obstetric hemorrhage protocols. Recent advances in hematologic management of PPH will be also be reviewed, including: (1) recognition of hypofibrinogenemia as a risk factor for severe PPH, (2) use of antifibrinolytic therapy, and (3) strategies for fibrinogen replacement therapy.

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The Impact of Severe Maternal Morbidity on Perinatal Outcomes in High Income Countries: Systematic Review and Meta-Analysis

Journal of Clinical Medicine ◽

10.3390/jcm9072035 ◽

2020 ◽

Vol 9 (7) ◽

pp. 2035

Author(s):

Tesfaye S. Mengistu ◽

Jessica M. Turner ◽

Christopher Flatley ◽

Jane Fox ◽

Sailesh Kumar

Keyword(s):

Systematic Review ◽

Maternal Morbidity ◽

Perinatal Death ◽

Meta Analysis ◽

Perinatal Outcomes ◽

Obstetric Hemorrhage ◽

Hypertensive Disorders ◽

Adverse Perinatal Outcomes ◽

Nicu Admission ◽

The Impact

While there is clear evidence that severe maternal morbidity (SMM) contributes significantly to poor maternal health outcomes, limited data exist on its impact on perinatal outcomes. We undertook a systematic review and meta-analysis to ascertain the association between SMM and adverse perinatal outcomes in high-income countries (HICs). We searched for full-text publications in PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Scopus databases. Studies that reported data on the association of SMM and adverse perinatal outcomes, either as a composite or individual outcome, were included. Two authors independently assessed study eligibility, extracted data, and performed quality assessment using the Newcastle–Ottawa Scale. We used random-effects modelling to calculate odds ratios (ORs) with 95% confidence intervals. We also assessed the risk of publication bias and statistical heterogeneity using funnel plots and Higgins I2, respectively. We defined sub-groups of SMM as hemorrhagic disorders, hypertensive disorders, cardiovascular disorders, hepatic disorders, renal disorders, and thromboembolic disorders. Adverse perinatal outcome was defined as preterm birth (before 37 weeks gestation), small for gestational age (SGA) (birth weight (BW) < 10th centile for gestation), low birthweight (LBW) (BW < 2.5 kg), Apgar score < 7 at 5 min, neonatal intensive care unit (NICU) admission, stillbirth and perinatal death (stillbirth and neonatal deaths up to 28 days). A total of 35 studies consisting of 38,909,426 women were included in the final analysis. SMMs associated with obstetric hemorrhage (OR 3.42, 95% CI: 2.55–4.58), severe hypertensive disorders (OR 6.79, 95% CI: 6.06–7.60), hepatic (OR 3.19, 95% CI: 2.46–4.13) and thromboembolic disorders (OR 2.40, 95% CI: 1.67–3.46) were significantly associated with preterm birth. SMMs from hypertensive disorders (OR 2.86, 95% CI: 2.51–3.25) or thromboembolic disorders (OR 1.48, 95% CI: 1.09–1.99) were associated with greater odds of having SGA infant. Women with severe hemorrhage had increased odds of LBW infant (OR 2.31, 95% CI: 1.57–3.40). SMMs from obstetric hemorrhage (OR 4.16, 95% CI: 2.54–6.81) or hypertensive disorders (OR 4.61, 95% CI: 1.17–18.20) were associated with an increased odds of low 5-min Apgar score and NICU admission (Severe obstetric hemorrhage: OR 3.34, 95% CI: 2.26–4.94 and hypertensive disorders: OR 3.63, 95% CI: 2.63–5.02, respectively). Overall, women with SMM were 4 times more likely to experience stillbirth (OR 3.98, 95% CI: 3.12–7.60) compared to those without SMM with cardiovascular disease (OR 15.2, 95% CI: 1.29–180.60) and thromboembolic disorders (OR 9.43, 95% CI: 4.38–20.29) conferring greatest risk of this complication. The odds of neonatal death were significantly higher in women with SMM (OR 3.98, 95% CI: 2.44–6.47), with those experiencing hemorrhagic (OR 7.33, 95% CI: 3.06–17.53) and hypertensive complications (OR 3.0, 95% CI: 1.78–5.07) at highest risk. Overall, SMM was also associated with higher odds of perinatal death (OR 4.74, 95% CI: 2.47–9.12) mainly driven by the increased risk in women experiencing severe obstetric hemorrhage (OR 6.18, 95% CI: 2.55–14.96). Our results highlight the importance of mitigating the impact of SMM not only to improve maternal health but also to ameliorate its consequences on perinatal outcomes.

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Obstetric Hemorrhage Risk Associated with Novel COVID-19 Diagnosis from a Single-Institution Cohort in the United States

American Journal of Perinatology ◽

10.1055/s-0040-1718403 ◽

2020 ◽

Vol 37 (14) ◽

pp. 1411-1416

Author(s):

Michelle J. Wang ◽

Melissa Schapero ◽

Ronald Iverson ◽

Christina D. Yarrington

Keyword(s):

Pregnant Women ◽

Maternal Morbidity ◽

Medical Center ◽

The United States ◽

Composite Outcome ◽

Obstetric Hemorrhage ◽

Increased Risk ◽

Chi Squared ◽

Student’S T ◽

The Impact

Objective The study aimed to compare the quantitative blood loss (QBL) and hemorrhage-related outcomes of pregnant women with and without a coronavirus disease 2019 (COVID-19) diagnosis. Study Design This retrospective cohort study of all live deliveries at Boston Medical Center between April 1, 2020 and July 22, 2020 compares the outcomes of pregnant women with a laboratory-confirmed COVID-19 positive diagnosis and pregnant women without COVID-19. The primary outcomes are QBL and obstetric hemorrhage. The secondary outcomes analyzed were a maternal composite outcome that consisted of obstetric hemorrhage, telemetry-level (intermediate care unit) or intensive care unit, transfusion, length of stay greater than 5 days, or intraamniotic infection, and individual components of the maternal composite outcome. Groups were compared using Student's t-test, Chi-squared tests, or Fisher's exact. Logistic regression was used to adjust for confounding variables. Results Of 813 women who delivered a live infant between April 1 and July 22, 2020, 53 women were diagnosed with COVID-19 on admission to the hospital. Women with a COVID-19 diagnosis at their time of delivery were significantly more likely to identify as a race other than white (p = 0.01), to deliver preterm (p = 0.05), to be diagnosed with preeclampsia with severe features (p < 0.01), and to require general anesthesia (p < 0.01). Women diagnosed with COVID-19 did not have a significantly higher QBL (p = 0.64). COVID-19 positive pregnant patients had no increased adjusted odds of obstetric hemorrhage (adjusted odds ratio [aOR]: 0.41, 95% confidence interval [CI]: 0.17–1.04) and no increased adjusted odds of the maternal morbidity composite (aOR: 0.98, 95% CI: 0.50–1.93) when compared with those without a diagnosis of COVID-19. Conclusion Pregnant women with COVID-19 diagnosis do not have increased risk for obstetric hemorrhage, increased QBL or risk of maternal morbidity compared with pregnant women without a COVID-19 diagnosis. Further research is needed to describe the impact of a COVID-19 diagnosis on maternal hematologic physiology and pregnancy outcomes. Key Points

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Obstetric hemorrhage risk assessment tool predicts composite maternal morbidity

Scientific Reports ◽

10.1038/s41598-021-93413-3 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Emer L. Colalillo ◽

Andrew D. Sparks ◽

Jaclyn M. Phillips ◽

Chinelo L. Onyilofor ◽

Homa K. Ahmadzia

Keyword(s):

Risk Assessment ◽

High Risk ◽

Risk Prediction ◽

Maternal Morbidity ◽

Assessment Tool ◽

The United States ◽

Low Risk ◽

Risk Assessment Tool ◽

Obstetric Hemorrhage ◽

Hemorrhage Risk

AbstractObstetric hemorrhage is one of the leading preventable causes of maternal mortality in the United States. Although hemorrhage risk-prediction models exist, there remains a gap in literature describing if these risk-prediction tools can identify composite maternal morbidity. We investigate how well an established obstetric hemorrhage risk-assessment tool predicts composite hemorrhage-associated morbidity. We conducted a retrospective cohort analysis of a multicenter database including women admitted to Labor and Delivery from 2016 to 2018, at centers implementing the Association of Women’s Health, Obstetric, and Neonatal Nurses risk assessment tool on admission. A composite morbidity score incorporated factors including obstetric hemorrhage (estimated blood loss ≥ 1000 mL), blood transfusion, or ICU admission. Out of 56,903 women, 14,803 (26%) were categorized as low-risk, 26,163 (46%) as medium-risk and 15,937 (28%) as high-risk for obstetric hemorrhage. Composite morbidity occurred at a rate of 2.2%, 8.0% and 11.9% within these groups, respectively. Medium- and high-risk groups had an increased combined risk of composite morbidity (diagnostic OR 4.58; 4.09–5.13) compared to the low-risk group. This established hemorrhage risk-assessment tool predicts clinically-relevant composite morbidity. Future randomized trials in obstetric hemorrhage can incorporate these tools for screening patients at highest risk for composite morbidity.

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PLACENTA ACCRETA SPECTRUM - A CASE SERIES

10.36106/gjra/5800919 ◽

2020 ◽

pp. 1-4

Author(s):

Medha Dadaji Davile ◽

Anil Charandas Humane ◽

Ashwini Kuchnur

Keyword(s):

Maternal Morbidity ◽

Placenta Accreta ◽

Placenta Previa ◽

Tertiary Care ◽

Obstetric Hemorrhage ◽

Adherent Placenta ◽

Maternal Morbidity And Mortality ◽

Life Threatening ◽

History Of ◽

Placenta Accreta Spectrum

Morbidly adherent placenta is a major cause for massive obstetric hemorrhage, which leads to maternal morbidity and mortality. Most accepted hypothesis for etiology of placenta accreta spectrum is defect in the endometrial–myometrial interface which leads to failure of normal decidualization in the uterine scar, which allows abnormal deep infiltration of placental anchoring villi and trophoblast. Maternal morbidity and mortality can occur as a result of massive and sometimes life-threatening obstetric hemorrhage which often requires blood transfusion. It becomes exponential and life threatening when placenta previa is associated with placenta accreta spectrum. There are several risk factors for placenta accreta spectrum, most common being previous caesarian section. Antenatal diagnosis of placenta accreta is highly desirable as outcomes are optimized when timely delivery occurs at a tertiary care facility accustomed to handle such cases. Here we are reporting six cases of placenta accreta spectrum managed by conventional and expectant way at our tertiary care hospital. Methods: Study was carried out in Government Medical College & Hospital, Nagpur. Case records of patients with placenta accreta syndrome between December 2019 and March 2020 were reviewed and analysed. Results: Six cases of placenta accreta syndrome were studied.100% patients had history of previous caesarean section, 5 patients had associated placenta previa. One out of six patients one had history of dilatation and evacuation for missed abortion.4 out of six underwent caesarean hysterectomy and 2 underwent conservative management with uterine preservation. Average blood loss was 2500 ml. Conservative management was successful in two patients. There was no maternal mortality in series. Conclusion : Among many risk factors, previous caesarean section is the most common. Therefore reducing rate of caesarean deliveries can reduce the prevalence of placenta accreta syndromes. Adherent placenta should be suspected in cases of previous caesarean with placenta previa, high parity, uterine curettage, and uterine surgeries.Conservative management should be reserved for selected patients. MRI is not mandatory for diagnosis of the condition.

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Successful management of total placenta previa with placenta accreta presenting with massive obstetric hemorrhage: A case report

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20183359 ◽

2018 ◽

Vol 7 (8) ◽

pp. 3417

Author(s):

Sairem Mangolnganbi Chanu ◽

Biswajit Dey ◽

Samarjit Dey ◽

Khairul Hadi ◽

Nalini Sharma ◽

...

Keyword(s):

Case Report ◽

Postpartum Hemorrhage ◽

Maternal Morbidity ◽

Placenta Accreta ◽

Placenta Previa ◽

Obstetric Hemorrhage ◽

Successful Management

Placenta previa and placenta accreta are important causes of serious fetal and maternal morbidity and even mortality necessitating hysterectomy. We report a case of total placenta previa with accreta in a 39-year-old female in the 32+2 weeks of pregnancy with successful delivery by cesarean. However, hysterectomy was performed to control postpartum hemorrhage.

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