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Severe Postpartum Hemorrhage from Uterine Atony: A Multicentric Study  [PDF]
Carlos Montufar-Rueda,Laritza Rodriguez,José Douglas Jarquin,Alejandra Barboza,Maura Carolina Bustillo,Flor Marin,Guillermo Ortiz,Francisco Estrada
Journal of Pregnancy , 2013, DOI: 10.1155/2013/525914
Abstract: Objective. Postpartum hemorrhage (PPH) is an important cause of maternal mortality (MM) around the world. Seventy percent of the PPH corresponds to uterine atony. The objective of our study was to evaluate multicenter PPH cases during a 10-month period, and evaluate severe postpartum hemorrhage management. Study Design. The study population is a cohort of vaginal delivery and cesarean section patients with severe postpartum hemorrhage secondary to uterine atony. The study was designed as a descriptive, prospective, longitudinal, and multicenter study, during 10 months in 13 teaching hospitals. Results. Total live births during the study period were 124,019 with 218 patients (0.17%) with severe postpartum hemorrhage (SPHH). Total maternal deaths were 8, for mortality rate of 3.6% and a MM rate of 6.45/100,000 live births (LB). Maternal deaths were associated with inadequate transfusion therapy. Conclusions. In all patients with severe hemorrhage and subsequent hypovolemic shock, the most important therapy is intravascular volume resuscitation, to reduce the possibility of target organ damage and death. Similarly, the current proposals of transfusion therapy in severe or massive hemorrhage point to early transfusion of blood products and use of fresh frozen plasma, in addition to packed red blood cells, to prevent maternal deaths. 1. Introduction National and regional statistics of maternal mortality (MM) are crucial to guide program planning of reproductive and sexual health and to develop guidelines for health promotion and international research. These statistics are also essential to guide decision making in entities involved in program development and allocation of financial and human resources. The lack of reliable data on MM has created difficulties in the evaluation of progress towards the Millennium Development Goals no.5 (MDG 5, http://www.undp.org/content/undp/en/home/mdgoverview.html), especially in developing countries where MM rates are known to be high. Postpartum hemorrhage (PPH) is a major cause of MM around the world with incidence of 2–11% [1–3]. According to the World Health Organization, 10.5% of live births were complicated with PPH, and reports from 2000 show that 13,795,000 women suffered PPH accounting for 13,200 of maternal deaths [4]. The chance of a woman dying during pregnancy and childbirth in Latin America and the Caribbean is 1?:?300 during the reproductive age. In the United States, the probability is 1?:?3,700 [5]. Direct obstetric causes of these conditions are consistent with those recorded in other parts of the world:
I. Marcovici
Jurnalul de Chirurgie , 2005,
Abstract: Postpartum hemorrhage has been defined as either a 10% change in hematocrit between admission and postpartum period or a need of erythrocyte transfusion. The incidence of postpartum hemorrhage is 3.9% for vaginal deliveries and 6.4% for cesarean delivery. Clinically the blood loss is often underestimated by as much as 30% - 50% resulting in a delay in addressing the problem. Postpartum hemorrhage can become rapidly catastrophic. The ACOG ranks postpartum hemorrhage as the third cause of maternal mortality after embolism and hypertensive disease. Predisposing factors for postpartum hemorrhage are: uterine atony (50%), lower genital tract lacerations (20%), uterine abnormalities (20%) etc. Management of the postpartum hemorrhage includes a rapid but thorough physical examination, specifically of the abdominal and pelvic regions, concurrent with laboratory evaluation and volume replacement therapy. Coagulation studies are also necessary. If no genital tract lacerations are found, some maneuvers must be done: uterine exploration followed by uterine massage and blunt curettage, if the products of conception are found in the uterine cavity. If postpartum hemorrhage is due to uterine atony then, uterotonic regimens should be used (methyl-ergonovine, 15-methyl prostaglandin F2 (alpha), prostaglandin E2 or misoprostol). When all other conservative methods of treatment of postpartum hemorrhage failed, before going for invasive procedures as uterine embolization and laparotomy, I strongly suggest the use of Intrauterine Balloon Tamponade. Invasive procedures comprise embolization and laparotomy with conservative techniques (ligation of the uterine blood supply and uterine compression sutures) or hysterectomy or/and Transvaginal Pressure Pelvic Pack. In conclusion, post-partum hemorrhage can become rapidly catastrophic. Once the diagnosis is made, a quick and methodic approach to the problem, following the algorithm bellow, can be very helpful. Also, remember the intrauterine balloon tamponade: very effective, does not require specialized training, it is easy to use and readily available in OR (operating room) and in my opinion it is underutilised.
The Active Management of Postpartum Uterine Atony—A Checklist Based Approach  [PDF]
Rachael Bailey, Michael R. Foley, Nicole Hall, Adiel Fleischer, Mary D’Alton, Gary A. Dildy, Michael A. Belfort, Gary D. Hankins, Steven L. Clark
Open Journal of Obstetrics and Gynecology (OJOG) , 2016, DOI: 10.4236/ojog.2016.611081
Abstract: Uterine atony remains the major cause of postpartum hemorrhage, and of death from postpartum hemorrhage in the United States. While existing guidelines outlining a general approach to postpartum hemorrhage are useful, recent data suggest that greater specificity may be necessary to significantly impact mortality. We present a highly specific and methodical approach to the management of uterine atony, which addresses what we believe to be the most common cause of preventable maternal hemorrhagic death in the US—lack of an intensive, focused approach to atony and perseverance with therapies that are not working. This protocol should result in cessation of hemorrhage by medical or surgical means within 1 hour of diagnosis. We then apply this protocol to a number of illustrative cases of maternal death due to atony. An approach involving the active management of uterine atony may assist clinicians in avoiding severe morbidity and mortality from uterine atony.
Uterine Rupture with Massive Late Postpartum Hemorrhage due to Placenta Percreta Left Partially In Situ  [PDF]
Mehmet Coskun Salman,Pinar Calis,Ozgur Deren
Case Reports in Obstetrics and Gynecology , 2013, DOI: 10.1155/2013/906351
Abstract: Placental adhesive disorders involve the growth of placental tissue into or through the uterine wall. Among these disorders, placenta percreta is the rarest one. However, it may cause significant complications. This report aimed to report a neglected patient with placenta percreta who developed uterine rupture with life-threatening late postpartum intra-abdominal hemorrhage. On admission, the patient had acute abdomen with moderate abdominal distention and was subjected to emergency laparotomy. A full-thickness defect of the anterior uterine wall involving the hysterotomy site was seen. Placental tissues occupied both sides of the incision and posterior bladder wall was also invaded by placenta. Total abdominal hysterectomy with partial resection of the posterior bladder wall was performed. 1. Introduction Placental adhesive disorders involve the growth of placental tissue into or through the uterine wall. Among these disorders, placenta accreta is the most common type where the chorionic villi are in contact with myometrium. The rarest one is placenta percreta in which the chorionic villi invade through uterine serosa and may involve the adjacent organs [1]. Therefore, placenta percreta may cause significant complications due to massive hemorrhage, infection, and injury to surrounding organs. Also, placenta percreta was reported to be associated with maternal mortality in approximately 6% of cases [2]. The management of patients with placenta percreta is of vital importance accordingly. Traditional management consisted of cesarean hysterectomy that may be associated with significant intraoperative and postoperative complications [3]. However, optimal management has yet to be defined and conservative management options are becoming more widely accepted to avoid surgery-related morbidity and even mortality [4]. Nevertheless, conservative approaches are not devoid of serious complications [4, 5]. The aim of this report is to describe a neglected case of placenta percreta initially managed conservatively who developed uterine rupture with life-threatening late postpartum intra-abdominal hemorrhage. The management options for placenta percreta were discussed as well. 2. Case Presentation A 35-year-old gravida 3, parity 2 woman was admitted to the hospital for vaginal bleeding and severe abdominal pain. Her past medical history was free of any medical problems. On her obstetric history, she had a vaginal delivery following an uneventful pregnancy course 8 years ago. Her second pregnancy was terminated via hysterotomy at 18th weeks due to multiple fetal
Uterine Artery Pseudoaneurysm in the Setting of Delayed Postpartum Hemorrhage: Successful Treatment with Emergency Arterial Embolization
Ankur M. Sharma,Brent E. Burbridge
Case Reports in Radiology , 2011, DOI: 10.1155/2011/373482
Abstract: Postpartum hemorrhage is a major cause of maternal mortality. Though uncommon, uterine artery pseudoaneurysm can follow uterine dilatation and curettage (D
Efficacy of Uterine Artery Embolization for Patients with Postpartum Hemorrhage  [PDF]
Young Ho Choi, Yasutaka Baba, Shunichiro Ikeda, Young Ho So, Sadao Hayashi, Masayuki Nakajo
Open Journal of Radiology (OJRad) , 2013, DOI: 10.4236/ojrad.2013.32008

Purpose: To investigate the efficacy of uterine arterial embolization (UAE) in patients with post-partum hemorrhage (PPH). Materials and Methods: The subjects were 40 women (mean age, 33 years; age range, 21 - 42 years) who underwent UAE for PPH at two institutes from June 2001 to May 2011. The rates of clinical success (avoidance of hysterectomy) and complications were calculated. Differences in related factors between primary PPH and secondary PPH and between caesarean section and vaginal delivery were examined. The risk factors associated with hysterectomy were also examined. Results: The overall clinical success rate was 90% (93% of primary PPH, 77% of secondary PPH, and 87.5% of PPH with cesarean section), and the overall complication rate was 10%. There were significant differences in time to PPH (P < 0.0001) and in blood infusion after UAE (P = 0.0158) between subtypes of primary and secondary PPH and in blood infusion before UAE (P = 0.0052) between delivery methods. The significant factors associated with hysterectomy were cesarean section (P = 0.02), severe PPH (>1000 mL bleeding, P = 0.03), and embolization of non-uterine arteries (P = 0.02).

Safety Pin Suture for Management of Atonic Postpartum Hemorrhage  [PDF]
Ali Abdelhamed M. Mostfa,Mostafa M. Zaitoun
ISRN Obstetrics and Gynecology , 2012, DOI: 10.5402/2012/405795
Abstract: Objective. To assess the efficacy of a new suture technique in controlling severe resistant uterine atonic postpartum hemorrhage. Patients and Methods. This is a retrospective observational study that included thirteen women with uterine atony and postpartum bleeding that did not react to usual medical management. All these women underwent compressing vertical suture technique in which the anterior and posterior walls of the uterus were attached so as to compress the uterus. The suture is transfixed at the uterine fundus, thus eliminating the risk of sutures sliding off at the uterine fundus (safety pin suture). Results. safety pin uterine compression suture was a sufficient procedure to stop the bleeding immediately in 92.2% of the women. None of the women developed complications related to the procedure. Conclusion. A new safety pin suture is a simple and effective procedure to control bleeding in patients with treatment-resistant, life-threatening atonic postpartum hemorrhage with the advantage of eliminating the risk of the sutures sliding off at the uterine fundus. 1. Introduction Primary postpartum hemorrhage (PPH) is a major obstetric complication that can follow delivery leading to catastrophic event (hysterectomy and/or maternal death) in patients not responding to medical treatment. Even in a saved patients it may be a major cause of maternal morbidity such as renal failure and/or Sheehan’s syndrome (a potentially life-threatening complication).The most common cause of PPH is uterine atony, which is responsible for at least 80 percent of cases [1]. Although risk factors and preventive measures are clearly known, some cases of PPH are unexpected. In developing countries, home vaginal deliveries (which still present in many areas) are poorly managed with increased risk of labor abnormalities that represent a risk factor to PPH and sometimes unavoidable hysterectomy. The general management of atonic PPH starts by conservative measures (uterine massage and uterotonics drugs) escalating to unavoidable surgical interventions (internal iliac artery ligation and hysterectomy) to control severe life-threatening bleeding [2]. Surgical uterine compression sutures, a mechanical method of compressing the uterus and closing the arterial bed to reduce bleeding, have been developed to avoid emergency hysterectomy and to preserve fertility in these patients [3–6]. 2. Patients and Method This is a retrospective observational study carried out at Obstetric and Gynecology Departments, Zagazig University Hospitals, Egypt on, 13 patients presented by severe atonic
A New Removable Uterine Compression by a Brace Suture in the Management of Severe Postpartum Hemorrhage  [PDF]
Abderrahim Aboulfalah
Frontiers in Surgery , 2014, DOI: 10.3389/fsurg.2014.00043
Abstract: Postpartum hemorrhage (PPH) is a life-threatening complication of delivery. It is the leading cause of maternal mortality. During the last 15 years, several total uterine compressive sutures were described in literature. They have proven their effectiveness and safety in the management of severe PPH as an alternative to hysterectomy. We present in this paper a new technique of uterine compressive sutures based on removable uterine brace compressive sutures with compression of the uterus against the pubis. This technique may be more effective by using two mechanisms of uterine bleeding control and also may prevent uterine synechia by respecting the uterine cavity and the removal of the suture 1 or 2 days later. We also present the results of a 15 patients’ series using this new suture.
Evaluation of compliance and outcomes of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in Pakistan
Lumaan Sheikh, Nida Najmi, Umair Khalid, Taimur Saleem
BMC Pregnancy and Childbirth , 2011, DOI: 10.1186/1471-2393-11-28
Abstract: An evidence based management protocol for massive postpartum hemorrhage was implemented at Aga Khan University Hospital, Karachi, Pakistan after an audit in 2005. We sought to evaluate the compliance and outcomes associated with this management protocol 3 years after its implementation. A review of all deliveries with massive primary postpartum hemorrhage (blood loss ≥ 1500 ml) between January, 2008 to December, 2008 was carried out. Information regarding mortality, mode of delivery, possible cause of postpartum hemorrhage and medical or surgical intervention was collected. The estimation of blood loss was made via subjective and objective assessment.During 2008, massive postpartum hemorrhage occurred in 0.64% cases (26/4,052). No deaths were reported. The mean blood loss was 2431 ± 1817 ml (range: 1500 - 9000 ml). Emergency cesarean section was the most common mode of delivery (13/26; 50%) while uterine atony was the most common cause of massive postpartum hemorrhage (14/26; 54%). B-lynch suture (24%) and balloon tamponade (60%) were used more commonly as compared to our previously reported experience. Cesarean hysterectomy was performed in 3 cases (12%) for control of massive postpartum hemorrhage. More than 80% compliance was observed in 8 out of 10 steps of the management protocol. Initiation of blood transfusion at 1500 ml blood loss (89%) and overall documentation of management (92%) were favorably observed in most cases.This report details our experience with the practical implementation of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in a developing country. With the exception of arterial embolization, relatively newer, simpler and potentially safer techniques are now being employed for the management of massive postpartum hemorrhage at our institution. Particular attention should be paid to the documentation of the management steps while ensuring a stricter adherence to the formulated protocols and guidelines in order
The Professional Medical Journal , 2007,
Abstract: Objectives: To describe the associated risk factor for primary Postpartum Hemorrhage (PPH) andits severity with increasing parity and duration of labour. Design: It was a descriptive study. Place and duration ofstudy: The Department of Obstetrics & Gynecology (Unit II) of Bahawal Victoria Hospital, Bahawalpur from January2004 to December 2004. Patient and method: Fifty patients with primary postpartum hemorrhage were included inthis study. Data was collected from the patients through a structured proforma. The variable studied were parity,duration of labour and risk factors for primary PPH. The results were statistically analyzed, chi-square test was appliedto find out the significance of parity and duration of labour and their relationship with severity of PPH. Simplepercentages were used to find associated risk factor for primary PPH. Results: The frequency of primary PPH inprimary para was 24% (12 patients) and in multi para was 76%(38 patients). Severity of PPH increased with increasingparity (P<.05). After merging the variable of parity severity of PPH increased in patients with prolonged labour innormally delivered patients (P<.05). As for as risk factors are concerned 60% had uterine atony while 16% got cervicaltear and the same number had retained placenta, 8% had preneal tear, Uterine inversion was seen in 6%, 4%presented with polyhydrominos, same with placenta previa type-1. 4% had vaginal laceration, 2% had DIC and 2%had abruptio placenta. Conclusion: The result of the study revealed a number of associated risk factors for primaryPPH and proved the relationship of its severity with increasing parity and duration of labour. Duration of labour had asignificant relationship with PPH even in Primipara.
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