Medicine › Pediatrics, Perinatology and Child Health

Maternal and fetal healthcare

Works Count: 43740

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Description

This cluster of papers focuses on the various aspects of maternal morbidity associated with pregnancy and childbirth, including conditions such as placenta accreta, postpartum hemorrhage, and peripartum hysterectomy. It also explores topics like racial/ethnic disparities, conservative management strategies, prenatal diagnosis techniques, and the impact of ICU admissions on maternal outcomes.

Keywords

Placenta Accreta; Postpartum Hemorrhage; Maternal Mortality; Severe Obstetric Morbidity; Prenatal Diagnosis; Peripartum Hysterectomy; Racial/Ethnic Disparities; Conservative Management; Near Miss Events; ICU Admissions

Incidence and predictors of severe obstetric morbidity: case-control study Commentary: Obstetric morbidity data and the need to evaluate thromboembolic disease

2001-05-05

Mark Waterstone

<h3>abstract</h3> <b>Objective:</b> To estimate the incidence and predictors of severe obstetric morbidity. <b>Design:</b> Development of definitions of severe obstetric morbidity by literature review. Case-control study from a defined delivery population … <h3>abstract</h3> <b>Objective:</b> To estimate the incidence and predictors of severe obstetric morbidity. <b>Design:</b> Development of definitions of severe obstetric morbidity by literature review. Case-control study from a defined delivery population with four randomly selected pregnant women as controls for every case. <b>Setting:</b> All 19 maternity units within the South East Thames region and six neighbouring hospitals caring for pregnant women from the region between 1 March 1997 and 28 February 1998. <b>Participants:</b> 48 865 women who delivered during the time frame. <b>Results:</b> There were 588 cases of severe obstetric morbidity giving an incidence of 12.0/1000 deliveries (95% confidence interval 11.2 to 13.2). During the study there were five maternal deaths attributed to conditions studied. Disease specific morbidities per 1000 deliveries were 6.7 (6.0 to 7.5) for severe haemorrhage, 3.9 (3.3 to 4.5) for severe pre-eclampsia, 0.2 (0.1 to 0.4) for eclampsia, 0.5 (0.3 to 0.8) for HELLP (Haemolysis, Elevated Liver enzymes, and Low Platelets) syndrome, 0.4 (0.2 to 0.6) for severe sepsis, and 0.2 (0.1 to 0.4) for uterine rupture. Age over 34 years, non-white ethnic group, past or current hypertension, previous postpartum haemorrhage, delivery by emergency caesarean section, antenatal admission to hospital, multiple pregnancy, social exclusion, and taking iron or anti-depressants at antenatal booking were all independently associated with morbidity after adjustment. <b>Conclusion:</b> Severe obstetric morbidity and its relation to mortality may be more sensitive measures of pregnancy outcome than mortality alone. Most events are related to obstetric haemorrhage and severe pre-eclampsia. Caesarean section quadruples the risk of morbidity. Development and evaluation of ways of predicting and reducing risk are required with particular emphasis paid on the management of haemorrhage and pre-eclampsia. <h3>What is already known on this topic</h3> Maternal mortality is used internationally as a measure of the quality of obstetric intervention, although it is now rare in the developed world Hospital based series estimating the incidence of severe obstetric morbidity have used different definitions Estimated incidence of severe obstetric morbidity ranges from 0.05 to 1.09 <h3>What this study adds</h3> With clear definitions and population based estimates of some severe obstetric morbidities this study estimated the overall incidence of severe obstetric morbidity as 1.2 % of deliveries Two thirds of the cases are related to severe haemorrhage, one third to hypertensive disorders Risk factors for severe maternal morbidity include maternal age >34, social exclusion, non-white, hypertension, previous postpartum haemorrhage, induction of labour, and caesarean section

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Factors associated with postpartum hemorrhage with vaginal birth.

1991-01-01

C. Andrew Combs , E L Murphy , Russell K. Laros

A case-control study was performed to study risk factors for postpartum hemorrhage. Cases of hemorrhage were defined by a hematocrit decrease of 10 points or more between admission and post-delivery … A case-control study was performed to study risk factors for postpartum hemorrhage. Cases of hemorrhage were defined by a hematocrit decrease of 10 points or more between admission and post-delivery or by the need for red-cell transfusion. Patients with antenatal bleeding were excluded. Among 9598 vaginal deliveries, postpartum hemorrhage occurred in 374 cases (3.9%). Three controls were matched to each case and multiple logistic regression was used to control for covariance among predictor variables. Factors having a significant association with hemorrhage were prolonged third stage of labor (adjusted odds ratio 7.56), preeclampsia (odds ratio 5.02), mediolateral episiotomy (4.67), previous postpartum hemorrhage (3.55), twins (3.31), arrest of descent (2.91), soft-tissue lacerations (2.05), augmented labor (1.66), forceps or vacuum delivery (1.66), Asian (1.73) or Hispanic (1.66) ethnicity, midline episiotomy (1.58), and nulliparity (1.45). These data may help predict postpartum hemorrhage and may be useful in counseling patients about the advisability of home delivery, intravenous access in labor, or autologous blood donation.

Placenta previa/accreta and prior cesarean section.

1985-07-01

Steven L. Clark , Paul P. Koonings , Jeffrey P. Phelan

To assess the relationship between increasing numbers of previous cesarean sections and the subsequent development of placenta previa and placenta accreta, the records of all patients presenting to labor and … To assess the relationship between increasing numbers of previous cesarean sections and the subsequent development of placenta previa and placenta accreta, the records of all patients presenting to labor and delivery with the diagnosis of placenta previa between 1977 and 1983 were examined. Of a total of 97,799 patients, 292 (0.3%) had a placenta previa. The risk of placenta previa was 0.26% with an unscarred uterus and increased almost linearly with the number of prior cesarean sections to 10% in patients with four or more. The effect of advancing age and parity on the incidence of placenta previa was much less dramatic. Patients presenting with a placenta previa and an unscarred uterus had a 5% risk of clinical placenta accreta. With a placenta previa and one previous cesarean section, the risk of placenta accreta was 24%; this risk continued to increase to 67% (two of three) with a placenta previa and four or more cesarean sections. Possible mechanisms and clinical implications are discussed.

Abnormal Placentation

2015-08-05

Robert M. Silver

Placental disorders such as placenta previa, placenta accreta, and vasa previa are all associated with vaginal bleeding in the second half of pregnancy. They are also important causes of serious … Placental disorders such as placenta previa, placenta accreta, and vasa previa are all associated with vaginal bleeding in the second half of pregnancy. They are also important causes of serious fetal and maternal morbidity and even mortality. Moreover, the rates of previa and accreta are increasing, probably as a result of increasing rates of cesarean delivery, maternal age, and assisted reproductive technology. The routine use of obstetric ultrasonography as well as improving ultrasonographic technology allows for the antenatal diagnosis of these conditions. In turn, antenatal diagnosis facilitates optimal obstetric management. This review emphasizes an evidence-based approach to the clinical management of pregnancies with these conditions as well as highlights important knowledge gaps.

Placenta accreta: prospective sonographic diagnosis in patients with placenta previa and prior cesarean section

1992-07-01

Harris J. Finberg , Jesse W. Williams

A prospective evaluation for possible placenta accreta was performed in 34 patients with placenta previa and a history of one or more cesarean sections. Sonographic criteria used included (1) loss … A prospective evaluation for possible placenta accreta was performed in 34 patients with placenta previa and a history of one or more cesarean sections. Sonographic criteria used included (1) loss of the normal hypoechoic retroplacental myometrial zone, (2) thinning or disruption of the hyperechoic uterine serosa-bladder interface, and (3) presence of focal exophytic masses. Of 18 patients with positive sonographic results, 14 had proof of placenta accreta and 16 of the patients underwent hysterectomy. Of 16 patients with negative sonographic results, only one had placenta accreta, and two patients required hysterectomy. Presence of numerous intraplacental vascular lacunae appears to be an additional risk criterion for placenta accreta, separate from the other criteria listed above.

Ultrasonography in obstetrics and gynecology

2015-10-26

P W Callen

Accuracy of Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of Placenta Accreta

2006-09-01

Carri R. Warshak , Ramez N. Eskander , Andrew Hull +4 more

The incidence of placenta accreta has increased dramatically over the last three decades, in concert with the increase in the cesarean delivery rate. Optimal management requires accurate prenatal diagnosis. The … The incidence of placenta accreta has increased dramatically over the last three decades, in concert with the increase in the cesarean delivery rate. Optimal management requires accurate prenatal diagnosis. The purpose of this study was to determine the precision and reliability of ultrasonography and magnetic resonance imaging (MRI) in diagnosing placenta accreta.A historical cohort study was performed with information gathered from our obstetric, radiologic, and pathology databases. Records from January 2000 to June 2005 were reviewed to identify patients with a diagnosis of placenta previa, low-lying placenta with a prior cesarean delivery, or history of a myomectomy to determine the accuracy of pelvic ultrasonography in the diagnosis of placenta accreta. The records of those considered to be suspicious for placenta accreta and subsequently referred for additional confirmation by MRI were also analyzed. The sonographic and MRI diagnoses were compared with the final pathologic or operative findings or with both.Of the 453 women with placenta previa, previous cesarean delivery and low-lying anterior placenta, or previous myomectomy, 39 had placenta accreta confirmed by pathological examination. Ultrasonography accurately predicted placenta accreta in 30 of 39 of women and correctly ruled out placenta accreta in 398 of 414 without placenta accreta (sensitivity 0.77, specificity 0.96). Forty-two women underwent MRI evaluation because of findings suspicious or inconclusive of placenta accreta by ultrasonography. Magnetic resonance imaging accurately predicted placenta accreta in 23 of 26 cases with placenta accreta and correctly ruled out placenta accreta in 14 of 14 (sensitivity 0.88, specificity 1.0).A two-stage protocol for evaluating women at high risk for placenta accreta, which uses ultrasonography first, and then MRI for cases with inconclusive ultrasound features, will optimize diagnostic accuracy.

Sonographic detection of placenta accreta in the second and third trimesters of pregnancy

2004-04-01

Christine H. Comstock , Joseph J. Love , Richard Bronsteen +4 more

Impact of multiple cesarean deliveries on maternal morbidity: a systematic review

2011-06-25

Nicole Marshall , Rongwei Fu , Jeanne‐Marie Guise

Pregnancy-Related Mortality in the United States, 2006–2010

2014-12-08

Andreea A. Creanga , Cynthia J. Berg , Carla Syverson +3 more

In Brief OBJECTIVE: To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2006–2010. METHODS: We used data from the … In Brief OBJECTIVE: To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2006–2010. METHODS: We used data from the Pregnancy Mortality Surveillance System and calculated pregnancy-related mortality ratios by year and age group for four race–ethnicity groups: non-Hispanic white, non-Hispanic black, Hispanic, and other. We examined causes of pregnancy-related deaths by pregnancy outcome during 2006–2010 and compared causes of pregnancy-related deaths since 1987. RESULTS: The 2006–2010 pregnancy-related mortality ratio was 16.0 deaths per 100,000 live births (20,959,533 total live births). Specific race–ethnicity pregnancy-related mortality ratios were 12.0, 38.9, 11.7, and 14.2 deaths per 100,000 live births for non-Hispanic white, non-Hispanic black, Hispanic, and other race women, respectively. Pregnancy-related mortality ratios increased with maternal age for all women and within all age groups, non-Hispanic black women had the highest risk of dying from pregnancy complications. Over time, the contribution to pregnancy-related deaths of hemorrhage, hypertensive disorders of pregnancy, embolism, and anesthesia complications continued to decline, whereas the contribution of cardiovascular conditions and infection increased. Seven of 10 categories of causes of death each contributed from 9.4% to 14.6% of all 2006–2010 pregnancy-related deaths; cardiovascular conditions ranked first. CONCLUSION: Relative to previous years, during 2006–2010, the U.S. pregnancy-related mortality ratio increased as did the contribution of cardiovascular conditions and infection to pregnancy-related mortality. Although the identification of pregnancy-related deaths may be improving in the United States, the increasing contribution of chronic diseases to pregnancy-related mortality suggests a change in risk profile of the birthing population. LEVEL OF EVIDENCE: II Relative to previous years, during 2006–2010, the U.S. pregnancy-related mortality ratio increased, as did the contribution of cardiovascular conditions and infection to pregnancy-related mortality.

The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage

2007-01-22

Bény Charbit , Laurent Mandelbrot , Emmanuel Samain +7 more

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Severe Maternal Morbidity Among Delivery and Postpartum Hospitalizations in the United States

2012-10-09

William M. Callaghan , Andreea A. Creanga , Elena V. Kuklina

OBJECTIVES: To propose a new standard for monitoring severe maternal morbidity, update previous estimates of severe maternal morbidity during both delivery and postpartum hospitalizations, and estimate trends in these events … OBJECTIVES: To propose a new standard for monitoring severe maternal morbidity, update previous estimates of severe maternal morbidity during both delivery and postpartum hospitalizations, and estimate trends in these events in the United States between 1998 and 2009. METHODS: Delivery and postpartum hospitalizations were identified in the Nationwide Inpatient Sample for the period 1998–2009. International Classification of Diseases, 9th Revision codes indicating severe complications were used to identify hospitalizations with severe maternal morbidity and related in-hospital mortality. Trends were reported using 2-year increments of data. RESULTS: Severe morbidity rates for delivery and postpartum hospitalizations for the 2008–2009 period were 129 and 29, respectively, for every 10,000 delivery hospitalizations. Compared with the 1998–1999 period, severe maternal morbidity increased by 75% and 114% for delivery and postpartum hospitalizations, respectively. We found increasing rates of blood transfusion, acute renal failure, shock, acute myocardial infarction, respiratory distress syndrome, aneurysms, and cardiac surgery during delivery hospitalizations. Moreover, during the study period, rates of postpartum hospitalization with 13 of the 25 severe complications examined more than doubled, and the overall mortality during postpartum hospitalizations increased by 66% (P<.05). CONCLUSIONS: Severe maternal morbidity currently affects approximately 52,000 women during their delivery hospitalizations and, based on current trends, this burden is expected to increase. Clinical review of identified cases of severe maternal morbidity can provide an opportunity to identify points of intervention for quality improvement in maternal care. LEVEL OF EVIDENCE: III

Menstrual Blood Loss–A Population Study

1966-01-01

Leif Hallberg , Ann‐Marie Hôgdahl , Lennart Nilsson +1 more

Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study

2000-11-18

Agustín Conde‐Agudelo

<h3>Abstract</h3> <b>Objective:</b> To study the impact of interpregnancy interval on maternal morbidity and mortality. <b>Design:</b> Retrospective cross sectional study with data from the Perinatal Information System database of the Latin … <h3>Abstract</h3> <b>Objective:</b> To study the impact of interpregnancy interval on maternal morbidity and mortality. <b>Design:</b> Retrospective cross sectional study with data from the Perinatal Information System database of the Latin American Centre for Perinatology and Human Development, Montevideo, Uruguay. <b>Setting:</b> Latin America and the Caribbean, 1985-97. <b>Participants:</b> 456 889 parous women delivering singleton infants. <b>Main outcome measures:</b> Crude and adjusted odds ratios of the effects of short and long interpregnancy intervals on maternal death, pre-eclampsia, eclampsia, gestational diabetes mellitus, third trimester bleeding, premature rupture of membranes, postpartum haemorrhage, puerperal endometritis, and anaemia. <b>Results:</b> Short (<6 months) and long (>59 months) interpregnancy intervals were observed for 2.8% and 19.5% of women, respectively. After adjustment for major confounding factors, compared with those conceiving at 18 to 23 months after a previous birth, women with interpregnancy intervals of 5 months or less had higher risks for maternal death (odds ratio 2.54; 95% confidence interval 1.22 to 5.38), third trimester bleeding (1.73; 1.42 to 2.24), premature rupture of membranes (1.72; 1.53 to 1.93), puerperal endometritis (1.33; 1.22 to 1.45), and anaemia (1.30; 1.18 to 1.43). Compared with women with interpregnancy intervals of 18 to 23 months, women with interpregnancy intervals longer than 59 months had significantly increased risks of pre-eclampsia (1.83; 1.72 to 1.94) and eclampsia (1.80; 1.38 to 2.32). <b>Conclusions:</b> Interpregnancy intervals less than 6 months and longer than 59 months are associated with an increased risk of adverse maternal outcomes.

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Preventability of Pregnancy-Related Deaths

2005-12-01

Cynthia J. Berg , Margaret Harper , Samuel Atkinson +6 more

In Brief OBJECTIVE: Although the risk of death from complications of pregnancy in the 20th century has decreased dramatically, several lines of evidence suggest that it has not reached an … In Brief OBJECTIVE: Although the risk of death from complications of pregnancy in the 20th century has decreased dramatically, several lines of evidence suggest that it has not reached an irreducible minimum. To further reduce pregnancy-related mortality, we must understand which deaths are potentially preventable and the changes needed to prevent them. We sought to identify all pregnancy-related deaths in North Carolina and conduct a comprehensive review examining ways in which the number of these deaths could potentially be reduced. METHODS: The North Carolina Pregnancy-Related Mortality Review Committee reviewed all of the 108 pregnancy-related deaths (women who died during or within 1 year of the end of pregnancy from a complication of pregnancy or its treatment) that occurred in the state in 1995–1999. For each death, the committee determined the cause of death, whether it could have been prevented, and if so, the means by which it might have been prevented. RESULTS: Although overall, 40% of pregnancy-related deaths were potentially preventable, this varied by the cause of death. Almost all deaths due to hemorrhage and complications of chronic diseases were believed to be potentially preventable, whereas none of the deaths due to amniotic fluid embolus, microangiopathic hemolytic syndrome, and cerebrovascular accident were considered preventable. Improved quality of medical care was considered to be the most important factor in preventing these deaths. Among African-American women, 46% of deaths were potentially preventable, compared with 33% of the deaths among white women. CONCLUSION: Despite the decline in pregnancy-related mortality rates, almost one half of these deaths could potentially be prevented, mainly through improved quality of medical care. In-depth review of pregnancy-related deaths can help determine strategies needed to continue making pregnancy safer. LEVEL OF EVIDENCE: III State-wide review of pregnancy-related deaths reveals 40 to be potentially preventable with changes in preconception care, patient adherence, the health care system structure, and quality of care.

The Epidemiology of Postpartum Hemorrhage in a Large, Nationwide Sample of Deliveries

2010-03-18

Brian T. Bateman , Mitchell F. Berman , Laura E. Riley +1 more

In this study, we sought to (1) define trends in the incidence of postpartum hemorrhage (PPH), and (2) elucidate the contemporary epidemiology of PPH focusing on risk factors and maternal … In this study, we sought to (1) define trends in the incidence of postpartum hemorrhage (PPH), and (2) elucidate the contemporary epidemiology of PPH focusing on risk factors and maternal outcomes related to this delivery complication.Hospital admissions for delivery were extracted from the Nationwide Inpatient Sample, the largest discharge dataset in the United States. Using International Classification of Diseases, Clinical Modification (ninth revision) codes, deliveries complicated by PPH were identified, as were comorbid conditions that may be risk factors for PPH. Temporal trends in the incidence of PPH from 1995 to 2004 were assessed. Logistic regression was used to identify risk factors for the most common etiology of PPH-uterine atony.In 2004, PPH complicated 2.9% of all deliveries; uterine atony accounted for 79% of the cases of PPH. PPH was associated with 19.1% of all in-hospital deaths after delivery. The overall rate of PPH increased 27.5% from 1995 to 2004, primarily because of an increase in the incidence of uterine atony; the rates of PPH from other causes including retained placenta and coagulopathy remained relatively stable during the study period. Logistic regression modeling identified age <20 or > or =40 years, cesarean delivery, hypertensive diseases of pregnancy, polyhydramnios, chorioamnionitis, multiple gestation, retained placenta, and antepartum hemorrhage as independent risk factors for PPH from uterine atony that resulted in transfusion. Excluding maternal age and cesarean delivery, one or more of these risk factors were present in only 38.8% of these patients.PPH is a relatively common complication of delivery and is associated with substantial maternal morbidity and mortality. It is increasing in frequency in the United States. PPH caused by uterine atony resulting in transfusion often occurs in the absence of recognized risk factors.

Abnormal placentation: Twenty-year analysis

2005-05-01

Serena Wu , Masha Kocherginsky , Judith U. Hibbard

Control of postpartum hemorrhage with uterine packing

1993-08-01

Robert C. Maier

Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery

2008-05-04

Steven L. Clark , Michael A. Belfort , Gary A. Dildy +3 more

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The B‐Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported

1997-03-01

Christopher B‐Lynch , Adeyemi Coker , A. H. Lawal +2 more

The B-Lynch suturing technique (brace suture) may be particularly useful because of its simplicity of application, life saving potential, relative safety, and its capacity for preserving the uterus and thus … The B-Lynch suturing technique (brace suture) may be particularly useful because of its simplicity of application, life saving potential, relative safety, and its capacity for preserving the uterus and thus fertility. Satisfactory haemostasis can be assessed immediately after application. If it fails, which has not yet been the case, other more radical surgical methods as mentioned in this paper and in the literature can be considered. The special advantage of this innovative technique is an alternative to major surgical procedures to control pelvic arterial pulse pressure or hysterectomy. This suturing technique has been successfully applied with no problems to date and no apparent complications.

Trends in postpartum hemorrhage: United States, 1994–2006

2010-03-30

William M. Callaghan , Elena V. Kuklina , Cynthia J. Berg

Pregnancy-Related Mortality in the United States, 1998 to 2005

2010-11-23

Cynthia J. Berg , William M. Callaghan , Carla Syverson +1 more

In Brief OBJECTIVE: To estimate the risk of women dying from pregnancy complications in the United States and to examine the risk factors for and changes in the medical causes … In Brief OBJECTIVE: To estimate the risk of women dying from pregnancy complications in the United States and to examine the risk factors for and changes in the medical causes of these deaths. METHODS: De-identified copies of death certificates for women who died during or within 1 year of pregnancy and matching birth or fetal death certificates for 1998 through 2005 were received by the Pregnancy Mortality Surveillance System from the 50 states, New York City, and Washington, DC. Causes of death and factors associated with them were identified, and pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births) were calculated. RESULTS: The aggregate pregnancy-related mortality ratio for the 8-year period was 14.5 per 100,000 live births, which is higher than any period in the previous 20 years of the Pregnancy Mortality Surveillance System. African-American women continued to have a three- to four-fold higher risk of pregnancy-related death. The proportion of deaths attributable to hemorrhage and hypertensive disorders declined from previous years, whereas the proportion from medical conditions, particularly cardiovascular, increased. Seven causes of death—hemorrhage, thrombotic pulmonary embolism, infection, hypertensive disorders of pregnancy, cardiomyopathy, cardiovascular conditions, and noncardiovascular medical conditions—each contributed 10% to 13% of deaths. CONCLUSION: The reasons for the reported increase in pregnancy-related mortality are unclear; possible factors include an increase in the risk of women dying, changed coding with the International Classification of Diseases, 10thRevision, and the addition by states of pregnancy checkboxes to the death certificate. State-based maternal death reviews and maternal quality collaboratives have the potential to identify deaths, review the factors associated with them, and take action on the findings. LEVEL OF EVIDENCE: III Reported pregnancy-related mortality rates increased as ascertainment methods changed. Cardiovascular and other medical conditions are now major causes of pregnancy-related death.

Incidence, risk factors, and temporal trends in severe postpartum hemorrhage

2013-07-16

Michael S. Kramer , Cynthia J. Berg , Haim A. Abenhaim +4 more

Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group

2009-11-27

Marian Knight , William M. Callaghan , Cynthia J. Berg +7 more

Postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Several recent publications have noted an increasing trend in incidence over time. The international PPH collaboration was … Postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Several recent publications have noted an increasing trend in incidence over time. The international PPH collaboration was convened to explore the observed trends and to set out actions to address the factors identified.We reviewed available data sources on the incidence of PPH over time in Australia, Belgium, Canada, France, the United Kingdom and the USA. Where information was available, the incidence of PPH was stratified by cause.We observed an increasing trend in PPH, using heterogeneous definitions, in Australia, Canada, the UK and the USA. The observed increase in PPH in Australia, Canada and the USA was limited solely to immediate/atonic PPH. We noted increasing rates of severe adverse outcomes due to hemorrhage in Australia, Canada, the UK and the USA.Key Recommendations 1. Future revisions of the International Classification of Diseases should include separate codes for atonic PPH and PPH immediately following childbirth that is due to other causes. Also, additional codes are required for placenta accreta/percreta/increta. 2. Definitions of PPH should be unified; further research is required to investigate how definitions are applied in practice to the coding of data. 3. Additional improvement in the collection of data concerning PPH is required, specifically including a measure of severity. 4. Further research is required to determine whether an increased rate of reported PPH is also observed in other countries, and to further investigate potential risk factors including increased duration of labor, obesity and changes in second and third stage management practice. 5. Training should be provided to all staff involved in maternity care concerning assessment of blood loss and the monitoring of women after childbirth. This is key to reducing the severity of PPH and preventing any adverse outcomes. 6. Clinicians should be more vigilant given the possibility that the frequency and severity of PPH has in fact increased. This applies particularly to small hospitals with relatively few deliveries where management protocols may not be defined adequately and drugs or equipment may not be on hand to deal with unexpected severe PPH.

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Severe acute maternal morbidity: a pilot study of a definition for a near‐miss

1998-09-01

Gerald D. Mantel , Eckhart Buchmann , Helen Rees +1 more

To test the application of a clinical definition of severe acute maternal morbidity.A one-year prospective descriptive multi-centre study.Kalafong and Pretoria Academic hospitals, catering for the delivery of indigent women in … To test the application of a clinical definition of severe acute maternal morbidity.A one-year prospective descriptive multi-centre study.Kalafong and Pretoria Academic hospitals, catering for the delivery of indigent women in the Pretoria Health Region.A 'near-miss' describes a patient with an acute organ system dysfunction, which if not treated appropriately, could result in death. The case notes of women fitting this definition and all maternal deaths were analysed and compared.Determine the primary obstetric factors and the organ systems that failed. Identification of episodes of sub-standard care and missed opportunities. Results One hundred and forty-seven near misses and 30 maternal deaths were identified. The commonest reasons for a near-miss were: emergency hysterectomy in 42 women (29%); severe hypotension in 40 (27%); and pulmonary oedema in 24 (16%). The most common initiating obstetric conditions were hypertension in 38 women (26%); haemorrhage in 38 (26%); and abortion or puerperal sepsis in 29 (20%). The primary obstetric factors amongst the maternal deaths were: hypertension (33%); sepsis (27%); and maternal medical diseases (17%) in 10, 8 and 5 women respectively. Sub-standard care was identified in 82 cases. Breakdown in the health care administration was identified in 33, and patient-orientated missed opportunities on 34 occasions.The definition of severe acute maternal morbidity identified nearly five times as many cases as maternal death. This definition allows for an effective audit system of maternal care because it is clinically based, the definition is robust and the cases identified reflect the pattern of maternal death.

Epidemiology of postpartum haemorrhage: a systematic review

2008-09-26

Guillermo Carroli , Cristina Cuesta , Edgardo Ábalos +1 more

Postpartum haemorrhage (PPH) is an important cause of maternal mortality. We conducted a systematic review of the prevalence of PPH with the objective of evaluating its magnitude both globally and … Postpartum haemorrhage (PPH) is an important cause of maternal mortality. We conducted a systematic review of the prevalence of PPH with the objective of evaluating its magnitude both globally and in different regions and settings: global figures, as well as regional, country and provincial variations, are likely to exist but are currently unknown. We used prespecified criteria to select databases, recorded the database characteristics and assessed their methodological quality. After establishing PPH (≥500 mL blood loss) and severe PPH (SSPH) (≥1000 mL blood loss) as main outcomes, we found 120 datasets (involving a total of 3,815,034 women) that reported PPH and 70 datasets (505,379 women) that reported SPPH in the primary analysis. The prevalence of PPH and SPPH is approximately 6% and 1.86% of all deliveries, respectively, with a wide variation across regions of the world. The figures we obtained give a rough estimate of the prevalence of PPH and suggest the existence of some variations. For a reliable picture of PPH worldwide – its magnitude, distribution and consequences – a global survey tackling this condition is necessary.

Maternal Morbidity in Cases of Placenta Accreta Managed by a Multidisciplinary Care Team Compared With Standard Obstetric Care

2011-01-05

Alexandra Eller , Michele A. Bennett , Rita Sharshiner +4 more

To compare maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team with similar cases managed by standard obstetric care.This was a retrospective cohort study of all … To compare maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team with similar cases managed by standard obstetric care.This was a retrospective cohort study of all cases of placenta accreta identified in the State of Utah from 1996 to 2008. Cases of placenta accreta were identified using International Classification of Diseases (ICD-9) codes for placenta accreta, placenta previa, and cesarean hysterectomy. Maternal morbidity was compared for cases managed by a multidisciplinary care team in two tertiary care centers and similar cases managed at 26 other hospitals using multivariable logistic regression analysis.One-hundred forty-one cases of placenta accreta were identified including 79 managed by a multidisciplinary care team and 62 cases managed by standard obstetric care. Women managed by a multidisciplinary care team were less likely to require large-volume blood transfusion (4 or more units of packed red blood cells) (43% compared with 61%, P=.031) and reoperation within 7 days of delivery for bleeding complications (3% compared with 36%, P<.001) compared with women managed by standard obstetric care. Women with suspected placenta accreta managed by a multidisciplinary team were less likely to experience composite early morbidity (prolonged maternal admission to the intensive care unit, large-volume blood transfusion, coagulopathy, ureteral injury, or early reoperation) than women managed by standard obstetric care (47% compared with 74%, P=.026). The odds ratio of composite early morbidity in women managed by a multidisciplinary team was 0.22, (95% confidence interval, 0.07- 0.70) in the multivariable model.Maternal morbidity is reduced in women with placenta accreta who deliver in a tertiary care hospital with a multidisciplinary care team.II

The management of placenta percreta: Conservative and operative strategies

1996-12-01

John O’Brien , J R Barton , Elvis S. Donaldson

Optimal management strategies for placenta accreta

2009-02-04

A.G. Eller , T. Flint Porter , Patrick Soisson +1 more

To determine which interventions for managing placenta accreta were associated with reduced maternal morbidity.Retrospective cohort study.Two tertiary care teaching hospitals in Utah.All identified cases of placenta accreta from 1996 to … To determine which interventions for managing placenta accreta were associated with reduced maternal morbidity.Retrospective cohort study.Two tertiary care teaching hospitals in Utah.All identified cases of placenta accreta from 1996 to 2008.Cases of placenta accreta were identified using standard ICD-9 codes for placenta accreta, placenta praevia, and caesarean hysterectomy. Medical records were then abstracted for maternal medical history, hospital course, and maternal and neonatal outcomes. Maternal and neonatal complications were compared according to antenatal suspicion of accreta, indications for delivery, preoperative preparation, attempts at placental removal before hysterectomy, and hypogastric artery ligation.Early morbidity (prolonged maternal intensive care unit admission, large volume of blood transfusion, coagulopathy, ureteral injury, or early re-operation) and late morbidity (intra-abdominal infection, hospital re-admission, or need for delayed re-operation). Results Seventy-six cases of placenta accreta were identified. When accreta was suspected, scheduled caesarean hysterectomy without attempting placental removal was associated with a significantly reduced rate of early morbidity compared with cases in which placental removal was attempted (67 versus 36%, P=0.038). Women with preoperative bilateral ureteric stents had a lower incidence of early morbidity compared with women without stents (18 versus 55%, P=0.018). Hypogastric artery ligation did not reduce maternal morbidity.Scheduled caesarean hysterectomy with preoperative ureteric stent placement and avoiding attempted placental removal are associated with reduced maternal morbidity in women with suspected placenta accreta.

Center of excellence for placenta accreta

2014-11-20

Robert M. Silver , Karin A. Fox , John R. Barton +5 more

Maternal mortality surveillance, United States, 1980-1985.

1988-12-01

Lisa M. Koonin , H K Atrash , Roger Rochat +1 more

To better define the incidence, causes, and risk factors associated with maternal deaths, the Division of Reproductive Health, Center for Chronic Disease Prevention and Health Promotion, CDC, coordinated a study … To better define the incidence, causes, and risk factors associated with maternal deaths, the Division of Reproductive Health, Center for Chronic Disease Prevention and Health Promotion, CDC, coordinated a study by the Maternal Mortality Collaborative, a Special Interest Group of the American College of Obstetricians and Gynecologists (ACOG). In 1983, this group established voluntary surveillance of maternal deaths for the years 1980-1985. The Maternal Mortality Collaborative reported 601 maternal deaths from 19 reporting areas for 1980-1985, representing a maternal mortality ratio of 14.1 per 100,000 live births. Overall, 39% more maternal deaths were reported by the Maternal Mortality Collaborative than by the National Center for Health Statistics for these reporting areas. Overall, women over 30 years of age had a higher risk of dying than did younger women. For each age group, women of black and other races who were 30 years and older having the highest risk. The leading causes of maternal deaths were embolism, hypertension in pregnancy, sequelae from ectopic pregnancy, hemorrhage, cerebrovascular accidents, and anesthesia complications. Of the 111 nonmaternal deaths, 90 (82%) were attributed to unintentional or intentional injuries. As a result of the success of this voluntary reporting system, the Division of Reproductive Health initiated National Pregnancy Mortality Surveillance in January 1988.

Beyond the Numbers: reviewing maternal deaths and complications to make pregnancy safer

2003-12-01

Gwyneth Lewis

Avoiding maternal deaths is possible, even in resource-poor countries, but requires the right kind of information on which to base programmes. Knowing the level of maternal mortality is not enough; … Avoiding maternal deaths is possible, even in resource-poor countries, but requires the right kind of information on which to base programmes. Knowing the level of maternal mortality is not enough; we need to understand the underlying factors that led to the deaths. Each maternal death or case of life-threatening complication has a story to tell and can provide indications on practical ways of addressing its causes and determinants. Maternal death or morbidity reviews provide evidence of where the main problems in overcoming maternal mortality and morbidity may lie, produce an analysis of what can be done in practical terms and highlight the key areas requiring recommendations for health sector and community action as well as guidelines for improving clinical outcomes. The information gained from such enquiries must be used as a prerequisite for action.

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Clinical risk factors for placenta previa–placenta accreta

1997-07-01

David A. Miller , Janet A. Chollet , T. Murphy Goodwin

WHO systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss)

2004-08-17

Lale Say , Robert Pattinson , A. Metin Gülmezoĝlu

Abstract Aim To determine the prevalence of severe acute maternal morbidity (SAMM) worldwide (near miss). Method Systematic review of all available data. The methodology followed a pre-defined protocol, an extensive … Abstract Aim To determine the prevalence of severe acute maternal morbidity (SAMM) worldwide (near miss). Method Systematic review of all available data. The methodology followed a pre-defined protocol, an extensive search strategy of 10 electronic databases as well as other sources. Articles were evaluated according to specified inclusion criteria. Data were extracted using data extraction instrument which collects additional information on the quality of reporting including definitions and identification of cases. Data were entered into a specially constructed database and tabulated using SAS statistical management and analysis software. Results A total of 30 studies are included in the systematic review. Designs are mainly cross-sectional and 24 were conducted in hospital settings, mostly teaching hospitals. Fourteen studies report on a defined SAMM condition while the remainder use a response to an event such as admission to intensive care unit as a proxy for SAMM. Criteria for identification of cases vary widely across studies. Prevalences vary between 0.80% – 8.23% in studies that use disease-specific criteria while the range is 0.38% – 1.09% in the group that use organ-system based criteria and included unselected group of women. Rates are within the range of 0.01% and 2.99% in studies using management-based criteria. It is not possible to pool data together to provide summary estimates or comparisons between different settings due to variations in case-identification criteria. Nevertheless, there seems to be an inverse trend in prevalence with development status of a country. Conclusion There is a clear need to set uniform criteria to classify patients as SAMM. This standardisation could be made for similar settings separately. An organ-system dysfunction/failure approach is the most epidemiologically sound as it is least open to bias, and thus could permit developing summary estimates.

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Active versus expectant management in the third stage of labour

2000-07-24

Walter Prendiville , Diana Elbourne , Susan McDonald

Background Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. Active management involves administration of a prophylactic … Background Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. Active management involves administration of a prophylactic oxytocic before delivery of the placenta, and usually early cord clamping and cutting, and controlled cord traction of the umbilical cord. Objectives The objective of this review was to assess the effects of active versus expectant management on blood loss, post partum haemorrhage and other maternal and perinatal complications of the third stage of labour. Search methods We searched the Cochrane Pregnancy and Childbirth Group trials register. Selection criteria Randomised trials comparing active and expectant management of the third stage of labour in women who were expecting a vaginal delivery. Data collection and analysis Trial quality was assessed and data were extracted independently by the reviewers. Main results Five studies were included. Four of the trials were of good quality. Compared to expectant management, active management (in the setting of a maternity hospital) was associated with the following reduced risks: maternal blood loss (weighted mean difference ‐79.33 millilitres, 95% confidence interval ‐94.29 to ‐64.37); post partum haemorrhage of more than 500 millilitres (relative risk 0.38, 95% confidence interval 0.32 to 0.46); prolonged third stage of labour (weighted mean difference ‐9.77 minutes, 95% confidence interval ‐10.00 to ‐9.53). Active management was associated with an increased risk of maternal nausea (relative risk 1.83, 95% confidence interval 1.51 to 2.23), vomiting and raised blood pressure (probably due to the use of ergometrine). No advantages or disadvantages were apparent for the baby. Authors' conclusions Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries).

Amniotic fluid embolism: Analysis of the national registry

1995-04-01

Steven L. Clark , Gary D.V. Hankins , Donald A. Dudley +2 more

Placenta Previa, Placenta Accreta, and Vasa Previa

2006-04-01

Yinka Oyelese , John C. Smulian

In Brief Placenta previa, placenta accreta, and vasa previa are important causes of bleeding in the second half of pregnancy and in labor. Risk factors for placenta previa include prior … In Brief Placenta previa, placenta accreta, and vasa previa are important causes of bleeding in the second half of pregnancy and in labor. Risk factors for placenta previa include prior cesarean delivery, pregnancy termination, intrauterine surgery, smoking, multifetal gestation, increasing parity, and maternal age. The diagnostic modality of choice for placenta previa is transvaginal ultrasonography, and women with a complete placenta previa should be delivered by cesarean. Small studies suggest that, when the placenta to cervical os distance is greater than 2 cm, women may safely have a vaginal delivery. Regional anesthesia for cesarean delivery in women with placenta previa is safe. Delivery should take place at an institution with adequate blood banking facilities. The incidence of placenta accreta is rising, primarily because of the rise in cesarean delivery rates. This condition can be associated with massive blood loss at delivery. Prenatal diagnosis by imaging, followed by planning of peripartum management by a multidisciplinary team, may help reduce morbidity and mortality. Women known to have placenta accreta should be delivered by cesarean, and no attempt should be made to separate the placenta at the time of delivery. The majority of women with significant degrees of placenta accreta will require a hysterectomy. Although successful conservative management has been described, there are currently insufficient data to recommend this approach to management routinely. Vasa previa carries a risk of fetal exsanguination and death when the membranes rupture. The condition can be diagnosed prenatally by ultrasound examination. Good outcomes depend on prenatal diagnosis and cesarean delivery before the membranes rupture. Prenatal diagnosis and carefully planned delivery optimize outcomes of pregnancies complicated by placenta previa, placenta accreta, and vasa previa.

Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

2017-04-26

Haleema Shakur‐Still , Ian Roberts , Bukola Fawole +7 more

Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of … Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage.In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283.Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65-1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52-0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88-1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group.Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation.

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Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging

2017-06-24

Eric Jauniaux , Sally Collins , Graham J. Burton

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Practice Bulletin No. 183: Postpartum Hemorrhage

2017-09-22

Maternal hemorrhage, defined as a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after … Maternal hemorrhage, defined as a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process, remains the leading cause of maternal mortality worldwide (1). Additional important secondary sequelae from hemorrhage exist and include adult respiratory distress syndrome, shock, disseminated intravascular coagulation, acute renal failure, loss of fertility, and pituitary necrosis (Sheehan syndrome).Hemorrhage that leads to blood transfusion is the leading cause of severe maternal morbidity in the United States closely followed by disseminated intravascular coagulation (2). In the United States, the rate of postpartum hemorrhage increased 26% between 1994 and 2006 primarily because of increased rates of atony (3). In contrast, maternal mortality from postpartum obstetric hemorrhage has decreased since the late 1980s and accounted for slightly more than 10% of maternal mortalities (approximately 1.7 deaths per 100,000 live births) in 2009 (2, 4). This observed decrease in mortality is associated with increasing rates of transfusion and peripartum hysterectomy (2-4).The purpose of this Practice Bulletin is to discuss the risk factors for postpartum hemorrhage as well as its evaluation, prevention, and management. In addition, this document will encourage obstetrician-gynecologists and other obstetric care providers to play key roles in implementing standardized bundles of care (eg, policies, guidelines, and algorithms) for the management of postpartum hemorrhage.

Reducing Disparities in Severe Maternal Morbidity and Mortality

2018-01-18

Elizabeth A. Howell

Significant racial and ethnic disparities in maternal morbidity and mortality exist in the United States. Black women are 3 to 4 times more likely to die a pregnancy-related death as … Significant racial and ethnic disparities in maternal morbidity and mortality exist in the United States. Black women are 3 to 4 times more likely to die a pregnancy-related death as compared with white women. Growing research indicates that quality of health care, from preconception through postpartum care, may be a critical lever for improving outcomes for racial and ethnic minority women. This article reviews racial and ethnic disparities in severe maternal morbidities and mortality, underlying drivers of these disparities, and potential levers to reduce their occurrence.

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Pregnancy-Related Mortality in the United States, 2011–2013

2017-07-11

Andreea A. Creanga , Carla Syverson , Kristi Seed +1 more

OBJECTIVE: To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2011–2013. METHODS: We conducted an observational study using population-based … OBJECTIVE: To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2011–2013. METHODS: We conducted an observational study using population-based data from the Pregnancy Mortality Surveillance System to calculate pregnancy-related mortality ratios by year, age group, and race–ethnicity groups. We explored 10 cause-of-death categories by pregnancy outcome during 2011–2013 and compared their distribution with those in our earlier reports since 1987. RESULTS: The 2011–2013 pregnancy-related mortality ratio was 17.0 deaths per 100,000 live births. Pregnancy-related mortality ratios increased with maternal age, and racial–ethnic disparities persisted with non-Hispanic black women having a 3.4 times higher mortality ratio than non-Hispanic white women. Among causes of pregnancy-related deaths, the following groups contributed more than 10%: cardiovascular conditions ranked first (15.5%) followed by other medical conditions often reflecting pre-existing illnesses (14.5%), infection (12.7%), hemorrhage (11.4%), and cardiomyopathy (11.0%). Relative to the most recent report of Pregnancy Mortality Surveillance System data for 2006–2010, the distribution of cause-of-death categories did not change considerably. However, compared with serial reports before 2006–2010, the contribution of hemorrhage, hypertensive disorders of pregnancy, and anesthesia complications declined, whereas that of cardiovascular and other medical conditions increased (population-level percentage comparison). CONCLUSION: The pregnancy-related mortality ratio and the distribution of the main causes of pregnancy-related mortality have been relatively stable in recent years.

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Pregnancy-related mortality surveillance--United States, 1987-1990.

1997-08-08

Koonin Lm , MacKay Ap , Cj Berg +2 more

The Healthy People 2000: National Health Promotion and Disease Prevention Objectives specifies goals of no more than 3.3 maternal deaths per 100,000 live births overall and no more than 5.0 … The Healthy People 2000: National Health Promotion and Disease Prevention Objectives specifies goals of no more than 3.3 maternal deaths per 100,000 live births overall and no more than 5.0 maternal deaths per 100,000 live births among black women; as of 1990, these goals had not been met. In addition, race-specific differences between black women and white women persist in the risk for pregnancy-related death.This report summarizes surveillance data for pregnancy-related deaths in the United States for 1987-1990.The National Pregnancy Mortality Surveillance System was initiated in 1988 by CDC in collaboration with the CDC/American College of Obstetricians and Gynecologists Maternal Mortality Study Group. Health departments in the 50 states, the District of Columbia, and New York City provided CDC with copies of death certificates and available linked outcome records (i.e., birth certificates or fetal death records) of all identified pregnancy-related deaths.During 1987-1990, 1,459 deaths were determined to be pregnancy-related. The overall pregnancy-related mortality ratio was 9.2 deaths per 100,000 live births. The pregnancy-related mortality ratio for black women was consistently higher than for white women for every risk factor examined by race. The disparity between pregnancy-related mortality ratios for black women and white women increased from 3.4 times greater in 1987 to 4.1 times greater in 1990. Older women, particularly women aged > or =35 years, were at increased risk for pregnancy-related death. The gestational age-adjusted risk for pregnancy-related death was 7.7 times higher for women who received no prenatal care than for women who received "adequate" prenatal care. The distribution of the causes of death differed depending on the pregnancy outcome; for women who died following a live birth (i.e., 55% of the deaths), the leading causes of death were pregnancy-induced hypertension complications, pulmonary embolism, and hemorrhage.Pregnancy-related mortality ratios for black women continued, as noted in previously published surveillance reports, to be three to four times higher than those for white women. The risk factors evaluated in this analysis confirmed the disparity in pregnancy-related mortality between white women and black women, but the reason(s) for this difference could not be determined from the available information.Continued surveillance and additional studies should be conducted to assess the magnitude of pregnancy-related mortality, to identify those differences that contribute to the continuing race-specific disparity in pregnancy-related mortality, and to provide information that policy makers can use to develop effective strategies to prevent pregnancy-related mortality for all women.

<i>Vital Signs:</i> Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017

2019-05-07

Emily E. Petersen , Nicole L. Davis , David A. Goodman +7 more

Background: Approximately 700 women die from pregnancy-related complications in the United States every year.Methods: Data from CDC's national Pregnancy Mortality Surveillance System (PMSS) for 2011-2015 were analyzed.Pregnancy-related mortality ratios (pregnancy-related … Background: Approximately 700 women die from pregnancy-related complications in the United States every year.Methods: Data from CDC's national Pregnancy Mortality Surveillance System (PMSS) for 2011-2015 were analyzed.Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births; PRMRs) were calculated overall and by sociodemographic characteristics.The distribution of pregnancy-related deaths by timing relative to the end of pregnancy and leading causes of death were calculated.Detailed data on pregnancy-related deaths during 2013-2017 from 13 state maternal mortality review committees (MMRCs) were analyzed for preventability, factors that contributed to pregnancy-related deaths, and MMRC-identified prevention strategies to address contributing factors.Results: For 2011-2015, the national PRMR was 17.2 per 100,000 live births.Non-Hispanic black (black) women and American Indian/Alaska Native women had the highest PRMRs (42.8 and 32.5, respectively), 3.3 and 2.5 times as high, respectively, as the PRMR for non-Hispanic white (white) women (13.0).Timing of death was known for 87.7% (2,990) of pregnancy-related deaths.Among these deaths, 31.3%occurred during pregnancy, 16.9% on the day of delivery, 18.6% 1-6 days postpartum, 21.4% 7-42 days postpartum, and 11.7% 43-365 days postpartum.Leading causes of death included cardiovascular conditions, infection, and hemorrhage, and varied by timing.Approximately sixty percent of pregnancy-related deaths from state MMRCs were determined to be preventable and did not differ significantly by race/ethnicity or timing of death.MMRC data indicated that multiple factors contributed to pregnancy-related deaths.Contributing factors and prevention strategies can be categorized at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care.Conclusions: Pregnancy-related deaths occurred during pregnancy, around the time of delivery, and up to 1 year postpartum; leading causes varied by timing of death.Approximately three in five pregnancy-related deaths were preventable.

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<scp>FIGO</scp> classification for the clinical diagnosis of placenta accreta spectrum disorders,

2019-06-07

Eric Jauniaux , Diogo Ayres‐de‐Campos , Jens Langhoff‐Roos +2 more

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Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016

2019-09-05

Emily E. Petersen , Nicole L. Davis , David A. Goodman +6 more

Approximately 700 women die in the United States each year as a result of pregnancy or its complications, and significant racial/ethnic disparities in pregnancy-related mortality exist (1). Data from CDC's … Approximately 700 women die in the United States each year as a result of pregnancy or its complications, and significant racial/ethnic disparities in pregnancy-related mortality exist (1). Data from CDC's Pregnancy Mortality Surveillance System (PMSS) for 2007-2016 were analyzed. Pregnancy-related mortality ratios (PRMRs) (i.e., pregnancy-related deaths per 100,000 live births) were analyzed by demographic characteristics and state PRMR tertiles (i.e., states with lowest, middle, and highest PRMR); cause-specific proportionate mortality by race/ethnicity also was calculated. Over the period analyzed, the U.S. overall PRMR was 16.7 pregnancy-related deaths per 100,000 births. Non-Hispanic black (black) and non-Hispanic American Indian/Alaska Native (AI/AN) women experienced higher PRMRs (40.8 and 29.7, respectively) than did all other racial/ethnic groups. This disparity persisted over time and across age groups. The PRMR for black and AI/AN women aged ≥30 years was approximately four to five times that for their white counterparts. PRMRs for black and AI/AN women with at least some college education were higher than those for all other racial/ethnic groups with less than a high school diploma. Among state PRMR tertiles, the PRMRs for black and AI/AN women were 2.8-3.3 and 1.7-3.3 times as high, respectively, as those for non-Hispanic white (white) women. Significant differences in cause-specific proportionate mortality were observed among racial/ethnic populations. Strategies to address racial/ethnic disparities in pregnancy-related deaths, including improving women's health and access to quality care in the preconception, pregnancy, and postpartum periods, can be implemented through coordination at the community, health facility, patient, provider, and system levels.

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Prevention and Management of Postpartum Haemorrhage

2016-12-16

Accurate documentation of a delivery with PPH is essential. DebriefingAn opportunity to discuss the events surrounding the obstetric haemorrhage should be offered to the woman (possibly with her birthing partner/s) … Accurate documentation of a delivery with PPH is essential. DebriefingAn opportunity to discuss the events surrounding the obstetric haemorrhage should be offered to the woman (possibly with her birthing partner/s) at a mutually convenient time. 1.Purpose and scope

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ACOG Practice Bulletin No. 76: Postpartum Hemorrhage

2006-10-01

Severe bleeding is the single most significant cause of maternal death world-wide. More than half of all maternal deaths occur within 24 hours of delivery, most commonly from excessive bleeding. … Severe bleeding is the single most significant cause of maternal death world-wide. More than half of all maternal deaths occur within 24 hours of delivery, most commonly from excessive bleeding. It is estimated that worldwide, 140,000 women die of postpartum hemorrhage each year-one every 4 minutes (1). In addition to death, serious morbidity may follow postpartum hemorrhage. Sequelae include adult respiratory distress syndrome, coagulopathy, shock, loss of fertility, and pituitary necrosis (Sheehan syndrome). Although many risk factors have been associated with postpartum hemorrhage, it often occurs without warning. All obstetric units and practitioners must have the facilities, personnel, and equipment in place to manage this emergency properly. Clinical drills to enhance the management of maternal hemorrhage have been recommended by the Joint Commission on Accreditation of Healthcare Organizations (2). The purpose of this bulletin is to review the etiology, evaluation, and management of postpartum hemorrhage.

Placenta accreta

2010-11-01

Michael A. Belfort

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In low-risk pregnant patients, does induction at 38 weeks have different maternal and fetal morbidity and mortality impact compared with induction at 39 weeks?

2025-06-25

Karl I. Devlin | Evidence-Based Practice

Placenta accreta spectrum disorder: A systematic review and meta‐analysis on conservative surgery

2025-06-24

Pedro Viana Pinto , Gonçalo Freitas , Rafael José Vieira +3 more | International Journal of Gynecology & Obstetrics

Postpartum hemorrhage and long-term cardiovascular disease risk: a comprehensive systematic review and meta-analysis

2025-06-24

Fiqih Faizara Ustadi , Alma Dhiani Paramita , Cinta Adinda Roswinabila +2 more | The Journal of Maternal-Fetal & Neonatal Medicine

Purpose: Postpartum hemorrhage (PPH) is a major contributor to maternal morbidity and mortality and may have long-term consequences on cardiovascular health. This systematic review and meta-analysis aimed to evaluate the … Purpose: Postpartum hemorrhage (PPH) is a major contributor to maternal morbidity and mortality and may have long-term consequences on cardiovascular health. This systematic review and meta-analysis aimed to evaluate the association between PPH and the subsequent risk of cardiovascular disease (CVD) in women. Materials and methods: A comprehensive literature search was conducted across major databases to identify cohort studies assessing cardiovascular outcomes in women with a history of PPH. Data from over 9.7 million participants were pooled using a random-effects model to account for inter-study heterogeneity. The primary outcomes included cardiovascular diseases and thromboembolism events. Subgroup analyses were conducted separately for cardiovascular and thromboembolism outcomes. Sensitivity analyses were conducted to examine the consistency and robustness of the pooled estimates. Results: Women with a history of PPH had a 1.76-fold increased risk of developing cardiovascular disease and 2.10-fold increased risk of thromboembolism. The risk was particularly elevated among those requiring transfusion. Cardiovascular risk was most frequent during the first year postpartum and persisted for up to 15 years, particularly among those with hypertensive disorders of pregnancy. Heterogeneity was substantial for cardiovascular disease outcome (I²=99%) and moderate for thromboembolic outcomes (I²=43%). Sensitivity analyses reduced heterogeneity for cardiovascular disease to 77.1%. Conclusions: PPH is associated with a significantly increased long-term risk of both cardiovascular and thromboembolism disease. These findings highlight the importance of postpartum cardiovascular risk screening and preventive interventions in women with a history of severe PPH. Future research should adopt standardized methodologies and focus on high-burden settings, particularly in low- and middle-income countries.

Clinical impact of a placenta accreta spectrum care national system in a Central American country

2025-06-24

Luis Raúl Altamirano , Rita López , Amparo Morales +7 more | International Journal of Gynecology & Obstetrics

A Prospective Study on the Clinical Spectrum and Outcomes of Obstetric Critical Care Admissions at Konaseema Institute of Medical Sciences, Amalapuram - A Tertiary Care Centre in Coastal India

2025-06-24

Varada A Hasamnis , Sri Vyjayanthi Kalyanapu , Laxmi Praveena Boddu +3 more | Cureus

Placenta accreta spectrum (schematic diagram)

2025-06-24

Dr Divyang Kapadiya | Radiopaedia.org

Complete septate uterus

2025-06-23

Sally El Bahy | Radiopaedia.org

Maternal Vulnerability Index and Severe Maternal Morbidity

2025-06-23

Nansi S. Boghossian , Joshua Radack , Molly Passarella +6 more | JAMA Network Open

Few studies have investigated the association of composite measures of neighborhood social determinants of health with severe maternal morbidity (SMM), and no research has examined this association for indices tailored … Few studies have investigated the association of composite measures of neighborhood social determinants of health with severe maternal morbidity (SMM), and no research has examined this association for indices tailored to maternal health. To examine the association of scores in the Maternal Vulnerability Index (MVI), a tool developed to measure maternal risk of adverse health outcomes, with SMM. This retrospective, population-based cohort study was conducted in 5 states (2008-2020 for Michigan, Oregon, and South Carolina; 2008-2018 for Pennsylvania; and 2008-2012 for California) among individuals delivering a fetal death or a live birth between 22 and 44 weeks. Analysis was conducted between August and October 2024. The MVI, a composite measure of 43 area-level indicators, was categorized into 6 themes encompassing physical, social, and health care environments. MVI score and themes were examined in quartiles (quartile 1 = lowest risk to quartile 4 = highest risk) based on residential zip code tabulation area. SMM during delivery hospitalization and after discharge within 42 days after delivery. Among 6 543 255 birthing individuals (3 568 631 ages 25-34 years [54.5%]; 472 145 Asian or Pacific Islander [7.2%], 824 239 Black [12.6%], 1 673 917 Hispanic [25.6%], and 3 346 807 White [51.2%]), there were 1 087 936 individuals in MVI quartile 1 (16.6%) and 1 376 658 individuals in MVI quartile 4 (21.0%). A total of 45 051 individuals (0.7%) had SMM during delivery hospitalization, while 13 534 individuals (0.2%) had SMM after discharge within 42 days after delivery. In adjusted analyses, there were no associations between MVI score or themes and SMM during delivery hospitalization. However, a dose-response association was observed between MVI score and SMM within 42 days after delivery (second MVI quartile: adjusted relative risk [aRR], 1.03; 95% CI, 0.95-1.11; third MVI quartile: aRR, 1.12; 95% CI, 1.03-1.23; fourth MVI quartile: aRR, 1.27; 95% CI, 1.14-1.41). The highest MVI quartile in themes of general health care (aRR, 1.27; 95% CI, 1.14-1.43), physical environment (aRR, 1.33; 95% CI, 1.22-1.46), physical health (aRR, 1.23; 95% CI, 1.12-1.35), reproductive health care (aRR, 1.30; 95% CI, 1.15-1.47), and socioeconomic determinants (aRR, 1.19; 95% CI, 1.02-1.39) was associated with SMM within 42 days after delivery. A dose-response association was observed between all MVI themes and SMM within 42 days after delivery (eg, physical environment MVI theme second quartile: aRR, 1.04; 95% CI, 0.96-1.13; third quartile: aRR, 1.14; 95% CI, 1.05-1.25; fourth quartile: aRR, 1.33; 95% CI, 1.22-1.46), except for the mental health and general health care themes. In this study, MVI score was not associated with SMM during delivery but was associated with postpartum SMM, suggesting that MVI may capture long-term risks more effectively than acute conditions during delivery hospitalization.

Risk factors for blood transfusion during cesarean section in women with major placenta previa

2025-06-23

Evgeni Baev , Karin Roth , Jonas Nagel +4 more | Research Square (Research Square)

<title>Abstract</title> Purpose The aim of this study was to evaluate risk factors for blood transfusion during cesarean section in women with major placenta previa. Methods A retrospective single-center cohort study … <title>Abstract</title> Purpose The aim of this study was to evaluate risk factors for blood transfusion during cesarean section in women with major placenta previa. Methods A retrospective single-center cohort study was conducted, including 110 women treated in the tertiary-care Department of Obstetrics and Gynecology at Karlsruhe Municipal Hospital from January 2014 till December 2021 who underwent cesarean section due to major placenta previa as defined in the new classification. The patients were divided into two groups: those who received a blood transfusion and those who did not. The two groups were compared to identify potential risk factors for blood transfusion. Results No remarkable differences between the two groups relative to the need for blood transfusion were seen after an analysis of six risk factors — maternal age, gestational age at delivery, indication for cesarean section, antepartum bleeding, use of assisted reproductive technology, and a history of previous curettage. A patient history including a previous cesarean section was the only statistically significant risk factor for blood transfusion in patients with major placenta previa. Conclusion A medical history including a previous cesarean section was the only independent statistically significant risk factor for blood transfusion in women with major placenta previa. This should be taken into account when cesarean sections are carried out in women with major placenta previa.

Uterine arteriovenous malformation

2025-06-21

Sally El Bahy | Radiopaedia.org

Decomposing Racial Disparities in Severe Maternal Morbidity Within Insurance Groups

2025-06-21

E. Kathleen Adams , Sara Markowitz , Michael R. Kramer +2 more | Health Economics

ABSTRACT Rates of severe maternal morbidity (SMM) are related to maternal, hospital, and residential factors, but the contribution of these factors to racial disparities in SMM within Medicaid and private … ABSTRACT Rates of severe maternal morbidity (SMM) are related to maternal, hospital, and residential factors, but the contribution of these factors to racial disparities in SMM within Medicaid and private insured groups is largely unknown. Linked Georgia vital records/hospital discharge data for 2016–2020 are used to identify SMM during delivery or within 42 days postpartum for Medicaid and private insured. The Oaxaca‐Blinder decomposition is used to describe the percentage of the Black‐White SMM gap explained, based on linear probability models without and with hospital fixed‐effects. While the rate of SMM is higher for Medicaid than private insured, the Black‐White SMM gap is lower within Medicaid than private insured (1.15 vs. 1.40 per 100 deliveries). Including hospital fixed‐effects increased the explained gap by 29.1 percentage points (from 13.8% to 42.9%) within Medicaid and by 9.4 percentage points (from 20.0% to 29.4%) within private insured. Residential factors significantly reduced the Black‐White gap explained for Medicaid (−19.6%) but were insignificant (∼0%) for privately insured. According to the Oaxaca‐Blinder algebraic calculation, differences in within‐hospital processes by race contribute a large portion of the discriminatory Black‐White SMM gap among Georgia deliveries while residential areas with greater provider access tends to reduce the gap among Medicaid insured.

Severe maternal morbidity in Louisiana by race, rurality, poverty, and availability of care

2025-06-20

Veronica Gillispie-Bell , Shalmali Bane , Jane Martin +3 more | Public Health

Síndrome de mendelson: uma análise abrangente das características gerais e dos desafios

2025-06-20

Sara Brandão , Ana Carolina Dantas de Souza , Joyce Rodrigues Façanha | Revista Interagir

A Síndrome de Mendelson é uma condição rara e potencialmente grave que ocorre durante o período periparto, associada à administração de anestesia. Objetivo: Abordar os aspectos fundamentais relacionados à síndrome, … A Síndrome de Mendelson é uma condição rara e potencialmente grave que ocorre durante o período periparto, associada à administração de anestesia. Objetivo: Abordar os aspectos fundamentais relacionados à síndrome, fornecendo uma visão sobre patogênese, fatores de risco, sintomas característicos, formas de prevenção e tratamento. Metodologia: Revisão integrativa via PubMed dos artigos publicados de 2013 a 2023, usando os descritores “Anesthesia”, “Obstetric Labor Complications”, “aspiration pneumonia” e a expressão booleana “AND”. Resultados: 15 artigos satisfaziam os critérios de inclusão, como foco em características da síndrome, relação direta com a saúde da mulher e consequências do diagnóstico tardio para a paciente. Conclusões: Nota-se a importância da implementação de protocolos clínicos baseados em evidências, juntamente à conscientização entre os profissionais de saúde sobre a síndrome, permitindo uma abordagem preventiva durante o atendimento obstétrico.

Normal Plasenta ve Plasenta Perkreata Vakalarında E ve P Kaderinin Dağılımı

2025-06-20

Mesut Kaplan , Aydın Ketani , Elif Ağaçayak | Dicle Medical Journal / Dicle Tip Dergisi

Amaç: Bu çalışmada, hamilelikte önemli fonksiyonlar üstlendiğine inanılan hücre adezyon moleküllerinden olan kaderinler (E- ve P-kaderin) hem normal hem perkreatalı insan plasentalarındaki lokalizasyonları ile ekspresyonlarını ve plasentasyona katılan dokularda bu … Amaç: Bu çalışmada, hamilelikte önemli fonksiyonlar üstlendiğine inanılan hücre adezyon moleküllerinden olan kaderinler (E- ve P-kaderin) hem normal hem perkreatalı insan plasentalarındaki lokalizasyonları ile ekspresyonlarını ve plasentasyona katılan dokularda bu faktörlerin rollerinin bulunup bulunmadığını araştırmaktır. Yöntemler: Çalışmamıza; Temmuz 2023 - Eylül 2023 tarihleri arasında Dicle Üniversitesi Tıp Fakültesi Kadın Hastalıkları ve Doğum Kliniği’ne başvuran normal plasenta yerleşimi olan 22 hasta ve plasenta perkreata spektrumu olan 22 hastanın, doğum sonrası elde edilen plasentalarından histolojik takip için küçük parçalar alındı. Plasenta perkreata spektrumu olan hastaların tanısı USG ile konulduktan sonra sezaryen sonrası plasentanın histopatolojik incelenmesi ile konfirme edildi. Alınan doku örnekleri rutin histolojik doku işleme sonrasında parafinde bloklandı. Parafin bloklardan seri kesitler alındı. Parafin kesitlere E- ve P-Kaderin proteinleri için immunohistokimyasal boyama yöntemi uygulandı. Bulgular: E- kaderin immmunaktivitesi normal plasentanın sinsityotrofoblast ve desidual hücrelerinde kuvvetli olmasına karşın perkreatalı plasentada bu immunoaktivitenin düşük olduğu, buna bağlı olarak koryon villus morfolojik yapılarında bozulma ve trofoblastik invazyonu etkileyebileceğini gözlemledik. E kaderin immunaktivitesi Perkeata olgularında belirteç olabileceği buna karşın normal plasentalarda ve perkreatalı plasentalarda P- kaderin immunaktivitesi e- kaderine göre zayıf olarak izlendi. Sonuç: E kaderin immunoaktivitesinin düşüklüğüne bağlı olarak, perkratalı plasentalarda koryon villus morfolojik yapılarında bozulma ve trofoblastik invazyonu etkileyebileceğini, bir belirteç olarak gözlenmesine karşın P kaderin immun aktivitesi normal ve perkratalı plasendalarda önemli bir ayrıt edici farklılığı ortaya koymamıştır.

Trombofilia e gestação: uma revisão integrativa

2025-06-20

Patrícia Barbosa , Andressa Teixeira Costa | Contribuciones a las Ciencias Sociales

Introdução: A trombofilia é definida como tendência à trombose causada por anomalias na cascata de coagulação. Objetivos: Compreender a necessidade do encaminhamento de gestantes com trombofilia gestacional para um pré-natal … Introdução: A trombofilia é definida como tendência à trombose causada por anomalias na cascata de coagulação. Objetivos: Compreender a necessidade do encaminhamento de gestantes com trombofilia gestacional para um pré-natal de alto risco e as complicações relacionadas a essa patologia. Metodologia: Trata-se de uma revisão sistemática da literatura, com base na estratégia PICO. Essa busca foi realizada em bases de dados online, nas plataformas eletrônicas: lilacs, pubmed, incluídos artigos relacionados a temática dos estudos. Foram pesquisados na língua inglesa e portuguesa. Resultados: A análise demonstrou a importância do rastreio de trombofilias em gestantes com histórico clínico sugestivo, sendo o encaminhamento ao pré-natal de alto risco fundamental para prevenir complicações graves como morte fetal intrauterina, restrição de crescimento intrauterino (RCIU), pré-eclâmpsia, trombose placentária e parto prematuro. Conclusão: O estudo contribuiu para o avanço do conhecimento na área de obstetrícia e para a melhoria do cuidado às gestantes com essa condição.

Maternal and Clinical Outcomes of Placenta Accreta Spectrum: Insights from a Retrospective Study in Bahrain

2025-06-18

K. C. Chacko , Reem Satam AlSubeaei , Soumyalekshmi Nair +2 more | Life

Placenta accreta spectrum (PAS) refers to a group of abnormal placental attachments in which the placenta adheres too deeply to the uterine wall, with varying degrees of invasion classified as … Placenta accreta spectrum (PAS) refers to a group of abnormal placental attachments in which the placenta adheres too deeply to the uterine wall, with varying degrees of invasion classified as accreta, increta, or percreta. Increased rates of uterine surgeries, advanced maternal age, and cesarean deliveries have all contributed to an increase in the incidence of PAS. Complications associated with PAS can lead to severe intrapartum or postpartum hemorrhage, hysterectomy, and significant maternal morbidity, making early diagnosis and management crucial for improving outcomes. Understanding the epidemiology and risk factors of PAS is crucial for developing early detection protocols and preventive strategies. Localized data, particularly from Bahrain, can inform targeted care approaches and optimize resource allocation, ultimately leading to improved clinical guidelines, enhanced patient education, and better healthcare outcomes for affected women. There are growing concerns about the impact of PAS on maternal health and healthcare resources in Bahrain, similar to trends observed in other regions. To improve patient education and management strategies, it is essential to comprehend the regional patterns, characteristics, and outcomes associated with PAS. However, the absence of comprehensive data specific to Bahrain hinders effective clinical decision-making and policy development. Addressing this gap is imperative for advancing maternal healthcare in the region.

Analysis of maternal fetal outcomes and complete blood count parameters according to the stages of placental abruption: a retrospective study

2025-06-18

S.F. Sener , Gülsüm Uysal , Cevdet Adıgüzel +1 more | European journal of medical research

To compare the demographic characteristics, maternal and perinatal outcomes and hemoglobin parameters according to stages diagnosed with placental abruption. Patients who underwent cesarean delivery due to clinical suspicion of placental … To compare the demographic characteristics, maternal and perinatal outcomes and hemoglobin parameters according to stages diagnosed with placental abruption. Patients who underwent cesarean delivery due to clinical suspicion of placental abruption after the 20th week of gestation were included in the study. We eliminated patients with persistent hematological disorders, those on anticoagulant medications, and individuals with uterine deformities. Demographic information, body mass index, initial laboratory results, duration of hospitalization, fetal APGAR scores, and transfers to maternal and neonatal critical care units were all documented from the data system. Patients were categorized into categories based on the stages of placental abruption as outlined in the 2022 emergency obstetric care guide. Stage 0: Asymptomatic patient. Stage I: There is vaginal bleeding, clinical pain in abdomen, no signs of maternal shock or fetal distress. Stage II: There may be vaginal bleeding, no maternal shock. Fetal distress is present. Stage III: There may be maternal shock, intrauterine fetal demise is present. Presence of coagulopathy (30%). The patients were categorized as follows: Group 1 stage 0-I; Group 2 stage II; and Group 3 stage III, and the gathered data were compared among the groups. A total of 150 patients were involved, with 50 patients in group 1. Group 2 comprised 59 patients, whereas Group 3 had 41 patients. Abruptions were most prevalent in group 3. The neutrophil/lymphocyte ratio (NLR) was statistically significantly elevated in groups 2 and 3. The platelet/lymphocyte ratio (PLR) was statistically significantly reduced in group 1. Hemoglobin and fibrinogen levels were deemed statistically significantly reduced in group 3. In group 2, the Apgar scores at 1 min and 5 min were the lowest, and the demand for newborn intensive care was the highest. The analysis of hemogram parameters at the initial assessment may aid in the diagnosis of abruption, complementing ultrasonography, particularly in cases of early clinical suspicion. We believe that commonly conducted, cost-effective, and straightforward hemogram parameters, when augmented by artificial intelligence, can provide therapeutic support through the interpretation of data such as PLR and NLP in instances of ambiguous laboratory diagnoses, such as placental abruption.

The impact of the WOMAN trial on local clinical practice in Thailand

2025-06-18

Patchareya Nivatpumin , Jitsupa Nithiuthai , Tripop Lertbunnaphong | Journal of Anesthesia

Statement of retraction: Different routes and forms of uterotonics for treatment of retained placenta: a randomized clinical trial*

2025-06-18

| The Journal of Maternal-Fetal & Neonatal Medicine

A comparative systematic review and meta-analysis of uterine artery resistance in pregnant women with and without previous history of cesarean section

2025-06-18

Arash Mohazzab , Azar Mohammadzadeh , Banafsheh Nikfar +4 more | PLoS ONE

Background Increased uterine artery resistance in pregnant women with a history of cesarean section has been suggested to contribute to adverse pregnancy outcomes. However, the literature presents conflicting reports on … Background Increased uterine artery resistance in pregnant women with a history of cesarean section has been suggested to contribute to adverse pregnancy outcomes. However, the literature presents conflicting reports on this association. In this comparative meta-analysis and systematic review, we aimed to evaluate the studies that reported uterine artery resistance using Color Doppler ultrasonography in pregnant women with and without a history of cesarean section. Methods We searched PubMed, Scopus, Web of Science, and Embase up to April 2024 using relevant keywords. Study selection was performed by two independent researchers, with conflicts resolved by a third. Risk of bias was assessed using the Newcastle-Ottawa Scale. The primary outcomes were the Pulsatility Index (PI) and Resistance Index (RI) Meta-analysis and meta-regression were conducted using STATA version 17. Results After screening 442 articles, the meta-analysis included six studies, encompassing 1,656 participants. We found a small but statistically significant increase in uterine artery resistance, based on PI, in women with a history of cesarean section (Hedges’s g = 0.15, 95% CI [0.03, 0.26], p = 0.01). Heterogeneity among studies was low (I² = 26.60%, p = 0.23), and no significant publication bias was detected (Egger’s test, p = 0.81). Analysis of the RI, based on two studies, showed a non-significant increase in the cesarean group (Hedges’s g = 0.19, 95% CI [−0.06, 0.43], p = 0.13). Conclusion A history of cesarean section may be associated with increased uterine artery resistance. These findings suggest a possible benefit in monitoring uterine artery resistance in subsequent pregnancies, mainly using Color Doppler ultrasonography, to better understand potential risks such as preeclampsia and intrauterine growth restriction. However, given the limited evidence, further studies are warranted to confirm these associations and clarify their clinical relevance.

Managing Placenta Accreta Spectrum: Diagnosis, Surgical Strategies, and Postoperative Care

2025-06-18

Atif Bashir Fazari , Ufwana Javid , Asma Fahad +2 more | Cureus

Correction to ‘Identification and Management of Maternal Sepsis During and Following Pregnancy’

2025-06-16

| BJOG An International Journal of Obstetrics & Gynaecology

The Predictive Role of Fetal Growth for Placental Invasion Anomalies in Placenta Previa

2025-06-16

Evrim Koca , Burcu Dinçgez Çakmak , Gülten Özgen +1 more | Zeitschrift für Geburtshilfe und Neonatologie

Abstract To evaluate the predictive role of fetal percentile for placental invasion anomalies in placenta previa cases. Study Design: Retrospective studyPlace & Duration of the Study: Training and Research Hospital, … Abstract To evaluate the predictive role of fetal percentile for placental invasion anomalies in placenta previa cases. Study Design: Retrospective studyPlace & Duration of the Study: Training and Research Hospital, January 2018 and December 2023 A total of 298 placenta previa cases was divided into two groups: PAS (placenta accreta spectrum)-positive placenta previa (n=98) and PAS-negative placenta previa (n=200). Then PAS-positive placenta previa cases were divided into two subgroups: placenta increta-accreta (n=59) and placenta percreta (n=39). Sociodemographic findings, obstetric features, fetal percentile measurements between 22 and 28 gestational weeks and perioperative characteristics of patients were recorded and compared between groups. Fetal percentile was significantly lower in PAS-positive placenta previa cases as compared to PAS-negative placenta previa cases (p<0.001). Moreover, fetal percentile≤52.5 discriminated PAS-positive placenta previa cases from PAS-negative placenta previa cases with 75.51% sensitivity and 51.5% specificity (p<0.001, AUC=0.654). In multivariate analysis, a fetal percentile of 52.5 and below increased the risk of PAS by approximately 4 times (Hosmer–Lemeshow p=0.101, model p<0.001). No significant difference was detected between placenta percreta and placenta accreta-increta groups in terms of fetal percentile (p=0.224). Fetal percentiles calculated between 22 and 28 gestational weeks could discriminate PAS-positive placenta previa cases from PAS-negative placenta previa cases, although it had no role in discriminating placenta percreta from accreta and increta cases. Therefore, the evaluation of fetal percentile in placenta previa cases can be considered as a supportive finding in the prediction of invasion anomaly although it does not determine the depth of invasion.

Maternal mortality prediction using WHO near miss criteria and Maternal severity models: Evidence from a Tertiary Care Study in India

2025-06-16

B. G. Ramu , Anil Hogade , Hema S Patil +1 more | Research Square (Research Square)

<title>Abstract</title> Background Maternal mortality remains a critical public health issue, particularly in low- and middle-income countries (LMICS). Over the past two decades, there has been a significant global reduction in … <title>Abstract</title> Background Maternal mortality remains a critical public health issue, particularly in low- and middle-income countries (LMICS). Over the past two decades, there has been a significant global reduction in maternal mortality. As maternal deaths continue to decline, measuring maternal morbidity—including the near-miss ratio, mortality index, severe maternal outcome ratio, and maternal near-miss mortality ratio—is essential for assessing the quality of obstetric care. This study was conducted to validate the performance of the WHO MNM criteria and compare predictive models that integrate the Maternal Severity Score and Maternal Severity Index to predict maternal mortality in a tertiary care setting. Methods A prospective observational study was conducted at KAHER’s Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, India (1st February 2024–31st January 2025). Pregnant women fulfilling the WHO maternal near-miss criteria were enrolled, and diagnostic accuracy tests for overall WHO criteria and organ dysfunction severity markers were performed. Pearson’s correlation coefficient was used to determine the association between MSS and MSI. Two binary logistic regression models to predict the probability of maternal death were developed and compared via the area under the receiver operating curve (AUROC), with additional assessment via Nagelkerke R² and the Hosmer–Lemeshow goodness-of-fit test. Results Out of the 295 women identified with the WHO maternal near miss criteria, 191 fulfilled the criteria for maternal near misses, and 15 resulted in maternal death. The severe maternal outcome ratio (SMOR) was 51.7, the MNM ratio was 47.9 per 1,000 live births, and the mortality index was 7.27%. indicating that a majority of women with life-threatening conditions survived with better quality of care. The diagnostic accuracy of the WHO near-miss criteria showed good sensitivity (100%) and high specificity (93.11%) and improved significantly, up to 95.43%, when the organ dysfunction subset was used. The number of cases with severity markers per thousand deliveries ranged from 0.49–24.82. The correlation between the Maternal Severity Score and the Maternal Severity Index was strong (R = 0.805, p < 0.001). supporting the internal validity of severity assessment tools, the multivariate logistic regression model that included additional clinical parameters performed better, achieving an AUROC of 0.939, indicating excellent discriminatory ability for predicting maternal mortality and underscoring the clinical utility of the enhanced model.

Unusual presentation of placenta percreta with bladder involvement at 20 weeks: a case report

2025-06-16

Syeda Mahrukh Fatima Zaidi , Farah Hikmet Majid , Jeorge Suman | Annals of Medicine and Surgery

Introduction and importance: Placenta percreta is a rare and severe form of placenta accreta spectrum (PAS), where the placenta invades beyond the myometrium, often involving adjacent structures such as the … Introduction and importance: Placenta percreta is a rare and severe form of placenta accreta spectrum (PAS), where the placenta invades beyond the myometrium, often involving adjacent structures such as the urinary bladder. The incidence of PAS is increasing, especially in countries with high cesarean section rates, and poses significant maternal risks, including life-threatening hemorrhage. Case presentation: A 27-year-old gravida 6, para five patient at 20 weeks gestation presented with hematuria, oliguria, and overflow incontinence. Her medical history included three previous cesarean sections. Ultrasound and cystoscopy confirmed bladder invasion by the placenta, consistent with placenta percreta. A multidisciplinary team decided on a cesarean hysterectomy with partial cystectomy due to significant bleeding. Clinical discussion: The management of placenta percreta with bladder involvement requires early diagnosis, careful planning, and timely intervention. This case highlights the importance of a multidisciplinary approach, with cesarean hysterectomy being the primary intervention. Preoperative strategies such as internal iliac artery occlusion can reduce blood loss and improve maternal outcomes. Bilateral internal iliac artery ligation was performed due to uncontrolled hemorrhage. Conclusion: This case underscores the critical role of early detection and multidisciplinary management in optimizing outcomes for patients with placenta percreta, particularly those with bladder involvement. The increasing incidence of PAS necessitates awareness and preparedness to manage such high-risk pregnancies in clinical settings like Pakistan.

Uterine isthmocele: obstetric outcomes after robotic-assisted laparoscopic repair

2025-06-14

Sierra J. Seaman , Arnold P. Advincula , Natalia S Parra +2 more | Journal of Robotic Surgery

Silent Danger: Risk Factors and Outcomes of Fortuitously Discovered Uterine Rupture – A 41-Case Cohort Study

2025-06-13

Narjes Karmous , Siwar Ghrab , A. Masmoudi +4 more | F1000Research

<ns5:p>Background Uterine rupture (UR) remains a major cause of maternal morbidity, especially in low-resource settings. While typically detected during labor, some cases are clinically silent, discovered incidentally during imaging/surgery, highlighting … <ns5:p>Background Uterine rupture (UR) remains a major cause of maternal morbidity, especially in low-resource settings. While typically detected during labor, some cases are clinically silent, discovered incidentally during imaging/surgery, highlighting a knowledge gap in risk assessment. In Tunisia, 1.5% of pregnancies involve UR, mostly scar-related. The study aim was to identify factors associated with the development of complete UR in cases that were incidentally found during pregnancy or delivery. Methods This was retrospective, longitudinal cohort study conducted over an eleven-year period, from January 2014 to December 2024, at the Gynaecology and Obstetrics department B, Charles Nicolle Hospital, Tunis, Tunisia. Asymptomatic UR cases (complete/incomplete) were analysed to compare clinical profiles, identify risk factors, and assess maternal and neonatal outcomes. Results A total of 41 cases of asymptomatic UR were included, which accounted for an average of 50% of the UR cases. In a cohort comparing complete UR cases (N=27) and incomplete UR cases (N=14), significant differences in duration of pregnancy and labor were found. The mean gestational age was longer in the incomplete UR group (p=0.03), and the duration of labor was also significantly longer (p=0.006). No significant differences were observed in sociodemographic characteristics, quality of prenatal care, or complications such as gestational diabetes or preeclampsia. Nonsignificant factors included pregnancy interval, scars number and labor stagnation. The analysis showed two significant predictors of complete UR outcomes. Prolonged labor (>220 minutes) was strongly associated with increased odds of complete UR (OR=45.231, 95% CI=2.591-789.486, p=0.009) and lower maternal weight (<68 kg) correlated with reduced odds of incomplete UR (OR=0.033, 95% CI=0.001–0.837, p=0.039), suggesting a protective effect per kilogram decrease. Conclusion Findings redefine UR as part of a broader clinical spectrum, not just an acute complication, enabling tailored surveillance and improved prevention in high-risk pregnancies.</ns5:p>

The efficacy of uterine artery embolization for postpartum hemorrhage with placenta accreta spectrum disorder: clinical outcomes in a cohord of 112 pregnant women

2025-06-13

Byung Soo Im , Ji Hoon Shin , Ji Hoon Kim +6 more | European Radiology

Multiple intraplacental hematomas preceding clinical deterioration in preeclampsia with severe features: A case report

2025-06-13

Nicholas Orlando , Kelsey Mumford , Marika Toscano +2 more | Radiology Case Reports

Validation of an Extended Maternal Comorbidity Index for Prediction of Severe Maternal Morbidity

2025-06-12

Ann M. Bruno , Grecio J. Sandoval , Brenna L. Hughes +7 more | Obstetrics and Gynecology

The expanded maternal comorbidity index developed by Leonard et al uses pre-existing maternal health conditions (eg, hypertension, asthma) to produce a risk score that predicts severe maternal morbidity (SMM). This … The expanded maternal comorbidity index developed by Leonard et al uses pre-existing maternal health conditions (eg, hypertension, asthma) to produce a risk score that predicts severe maternal morbidity (SMM). This tool has been adopted into clinical and research use without external validation in a data source not reliant on administrative codes. We assessed the validity of the maternal comorbidity index to predict SMM in a modern obstetric cohort using data derived from detailed medical record abstraction. In this secondary analysis of a multicenter cohort of patients delivering at 17 U.S. hospitals (2019–2020), the maternal comorbidity index risk score was applied to all individuals and the performance of the score to predict SMM was assessed using the area under the receiver operating curve (AUC). Of 20,898 individuals in this cohort, 668 (3.2%) experienced SMM. The AUC for the maternal comorbidity index was 0.72 (95% CI, 0.70–0.74) to predict SMM and 0.83 (95% CI, 0.79–0.86) to predict SMM without transfusion. The expanded maternal comorbidity index for prediction of SMM was externally valid, and findings support the ongoing use of this tool.

Accreta centers and maternal morbidity for patients with placenta accreta spectrum disorders in California: a mixed-methods population-based study

2025-06-12

Kimberly D. Gregory , Moshe Fridman , Samia Saeb +2 more | The Journal of Maternal-Fetal & Neonatal Medicine

We evaluated whether placenta accreta spectrum (PAS) patients who delivered at accreta centers had reduced severe maternal morbidity (SMM), and we tested for the presence of racial disparity in SMM … We evaluated whether placenta accreta spectrum (PAS) patients who delivered at accreta centers had reduced severe maternal morbidity (SMM), and we tested for the presence of racial disparity in SMM at these centers. This is a mixed-methods, cross-sectional, population-based study of California hospitals with at least 200 annual delivery discharges from 2019 to 2021. Hospital discharge data from 2018 were used to assess the distribution of PAS cases in California hospitals and identify "high-volume" accreta hospitals (≥6 PAS cases). Hospitals meeting 7 predefined criteria by interview were labeled as accreta centers. Delivery discharges with PAS diagnostic codes from 2019 to 2021 were aggregated for these hospitals. Bivariate analyses were performed between patient risk factors and "performance" SMM (pSMM) (Yes/No). pSMM is a modified version of the Centers for Disease Control and Prevention SMM measure for hospital comparisons of potentially preventable SMM. We report rates of pSMM (defined without counting hysterectomy) by center status. A multiple hierarchical logistic regression model was constructed for the pSMM outcome. Observed-to-expected (O/E) ratios for pSMM were calculated to evaluate differences by race/ethnicity. There were 25 high-volume study hospitals, of which 17 (68%) qualified as accreta centers. Of 1791 PAS cases in California (prevalence of 0.15%), 788 delivered at the 25 hospitals and composed the study population. Centers delivered 93.4% of the percreta cases, 89.6% of increta cases, and 79.5% of the accreta cases, p = .0003. Rates of pSMM were 8.8% (n = 70) overall, (8.4% in centers and 11.0% in non-centers; p = .323). PAS patients were more likely to experience pSMM if they were delivered at non-centers (odds ratio 2.09, 95% confidence interval 0.91-4.80, p = .080). No differences in aggregate O/E ratios by race/ethnicity were identified. PAS patients delivered at non-centers were twice as likely to experience pSMM, although this finding did not reach statistical significance. As rates of PAS increase, the development of standardized metrics to track improvement in clinical and patient-reported outcome measures appears warranted.

Tranexamic Acid in Postpartum Hemorrhage Management: A Multinational Systematic Review of Efficacy and Safety in Both Vaginal and Cesarean Births

2025-06-10

Nisreen Ali | Cureus

Histerectomía obstétrica por hemorragia posparto refractaria: predictores preoperatorios y desenlaces a doce meses. Reporte de un caso

2025-06-09

Daniela Camila Tapia Valarezo , Dayanara Pilar Briones Villamar , Katiuska Narcisa Orrala Ruiz +2 more | Arandu-UTIC.

La hemorragia posparto refractaria constituye una emergencia obstétrica potencialmente letal. Se describe el caso de una primigesta de 19 años atendida en un hospital de referencia de Guayaquil, Ecuador, que … La hemorragia posparto refractaria constituye una emergencia obstétrica potencialmente letal. Se describe el caso de una primigesta de 19 años atendida en un hospital de referencia de Guayaquil, Ecuador, que desarrolló hemorragia posparto masiva tras un parto vaginal eutócico. A pesar del algoritmo escalonado de manejo (uterotónicos, taponamiento intrauterino y protocolo de transfusión masiva 1:1:1), el sangrado superó 1 500 mL en los primeros 45 min, con índice de choque > 1 y lactato 4,2 mmol/L. Ante el deterioro hemodinámico y la ecografía que reveló atonía uterina persistente con coágulos intrauterinos, se activó el equipo interdisciplinario y se practicó histerectomía obstétrica subtotal a las 2 h posparto. Los predictores preoperatorios identificados fueron: índice de choque elevado, requerimiento de >4 unidades de glóbulos rojos, falla del taponamiento y presencia de coagulopatía incipiente (fibrinógeno < 200 mg/dL). La evolución posoperatoria fue favorable; requirió cuidados intensivos por 24 h sin complicaciones infecciosas ni trombóticas. Al seguimiento de 12 meses, la paciente presentó función hormonal normal, hemoglobina 12,6 g/dL, adecuada recuperación psicosocial y reintegración a sus actividades. Este caso resalta la utilidad de parámetros clínicos simples y la ventana de decisión temprana para optimizar resultados en contextos de recursos intermedios.