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Peripartum hysterectomy (PH) is usually undertaken in cases of life-threatening obstetric haemorrhage to prevent the death of the mother. Obstetric haemorrhage, a leading indication for PH, is a major cause of maternal deaths globally, particularly in regions with limited access to advanced medical care. The cause of the per vaginal bleeding was due to the patient in labour with a cervical stitch, and immediate action was taken in the form of a lower segment caesarean section. After the patient's abdominal drain is noticed with fresh blood collection, an emergency obstetric hysterectomy is done.

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OBJECTIVE: Early diagnosis of retained products of conception (RPOC) is critical for directing clinical management and for preventing associated complications. This study aimed to evaluate the utility of post-delivery ultrasound in patients with risk factors for RPOC. STUDY DESIGN: A retrospective cohort-study was conducted in a single tertiary university-affiliated hospital (January 2016-September 2022). Sonographic evaluation, including endometrium thickness measurement and color Doppler, were reviewed of women with risk factors for RPOC: postpartum hemorrhage, a hemoglobin drop > 4 g/dl, manual removal of the placenta, and suspicious placenta. Results of early postpartum ultrasound (within 48 h), misoprostol administration and hysteroscopies were evaluated. RESULTS: Of the 591 women included, RPOC was suspected in 141 (24%). Endometrial thickness > 5 mm was associated with sonographic RPOC diagnosis in 58%. Suspected sonographic RPOC was concluded for 100%, 92% and 7% of the women with marked, moderate, and undetectable vascularity, respectively, p < 0.001. Misoprostol 1000 mcg per rectum (PR) was administered to 86% of those with suspected RPOC; only 11% of them needed an operative hysteroscopy for removal of the RPOC. RPOC on a pathology report was confirmed for 71% of those who underwent hysteroscopy. CONCLUSIONS: Postpartum transabdominal ultrasonography within 48 h of delivery was effective for assessing RPOC. For appropriate triage, color Doppler grading increased the accuracy of RPOC diagnosis. Misoprostol treatment was successful in 88% of women with suspected sonographic RPOC. The combination of sonographic evaluation and misoprostol treatment for suspected RPOC might lower the rate of unnecessary invasive procedures.

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The spontaneous rupture of an ovarian artery aneurysm (OAA) is an extremely uncommon and life-threatening event. Here, we describe the case of a 34-year-old G6P5015 female who underwent spontaneous vaginal delivery. Following delivery, she experienced hypotension and reported right-sided abdominal pain. A contrast-enhanced computed tomography (CT) angiogram revealed an aneurysmal dilation, extravasation, pseudoaneurysms, and a large retroperitoneal hematoma attributable to a rupture of the right ovarian artery. Subsequently, an exploratory laparotomy was performed, and then a transcatheter arterial embolization (TAE) by interventional radiology (IR). At a proximal site, IR successfully embolized both the ovarian and uterine arteries. This case highlights the significance of rapid intervention in managing an OAA. Additionally, we discuss the risk factors and treatment alternatives for OAA, underscoring the importance of considering it in the differential diagnosis when encountering atypical hypotension in the postpartum period.

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Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality worldwide, with uterine atony being the most significant contributing factor. Other risk factors for PPH include increased maternal age, coagulation abnormalities, retained placenta, and prolonged third-stage labor. Despite the potential for prevention through early detection and management, PPH can still occur even in the absence of known risk factors. For this reason, adequate preparation and comprehensive management strategies must be implemented. This study, which comprises research from 2006 to 2023, reviews and analyzes various prevention and management techniques for PPH, including surgical and nonsurgical approaches. Key findings indicate that the presence of well-trained critical control teams is essential for the effective management of PPH. In addition, early detection techniques have significantly reduced mortality outcomes associated with PPH, highlighting their importance in patient care.

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Uterine inversion is characterized by the folding of the fundus into the uterine cavity. While infrequent, it ranks among the most serious complications of childbirth, posing a significant risk of mortality primarily due to hemorrhage and shock. Retained placenta after vaginal delivery is diagnosed when placenta does not spontaneously deliver within 18-60 min. Manual placenta can be considered first if retained placenta occurs. A 29-year-old woman with parity status P2A0 came to maternal emergency referred from the first health care provider with severe post-partum hemorrhage after delivering her second living 3100 g baby 2 h before admission. The midwife reported that the placenta was hard to have. There was a resistance felt inside when she tried to do umbilical cord traction. The manual placenta was not done. After several trials, the placenta finally came out, followed by fundus of uterine. Acute hemorrhage occurred, causing a decrease of hemoglobin level to 7.8 g/dl. At maternal emergency, the placenta delivered spontaneously yet the fundus still inverted. Fast reposition of uterine done by doctor on duty to stop the hemorrhage. Following successful repositioning and 4 days of observation, the patient was discharged from the hospital with no signs of hemorrhage and favorable results on abdominal ultrasonography.

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Background: Despite a range of available treatments, it is still sometimes challenging to treat patients with severe post-partum hemorrhage (sPPH). Objective: This study evaluated the efficacy and safety of recombinant activated factor VIIa (rFVIIa) in sPPH management. Methods: An open-label, multi-center, randomized controlled trial (RCT; NCT00370877) and four observational studies (OS; OS-1 (NCT04723979), OS-2, OS-3, and OS-4) were analyzed regarding efficacy (need for subsequent invasive procedures, including uterine compression sutures, uterine or iliac artery ligations, arterial embolization, or hysterectomy) and safety (incidence of thromboembolic events (TE) and maternal mortality) of rFVIIa for sPPH. The RCT, and OS-1 and OS-2, included a control group of women who did not receive rFVIIa (with propensity score-matching used in OS-1 and OS-2), whereas OS-3 and OS-4 provided descriptive data for rFVIIa-exposed women only. Results: A total of 446 women exposed to rFVIIa and 1717 non-exposed controls were included. In the RCT, fewer rFVIIa-exposed women (50% [21/42]) had an invasive procedure versus non-exposed women (91% [38/42]; odds ratio: 0.11; 95% confidence interval: 0.03-0.35). In OS-1, more rFVIIa-exposed women (58% [22/38]) had an invasive procedure versus non-exposed women (35% [13.3/38]; odds ratio: 2.46; 95% confidence interval: 1.06-5.99). In OS-2, 17% (3/18) of rFVIIa-exposed women and 32% (5.6/17.8) of non-exposed women had an invasive procedure (odds ratio: 0.33; 95% confidence interval: 0.03-1.75). Across all included women, TEs occurred in 1.5% (0.2% arterial and 1.2% venous) of rFVIIa-exposed women and 1.6% (0.2% arterial and 1.4% venous) of non-exposed women with available data. Conclusions: The positive treatment effect of rFVIIa on the RCT was not confirmed in the OS. However, the safety analysis did not show any increased incidence of TEs with rFVIIa treatment.

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Severe post-partum hemorrhage (PPH) is a major cause of maternal mortality worldwide. Recombinant activated factor VII (rFVIIa) has recently been approved by the European Medicines Agency for the treatment of severe PPH if uterotonics fail to achieve hemostasis. Although large randomized controlled trials are lacking, accumulated evidence from smaller studies and international registries supports the efficacy of rFVIIa alongside extended standard treatment to control severe PPH. Because rFVIIa neither substitutes the activity of a missing coagulation factor nor bypasses a coagulation defect in this population, it is not immediately evident how it exerts its beneficial effect. Here, we discuss possible mechanistic explanations for the efficacy of rFVIIa and the published evidence in patients with severe PPH. Recombinant FVIIa may not primarily increase systemic thrombin generation, but may promote local thrombin generation through binding to activated platelets at the site of vascular wall injury. This explanation may also address safety concerns that have been raised over the administration of a procoagulant molecule in a background of increased thromboembolic risk due to both pregnancy-related hemostatic changes and the hemorrhagic state. However, the available safety data for this and other indications are reassuring and the rates of thromboembolic events do not appear to be increased in women with severe PPH treated with rFVIIa. We recommend that the administration of rFVIIa be considered before dilutional coagulopathy develops and used to support the current standard treatment in certain patients with severe PPH.

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OBJECTIVE: Up to 4.8% of all vaginal deliveries are complicated by significant cervical tears related to maternal compromise, yet the location of the cervical tear and its impact on the attributed risk have not been studied to date. This study aimed to determine the associations between the location and characteristics of cervical tears with short-term maternal complications and outcomes. METHODS: This is a retrospective cohort study. Included were all patients that delivered vaginally at our institute between the years 2009-2020 and were diagnosed with a cervical tear. Maternal complications were compared between cases with posterior cervical tears and cases with anterior or lateral cervical tears. Exclusion criteria included patients who delivered by cesarean delivery and preterm labor below 37.0 weeks of gestation. RESULTS: Overall, 96 patients were diagnosed with posterior cervical tears, while 117 patients were diagnosed with anterior or lateral tears. Maternal demographics and pregnancy characteristics were similar between the groups. There were also no differences in delivery outcomes between the groups. Patients with posterior cervical tears had a higher rate of disseminated intravascular coagulation (DIC) (6.25 % vs. 0.9 %, p = 0.04) and prolonged hospitalization (35.4 % vs. 23.1 %, p = 0.05), as compared to patients with anterior or lateral tears. There were no differences in other maternal complications. CONCLUSIONS: Cases of posterior cervical tears are at higher risk for maternal adverse outcomes (DIC and prolonged hospitalization), as compared to cases of anterior or lateral tears.

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Postpartum hypertension can significantly increase maternal morbidity and mortality, and hence it requires prompt interdisciplinary evaluation and interventions. We present a case of a gravid patient with significant comorbidities who required multiple treatments and care from several specialists following a complicated vaginal delivery. The outcome of this case depended on a focused differential diagnosis and interdisciplinary consultation with the several teams involved. This case report illustrates the importance of effective communication and an interdisciplinary approach in the management of postpartum hypertensive emergencies. Such an approach is crucial in reducing maternal complications following postpartum hypertension, as well as reducing the length of hospital stay to improve maternal and fetal outcomes.

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Postpartum hemorrhage (PPH) remains a major cause of maternal mortality. Tranexamic acid (TxA) has shown effectiveness in reducing PPH-related maternal bleeding events and deaths. We conducted a cohort study including parturient women at high risk of bleeding after undergoing a cesarean section (CS). Participants were divided into two groups: the treatment group received prophylactic 1-g TxA before surgery (n = 500), while the comparison group underwent CS without TxA treatment (n = 500). The primary outcome measured increased maternal blood loss following CS, defined as more than a 10% drop in hemoglobin concentration within 24 h post-CS and/or a drop of ≥2 g/dL in maternal hemoglobin concentration. Secondary outcomes included PPH indicators, ICU admission, hospital stay, TxA complications, and neonatal data. TxA administration significantly reduced hemoglobin decrease by more than 10%: there was a 35.4% decrease in the TxA group vs. a 59.4% decrease in the non-TxA group, p < 0.0001 and hemoglobin decreased by ≥2 g/dL (11.4% in the TxA group vs. 25.2% in non-TxA group, p < 0.0001), reduced packed red blood cell transfusion (p = 0.0174), and resulted in lower ICU admission rates (p = 0.034) and shorter hospitalization (p < 0.0001). Complication rates and neonatal outcomes did not differ significantly. In conclusion, prophylactic TxA administration during high-risk CS may effectively reduce blood loss, providing a potential intervention to improve maternal outcomes.

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Hemostasis hysterectomy is a mutilating technique responsible for definitive side effect on the woman's fertility. The aim was to document to document hemostasis hysterectomies performed in obstetrics units of university hospitals in Côte d'Ivoire. This was a retrospective, cross-sectional, and descriptive study from January 2013 to January 2018 in the three university hospital centers of Abidjan. It involved all parturients of the said university hospital centers who presented a severe postpartum hemorrhage and in whom a hemostasis hysterectomy was performed. The overall frequency of hemostasis hysterectomy in the three university hospitals was 0.32%. The most common etiologies were atony and uterine rupture. Hemostasis hysterectomy was indicated immediately. The deaths recorded were most often intraoperative and in the immediate postoperative period. The reduction of its incidence requires a good surveillance of the third period of delivery.

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The obstetrical follow-up of patients with a severe hypofibrinogenemia requires a multidisciplinary collaboration because of potential maternal-fetal complications (recurrent miscarriages, intrauterine fetal demise, post-partum hemorrhage, thrombosis). We report the obstetrical management of a multiparous patient with a severe congenital hypofibrinogenemia associated with a platelet disorder (abnormal phospholipid externalization). A therapeutic strategy based on a biweekly administration of fibrinogen concentrates associated with enoxaparin and aspirin allowed the maintenance of pregnancy. But this last one got complicated by a placenta percreta requiring a salvage hysterectomy with an appropriate hemorrhage prophylaxis.

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Secondary postpartum hemorrhage is one of the important cause of postpartum morbidity and mortality. Uterine artery pseudoaneurysm is a rare, potentially fatal but treatable cause of secondary post-partum hemorrhage. If not diagnosed timely, it can lead to life-threatening hemorrhage. We report the case of a 41-year-old woman who presented with profuse vaginal bleeding on 32nd day of cesarean section. On imaging a left uterine artery pseudoaneurysm was found in the uterine wall with blood clots in the uterine cavity. Patient was managed with aggressive fluid resuscitation and immediate interventional radiology procedure of selective embolization of pseudoaneurysm. High index of suspicion is needed to search for rare vascular causes like pseudoaneurysm.

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BACKGROUND: Patients with a bleeding tendency with normal laboratory tests have been described as having an unclassified bleeding disorder or bleeding disorder of unknown cause (BDUC). There are very little data available on how to manage pregnancy. OBJECTIVES: To study management and outcomes of these patients at four United Kingdom hemophilia comprehensive care centers. METHODS: Retrospective case note review from 2010-2020. RESULTS: Sixty deliveries in 36 patients were recorded. The median International Society on Thrombosis and Haemostasis bleeding assessment tool score was 9. In 54 cases for which data were available, the odds ratio for post partum hemorrhage (PPH) was 6.3 for no primary hemostatic prophylaxis versus prophylaxis (95% confidence interval 1.2-34.2, p < .05); 7/9 (78%) versus 16/45 (36%) PPH incidence for the groups, respectively. Hemostatic prophylaxis was with tranexamic acid but some patients received desmopressin or platelet infusions. Secondary PPH was seen in 5/60 (8%) of cases. No neonatal bleeding complications or maternal thromboembolic complications were noted. Avoidance of regional anesthesia and fetal delivery precautions were commonly advised, but in the small number of cases in which they occurred no complications were noted. CONCLUSIONS: Despite hemostatic prophylaxis PPH was commonly seen. Further prospective studies of BDUC patients are required to determine optimal management in pregnancy as well as determine the pathophysiological basis of bleeding.

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Postpartum hemorrhage (PPH) is a major cause of maternal death and morbidity worldwide. Throughout the years, there have not been many studies looking into the association of race and ethnicity with the occurrence of PPH. The goal of this study was to assess race and ethnicity as risk factors in the development of PPH in pregnant women. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) standards, we conducted the analysis and conducted a literature search using Google Scholar and PubMed. After applying our inclusion and exclusion criteria, the search technique yielded a total of eight articles. The analysis included seven observational studies and one randomized controlled trial. The incidence of PPH was chosen as the major outcome measure. An evaluation of eight studies revealed that although Hispanics, Asians, Native Hawaiians, and other Pacific Islanders (NHOPI) have a higher chance of developing PPH caused by uterine atony, Caucasians had a greater rate of transfusion than the other groups. In addition, compared to Caucasians, African Americans or African descendants had a lower risk of atonic PPH but increased odds of atonic PPH requiring interventions. On the other hand, compared to non-native groups, Native Americans had increased odds of uterine atony. The results showed that, in contrast to other races/ethnicities, Caucasians had the lowest risk of PPH. Additionally, it was shown that African Americans or those descended from Africans had a higher chance of PPH but a lower risk of atonic PPH.

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Objectives: To evaluate the effectiveness of Tranexamic Acid in preventing postpartum hemorrhage against placebo in high-risk women undergoing cesarean section. Methods: A double-blinded placebo-controlled comparative trial was conducted at the Obstetrics and Gynecology Department of Nishtar Hospital for one year, from 15th June 2020 to 15th June 2021. A total of 60 women who were at high risk of postpartum hemorrhage and had to undergo elective cesarean sections were included in the study. Among them, initial 30 patients were administered Tranexamic Acid before skin incision whereas later 30 were treated as the placebo group. These women were then observed for blood loss during surgery and within 24 hrs. after surgery and any postoperative complications such as thromboembolic events, the need for additional uterotonic agents, and blood transfusions. Results: Out of 60 women, 30 were placed in each group. The groups had no significant difference in terms of baseline data and post-partum hemorrhage-associated risk factors (p>0.05). However, the occurrence rate of primary post-partum hemorrhage (blood loss greater than 1000 ml) was significantly less in a tranexamic acid group than the placebo group (16.6% vs 60%, respectively, p<0.01). Similarly, the requirement of additional uterotonic agents (13.3% vs 43.3%, respectively) and the need for blood transfusion (6.0% vs 23.3%, respectively) was lower in a tranexamic group than in the placebo group. Conclusion: The study highlighted the significance of tranexamic acid in controlling post-partum hemorrhages, the requirement of additional uterotonic agents, improving post-partum hemoglobin, and the need for blood transfusion.

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BACKGROUND: There is insufficient high-quality evidence to either support or discourage water birth (WB). OBJECTIVES: To examine different maternal complications of WB compared to standard land birth (LB). The primary outcomes were postpartum hemorrhage and genital trauma. The secondary outcome included the risk of retained placenta and shoulder dystocia. METHODS: We searched the electronic databases including PubMed, MEDLINE, Embase, Scopus, EBSCO. In addition, we searched in Google Scholar and ClinicalTrials.gov. The pooled results were used to evaluate the association between WB and obstetric outcomes. This systematic review (SR) was reported according to PRISMA statement 2020. Statistical meta-analyses were performed using Cochrane RevMan version 5.4 software (http://www.cochrane.org). RESULTS: This systematic review included 22 studies (20 observational studies and 2 RCT). The pooled results showed lower risk of major PPH compared to the LB group (OR = 0.76, 95% CI: 0.66-0.89), no significant difference (OR: 0.94, 95% CI: 0.50-1.78) in the incidence of minor PPH (500-1000 mL blood loss) between WB and LB, no significant difference in the rate of third- and fourth-degree lacerations (OR = 0.87, 95% CI: 0.71-1.07) and in the incidence of retained placenta (OR = 1.30, 95% CI: 0.50-3,35), fewer shoulder dystocia for WB (OR = 0.42, 95% CI: 0.35-0.50). However, compared with the LB group, the rate of first-second-degree tears in the WB group increased by 45% (OR = 1.45, 95% CI: 1.16-1.81). CONCLUSION: We support ACOG guidelines recommendation for further RCT to assess the impact of water immersion during delivery on maternal outcomes.

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Placenta accreta spectrum (PAS) is a potentially life-threatening disorder with unique anesthetic challenges, and its incidence has increased over the past decades. We review current guidelines and best practice evidence for antenatal diagnosis and preoperative evaluation, management pathways, multidisciplinary staff coordination, and surgery location. We address specific considerations for choice of anesthesia modality, the role of interventional radiology, and various techniques for minimizing hemorrhage for both planned and unplanned cases, as well as postoperative care for the PAS patient.

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Choriocarcinoma is a disease associated with uncontrollable proliferation and malignant change of cells of the placenta and belongs to the malignant end of the spectrum in gestational trophoblastic disease. These tumours are usually developed after molar pregnancies, and their incidence after full-term pregnancies is extremely rare. We present a very rare case of a 30-year-old lady, admitted with a five-month history of vaginal bleeding after a normal pregnancy. The human chorionic gonadotropin (hCG) was at a level of 209,566. A pelvic ultrasound scan revealed an endometrial thickness of 6 cm and the presence of an intra-uterine mass measuring 56 × 50 × 45 mm. After discussion with the regional gestational trophoblastic disease centre, we proceeded to a surgical evacuation of the uterus, which confirmed a post-partum choriocarcinoma (International Federation of Gynaecology and Obstetrics (FIGO) score 9). Care was continued in the specialised centre with multi-agent chemotherapy. The response was excellent, and the patient was subsequently discharged after 10 cycles of chemotherapy, and a 10-year follow-up was arranged. Choriocarcinomas after full-term pregnancies are a rare entity. Even when they happen, they are usually associated with pregnancy complications in the ante-natal period. The prognosis is usually very good, provided that prompt diagnosis and referral to a specialised centre are made. Low-risk patients are usually treated with methotrexate monotherapy, whereas high-risk women would normally require multi-agent chemotherapy. The diagnosis of choriocarcinoma might be proven challenging even for experienced clinicians. Women should be informed that the prognosis is usually excellent, provided that they receive the right treatment.