Having a baby has many benefits, but you need to be aware that there are risks involved. One of the most common is Postpartum Hemorrhage. It occurs when blood clots form within the mother’s uterus. The condition is usually severe and requires immediate medical attention.
Laparotomy and hysterectomy
Compared with vaginal birth, cesarean birth has a higher incidence of postpartum hemorrhage. The risk of EPH is also increased in countries with high rates of CS. Moreover, women with preexisting medical conditions may require counseling and referral to specialist centers. Despite the infrequent occurrence of fatal bleeding after gynecological surgery, the need for timely medical management is critical.
During a laparotomy, the surgeon should use knowledge, technical skills, and judgment to control bleeding. Surgical intervention should be guided by good exposure of tissue and the use of precise sutures and clamping of vessels. The timing of blood transfusion should be determined by the patient’s medical history.
A study at the Filantropia Clinical Hospital in Bucharest, Romania, was conducted to estimate the incidence of EPH. It used a nationwide population-based cohort of pregnant women who had suffered SAMM. The objective was to identify risk factors, evaluate maternal outcomes, and compare them with controls.
The study included 36,099 births. A total of 96 women underwent emergency hysterectomies during the study period. During this time, three deaths occurred. Two were due to intra-abdominal bleeding. A third woman died during a hysterectomy.
The overall incidence of laparotomy after childbirth was 6.0 per 10,000 women. The risk was 16 times higher in women with a cesarean birth. However, the incidence was 1.8 per 10,000 vaginal births.
The study found that the risk of postpartum laparotomy was significantly higher in women with a cesarean than in women with a vaginal birth. Incidence was also higher in women with multiple comorbidities. The study suggested that women with a preexisting condition should be referred to a specialist center before undergoing a hysterectomy.
The risk of peripartum hysterectomy was associated with severe maternal morbidity. The study identified several risk factors, including abnormal placentation, uterine atony, and sepsis.
The incidence of re-laparotomy was comparable between planned and emergency cesarean sections. The proportion of re-laparotomy due to intra-abdominal bleeding was similar for planned and emergency cesarean sections. It was more common to have re-laparotomy due to a bladder injury than a cesarean scar bleed.
During a laparotomy, bleeding blood vessels are sealed with uterine compression sutures. This prevents further bleeding. In addition, pelvic CT scanning can help in localizing bleeding.
Tranexamic acid
Approximately 6 percent of women in the world give birth and develop postpartum hemorrhage. Several interventions are used to reduce the risk of postpartum hemorrhage. One intervention is the use of antifibrinolytic agents to prevent blood loss. The effectiveness of these agents has been demonstrated in reducing blood loss in various surgical procedures and is considered to be a promising technique for preventing postpartum hemorrhage.
Tranexamic acid is an inexpensive antifibrinolytic pharmacologic agent that inhibits the fibrinolytic pathway by blocking lysine-binding sites on plasminogen molecules. The drug has a half-life of two hours and is administered in the form of a granule or a solution. It is given as soon as possible after bleeding begins.
Tranexamic acid is an approved drug in the US for the treatment of postpartum hemorrhage. It is also approved as an adjunct to uterotonics for the prevention of postpartum hemorrhage. The World Health Organization (WHO) recommends the use of tranexamic acid as part of a comprehensive PPH treatment package.
The WOMAN trial is the largest randomized, double-blind, placebo-controlled trial of the use of tranexamic acid to reduce the risk of postpartum hemorrhage and death from bleeding in women with PPH following vaginal delivery. It included 20,060 women. The main outcomes of the study were mortality, morbidities, and thromboembolic events. In addition, the primary outcome was a hysterectomy within 42 days of randomization.
The results of the trial suggested that early administration of TXA reduced the risk of postpartum hemorrhage. However, it did not reduce all-cause mortality. Among the women who were still alive at delivery, those in the intervention group had a lower risk of hysterectomy. The mean hemoglobin levels were not significantly different between the groups.
The WHO updated their recommendation regarding tranexamic acid for postpartum hemorrhage in light of the WOMAN trial. The current guidelines do not recommend routine administration of tranexamic acid after cesarean deliveries. It may be used before a cesarean delivery to decrease blood loss, but this practice may not be justified. Moreover, it is associated with an increased risk of spinal drug errors.
The WOMAN trial was designed to assess whether TXA administered before the delivery of the placenta could reduce the risk of postpartum hemorrhage. To evaluate the effect of the drug, the volume of blood lost from the placenta was measured 2 hours after delivery, and the hematocrit was measured 12-24 hours after delivery. The study found that total blood loss was reduced by 18.7 percent in the intervention group. In addition, the mean hematocrit was decreased in the group receiving the tranexamic.
Placental implantation abnormalities
During delivery, a woman may experience an abnormality of the placenta. This condition may lead to postpartum hemorrhage. Understanding normal placental development and anatomy is essential for diagnosing and treating this condition. A multidisciplinary team of specialists will help reduce morbidity and mortality.
Implantation abnormalities are a group of disorders associated with an increased rate of maternal morbidity. These disorders occur during the early stages of implantation. They include various entities of different severity. The etiology of these conditions is largely unknown. However, there are several risk factors that are known.
Abnormal decidualization is one of the leading causes of abnormal placentation. In this condition, the trophoblast attaches to the chorionic villi in the myometrium without intervening decidua. This invasion may result in the placement of the placenta in the lower uterine segment. This can be due to trauma or anti-invasive factors.
MRI can help identify implantation abnormalities. The images can show a focal thinning of the myometrium, a bulge in the uterine serosa with a distorted uterine outline, and an interruption of the junctional zone. The uterine serosa-bladder wall interface can also show increased vascularity. In addition, dilated tortuous vessels can be noted in the uterine serosa. This condition is referred to as morbidly adherent placenta.
Placental accreta is an uncommon condition in which the placenta grows too deeply into the uterine wall. This can cause massive hemorrhage. In this situation, a cesarean section is usually performed. During this surgery, the uterus is pushed back towards the posterior fornix. This is the last resort in uncontrolled postpartum hemorrhage.
The condition of placenta accreta can be diagnosed prenatally. A pregnant woman who has had a previous Caesarean delivery or is at high risk of developing postpartum hemorrhage may be at higher risk.
Placental implantation abnormalities can be treated with cesarean hysterectomy and other interventions. Treatment strategies vary depending on the expertise of the hospital or clinic. These procedures are often performed as elective surgeries. This will also depend on the local availability of a specialist multidisciplinary team.
Placental implantation abnormalities are a major cause of postpartum hemorrhage. These conditions are life-threatening. They are also associated with an increased risk of maternal death.
Transfusions
During pregnancy, there are many hematologic changes that may occur. A transfusion is a common therapy that can save a mother’s life. The risks associated with blood transfusion are minimal. A transfusion can also help to prevent serious harm to the mother’s health. However, obstetric hemorrhage (OH) is the leading cause of maternal morbidity and mortality worldwide. It is important to understand the differences between normal physiologic changes and pathologic laboratory perturbations.
In order to determine the effectiveness of transfusions during a cesarean delivery, an audit of medical records was performed. Data were obtained from a local obstetric database, a linkage of the Danish Medical Birth Registry, and local transfusion databases. A total of 201 transfusion episodes were identified. The following parameters were assessed: the volume of transfused blood products, the fibrinogen dose in g, and the number of red blood cells. The results showed that there was a significant decrease in transfusion usage after CS.
There were five transfusion-related adverse events recorded. One was severe and required admission to the intensive care unit. The other four were moderate. The overall rate of RBC transfusions was 0.48 +- 0.04%. This is lower than the national French transfusion guidelines of 7.0 g/dL for RBC transfusion. This may be due to the fact that these are all cases of RBC transfusion given within seven days of delivery. The higher rate might be due to other causes of postpartum anemia.
For a more thorough analysis of the effects of massive transfusion, a larger randomized study is needed. In the meantime, early identification of coagulation changes will help reduce the need for transfusion. This will help to shorten the length of hospital stay and the need for ICU admission.
In addition, multi-professional obstetric skills training is an effective means to reduce the incidence of OH. This training will also help to reduce the time needed to perform surgical interventions. In high-resource countries, the rates of postpartum hemorrhage have increased. In addition, severe adverse outcomes have also been increasing.
These findings have led to renewed interest in targeted approaches to transfusion during cesarean delivery. A review of these studies highlights the unique hematologic conditions that occur during pregnancy. It also discusses the need for comprehensive obstetric care.
Health Sources:
Health A to Z. (n.d.). HSE.ie. https://www2.hse.ie/az/
U.S. National Library of Medicine. (n.d.). https://www.ncbi.nlm.nih.gov/
Directory Health Topics. (n.d.). https://www.healthline.com/directory/topics
Health A-Z. (2022, April 26). Verywell Health. https://www.verywellhealth.com/health-a-z-4014770
Harvard Health. (2015, November 17). Health A to Z. https://www.health.harvard.edu/health-a-to-z
Health Conditions A-Z Sitemap. (n.d.). EverydayHealth.com. https://www.everydayhealth.com/conditions/
