Objective
To quantify reporting errors, measure incidence of postpartum haemorrhage (PPH) and define risk factors for PPH (≥500 ml) and progression to severe PPH (≥1500 ml).
Design
Prospective ...observational study.
Setting
Two UK maternity services.
Population
Women giving birth between 1 August 2008 and 31 July 2009 (n = 10 213).
Methods
Weighted sampling with sequential adjustment by multivariate analysis.
Main outcome measures
Incidence and risk factors for PPH and progression to severe PPH.
Results
Errors in transcribing blood volume were frequent (14%) with evidence of threshold preference and avoidance. The incidences of PPH ≥500, ≥1500 and ≥2500 ml were 33.7% (95% CI 31.2–36.2), 3.9% (95% CI 3.3–4.6) and 0.8% (95% CI 0.6–1.0). New independent risk factors predicting PPH ≥ 500 ml included Black African ethnicity (adjusted odds ratio aOR 1.77, 95% CI 1.31–2.39) and assisted conception (aOR 2.93, 95% CI 1.30–6.59). Modelling demonstrated how prepregnancy‐ and pregnancy‐acquired factors may be mediated through intrapartum events, including caesarean section, elective (aOR 24.4, 95% CI 5.53–108.00) or emergency (aOR 40.5, 95% CI 16.30–101.00), and retained placenta (aOR 21.3, 95% CI 8.31–54.7). New risk factors were identified for progression to severe PPH, including index of multiple deprivation (education, skills and training) (aOR 1.75, 95% CI 1.11–2.74), multiparity without caesarean section (aOR 1.65, 95% CI 1.20–2.28) and administration of steroids for fetal reasons (aOR 2.00, 95% CI 1.24–3.22).
Conclusions
Sequential, interacting, traditional and new risk factors explain the highest rates of PPH and severe PPH reported to date.
We report the case of a 14 year old girl who presented with a non-metastatic Ewing's sarcoma involving her superior pubic ramus. She received 14 courses of alkylating agent-based chemotherapy and ...direct radiation to her hemi-pelvis (55 Gy) and is alive and disease-free 8 years later. Multiple biopsies of ovarian cortical tissue were cryopreserved, with her written consent, before treatment began. Ovarian failure was confirmed on completion of treatment with cessation of menses and persistently elevated serum gonadotrophin and low estradiol levels on repeated measurement over 2 years. HRT was initiated. Irregular vaginal bleeding occurred due to radiation vaginitis. Reimplantation of ovarian cortical tissue was considered at 19 years as fertility was desired, but the decision deferred. A spontaneous conception occurred 1 year later and a healthy boy (birthweight 2.9 kg, 3rd–10th centile) was delivered at term by elective Caesarean section. This is the first case of a spontaneous conception occurring in a young woman with documented ovarian failure in whom ovarian cortical tissue had been cryopreserved. Clinicians should be aware of the possibility of spontaneous conception despite confirmed ovarian failure in young women successfully treated for cancer.
The case of a 26-year-old pregnant woman with an unusually high human chorionic gonadotropin (HCG) lab result is presented. Ovarian cysts were found to be the cause.
Summary
Real-time ultrasound and portable bladder scanners are commonly used instead of catheterisation to determine bladder volumes in postnatal women but it is not known whether these are accurate. ...Change in bladder volumes measured by ultrasound and portable scanners were compared with actual voided volume (VV) in 100 postnatal women. The VV was on average 41 ml (CI 29 - 54 ml) higher than that measured by ultrasound, and 33 ml (CI 17 - 48 ml) higher than that measured by portable scanners. Portable scanner volumes were 9 ml (CI −8 - 26 ml) higher than those measured by ultrasound. Neither method is an accurate tool for detecting bladder volume in postnatal women.
Objectives To compare the effect of delivering early to pre‐empt terminal hypoxaemia with delaying for as long as possible to increase maturity.
Design A randomised controlled trial.
Setting 69 ...hospitals in 13 European countries.
Participants Pregnant women with fetal compromise between 24 and 36 weeks, an umbilical artery Doppler waveform recorded and clinical uncertainty whether immediate delivery was indicated.
Methods The interventions were ‘immediate delivery’ or ‘delay until the obstetrician is no longer uncertain’. The data monitoring and analysis were Bayesian.
Main outcome measures ‘Survival to hospital discharge’ and ‘developmental quotient at two years of age’, this latter to be reported later.
Results Of 548 women (588 babies) recruited, outcomes were available on 547 mothers (587 babies). The median time‐to‐delivery intervals were 0.9 days in the immediate group and 4.9 days in the delay group. Total deaths prior to discharge were 29 (10%) in the immediate group versus 27 (9%) in the delay group (odds ratio 1.1, 95% CI 0.61–1.8). Total caesarean sections were 249 (91%) in the immediate group versus 217 (79%) in the delay group: (OR 2.7; 95% CI 1.6–4.5). These odds ratios were similar for those randomised at gestational ages above or below 30 weeks.
Interpretation The lack of difference in overall mortality suggests that clinicians participating in this trial were on average prepared to randomise at about the correct equivocal threshold between delivery and delay. However, there was insufficient evidence to convince enthusiasts for either immediate or delayed delivery that they were wrong.
To compare the effect of delivering early to pre-empt terminal hypoxaemia with delaying for as long as possible to increase maturity.
A randomised controlled trial.
69 hospitals in 13 European ...countries.
Pregnant women with fetal compromise between 24 and 36 weeks, an umbilical artery Doppler waveform recorded and clinical uncertainty whether immediate delivery was indicated.
The interventions were ‘immediate delivery’ or ‘delay until the obstetrician is no longer uncertain’. The data monitoring and analysis were Bayesian.
‘Survival to hospital discharge’ and ‘developmental quotient at two years of age’, this latter to be reported later.
Of 548 women (588 babies) recruited, outcomes were available on 547 mothers (587 babies). The median time-to-delivery intervals were 0.9 days in the immediate group and 4.9 days in the delay group. Total deaths prior to discharge were 29 (10%) in the immediate group
versus 27 (9%) in the delay group (odds ratio 1.1, 95% CI 0.61–1.8). Total caesarean sections were 249 (91%) in the immediate group
versus 217 (79%) in the delay group: (OR 2.7; 95% CI 1.6–4.5). These odds ratios were similar for those randomised at gestational ages above or below 30 weeks.
The lack of difference in overall mortality suggests that clinicians participating in this trial were on average prepared to randomise at about the correct equivocal threshold between delivery and delay. However, there was insufficient evidence to convince enthusiasts for either immediate or delayed delivery that they were wrong.
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