Unexpected placenta accreta spectrum in an unscarred uterus causing catastrophic post-partum hemorrhage: a case report and review of the literature.

Placenta accreta spectrum (PAS) disorder is a fatal condition responsible for obstetric haemorrhage, which contributes to increased feto-maternal morbidity and mortality. The main contributing factor is a scarred uterus, often from a previous cesarean delivery, myomectomy, or uterine instrumentation. The occurrence of PAS in an unscarred uterus is extremely rare, with only anecdotal cases reported so far in the literature. We document one such case of unexpected placenta increta without identifiable risk factors presenting with severe postpartum hemorrhage. The management is often challenging, especially in low-middle-income countries like India with limited access to healthcare, where most cases are identified only at the time of delivery. We narrate a case of a 25-year-old woman of North Indian ethnicity, para 2 live 2, who presented to our emergency in shock with retained placenta and severe postpartum haemorrhage. She had undergone a normal vaginal delivery at 37 weeks and 2 days of pregnancy at a local hospital around 2 h before. The patient had not undergone antenatal checkups or sonography during her pregnancy. Manual removal of the placenta was attempted under anaesthesia, which was unsuccessful. So, keeping the diagnosis of the morbidly adherent placenta in mind and the deteriorating condition of the patient, an emergency laparotomy followed by a supracervical hysterectomy was performed after the conservative methods failed to control the haemorrhage. Simultaneously, she was given four units of packed red cells and fresh frozen plasma in a ratio of 1:1, along with vasopressors and fluid replacement therapy to attain hemodynamic stability. Post-operatively, the patient was shifted to the intensive care unit (ICU) for close monitoring. She was discharged after five days in satisfactory condition. A histopathological examination later on revealed placenta increta. Although very rare, PAS in an unscarred uterus with no other known risk factors is associated with a significant rate of maternal morbidity and mortality. This case highlights the importance of screening for radiological signs of adherent placenta during prenatal visits, even in low-risk populations. Any patient suspected of PAS should be referred to a well-equipped centre for optimal care. Also, young obstetricians should be imparted skill-based training to manage such emergencies with a multidisciplinary team approach.

Garg P ，Semwal S ，Bansal R 《BMC Pregnancy and Childbirth》

Uterotonics for management of retained placenta.

Retained placenta is a significant cause of maternal death from postpartum haemorrhage. Traditionally, it is managed by manual removal under anaesthesia, which carries risks of haemorrhage, infection, and uterine perforation. Uterotonics may offer an alternative for delivering the retained placenta since they induce uterine contractions. However, evidence regarding uterotonic agents for retained placenta is still limited. To assess the benefits and harms of uterotonics for women with retained placenta after vaginal delivery for preventing postpartum haemorrhage. We searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, and WHO ICTRP; and checked references of included studies and pertinent systematic reviews to identify additional studies. The latest search date was 25 April 2024. We included randomised controlled trials (RCTs) and non-randomised studies of interventions in women who underwent vaginal delivery with retained placenta comparing one uterotonic with another uterotonic, placebo, or no treatment. We excluded studies that compared different uterotonics administered by umbilical vein injection. Our main outcomes were manual removal of the placenta; postpartum haemorrhage of 1000 mL or more; adverse effects, such as shivering; blood transfusion; maternal death; severe morbidity (admission to the intensive care unit); and blood loss in millilitres. The primary time point of interest for all outcomes was the end of the study period. We used the Cochrane RoB 2 tool to assess bias in RCTs and the ROBINS-I tool to assess bias in non-randomised studies of interventions. We synthesised results for each outcome using a random-effects meta-analysis, where possible, employing Mantel-Haenszel with risk ratio (RR) or inverse variance with mean difference (MD), as appropriate. Where this was not possible due to the nature of the data, we synthesised results using narrative synthesis methods. We used GRADE to assess the certainty of evidence for each outcome. We included five studies with 560 women, comprising four RCTs and one non-randomised study. The studies were conducted in the Netherlands, Tanzania, and Egypt. Three RCTs compared uterotonics (sulprostone or misoprostol) with placebo or no treatment. One RCT compared oxytocin, intravenous carbetocin, and sublingual misoprostol. One non-randomised study compared intraumbilical oxytocin to oxytocin infusion. Systemic uterotonic agents versus placebo or no treatment Sulprostone or misoprostol may result in little to no difference in the rate of manual removal of the placenta (RR 0.82, 95% confidence interval (CI) 0.54 to 1.27; 3 RCTs, 244 women; low-certainty evidence), and probably results in little to no difference in postpartum haemorrhage (RR 0.80, 95% CI 0.55 to 1.15; 2 RCTs, 194 women; moderate-certainty evidence), and blood transfusion (RR 0.72, 95% CI 0.43 to 1.22; 3 RCTs, 244 women; moderate-certainty evidence) compared to placebo or no treatment. We are very uncertain about the effect of misoprostol on shivering (RR 10.00, 95% CI 1.40 to 71.49; 1 RCT, 70 women; very low-certainty evidence) and the effects of uterotonic agents on mean blood loss (MD -205.26 mL, 95% CI -536.31 to 125.79; 3 RCTs, 244 women; very low-certainty evidence). No study assessed maternal death or severe morbidity. Intravenous carbetocin versus sublingual misoprostol Intravenous carbetocin probably does not reduce the need for manual removal of the placenta (RR 0.79, 95% CI 0.52 to 1.20; 1 RCT, 185 women; moderate-certainty evidence), and may not reduce blood transfusion (RR 0.48, 95% CI 0.09 to 2.58; 1 RCT, 185 women; low-certainty evidence) compared to sublingual misoprostol. The study did not assess postpartum haemorrhage of 1000 mL or more, adverse effects (shivering), maternal death, severe morbidity, and blood loss. Sublingual misoprostol versus oxytocin intraumbilical venous injection Sublingual misoprostol probably results in little to no difference in the rate of manual removal of the placenta (RR 1.09, 95% CI 0.73 to 1.61; 1 RCT, 187 women; moderate-certainty evidence) and may not reduce the need for blood transfusion (RR 1.05, 95% CI 0.27 to 4.09; 1 RCT, 187 women; low-certainty evidence) compared to oxytocin intraumbilical venous injection. The study did not assess postpartum haemorrhage of 1000 mL or more, adverse effects (shivering), maternal death, severe morbidity, and blood loss. Intravenous carbetocin versus oxytocin intraumbilical venous injection Intravenous carbetocin probably does not reduce the rate of manual removal of the placenta (RR 0.86, 95% CI 0.56 to 1.32; 1 RCT, 190 women; moderate-certainty evidence), and may result in little to no difference in reducing blood transfusions (RR 0.51, 95% CI 0.10 to 2.72; 1 RCT, 190 women; low-certainty evidence) compared to intraumbilical venous injection. The study did not assess postpartum haemorrhage of 1000 mL or more, adverse effects (shivering), maternal death, severe morbidity, and blood loss. Oxytocin infusion versus oxytocin intraumbilical venous injection The evidence from one non-randomised study is very uncertain about the effect of oxytocin infusion on manual removal of the placenta compared to oxytocin intraumbilical venous injection (RR 0.90, 95% CI 0.71 to 1.13; 1 study, 35 women; very low-certainty evidence). The study did not assess our other outcomes of interest. Current evidence suggests that uterotonic agents (such as misoprostol and sulprostone) may result in little to no difference in the rates of manual removal of the placenta, and probably result in little to no difference in postpartum haemorrhage and the need for blood transfusions, compared to placebo or no treatment in the management of retained placenta. The evidence is very uncertain about their effects on blood loss and the effect of misoprostol on shivering. There is probably little to no difference in effects and there may be no difference in safety between one uterotonic agent over another. We found no useable data for maternal death and admission to the intensive care unit. Further large-scale studies are necessary to evaluate uterotonics versus placebo, compare different uterotonic agents, or assess combined uterotonic regimens. Additional research should focus on identifying specific adverse effects, maternal satisfaction and well-being, breastfeeding rates at discharge, and postpartum anaemia. This Cochrane review was funded by UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP). Registration (13 July 2024): Prospero, CRD42024564386.

Sothornwit J ，Ngamjarus C ，Pattanittum P ，Waidee T ，Jampathong N ，Jongjakapun A ，Kongwattanakul K ，Lumbiganon P ... -  《Cochrane Database of Systematic Reviews》

Cell salvage for the management of postpartum haemorrhage.

Postpartum haemorrhage (PPH), defined as a blood loss of 500 mL or more within 24 hours of birth, is the leading global cause of maternal morbidity and mortality. Allogenic blood transfusions are a critical component of PPH management, yet are often unfeasible, particularly in resource-poor settings where maternal morbidity is highest. Autologous cell salvage in the management of PPH has been proposed to combat limitations in access to allogenic blood and potential transfusion-related risks. This review examines the benefits and harms of using cell salvage for pregnant women during birth. To assess the benefits and harms of cell salvage when used during birth. We searched the CENTRAL, MEDLINE, Ovid Embase, and Global Index Medicus databases and the ICTRP and ClinicalTrials.gov trials registers. We also carried out reference checking and citation searching, and contacted study authors to identify all relevant studies. The latest search date was 8 February 2024. We included randomised controlled trials (RCTs) in pregnant women (24 weeks or more gestation) comparing use of cell salvage following caesarean or vaginal birth with routine care (defined as no cell salvage). We did not place any restrictions on mode of birth, ethnicity, race, socioeconomic status, education level, or place of residence. Critical outcomes for this review were risk of allogenic blood transfusion, risk of transfusion-related adverse reactions, risk of haemorrhage, transfer to higher level of care, length of hospitalisation, length of operation, and risk of sepsis. Important outcomes were estimated blood loss, blood loss ≥ 500 mL, blood loss ≥ 1000 mL, use of additional uterotonics or tranexamic acid, maternal death, postpartum haemoglobin concentration, change in haemoglobin, major surgery including hysterectomy, future major surgery, end-organ dysfunction or failure, amniotic fluid embolism, side effects, clotting abnormalities, maternal experience/satisfaction, maternal well-being, and breastfeeding. We assessed risk of bias using the Cochrane risk of bias tool (RoB 1) for each critical outcome from each RCT. We conducted a meta-analysis for each outcome where data were available from more than one study using a random-effects model. If data could not be analysed using meta-analysis, we synthesised results narratively using the Synthesis Without Meta-analysis (SWiM) guidance. We used GRADE to assess the certainty of evidence for each outcome. We included six RCTs with 3476 participants. All trials involved pregnant women having a caesarean birth. Three trials were conducted in high-income countries, and three were conducted in an upper-middle-income country. Allogenic blood transfusion Intraoperative cell salvage at caesarean birth may reduce the need for allogenic transfusions received by participants, although the 95% confidence interval (CI) includes the possibility of an increase in effect. Low-certainty evidence from three studies found the risk of donor transfusions was possibly lower in participants with cell salvage (risk ratio (RR) 0.45, 95% CI 0.15 to 1.33; P = 0.15, I2 = 33%; 3 RCTs, 3115 women; low-certainty evidence). The absolute risk of transfusion was very low in the studies (4% in women not treated with cell salvage and 2% in women treated with cell salvage). Transfusion-related adverse reactions The evidence is very uncertain about the risk of transfusion-related adverse reactions in participants with intraoperative cell salvage (RR 0.48, 95% CI 0.09 to 2.62; P = 0.39; 4 RCTs, 3304 women; very low-certainty evidence). Haemorrhage Two studies reported risk of haemorrhage and found that there was probably no difference between arms (RR 0.88, 95% CI 0.67 to 1.15; P = 0.36, I² = 0%; 2 RCTs, 3077 women; moderate-certainty evidence). Length of hospitalisation The evidence is very uncertain about whether interoperative cell salvage at caesarean birth affects length of hospitalisation. Three studies reported length of hospitalisation (MD -2.02 days, 95% CI -4.73 to 0.70; P = 0.15, I2 = 100%; 3 RCTs, 3174 women; very low-certainty evidence). Length of operation Two studies reported on length of operation. However, meta-analysis was not possible due to statistical heterogeneity and divergence of study findings; the direction of effect could not be determined. We evaluated the evidence as very low certainty. Sepsis One study reported risk of sepsis, finding that there was possibly no difference between arms (RR 1.00, 95% CI 0.43 to 2.29; P = 0.99; 1 RCT, 2990 women; low-certainty evidence). Estimated blood loss Cell salvage at caesarean birth may reduce blood loss. Two studies reported that estimated blood loss was possibly lower in women who had cell salvage compared to those who did not (MD -113.59 mL, 95% CI -130.41 to -96.77; P < 0.00001, I2 = 0%; 2 RCTs, 246 women; low-certainty evidence). Postpartum haemoglobin concentration Cell salvage at caesarean birth may increase day one postpartum haemoglobin. Three studies reported day one postpartum haemoglobin levels (MD 6.14 g/L, 95% CI 1.62 to 10.65; P = 0.008, I2 = 97%; 3 RCTs, 3070 women; low-certainty evidence). Amniotic fluid embolism Three trials reported risk of amniotic fluid embolism and no cases were observed (n = 3226 women). Cell salvage may reduce the need for allogenic blood transfusion, may reduce blood loss, and may increase day one postpartum haemoglobin in pregnant women having caesarean birth (low certainty). Cell salvage may make little to no difference to the risk of sepsis (low certainty) and probably makes little to no difference to the risk of haemorrhage (moderate certainty). The effect of cell salvage on risk of transfusion-related adverse reactions is very uncertain. The effect of cell salvage on the length of hospital stay was both clinically and statistically heterogenous, with a very low certainty of evidence. The effect of cell salvage on length of operation is divergent and meta-analysis was not possible due to significant statistical heterogeneity; the evidence is of very low certainty. No cases of amniotic fluid embolism were reported among the included trials. Studies in low- and middle-income settings are needed. This review had no dedicated funding. This review was registered with PROSPERO (CRD42024554204).

Dey T ，Brown D ，Cole MG ，Hill RA ，Chaplin M ，Huffstetler HE ，Curtis F ... -  《Cochrane Database of Systematic Reviews》

Defining the optimum strategy for identifying adults and children with coeliac disease: systematic review and economic modelling.

Elwenspoek MM ，Thom H ，Sheppard AL ，Keeney E ，O'Donnell R ，Jackson J ，Roadevin C ，Dawson S ，Lane D ，Stubbs J ，Everitt H ，Watson JC ，Hay AD ，Gillett P ，Robins G ，Jones HE ，Mallett S ，Whiting PF ... -  《-》

Postpartum hospital use among survivors of intimate partner violence.

More than 1 in 3 individuals who identify as female, experience either intimate partner violence (IPV) or sexual assault during their lifetime, and sexual violence committed by an intimate partner is at its highest during their reproductive years.1 As many as 20% of pregnant individuals may experience IPV, and IPV during pregnancy has been associated with an increased risk for adverse maternal and neonatal outcomes, making pregnant individuals an especially vulnerable population.1 In fact, >50% of pregnancy-associated suicides and >45% of pregnancy-associated homicides are associated with IPV and these often occur during the postpartum period.2 Although >50% of maternal deaths occur postpartum,3 little research has examined whether IPV is associated with markers of postpartum maternal morbidity, including hospital readmission and emergency department (ED) visits.4 In addition, few studies have examined the feasibility of ascertaining IPV at the delivery hospitalization using billing codes. Although the International Classification of Diseases, Tenth Revision (ICD-10) codes include factors related to social determinants of health, ICD-10 codes are largely underutilized for the purpose of understanding risk of disease and adverse outcomes.5 The primary objective of this study was to investigate the association of IPV screening at delivery with the incidence of postpartum hospital use. Another objective was to examine the possibility of using ICD-10 codes at the delivery hospitalization to identify IPV in pregnant individuals. This was a retrospective cohort of birth data linked with inpatient and outpatient hospital claims data, including deliveries of individuals residing in the New York City metropolitan area between 2016 and 2018. Thirty-day hospital use was ascertained by either a readmission or an ED visit within 30 days of discharge. We identified the incidence of IPV from the delivery hospital discharge records using 36 IPV-related ICD-10 codes that we identified in the literature, including those defined for adult psychological and sexual abuse. We estimated the associations between IPV identified during the delivery hospitalization and postpartum hospital use using a multivariable logistic regression and separately adjusting for demographic and structural determinants of health, psychosocial factors, comorbidities, and obstetrical complications. All analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). This study was approved by our institutional review board. IPV was indicated on the discharge records of 348 individuals (0.11%). As shown in the Table, the overall incidence of ED visits among individuals with an IPV-related diagnosis was 12.9%. The incidence of a postpartum ED visit was significantly higher among individuals with an IPV diagnosis than among those without (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.1-3.9), and this was true after sequentially adjusting for demographic and structural determinants of health (OR, 2.0; 95% CI, 1.4-2.7), comorbidities and pregnancy complications (OR, 1.9; 95% CI, 1.4-2.6), psychosocial factors (OR, 1.5; 95% CI, 1.1-2.0), and obstetrical complications (OR, 1.5; 95% CI, 1.1-2.0). The incidence of either a postpartum ED visit or readmission was also higher among those patients with an IPV-related diagnosis (OR, 2.7; 95% CI, 2.0-3.6). However, there was no significant difference in postpartum readmissions alone among patients with or without an IPV-related diagnosis. This study established that postpartum ED visits are significantly higher among individuals with an IPV-related diagnosis during the delivery hospitalization in a large citywide database, even after adjusting for established risk factors for postpartum ED use. Because ED visits have been identified as a possible marker of maternal morbidity and mortality,4 this finding may suggest that individuals affected by IPV could benefit from screening throughout pregnancy, including during the delivery hospitalization, to prevent adverse postpartum outcomes. However, as established in this study, IPV identified solely by ICD-10 codes during the delivery hospitalization is rare and likely underreported. It is possible that underdetection of IPV is because of insufficient clinician screening, a lack of documentation in the medical records using ICD-10 codes, and the medical status of the pregnant individual at the time of delivery. This finding demonstrates a need to screen and record findings thoroughly during the pregnancy period, including at delivery hospitalization, for any IPV-related diagnoses. A limitation of our data is that we were not able to ascertain hospital use outside of New York City and did not include other time points during an individual's pregnancy. Future research should identify at which time points IPV screening occurs during care of a pregnant individual and whether this may affect postpartum ED visit rates. As a clinical outcome, maternal mortality is preventable and screening for risk factors such as IPV throughout the perinatal period, including at delivery admission and during the postpartum period, is imperative for comprehensive obstetrics care.

Rao MG ，Stone J ，Glazer KB ，Howell EA ，Janevic T ... -  《-》