Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial).
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OBJECTIVE: To ascertain whether a clinically important difference exists in the incidence of gynaecological infection between surgical management and expectant or medical management of miscarriage. DESIGN: Randomised controlled trial comparing medical and expectant management with surgical management of first trimester miscarriage. SETTING: Early pregnancy assessment units of seven hospitals in the United Kingdom. PARTICIPANTS: Women of less than 13 weeks' gestation, with a diagnosis of early fetal demise or incomplete miscarriage. INTERVENTIONS: Expectant management (no specific intervention); medical management (vaginal dose of misoprostol preceded, for women with early fetal demise, by oral mifepristone 24-48 hours earlier); surgical management (surgical evacuation). MAIN OUTCOME MEASURES: Confirmed gynaecological infection at 14 days and eight weeks; need for unplanned admission or surgical intervention. RESULTS: 1200 women were recruited: 399 to expectant management, 398 to medical management, and 403 to surgical management. No differences were found in the incidence of confirmed infection within 14 days between the expectant group (3%) and the surgical group (3%) (risk difference 0.2%, 95% confidence interval - 2.2% to 2.7%) or between the medical group (2%) and the surgical group (0.7%, - 1.6% to 3.1%). Compared with the surgical group, the number of unplanned hospital admissions was significantly higher in both the expectant group (risk difference - 41%, - 47% to - 36%) and the medical group (- 10%, - 15% to - 6%). Similarly, when compared with the surgical group, the number of women who had an unplanned surgical curettage was significantly higher in the expectant group (risk difference - 39%, - 44% to - 34%) and the medical group (- 30%, - 35% to - 25%). CONCLUSIONS: The incidence of gynaecological infection after surgical, expectant, and medical management of first trimester miscarriage is low (2-3%), and no evidence exists of a difference by the method of management. However, significantly more unplanned admissions and unplanned surgical curettage occurred after expectant management and medical management than after surgical management. TRIAL REGISTRATION NATIONAL RESEARCH REGISTER: N0467011677/N0467073587. (+info)
The impact of primary postpartum hemorrhage in "near-miss" morbidity and mortality in a tertiary care hospital in North India.
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AIM: To assess risk factors, mortality and "near-miss" morbidity in early PPH. SETTING AND DESIGN: Retrospective analysis of 178 women with early PPH (within 24 h of delivery) over 4 consecutive years in a tertiary care hospital in North India. MATERIALS AND METHODS: All case sheets of patients identified by labor record registers as having early PPH were reviewed by the same person to identify the actual impact of condition. The data was analyzed by chi-square analysis. RESULT: Early PPH (loss of blood that caused significant alteration in maternal condition or blood loss 500 in vaginal deliveries or> 1000 cc in cesarean section) was recorded in 178; 90 delivered in hospital (Group-A) and 88 referred after delivery (Group-B) from various peripheral centers, i.e., maternity hospitals, nursing homes, district and community health centers. The maternal mortality ratio during this period was 1049/100,000 (139 deaths/13248 live births; direct maternal deaths = 94). Early PPH accounted for 11/94 direct maternal deaths (11.7%). Of these 11 deaths, 3 were in group A and 8 in group B. "Near-miss" morbidity was higher than mortality (Total 19/178; 5/90 in Group-A and 14/88 in Group-B). Delayed referral and lack of active 3rd stage management in Group-B were responsible for most of the adverse events. CONCLUSION: Both "near-miss" morbidity and mortality in early PPH reflect the level of obstetric care in the developing world. These need to be reduced by strengthening peripheral delivery facilities, active 3rd stage management and early referral. (+info)
Ultrasound finding of an echogenic mass in women with secondary postpartum hemorrhage is associated with retained placental tissue.
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OBJECTIVES: To describe sonographic findings associated with retained placental tissue in patients with secondary postpartum hemorrhage, and to compare these findings with those of women with a normal puerperium. METHODS: This was a prospective observational study of 79 women with secondary postpartum hemorrhage. Ultrasound examinations were performed on the day the patients presented with clinical symptoms and were scheduled for postpartum days 1, 3, 7, 14, 28 and 56, continuing until uterine surgical evacuation was performed or until the bleeding stopped. The maximum anteroposterior (AP) diameters of the uterus and uterine cavity were measured and morphological findings in the cavity were recorded. The findings were compared with previously published results from a normal population. RESULTS: The patients were divided into two groups. Group 1 (n = 18) underwent surgery and Group 2 (n = 61) was treated conservatively. Sonography revealed an echogenic mass in the uterine cavity in 17 patients from Group 1, and in 14 of these patients histology confirmed placental tissue. The AP diameter of the uterine cavity was above the 90(th) percentile in all but two of the 18 Group 1 patients. In 18 patients from Group 2 the cavity was empty and in 43 a mixed-echo pattern was found. The uterine cavity was wider compared with the controls, but the values largely overlapped. CONCLUSION: This report supports the opinion that the sonographic finding of an echogenic mass in the uterine cavity in women with secondary postpartum hemorrhage is associated with retained placental tissue. (+info)
The postpartum visit--why wait 6 weeks?
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BACKGROUND: In many western countries, the traditional 6 week check is a routine medical review of a mother and her baby 6 weeks after the birth. In Australia, general practitioners perform the majority of postpartum assessments. OBJECTIVE: This article discusses some of the common issues that concern women following the birth of a baby, and the medical conditions GPs need to address in the postpartum period. DISCUSSION: The research literature does not support any benefit of a 6 week check. However, clinical evidence, our expertise as GPs, and our personal experiences, clearly indicate that the postpartum period is a time of tremendous change, increased health problems, and emotional upheaval for new parents. General practitioners are in an ideal position to assist families during this period and may consider a sooner rather than later, proactive rather than reactive, approach to postpartum care. (+info)
Safety and efficacy of ginkgo (Ginkgo biloba) during pregnancy and lactation.
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BACKGROUND: There is a lack of basic knowledge on the part of both clinicians and patients as to the indications for use and safety of herbal medicines used in pregnancy and lactation. This is one article in a series that systematically reviews the evidence for commonly used herbs during pregnancy and lactation. OBJECTIVES: To systematically review the literature for evidence on the use, safety, and pharmacology of ginkgo focusing on issues pertaining to pregnancy and lactation. METHODS: We searched 7 electronic databases and compiled data according to the grade of evidence found. RESULTS: There is some very weak scientific evidence from animal and in vitro studies that ginkgo leaf has antiplatelet activity, which may be of concern during labour as ginkgo use could prolong bleeding time. Low-level evidence based on expert opinion shows that ginkgo leaf may be an emmenagogue and have hormonal properties. The safety of ginkgo leaf during lactation is unknown. Patients and clinicians should be aware of past reports of ginkgo products being adulterated with colchicine. CONCLUSIONS: Ginkgo should be used with caution during pregnancy, particularly around labour where its anti-platelet properties could prolong bleeding time. During lactation the safety of ginkgo leaf is unknown and should be avoided until high quality human studies are conducted to prove its safety. (+info)
Management of primary postpartum haemorrhage with arterial embolisation in Hong Kong public hospitals.
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OBJECTIVE: To assess the utilisation, effectiveness, and safety of arterial (angiographic) embolisation for management of severe primary postpartum haemorrhage in Hong Kong public hospitals. DESIGN. Retrospective study. SETTING: All eight obstetrics and gynaecology units of the Hospital Authority in Hong Kong. PATIENTS: Women who underwent arterial embolisation for primary postpartum haemorrhage from July 1999 to June 2004 inclusive. MAIN OUTCOME MEASURES: Cause of primary postpartum haemorrhage, estimated blood loss, patient condition before embolisation, and the intervals between the diagnosis of postpartum haemorrhage and the procedure. RESULTS: Primary postpartum haemorrhage occurred in 7200 (3.9%) cases of 183,700 deliveries; 90 (0.05%) underwent total hysterectomy, whilst 29 (0.016%) received angiographic embolisation. Arterial embolisation was 90% effective in treating medically uncontrollable primary postpartum haemorrhage, except in three patients who failed to respond and underwent a hysterectomy. All 29 patients survived, although due to severe haemorrhage one had a cardiac arrest, whilst another had transient right-leg claudication. Six patients developed mild fever. CONCLUSIONS: In Hong Kong, arterial embolisation for severe primary postpartum haemorrhage is a safe and effective treatment modality but is underutilised. If first-line medical treatment fails and patients are haemodynamically stable, the procedure should be considered an alternative management option. A prompt decision and early resort to arterial embolisation are advisable so as to reduce the morbidity and avoid resorting to open surgery. (+info)
A randomised trial of carbetocin versus syntometrine in the management of the third stage of labour.
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OBJECTIVE: Syntometrine is an effective uterotonic agent used in preventing primary postpartum haemorrhage but has adverse effects including nausea, vomiting, hypertension and coronary artery spasm. Carbetocin is a newly developed long-acting oxytocin analogue that might be used as an uterotonic agent. We compare the efficacy and safety of intramuscular (IM) carbetocin with IM syntometrine in preventing primary postpartum haemorrhage. DESIGN: Prospective, double-blinded, randomised controlled trial. SETTING: Delivery suite of a university-based obstetrics unit. POPULATION: Women with singleton pregnancy achieving vaginal delivery after and throughout 34 weeks. METHODS: Three hundred and twenty-nine eligible women were randomised to receive either a single dose of 100 microgram IM carbetocin or 1 ml IM syntometrine (a mixture of 5 iu oxytocin and 0.5 mg ergometrine) at the end of second stage of labour. MAIN OUTCOME MEASURES: Difference in haemoglobin drop measured 2 days after delivery between the two groups. RESULTS: There was no difference in the drop of haemoglobin concentration within the first 48 hours between the two groups. The incidence of additional oxytocic injections, postpartum haemorrhage (blood loss > or = 500 ml) and retained placenta were also similar. The use of carbetocin was associated with significant lower incidence of nausea (relative risk [RR] 0.18, 95% confidence interval [CI] 0.04-0.78), vomiting (RR 0.1, 95% CI 0.01-0.74), hypertension 30 minutes (0 versus 8 cases, P < 0.01) and 60 minutes (0 versus 6 cases, P < 0.05) after delivery but a higher incidence of maternal tachycardia (RR 1.68, 95% CI 1.03-3.57). CONCLUSIONS: IM carbetocin is as effective as IM syntometrine in preventing primary postpartum haemorrhage after vaginal delivery. It is less likely to induce hypertension and has a low incidence of adverse effect. It should be considered as a good alternative to conventional uterotonic agents used in managing the third stage of labour. (+info)
Acquired hemophilia as a cause of primary postpartum hemorrhage.
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A 32-year-old primigravid woman developed acquired factor VIII inhibitor after delivery. She presented with postpartum hemorrhage and large hematoma in episiotomy site. Laboratory examinations showed markedly prolonged activated partial thromboplastin time, low levels of factor VIII (8%), and factor VIII inhibitor (2 Bethesda units). The bleeding was controlled successfully using combined treatment with factor VIII, intravenous immunoglobulin, steroids, and recombinant factor VIIa. Six months after delivery, factor VIII inhibitor was not present and factor VIII concentration increased to normal range. Acquired hemophilia is a life-threatening disorder. Precise screening of coagulation factors is essential for diagnosis of persisting postpartum hemorrhage. (+info)