Strategies to manage postpartum haemorrhage

Postpartum haemorrhage (PPH) is a global problem and the solutions to reducing it are complex. This thesis uses a mixture of research methods to investigate strategies that might improve the burden of blood loss following childbirth. The main findings are: 1. The use of contraception medication prior to pregnancy warrants further research as progesterone only contraception in particular might be associated with an increase in the risk of subsequent PPH; 2. The use of antidepressant medication during late pregnancy does not appear to increase the risk of PPH; 3. Following childbirth, a preventative uterotonic drug may not need to be given immediately; a delay of up to 5 minutes does not appear to increase the risk of bleeding; 4. There is little evidence to recommend the use of oxytocin, carbetocin, or misoprostol over each other for use as a first line drug to treat PPH; 5. Less than half of patients who had a PPH of 500mL received treatment uterotonic medication; 6. There is no appreciable long-term effect of PPH on mental health, but there is an increased risk of developing postnatal depression and post traumatic stress disorder; 7. There is no appreciable effect of PPH on cardiovascular health

Management of obstetric postpartum hemorrhage: a national service evaluation of current practice in the UK

BACKGROUND: Postpartum hemorrhage (PPH) continues to be one of the major causes of maternal mortality and morbidity in obstetrics. Variations in practice often lead to adverse maternity outcomes following PPH. Our objective was to assess the current practice in managing PPH in the UK. METHODS: We performed a national multicenter prospective service evaluation study over one calendar month and compared the current performance to national standards for managing PPH. We used a standardized data collection tool and collected data on patients’ demographics, incidence of PPH, estimated blood loss (EBL), prophylactic and treatment measures, onset of labor, and mode of delivery. RESULTS: We collected data from 98 obstetric units, including 3663 cases of primary PPH. Fifty percent of cases were minor PPH (EBL 500–1000 mL, n=1900/3613, 52.6%) and the remaining were moderate PPH (EBL >1000 to <2000 mL, n=1424/3613, 39.4%) and severe PPH (EBL >2000 mL, n=289/3613, 8%). The majority of women received active management of the third stage of labor (3504/3613, 97%) most commonly with Syntometrine intramuscular (1479/3613, 40.9%). More than half required one additional uterotonic agent (2364/3613, 65.4%) most commonly with Syntocinon intravenous infusion (1155/2364, 48.8%). There was a poor involvement of consultant obstetricians and anesthetists in managing PPH cases, which was more prevalent when managing major PPH (p=0.0001). CONCLUSION: There are still variations in managing PPH in the UK against national guidelines. More senior doctor involvement and regular service evaluation are needed to improve maternal outcomes following PPH

Postpartum haemorrhage and risk of long-term hypertension and cardiovascular disease : an English population-based longitudinal study using linked primary and secondary care databases

Objective To investigate the long-term risk of developing hypertension and cardiovascular disease (CVD) among those women who suffered a postpartum haemorrhage (PPH) compared with those women who did not. Design Population-based longitudinal open cohort study. Setting English primary care (The Health Improvement Network (THIN)) and secondary care (Hospital Episode Statistics (HES)) databases. Population Women exposed to PPH during the study period matched for age and date of delivery, and unexposed. Methods We conducted an open cohort study using linked primary care THIN and HES Databases, from 1 January 1997 to 31 January 2018. A total of 42 327 women were included: 14 109 of them exposed to PPH during the study period and 28 218 matched for age and date of delivery, and unexposed to PPH. HRs for cardiovascular outcomes among women who had and did not have PPH were estimated after controlling for covariates using multivariate Cox regression models. Outcome measures Risk of hypertensive disease, ischaemic heart disease, heart failure, stroke or transient ischaemic attack. Results During a median follow-up of over 4 years, there was no significant difference in the risk of hypertensive disease after adjustment for covariates (adjusted HR (aHR): 1.03 (95% CI: 0.87 to 1.22); p=0.71). We also did not observe a statistically significant difference in the risk of composite CVD (ischaemic heart disease, heart failure, stroke or transient ischaemic attack) between the exposed and the unexposed cohort (aHR: 0.86 (95% CI: 0.52 to 1.43; p=0.57). Conclusion Over a median follow-up of 4 years, we did not observe an association between PPH and hypertension or CVD

Postpartum haemorrhage and risk of mental ill health : a population-based longitudinal study using linked primary and secondary care databases

There is a gap in the literature investigating the impact of obstetric complications on subsequent mental ill health outcomes. The aim of this study was to establish the association between post-partum haemorrhage (PPH) and mental ill health. We conducted a retrospective open cohort study utilizing linked primary care (The Health Improvement Network (THIN)) and English secondary care (Hospital Episode Statistics (HES)) databases, from January 1, 1990 to January 31, 2018. A total of 42,327 women were included: 14,109 of them were exposed to PPH during the study period and 28,218 unexposed controls were matched for age and date of delivery. Hazard ratios (HRs) for mental illness among women with and without exposure to PPH were estimated after controlling for covariates. Women who had had PPH were at an increased risk of developing postnatal depression (adjusted HR: 1·10, 95%CI: 1·01–1·21) and post–traumatic stress disorder (PTSD) (adjusted HR: 1·17, 95%CI: 0·73–1·89) compared to women unexposed to PPH. When restricting the follow–up to the first year after childbirth, the adjusted HR for PTSD was 3·44 (95% CI 1·31–9·03). No increase in the overall risk was observed for other mental illnesses, including depression (adjusted HR: 0·94, 95%CI: 0·87–1·01), severe mental illness (adjusted HR: 0·65, 95%CI: 0·40–1·08, p = 0·239) and anxiety (adjusted HR: 0·99, 95%CI: 0·90–1·09). PPH is associated with a significant increase in the risk of developing postnatal depression and PTSD in the first year after delivery. Active monitoring for mental illness should form an integral part of the follow–up in women who suffered a PPH

Trial application of a technique for human error analysis (ATHEANA)

The new method for HRA, ATHEANA, has been developed based on a study of the operating history of serious accidents and an understanding of the reasons why people make errors. Previous publications associated with the project have dealt with the theoretical framework under which errors occur and the retrospective analysis of operational events. This is the first attempt to use ATHEANA in a prospective way, to select and evaluate human errors within the PSA context

First-line uterotonics for treating postpartum haemorrhage: a systematic review and network meta-analysis

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: Primary To assess the relative effectiveness and produce a clinically meaningful hierarchy of first‐line uterotonic drugs for the treatment of postpartum haemorrhage (PPH). Secondary To assess the relative risks and produce side effect hierarchies of first‐line uterotonic drugs for the treatment of PPH

Kafka at the West Bank checkpoint: de-normalizing the Palestinian encounter before the law

The checkpoint has emerged as a quintessential trope within the contemporary Palestinian imagination, to such an extent that “checkpoint narratives” have arguably come to assume a dangerously “normalized” status as everyday, even iconic features of Palestinian existence. Turning to the films Route 181 by Michel Khleifi and Eyal Sivan, and like twenty impossibles by Annemarie Jacir, this article explores how alternative representations (and theorizations) of checkpoint encounter might serve to “de-normalize” the checkpoint in a way that invites us to interrogate the very nature of the checkpoint apparatus in itself, including the nature of the “law” that it represents. Mobilizing the critical paradigms of the “state of exception” and “homo sacer” drawn from the theoretical work of Giorgio Agamben and the literary work of Franz Kafka, the article argues that apprehension of the enduring oddity and abnormality of the checkpoint serves as a vital mode of critical resistance to the policies of “spatio-cide”, “securitization” and colonialism exercised at the hands of the State of Israel through the checkpoint mechanism