Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

The aims of severe perioperative bleeding management are three-fold. First, preoperative identification by anamesis and laboratory testing of those patients for whom the perioperative bleeding risk may be increased. Second, implementation of strategies for correcting preoperative anaemia and stabilisation of the macro- and microcirculations in order to optimise the patient’s tolerance to bleeding. Third, targeted procoagulant interventions to reduce the amount of bleeding, morbidity, mortality and costs. The purpose of these guidelines is to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthetists throughout Europe to integrate this knowledge into daily patient care wherever possible. The Guidelines Committee of the European Society of Anaesthesiology (ESA) formed a task force with members of scientific subcommittees and individual expert members of the ESA. Electronic databases were searched without language restrictions from the year 2000 until 2012. These searches produced 20 664 abstracts. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. At the suggestion of the ESA Guideline Committee, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was initially used to assess the level of evidence and to grade recommendations. During the process of guideline development, the official position of the ESA changed to favour the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This report includes general recommendations as well as specific recommendations in various fields of surgical interventions. The final draft guideline was posted on the ESA website for four weeks and the link was sent to all ESA members. Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

https://epub.ub.uni-muenchen.de/24023/1/oa_24023.pdf

Management of severe perioperative bleeding Guidelines from the European Society of Anaesthesiology

Is vitamin D deficiency a major global public health problem

The increasing use of nanomaterials has raised concerns about their potential risks to human health Recent studies have shown that nanoparticles can cross the placenta barrier in pregnant mice and cause neurotoxicity in their offspring, but a more detailed understanding of the effects of nanoparticles on pregnant animals remains elusive Here, we show that silica and titanium dioxide nanoparticles with diameters of 70 nm and 35 nm, respectively, can cause pregnancy complications when injected intravenously into pregnant mice The silica and titanium dioxide nanoparticles were found in the placenta, fetal liver and fetal brain Mice treated with these nanoparticles had smaller uteri and smaller fetuses than untreated controls Fullerene molecules and larger (300 and 1,000 nm) silica particles did not induce these complications These detrimental effects are linked to structural and functional abnormalities in the placenta on the maternal side, and are abolished when the surfaces of the silica nanoparticles are modified with carboxyl and amine groups

Silica and titanium dioxide nanoparticles cause pregnancy complications in mice.

Objective  To develop a practical evidence based list of clinical risk factors that can be assessed by a clinician at ≤16 weeks’ gestation to estimate a woman’s risk of pre-eclampsia. Design  Systematic review and meta-analysis of cohort studies. Data sources  PubMed and Embase databases, 2000-15. Eligibility criteria for selecting studies  Cohort studies with ≥1000 participants that evaluated the risk of pre-eclampsia in relation to a common and generally accepted clinical risk factor assessed at ≤16 weeks’ gestation. Data extraction  Two independent reviewers extracted data from included studies. A pooled event rate and pooled relative risk for pre-eclampsia were calculated for each of 14 risk factors. Results  There were 25 356 688 pregnancies among 92 studies. The pooled relative risk for each risk factor significantly exceeded 1.0, except for prior intrauterine growth restriction. Women with antiphospholipid antibody syndrome had the highest pooled rate of pre-eclampsia (17.3%, 95% confidence interval 6.8% to 31.4%). Those with prior pre-eclampsia had the greatest pooled relative risk (8.4, 7.1 to 9.9). Chronic hypertension ranked second, both in terms of its pooled rate (16.0%, 12.6% to 19.7%) and pooled relative risk (5.1, 4.0 to 6.5) of pre-eclampsia. Pregestational diabetes (pooled rate 11.0%, 8.4% to 13.8%; pooled relative risk 3.7, 3.1 to 4.3), prepregnancy body mass index (BMI) >30 (7.1%, 6.1% to 8.2%; 2.8, 2.6 to 3.1), and use of assisted reproductive technology (6.2%, 4.7% to 7.9%; 1.8, 1.6 to 2.1) were other prominent risk factors. Conclusions  There are several practical clinical risk factors that, either alone or in combination, might identify women in early pregnancy who are at “high risk” of pre-eclampsia. These data can inform the generation of a clinical prediction model for pre-eclampsia and the use of aspirin prophylaxis in pregnancy.

https://www.bmj.com/content/bmj/353/bmj.i1753.full.pdf

Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies

Objective: The objective of the study was to determine whether vitamin D (vitD) supplementation during pregnancy affects obstetric and neonatal outcomes. Setting: The study was conducted at a university hospital in Karachi, Pakistan. Methods: The study was a single-center, open-label, randomized, controlled trial of routine care (group A, 200 mg ferrous sulfate and 600 mg calcium daily) vs vitD supplementation (group B, 4000 IU vitamin D3 daily), started at 20 weeks and continued till delivery. Maternal serum samples of 25-hydroxyvitamin D (25OHD) were collected at baseline and delivery. Neonatal vitD status was assessed in cord blood or in neonatal serum samples within 48 hours of birth. Obstetric outcomes included gestational hypertension, gestational diabetes, and preterm labor, and neonatal well-being included small for gestational age, birth weight, length, head circumference, and 1- and 5-minute Apgar scores. Results: Of 207 gravidae enrolled, 193 completed the trial. Maternal age, vitD status, and ...

/pdf/obstetric-and-neonatal-outcomes-of-maternal-vitamin-d-38nmzxdd9x.pdf

Obstetric and neonatal outcomes of maternal vitamin D supplementation: results of an open-label, randomized controlled trial of antenatal vitamin D supplementation in Pakistani women.

High prevalence of vitamin D deficiency in Pakistani mothers and their newborns

Normal pregnancy is characterized by profound changes in nearly every organ system to accommodate the demands of the fetoplacental unit. Maternal hematological adaptations to the pregnant state are reviewed in this chapter. The most significant hematological changes are physiologic anemia, neutrophilia, mild thrombocytopenia, increased procoagulant factors, and diminished fibrinolysis. This chapter will review the pregnancy-associated changes in plasma volume, red blood cells, white blood cells, platelets, and coagulation factors.

Hematologic Changes in Pregnancy

OBJECTIVE: To describe the socio-demographic characteristics and the three delays of maternal mortality in a tertiary teaching hospital. STUDY DESIGN: Retrospective observational study. PLACE AND DURATION OF STUDY: Department of Obstetrics and Gynaecology Unit III Civil Hospital Karachi from April 2005 to May 2008. METHODOLOGY: One hundred and four consecutive maternal deaths were reviewed. Data regarding age parity sociodemographic characteristics booking status referral source cause of death and the three delays was collected on structured proformas analyzed by the statistical software SPSS version 13 and presented in the form of frequencies and percentages. RESULTS: The projected maternal mortality ratio was 1650/100000 live births. The mean age was 28+/-6.2 years and median parity was two. Seventy-one women (68%) were uneducated 65 (62.5%) belonged to lower socioeconomic class and 60 (58%) had received no antenatal care. Ninety-eight women (94%) had one or more delays with 70 (71%) having the first delay 73 (74%) having the second delay and 47 (48%) the third delay. The most frequent reasons for first second and third delays were lack of awareness in 88.5% women long distance in 39.7% women and difficulty in getting blood in 49% women respectively. CONCLUSION: The very high maternal mortality ratio suggests lack of access of women to quality healthcare facilities. A majority of these women suffered first and second delays in their management which could be due to their poor sociodemographic factors.

Socio-demographic characteristics and the three delays of maternal mortality.

Objective: To determine the obstetric causes for stillbirth in low socio-economic settings. Methods: A case-control retrospective study through data analysis was conducted at a tertiary university hospital, from January to June 2008. All pregnant women diagnosed with stillbirth after 28 weeks of gestation were included in the study. They were compared with women who had live birth during the study period. Both groups were identified from the admission, and labour room registers. The risk factors studied were maternal age, parity, gestational age, hypertensive disorders of pregnancy, antepartum haemorrhage, obstructed labour and Prematurity. Stillbirth was defined as foetal death after 28 weeks of gestation. Results: Of the 1011 deliveries in the selected period, there were 100 still births (98/1000 deliveries). Both nulliparity and grand multiparity were significantly associated with stillbirths (p < 0.003 and p < 0.009 respectively). From the binary logistic regression analysis, obstetric factors which were significantly associated with stillbirth were obstructed labour ( OR 16.2, CI 5.5-47), hypertensive disorders (OR 9.6 CI 4-23), abruptio placentae ( OR 136, CI 52-356), placenta previa ( OR 71, CI 21-230), and preterm labour (OR 15 CI 4-54). Gender was not found significantly associated with stillbirth (p < 0.432) Conclusion: Majority of stillbirths were due to risk factors which can be identified in the antenatal period. (JPMA 59:744; 2009).

Nazli Hossain

Papers

Obstetric and neonatal outcomes of maternal vitamin D supplementation: results of an open-label, randomized controlled trial of antenatal vitamin D supplementation in Pakistani women.

High prevalence of vitamin D deficiency in Pakistani mothers and their newborns

Hematologic Changes in Pregnancy

Socio-demographic characteristics and the three delays of maternal mortality.

Obstetric causes of stillbirth at low socioeconomic settings