Identification of feto-maternal haemorrhage around labour using flow cytometry immunophenotyping

Objective

To determine the normal range of feto-maternal haemorrhage (FMH) due to labour, and to investigate if the type of delivery might influence the volume of FMH.

Study design

In a prospective cohort trial setting we studied 346 women in their 3rd trimester of gestation. Women were classified according to the type of delivery: vaginal, instrumental and caesarean section. Fetal erythrocytes in maternal blood were measured by flow cytometry immunophenotyping using a fluorochrome-conjugated monoclonal antibody against fetal haemoglobin. For each woman, two blood samples were studied; one pre-labour and one post-labour. The difference between FMH values obtained post- and pre-delivery was established as FMH due to delivery.

Results

FMH due to labour ranged between <0.01 and 25.19 ml, being <1.15 ml in 96.13% of cases. This value was established as the upper limit of normal FMH due to delivery. No statistical significance was found between the volume of FMH and type of delivery. Analyzing distributions of groups, most data followed a normal distribution, apart from some patients who had higher volume of FMH. Among these patients caesarean sections showed a higher FMH volume, with statistically significant differences between vaginal deliveries and caesarean sections (p = 0.001), and between instrumental deliveries and caesarean sections (p = 0.008).

Conclusions

FMH due to labour is small. The route of delivery could not be established as a risk factor for FMH but caesarean section increases the risk of suffering a higher amount of transplacental bleeding.     

Sinusoidal fetal heart rate pattern in severe fetal anemia from feto-maternal transfusion

A case is reported where a sinusoidal fetal heart rate pattern was found in a fetus at 34 weeks. This pattern, at first isolated and later persistent for several hours, during a normal pregnancy became progressively transformed into a silent pattern. Cesarean delivery then performed resulted in the birth of an infant affected by a severe anemia due to a major feto-maternal transfusion and it died aged 36 h. The authors enquire into the significance of this pattern when found in apparently normal pregnancies, not involving rhesus iso-immunization, and they suggest a possible management when confronted with a sinusoidal fetal heart pattern.     

Evaluation of placental drainage as a method of placental delivery in vaginal deliveries

Methods We describe a prospective study, done over a 2-year period in which a total of 958 women having a vaginal delivery were randomised to the drainage method (478 women) or controlled cord traction method (480 women) for placental delivery.Results The mean age, parity, gestation and birth weight were similar in the two groups. The mean duration of third stage of labor was 3.24 min and 3.2 min in the placental drainage group in contrast to 8.57 min and 6.20 min in controlled cord traction method in primigravida and multigravida respectively.Conclusion Placental drainage significantly reduces the duration of third stage of labour in vaginal deliveries.     

Role of low placental share in twin-twin transfusion syndrome complicated by intrauterine growth restriction

Objectives

Prior studies have demonstrated that donor twin survival following treatment of twin-twin transfusion syndrome (TTTS) was highly associated with donor intrauterine growth restriction (IUGR). Here, we hypothesized that donor IUGR may be attributed in part to low placental share.

Study design

The study population consisted of all patients who underwent laser treatment for TTTS at a single institution between 2006-2010. Only those pregnancies with dual survival at birth were included so that placental share information could be interpreted. We examined the relationships between Quintero Stage (with separate analysis of Stage III patients with critically abnormal donor Doppler findings) and low placental share (defined as ≤ 30%) with IUGR (<10th percentile) using chi-square analysis and multivariable logistic regression modeling.

Results

Of 210 patients treated, 159 (75.7%) had dual survivors at birth. Of these, placental share was documented in 90 cases (56.6%). Twenty-seven (30.0%) had low placental share, and 37 (41.1%) had IUGR. IUGR was associated with low placental share (63.0% vs. 31.7%, P = 0.0116). IUGR was also associated with Stage III patients (57.4% vs. 23.3%, P = 0.0021), and in particular with Stage III patients with donor involvement (77.8% vs. 25.4%, P < 0.0001). In logistic regression modeling, both low placental share and Stage III with donor involvement were independent risk factors for IUGR (OR = 3.5 [1.2-10.3], P = 0.0206, and OR = 10.1 [3.3-30.6], P < 0.0001, respectively).

Conclusions

Donor IUGR in TTTS pregnancies appears to be associated, in part, with low placental share.     

A pilot randomized controlled trial of controlled cord traction to reduce postpartum blood loss

Objective

To evaluate whether controlled cord traction (CCT) for management of the third stage of labor reduced postpartum blood loss compared with a “hands-off” management protocol.

Methods

Women with imminent vaginal delivery were randomly assigned to either a CCT group or a hands-off group. The women received prophylactic oxytocin. The primary outcome was blood loss during the third stage of labor.

Results

In total, 103 women were allocated to the CCT group and 101 were allocated to the hands-off group. Median blood loss in the CCT group and the hands-off group was 282.0 mL and 310.2 mL, respectively. The difference in blood loss (- 28.2 mL) was not significant (95% confidence interval, - 92.3 to 35.9; P = 0.126). Blood collection in the hands-off group took 1.2 minutes longer than in the CCT group, which may have contributed to this difference.

Conclusion

CCT may reduce postpartum blood loss. The present findings support conducting a large trial to determine whether CCT can prevent postpartum hemorrhage.     

Impact of cesarean section on placental transfusion and iron-related hematological indices in term neonates: A systematic review and meta-analysis

Evidence suggests that cesarean section is likely associated with a reduced placental transfusion and poor hematological status in neonates. However, clinical studies have reported somewhat inconsistent results. We conducted a systematic review and meta-analysis to examine whether cesarean section affects placental transfusion and iron-related hematological indices. Pubmed, Web of Science, ScienceDirect, and Ovid Databases were searched for relevant studies published before April 9, 2013. Mean differences between cesarean section and vaginal delivery in outcomes of interests (placental residual blood volume; hematocrit level, hemoglobin concentration, and erythrocyte count in cord/peripheral blood) were extracted and pooled using a random effects model. We identified 15 studies (n = 8477) eligible for the meta-analysis. Compared with neonates born vaginally, those born by cesarean section had a higher placental residual blood volume [weighted mean difference (WMD), 8.87 ml; 95% confidence interval (CI), 2.32 ml–15.43 ml]; a lower level of hematocrit (WMD, −2.91%; 95% CI, −4.16% to −1.65%), hemoglobin (WMD, −0.51 g/dL; 95% CI, −0.74 g/dL to −0.27 g/dL) and erythrocyte (WMD, −0.16 × 10¹²/L; 95% CI, −0.30 × 10¹²/L to −0.01 × 10¹²/L). Subgroup analysis showed that the WMD for hematocrit in neonate's peripheral blood (−6.94%; 95% CI, −9.15% to −4.73%) was substantially lower than that in cord blood (−1.75%; 95% CI, −2.82%, −0.68%) (P value for testing subgroup differences <0.001). In conclusion, cesarean section compared with vaginal delivery is associated with a reduced placental transfusion and poor iron-related hematologic indices in both cord and peripheral blood, indicating that neonates delivered by cesarean section might be more likely affected by iron-deficiency anemia in infancy.     

Individual placental territories after selective laser photocoagulation of communicating vessels in twin-twin transfusion syndrome

OBJECTIVE: Intrauterine fetal death of one or both twins after laser therapy (selective photocoagulation of communicating vessels) may occur, in part, from insufficient individual placental mass. The objective of this study was to assess the percentage of individual placental mass (individual placental territory) that is associated with fetal survival in twin-twin transfusion syndrome after selective photocoagulation of communicating vessels. STUDY DESIGN: Placentas from 72 patients with selective photocoagulation of communicating vessels-treated twin-twin transfusion syndrome without intrauterine fetal death and from 61 monochorionic pregnancies without twin-twin transfusion syndrome (control subjects) were assessed. The placentas were weighed fresh (total placental mass) and cut along the vascular equator, which yielded the individual placental mass and the individual placental territory. Patency of anastomoses was ruled out with air-injection. The individual fetoplacental ratio was obtained by dividing birth weight by the corresponding individual placental mass. RESULTS: The 5th percentile individual placental territory that was associated with fetal survival was 27% in control subjects and 18% in cases with twin-twin transfusion syndrome, with a minimum of 10% to 14%, respectively. There were no differences in total placental mass, individual placental mass, individual placental territory, or individual fetoplacental ratio between pregnancies with twin-twin transfusion syndrome and control subjects. However, corrected for gestational age, the birth weight of recipient and donor twins were significantly smaller than control subjects. The individual placental territory of donors was statistically smaller than that of recipients. Individual placental territories were not different within control subjects. CONCLUSION: Fetal survival typically is associated with at least 18% of individual placental territory after selective photocoagulation of communicating vessels for twin-twin transfusion syndrome, but it can occur with as little as 10% to 14% individual placental territory. Decreased birth weight of the donor twin could result from relative decreased percentage of individual placental territory or from the loss of nutrients to the recipient twin. Decreased birth weight of the recipient twin could result from partial deprivation of functional placental tissue after surgery. Our findings may contribute to the understanding of normal and pathologic monochorionic twin gestations, in the counseling of patients, and potentially to the improvement of surgical treatment of twin-twin transfusion syndrome.     

Unfractionated heparin and placental pathology in high-risk pregnancies: Secondary analysis of a pilot randomized controlled trial

Introduction

Heparin is often prescribed during pregnancy with the intention of improving perinatal outcomes on the basis that it exerts an anticoagulant action in the inter-villous space. Accumulating in-vitro and in-vivo evidence indicates that heparin's beneficial effects in pregnancy may result from ‘non-anticoagulant’ effects including the promotion of angiogenesis.

Methods

To study the effect of heparin within the placenta, we performed secondary analyses on a pilot trial where 32 women with negative thrombophilia screens and second-trimester evidence of placental insufficiency were randomized to standard care or antenatal self-administration of unfractionated heparin (UFH) 7500IU twice-daily. Serial placental ultrasound images were reviewed and compared with histo-pathologic findings following delivery.

Results

There were no differences between the two arms in either the evolution of abnormal placental lesions on ultrasound (p = 0.75) or evidence of maternal vascular under-perfusion on histopathology (p = 0.89). In pregnancies considered at increased risk for adverse pregnancy outcomes based on previous history or abnormal serum marker screen, early (second-trimester) placental ultrasound, reflecting developmental pathology had better test characteristics (sensitivity 77.8%; positive predictive value 80.8%) for predicting adverse pregnancy outcomes than third-trimester ultrasound that is reflective of placental thrombotic injury.

Conclusions

Administration of UFH did not prevent the development or evolution of abnormal placental lesions on placental ultrasound or evidence of maternal vascular underperfusion on placental histo-pathology. Second-trimester placental ultrasound may be of value in predicting those at greatest risk of adverse outcomes.     

Antenatal sonographic detection of an unusual placental lake under the cord insertion

Presentation We detected an unusual placental lake under the membranes between the two lobes of a placenta bilobate with a turbulent blood flow in it. This was an extraordinary maternal lake: simply the accumulation of maternal blood inside the intervillous space in an area where villous structures were absent between the placental lobes. The lake reduced in size and became almost invisible during the Braxton Hicks contractions, and enlarged up to its previous dimensions at the end of contractions. This extraordinarily huge lake showed an interesting dynamic appearance on sonographic examination. Outcome Although it caused no complications during the course of the pregnancy it produced an obstetric hemorrhage, which took place during the second stage of the delivery. Pathologic examination confirmed the diagnosis of placenta bilobate. We present its interesting appearance and clinical outcome in this paper.     

A prospective randomised double-blind placebo controlled trial to assess whether gas drains reduce shoulder pain following gynaecological laparoscopy

OBJECTIVE: To assess the effects on patient discomfort of an intraabdominal passive gas drain left for four hours postoperatively following gynaecologic laparoscopic surgery. DESIGN: A prospective randomised double-blinded placebo controlled trial. SETTING: University tertiary hospital and private hospital. POPULATION OR SAMPLE: Eighty women having a laparoscopic gynaecological procedure for benign disease. METHODS: A drain was placed via the umbilical port at the conclusion of the surgical procedure and was removed four hours postoperatively. The researcher, assessor and patient were all blinded as to the patency or occlusion of the drain. Patients were asked to complete questionnaires at regular intervals up to five days postoperatively. MAIN OUTCOME MEASURES: Visual analogue scale (VAS) to assess overall pain, shoulder and chest pain, abdominal pain, bloating and energy prior to surgery and at intervals up to five days postoperatively. RESULTS AND CONCLUSIONS: No complications were attributed to the presence and withdrawal of the drain tube. Shoulder pain following operative or diagnostic laparoscopy was significantly reduced for 12, 24, 48 and 72 hours by the presence of a patent passive gas drain for the first four hours postoperatively. The drains were easy to use and had no associated morbidity We recommend that in the absence of the need for an active drain, all patients undergoing laparoscopy should have a gas drain inserted for a period of four hours after the completion of the procedure.     

Massive idiopathic feto-maternal transfusion associated with dilatation of umbilical vein: case report and review of literature

Abstract

Feto-maternal transfusion (FMT) or haemorrhage occurs when there is an entry of fetal blood into the maternal circulation in pregnancy or during delivery. It has been stated that very small amount of fetal red cells are normally detectable in maternal circulation in all pregnancies. However, massive FMT is rare and even rarer is the resultant severe anaemia which may cause severe fetal morbidity or early neonatal death in apparently uneventful normal pregnancy. Massive FMT is regarded as a pathological condition with a variety of clinical presentations essentially secondary to the fetal anaemia. We present a case of FMT associated with umbilical vein dilation and speculate whether this finding is of prognostic value.     

A randomised controlled trial of moxibustion for breech presentation

OBJECTIVES: To evaluate the efficacy of moxibustion for the correction of fetal breech presentation in a non-Chinese population. DESIGN: Single-blind randomised controlled trial (RCT). SETTING: Six obstetric departments in Italy. SAMPLE: Healthy non-Chinese nulliparous pregnant women at 32-33 weeks + 3 days of gestational age with the fetus in breech presentation. METHODS: Random assignment to treatment or observation. Treatment consisted of moxibustion (stimulation with heat from a stick of Artemisia vulgaris) at the BL 67 acupuncture point (Zhiyin) for one or two weeks. Two weeks after recruitment, each participant was subjected to an ultrasonic examination of the fetal presentation. MAIN OUTCOME MEASURE: Number of participants with cephalic presentation in the 35th week. RESULTS: The study was interrupted when 123 participants had been recruited (46% of the planned sample). Intermediate data monitoring revealed a high number of treatment interruptions. At this point no difference was found in cephalic presentation in the 35th week (treatment group: 22/65, 34%; control group: 21/58, 36%; RR 0.95; 99% CI 0.59-1.5). CONCLUSIONS: The results underline the methodological problems evaluating of a traditional treatment transferred from a different cultural context. They do not support either the effectiveness or the ineffectiveness of moxibustion in correcting fetal breech presentation.     

A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy

OBJECTIVE: To evaluate outpatient versus daycase endometrial polypectomy by comparing success rate, complications, patient tolerance, pain score, analgesia requirement and recovery. DESIGN: A randomised controlled trial. SETTING: A large UK Teaching hospital. POPULATION: Forty consecutive women diagnosed with an endometrial polyp at outpatient hysteroscopy were randomly assigned in equal proportions to outpatient or daycase polyp removal. METHODS: The outpatient cohort underwent endometrial polypectomy either using grasping forceps or a bipolar electrode (Versapoint; Gynecare Inc., Menlo Park, CA, USA) introduced down the operating channel of a rigid hysteroscope (Versascope; Gynecare Inc.). The daycase cohort underwent traditional endometrial polyp resection using a hysteroscopic, monopolar, electrosurgical resecting loop, performed under general anaesthetic. MAIN OUTCOME MEASURES: The main outcome measures were as follows: success rates and intra or postoperative complications, time away from home, analgesia requirements, pain scores on the day of and one day after endometrial polypectomy, return to work and preoperative fitness and preference for the location of a future endometrial polypectomy. RESULTS: The majority of women from both cohorts were premenopausal (62.5%), parous (85%) and in paid employment (62.5%). One woman allocated to outpatient polypectomy had cervical stenosis and dilatation was unsuccessful in the outpatient setting. There were no other intra or postoperative complications in either arm of the study. The mean intraoperative visual analogue style (0-100 mm) pain score during outpatient polypectomy was 23.7 mm (1-62). A proportion of women (20%) described no intraoperative discomfort; however, the majority (75%) described mild or moderate intraoperative discomfort. More women in the outpatient cohort (58%) described themselves as pain free for the remainder of the day than in the daycase cohort (28%) (P= 0.09). The day after the procedure, all women from the outpatient group described slight or no discomfort compared with only 41% of women from the daycase group (P= 0.02). All women undergoing outpatient polypectomy had a significantly shorter mean time away from home (3.24 [1.5-5] hours) than women undergoing daycase polypectomy (7.42 [6-10.5] hours), P < 0.0005. Similarly, women from the outpatient cohort had a significantly faster mean return to preoperative fitness (1 [0-4] day versus 3.2 [1-13] days; P= 0.001) and required less postoperative analgesia than the daycase cohort. Ninety-five percent of women from the outpatient cohort and 82% of women from the daycase cohort stated they would prefer to undergo an endometrial polypectomy in the outpatient setting should they require a further polyp removal. CONCLUSION: Endometrial polypectomy can be successfully performed in the outpatient setting with minimal intraoperative discomfort, a significantly shorter time away from home and faster recovery and is preferred by women when compared with daycase polypectomy. Resources need to be made rapidly available to undertake larger scale research and develop this service across the UK.