Risk factors for postpartum hemorrhage in a cohort of 6011 Italian women

Introduction

Postpartum hemorrhage is responsible for 25% of maternal pregnancy-related deaths and it is the first cause of maternal morbidity and mortality worldwide.

Objective

To define the prevalence of postpartum hemorrhage and associated risk factors after vaginal birth and to develop a risk model that improves postpartum hemorrhage prediction.

Patients and methods

All women who underwent a vaginal delivery at the Obstetric Unit of a large University hospital in Milan (Italy) between July 2007and September 2009 were enrolled. Postpartum hemorrhage was defined as ≥ 500 mL blood loss. A nomogram tailored to predict postpartum hemorrhage was developed, summarizing the impact of each covariate on the probability of postpartum hemorrhage.

Results

6011 women were studied (24% had blood loss ≥ 500 mL and 4.8% ≥ 1000 mL). Nulliparity, episiotomy, retained placenta and high neonatal body weight were confirmed as risk factors for postpartum hemorrhage. The odds ratio of postpartum hemorrhage was 0.86 (95%CI 0.78-0.90) for each 1 gr/dL increase in ante-partum hemoglobin. An extensive internal validation of the developed nomogram demonstrated a good stability of the risk model.

Conclusions

Low ante-partum hemoglobin is a new potentially modifiable risk factor for postpartum hemorrhage. A nomogram to predict the probability of postpartum hemorrhage is now available for external validation.     

The risk of postpartum hemorrhage in women using high dose of low-molecular-weight heparins during pregnancy

Background

Low-molecular-weight heparins (LMWH) are the most commonly used anticoagulant during pregnancy for prevention or treatment of VTE. However, the size of the associated risk of postpartum haemorrhage (PPH) is unknown.

Objective

To assess the bleeding risk of high dose LMWH, also in relation to time between last dose LMWH and delivery.

Material and methods

From 1999 to 2009, we followed 88 pregnant women who were started on therapeutic anticoagulation. Controls were pregnant women without LMWH, matched 1:4 for parity, mode of delivery, age, gestational age and delivery date. PPH was defined as > 500 ml blood loss for vaginal delivery (severe PPH in vaginal delivery as > 1000 ml) and > 1000 ml for cesarean section (CS). Women were divided into subgroups by the interval between last dose of anticoagulation and delivery (< 12, 12-24 hrs, > 24 hrs).

Results

Risk of PPH after vaginal delivery was 30% and 18% for LMWH-users and non-users, respectively (OR 1.9, 95%CI 1.1-3.5). Risk of severe PPH after vaginal delivery was not different (5.6 vs 5.0%; OR 1.1; 0.4-3.6). Risk of PPH after CS was 12% in LMWH-users and 4% in non-users (OR 2.9; 0.5-19.4). Both events of LMWH-users occurred after emergency CS. The risk of PPH associated with delivery within 24 hours after last dose of LMWH was 1.2 fold higher (95%CI 0.4-3.6) compared to a larger interval.

Conclusion

High dose LMWH carries an increased risk of more than 500 mL blood loss after vaginal delivery. However, this results not in more clinical relevant severe PPHs. The interval between last dose of LMWH and delivery does not influence the risk of PPH.     

PPH与Milligan-Morgan术治疗Ⅲ～Ⅳ期混合痔的临床效果观察

目的比较痔上黏膜环切术(PPH术)与传统痔切除术(Milligan-Morgan术)治疗Ⅲ~Ⅳ期混合痔的临床效果,探讨治疗Ⅲ~Ⅳ期混合痔的最佳术式。方法将100例混合痔患者随机分为PPH术组,Milligan-Morn术(M-M组),并进行对比观察。结果与M-M术相比,PPH术无Milligan-Morgan术常见的肛门部水肿等并发症,术后肛门部疼痛轻,术后恢复快,住院时间短,差异有统计学意义(P<0.05)。结论在治疗Ⅲ~Ⅳ期混合痔时,应首选PPH术治疗Ⅲ~Ⅳ期环状痔患者,可显著减轻术后疼痛,加快患者术后恢复,减少术后并发症。     

Milligan-Morgan术联合PPH治疗重度混合痔46例评价管建国

目的探讨重度混合痔的手术方法。方法通过对2005年8月～2012年5月我院86例重度混合痔患者Milligan-Morgan(M-M)术+PPH 46例(观察组)与单纯M-M术40例(对照组)术后住院时间、疼痛强度、尿潴留、出血量、肛门狭窄、痔疮复发等进行分析比较。结果观察组术后痔疮复发率与对照组差异显著(P<0.05),两组在术后住院时间、疼痛强度、术后出血量、尿潴留、肛门狭窄等方面无显著差异(P>0.01)。结论 PPH术+外剥内扎术治疗重度混合痔能有效降低痔疮复发。     

PPH联合外剥内扎术治疗环状混合痔的必要性

目的探讨环状混合痔的联合手术治疗方法。方法回顾分析了2008年10月至2012年6月我院用PPH联合外剥内扎术治疗198例环状混合痔的临床资料。结果此组患者全部痊愈,近远期效果均满意。结论联合使用PPH和外剥内扎的手术治疗效果明显优于单一的手术方法。     

PPH治疗环状混合痔34例临床疗效观察

目的探讨PPH术在环状混合痔中临床应用价值。方法对34例环状混合痔施痔上黏膜环切吻合术临床资料进行分析。结果术后随访6个月32例效果满意,满意率94.1%。术后有5例(14.7%)患者述有轻微疼痛,2例(5.8%)疼痛明显者给予口服镇痛药1d后缓解;平均手术时间15min,平均住院时间4d,无1例复发。结论使用PPH治疗环状混合痔具有痛苦小,手术时间短,损伤小,恢复快等优点。近期疗效满意。     

PPH治疗直肠前突52例疗效观察

为探讨吻合器痔上黏膜环切术（PPH）治疗直肠前突的临床疗效,对52例直肠前突患者采用PPH治疗。结果显示,创面愈合时间5～7d。术后1周,痊愈37例（71．2％）,显效6例（11．5％）,有效5例（9．6％）,无效4例（7．7％）,总有效率为92．3％（48／52）。本组病例术后均未发生黏膜感染、坏死、出血和直肠阴道瘘。随访10～20个月,无复发。结果表明,PPH治疗直肠前突操作简单、患者痛苦轻、创面愈合快、疗效确切。     

混合痔外剥内扎术150例疗效观察

<正>2006年以来,我们采取外剥内扎术治疗混合痔150例,取得满意疗效,现报告如下。1临床资料本组150例,男78例,女72例,年龄18～65岁,病程最短6个月,最长25a,以静脉曲张外痔为主的混合痔102例,以结缔组织外痔为主的混合痔48例。其中环状混合痔16例。     

PPH不同时期治疗嵌顿痔的对比研究

目的研究PPH不同时期治疗嵌顿痔的临床疗效。方法 52例患者随机分为2组,治疗组就诊时即行PPH术,对照组经消炎、消肿治疗7d后后再行PPH术。结果治疗组、对照组有效率均为100%,2组有疗效率比较无显著性差异（P〉0.05）,2组并发症比较差异无显著性（P〉0.05）。术后疼痛时间、康复时间比较以治疗时间最短,两组比较差异具有显著性（P〈0.05）。结论应当在患者入院即刻行PPH术。