What is the effect of postpartum hemorrhage on physical activity after cesarean?

Studies using estimated blood loss show the association of either human papillomavirus (HPV) or cervical intraepithelial neoplasia (CIN) with postpartum hemorrhage (PPH). We study the association of HPV or CIN with either blood loss or PPH as measured by the more precise measure of quantitative blood loss (QBL). We retrospectively studied 2,334 peripartum women with a documented Pap smear prior to de- livery. The main predictor variable had categories for HPV and CIN as compared to normal cytology. Covariates included demographics, medical/surgical history, and pregnancy variables. Model 1 included the whole sample. Model 2 included only those with an operative vaginal delivery or a cesarean delivery. Outcome measures were QBL and PPH measured by QBL. We found in model 1 that those HPV positive and those with CIN were each not significantly associated with QBL. In model 2, those HPV positive were significantly associated with increased QBL (B = 0.11, SE = 0.05, p = 0.047), while CIN was not significantly associated with QBL. In model 1, those HPV positive and those with CIN were each not significantly associated with PPH. In model 2, those HPV positive were significantly associated with increased odds for PPH (OR:11.03, 9% CI:1.77, 68.74, p = 0.01) while CIN was not significantly associated with PPH. In conclusion, the presence of HPV was positively associated with an increase in the QBL and PPH at time of delivery for those with operative vaginal and cesarean deliveries. We suggest that clinicians take HPV results of Pap smears into consideration when considering a patient's risk of PPH.

Quantitative blood loss after vaginal delivery: a retrospective analysis of 104 079 measurements at 41 institutions

A Softer Approach to Quantitative Blood Loss Measurement

Variance in Estimated Blood Loss Versus Quantitative Blood Loss After Birth

Postpartum hemorrhage is a leading cause of maternal mortality. Antifibrinolytic therapy has the potential to influence outcomes in postpartum hemorrhage, but the incidence of elevated fibrinolytic activity in postpartum hemorrhage is unknown. We retrospectively reviewed thromboelastography (TEG) results obtained for postpartum hemorrhage from 118 deliveries at The University of Chicago. TEG results were obtained as part of our postpartum hemorrhage protocol when blood loss exceeded 500 mL after vaginal delivery or 1000 mL after cesarean delivery. Our primary outcome was the incidence of elevated fibrinolytic activity, which we predefined as clot lysis ≥3% at 30 minutes (Ly30) on kaolin TEG. Platelet-mediated clot retraction can also lead to an elevated Ly30 on kaolin TEG. Therefore, to distinguish between fibrinolysis and clot retraction, we evaluated clot lysis using functional fibrinogen TEG, which contains a platelet inhibitor. We considered a kaolin TEG Ly30 ≥3% in conjunction with a nonzero functional fibrinogen TEG Ly30 suggestive of elevated fibrinolytic activity. We also recorded quantitative blood loss, primary etiology of hemorrhage, standard laboratory measurements of coagulation, and demographic and obstetric characteristics of the study population. The median kaolin TEG Ly30 was 0.2% (interquartile range: 0%-0.8%). Fifteen of 118 women (12.7%; 95% confidence interval, 7.9%-19.9%) had kaolin TEG Ly30 values ≥3%. Of 15 patients with elevated Ly30 values, functional fibrinogen TEG Ly30 was available for 13, of which none demonstrated detectable clot lysis. Our observation that none of the patients in our sample with kaolin TEG Ly30 values ≥3% had a nonzero functional fibrinogen TEG Ly30 value suggests that the observed elevations in kaolin TEG Ly30 may have been secondary to platelet-mediated clot retraction as opposed to fibrinolysis. Platelet-mediated clot retraction should be distinguished from fibrinolysis when assayed using viscoelastic techniques in postpartum hemorrhage. Further research is necessary to determine the optimal methods to assess fibrinolytic activity in postpartum hemorrhage.

Postpartum hemorrhage causes approximately 11% of maternal deaths in the United States and is the leading cause of death that occurs on the day of birth. Importantly, 54-93% of maternal deaths due to obstetric hemorrhage may be preventable. Studies that have evaluated factors associated with identification and treatment of postpartum hemorrhage have found that imprecise health care provider estimation of actual blood loss during birth and the immediate postpartum period is a leading cause of delayed response to hemorrhage. Although current data do not support any one method of quantifying blood loss as superior to another, quantification of blood loss, such as using graduated drapes or weighing, provides a more accurate assessment of actual blood loss than visual estimation; however, the effectiveness of quantitative blood loss measurement on clinical outcomes has not been demonstrated. Successful obstetric hemorrhage bundle implementation is associated with improved outcome measures related to obstetric hemorrhage. However, further research is necessary to better evaluate the particular effect of quantitative blood loss measurement in reducing maternal hemorrhage- associated morbidity in the United States.

Introduction: Evidence supporting the effects of supervised exercise therapy (SET) on alleviating symptoms and improving walking ability for patients with symptomatic peripheral artery disease (PAD) is robust and well recognized. However, little is known about the impact of SET on free-living physical activity (PA). The aim of this study was to examine the relationship between participation in SET and changes in free-living PA among individuals in the the EX ercise Training to Reduce Claudication: Arm ER gometry versus T readmill Walking ( EXERT ) trial. Methods: In this randomized, controlled trial, 104 participants (mean age 68±9; 29% female) were allocated to receive treadmill (TM) exercise (n=41), upper body ergometry (UBE) exercise (n=42), or usual-care (UC) (n=21) for 12 weeks. Exercise participants attended SET three times per week; UC participants met with study staff weekly. PA was measured over 7 days via waist-worn ActiGraph accelerometers at baseline, 6, and 12 weeks. Steps per day was the primary outcome. Secondary outcomes were proportion of time in light and moderate to vigorous physical activity (MVPA), and sedentary time. PA was controlled for in TM participants by using SET logs. Results were analyzed using descriptive statistics, two-sample t-tests, and analysis of variance. Results: Regardless of randomization, average daily steps were low at baseline and 6 weeks (4,013 steps, p =.72; and 3,911 steps, p =.84, respectively), and slightly higher at 12 weeks (4,307 steps; p =.93). Although not statistically significant but perhaps clinically relevant, UBE participants exhibited greater increases in MVPA over 12 weeks (0.9% to 1.3%; F =.48, p =.62) compared to TM (1.2% to 1.3%; F =.35, p =.71) and UC (1.3% to 1.5%, F =.03, p =.97); similarly all participants exhibited reductions in sedentary time and increases in free-living PA between baseline and 12 weeks. Conclusions: These data suggest individuals with PAD attending SET replace sedentary time with light or moderate intensity PA regardless of exercise modality. Despite study participants meeting the recommended daily steps for adults with chronic conditions (3,500-5,500 steps), it is suspected that they did not reach the daily goal of 30 minutes of enhanced PA to reduce health risks. Future research should incorporate activity tracking devices that can provide feedback on PA as an approach to meet daily PA goals. Activity tracking devices used in conjunction with SET may further improve walking distance, symptom management, and quality of life among patients with symptomatic PAD.

Objective: We aimed to evaluate the relationship between mode of first delivery with subsequent placenta previa, placenta accreta/increta, and significant postpartum hemorrhage (PPH).Method: This retrospective cohort study included women with two consecutive singleton deliveries between 2007 and 2017 at our institution if the women were nulliparous and delivered at term at the time of first delivery. The first pregnancy delivery mode was classified as (1) vaginal delivery, (2) antepartum cesarean delivery (CD) without labor, or (3) intrapartum CD after the onset of labor. Within these three groups, rates of placenta previa, placenta accreta/increta, and significant PPH at the time of the second delivery were compared. Significant PPH was defined as hemorrhage requiring a blood transfusion.Results: A total of 8208 women were analyzed. Most first deliveries were vaginal (n = 5210, 63.5%), followed by antepartum CD (n = 2432, 29.6%) and intrapartum CD (n = 566, 6.9%). The incidence of placenta previa in subsequent deliveries differed by previous delivery mode: vaginal, 0.9%; antepartum CD, 2.0%; intrapartum CD, 1.6% (p < .001). Similar differences were also observed with respect to placenta accreta/increta (0.5 versus 1.5 versus 0.9%, p < .001) and PPH (0.6 versus 1.2 versus 0.4%, p = .017). Compared to the previous vaginal delivery group, the antepartum CD group had increased risks of placenta previa (aORs 2.02, 95% CI 1.35–3.05), placenta accreta/increta (aOR 2.52; 95% CI 1.53–4.14) and PPH (aOR 1.78, 95% CI 1.14–2.98) in subsequent pregnancies. However, the previous intrapartum CD was not significantly associated with increased risks of these complications.Conclusion: Previous antepartum CD was associated with two-fold increased risks of placenta previa, placenta accreta/increta, and significant PPH in the second delivery compared to women with a prior vaginal delivery. The increased risks of subsequent abnormal placentation following primary antepartum CD may be important for counseling concerning nonmedically indicated elective cesarean.Condensation: Previous antepartum cesarean delivery (CD) was associated with two-fold increased risks of placenta previa, placenta accreta/increta, and significant PPH in the second delivery.

Diabetes mellitus is a metabolic disorder characterized by elevated blood and tissue glucose levels due to absolute or relative insulin deficiency. In addition to a number of systemic complications, diabetes in pregnant women is associated with poor perinatal outcome. A recent study claimed that not merely the presence of diabetes but also poor glycemic control during pregnancy is associated with adverse maternal outcome. However, the available evidence was limited while there was no such local published material which necessitated the present study.&#x0D; OBJECTIVE: The objectives of this study were to determine the frequency of uncontrolled diabetes mellitus in late 3rd trimester among diabetic pregnant women presenting at a teaching hospital in Punjab and to compare the maternal outcome among pregnant women with controlled versus uncontrolled diabetes mellitus.&#x0D; STUDY DESIGN: It was a descriptive case series.&#x0D; SETTING: Research was conducted at Department of Obstetrics and Gynecology, Sir Ganga Ram Hospital Lahore.&#x0D; DURATION: Duration of study was 6 months after the approval of synopsis from 01/08/2017 to 31/12/2017 (4 months) and 01/04/2018 to 31/05/2018 (2 months).&#x0D; MATERIAL AND METHODS: This study involved 217 diabetic pregnant women aged between 18-35 years presenting after 34 weeks of gestation. HbA1c levels were acquired and those with ?6% HbA1c levels were labeled to have uncontrolled diabetes. Frequency of polyhydramnios, cesarean delivery and postpartum hemorrhage was noted and compared between women with controlled and uncontrolled diabetes. A written informed consent was obtained from every patient.&#x0D; RESULTS: The mean age of the patients was 30.1±3.9 years while the mean gestational age was 39.6±1.6 weeks. Majority (n=190, 87.6%) of the patients were aged between 26-35 years followed by 27 (12.4%) patients aged between 18-25 years. There were 75 (34.6%) primiparas and 142 (65.4%) multiparas. 36 (16.6%) patients had pre-pregnancy diabetes while 181 (83.4%) patients had gestational diabetes. 74 (34.1%) patients were taking oral hypoglycemic while 143 (65.9%) patients were on insulin. HbA1c levels ranged from 5.5% to 7.7% with a mean of 6.5±0.66%. Taking a cut-off value of ?6.0%, 146 (67.3%) patients had uncontrolled diabetes. 46 (21.2%) patients had polyhydramnios, 146 (67.3%) patients required cesarean delivery and 31 (14.3%) patients acquired post-partum hemorrhage. The frequency of polyhydramnios (27.4% vs. 8.5%; p-value=0.001), cesarean delivery (84.9% vs. 31.0%; p-value&lt;0.001) and postpartum hemorrhage (21.2% vs. 0.0%; p-value&lt;0.001) was significantly higher in patients with uncontrolled diabetes.&#x0D; CONCLUSION: A substantial proportion of diabetic women in late 3rd trimester had poor glycemic control and had significantly higher frequency of polyhydramnios, cesarean delivery and postpartum hemorrhage than women with good glycemic control which advocates routine monitoring and strict glycemic control in diabetic pregnant women to improve the maternal outcome in future practice.

University of California, Davis, California Financial Disclosure Dr. Creinin receives speaking honoraria from Allergan and Merck & Co., serves on an Advisory Board for Merck & Co. and is a consultant for Estetra, Health Decisions, and Medicines360. The Department of Obstetrics and Gynecology, University of California, Davis, receives research funding for contraceptive clinical trials from Contramed, Medicines360, Merck & Co., NIH/NICHD and the Society of Family Planning.

Healthcare burden associated with postpartum hemorrhage after cesarean delivery: a contemporary cohort

122 Effect of preoperative thrombocytopenia on blood transfusion after cesarean deliveries

106 Prediction of postoperative day 1 hemoglobin level after cesarean delivery

Background The risk and benefits of coronavirus disease 2019 (COVID-19) vaccination during pregnancy are under investigation. Pooled evidence regarding neonatal and maternal outcomes in relation to COVID-19 vaccination during pregnancy is scarce. Methods We searched PubMed and EMBASE databases in April 2022 without language restrictions. We included Prospective trials and observational studies comparing the women who received at least one COVID-19 vaccination during pregnancy with those who did not and reporting neonatal outcomes. Two independent investigators extracted relevant data from each study. Odds ratios (ORs) were calculated using random-effects models. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The primary outcomes were the neonatal outcomes, including preterm birth, small-for-gestational-age (SGA), low Apgar score (&amp;lt; 7 at 5 min), neonatal intensive care units (NICU) admission, and intrauterine fetal death (IFD). The secondary outcomes were maternal outcomes, including maternal SARS-CoV-2 infection, cesarean delivery, postpartum hemorrhage, and chorioamnionitis. Results Nine observational studies involving 81,349 vaccinated (mean age, 32.0±4.6 years) and 255,346 unvaccinated women during pregnancy (mean age, 30.5±5.1 years) were included. COVID-19 vaccination during pregnancy was associated with lower risk of NICU admission (OR, 0.88; 95% confidence intervals [CI], 0.80-0.97) and IFD (OR, 0.73; 95% CI, 0.57-0.94), whereas it was not associated with preterm birth (OR, 0.89; 95% CI, 0.76-1.04), SGA (OR, 0.99; 95% CI, 0.94-1.04), and low Apgar score (OR, 0.94; 95% CI, 0.87-1.02). COVID-19 vaccination during pregnancy was associated with a lower risk of maternal SARS-CoV-2 infection (OR, 0.46; 95% CI, 0.22-0.93), but not associated with increased risk of cesarean delivery (OR, 1.05; 95% CI, 0.93-1.20), postpartum hemorrhage (OR, 0.95; 95% CI, 0.83-1.07), and chorioamnionitis (OR, 0.95; 95% CI, 0.83-1.07). Flowchart of study selection Forest plots showing the odds ratio of neonatal outcomes a: neonatal intensive care units admission, b: intrauterine fetal death, c: preterm birth, d: small for gestational age, e: low Apgar score Forest plots showing the odds ratio of maternal outcomes a: maternal SARS-CoV-2 infection, b: cesarean delivery, c: postpartum hemorrhage, d: chorioamnionitis Conclusion COVID-19 vaccination during pregnancy did not increase the risk of peripartum outcomes but decreased the risk of NICU admission, IFD, and maternal COVID-19 infection. COVID-19 vaccination should be encouraged for pregnant women. Disclosures All Authors: No reported disclosures.

INTRODUCTION: Umbilical cord blood collection (UCBC) for stem-cell banking is routinely performed during cesarean sections (CS). Few studies have examined the maternal effect. This study's objective is to evaluate whether UCBC during CS is associated with increased maternal blood loss and morbidity. METHODS: This was a single-center retrospective cohort study of primary CS (PCS) in 2021. Exclusion criteria were age less than 18, multifetal gestation, gestational age less than 34 weeks, emergency, and infection. Data were compared between participants with and without UCBC during PCS. Extensive demographic data was collected and compared. The primary outcome was quantitative blood loss (QBL). Secondary outcomes were operative time, hemorrhage medication usage, and blood transfusion (BT). RESULTS: Eight hundred two PCS were reviewed, and 191 were excluded. Of the remaining 611, UCBC was attempted in 151 (24.7%). The UCBC cohort had higher gestational age (39.1 versus 38.7; P=.007), were less often in labor (P=.004) or on magnesium (P=.022), and were more likely to be scheduled (P=.002). Quantitative blood loss was higher with UCBC (1,091.5 versus 1,007.5 mL; P=.075). In non-labored PCS, the QBL difference was statistically significant (941.8 versus 798 mL; P=.034). Umbilical cord blood collection was associated with increased operative time (62.4 versus 56.8 minutes; P&lt;.001) and postoperative BT (7.2% versus 3.3%; P=.036). There were no associations between UCBC and usage of hemorrhage medications. CONCLUSION: Umbilical cord blood collection increases QBL in nonlabored PCS. Umbilical cord blood collection increases operative time and postoperative BT in PCS. Patients should be appropriately counseled and selected for UCBC based on hemorrhage risk factors.