Sabaratnam Arulkumaran

Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails.

We performed a systematic review to identify all studies evaluating the success rates of treatment of major postpartum hemorrhage by uterine balloon tamponade, uterine compression sutures, pelvic devascularization, and arterial embolization. We included studies reporting on at least 5 cases. All searches were performed independently by 2 researchers and updated in June 2006. Failure of management was defined as the need to proceed to subsequent or repeat surgical or radiological therapy or hysterectomy, or death. As the search identified no randomized controlled trials, we proceeded to search for observational studies. This identified 396 publications, and after exclusions, 46 studies were included in the systematic review. The cumulative outcomes showed success rates of 90.7% (95% confidence interval [CI], 85.7%–94.0%) for arterial embolization, 84.0% (95% CI, 77.5%–88.8%) for balloon tamponade, 91.7% (95% CI, 84.9%–95.5%) for uterine compression sutures, and 84.6% (81.2%–87.5%) for iliac artery ligation or uterine devascularization (P = 0.06). At present there is no evidence to suggest that any one method is better for the management of severe postpartum hemorrhage. Randomized controlled trials of the various treatment options may be difficult to perform in practice. As balloon tamponade is the least invasive and most rapid approach, it would be logical to use this as the first step in the management. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that there are no randomized controlled studies on various methods of treating postpartum hemorrhage (PPH), state that the success rate for one method is no better than another method in the management of severe PPH, and explain that after medical management fails the next logical approach is the use of the balloon tamponade.

Fetal and maternal lactate increase during active second stage of labour

Objective To determine longitudinally fetal and maternal blood lactate concentrations during the second stage of labour.

Medical Treatment of Placenta Accreta with Methotrexate

Placenta accreta is a rare condition and is associated with considerable maternal morbidity and mortality. Though the surgical approach of hysterectomy is a definitive therapy, there are occasions when conservation of the uterus is desired by the patient. We report a case of placenta accreta successfully treated with intravenous methotrexate. After 2 weeks of treatment no signs of placenta could be visualized on ultrasound examination of the uterus. The patient was discharged after 15 days and has since been well. Such therapy may be useful in exceptional cases in institutions with adequate facilities for careful monitoring and management of the patient.

Fetal electrocardiogram: ST waveform analysis in intrapartum surveillance

ST waveform analysis of fetal electrocardiogram (ECG) for intrapartum surveillance (STAN) is a newly introduced method for fetal surveillance. The purpose of this commentary is to assist in the proper use of fetal ECG in combination with cardiotocography (CTG) during labour. Guidelines and recommendations concerning CTG and ST waveform interpretation and classification are stated that were agreed on by the European experts on ST waveform analysis for intrapartum surveillance during a meeting in Utretcht, the Netherlands in January 2007.

Influence of breastfeeding and nipple stimulation on postpartum uterine activity.

Ninety-nine percent of all maternal deaths occur in the developing countries, and postpartum haemorrhage (PPH) makes a major contribution to these deaths (Ratnam et al. 1989). Despite data showing that oxytocic drugs used routinely reduce the risk of PPH by 40%, or that postpartum haemorrhage can be prevented in one of every 22 women given an oxytocic (Prendeville et al. 1988), oxytocic drugs are not available for routine use in the third-stage of labour in many parts of most developing countries. Women who breastfeed are known to experience afterpains when the infant suckles. We quantified the effect of breastfeeding or nipple stimulation on postpartum uterine activity. Each individual acted as her own control.

Potassium channels in the human myometrium.

The contractility of the human uterus is under the fine control of a variety of interacting bioactive agents. During labour, the excitability of the uterus is drastically transformed in comparison with the non‐labour state and is manifest at the membrane level via the acivity of uterine ion channels. This article reviews the contribution of potassium (K+) channels to human uterine excitability.

Cesarean section for non-medical reasons.

Cesarean section without medical indication is cited as a factor in the increase in the rate of cesarean delivery in modern obstetric practice. Individual obstetricians often express strong views supporting or refuting the right of women to request operative delivery and their rights to decline or fulfill this request. Such strong opinions may be misplaced as the available evidence does not conclusively support either view‐point.

A new molecular variant of luteinizing hormone associated with female infertility

OBJECTIVE To investigate whether the newly described G1502 to A1502 mutation in exon 3 of the LH beta-subunit gene, causing the amino acid substitution of Ser102 for Gly102, is related to female infertility. DESIGN Screening of fertile and infertile women for the G1502 to A1502 mutation in the LH beta-subunit gene. SETTING Clinics and laboratories of the National University Hospital obstetrics and gynecology department, Singapore. PATIENT(S) Two hundred twelve healthy fertile women; 40 infertile women with menstrual disorders, polycystic ovary syndrome, and endometriosis; and 12 women with idiopathic infertility. INTERVENTION(S) Exon 3 of the LH beta-subunit gene was analyzed using polymerase chain reaction (PCR), restriction fragment length polymorphism (RFLP), and PCR-mediated direct DNA sequencing. MAIN OUTCOME MEASURE(S) The PCR products of patients were analyzed by RFLP, and the results were compared with those of fertile controls. DNA sequencing radiographs were compared between two mutation-bearing patients and four controls. RESULT(S) The mutation was identified in only two infertile women with endometriosis; other women studied were found to be negative for this mutation. CONCLUSION(S) The missense mutation in the LH beta-subunit gene may be implicated in female infertility, possibly endometriosis-associated infertility in some women.

Current strategies for the prevention of postpartum haemorrhage in the third stage of labour.

Purpose of review Despite evidence that active management of the third stage of labour reduces the incidence of postpartum haemorrhage, expectant management is still widely practised. Factors accounting for this situation include the desire for a more natural experience of childbirth, the philosophy that active management is unnecessary in low-risk women, and avoidance of the adverse effects of conventional uterotonic agents. This review will evaluate the various strategies currently used for the prevention of primary postpartum haemorrhage. Recent findings Since publication of the first systematic review comparing active with expectant management in 1988, active management of the third stage using oxytocics has become increasingly adopted. Recent surveys, however, show that there are still wide variations in practice around the world. Recent interest has focused on the use of misoprostol for the prevention of postpartum haemorrhage. Carbetocin, an oxytocin receptor agonist, shows promise but has not been evaluated for use after vaginal births. Summary Active management of the third stage of labour is superior to expectant management in terms of blood loss, postpartum haemorrhage and other serious complications, but is associated with unpleasant side effects and hypertension when ergometrine is included. Intramuscular oxytocin results in fewer side effects. Oral and rectal misoprostol has been extensively assessed and found to be less effective than conventional oxytocics with more side effects. Until alternative regimes of misoprostol are studied in large controlled trials, misoprostol is not recommended for routine use in the third stage of labour. Of the remaining uterotonic agents evaluated, intramuscular carbetocin appears the most promising.

Review of the first 1502 cases of ECG‐ST waveform analysis during labour in a teaching hospital

Objective  To assess the impact of introduction of the STAN monitoring system.