Raised nitric oxide levels may cause atonic postpartum hemorrhage in women with anemia during pregnancy

Soltan, M.H.; Ibrahim, Emad M.; Tawfek, Mohammad; Hassan, Hesham; Farag, Fady

doi:10.1016/j.ijgo.2011.09.017

Cited by 20 publications

(27 citation statements)

References 20 publications

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“…9,23,30,31 This phenomenon is explained by impaired uterine muscle strength secondary to decreased uterine perfusion seen in patients with decreased iron stores. 34 In regard to hypertensive disorders of pregnancy, a one-thirdfold increase in these diagnoses was seen in women with anemia, also similar to findings of previous studies, and likely related to decreased uterine and placental perfusion. 7,9,34 Due to this finding, an additional logistic regression was performed to evaluate the impact of chronic hypertension, particularly in regard to eclampsia and other hypertensive disorders of pregnancy, by including it in the model, and the results were essentially unchanged from those seen in Table 4.…”

Section: Resultssupporting

confidence: 88%

“…34 In regard to hypertensive disorders of pregnancy, a one-thirdfold increase in these diagnoses was seen in women with anemia, also similar to findings of previous studies, and likely related to decreased uterine and placental perfusion. 7,9,34 Due to this finding, an additional logistic regression was performed to evaluate the impact of chronic hypertension, particularly in regard to eclampsia and other hypertensive disorders of pregnancy, by including it in the model, and the results were essentially unchanged from those seen in Table 4. Lastly, higher rates of infectious morbidity observed with anemia in our study are supported by previous studies 9, 30 and likely explained by inadequate blood flow and oxygen delivery necessary for wound healing and infection control.…”

Section: Resultssupporting

confidence: 88%

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Maternal anemia and severe maternal morbidity in a US cohort

Harrison¹,

Lauhon²,

Colvin³

et al. 2021

American Journal of Obstetrics & Gynecology MFM

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Section: Resultssupporting

confidence: 88%

Section: Resultssupporting

confidence: 88%

Maternal anemia and severe maternal morbidity in a US cohort

Harrison¹,

Lauhon²,

Colvin³

et al. 2021

American Journal of Obstetrics & Gynecology MFM

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“…Second, there is some evidence that the chronic hypoxic environment caused by anemia can upregulate or dysregulate placental vascularity, which may increase the vulnerability of the placenta and uterus to vascular fragility and PPH. Third, anemia has been associated in some studies, with uterine atony (implicated in PPH), perhaps related to tissue iron deficiency. Fourth, postpartum blood loss of <500 mL (not meeting the standard definitions of PPH), which is the volume of a blood donation and therefore considered inconsequential for nonanemic individuals, may be poorly tolerated in patients with low hemoglobin levels.…”

Section: Discussionmentioning

confidence: 99%

Maternal death and postpartum hemorrhage in sub‐Saharan Africa – A pilot study in metropolitan Mozambique

Lancaster

Barnes

Correia

et al. 2020

Research and Practice in Thrombosis and Haemostasis

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Background Maternal mortality in sub‐Saharan Africa is approximately 500 to 1000 per 100 000 births (vs. approximately 5‐20 in developed countries). Postpartum hemorrhage (PPH) is deemed responsible for 30% to 50% of the deaths. Objective To study PPH, risk factors, and mortality in metropolitan Mozambique to inform future studies and intervention strategies. Materials/Methods Retrospective cross‐sectional data extraction from all charts available to us (n = 495) recording deliveries between January and June 2018 at Maputo Central Hospital. Data included age, maternal survival, HIV status, parity, delivery mode, complications, vital signs, laboratory values, and maternal/fetal data. PPH was determined by charted diagnosis, interventions for hemorrhaging, placental abruption, transfusion, or blood loss. Autopsy reports from all deceased patients (n = 35) were examined. Results Median age was 29 years with 17% HIV prevalence. Risk factors for PPH (frequency, 12%) included parity (adjusted odds ratios (AORs) for 3+ versus nulliparity, 7.20 (95% confidence interval [CI], 2.46‐21.10), gestation length (AOR, 0.86; CI, 0.81‐0.92 per week), and body temperature (AOR, 1.10; CI, 1.04‐1.16 per 0.1°C). Maternal mortality was strongly associated with PPH (AOR, 5.22; 95% CI, 2.26‐12.08) and HIV (AOR, 11.66; 95% CI, 4.72‐28.78). Laboratory values (n = 241) were available from mothers experiencing complications (approximately 50%). Anemia (prevalence 54%) was a strong predictor of PPH with an inverse relationship between hemoglobin levels on admission (AOR, 0.62; 95% CI, 0.50‐0.77 per g/dL higher hemoglobin) and the probability of later suffering from PPH. Mothers who died following PPH had lower median hemoglobin (6.2 g/dL) than mothers who survived (9.2 g/dL). Protocols to estimate peripartum blood loss were not used; antifibrinolytics and/or cryoprecipitate were unavailable. Conclusion Postpartum hemorrhage is a serious problem even in metropolitan areas of sub‐Saharan Africa, and anemia influenced bleeding and death substantially. To address this problem, it is critical to raise awareness and region‐specific prevention and intervention protocols.

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“…There is a 8–10-fold increase in maternal mortality ratio (MMR) when Hb falls below 5 g/dL 3. Anaemia, which was present in this patient, caused a weak and non-reassureable uterine tone4 Anaemia causes rise in nitric oxide levels, which is responsible for hypotonic myometrium in atonic PPH 4. In the Indian context, haemorrhage is the chief cause of maternal deaths, that is, 31% 5.…”

Section: Discussionmentioning

confidence: 70%

Exsanguinated uterus after massive atonic postpartum haemorrhage

et al. 2013

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SUMMARYThis article addresses issues related to pregnancy anaemia and late referral by a village birth attendant in resource poor setting in a central state of India. A young anaemic woman had labour onset at her village, a birth attendant tried to deliver her but failed. When she came to our hospital, had established septicaemia and absolutely nonreassurable uterine tone leading to intractable atonic postpartum haemorrhage. She died after 5 days because of coagulopathy and multiorgan failure. Huge budgets are being spent for the promotion of institutional deliveries but still the maternal mortality ratio has not reduced. The epidemiology of childbirth, social awareness for safe labour and administrative lethargy towards implementation of government programmes have not changed. The tertiary care-blood and componentsmultidisciplinary approach could not prevent the death of an anaemic woman. Unless there is a grassroot level change in the healthcare delivery system at the village level, the scenario might not change. BACKGROUND

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Raised nitric oxide levels may cause atonic postpartum hemorrhage in women with anemia during pregnancy

Abstract: Even moderate anemia can raise levels of NO and enhance its biologic effects, which in turn can result in uterine muscle relaxation and atonic PPH. Preventing or treating anemia during pregnancy could avoid these complications.

Cited by 20 publications

References 20 publications

Maternal anemia and severe maternal morbidity in a US cohort

Maternal anemia and severe maternal morbidity in a US cohort

Maternal death and postpartum hemorrhage in sub‐Saharan Africa – A pilot study in metropolitan Mozambique

Exsanguinated uterus after massive atonic postpartum haemorrhage

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