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SEVERE POSTPARTUM HEMORRHAGE: Etiology, Management and Long-Term Outcome with Special Emphasis on Novel Methods of Management Maiju Grönvall

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SEVERE POSTPARTUM HEMORRHAGE: Etiology, Management and Long-Term Outcome with Special Emphasis on Novel Methods of Management Maiju Grönvall Department of Obstetrics and Gynecology Helsinki University Hospital and University of Helsinki Finland Doctoral Program in Clinical Research SEVERE POSTPARTUM HEMORRHAGE: Etiology, management and long-term outcome with special emphasis on novel methods of management Maiju Grönvall DOCTORAL DISSERTATION To be presented for public discussion with the permission of the Faculty of Medicine of the University of Helsinki, in the Lecture Room 2, Haartman Institute, Haartmaninkatu 3, Helsinki, on the 3rd of April 2020, at 12 noon. Supervised by: Adjunct Professor Vedran Stefanovic, M.D., Ph.D. Department of Obstetrics and Gynecology Helsinki University Hospital and University of Helsinki, Helsinki, Finland Adjunct Professor Minna Tikkanen, M.D., Ph.D. Department of Obstetrics and Gynecology Helsinki University Hospital and University of Helsinki, Helsinki, Finland Reviewed by: Professor Per Olofsson, M.D., Ph.D., B.Sc. Institution of Clinical Sciences Lund University, Malmö, Sweden Adjunct Professor Anne Kuitunen, M.D., Ph.D. Department of Intensive Care Tampere University Hospital and University of Tampere, Tampere, Finland Official Opponent: Adjunct Professor Jyrki Jalkanen, M.D., Ph.D. Department of Obstetrics and Gynecology Central Finland Central Hospital, Jyväskylä, Finland University of Tampere, Tampere, Finland Drawings and cover design Katja Saastamoinen The Faculty of Medicine uses the Urkund system (plagiarism recognition) to examine all doctoral dissertations ISBN 978-951-51-5884-0 (paperback) ISBN 978-951-51-5885-7 (PDF) Unigrafia Helsinki 2020 To Aaro, Perttu, Urho and Ilmari TABLE OF CONTENTS ABSTRACT ............................................................................................................................................ 7 LIST OF ORIGINAL PUBLICATIONS ....................................................................................................... 9 ABBREVIATIONS ................................................................................................................................ 10 1 INTRODUCTION ........................................................................................................................... 11 2 REVIEW OF THE LITERATURE ...................................................................................................... 13 2.1 POSTPARTUM HEMORRHAGE ................................................................................................... 13 2.1.1 Definitions .......................................................................................................................... 13 2.1.2 Incidence ............................................................................................................................ 14 2.1.3 Etiology ............................................................................................................................... 14 Uterine atony ........................................................................................................................... 15 Placental retention ................................................................................................................... 15 Placenta previa ......................................................................................................................... 16 Abnormally invasive placenta .................................................................................................. 18 Genital tract trauma ................................................................................................................. 20 Coagulation disorders .............................................................................................................. 20 2.1.4 Risk factors ......................................................................................................................... 21 2.1.5 Prevention .......................................................................................................................... 24 2.1.6 Screening for placenta previa and antenatal diagnosis of abnormally invasive placenta . 25 2.1.7 Management ...................................................................................................................... 27 General principles .................................................................................................................... 27 Conservative management ...................................................................................................... 29 Tamponade .............................................................................................................................. 30 Pelvic arterial embolization ..................................................................................................... 30 Surgical management .............................................................................................................. 31 Uterine compression sutures .................................................................................................... 31 Artery ligation.................................................................................................................... 32 Hysterectomy .................................................................................................................... 32 Management of placenta previa .............................................................................................. 33 Management of abnormally invasive placenta ....................................................................... 34 2.1.8 Consequences..................................................................................................................... 36 Physical outcomes .................................................................................................................... 36 Psychological outcomes ........................................................................................................... 36 2.2 BAKRI BALLOON TAMPONADE .................................................................................................. 40 2.2.1 Device ................................................................................................................................. 40 2.2.2 Placement ........................................................................................................................... 40 2.2.3 Obstetric indications .......................................................................................................... 42 2.2.4 Contraindications ............................................................................................................... 43 2.2.5 Combination with other treatment methods .................................................................... 44 2.2.6 Success rate ........................................................................................................................ 45 2.2.7 Factors related to failure .................................................................................................... 46 2.2.8 Complications ..................................................................................................................... 46 2.2.9 Long-term outcomes .......................................................................................................... 47 2.3 INTERVENTIONAL RADIOLOGY PROCEDURES ........................................................................... 48 2.3.1 Obstetric indications .......................................................................................................... 48 2.3.2 Method ............................................................................................................................... 49 Acute postpartum hemorrhage ............................................................................................... 50 Anticipated postpartum hemorrhage due to abnormally invasive placenta .......................... 51 2.3.3 Embolization materials ....................................................................................................... 52 2.3.4 Success rate and factors related to failure ......................................................................... 52 Pelvic arterial embolization ..................................................................................................... 52 Temporary prophylactic balloon occlusion .............................................................................. 53 2.3.5 Short-term complications................................................................................................... 54 2.3.6 Long-term outcomes .......................................................................................................... 55 Fertility and menstruation ....................................................................................................... 55 Pregnancies .............................................................................................................................. 55 Psychological outcomes ........................................................................................................... 56 3 AIMS OF THE STUDY ....................................................................................................................... 57 4 MATERIALS AND METHODS ........................................................................................................... 58 4.1 STUDY I .....................................................................................................................................
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