AN AUDIT OF PRIMARY POST PARTUM HAEMORRHAGE
AbstractBackground: Postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity andmortality .Its causes & risk factors are important for its prevention and management. Poor, unhealthy, highparity women delivering away from health facility are usual victims. The purpose of this study is todetermine causes of PPH, risk factors, preventable factors and to assess treatment measures adopted.Methods: This retrospective study is carried out in Gynaecology 'B' unit of Ayub Teaching HospitalAbbottabad. All patients admitted with PPH or developed PPH within hospital from 1st Jan–31st Dec 2006are included. Exclusion criteria were patients with bleeding disorders and on anticoagulants. Records ofadmissions, deliveries, caesareans, major & minor procedures and history charts were thoroughlyevaluated for details. Details included age, parity, socioeconomic status, transportation facility, distancefrom hospital, onset of labours, birth attendant skilled/unskilled, evaluation of risk factors, duration oflabour and mode of delivery. Patient’s general health, anaemia, shock, abdominal and pelvic examinationand laboratory findings were also taken in to account. Treatment measures including medical, surgical,blood transfusions were evaluated. Results: The most important cause was uterine atony, 96 (70.5%) andtraumatic lesions of genital tract, 40 (29.4%). Factors causing uterine atony were augmented labour 20(20.9%), prolonged labour 21 (21.9%), retained placental tissues, 11 (12.5%), retained placenta, 11(11.4%) Couvelliar uterus, 10 (10.4%), placenta preavia, 8 (8.3%), placenta increta, 7 (7.3%),chorioamnionitis 5 (5.2%), and multiple pregnancy, 2 (2.1%). Risk factors, grand multiparity 70 (51.5%),antepartum haemorrhage 12 (8.9%), instrumental delivery 10(7.3%), previous PPH, 6 (4.5%),choreoamnionitis, 5 (3.6%), multiple pregnancy, 2 (1.5%), no risk factor, 21 (15.4%). Socioeconomicstatus was poor (75) & lower middle class (61). Induced labour, 33 (24.3%), augmented labour 62(45.5%).Uterotonics used for prophylaxis in 30 (22%), for treatment of PPH, 106 (78%). Patientsdelivered by traditional birth attendants 70 (51.4%), lady health workers 40 (29.4%) & doctors 26(19.2%).Uterine massage performed in 30 (22%), minor surgical procedures 33 (24.3%), manual removalof retained placenta, 11 (8%), hysterectomy, 50 (36.7%), & compression sutures were applied in 3 (2.2%).Maternal deaths due to PPH were 6 (40%). Conclusions: PPH can be prevented by avoiding unnecessaryinductions/augmentations of labour, risk factors assessment and active management of 3rd stage of labour.It needs critical judgment, early referral and early resuscitation by birth attendant. There is room fortemponade and compression sutures. Hysterectomy should be the last option.Keywords: Post Partum Haemorrhage, Uterine atony, Uterotonics, Compression sutures.
Michael S. Rogers, Alan M.Z. Chang. Post partum hemorrhage
and other problems of the third stage. High Risk pregnancy
management options 3rd ed. Elsevier 2006: 1560–65.
Obstetrical Haemorrhage In: Cunningham FG, Grant NF,
Gilstrapa LC, Hauth JC, Leveno KJ, Wenstrom KD,
ediotors.21st William’s Obstetrics. Newyork: McGrawhill
Smith Jr. Postpartum haemorrhage (homepage on the internet
Medicine.com Inc (update 2004 Nov 24; cited 2005 May 06).
Available from: http//www.emedicine.com.
Boumeester FW, Bolte AC, Van Geinun HP.
Pharmacological and surgical therapy for primary post
partum hemorrhage. Curr Pharma 2005;11:759–73.
World Health Organization. Attending to 136 million births,
every year: make every mother and child count: The world
Report 2005. Geneva, Switzerland: WHO, 2005. p. 62–3.
Abou Zahr C. Global burden of maternal death and disability.
In: Rodeck C,ed. Reducing maternal death and disability in
pregnancy. Oxford: Oxford University Press; 2003.p1–11.
Khushk IA, Baig LA. Maternal mortality in Pakistan : No
room for complacency. J Coll Physicians Surg Pak
Tamizian O, Arulkumaran S. The surgical management of
postpartum haemorrhage. Best Pract Res Clin Obstet
Elbourne DR, Prendiville WJ, Carroli G, Wood J, McDonald
S. Prophylactic use of Oxytocin in the third stage of labour.
Cochrane Database Syst Rev 2001;(4):CD001808.
Mac-Mullen NJ, Dulski LA, Meagher B. Parental hemorrhage.
MCN Am J Matern Child Nurse 2005;30:46–51.
Wain Scott MP. Pregnancy Post partum hemorrhage (home page
on internet) e Medicine .com Inc (updated 2004 Nov 24; cited
May 10). Available from: http://www.emedicine .com.
Tesseir V. Pierre F. Risks of Post partum hemorrhage during
labour and clinical & pharmacological prevention. J Gynecol
Obstet Biol Reprod 2004;33:4529–56.
Hofmeyr GJ, Ferreira S, Nikodem VC, Singata LM, Jafta Z,
Maholwana B et al. Misoprostol for treating Post partum
hemorrhage; a randomized controlled trial. BMC. Pregnancy
child birth 2004;4:16.
Litch JA. Summary of the evidence base for active
management of the third stage of labour. Preventing
postpartum hemorrhage: a toolkit for providers. Seattle, WA:
Program for Appropriate Technology for Health (PATH);
Kane TT, EI-Kady AA, Saleh S, Hage M, Stanback J, Potter
L. Maternal mortality in Giza, Egypt: magnitude, causes, and
prevention. Study Fam Plann 1992;23:45–57.
A Lalonde, B.A. Daviss, Postpartum hemorrhage today:
ICM/FIGO initiative 2004-2006. International journal of
Gynaecology and Obstetrics (2006);94:243–53.
17: Abu-Heija AT, Chalabi HE. Great grandmultiparity: is it
a risk? J Gynaecol 1998;18:136–8.
World Health Organization. Coverage of maternity care: a
listing of the available information, 4th ed. Geneva: World
Health Organization; 1997.
George Condous, Tom Bourne. Postpartum uterine atony.
Progress in obstetrics and Gynaecology editor John Stud Vol
: pp 164–74.
Sherman SJ, Greenspoon JS, Nelson JM, Paul RH.
Identifying the obstetric patient at high risk of multiple-unit
blood transfusions. J Reprod Med 1992;37:649–52.
Elbourne DR, Prendivilli WJ, Carroli G, Woodi J, Mc
Donald S. Prophylactic use of oxytocin in third stage of
labour. Cochrane Libr 2004;3:6.
Prendiville WJ, Elbourne D, McDonald s. Active vs. exrectant
management in the third stage of labour. The Cochrane library.
Issue 3. Oxford, England: Update software; 2003.
Prendiville WJ, Elbourne D, McDonald S: Active versus
expectant management in the third stage of labour. Cochrane
Database Syst Rev 2000;2:CD000007.
International Confederation of Midwives; International
Federation of Gynaecologists and Obstetrician. Joint
statement: management of the third stage of labour to prvent
post-partum haemorrhage. J Midwifery Womens Health
Lokugamage AU, Sullivan KR, Niculescu I. A randomized
study comparing rectally administered misoprostol versus
Syntometrine combined with an Oxytocin infusion for the
J Ayub Med Coll Abbottabad;19(4)
cessation of primary post partum hemorrhage. Acta Obstet
Gynaecol Scand 2001;80:835–9.
Prata N, Mbaruku G, Cammbell M, Potts M, Bahidnia M.
Controlling postpartum hemorrhage after home birth in
Tanzania. Int J Gynaecol Obstet 2005;90:51–5.
Rizwi F, Mackey R, Barrett T, Mekenna P, Geary M.
Successful reduction of massive Post partum hemorrhage by
use of guidelines and staff education. Br J Obstet Gynecol
Chalmers B, Wu Wen S. Perinatal care in Canada. BMC
Women’s health 2004;4(1):3.
Bakri YN, Amri A, Abdul Jabbar F. Tamponade balloon for
obstetrical bleeding. Int J Gynaecol Obster 2001;74:139–42.
Condous GS, ArulKumaram S, Symonds I, Chapman R,
Sinha A, Razwi k. The “Tamponade test” in the management
of massive post partum hemorrhage. Obstet Gynecol
Condous GS, Arulkumaran S, Symonds I, Chapman R, Sinha
A, Razvi K. The “tamponade test” in the management of
massive postpartum haemorrhage. Obstet Gynecol
Akhter S, Begum MR, Kabir J. Condom hydrostatic
tamponade for massive postpartum hemorrhage. Int J
Gynaecol Obster 2005;90:134–5.
Danso D, Reginald P. Combined B-lynch Suture with
intrauterine balloon catheter triumphs over massive post
partum hemorrhage. Br J obstet Gynecol 2002;109(8):963.
Hayma RG, Arulkumaran S, Steer PJ: Uterine compression
sutures: surgical management of postpartum hemorrhage.
Obstet Gynecol 2002;99:502–6.
Tamizian O, Arulkumaran S. The surgical management of
post-partum haemorrhage. Best Pract Res Clin Obstet
Scottish Programme for Clinical Effectiveness in
Reproductive Health (SPCERH). Scottish Confidential Audit
of Sever Maternal Morbidity, 2nd Annual Report, 2004.
Kwee A, Bots ML, Visser GH, Brunse HW. Emergency
peripartum Hysterectomy: a prospective study in the
Netherlands. Eur J Obstet Gynecol Reprod Biol
Journal of Ayub Medical College, Abbottabad is an OPEN ACCESS JOURNAL which means that all content is FREELY available without charge to all users whether registered with the journal or not. The work published by J Ayub Med Coll Abbottabad is licensed and distributed under the creative commons License CC BY ND Attribution-NoDerivs. Material printed in this journal is OPEN to access, and are FREE for use in academic and research work with proper citation. J Ayub Med Coll Abbottabad accepts only original material for publication with the understanding that except for abstracts, no part of the data has been published or will be submitted for publication elsewhere before appearing in J Ayub Med Coll Abbottabad. The Editorial Board of J Ayub Med Coll Abbottabad makes every effort to ensure the accuracy and authenticity of material printed in J Ayub Med Coll Abbottabad. However, conclusions and statements expressed are views of the authors and do not reflect the opinion/policy of J Ayub Med Coll Abbottabad or the Editorial Board.
USERS are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles, or use them for any other lawful purpose, without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open access.
AUTHORS retain the rights of free downloading/unlimited e-print of full text and sharing/disseminating the article without any restriction, by any means including twitter, scholarly collaboration networks such as ResearchGate, Academia.eu, and social media sites such as Twitter, LinkedIn, Google Scholar and any other professional or academic networking site.