European Journal of Cardiovascular Medicine

Postpartum haemorrhage is the most common type of obstetric haemorrhage and accounts for the majority of cases¹. Traditionally primary postpartum haemorrhage is defined as blood loss of 500 ml or more of blood from the genital tract within 24 hours of delivery. Postpartum haemorrhage can be minor (500-1000 ml) or major (more than 1000 ml) ². Major is further divided into moderate (1000-2000 ml) and severe (more than 2000 ml). Secondary PPH is defined as abnormal or excessive bleeding from the birth canal and between 24 hours and 12 weeks postnatally³. Uterine atony, genital tract trauma, retained placental tissue and coagulopathy are important causes of postpartum haemorrhage. Secondary PPH is caused by retained tissues, endometritis, placental site trophoblastic tumour, arterio-venous malformations⁴.

It is estimated that worldwide 1,40,000 women die of PPH annually, i.e. one in every four minutes². Postpartum haemorrhage affects about 4-6% of all deliveries. Overall postpartum haemorrhage accounts for an estimated 25% of maternal mortality worldwide. Globally incidence of severe postpartum haemorrhage is around 10.5% of live births⁵. Postpartum haemorrhage is a significant contributor to maternal morbidity and long term complications. About 1.2% of women with postpartum haemorrhage had severe maternal outcome with organ dysfunction⁶. More than half of all deaths occur within 24 hours of delivery most commonly from excessive bleeding. One of the Millennium Development Goals set by the United Nations in 2000 is to reduce maternal morbidity by three quarters. Therefore identification of risk factors, prevention and treatment of postpartum haemorrhage are vital steps towards         improving            health    care of    women   during         childbirth              and         the achievement of Millennium Development Goals⁷.

The effects of haemorrhage depend to large extent on maternal non- pregnant blood volume and consequent pregnancy induced hypervolemia. Hence the traditionally used values of blood volume to define PPH may not be clinically useful⁸. The WHO near- miss approach for maternal health proposed operational definition of severe postpartum haemorrhage as genital bleeding after delivery with at least one of the following: perceived abnormal bleeding (1000 ml or more) or any bleeding with hypotension or blood transfusion⁹. Severe PPH and major PPH are often used synonymously. Estimation of blood loss after delivery is notoriously inaccurate. Standard care for prevention of PPH is administering oxytocin immediately after delivery¹⁰. In countries like India, a majority of risk factors like anemia, pre eclampsia etc. predispose women to PPH. Identification of the risk factors predisposing to PPH can help reduce the burden of morbidity and mortality caused by PPH¹¹.

The present study will study the relation between determinants or risk factors of major PPH and maternal outcome recorded in terms of duration of hospital stay, number of blood and blood product transfusions, admission to ICU and death as adverse outcome. Outcome of delivery will be recorded in terms of live births or still births, birth weight and admission to neonatal intensive care unit. Association between determinants of major PPH and maternal outcome and neonatal outcome is expected to be established by the present study.

Aim: To study the role of risk factors in determining maternal and fetal outcome in major postpartum haemorrhage.

study was carried out in women who had major PPH after delivery admitted in labour ward of Department of Obstetrics & Gynaecology, Tertiary Care Teaching Hospital over a period of 1 year.

Cases were selected by census method and controls selected were women who had delivered immediately after the case on the same day.

Inclusion criteria:

• Cases included in the study are women delivered in Hospital with major postpartum
• Women delivered outside and referred to hospital with postpartum haemorrhage.
• Controls are women who have delivered in Hospital without postpartum haemorrhage.

Exclusion criteria:

• Pregnancies with gestational age less than 20

Study methods:

Major postpartum haemorrhage in the present study is defined as blood loss of more than 1000 ml as estimated in postpartum woman with bleeding with either two of the following: systolic blood pressure 90 mm of Hg or pulse rate more than 100 per minute or any postpartum bleeding that requires blood transfusion irrespective of the blood loss.

Controls were selected from women who had to a singleton foetus and who had no postpartum haemorrhage and did not fulfil the criteria set for cases. For every case of major PPH included in the study a control was  selected who has delivered on the same day after the case was delivered.

A detailed case history was taken in the proforma which includes details of the woman from conception till delivery. As per the literature available risk factors were elicited from patient’s history and case records for analysis in outcome of postpartum haemorrhage.

The factors determining outcome are maternal age more than 35 years, parity, maternal anemia (Hb< 9 g/dl), obesity (BMI > 35), abruptio placenta, placenta previa, multiple pregnancy, coagulation disorders, pre- eclampsia/ gestational hypertension, chronic hypertension, previous postpartum haemorrhage, induction of labour, augmentation of labour, prolonged labour, delivery by caesarean section-emergency and elective, operative vaginal delivery by forceps and vacuum, pyrexia in antenatal period and labor, retained placenta, adherent placenta, perineal tear (third or fourth degree) or any trauma to the genital tract.

Treatment administered to cases of major postpartum haemorrhage will be as per the hospital protocol. Rapid assessment of vitals is done and monitoring of vitals is done at periodic intervals. A team work in resuscitation is done by obstetricians, anaesthetists, staff nurses and blood bank staff. Protocol of assessing airway, breathing and circulation is followed. Oxygen is administered via mask at 10 L/min to keep saturation more than 95%. If the patient is not breathing, patient is intubated with the help of anaesthetist. Indwelling urinary catheter is placed to monitor urine output. Uterine massage is done to decrease bleeding. While massaging is continued causes of bleeding are explored for atony, trauma, retained placental tissue and bleeding disorder. Initial resuscitation is done with crystalloid solutions- 0.9% NS and ringer lactate as rapid fluid bolus of 2 litres. As vigorous massage is continued, 20 units oxytocin in 500 ml of RL is administered intravenously. Methyl ergometrine 0.2 mg is given i.m. and repeated after 2-4 hrs and no contraindication if there is no response. Carboprost (15 methyl prostaglandin F₂ alpha) 0.25 mg is administered i.m. when there is no response to methyl ergometrine. A second dose was repeated after 15 min. Maximum of 8 doses of carboprost can be given. Misoprostol 1000 mcg per rectum remain the third line of management agent. Patient is reassessed at 10 minutes. If systolic BP is less than 90 mm Hg and pulse rate more than 110 per minute, blood transfusion with compatible cross matched blood is started. Uterine cavity and genital tract is explored. Trauma to the genital tract is repaired. Refractory cases are managed by surgical management. Hemostatic B lynch sutures are applied. Uterine rupture is repaired. Uterine artery or internal iliac artery ligation was done and hysterectomy was done in cases refractory to all measures. With abnormal coagulation profiles, blood products like FFP and platelets are transfused.

Routinely done investigations and investigations specific to the risk factor along with ultrasonography reports of antenatal period were recorded in the proforma. Maternal outcome is recorded in terms of duration of hospital stay, number of blood and blood product transfusions, admission to ICU and death as adverse outcome. Outcome of delivery is recorded in terms of live birth or still birth, birth weight and admission to NICU.

Statistical Analysis:

Data was entered in MS EXCEL 2013 Microsoft Corporation Publication. Results were analysed using SPSS version 20 and MED CALC 12.5.0. softwares. Data of cases and controls were compiled into cross tabulations to study the percentages of variables i.e. the risk factors leading to major PPH. Percentages were corrected to decimels for convenience. Association between risk factors and occurrence of major PPH and association of maternal and perinatal outcome with major PPH were studied by calculating odd’s ratio and p value for testing the significance.

In the present study 102 cases of postpartum haemorrhage were identified and were compared with 102 controls.

Table 1: Frequency distribution of age in cases and controls

The present study included cases delivered in the institution as well as cases delivered outside the institute.

Table 2: Age wise distribution of causes of major PPH

Table 3: Frequency distribution of causes of PPH

Cause of major PPH was atonic in a major number of cases followed by traumatic PPH.

Table 4: Mode of delivery in atonic and traumatic PPH

Table 5: Distribution of parity in cases and controls

Primiparous women formed majority in cases in the present study whereas in controls multiparous women were more.

Table 6: Maternal outcome of major postpartum haemorrhage

Blood transfusions were done in 99 cases and bood products like fresh frozen plasma was transfused in 19 cases. Platelets were transfused in 14 cases. A total of 19 cases had blood product transfusions. None of the controls had any adverse outcome.

Table 7: Maternal complications of major PPH

The present study included both cases which delivered in the institute as well as referral cases of PPH. Among the 102 cases (via Table 5), 87.3%(n=89) of cases delivered in the institute and 12.7%(n=13) cases were referred to the institute for management of PPH.

Atonic PPH accounted for 74.5%(n=77) of all cases. Traumatic PPH 9.8%(n=10), abnormal coagulation 3.9%(n=4), combined atonic and traumatic PPH 8.8%(n=9) and combined traumatic PPH with abnormal coagulation 2%(n=2).

Results can be compared to the study by Anju Padmasekar, Shyamala Jothy where the commonest cause was atonic PPH (64.7%)¹². Results are consistent with study by Solwayo Ngwenya with 82.4% being atonic PPH, study by Lill Trine Nyflot, Babill Stary Pedersen, Lisa Forsen, Siri Vangen with Maximum women in both cases and controls were between 21 to 25 years. 47.1%(n=48) of cases of major PPH and 53%(n=54) of the controls were in the age group 21-25 years. 27.5%(n=28) of cases of major PPH were less than 20 years compared to 15.7%(n=16) of controls. 0.9%(n=1) cases were more than 35 years compared to 1.9%(n=2) of controls. There is no statistical significant difference between cases and controls. Mean age is 22.9(SD±4.4) years in cases and 23.9(SD±3.6) years in controls. Mean age in study by Chandrika S. Kodla is 25.5±4.14 years, Solwayo Ngwenya 27.7 years and 28.3 years in study by Padmasekar A. et al. ¹⁴

Primigravidas constituted 42.2%(n=43) of cases and 14.7%(n=15) of controls(via table 8). Multigravidas constituted 57.8%(n=59) cases and 85.3%(n=87) controls. Parity is similar to study by Al-Zirqi et al with 43.94% primiparous women and study by Kaul V et al with 47.1% primiparas^15,16. Contrasting difference was seen in study by Padmasekar A. et al with 24.3% primiparas and study by Chandrika S Kodla with 33.91% primiparas among cases of PPH^17,18.

Paradoxically odds of major PPH were less in multigravidas in the present study and this was statistically significant. This can be explained due to the fact that it may be due to the characteristics of primiparous women predisposing to PPH. Similar results were seen in study by Lill Trine Nyflot with major PPH occurring in 60.4% of primiparous women¹⁹.

93.1% (n=95) of cases and 100% (n=102) controls had regular antenatal checkups during pregnancy. The odds of having major PPH with regular antenatal checkups was less but it was not statistically significant in the present study. However the clinical importance of regular antenatal checkups in preventing antenatal and postnatal complications especially postpartum hemorrhage cannot be ruled out.

Iron and folic acid are supplemented to all pregnant women irrespective of their anaemia status. 91.2% (n=93) of cases and 88.2%(n=90) of controls had received IFA prophylaxis. Paradoxical relation was observed with major PPH occurring in cases who had more intake of IFA compared to controls but it was not statistically significant. This paradox can be due to the risk of major PPH being dependent more on the anemic status of the woman rather than IFA intake.

The present study suggests that majority cases of major PPH can be predicted based on the risk factors which are recognised antenatally especially anemia and hypertensive disorders of pregnancy. Regular antenatal check ups, recognition and correction of risk factors can prevent major PPH and debilitating complications of major postpartum haemorrhage. Implementation of national programmes like Weekly IFA prophylaxis programme in India can help reduce the burden of postpartum haemorrhage indirectly by reducing the prevalence of anemia.This will aid in significant reduction in maternal morbidity and mortality.

1. Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52. BJOG An Int J Obstet Gynaecol. 2017;124(5):e106–
2. AbouZahr C. Global burden of maternal death and disability. Br Med Bull. 2003;67(December):1–11.
3. Gulmezoglu AM, Souza JP, Mathai M. WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage. World Health Organization. 2012. 1-48 p.
4. World Health Organization. The WHO near-miss approach for maternal health. 2011;29.
5. Bose P, Regan F, Brown S. A Pictorial Reference Guide to Aid Visual Estimation of Blood Loss at Obstetric Haemorrhage : Accurate Visual Assessment is Associated with Fewer Blood Transfusions. :2000.
6. Bhide A, Daftary S, Arulkumaran S, Damania KR. Practical Guide to High-Risk Pregnnacy & Delivery: A South Asian Perspective 2015, 4 th ed.Reed Elsevier India. p 392.
7. Zhang W-H, Deneux-Tharaux C, Brocklehurst P, Juszczak E, Joslin M, Alexander S. Effect of a collector bag for measurement of postpartum blood loss after vaginal delivery: cluster randomised trial in 13 European countries. Bmj. 2010;340(feb01 1):c293–c293.
8. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS. 24 th ed.William's Obstetrics. Mc Graw Hill 2014. p
9. Tort J, Rozenberg P, Traoré M, Fournier P, Dumont A. Factors associated with postpartum hemorrhage maternal death in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey. BMC Pregnancy Childbirth. BMC Pregnancy and Childbirth; 2015;15:235.
10. Wandabwa J, Doyle P, Todd J, Ononge S, Kiondo P. Risk Factors for Severe Post Partum Haemorrhage in Mulago Hospital , Kampala , Uganda. 2008;85(2):64–71.
11. Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B. Prevalence and risk factors of severe obstetric haemorrhage. BJOG An Int J Obstet Gynaecol. 2008;115(10):1265–72.
12. Belghiti J, Kayem G, Dupont C, Rudigoz R-C, Bouvier-Colle M-H, Deneux-Tharaux C. Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case- control study. BMJ Open. 2011;1(2):e000514–e000514.
13. Zhang J, Bricker L, Wray S, Quenby S. Poor uterine contractility in obese women. BJOG An Int J Obstet Gynaecol. 2007;114(3):343–8.
14. Sebire NJ, Jolly M, Harris J, Regan L, Robinson S. Is maternal underweight really a risk factor for adverse pregnancy outcome? A population-based study in London. Br J Obstet Gynaecol. 2001;108(1):61–6.
15. Denison FC, Price J, Graham C, Wild S, Liston Maternal obesity,
16. length of gestation, risk of postdates pregnancy and spontaneous onset of labour at term. BJOG An Int J Obstet Gynaecol. 2008;115(6):720–5.
17. Cawley J, Burkhauser R V. Beyond BMI: The Value Of More Accurate Measures in Social Sciences Research. Natl Bur Econ Res Work Pap . 2006;1–50.
18. Rayamajhi R, Thapa M, Pande S. The challenge of grand multi-parity in obstetric practice. Kathmandu Univ Med J (KUMJ) 2006 Jan- Mar;4(1):70–74.
19. Sosa CG, Althabe F, Belizán JM, Buekens P. Risk factors for postpartum hemorrhage in vaginal deliveries in a Latin-American population. Obstet Gynecol . 2009;113(6):1313–9.
20. Kashani E, Azarhoush R. Peripartum hysterectomy for primary postpartum hemorrhage : 10 years evaluation. 2012;2(1):32–6.
21. Allen VM, O’Connell CM, Baskett TF. Maternal and perinatal morbidity of caesarean delivery at full cervical dilatation compared with caesarean delivery in the first stage of labour. BJOG An Int J Obstet Gynaecol. 2005;112(7):986–90.