Gouri Salunkhe^1*, Satyajeet Salunkhe²

^1,2Assistant Professor, Department Gynaecology and Obstetrics, Bharati Vidyapeeth University, Sangli, Maharashtra, INDIA.

Email: drgouri1980@gmail.com

RESULTS

During two year study period, 4892 deliveries were conducted at our hospital, 86 patients had postpartum hemorrhage (1.76 %), majority were from 21-24 years (37.21 %) followed by 25-29 years age group (31.4 %). Mean age of study group was 23.53 ± 3.92 years. As per parity status majority were primiparous (51.16 %) followed by parity status >2 (26.74 %). As per gestational age majority were from 38-40 weeks (31.4 %) followed by 36-38 weeks (26.74 %)

Table 1: General characteristics

In present study common risk factors were severe anaemia (Hb < 7 gm%) (36.05 %), previous LSCS (26.74 %), hypertensive disorders of pregnancy (22.09 %), premature rupture of membranes (17.44 %), hypothyroidism (17.44 %), abruptio placentae (17.44 %), Prolonged labor (15.12 %) and placenta previa (15.12 %).

Table 2: Risk factors associated with PPH

Interventions other than more than 2 uterotonics (100.00 %) and > 2 PCV blood transfusions (84.88%), were bilateral uterine artery ligation (45.35%), bilateral uterine artery ligation + bilateral internal iliac artery ligation (9.30%), obstetric hysterectomy (15.12%) and perineal tear repair (9.30%). Mortality was noted in six patients (atonic PPH – 3 cases, mixed PPH 2 cases, placenta accreta spectrum- 1 case).

Table 3: Management outcomes.

DISCUSSION

Atonicity of the uterus is the commonest cause of PPH: with the separation of the placenta, the uterine sinuses, which are torn, cannot be compressed effectively due to imperfect contraction and retraction of the uterine musculature and the bleeding continues.⁶ Apart from an increased risk of maternal mortality (12 to 17.2%) EPH may lead to further serious complications related to severe anemia, such as acute kidney injury (29.3%), hepatic failure, Sheehan Syndrome, adult respiratory distress syndrome (24.6%) and disseminated intravascular coagulopathy (DIC) (11.7%)⁷ Rajeshwari, et al.,⁸ studied 142 women with postpartum hemorrhage, majority of the women were primiparous, in the age group of 25 to 29 years, and, pre-existing anaemia was seen in 11%, PROM in 16%, hypothyroidism in 20% were found as risk factors and 19% of the woman underwent secondary LSCS. Similar findings were noted in present study. Chandrika SK⁹ noted that severe obstetrical hemorrhage (more than 1500 ml) was in 115 patients (prevalence of 0.9%). The prevalence of severe obstetric hemorrhage was 0.9 %. A large proportion of the patients (62%) were multipara. Mortality in this study was 21.73% and morbidity was 78.26%. Most common cause of obstetric hemorrhage in this study was uterine atonic PPH. In a study of 80 cases of PPH, Yogesh T et al.,¹⁰ noted that PPH was common between 25 – 28 years of age, mean gestational age of the 36.5 ± 3.4 weeks and of higher parity. Preeclampsia (35%) followed by Prolonged labour (26.3) were important risk factors for PPH. Nanani M.¹¹ studied 200 cases of PPH, most common risk factor for the post-partum hemorrhage was the atonicity of the uterus (84%) followed by PIH (37%), APH (22.5%), prolonged labour (14%) and retained placental products (8.5%) cases of PPH. Others were large baby induced PPH (7%), genital tract Injuries (6.5%), ruptured uterus (4.5%), multi parity (4.5%), infections (2.5%) and uterine inversion (1%). In a study Kebede BA et al.,¹² noted that among 422 study participants, overall prevalence of primary postpartum hemorrhage was 16.6%. Mothers aged 35 and above [AOR = 6.8, 95% CI (3.6, 16.0)], pre-partum anemia [AOR = 5.3, 95% CI (2.2, 12.8)], complications during labor [AOR = 1.8, 95% CI (2.8, 4.2)], history of previous postpartum hemorrhage [AOR = 2.7, 95% CI (1.1, 6.8)] and instrumental delivery [AOR = 5.3, 95% CI (2.2, 12.8)] were significant predictors of primary postpartum hemorrhage. PPH may be aggravated by pre-existing anaemia and, in such instances, the loss of a smaller volume of blood may still result in adverse clinical sequelae. Anaemia in pregnancy is common and linked to postpartum hemorrhage in terms of uterine atony. The more severe the anaemia, the more likely the greater blood loss and adverse outcome. It is possible to early identify mothers with anemia in their antenatal care follow-up, and take appropriate measures.¹² The speed with which death from PPH occurs presents a major challenge in settings with poor communications and referral systems and shortages of necessary drugs and equipment. Active management of the third stage of labour is highly effective at preventing postpartum hemorrhage among facility-based deliveries. It is more effective than physiological management in preventing blood loss, severe postpartum hemorrhage (>500 ml) and prolonged third stage of labour.¹³ Given that PPH can occur without warning, rural communities should consider ways to increase both primary prevention (iron supplementation, AMTSL) and secondary prevention of PPH (availability of obstetric first aid, availability of transport, and availability of emergency

obstetric care).¹⁴

CONCLUSION

In present study, significant risk factors for post-partum hemorrhage were 21-24 years age, primipara, severe anaemia (Hb < 7 gm%), previous LSCS, hypertensive disorders of pregnancy, premature rupture of membranes, hypothyroidism, abruptio placentae, prolonged labor and placenta previa. Anemia is a correctable entity, significantly associated with uterine atony and should be corrected antenatally on a priority basis.

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