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Postpartum hemorrhage is related to the hemoglobin levels at labor: Observational study

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Background: Anemia in pregnancy is common and linked to postpartum hemorrhage in terms of uterine atony. The more severe the anemia, the more likely the greater blood loss and adverse outcome. The aim of this study was to examine the association between anemic women at labor and postpartum hemorrhage (PPH) during emergency cesarean delivery and to assess the hemoglobin (Hb) values at which the emergency hysterectomy is needed. Methods and patients: A cross-sectional study was carried out between (Aug. 1st 2012 and Jul. 30th 2013) at Al Thawra General hospital. Fifty-three cases were included in the study. Results: Postpartum hemorrhage was developed in 53 women (29.1%). Out of 53 women, 21 cases (39.6%) had severe uterine atony and required emergency hysterectomy and the remaining 32 cases (60.37%) responded to the conservative measures (p 0.03). Most of the hysterectomized women 80.75% (17/21) had Hb levels ⩽ 7 versus 12.5% of the nonhysterectomized patients [OR 29.75; 95% CI 6.564–134.53; p < 0.01]. There was a strong correlation between low Hb levels and blood loss [r = −.619; p < 0.00]. Conclusion: Our study supports the association between anemia (Hb < 10) and the risk of PPH. We also provide evidence of the association between severe anemia and emergency hysterectomy.
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Postpartum hemorrhage is related to the
hemoglobin levels at labor: Observational study
Kaima A. Frass
*
Associate Professor Obstetrics and Gynecology, Sana’a University, Yemen
Received 16 August 2014; accepted 11 December 2014
KEYWORDS
Uterine atony;
Postpartum hemorrhage;
Anemia in pregnancy
Abstract Background: Anemia in pregnancy is common and linked to postpartum hemorrhage in
terms of uterine atony. The more severe the anemia, the more likely the greater blood loss and
adverse outcome. The aim of this study was to examine the association between anemic women
at labor and postpartum hemorrhage (PPH) during emergency cesarean delivery and to assess
the hemoglobin (Hb) values at which the emergency hysterectomy is needed. Methods and patients:
A cross-sectional study was carried out between (Aug. 1st 2012 and Jul. 30th 2013) at Al Thawra
General hospital. Fifty-three cases were included in the study. Results: Postpartum hemorrhage was
developed in 53 women (29.1%). Out of 53 women, 21 cases (39.6%) had severe uterine atony and
required emergency hysterectomy and the remaining 32 cases (60.37%) responded to the conserva-
tive measures (p0.03). Most of the hysterectomized women 80.75% (17/21) had Hb levels 67 ver-
sus 12.5% of the nonhysterectomized patients [OR 29.75; 95% CI 6.564–134.53; p< 0.01]. There
was a strong correlation between low Hb levels and blood loss [r=.619; p< 0.00]. Conclusion:
Our study supports the association between anemia (Hb < 10) and the risk of PPH. We also pro-
vide evidence of the association between severe anemia and emergency hysterectomy.
ª2014 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
1. Introduction
Anemia in pregnancy is defined as hemoglobin level below
11 g/dl (WHO).
1
It is one of the public health problems mostly
in developing countries.
2
World Health Organization (WHO)
reported that the prevalence of anemia during pregnancy in
developing countries exceeds 50%.
1
In pregnancy, anemia is
mainly nutritional due to dietary deficiency of iron and folates
3
but impaired absorption, chronic blood loss, increased require-
ment, concurrent medical disorders and malaria are other con-
tributing factors for anemia.
4
It has long been considered that
anemia increases the risk of postpartum hemorrhage (PPH)
5
and the two conditions together contribute to 40–43% of
maternal deaths in Africa and Asia.
6
Few studies exist that have linked the risk of PPH by level
of anemia and indicate a weak association.
7
Recently small
studies demonstrated causal – relationship between severe ane-
mia and uterine atony which is the main cause of PPH
accounting for about 90% in most studies.
8
Similar to other less developing countries, anemia is preva-
lent in our area particularly in remote setting where the acces-
sibility to antenatal care services is difficult. It is not
uncommon to see women at time of labor with uncorrected
*Address: PO Box: 25244, Yemen. Mobile: +967 733234474.
E-mail address: kaimafrass@hotmail.com.
Peer review under responsibility of Alexandria University Faculty of
Medicine.
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HOSTED BY
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http://dx.doi.org/10.1016/j.ajme.2014.12.002
2090-5068 ª2014 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
Please cite this article in press as: Frass KA Postpartum hemorrhage is related to the hemoglobin levels at labor: Observational study, Alex J Med (2015), http://
dx.doi.org/10.1016/j.ajme.2014.12.002
moderate to severe anemia. They are often unbooked and
seeking hospital only when severe obstetric complications have
already developed. The aim of this study was to find out the
rate of PPH among women with low hemoglobin concentra-
tion (Hb < 10) during emergency cesarean delivery and to
assess the Hb level at which cesarean hysterectomy is needed.
2. Patients and methods
This study was a cross-sectional observational trial conducted
over a year (from August 1st 2012 to July 30th 2013) in Al
Thawra General Hospital. The study included all singleton
pregnant women, 38 weeks gestational age or more (based
on early first trimester ultrasonography and/or LMP), who
delivered by cesarean section and having moderate to severe
anemia (Hb < 10 g/dl) at admission. Anemia is defined
according to WHO criteria: mild (Hb 10–10.9 g/dl), moderate
(Hb 7–9.9) and severe (Hb < 7).
We excluded from the study any women with risk factors
for uterine atony [i.e. over distended uterus, parity P5, his-
tory of previous PPH, bleeding tendency, etc.]. Fifty-three
women met our criteria were included in this study. An
informed consent was taken from each participant and the eth-
ical approval was obtained from the hospital ethics committee.
The study was conducted in accordance with the Helsinki dec-
laration. Maternal characteristics such as age, parity, gesta-
tional age, booking status, previous scar and pregnancy
complications were noted. Clinical evaluation and routine
investigation including initial hemoglobin levels, urine analysis
and other tests were performed as indicated.
The hospital protocol for prevention of PPH was followed
which relies on the administration of 600 lg misoprostol (3
tablets) rectally at the time of scrubbing, in addition to oxyto-
cin infusion (20 units in 500 ml normal saline solution infused
over 30 min). Circumstances in which additional uterotonic
agents are required, injection of methyl ergometrine (if no con-
traindication), increasing the oxytocin infusion doses, local
injection of either or both drugs are used as appropriate.
Cesarean section was performed as standard by the senior-in
charge and one resident doctor, under spinal anesthesia with
Pfannenstiel skin and lower uterine segment transverse inci-
sions. The intraoperative blood loss was estimated by using
the calibrated Steri-Drape TM Loban TM 2 (3M Health Care,
St. Paul, Minnesota, USA) for all cases. Collected blood
within the drape was added to the content of suction bottle
and counted. The surgical swabs were weighed and the differ-
ences in weight between soaked and dry [1 g = 1 m] were
added. All patients received prophylactic antibiotics and blood
transfusion. Hysterectomy was performed by senior in charge
and on-call consultant after discussion when conservative mea-
sures failed to restore uterine tonus namely bimanual uterine
massage, use of additional uterotonic agents, compression
sutures and uterine artery ligation.
The outcome measures were the rate of PPH in these ane-
mic patients, the level of Hb among those women who needed
hysterectomy, estimation of blood loss, amount of blood trans-
fused the interval from delivery till completing the hysterec-
tomy and the type of hysterectomy.
2.1. Statistical analysis
Analysis of the data was carried out using SPSS version 21.
Values given are mean ± SD or percentages as appropriate.
Independent sample t-test was used to evaluate the association
between continuous variables and Chi-square test for categor-
ical variables.
Anemia
Hb<11
N=182
PPH
N=53
No PPH
N=129
Severe anemia
N=22
ConservaƟve
N=4
Moderate anemia
N=31
ConservaƟve
N=28
Hysterectomy
N=17
Hysterectomy
N=4
Figure 1 Flow chart.
2 K.A. Frass
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Odds ratio and 95% confidence interval (CI) were calcu-
lated. A pvalue of 60.05 was considered statistically
significant.
3. Results
A total of 11,680 deliveries were recorded. One hundred
eighty-two women had Hb 611 g/dl at the time of admission.
Of these, 53 women (29.1%) were developed PPH due to uter-
ine atony during cesarean section (Fig. 1). Maternal obstetrics
and demographic data are shown in Table 1. Of the 53 women
who developed uterine atony, 32 cases (60.37) were successfully
managed by conservative measures: additional uterotonic
drugs 49% (26/53), 4 cases (7.5%) by B-Lynch compressive
sutures with success rate of 50%, 4 cases (7.5%) by uterine
artery ligation with success rate of 75%, and internal iliac
artery ligation in only one case (1.8%). Severe bleeding that
required emergency hysterectomy was developed in 39.6%
(21/53) of cases. The difference was statistically significant
(p< 0.03) (Table 2). We further analyzed hysterectomized
and nonhysterectomized patients as regards Hb, blood loss,
and parity. We found that the majority of hysterectomized
women 80.95% (17/21) had Hb 67 and 87.5% (28/32) of non-
hysterectomized patients had Hb > 7. The difference was sig-
nificant {OR 29.75; 95% CI 6.564–134.53; p.00}.
The mean blood loss among hysterectomized patients was
1688 ± 238.7 ml versus 1517.18 ± 353.23 ml in the nonhyster-
ectomized patients. The difference was significant (P= 0.05).
The amount of bleeding (>1500 ml) was significantly higher
in the hysterectomized than that in the nonhysterectomized
women [OR 6.5; 95% CI 1.28–32.8; P= 0.01] (Table 3).
Nineteen women (91.47%) had cesarean hysterectomy
while the remaining 2 cases (9.5%), the hysterectomy was per-
formed after abdominal closure due to persistent vaginal
bleeding.
Subtotal hysterectomy was the commonest type of opera-
tion performed (80.95%). Disseminated intravascular coagu-
lopathy (DIC) was developed in 7 cases (33.3%) of
hysterectomized group versus one case (3.1%) of conservative
group. Eight cases of the two groups were admitted to inten-
sive care unit (ICU). There was no maternal mortality
recorded in our study.
4. Discussion
The present study shows that 29.1% of anemic women were
developed PPH during cesarean delivery due to uterine atony.
Prior studies have demonstrated that severe anemia may impair
myometrial contractility resulting from impaired transport of
hemoglobin and oxygen to uterus causing tissue enzymes and
cellular dysfunction.
9,10
In this study severe uterine atony
required emergency hysterectomy was occurred in 39.6%
(32/53) of women who had severe anemia (Hb 67 g/dl).
This finding indicates that for the patients with Hb of 7 or
less the odds (or likelihood) of having PPH due to uterine
atony increases greatly compared to patients with Hb 7.1–10
(p= .00). Although nulliparous women were associated with
11.6% increased risk for developing PPH in our patients, this
tendency was not significantly different from women with par-
ity > 1 (p= 0.86). This result is consistent with other study.
11
The results of the present study showed lower mean blood
loss 1584.9 ± 321.8) than 4700 ± 1949 that reported by Zam-
zami Yamani who analyzed 17 cases of peripartum hysterec-
tomy at king Abdulaziz University Hospital. Only 9 cases
had uterine atony while the remaining 8 cases were presented
with placenta previa and morbid adherent placenta with pre-
via.
12
The differences in the population contributing factors
could partly explain such expected variation. Additionally all
women in our study received rectal misoprostol and oxytocin
intraoperatively. The combination of these agents may be
responsible for reduction of hemorrhage and thus better out-
come. This suggests the importance of the active management
of the third stage of labor in reducing blood loss. Elbourrne
et al.
13
reported significant reduction of the amount of blood
loss when prophylactic administration of uterotonic agents
during the third stage of labor. Similarly Badejoko et al.
14
reported dramatic effect of rectal misoprostol (600 lg) in pre-
vention of PPH comparable with oxytocin infusion.
The correlation between Hb values and blood loss was
inversely significant (Pearson R = .619 at P< 0.00) indicat-
ing the more severe the anemia, the more likely of greater
blood loss.
This result highlights the need to increase the population
awareness to utilize the available maternity care services along
with the promotion of iron and folates supplementation for all
pregnant women. The screening and therefore treatment of
anemia must be essential part of antenatal care components
particularly in setting where malaria and other infectious dis-
eases are prevalent. Of note, the specific cause of anemia was
not considered in this study.
We found that cesarean – hysterectomy was done in
(39.6%) of cases with uterine atony, similar to other studies.
15,16
Table 1 Maternal characteristics.
Variable
Age, year 27.96 ± 4
Parity
P
1
12 (22.6)
>1 41 (77.4)
Mean ± SD 2.64 ± 1.16
Gestational age (week) 38.7 ± 0.76
Location
Rural 35 (66)
Urban 18 (34)
Education
None 15 (28.3)
Primary school 26 (49)
Secondary school 12 (22.6)
Booking status
Yes 23 (43.4)
No 30 (56.6)
Indication for C/S
Obstructed labor 15 (28.3)
Fetal distress 12 (22.6)
Prior scar 4 (7.5)
Malpresentation 8 (15)
CPD 7 (13.2)
Preeclampsia–eclampsia 7 (13.2)
The data present as mean ± SD or n(%).
C/S: cesarean section; CPD: cephalopelvic disproportion.
Postpartum hemorrhage 3
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Recently, the reported success rate for uterine compression
sutures is 92% and for uterine artery ligation up to 85%.
17
It is noticed in this study that additional measures such as bal-
loon tamponade and systemic pelvic devascularization were
underutilized in our hospital. This could possibly be related
to the probability that in these anemic women in particular
other surgical conservative techniques may further increase
blood loss with possible risk of failure or might be due to lack
of experience. The mean time from delivery to completing hys-
terectomy in this study was (155.71 ± 52.4 min). This finding
is in contrast to the Forna et al.
18
who analyzed 38 cases of
cesarean-hysterectomy from 1990 to 2002 and found the mean
time as (303.1 ± 219.9) min.
The variation may likely be explained by the type of hys-
terectomy. In the current study total abdominal hysterectomy
was performed in only 4 cases (7.5%) compared to (50.9%)
in their study. Although there is no consensus as the appro-
priate timing for resorting to hysterectomy in atonic uterus,
17
the patient’s general condition, the severity of blood loss,
and the effectiveness of the conservative measures should
direct the decision-making process. However, because anemic
women have poor tolerance to even mild bleeding,
19
rapid
deterioration in the hemodynamic stability should be
considered.
According to our results, we proposed that severe anemia
(Hb 67 g/dl) combined with ongoing bleeding despite other
Table 2 Outcome results of the two groups.
Variable Hyesterectomized (n= 21) Conservative (n= 32) aOR 95% CI Pvalue
Surgical measures
B-lynch 2 (9.52) 2 (6.25) 3.00 .46
Uterine artery ligation 1 (4.8) 3 (9.37) (.150–59.89)
Internal iliac art. ligation 1 (3.1)
Types of hysterectomy
Subtotal 17 (80.95)
Total 4 (19)
No. of units blood transfused 5.84 ± 2.4 4.05 ± 2.4 0.01
Time from delivery till
Completing hysterectomy (min) 155.71 ± 52.4
Time from atony to recovery (min) 62.43 ± 13.44
Birth weight (g) 2938 ± 369.4 2981.2 ± 13.44 .96
DIC 7 (33.3) 1 (3.1)
Admission to ICU 6 (28.6) 2 (6.25)
Fever 5 (23.8) 2 (6.25)
Length of hospital stay (day) 7.90 ± 1.673 7.03 ± 1.4 .00
*
aOR: adjusted odd ratio.
The data present as means ± SD, n(%).
DIC: disseminated intravascular coagulation.
*
Significant.
Table 3 Comparison between hysterectomized and nonhysterectomized patients.
Variable Hysterectomized (n21) Nonhysterectomized (n= 32) OR (95% CI) Pvalue
Hb level (g/dl) 29.75 0.00
*
6–7 17 (80.95) 4 (12.5) (6.564–134.83)
7.1–8 2(9.5) 6 (18.75)
8.1–9 2 (9.5) 16 (50)
9.1–10 6 (18.75)
Mean ± SD 6.819 ± .672 8.46 ± 0.94 0.00
*
Estimated blood loss (ml)
>1000–1500 2 (9.52) 13 (40.6) 6.5 0.01
>1500 19 (90.47) 19 (59.4) (1.288–32.86)
Mean ± SD 1688 ± 238.7 1517.18 ± 353.2 0.05
Parity
1 5 (23.8) 7 (21.9) 1.116
>1 16 (76.2) 25 (78.1) (3.02–4.128) 0.00
Mean + SD 2.61 ± 1.2 2.656 ± 1.15 0.88
OR: odds ratio.
The data present as means + SD, n(%).
CI: confidence interval.
*
Significant.
4 K.A. Frass
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conservative measures is predictors of persistent myometrial
contractility failure, and warrant early hysterectomy.
Few studies have addressed the causal-relationship between
severe anemia and PPH, but there is no data as what is the
exact value of Hb at which the potential uterine atony could
be imminent. Such investigation will provide the obstetricians
a new sophisticated tool to recognize pregnant women at risk
and therefore providing them with the standards of care. Our
work can be of particular relevance that may enhance
researchers to address the issue.
The present study has certain limitations. We used the
available sample size that could be small and may not be rep-
resentative for whole population. Also the study considered
only women who underwent cesarean section while vaginal
delivery was not included because this subgroup of anemic
women are poor, mostly from remote settings, unbooked,
often deliver at home and seeking hospital only when severe
complications have already developed. We also did not con-
sider the prevalence of anemia because this study was designed
to assess women with Hb < 10 g/dl. Mild anemia is common
and tends to have less significant impact on labor and delivery
complications.
5. Conclusion
The finding of this study support the link between low hemo-
globin levels at delivery and the potential risk of PPH which
remains currently debated. Also we provide evidence of the
association between severe anemia and severe uterine atony
requiring emergency hysterectomy.
Further studies with larger sample size to confirm these
findings are required. In this subgroup of anemic women
who develop severe PPH due to uterine atony, early decision
of hysterectomy to save their lives is potential and should be
considered when other measures are ineffective.
6. Disclosure
The author declared that there is no conflict of interest.
Acknowledgments
We thank Dr. BoranAltincicek in Bonn University, Germany
for his assistant in statistical analysis and for all colleagues
for their kindly helping in the data collection and support.
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Postpartum hemorrhage 5
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... Maternal IDA impacts pregnancy outcomes; the best documented are the association with preterm birth, low birthweight and small-for-gestational age infants, and neurocognitive and other developmental impairments in the offspring in later childhood [6][7][8][9][10][11]. An association with postpartum haemorrhage (PPH) has also been reported [12][13][14][15][16][17][18][19], but this was not mentioned in other studies and reviews on PPH [20][21][22][23]. Yet PPH, defined as blood loss of 500 mL or more within 24 h after vaginal delivery, or 1000 mL or more during and following caesarean delivery [22], is a leading cause of maternal mortality and morbidity globally [21,22], and it has exhibited a consistently increasing trend in the past decades even in developed countries such as the USA [21,24] and in countries with advanced public health care systems such as Canada [25,26] and Ireland [27]. ...
... This, together with the relatively large sample size, would ensure consistency and robust results. Our study was limited by the lack of data on the actual Hb levels, the gestation at diagnosis of anaemia and the amount of assessed blood loss, so that we could not relate the estimated blood loss to the level of Hb as reported before [16], or analyse further the influence of the gestation at diagnosis of IDA with the incidence of PPH. In addition, we did not examine the role of chorioamnionitis and prolonged labour which are reported risk factors for PPH. ...
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The purpose of this retrospective cohort study is to determine if iron deficiency anaemia (IDA) is associated with increased atonic postpartum haemorrhage (PPH) following labour. Women with singleton pregnancy carried to 24 or more weeks gestation, who were delivered under our care from 1997 to 2019, constituted the study population. A diagnosis of IDA was based on the finding of haemoglobin <10 g/dL and serum ferritin <15 μg/L in the absence of haemoglobinopathies. Women with elective caesarean section were excluded. Maternal characteristics, use of oxytocin, labour outcome and occurrence of PPH were compared between women with and without a diagnosis of IDA. The 1032 women (0.86%) with IDA exhibited slightly but significantly different maternal characteristics and had significantly higher incidence of total (4.5% versus 3.2%, p = 0.024) and atonic PPH (3.1% versus 2.0%, p = 0.011) despite similar incidences of labour induction, augmentation, and instrumental and intrapartum caesarean delivery. Multivariate analysis with adjustment for the effects of age, body mass index, height, parity, abortion history, labour induction and augmentation, instrumental delivery and infant macrosomia demonstrated that IDA was independently associated with total PPH (adjusted relative risk, aRR: 1.455, 95% confidence ratio, CI: 1.040–2.034) and atonic PPH (aRR: 1.588, 95% CI: 1.067–2.364). Our results indicate that despite the low prevalence in our population, IDA was independently associated with atonic PPH, probably consequent to placental adaptive changes in the presence of IDA. The correction and prevention of IDA could be the most important measure in countering the rising global prevalence of atonic PPH.
... This systematic review and meta-analysis revealed that the pooled magnitude of postpartum hemorrhage in Ethiopia was 8.24%. This report was in line with studies conducted in Uganda 9% [56] and Japan 8.7% [57], but much lower than report studies in Pakistan 21.3% [58], Cameroon 23.6% [59], and Yemen 29.1% [60]. The discrepancy could be due to the difference in maternal health services utilization (prenatal, natal, and postnatal care) between the countries. ...
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Background: Postpartum hemorrhage or postpartum bleeding (PPH) is often defined as loss of > 500 ml of blood after vaginal delivery or > 1000 ml after cesarean delivery within 24 h. Postpartum hemorrhage is a leading direct cause of maternal morbidity and mortality in Ethiopia. Therefore, the main objective of this systematic review and meta-analysis was to estimate the pooled magnitude of postpartum hemorrhage and the pooled effect size of the associated factors in Ethiopia. Methods: Primary studies were searched from PubMed/MEDLINE online, Science Direct, Hinari, Cochrane Library, CINAHL, African Journals Online, Google and Google Scholars databases. The searching of the primary studies included for this systematic review and meta-analysis was limited by papers published from 2010 to October 10/2021. The data extraction format was prepared in Microsoft Excel and extracted data was exported to Stata Version 16.0 statistical software for analysis. A random effect meta-analysis model was used. Statistical heterogeneity was evaluated by the I2 test and Egger's weighted regression test was used to assess publication bias. Result: A total of 21 studies were included in this meta-analysis. The pooled magnitude of postpartum hemorrhage in Ethiopia was 8.24% [(95% CI 7.07, 9.40]. Older age [OR = 5.038 (95% CI 2.774, 9.151)], prolonged labor [OR = 4.054 (95% CI 1.484, 11.074)], absence of anti-natal care visits (ANC) [OR = 13.84 (95% CI 5.57, 34.346)], grand-multiparty [OR = 6.584 (95% CI 1.902, 22.795)], and history of postpartum hemorrhage [OR = 4.355 (95% CI 2.347, 8.079)] were factors associated with the occurrence of postpartum hemorrhage. Conclusions: The pooled magnitude of postpartum hemorrhage among post-natal mothers in Ethiopia was moderately high. The finding of this study will strongly help different stakeholder working in maternal and child health to focus on the main contributors' factors to reduce post-partum hemorrhage among postnatal mothers. Health professionals attending labor and delivery should give more attention to advanced aged mothers, grand-multipara mothers and mothers who had a history of post-partum hemorrhage due to higher risk for postpartum hemorrhage. Encouraging to continue ANC visit and prevent prolonged labor should also be recommended to decrease postpartum hemorrhage.
... A study in Assam India showed that women with severe anaemia had higher odds of developing PPH, small for age neonates and perinatal death [12] . Kaima Frass showed the link between anaemia, uterine atony and PPH in anaemic women who had Caesarean Section; in his study, 39.6% (32/53) of women with severe anaemia had an emergency hysterectomy for uterine atony [13] . We found in this study that the adjusted regression analysis revealed that for every unit increase in PCV of study participants, there was a 16% decrease in the probability of occurrence of post-partum haemorrhage and this probability was statistically significant (p<0.001). ...
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Background: Anaemia in pregnancy is associated with high foeto-maternal morbidity and mortality. It has significant prevalence in Africa with poor pregnancy outcome. Methods: We assessed pregnant women presenting in labour, documented their booking status, age, haematocrit at presentation, their mode of delivery and occurrence of post-partum haemorrhage or not as well. Results: Four hundred and sixty-two (462) women were included in the study. Modal age group was 26-35 years [299 (64.7%)]. Majority were booked 402 (87.2%), 335 (70.3%), and 47 (10.2%), had moderate to severe anaemia and post-partum haemorrhage respectively. Patient’s booking status and packed cell were significantly associated with post-partum haemorrhage p= 0.04 and p<0.001 respectively. Conclusion: Anaemia in late pregnancy is common in our community, 70.3% of the women presented with varying degrees of anaemia. Booking status and packed cell volume are strong predictors of post-partum haemorrhage. Keywords: Anaemia, pregnancy, gestational age
... 2 With regards to maternal health, the effects can include increased cardiovascular strain, reduced mental and physical performance, an increased risk of postpartum anaemia and postpartum haemorrhage, a lower ability to tolerate blood loss -leading to circulatory shock and effects on thyroid and immune functions. [6][7][8] Furthermore, severe anaemia may require blood transfusion, particularly if there is also significant blood loss during delivery. 9 Existing evidence shows that anaemia in pregnancy increases the risk of low birth weight, preterm delivery, increased perinatal and neonatal mortality, birth asphyxia, IUFD, intrauterine growth restriction as well as NICU admission. ...
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Introduction: Anaemia during pregnancy is an important factor to maternal mortality, morbidity and poor foetal outcomes. It remains one of the utmost unresolved public health problems in developing countries, including Ethiopia. This study aimed to assess the prevalence and associated factors of anaemia among pregnant women in the public health facilities of Hossana Town, Southern Ethiopia.
... P< 0.01]. This report was in line with studies conducted in Uganda 9% [50] and Japan 8.7% [51], but much lower than study reports from Pakistan 21.3% [52], Cameroon 23.6% [53], and Yemen 29.1% [54]. The discrepancy could be due to the difference in maternal health services utilization (prenatal, natal, and postnatal care) between the countries. ...
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Background: Postpartum hemorrhage or postpartum bleeding (PPH) is often defined as loss of > 500 ml of blood after vaginal delivery or > 1,000 ml after cesarean delivery within 24 hrs. Postpartum hemorrhage is a leading direct cause of maternal morbidity and mortality in Ethiopia. Therefore, the main objective of this systematic review and meta-analysis was to estimate the pooled magnitude of postpartum hemorrhage and the pooled effect size of the associated factors in Ethiopia. Methods: Primary studies were searched in PubMed / MEDLINE online, Science Direct and Hinari Cochrane Library, CINAHL, African Journals Online databases, Google and Google Scholars. The search for studies was not limited by time and all articles up to October 10/2021 were included. The data extraction format was prepared in Microsoft Excel. The data extracted from the Microsoft Excel format was exported to Stata Version 16.0 statistical software for analysis. A random effect meta-analysis model was used. Statistical heterogeneity was evaluated by the I² test and Egger's weighted regression test was used to assess publication bias. Result: A total of 165 records from the electronic databases were excluded, but 145 records were excluded for different reasons, and finally 20 studies were included in this final analysis. The pooled magnitude of postpartum hemorrhage in Ethiopia was 8.18% [(95% CI; 6.996 - 9.363]. Older age [OR= 5.038 (95% CI; 2.774 - 9.151)], prolonged labor [OR = 4.054 (95% CI; 1.484 - 11.074)], absence of ANC visit [OR = 13.84 (95% CI; 5.57 - 34.346)] grand-multiparty, [OR = 6.584 (95% CI; 1.902 - 22.795)], and history of postpartum hemorrhage [OR = 4.355 (95% CI; 2.347 - 8.079)] were identified as factors for the occurrence of postpartum hemorrhage. Conclusions: This study concludes that the magnitude of postpartum hemorrhage in Ethiopia was moderately high. The finding was strongly help different stakeholder working in maternal and child health to focus on the main contributors factors to reduce PPH. Health professionals attending delivery should emphasize high-risk groups of mothers. Encouraging ANC visit and prevent prolonged labor should be recommended to reduce the occurrence of postpartum hemorrhage.
... The underlays, drapes, gauze and pads were weighed before surgery and 4 hours after surgery using a digital weighing scale (Seca GmbH and co, Hamburg, Germany) which was calibrated before and between use. The difference in weight between the dry and soaked underlay, drapes, and pads were used to estimate the blood loss because a 1-gram difference is equivalent to 1 mL of blood [17]. The PCV values of the women were checked 24 hours after the CS to determine the differences in their pre-and post-operative PCV values. ...
... As a result, this research backs up the correlation between anemia and PPH, and it also provides evidence for the link between extreme anemia and immediate hysterectomy. 6 Another study discovered a link between PPH occurrence and prior medical history, anemia, and previous PPH. 7 According to one study, women who had wound dehiscence after a cesarean section had a high rate of anemia, and as a result of the underlying anemia, they were more vulnerable to infection. ...
Chapter
PPH is a major cause of maternal death. Hysterectomy is safe to treat uncontrollable PPH. However, it may not be the best option for women who want to have children. The risk score tool to detect PPH earlier is needed in low-resource cities such as Chiang Rai and Sakon Nakhon province. This study aims to perform a risk score tool to prevent PPH in the northern and northeastern hospitals in Thailand; using mixed methods, identify risk factors for PPH from 20 articles globally and in Thailand using Med Calc, and develop the tool for prediction of PPH; and tool testing and a one-year follow-up on PPH-related hysterectomy cases. Results showed that this risk score tool can detect PPH earlier, reducing the number of PPH and hysterectomy cases. This risk score tool needs to be implemented in the same situations as hospitals to save pregnant women’s lives.
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Post-partum haemorrhage is a one among leading causes of maternal mortality globally. Lack of manpower and appropriate equipment makes this problem incomparably high in poorer African settings than developed countries. Training, planning and effectively utilization of the few available equipment and personnel would make a difference in most African settings including Zanzibar. Studies in this area would inform the gape in knowledge equipment and manpower deficit in which if settled PPH and maternal mortality will be reduced. Aim: This study aimed atexploring the knowledge and practice of nurse midwives on prevention and management of post-partum haemorrhage at Mnazi Mmoja Hospital, Zanzibar Setting: Mnazi mmjoa Hospital in Zanzibar Urban/West. Methods: A descriptive cross sectional qualitative study design was conducted in which face to face interview was conducted with each nurse (n=15) at obstetric department/section on issues pertaining to PPH. English interview guide was used during the discussion and the voice recorder was used to record the conversations. Meanwhile the researcher noted down important points and events as the discussion proceeded. After each interview key points were summarized in the presence of interviewee for confirmation and further elaboration where necessary. All recorded interviews were transcribed and translated per verbatim. The translated transcripts were coded by using different colors in Microsoft Word computer program.Codes were assembled in small meaning units and these units were later gathered (depending on their relationship to each other) to create categories which are the results for this study. Results: The predetermined theme for this study was the status quo of PPH at Mnazi Mmoja Hospital. Under this theme five categories were formed, the five theme are; PPH as a serious situation, Causes and risk for PPH, assessment and management of PPH, preparedness as prevention of PPH and areas of inconsistence. Conclusion: There substantially good knowledge among midwives concerning risk factors, prevention, and monitoring a PPH event. However there are insufficient staff (to form a team) and necessary equipment to handle an event of PPH.
Article
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Background: Postpartum haemorrhage (PPH) remains a major global burden contributing to high maternal mortality and morbidity rates. Assessment of PPH risk factors should be undertaken during antenatal, intrapartum and postpartum periods for timely prevention of maternal morbidity and mortality associated with PPH. The aim of this study is to investigate and model risk factors for primary PPH in Rwanda. Methods: We conducted an observational case-control study of 430 (108 cases: 322 controls) pregnant women with gestational age of 32 weeks and above who gave birth in five selected health facilities of Rwanda between January and June 2020. By visual estimation of blood loss, cases of Primary PPH were women who changed the blood-soaked vaginal pads 2 times or more within the first hour after birth, or women requiring a blood transfusion for excessive bleeding after birth. Controls were randomly selected from all deliveries without primary PPH from the same source population. Poisson regression, a generalized linear model with a log link and a Poisson distribution was used to estimate the risk ratio of factors associated with PPH. Results: The overall prevalence of primary PPH was 25.2%. Our findings for the following risk factors were: antepartum haemorrhage (RR 3.36, 95% CI 1.80-6.26, P<0.001); multiple pregnancy (RR 1.83; 95% CI 1.11-3.01, P = 0.02) and haemoglobin level <11 gr/dL (RR 1.51, 95% CI 1.00-2.30, P = 0.05). During the intrapartum and immediate postpartum period, the main causes of primary PPH were: uterine atony (RR 6.70, 95% CI 4.78-9.38, P<0.001), retained tissues (RR 4.32, 95% CI 2.87-6.51, P<0.001); and lacerations of genital organs after birth (RR 2.14, 95% CI 1.49-3.09, P<0.001). Coagulopathy was not prevalent in primary PPH. Conclusion: Based on our findings, uterine atony remains the foremost cause of primary PPH. As well as other established risk factors for PPH, antepartum haemorrhage and intra uterine fetal death should be included as risk factors in the development and validation of prediction models for PPH. Large scale studies are needed to investigate further potential PPH risk factors.
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Management of post-partum haemorrhage (PPH) involves the treatment of uterine atony, evacuation of retained placenta or placental fragments, surgery due to uterine or birth canal trauma, balloon tamponade, effective volume replacement and transfusion therapy, and occasionally, selective arterial embolization. This article aims at introducing pregnancy- and haemorrhage-induced changes in coagulation and fibrinolysis and their relevant compensatory mechanisms, volume replacement therapy, optimal transfusion of blood products, and coagulation factor concentrates, and briefly cell salvage, management of uterine atony, surgical interventions, and selective arterial embolization. Special attention, respective management, and follow-up are required in women with bleeding disorders, such as von Willebrand disease, carriers of haemophilia A or B, and rare coagulation factor deficiencies. We also provide a proposal for practical instructions in the treatment of PPH.
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Many maternal deaths across the world result from complications of the third stage of labour (when the placenta is delivered). OBJECTIVES: To examine the effect of oxytocin given prophylactically in the third stage of labour on maternal and neonatal outcomes. SEARCH STRATEGY: Relevant trials were identified in the Cochrane Collaboration Controlled Trials Register and the Pregnancy and Childbirth Review Group's Specialised Register of Controlled Trials. Date of last search: May 2001. SELECTION CRITERIA: All acceptably randomised or quasi-randomised controlled trials including pregnant women anticipating a vaginal delivery where oxytocin was given prophylactically for the third stage of labour. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed studies for relevance and methodological quality, and extracted data. Analysis was by intention to treat. Subgroup analyses were based on extent of selection bias, oxytocin in the context of active or expectant management of the third stage, and timing of administration. Results are presented as relative risks, and weighted mean difference, both with 95% confidence intervals using a fixed effects model. MAIN RESULTS: In seven trials involving over 3000 women in hospital and/or developed country settings, prophylactic oxytocin showed benefits (reduced blood loss (relative risk (RR) for blood loss > 500 ml 0.50; 95% confidence interval (CI) 0.43, 0.59) and need for therapeutic oxytocics (RR 0.50; 95% CI 0.39, 0.64).) compared to no uterotonics, although there was a non-significant trend towards more manual removal of the placenta (RR 1.17; 95% CI 0.79, 1.73) which was most marked in the expectant management subgroup, and blood transfusions (RR 1.30; 95% CI 0.50, 3.39) in the trials with more manual removals of the placenta). In six trials involving over 2800 women, there was little evidence of differential effects for oxytocin versus ergot alkaloids, except ergot alkaloids are associated with more manual removals of the placenta (RR 0.57; 95% CI 0.41, 0.79), and with the suggestion of more raised blood pressure (RR 0.53; 95% CI 0.19, 1.58) than with oxytocin. In five trials involving over 2800 women, there was little evidence of a synergistic effects of adding oxytocin to ergometrine versus ergometrine alone. For all other outcomes in the comparisons either there are no data or the number of adverse events is very small, and so definite conclusions cannot be drawn. REVIEWER'S CONCLUSIONS: There are strong suggestions of benefit for oxytocin in terms of postpartum haemorrhage, and the need for therapeutic oxytocics, but without sufficient information about other outcomes and side-effects it is difficult to be confident about the trade-offs for these benefits, especially if the risk of manual removal of the placenta may be increased. There seems little evidence in favour of ergot alkaloids alone compared to either oxytocin alone, or to Syntometrine, but the data are sparse. More trials are needed in domiciliary deliveries in developing countries, which shoulder most of the burden of third stage complications.
Chapter
Maternal mortality continues to be high and maternal nutrition poor in the developing world. However, the specific role of nutrition in affecting maternal health and survival remains unclear. Recent trials provide support for a specific and perhaps important place for nutrition in reducing the burden of maternal mortality in developing countries. Specific nutrition interventions have been shown to be efficacious against some causes of maternal mortality. Calcium supplementation during pregnancy in high-risk populations or populations with dietary deficiency can reduce the risk of eclampsia and severe morbidity and mortality related to hypertensive disorders of pregnancy. Magnesium sulfate is a low-technology and inexpensive means to reduce the risk of eclampsia. Maternal anemia is likely to increase the risk of maternal mortality. Antenatal iron supplementation when done adequately can bring about improvements in hemoglobin concentrations that are likely to reduce the risk of maternal mortality by about 25%. Maternal vitamin A deficiency may be associated with an increased risk of maternal deaths, but further evidence is needed. Antenatal nutritional interventions that are able to achieve high coverage may likely be an effective means for impacting maternal survival in undernourished populations of the world where the burden of maternal mortality is high.
Article
Aim: The aim of this study was to evaluate the efficacy of adjunctive rectal misoprostol compared to oxytocin infusion in the prevention of primary postpartum hemorrhage after routine active management of the third stage of labor in women with identifiable risk factors for uterine atony. Material and Methods: A double-blind randomized controlled trial was carried out at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. A total of 264 parturients with known risk factors for postpartum hemorrhage were randomized to receive either rectal misoprostol (600 µg; n = 132) or oxytocin infusion (20 IU in 500 mL; n = 132) after routine active management of the third stage of labor. Intrapartum blood loss was measured using a combination of the BRASSS-V calibrated drapes and differential pad weighing. Hematocrit was measured intrapartum and 24 h postpartum. Results: There was no significant difference (P = 0.07) in the mean intrapartum blood loss between the misoprostol (387.28 ± 203.09 mL) and oxytocin (386.73 ± 298.51 mL) groups. There was also no difference in the requirement for additional intervention for uterine atony (P = 0.74). Postpartum hematocrit drop and blood transfusion were, however, significantly less in the misoprostol group. Conclusion: Rectal misoprostol is as effective as oxytocin infusion as an adjunct for prevention of postpartum hemorrhage in women with risk factors for uterine atony and is associated with a lower hematocrit drop and blood transfusion postpartum. However, shivering, pyrexia and vomiting are more frequent with misoprostol, though usually self-limited.
Article
Emergency peripartum hysterectomy (EPH), is performed when life-threatening obstetric conditions occur. The authors attempt to assess the incidence of EPH as well as to investigate risk factors and patients' characteristics. A retrospective study of all cases of EPH performed at the 2nd Department of Obstetrics and Gynecology, Medical School of Athens University, from 1994 to 2009 has been conducted. Data were abstracted from individual medical charts and laboratory records. Among 16,182 deliveries, 15 EPH were performed (0.92 per 1,000 deliveries). Indication was uncontrollable haemorrhage due to placenta accreta (73.3%) or uterine atony (26.6%). Incidence of 1.54 EPHs per 1,000 caesarean sections and 0.51 per 1,000 vaginal deliveries, were noted. Morbidity rate was 46.6%. One (6.6%) mother died because of pulmonary embolism. In conclusion, peripartum hysterectomy is a severe but life-saving procedure. Caesarean section increases the risk of EPH. Obstetricians should always be prepared to confront this emergency situation.
Article
Background: According to a World Health Organization (WHO) review of nationally representative surveys from 1993 to 2005, 42% of pregnant women have anemia worldwide. Almost 90% of anemic women reside in Africa or Asia. Most countries have policies and programs for prenatal iron-folic acid supplementation, but coverage remains low and little emphasis is placed on this intervention within efforts to strengthen antenatal care services. The evidence of the public health impact of iron-folic acid supplementation and documentation of the potential for scaling up have not been reviewed recently. Objective: The purpose of this review is to examine the evidence regarding the impact on maternal mortality of iron-folic acid supplementation and the evidence for the effectiveness of this intervention in supplementation trials and large-scale programs. Methods: The impact on mortality is reviewed from observational studies that were analyzed for the Global Burden of Disease Analysis in 2004. Reviews of iron-folic acid supplementation trials were analyzed by other researchers and are summarized. Data on anemia reduction from two large-scale national programs are presented, and factors responsible for high coverage with iron-folic acid supplementation are discussed. Results: Iron-deficiency anemia underlies 115,000 maternal deaths per year. In Asia, anemia is the second highest cause of maternal mortality. Even mild and moderate anemia increase the risk of death in pregnant women. Iron-folic acid supplementation of pregnant women increases hemoglobin by 1.17 g/dL in developed countries and 1.13 g/dL in developing countries. The prevalence of maternal anemia can be reduced by one-third to one-half over a decade if action is taken to launch focused, large-scale programs that are based on lessons learned from countries with successful programs, such as Thailand and Nicaragua. Conclusions: Iron-folic acid supplementation is an under-resourced, affordable intervention with substantial potential for contributing to Millennium Development Goal 5 (maternal mortality reduction) in countries where iron intakes among pregnant women are low and anemia prevalence is high. This can be achieved in the near term, as policies are already in place in most countries and iron-folic acid supplements are already in lists of essential drugs. What is needed is to systematically adopt lessons about how to strengthen demand and supply systems from successful programs.
Article
Prevalence of anaemia in India is among the highest in the world. Prevalence of anaemia is higher among pregnant women and preschool children. Even among higher income educated segments of population about 50 per cent of children, adolescent girls and pregnant women are anaemic. Inadequate dietary iron, folate intake due to low vegetable consumption, perhaps low B12 intake and poor bioavailability of dietary iron from the fibre, phytate rich Indian diets are the major factors responsible for high prevalence of anaemia. Increased requirement of iron during growth and pregnancy and chronic blood loss contribute to higher prevalence in specific groups. In India, anaemia is directly or indirectly responsible for 40 per cent of maternal deaths. There is 8 to 10-fold increase in MMR when the Hb falls below 5 g/dl. Early detection and effective management of anaemia in pregnancy can contribute substantially to reduction in maternal mortality. Maternal anaemia is associated with poor intrauterine growth and increased risk of preterm births and low birth weight rates. This in turn results in higher perinatal morbidity and mortality, and higher infant mortality rate. A doubling of low birth weight rate and 2 to 3 fold increase in the perinatal mortality rates is seen when the Hb is <8 g/dl. Intrauterine growth retardation and low birth weight inevitably lead to poor growth trajectory in infancy, childhood and adolescence and contribute to low adult height. Parental height and maternal weight are determinants of intrauterine growth and birth weight. Thus maternal anaemia contributes to intergenerational cycle of poor growth in the offspring. Early detection and effective management of anaemia in pregnancy can lead to substantial reduction in undernutrition in childhood, adolescence and improvement in adult height.
Article
To identify health-related risk factors for the development of post partum hemorrhage (PPH) in Saudi women and to estimate the incidence of primary PPH. A case-control study was conducted between July 1, 2007 and June 30, 2008 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. One hundred and one patients with PPH and 209 control patients were included. Bivariate associations between the different risk factors for the development of PPH were studied. Multivariate logistic regression analysis to identify significant risk factors for the occurrence of this obstetrics complication was carried out. High parity was associated with a 17% increased risk of PPH. Risk factors in preeclampsia was associated with >6-fold increase. History of antepartum hemorrhage (APH) increased the risk for PPH by >8-fold. Other factors were: multiple pregnancy, vaginal delivery, prolonged third stage of labor, and presence of cardiotocograph (CTG) abnormalities. Risk factors for developing PPH among Saudi women are comparable to other reported studies with a greater influence of parity, presence of APH, multiple gestation, CTG abnormalities and prolonged third stage of labor. There is a need for patient education on family planning and antenatal care, physician education on active management of the third stage, and correct estimation of blood loss.