Postpartum haemorrhage: various method of management in arural tertiary care hospital

Introduction: Post-partum haemorrhage is defined as blood loss from the genital tract, exceeding 500ml within 24hours of vaginal delivery and 1000ml during caesarean section. It is also now a day defined as any blood loss that has a potential to produce or produces hemodynamic instability. Massive obstetric haemorrhage is a major cause of maternal mortality and morbidity worldwide. Aims and Objectives: Objective of the study is to evaluate the most common etiology and method of management of Postpartum Haemorrhage in a rural tertiary care hospital of SAH &RC. Materials and Methods: A prospective study was done from June 2017 to June 2018 in Department of Obstetrics and Gynaecology at Adichunchanagiri Institute of Medical sciences, Bellur, Karnataka, India. The study included all cases of normal vaginal deliveries, assisted vaginal deliveries and Caesarean section. Result: A total of 1877women were delivered. Out of which 923 (49.17%) women delivered vaginally and 954 (50.82%) women delivered through cesarean section. Out of 1877 delivered women, 69 (3.67%) developed PPH. out of 69(3.79%), 66(95.65%) had atonic PPH and 3(4.34%) had traumatic PPH. out of 66 atonic PPH cases 54(81.81%) managed medically. Other modalities were B lynch suture 7(10.6%), Hayman suture 2(3.03%), suction cannula 1(1.51%), internal iliac artery ligation 1(1.51%), peripartum hysterectomy 1(1.51%). Most of the cases have been managed medically. Conclusion: In an era with availability of excellent uterotonics and active management of third stage of labor even today PPH stands first as the cause of maternal mortality and morbidity.This study highlights the existing variable practices for management of PPH. Haemorrhage associated mortality can be prevented by critical judgment and early intervention.


Introduction
Post-partum haemorrhage is the leading cause of maternal morbidity and mortality and accounts for one quarter of cases of maternal mortality worldwide [1]. It is among the manageable causes of maternal mortality that if managed properly can prevent most of the cases of maternal deaths.
According to WHO, obstetric haemorrhage causes 127000 deaths annually worldwide and is the leading cause of maternal mortality [2]. Post-partum haemorrhage is defined as blood loss from the genital tract, exceeding 500ml within 24hrs of vaginal delivery and 1000ml during caesarean section [3]. It is also now a day defined as any blood loss that has a potential to produce or produces hemodynamic instability. Massive obstetric haemorrhage is a major cause of maternal mortality and morbidity worldwide. It is not only life-threatening situation but also an obstetrician'snightmares [4]. Many national and international studies show that uterine atony is the commonest cause of PPH followed by trauma to genital tract, adherent placenta, uterine angle extension and retained placenta [5]. Primary (immediate) PPH occurs within the first 24 hours after delivery. Approximately 70% ofimmediate PPH are due to uterine atony. Atony of the uterus is defined as the failure of the uterus to contract adequately after the child is born [6]. Uterine atony is the most common cause of PPH, in about 75-90% of cases.
Other causes include placenta previa, accreta, lower genital tract laceration, coagulopathy, uterine inversion and ruptured uterus [7]. Secondary (late) PPH occurs between 24 hours after delivery of the infant and 6 weeks postpartum. Most late PPH is due to retained products of conception, infection, or both [6]. Generally, PPH requires early recognition of its cause, immediate control of the bleeding source by medical, mechanical, invasive-non-surgical and surgical procedures, rapid stabilization of the mother's condition, and a multidisciplinary approach [8]. PPH can be minor (500 -1000 ml) or major (more than 1000 ml), major can be divided into moderate (1000 -2000 ml) and severe (more than 2000 ml) [9].
Oxytocin, syntometrine, ergometrine, PGF2 alpha and misoprostol are different medical preparations used as uterotonics for prophylaxis and therapeutic management of PPH. The two main aspects of management of PPH are resuscitation and identification/management of underlying cause. Interventions like application of compression sutures, internal iliac artery ligation, uterine artery embolization and hysterectomy are other life saving measures.

Number of PPH Cases 69
Out of 69 who developed PPH, 40 (57.97%) were primipara and 29 (42.02%) were multipara.    In this studymedical management was done by giving 1)oxytocin10 IU IM or 20-40 IU in 1 liter ofnormal saline at 60 drops per minute, and continue oxytocin (20 IU in 1 litre of iv fluids at 40 drops per minute) until haemorrhage stops, 2) Ergometrine 0.2 mg im or can be given slowly iv may be repeated as required at interval of 2-4 hours, 3) PGF2 or carboprost 0.25 mg dose can be repeated every 15 minutes for a total dose of 2 mg (maximum of 8 doses), 4)PGE1 or misoprostol dose vary from 400μg to maximum of 1200μg.

Discussion
Postpartum hemorrhage is the leading cause of morbidity and mortality among pregnant ladies throughout the world causing 140,000 deaths each year globally, this corresponds to the one women dying in every 4 minutes and it is the 5th most common cause of maternal mortalitythroughout the world [10,[11][12][13][14][15]. Postpartum hemorrhage is a leading cause of

Original Research Article
Obsgyne Review: Journal of Obstetrics and Gynecology Available online at: www.medresearch.in 96 |P a g e maternal mortality. The place of delivery and severity of hemorrhage determine the outcome. Commonest mode of delivery which was found in present study was C-sectionfollowed by spontaneous vaginal delivery and instrumental vaginal delivery.If the woman has developed PPH following delivery in a health facility, the immediate medical and surgical interventions are possible. It is not so, when woman delivers at home or in a small hospital ill equipped with facilities to manage obstetric emergencies, Diagnosis of PPH and decision to transfer to hospital or tertiary care Centre is very crucial. Home deliveries and deliveries in small facilities have negative influence on the outcome.Most important and major finding in our study was that the most common cause ofpostpartum hemorrhage was uterine atony, which is loss of tone in the uterine musculature. Data support the routine use of active management of the third stage of labor (AMTSL) by all skilled birth attendants, regardless of where they practice; AMTSL reduces the incidence of PPH, the quantity of blood loss, and the need for blood transfusion, and thus should be included in any program of intervention aimed at reducing death from PPH [16]. The usual components of AMTSL include: 1) Administration of oxytocin (the preferred storage of oxytocin is refrigerationbut it may be stored at temperatures up to 30 °C for upto 3 months without significant loss of potency) or another uterotonicdrug within 1 minute after birth of the infant. 2) Controlled cord traction.3) Uterine massage after delivery of the placenta.The Bristol [17] and Hinchingbrooke [18] studies compared active versus expectant (physiologic) management of the third stage oflabor. Both studies clearly demonstrated that, when active management was applied, the incidence of PPH was significantly lower(5.9% with AMTSL vs 17.9% with expectant management [17]; and6.8% with AMTSL vs 16.5% without [18]. FIGO promotes the routine use of AMTSL as the best, evidence-based approach for the prevention of PPH and emphasizes that every effort should be made to ensure that AMTSL is used at every vaginal birth where there is a skilled birth attendant. However, FIGO recognizes that there may be circumstances where the accessibility or the supply of uterotonics may be sporadic owing to interruptions in the supply chain, or it may be nonexistent in a country because it is not part of the approved list of essential medicines or included in the national guidelines/protocols. It is in this context that the birth attendant must know how to provide safe care (physiologic management) to prevent PPH in the absence of uterotonic drugs [6]. Most maternal deaths due to PPH occur in low income countries in settings (both hospital and community) where there are no birth attendants or where birth attendants lack the necessary skills or equipment to prevent and manage PPH and shock. The Millennium Development Goal of reducing the maternal mortality ratio by 75% by 2015 will remain beyond our reach unless we prioritize the prevention and treatment of PPH in low-resource areas [19].  [20] 3.55% Edhi et al. [22] 1.7% In this study, incidence of PPH was found to be 3.67%,, this finding is similar when it is compared with the study conducted by Tasneem F et al [20], in which incidence of PPH was found to be 3.55%. A systematic re-view reported the highest rates of PPH in Africa (27.5%), and the lowest in Oceania (7.2%), with an overall rate globally of 10.8%.9 The rate in both Europe and North America was around 13% [22]. In this study we found bimodal distribution of incidence of PPH in relation to parity i.e. primipara 57.97% and multipara 42.03%. Reason being different predisposing actors in primigravida like teenage pregnancy, preeclampsia, eclampsia, abruption, anemia, dysfunctional labor, uterine over activity while high parity is the reason in multipara. In 71 % of PPH there is no identifiable risk factor but PPH is not major in this group. We found major PPH in maximum patients with one or more risk factors like anemia, preeclampsia, eclampsia, antepartumhaemorrhage and twins.   [20] 79.17% 16.67% In this studymajor cause of PPH was found to be the uterine atonythat is 95.65%,this finding is similar when it is compared with the study conductedby Tasneem et al [19], in which they also found that uterine atony is the major cause of PPH (86%), whereas study conducted by Solanke et al [20], they found 79.17% of PPH is due to uterine atony. In international studies uterine atony was the most common cause of PPH, ranging from 50% to 76% of cases [23,24].

Conclusion
In an era with availability of excellent uterotonics and active management of third stage of labor even today PPH stands first as the cause of maternal mortality and morbidity. This study highlights the existing variable practices for management of PPH. The frequency and impact of severe hemorrhage can be effectively reduced by reducing avoidable risk factors, especially those related to obstetric interventions as increased CS rate and induction and augmentation of labour with injudicious use of uterotonics. Other risk factors not amenable to change such as age, ethnic origin, and preexisting medical diseases or bleeding disorders can be minimized byextra vigilance and planned conjoined management.Uterine atony is the most common cause ofpostpartum haemorrhage, so its incidence can be lowered by universal adoption of AMTSL. Institutional deliveries, timely intervention, judicial approach anaesthesia, ICU back up and availability of blood and blood component facilitieswill improve clinical outcome. Avoidance of delays in identification and transfer, high risk pregnancy identification and timely referral, capacity building of peripheral health workers in use of medication and uterine massage therapy will go a long way in reducing the maternal mortality related to atonic postpartum hemorrhage. Every pregnancy should culminate in healthy mother and healthy baby and for that we need to ensure that all women have access to high quality essential and emergency obstetric service at first referral unit (FRU) level to reduce maternal mortality.