Application of Non Pneumatic Anti- Shock Garment (NASG) in 100 patients of postpartum haemorrhage: analysis of causes, management and outcome in a tertiary centre of south Rajasthan

Objectives: The present study was performed to assess the role of NASG (non pneumatic anti shock garment) in the management of postpartum haemorrhage. Material and Methods: The present study is a retrospective study carried out in the department of Obstetrics & Gynaecology of a tertiary care institute of southern Rajasthan during the period of six years from July 2009 to June 2015. 100 patients of postpartum haemorrhage (PPH) with gestational age ≥28 weeks were included in the study. All the patients delivered at our institute and BMI ~18.5-24.9 kg/m so that NASG was meticulously applied. Results: 100 patients of PPH were included in present study and NASG were applied to them. Age of the patients ranged from 18 to 45 years with the mean age of 25.99 years. 13% of the patients were grand multipara while 20% patients were primi and remaining 63% were multipara. The most common cause of PPH was atonic uterus (77%), of which commonest etiology was maternal anaemia (37.6%). Next common cause was trauma of genital tract (19%) out of which vaginal injuries were the most common (47.36%). Other rare causes were tissue factor (3%) and coagulopathies (1%).67% of the study participants had normal delivery while 29% patients had caesarian sections and remaining(4%) had instrumental delivery. After NASG application, 53% patients responded to medical management, 32% were managed surgically and rests 15% were stabilized by manoeuvres. 57% patients stayed for three days in the hospital while 29% stayed for five days. Only 3% patients had a hospital stay of ≥ six days. Conclusion: The present study concluded that majority of patients suffering from PPH were multigravidas in the reproductive age group of 21-30 years. The major cause of PPH was uterine atony followed by genital tract injuries. Use of NASG in these patients significantly reduced any major surgical intervention. Most of these patients were successfully managed by uterotonics, blood components and supportive care. Even a substantial decrease in theduration of stay in hospital and ICU stay was noted.


Introduction
Postpartum haemorrhage (PPH) is one of the most dreadful nightmares for an obstetrician. Unfortunately, each one of us has experienced it sooner or later. It is the most frequently asked topic for viva voce and various other assessments. It is also most common cause of maternal mortality in India and worldwide. Sarcastically speaking, oneof the Seven Wonders of the world-The TAJ was built only because of PPH. Such is the magnitude of PPH, so it is our duty to prevent and predict this multifaceted monster in disguise. 12 weeks [1]. Every day, around 830 women die from pregnancy or childbirth-related complications worldwide. Almost 52% of maternal mortality is due to these three causes-haemorrhage, sepsis, and hypertensive disorders. As per WHO 25% of maternal mortality is contributed by PPH. Incidence of PPH varies from 2% -4% following vaginal delivery and 6% post operatively (cesarean section). Around 50% cases of PPH are attributed to uterine atony. [2].
The causes of PPH are classified as 4 Ts:  Tone:uterine atony due to overdistention, exhaustion or retained products.  Trauma:cervical/vaginal/perineal tears rupture uterus.  Tissue:retained placenta (normal/abnormal)  Thrombin:intrauterine death, amniotic fluid embolism, disseminated intravascular coagulation (DIC) [3] PPH is like a rolling stone. The catastrophe of events leading to shock and death are quite speedy; therefore even a timely referral from peripheries can be fatal. So a device like NASG (non pneumatic anti shock garment) can be of immense help while referring from peripheral (primary/secondary) health centre as well as commencing the definitive therapy at the tertiary centre. The time of revival can then be lengthened so as to save the patient's life.
NASG is a non pneumatic anti shock garment. As the name suggests, it overcomes the disadvantages of pneumatic ones (like compartment syndrome, acidosis, compromising renal perfusion). It is FDA approved counter pressure garment which is made up of three way stretch neoprene with Velcro fasteners and a soft abdominal ball for uterine compression. It is designed in such a manner so that it is easily applied and requires minimal skill. It maintains a pressure of 20-40 mm of Hg so that hemostasis is adequately maintained without ischaemia. This range of pressure causes no discomfort to the patients. It is hassle free due to absence of tubings, cuffs, bladders. It can be easily cleaned by using bleaching powder solution. This quality even makes it easy to maintain, inexpensive and free from risk of over inflation. [4] Application of NASG causes compression of peripheral vessels and diverts the flow to the vital organs. Thus there is translocation of the blood reducing total vascular volume while expanding the central circulation. It also has a tamponade effect on splanchnic plexus thereby reducing the bleeding [5].

Material and Methods
The present study is a retrospective study carried out in the Department of Obstetrics & Gynaecology, R.N.T Medical College, Udaipur for six years from July 2009 to June 2015 Setting: Tertiary care Type of study: Retrospective longitudinal study Participants: In the present study, 100 patients of postpartum haemorrhage with gestational age ≥28 weeks were included.
All the patients delivered at our institute and BMI ~18.5-24.9 kg/m 2 so that NASG was meticulously applied.These patients were chronologically selected as per date of admission fitting the inclusion criteria.

Type of participants:
All 100 patients were evaluated in terms of their demographic profile, causes of postpartum haemorrhage, management and their maternal outcome. All the patients/attendants included in the study gave written informed consent.
It was ensured that their personal details including obstetric history would remain confidential.
Inclusion Criteria-All the patients of postpartum haemorrhage (whether in shock or not) were included.
The causes were divided into following categories viz.
 Tone-atonic due to Grand multipara: A pregnant female with previous 4 or more viable births Multifetal pregnancy: Twins, triplets and so on Polyhydramnios: As per ultrasonography, single largest pocket of vertical length more than 8 cm or the AFI>20.
Macrosomia: birth weight >3500 or 4000 g (large for gestational age with a birth weight greater than the 90 th percentile of the expected weight.

ICU admission 4. Hospital stay
Demographic profiles such as age, parity, were also taken into account.
3. Underweight pts with BMI<18.5 kg/m 2 , overweight patients with BMI>25 kg/m 2 were excluded as NASG was available in medium size at our institute.
4. Cases of PPH with uterine inversion were not included.
5. Patients unwilling for NASG application were also not included in the study.

Results
100 patients delivered institutionally who suffered from PPH followed by NASG application during the given study period of six years from July 2009 to June 2015 were included in the study. All these patients matched the inclusion criteria and were included in chronological order of their date /time of admission.
In the present study, age of patients ranged from 18 to 45 years with the mean age of 25.99 years. 13% of the patients were grand multipara while 20% patients were primi and remaining 63% were multipara. Table 1, 2 describe the demographic profile and obstetric history of the patients included in the present study  The most common cause of PPH was atonic uterus (77%), of which commonest etiology was maternal anaemia (37.6%). Next common cause was trauma of genital tract (19%) out of which vaginal injuries were the most common (47.36%).
Other rare causes were tissue factor (3%) and coagulopathies (1%). Table 3 Original Research Article Obsgyne Review: Journal of Obstetrics and Gynecology Available online at: www.medresearch.in 136 |P a g e  Total 100 100 After NASG application, 53% patients responded to medical management, 32% were managed surgically and rests 15% were stabilized by manoeuvres. (Table 5).

Original Research Article
Obsgyne Review: Journal of Obstetrics and Gynecology Available online at: www.medresearch.in 137 |P a g e

Total 100 100
Out of 100 patients, only 43 patients had ICU stay. Among these, 67.44% patients stayed in ICU for two days, 25.58% stayed for eleven days, 6.97% patients stayed for ≥ three days.

Discussion
In the present study, majority of the patients (63%) were in the age group 21-30 years, followed by 21% in the age group >30 years. 16% patients were less than 20 years of age. Similar studies done in the past had similar findings.
This is due to the fact that reproductive potential is highest in this age group in India. In a study by Oladosu A et al in 2010 mean age of patients in NASG application group was 30.2 years [7]. As per another study by Kodla C S et al in 2015, 83.47% patients of PPH were in the age group of 21-30 years [8].
Another study by Escobar M F et al in 2017 found that mean age of the study subjects was 25± 6 years in a similar study [9]. Bangal VB et al in 2019 also observed 60% patients were in the age group of 20-30 years. [10].
Considering the obstetric history, 67% patients are multipara, 20 % primi and rest 13% are grand multipara in the present study. It can be observed here that both multipara and grand multipara account for ~70% of cases of PPH. This is quite significant as it is itself a risk factor for atonic PPH. In another similar study by Oladosu A et al in 2010, mean parity of study subjects was 5.7 [7].
A PPH related study by Kodla C S et al in 2015 also observed that 65.07% cases were primarily multipara and grand multipara [8]. Escobar M F et al in 2017 found that while 52% patients were primi, remaining 48% were multipara and grandmultipara [9]. One more study by Bangal VB et al in 2019 observed that 84% patients were multipara and grandmultipara [10].

Original Research Article
Obsgyne Review: Journal of Obstetrics and Gynecology Available online at: www.medresearch.in 138 |P a g e In the present study, the most common cause of PPH was atonic uterus (77%), of which commonest etiology was maternal anaemia (37.6%). Next common cause was trauma of genital tract (19%) out of which vaginal injuries were the most common (47.36%). Other rare causes were tissue factor (retained products/placenta) (3%) and coagulopathies (1%). In a study by Oladosu A et al in 2010, uterine atony (42%) was the leading cause followed by tissue factor (retained products/placenta) (36.2%). Genital tract trauma accounted for 20.7% [7].
In the present study, 67% of the participants had normal delivery while 29% patients had caesarean sections and remaining (4%) had instrumental delivery (instrumental or forceps delivery). In a study by Kodla

Conclusion
The present study concluded that majority of patients suffering from PPH were multigravida in the reproductive age group of 21-30 years.
The major cause of PPH was uterine atony followed by genital tract injuries. Use of NASG in these patients significantly reduced any major surgical intervention.
Most of these patients were successfully managed by uterotonics, blood components and supportive care.
Even a substantial decrease in the duration of stay in hospital and ICU stay was noted. The best part of the study is that NASG is a simple device which can be used by a pre-sensitized minimally trained healthcare worker. Still I emphasize that preventive measures like mock drills of PPH with NASG application are needed to combat this multiheaded monster( PPH).
Our country should realize the cost effectiveness of its prophylaxis. However, PPH being multifactorial in etiology continues to haunt the obstetricians.

Limitations-The limitations of this study are
1) The sample size can be increased and the sample collection could be multicentric so that generalizability of the study increases.
2) The maternal blood loss can be quantified after NASG application.
3) The study design could be comparative to assess outcome with/without NASG.

What the study adds to the existing knowledge?
NASG is life saving and cost effective measure in managing PPH particularly in a low resource setup in South Rajasthan.
This study reiterates that early application of NASG reduced the need of blood products, surgery, post operative hospital and ICU stay.