Cause Of Postpartum Hemorrhage Research Articles

Determinants of postpartum uterine atony in urban South Ethiopia: a community-based unmatched nested case–control study

BackgroundUterine atony is the most common cause of postpartum hemorrhage, which is the leading preventable cause of maternal morbidity and mortality. Despite several interventions uterine atony-related postpartum hemorrhage remains a global challenge. Identifying risk factors of uterine atony helps to reduce the risk of postpartum hemorrhage and subsequent maternal death. However, evidence about risk factors of uterine atony is limited in the study areas to suggest interventions. This study aimed to assess determinants of postpartum uterine atony in urban South Ethiopia.MethodsA community-based unmatched nested case–control study was conducted from a cohort of 2548 pregnant women who were followed-up until delivery. All women with postpartum uterine atony (n = 93) were taken as cases. Women who were randomly selected from those without postpartum uterine atony (n = 372) were taken as controls. Using a case to control ratio of 1:4, the total sample size was 465. An unconditional logistic regression analysis was done using R version 4.2.2 software. In the binary unconditional logistic regression model variables that have shown association at p < 0.20 were recruited for multivariable model adjustment. In the multivariable unconditional logistic regression model, statistically significant association was declared using 95% CI and p < 0.05. Adjusted odds ratio (AOR) used to measure the strength of association. Attributable fraction (AF) and population attributable fraction (PAF) were used to interpret the public health impacts of the determinants of uterine atony.ResultsIn this study, short inter-pregnancy interval < 24 months (AOR = 2.13, 95% CI: 1.26, 3.61), prolonged labor (AOR = 2.35, 95% CI: 1.15, 4.83), and multiple birth (AOR = 3.46, 95% CI: 1.25, 9.56) were determinants of postpartum uterine atony. The findings suggest that 38%, 14%, and 6% of uterine atony in the study population was attributed to short inter-pregnancy interval, prolonged labor, and multiple birth, respectively, which could be prevented if those factors did not exist in the study population.ConclusionsPostpartum uterine atony was related to mostly modifiable conditions that could be improved by increasing the utilization of maternal health services such as modern contraceptive methods, antenatal care and skilled birth attendance in the community.

A Clinical Study on Management of Major Primary Postpartum Haemorrhage at Tertiary Care Centre

Introduction Postpartum Haemorrhage (PPH) remains one of the leading causes of maternal morbidity and mortality worldwide . It is estimated that about one quarter to one half of preventable maternal deaths are because of haemorrhage . It is defined by the royal college of obstetrician and gynaecologist ( RCOG) as blood loss from the genital tract within the first 24 hours after birth of at least 500ml ( minor) and at least 1000ml ( major)Early transfusion of blood and blood products prevent from developing coagulopathy . Causes of post-partum haemorrhage (PPH) are commonly ascribed to the four Ts (tone, trauma, tissue, 4 thrombin). Uterine atony is responsible for most of cases . Aims and objectives 1. To know the current clinical practice in management of major primary postpartum haemorrhage at tertiary care centre 2. To evaluate the causes of major primary postpartum haemorrhage Methodology This study aimed to assess the clinical practices used by Pannadhay Mahila Hospital, Udaipur. in managing major PPH. A retrospective study of the management of PPH over a period of 2 months from march 2023 to april 2023 was carried out. The Following criteria were examined: history of previous PPH causes of PPH, use of oxytocin in the first stage for more than 6 hours. role of blood transfusion, presence of senior faculty, and type of uterotonics used. Results: a total of 50 patients were diagnosed with major PPH among which 26 had caesarean delivery. Two major risk factors were analysed, one was Use of oxytocin in first stage for more than 6 hours and History of previous PPH. Uterine atony was commonest cause in 64% of cases followed by retained product of conception. Use of uterotonics were analysed among the patients which was consistent with current practice guideline. Conclusion: This study indicates that the management of women with major PPH in Pannadhay Mahila Hospital Udaipur is consistent with the current clinical practice. Uterine atony is responsible for most of cases. Early, aggressive, and coordinated intervention by health care professionals is critical in minimizing blood loss to ensure optimal clinical outcomes in management of women with major PPH

Incidence and Risk Factors for Postpartum Hemorrhage: A Case-Control Study in a Tertiary Hospital in Greece.

Background and Objectives: Postpartum hemorrhage (PPH) is an obstetrical emergency and although the mortality rate from PPH has decreased, it is still considered a challenge in obstetrics. This study aimed to estimate the rate of primary PPH, as well as to investigate the potential risk factors and management options. Material and methods: This was a retrospective case-control study of all cases with PPH (blood loss > 500 mL, irrespective of the mode of delivery) managed in the Third Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Greece, from 2015 to 2021. The ratio of cases to controls was estimated to be 1:1. The chi-squared test was used to examine if there was any relationship between several variables and PPH, while subgroup multivariate logistic regression analyses of certain causes of PPH were also conducted. Results: During the study period, from a total of 8545 births, 219 (2.5%) pregnancies were complicated with PPH. A maternal age > 35 years (OR: 2.172; 95% CI: 1.206-3.912; p = 0.010), preterm delivery (<37 weeks) (OR: 5.090; 95% CI: 2.869-9.030; p < 0.001) and parity (OR: 1.701; 95% CI: 1.164-2.487; p = 0.006) were identified as risk factors for PPH. Uterine atony was the main cause of PPH in 54.8% of the women, followed by placental retention in 30.5% of the sample. Regarding management, 57.9% (n = 127) of the women received uterotonic medication, while in 7.3% (n = 16), a cesarean hysterectomy was performed to control PPH. Preterm delivery (OR: 2.162; 95% CI: 1.138-4.106; p = 0.019) and delivery via a cesarean section (OR: 4.279; 95% CI: 1.921-9.531; p < 0.001) were associated with a higher need for multiple treatment modalities. Prematurity (OR: 8.695; 95% CI: 2.324-32.527; p = 0.001) was identified as an independent predictor for an obstetric hysterectomy. From the retrospective analysis of the births complicated by PPH, no maternal death was identified. Conclusions: Most of the cases complicated with PPH were managed with uterotonic medication. An advanced maternal age, prematurity and multiparity had a significant impact on the occurrence of PPH. More research is needed on the risk factors of PPH, while the establishment of validated predictive models would be of value.

Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage.

Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.

Risk factors of postpartum hemorrhage due to uterine atony: a retrospective cohort study

Background: Postpartum hemorrhage (PPH) continues to be a significant global burden leading to high maternal mortality and morbidity rates. Uterine atony is the most prevalent cause of postpartum hemorrhage, accounting for 75% to 90% of cases.&#x0D; Aim: Research uterine atony related PPH at Hospital of Hue University of Medicine and Pharmacy’s Department of Obstetrics and Gynecology.&#x0D; Materials and methods: In this study, we conducted a retrospective case-control study to determine the risk factors for PPH among a cohort of women who gave birth between August 2020 and June 2021 at the Department of Obstetrics and Gynecology, Hue University of Medicine and Pharmacy Hospital. PPH was defined as an estimated blood loss ≥500 mL. Logistic regression analysis was used to identify independent risk factors for PPH.&#x0D; Results: After the vaginal deliveries, we collected data from 147 patients, including 49 women with PPH caused by uterine atony and 98 without PPH. Maternal characteristics significantly associated with PPH included: pre-delivery anemia (adjusted OR [aOR] 4.0, 95% Confidence interval [CI]: 1.7 - 11.2), macrosomia (aOR = 4.3; 95%CI 1.1 - 16.8) and grand parity (aOR = 4.7; 95%CI: 1.7 - 13.9).&#x0D; Conclusions: All pregnant women should have their risks associated with postpartum hemorrhage evaluated and monitored during their pregnancies’ prenatal, labor, and postpartum stages.

Maternal Coagulation Disorders and Postpartum Hemorrhage.

Coagulation disorders are rare causes of postpartum hemorrhage. Disturbances in coagulation should be suspected in patients with a family history of coagulopathy, those with a personal history of heavy menstrual bleeding, and those with persistent bleeding despite correction of other causes. The coagulopathic conditions discussed include disseminated intravascular coagulation, platelet disorders, and disturbances of coagulation factors. These should not be overlooked in the evaluation of obstetric hemorrhage, as diagnosis and appropriate treatment may prevent severe maternal morbidity and mortality.

Evaluation of factors that contributes to post-partum haemorrhage in Pregnant Women at KIU-TH

Postpartum haemorrhage (PPH) is the world’s leading cause of maternal death and accounts for an estimated 127,000 deaths each year. Identification of some of the risk factors such as; previous postpartum haemorrhage, multiple pregnancies, macrosomia, induction of labour, operative vaginal deliveries and cesarean section would help in preventing PPH. The aim of this research was to assess the factors contributing to postpartum haemorrhage (PPH) among pregnant women who attend delivery services in Kampala International University Teaching Hospital (KIU-TH). This study used a crosssectional descriptive design where by a cross-section of respondents involving 68 respondents were sampled to represent the target population, in these case women who received maternity service from KIU-TH. Only quantitative methods of data collection using questionnaires with closed ended questions were employed for both mothers and health workers. During the study period, 58 women who delivered in the unit and 20 women developed postpartum haemorrhage giving the frequency of postpartum haemorrhage 34.6%. The majority of the women 30% were between 30-34 years of age. Among the women who developed PPH retained placental tissues was the most common cause 50% followed by uterine atony which was 30%. The rest of the causes of PPH were laceration 20%. Postpartum haemorrhage is still a leading but preventable cause of maternal morbidity and mortality in our country due to underutilization of health facilities, the major cause is retained placental tissues followed by uterine atony. Keywords: post-partum haemorrhage, pregnant women, delivering, Uganda

Efficacy of Preoperative Intravenous Tranexamic Acid Before Cesarean Section in Placenta Previa: A Randomized Double Blind Control Trial

Background: Placenta previa is a common cause of postpartum hemorrhage (PPH) that contributes substantively to maternal morbidity and mortality rates. Tranexamic acid is an antifibrinolytic drug that is useful for the treatment of PPH. The recommendation from many guidelines is to start giving tranexamic acid as soon as PPH is diagnosed to reduce postpartum blood loss. Furthermore, some studies report the beneficial use of tranexamic acid given as a prophylactic before Cesarean section to decrease intraoperative blood loss and prevent PPH. To the authors’ knowledge, in high-risk obstetrics case such as placenta previa, there was insufficient data to support recommendations of the use of tranexamic acid for prevent PPH. Objective: To evaluate the efficacy of supplementary intravenous tranexamic acid before cesarean section versus prophylactic intravenous oxytocin after placenta delivery alone to decrease intraoperative blood loss and prevent PPH in placenta previa. Material and Methods: The present study conducted a double blinded placebo control trial comparing adjunct 1 g tranexamic acid given intravenously before skin incision with prophylactic intravenous oxytocin after placenta delivery alone before cesarean section for placenta previa. The study recruited 60 women who were diagnosed with placenta previa at gestational age (GA) of more than 28 completed weeks undergoing emergency cesarean section due to active bleeding or scheduled for elective cesarean section at 37 completed weeks at Chonburi Hospital between July 2021 and July 2022. The primary outcome was intraoperative blood loss. Results: Sixty diagnosed placenta previa women were recruited, with 30 patients per group. Group I patients were given 1 g tranexamic acid and Group II were given a placebo of 100 ml NSS before skin incision. Both groups received intravenous oxytocin 20 units after placenta delivery. The main outcome showed that preoperative tranexamic acid intravenous reduced intraoperative blood loss significantly compared with the placebo at 349.5 ml (range of 168 to 2,200) versus 619 ml (range of 288 to 3,243), p&lt;0.001. The secondary outcome showed a significant decrease in the incidence of PPH at 4 (13.33%) versus 10 (33.33%), p=0.030 and decreased in the incidence of blood transfusion of more than one unit from 5 (16.67%) versus 13 (43.33%), p=0.047. Conclusion: Prophylactic supplementary 1 g tranexamic acid intravenously before cesarean section to prophylactic intravenous oxytocin after placental delivery was found to effectively reduce intraoperative blood loss and PPH. Keywords: Tranexamic acid; Preoperative; Placenta previa; Intraoperative blood loss; Cesarean section

Eficacia y seguridad de la embolización de arterias uterinas en el manejo de la hemorragia posparto

ObjectiveTo demonstrate the safety and efficacy of endovascular treatment in postpartum hemorrhage. Material and methodsWe conducted a retrospective observational study with a sample from our Interventional Vascular Radiology unit, from 2004 to 2020. Patients who developed postpartum hemorrhage treated by arterial embolization were selected. Inclusion criteria were established to standardize the study group. Variables for the study of the efficacy and safety of the technique are defined. ResultsThe final sample of the study was 56 patients. Technical success turned was 100%, while clinical success after endovascular treatment was 92.85%, with a hysterectomy rate due to failed arterial embolization of 7.14%, with uterine rupture observed in 3 cases as a cause of postpartum hemorrhage. No technique-related mortality was recorded. The rate of periprocedural complications was 3.56%, the same as that of late complications. No major or infectious complications were recorded. The pregnancy rate after embolization was 23.52%. ConclusionsSelective arterial embolization of the uterine artery in postpartum hemorrhage is a safe and effective procedure, being a therapeutic alternative in the face of failure of pharmacological and obstetric management, with preservation of fertility.

Repeat uterine artery embolization (UAE) for recurrent postpartum hemorrhage in patients who underwent UAE after a previous delivery: a multicenter study.

To evaluate angiographic findings and outcomes of repeat uterine artery embolization (UAE) for recurrent postpartum hemorrhage (PPH) in patients who previously underwent UAE for PPH after a previous delivery. Among 1805 patients who underwent UAE for PPH from 2007 to 2020 at four participating hospitals, the data of 21 (1.16%) patients who underwent UAE for PPH after subsequent delivery were collected and analyzed retrospectively. The rate of placental abnormalities, causes of PPH, angiographic findings, and clinical success rate were evaluated. The technical success rates were 100% and 95.2%, and clinical success rates were 85.7% and 95.2% in association with first and second UAEs, respectively. The time intervals between first and second UAEs ranged from 15.6 to 103.3months (46.5 ± 25.0months). The rate of placental abnormalities was significantly higher in association with second UAEs than with first UAEs (71.4% vs. 42.8%, p = 0.034). The causes of PPH were different between first and second UAEs with borderline significance (p = 0.049); uterine atony (81.0%) and placenta accreta spectrum (57.1%) were most common in association with first and second UAEs, respectively. During second UAEs, obliterated arteries were observed in 27 uterine arteries (27/42, 64.3%) of 16 patients (16/21, 76.2%), with partial obliteration predominating over total obliteration. Collateral arteries were observed in 15 patients during second UAEs. Repeat UAE is safe and effective for recurrent PPH after subsequent delivery in patients with prior UAE. Obliteration of UAs and formation of collateral arteries are common at the second UAEs. • The rate of placental abnormalities was significantly higher in association with second UAEs than with first UAEs (71.4% vs. 42.8%, p = 0.034). • Obliteration of UAs and formation of collateral arteries are common at the second UAEs. • Repeat UAE is safe and effective for recurrent PPH after subsequent delivery in patients with prior UAE.

Outcome Of B-Lynch Application In Patients With Post-Partum Hemorrhage Following Cesarean Section.

The most common cause of post partum hemorrhage after a cesarean section is uterine atony. The main aim of this study was to examine the outcomes of the B-Lynch procedure in patients who experienced primary PPH after cesarean section. This study spanned one year, from August 2020 to August 2021, at Ayub Teaching Hospital. Patients who developed post-partum hemorrhage after a cesarean section were enrolled in this study and a thorough review of their records was conducted to identify those who received B-Lynch sutures and assess the resulting outcomes. Out of the 87 patients who experienced PPH, 24 (27.6%) patients received the B-Lynch procedure. Among these 24 patients, only two (8.3%) needed hysterectomy, while the remaining 22 successfully recovered after receiving the B-Lynch procedure. The B-Lynch technique proves to be a safe, effective, and easily applicable method for stopping hemorrhage in patients who experienced significant initial postpartum hemorrhage due to uterine atony.

POSTPARTUM HEMORRHAGE

Postpartum haemorrhage (PPH) is the primary cause of maternal mortality and morbidity worldwide: in fact, about a quarter of deaths that occur during pregnancy, childbirth or the puerperium are caused by postpartum hemorrhage. There are many causes of postpartum haemorrhage, the most important are: uterine atony, lacerations of the cervix and/or perineum, retention of placental material, coagulation problems, uterine inversion, uterine rupture. This causes of PPH are represented by the '4Ts' formula: tone, tissue, trauma, thrombin. An important role is played by prevention: identification of risk factors, prophylaxis with oxytocin at the time of delivery, early treatment. The first important thing is the quantification of blood loss because the clinical signs are often blurred and due to frank anaemia resulting in tachycardia, small and frequent pulse, hypotension, sweating, paleness. As previously mentioned, it is important to act early in the case of PPH through maintenance of volaemia and targeted therapies that differ according to the cause of PPH (the 4T algorithm is useful). Early intervention reduces the need for blood transfusions and reduces the incidence of serious complications such as DIC. However, the management of postpartum haemorrhage is not limited to the postpartum phase, but the patient must be monitored in the puerperium, a phase in which the thromboembolic risk is increased. The couple must also be informed of the risk of PPH in future pregnancies. PPH represents a serious risk for the patient and requires multidisciplinary input and proper preparation of the team working in the delivery room.

Postpartum hemorrhage management according to the underlying cause

Postpartum hemorrhage (PPH) is still a significant cause of death worldwide. This condition is classically defined as a blood loss of 500 ml or more within 24 hours after birth. Their most common causes are uterine atony, placental retention, coagulation disorders or genital trauma, and the management depends on each cause. PPH remains the leading cause of maternal mortality in low-income countries and stands out as the primary cause of nearly one quarter of all maternal deaths globally. Most deaths resulting from postpartum hemorrhage take place during the first 24 hours after birth, and the majority of these could be prevented through prophylactic uterotonics during the third stage of labor and by timely and appropriate management. Postpartum hemorrhage can occur in patients without priorly known risk factors for bleeding. The proper management of postpartum hemorrhage implies rapid diagnosis and treatment. The four Ts mnemonic can be used to diagnose and cure the four most common causes of postpartum hemorrhage: uterine atony (Tone); laceration, hematoma, inversion, rupture (Trauma); retained tissue or invasive placenta (Tissue); and coagulopathy (Thrombin). Fast-diagnosing team-based care significantly reduces the morbidity and mortality associated with postpartum hemorrhage, no matter the cause. This article plans to provide a scheme for the strategic policy and steps needed to ensure effective interventions in all PPH cases.

Success Rate and Long-Term Effects of Embolization of Pelvic Arteries for the Treatment of Postpartum Hemorrhage

Introduction: Postpartum hemorrhage (PPH) is the leading cause of peripartal maternal mortality and accounts for 25% of all maternal deaths worldwide. The most common reasons of PPH are uterine atony, retained placenta, or placenta accreta spectrum. Treatment of PPH depends on the etiology and corresponds to a stepwise approach, which follows the German, Austrian and Swiss guideline for the diagnosis and therapy of PPH in Switzerland. In severe ongoing PPH, hysterectomy has been the ultima ratio for many decades. Nowadays, interventional embolization of the pelvic arteries (PAE) has become a popular alternative. Besides being a highly effective minimally invasive method, PAE avoids hysterectomy with consecutively reduced morbidity and mortality. However, data on the long-term effects of PAE on fertility and menstrual cycle are scarce. Methods: We performed a monocentric study consisting of a retro- and a prospective part including all women who had undergone a PAE between 2012 and 2016 at University Hospital Zurich. Descriptive characteristics of patients and efficacy of PAE defined as cessation of bleeding were analyzed retrospectively. In the prospective part, all patients were contacted for a follow-up questionnaire regarding menstruation and fertility after embolization. Results: Twenty patients with PAE were evaluated. Our data showed a success rate of PAE in 95% of patients with PPH; only 1 patient needed a second, then successful, PAE. No patient needed a hysterectomy or any other surgical intervention. In our study, an association between mode of delivery and identified etiology of PPH is observed. After spontaneous delivery (n = 6), the main reason of severe PPH was retained placenta (n = 4), while after cesarean section (n = 14), uterine atony was identified in most cases (n = 8). Regarding menstruation after embolization, all women reported regular menstruation after the breastfeeding period (100%). The majority reported a regular pattern with a shorter or similar duration (73%) and lower or similar intensity (64%). Dysmenorrhea decreased in 67% of patients. Four patients planned another pregnancy, of whom only one had become pregnant with assisted reproductive technology and ended up in a miscarriage. Discussion: Our study confirms the efficacy of PAE in PPH, thus obviating complex surgical interventions and associated morbidity. The success of PAE does not depend on the primary cause of PPH. Our results may encourage the prompt decision to perform PAE in the management of severe PPH in case of failure of conservative management and help physicians in the post-interventional counseling regarding menstruation patterns and fertility.

Natural pigment production technology using Senduduk leaves (Melastoma malabathricum L.) in preventing the risk of postpartum hemorrhage at the Murniati Maternity Clinic, Asahan Regency in 2022

Several causes of postpartum hemorrhage include: uterine atony, trauma and lacerations, placental retention, and thrombophilia. Losing a lot of blood causes signs of shock, namely paleness, low blood pressure, fast and small pulse, cold extremities, and so on. The purpose of this research is to make senduduk leaves as a medical ingredient to treat postpartum hemorrhage that occurs due to pathological labor conditions that do not have side effects. The research method used an analytic experimental approach with a post-test only with control group design. The experimental group and the control group were not randomly selected. The experimental class received treatment while the control class did not receive treatment. The research was conducted at the Murniati Maternity Clinic, Asahan District. The results of the analysis showed that the value of the risk of postpartum hemorrhage in the intervention group did not experience bleeding, 8 respondents or equal to (80%). Most of the risk values for postpartum hemorrhage in the control group experienced bleeding, as many as 7 respondents or (70%). There is an influence of natural pigment production technology using senduduk leaves in preventing the risk of postpartum hemorrhage at the Murniati Maternity Clinic in 2022 with p = 0.035, (&lt;0.05).

Trans-arterial embolization for intractable primary postpartum hemorrhage caused by arterial aneurysms with arteriovenous fistulas in the lower vagina bilaterally: a case report

Failure of conservative management for controlling postpartum hemorrhage (PPH) is not uncommon, particularly when PPH is caused by vascular lesions. Awareness of this possibility and initiating timely trans-arterial embolization (TAE) are essential for improving the outcome. Herein, we describe the case of a 34-year-old woman presenting with arterial aneurysms with arteriovenous fistulas in the lower vagina bilaterally, which caused intractable PPH. Conservative management failed to resolve the PPH; however, TAE successfully controlled the bleeding, and the patient recovered smoothly. Knowledge of this possible etiology for intractable PPH is crucial for timely TAE. This case report aims to highlight the pivotal role of TAE in detecting and treating this unusual cause of PPH.

Protocol for postpartum haemorrhage including massive transfusion.

Postpartum haemorrhage (PPH) is one of the most common causes of maternal mortality worldwide. Management of PPH depends on the severity of bleeding. If the bleeding is severe, aorta compression can reduce bleeding. It should be followed by insertion of two coarse needles for intravenous access and blood sampling for haemoglobin and haemostasis. Further on, monitoring of vital parameters, as well as provision of extra oxygen and warm crystalloids, should be performed. Uterine atony is the most common cause of PPH and local guidelines for uterotonic drug selection should be followed. Patients with ongoing bleeding should immediately receive surgical care for bleeding control. During severe ongoing bleeding, haemostasis care includes early tranexamic acid, transfusion in ratio 4:4:1 (blood:plasma:platelets), and extra fibrinogen intravenously. If not severe PPH, use goal-directed therapy. During general anaesthesia and uterine atony, stop volatile anaesthesia and change to intravenous anaesthesia.

Frequency and Clinical Outcomes of Women with Postpartum Hemorrhage at a Tertiary Care Hospital

Background and aim: Postpartum hemorrhage (PPH) is still a leading cause of maternal morbidity and mortality globally. Postpartum hemorrhage is characterized as excessive bleeding (&gt; 500 ml) from the vaginal tract following childbirth. The present study aimed to determine the frequency and clinical outcomes of women with postpartum hemorrhage. Materials and Methods: This cross-sectional study was conducted on 1346 patients who underwent vaginal delivery in the department of obstetrics and gynecology, Kausar Hospital, Khairpur Mirs from March 2021 to March 2022. The study included all the women who had postpartum hemorrhage following vaginal birth in the labor room or who were referred with primary postpartum hemorrhage. Patients with prior history of bleeding disorders and on warfarin were excluded from the study. SPSS version 26 was used for data analysis. Results: Of the total 1346 patients, the prevalence of postpartum hemorrhage was 12.6% (n=170). Out of 170 PPH cases, the incidence of primary and secondary PPH was 138 (81.2%) and 32 (18.8%) respectively. The age-wise distribution of patients were as follows: 26 (15.3%) had &lt;20 years, 62 (36.4%) in 21-30 years, 68 (40.1%) in 31-40 years, and 14 (8.2%) in &gt;40 years. The incidence of primiparas, multipara, and grand multipara were 34 (20%), 58 (34.1%), and 78 (45.9%) respectively. The booked and unbooked patients were 56 (32.9%) and 114 (67.1%) respectively. Among 170 PPH patients, the incidence of spontaneous vaginal delivery, instrumental delivery, and cesarean section were 52 (30.6%), 56 (32.9%), and 62 (36.5%) respectively. The major causes of PPH was uterine atony, perineal and vaginal tears, and prolong labor found in 112 (65.9%), 56 (32.9%), and 38 (22.4%) respectively. Conclusion: The present study concluded that the prevalence of PPH was 12.6% among total cases. Primary PPH was more prevalent than secondary PPH and uterine atony was the most common cause followed by perineal and vaginal tears and prolong labor. Additionally, unbooked patients were more susceptible to PPH. Risk factors assessment, unnecessary induction, and third stage labor active management can prevent the PPH. Keywords: Postpartum hemorrhage, Clinical outcomes, Uterine atony

A Case of Ischemic Necrosis of the Uterus Secondary to Infection Following Cervical Suturing for Lack of Uterine Contraction during Cesarean Delivery and Review of the Literature

Weak uterine contractions during cesarean section are the most common cause of Postpartum Hemorrhage (PPH) [1], accounting for 70-80% of cases, with a progressive increase [2-4], For weak uterine contractions in addition to the first use of uterine contraction agents, when they are ineffective, surgical treatment needs to be used as early as possible [5,6].

DETERMINANTS OF OUTCOME OF MAJOR POSTPARTUM HAEMORRHAGE

Postpartum haemorrhage is the most common type of obstetric haemorrhage and accounts for the majority of cases. Traditionally primary postpartum haemorrhage is dened 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). Major is further divided into moderate (1000-2000 ml) and severe (more 1 than 2000 ml) . Secondary PPH is dened as abnormal or excessive bleeding from the birth canal and between 24 hours 1 and 12 weeks postnatally . 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 malformations.