Incidence Of Primary Postpartum Haemorrhage Research Articles

Delayed versus early umbilical cord clamping for near-term infants born to preeclamptic mothers; a randomized controlled trial

ObjectiveThis study aims to assess delayed versus early umbilical cord clamping in preeclamptic mothers undergoing scheduled caesarean delivery regarding the maternal intra-operative blood loss and neonatal outcomes.MethodsA clinical trial was conducted on 62 near-term preeclamptic mothers (36-38+6 weeks) who were planned for caesarean delivery. They were randomly assigned into two groups. The first group was the early cord clamping (ECC) group (n= 31), in which clamping the umbilical cord was within 15 seconds, while the second group was the delayed cord clamping (DCC) group (n= 31), in which clamping the umbilical cord was at 60 seconds. All patients were assessed for intra-operative blood loss and incidence of primary postpartum haemorrhage (PPH). Otherwise, all neonates were assessed for APGAR scores, the need for the neonatal intensive care unit (NICU) admission due to jaundice, and blood tests (haemoglobin, haematocrit. and serum bilirubin).ResultsThere was not any significant difference between the two groups regarding the maternal estimated blood loss (P=0.673), the rates of PPH (P=0.1), post-delivery haemoglobin (P=0.154), and haematocrit values (P=0.092). Neonatal outcomes also were showing no significant difference regarding APGAR scores at the first minute (P=1) and after 5 minutes (P=0.114), day 1 serum bilirubin (P=0.561), day 3 serum bilirubin (P=0.676), and the rate of NICU admission (P=0.671). However, haemoglobin and haematocrit values were significantly higher in the DCC group than in the ECC group (P<0.001).ConclusionThere is no significant difference between DCC and ECC regarding maternal blood loss. However, DCC has the advantage of significantly higher neonatal haemoglobin.Trial registrationIt was first registered at ClinicalTrials.gov on 10/12/2019 with registration number NCT04193345.

Incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia.

BackgroundOf the 1010 reported maternal deaths in 2018, just over 65% occurred in hospitals in Ethiopia. However, there is a lack of standardised data about the contributing factors. This study aimed to investigate the incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births in northwest Ethiopia.MethodsA retrospective cohort design was used; an audit of 1060 maternity care logbooks of adult women post-partum at Felege Hiwot Referral Hospital and University of Gondar Comprehensive Specialized Hospital. The data were abstracted between December 2018 and May 2019 using a systematic random sampling technique. We used the Facility Based Maternal Death ion Form containing sociodemographic characteristics, women’s medical history, and partographs. Primary postpartum haemorrhage was defined as the estimated blood loss recorded by the staff greater or equal to 500 ml for vaginal births and 1000 ml for caesarean section births, or the medical doctor diagnosis and recording of the woman as having primary postpartum haemorrhage. The data analysis was undertaken using Stata version 15. Variables with P ≤ 0.10 for significance were selected to run multivariable logistic analyses. Variables that had associations with primary postpartum haemorrhage were identified based on the odds ratio, with 95% confidence interval (CI) and P-value less than 0.05.ResultsThe incidence of primary postpartum haemorrhage in the hospitals was 8.8% (95% CI: 7.2, 10.6). Of these, there were 7.4% (95% CI: 2.1, 13.3) maternal deaths. Eight predictor variables were found to be independently associated with primary postpartum haemorrhage, including age ≥35 years (AOR: 2.20; 95% CI: 1.08, 4.46; P = 0.03), longer than 24 hours duration of labour (AOR: 7.18; 95% CI: 2.73, 18.90; P = 0.01), vaginal or cervical lacerations (AOR: 4.95; 95% CI: 2.49, 9.86; P = 0.01), instrumental (forceps or vacuum)-assisted birth (AOR: 2.92; 95% CI: 1.25, 6.81; P = 0.01), retained placenta (AOR: 21.83; 95% CI: 6.33, 75.20; P = 0.01), antepartum haemorrhage in recent pregnancy (AOR: 6.90; 95% CI: 3.43, 13. 84; p = 0.01), women in labour referred from primary health centres (AOR: 2.48; 95% CI: 1.39, 4.42; P = 0.02), and births managed by medical interns (AOR: 2.90; 95% CI: 1.55, 5.37; P = 0.01).ConclusionWe found that while the incidence of primary postpartum haemorrhage appeared to be lower than in other studies in Africa the associated maternal mortality was higher. Although most factors associated with primary postpartum haemorrhage were consistent with those identified in the literature, two additional specific factors, were found to be prevalent among women in Ethiopia; the factors were referred women in labour from primary health facilities and births managed by medical interns. Maternal healthcare providers in these hospitals require training on the management of a birthing emergency.

Effects of multifaceted interventions to prevent and manage primary postpartum haemorrhage in referral hospitals: a quasi-experimental study in Nigeria

IntroductionPrimary postpartum haemorrhage (PPH) is the leading cause of Nigeria’s high maternal mortality rate. This study investigated the effectiveness of a set of multifaceted interventions to manage and reduce PPH...

325The incidence of primary postpartum haemorrhage following in-hospital birth: a systematic review and meta-analysis

Abstract Background Although primary postpartum haemorrhage is a leading cause of maternal mortality, in the wider literature, there is inconsistent results in studies about its incidence. This study was designed to determine the pooled incidence of primary postpartum haemorrhage among women following in-hospital births. Methods This review used a systematic review and meta-analysis approach. We systematically searched electronic databases of Ovid MEDLINE, Ovid Emcare, Embase, PsycINFO, and CINAHL. Studies reporting the incidence of primary postpartum haemorrhage following in-hospital births were included. The pooled incidence of primary postpartum haemorrhage with a 95% confidence interval was calculated using random-effects model. Heterogeneity test between studies, and publication bias were assessed with I-square statistics and Egger’s test respectively. Results Ten of the 1548 studies were found to be eligible and were included in this systematic review and meta-analysis. The pooled incidence of primary postpartum haemorrhage following in-hospital births was nearly 12% (95% CI: 7.74- 17.61), with no evidence of between studies heterogeneity. Conclusions The incidence of primary postpartum haemorrhage following in-hospital births was high, and suggest that preventive strategies implemented to reduce its occurrence needs further strengthening using training. Key messages The result of this review suggests that globally at least one in ten women experience a primary postpartum haemorrhage following in-hospital births. This is higher than anticipated. The application of the recommended strategies for the prevention of primary postpartum haemorrhage should be re-emphasized.

322Incidence, and mortality associated with primary postpartum haemorrhage following hospital births in northwest Ethiopia

Abstract Background Primary postpartum haemorrhage remains the primary cause of maternal mortality, in low-resource countries such as Ethiopia. National datasets about the incidence of primary postpartum haemorrhage are often limited, incomplete or unavailable. This study was designed to determine the incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births. Methods This was a cross-sectional study design, an audit of 1060 maternity care logbooks of discharged women. The data were abstracted December to May 2018/2019 using systematic random sampling. The tool used was the Facility Based Maternal Death Abstraction Form. Data were entered, cleaned then analysed using SPSS version 25. Bivariate logistic regression was fitted. Adjusted odds ratio with 95% confidence interval was used to determine the statistical significance. Results The incidence of primary postpartum haemorrhage was nearly 9.0% (95% CI: 6.91, 10.73). Of these, there was 7% maternal mortality. Unique to women in Ethiopia health facility referrals of women in labour (AOR: 2.13; 95% CI: 1.19, 3.80), birth attended by final year medical students (AOR: 3.59; 95% CI: 1.89, 6.84), women who were discharged as early as six hours following birth (AOR: 3.50; 95% CI: 1.24, 9.91) were associated with primary postpartum haemorrhage (p &amp;lt; 0.05). Conclusions The reported incidence of primary postpartum haemorrhage was relatively low, however, the associated deaths of women found was comparatively high. Key messages The increased maternal mortality appears to be directly related to the three delays model.

Assessment of von Willebrand disease and pregnancy outcomes at regional Australian hospitals.

von Willebrand disease (vWD) is a heterogeneous hereditary bleeding disorder and is associated with risk of primary postpartum haemorrhage (PPH). An observational study at a tertiary referral centre in Australia of 16 women with 23 deliveries with a median age of 27.5years (range, 21-39; IQR=9). Median gestational age at delivery was 39weeks (range, 35-41; IQR=1.1). All cases had type 1 vWD, apart from one case with type 2. Patients were managed in combined obstetrics and haematology clinics. PPH occurred in ten deliveries (44%). Intravenous desmopressin was administered in 6 cases, and IV human vWF was administered in 4 cases. Two cases with mild vWD had received oral tranexamic acid. The median Apgar score at 1 and 5min was 9 (IQR=1.0), while the median Apgar score at 10min was 10.0 (IQR=0.0). One case required transfusion of blood products postdelivery. There were no other significant complications observed. vWD was associated with a high incidence of primary PPH. Individualised treatment to restore haemostasis, according to the severity of the disease, could achieve as possible, normal haemostasis with favourable outcomes for both mothers and their infants. Further studies to confirm our findings are warranted.

Incidence, and mortality associated with primary postpartum haemorrhage in northwest Ethiopia

Abstract Background Primary postpartum haemorrhage remains the primary cause of maternal mortality, in low-resource countries such as Ethiopia. National datasets about the incidence of primary postpartum haemorrhage are often limited, incomplete or unavailable. Objective This study was designed to determine the incidence and mortality associated with primary postpartum haemorrhage following in-hospital births in Ethiopia. Methods A cross-sectional study design, this study was an audit of 1060 maternity care logbooks (medical records) of discharged women. The data were abstracted from December to May 2018/2019 using systematic random sampling technique. The tool used was the Facility Based Maternal Death Abstraction Form, adapted from the Maternal and Perinatal Death Response Team of Ethiopia. Data were entered and cleaned then analysed using SPSS version 25. Bivariate logistic regression was fitted. Adjusted odds ratio with 95% confidence interval was used to determine the statistical significance. Results The incidence of primary postpartum haemorrhage was nearly 9.0% (95% CI: 6.91, 10.73). Of these, there was 7% maternal mortality. Unique to women in Ethiopia health facility referrals of women in labour (AOR: 2.13; 95% CI: 1.19, 3.80), birth attended by final year medical students (AOR: 3.59; 95% CI: 1.89, 6.84), women who were discharged at six hours following birth (AOR: 3.50; 95% CI: 1.24, 9.91) were associated with primary postpartum haemorrhage (p &amp;lt; 0.05). Conclusions This study found that the reported incidence of primary postpartum haemorrhage was relatively low, however, the associated deaths of women found was comparatively high. Key messages The increased maternal mortality appears to be associated with the three delays model ‘delay in seeking care’; ‘delay in reaching health care’ and ‘delay in receiving quality care’. Maternal mortality and morbidity in Ethiopia are influenced by delays in deciding to seek care, delay in reaching the health facility, and delay in receiving quality care.

Incidence and Mortality Associated with Primary Postpartum Haemorrhage Following In-Hospital Births in Northwest Ethiopia

Background: Primary postpartum haemorrhage remains the primary cause of maternal mortality in low-resource countries such as Ethiopia. National datasets about the incidence of primary postpartum haemorrhage are often limited, incomplete or unavailable. This study was designed to determine the incidence, mortality, and factors associated with primary postpartum haemorrhage following in-hospital births. Methods : This was a cross-sectional study design, an audit of 1060 maternity care logbooks of discharged women. The data were abstracted December to May 2018/2019 using systematic random sampling. The tool used was the Facility Based Maternal Death Abstraction Form. Data were entered, cleaned then analysed using SPSS version 25. Bivariate logistic regression was fitted. Adjusted odds ratio with 95% confidence interval was used to determine the statistical significance. Findings: The incidence of primary postpartum haemorrhage was nearly 9.0% (95% CI: 6.91, 10.73). Of these, there was 7% maternal mortality. Predominant to women in Ethiopia health facility referrals of women in labour (AOR: 2.13; 95% CI: 1.19, 3.80), birth attended by a medical intern (AOR: 3.59; 95% CI: 1.89, 6.84), women who were discharged six hours following birth (AOR: 3.50; 95% CI: 1.24, 9.91) were associated with primary postpartum haemorrhage (p<0.05). Conclusion: This study found that the reported incidence of primary postpartum haemorrhage was relatively low. However, the associated deaths of women found was comparatively high. Three factors prevail for women in Ethiopia, women discharged 6 hours postpartum, transfers from primary health centres, birth attendance by a medical intern. Funding Statement: This study was unfunded. Declaration of Interests: The authors declare that there are no conflicts of interest. Ethics Approval Statement: Before commencing data collection ethics approval was sought and approved by Human Research Ethics Committee, Monash University (Project ID: 14113) on 24/08/2018 and Institutional Review Board for Human Research of the University of Gondar on December 20/2018. As the women were already discharged, and not all contactable in rural areas, they could not consent to this research retrospectively providing permission to the reviewing of their maternity care logbooks. The ethics committees granted a waiver of consent.

EFFECTS OF SUBLINGUAL MISOPROSTOL AS ADJUNCT TO OXYTOCIN FOR ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR IN PATURIENTS AT RISK OF POST-PARTUM HAEMORRHAGE IN ABAKALIKI : A COMPARISON OF 200 VERSUS 400 MICROGRAMS

Background: Postpartum Haemorrhage (PPH) still remains a major cause of maternal mortality despite adequate knowledge of its causes and treatment. Oxytocin administration is one of the major components of active management of third stage of labour (AMTSL). Evidence suggest benefit of misoprostol as an adjunct however optimal dose is yet to be determine considering the dose depended side effect profile of misoprostol. . Objective: This study evaluated the efficacy and side effect profile of 200µg versus 400µg of prophylactic sublingual misoprostol as adjunct to AMTSL among parturient at risk for PPH. Methods: This was a double blinded, single centre, randomized controlled trial involving two hundred and forty parturient with 2.1% drop out rate , thus 235 of them were analyzed; 117 (48.8%) and 118(49.2%) for 200 and 400 microgram group respectively. Data was analyzed using Statistical Package for Social Science (IBM SPSS) software (version 24, Chicago II, USA). Continuous variables were presented as mean and standard deviation (Mean ± 2SD), while categorical variables were presented as numbers and percentages. Chi-square test (X2) was used for comparison between groups for qualitative variables while t-test was used for comparison between groups for quantitative variables. A difference with a P value <0.05 was considered statistically significant. Results: The mean blood loss was similar between the 200µg and 400µg groups of the study with 280.68±179.40mls and 253.86±169.80mls for the 200µg and 400µg groups respectively and p=0.240. The occurrence of primary postpartum haemorrhage (PPH) was equally similar between the two groups with incidence of 9.4% and 7.6% for the 200µg and 400µg groups respectively, p=0.7997. The risk ratio (RR) for developing PPH was 0.888 (95% CI; 0.537-1.467). The need for additional oxytocics to control bleeding was equally the same between the study groups with p=0.132. However, more participants in the 400µg group had one or more of the side effects of sublingual misoprostol compared to the participants in the 200µg group with RR 1.5759 (95% CI; 1.239-2.004), p<0.001. Shivering and fever were the side effects with significant difference between the two groups with p-values of 0.015 and 0.023 for shivering and fever respectively. Conclusion: Sublingual misoprostol as an adjuvant to AMTSL in the doses of 200µg and 400µg are equally effective in reducing blood loss and the incidence of primary PPH, among women at increased risk for PPH. However, misoprostol induced side effects were significantly higher with 400µg.

Incidence, trends and severity of primary postpartum haemorrhage in Australia: A population-based study using Victorian Perinatal Data Collection data for 764244 births.

Increasing incidence and severity of postpartum haemorrhage, together with postpartum haemorrhage-associated morbidities, have been reported in many high-resource countries. In-depth analysis of such factors in Victorian births since 2002 was lacking. Our aim was to determine the incidence and trends for primary postpartum haemorrhage (World Health Organization and International Classification of Diseases 10th revision, Australian Modification definitions) for all confinements in Victoria, Australia, for the years 2003-2013 and the incidence and trends for severe postpartum haemorrhage (≥1500mL) for 2009-2013. In this population-based cross-sectional study de-identified data from the Victorian Perinatal Data Collection were analysed for confinements (excluding terminations) from 2003 to 2013 (n=764244). Perinatal information for all births ≥20weeks (or of at least 400g birthweight if gestation was unknown) were prospectively collected. One in five women (21.8%) who gave birth between 2009 and 2013 experienced a primary postpartum haemorrhage and one in 71 women (1.4%) experienced a severe primary postpartum haemorrhage. The increasing trends in incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage, blood transfusion, admission to an intensive care or high dependency unit and peripartum hysterectomy were significant (P<0.001). Women who had an unassisted vaginal birth had the lowest incidence of primary postpartum haemorrhage. The highest incidence was experienced by women who had an unplanned caesarean section birth. Women who had a forceps birth had the highest incidence of severe primary postpartum haemorrhage. The incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage and associated maternal morbidities have increased significantly over time in Victoria.

Primary Post-Partum Haemorrhage; the Pilgrim Hospital’s Experience, Boston, Lincolnshire, United Kingdom

Aim: This study was to investigate the incidence of primary post-partum haemorrhage (PPH), during the biennial period of 2007 to 2008; its management and outcomes and to learn from any peculiar challenges that the unit had faced in the management of these women in relation to PPH. The study was aimed to explore any significant risk factors, adverse outcomes and associated risks and compared these with standards, guidelines and other published acceptable practices. It was also aimed to critically appraise our methods of estimation of blood loss (EBL, blood loss) in the unit. Methods: We reviewed the Pilgrim Hospital Monthly Maternity Statistical Run from 2005 to 2008 for information on trends. We conducted a preliminary review of the Birth Register of 2007-8 with elimination criteria from the definition of primary postpartum haemorrhage (PPH), to identify the target population to be included in the study. Once the target population was identified, the investigators chose a study population of 100 of these women and had used a systematic approach to make sure that the study population clearly reflected with good precision, the target population. This was done as follows: Each of the 4 investigators had a group of 25 women to study and each group comprised of 8 women who had normal birth; 8 women who had vaginal operative deliveries; 8 women who had caesarean section and one additional woman with a mode of delivery randomly picked by each of the investigators but with this randomly picked mode of delivery different from that picked by the 3 other investigators. A careful review of 100 case notes was conducted in stages by investigators to ascertain the management these women and the outcomes of such management. The investigators met formally about three times and informally many times to articulate, review, updated and implement the strategies for the study. Results: From the preliminary screening, the following specific data was collated: i. The number of deliveries for 2007 was 1963 and that of 2008 was 2169. ii. The total number of deliveries for the same period was 4132. The number of women delivered whose blood loss met the criteria for PPH were 390 or giving rise to an incidence of 9.44% (cf 2-11%) for the 2 years (20072008) or average incidence of 4.72% (cf 2-11%) for each of the 2 years. iii. These 390 cases as stated earlier constituted the target population. The number of women whose blood loss did not meet the criteria were 621 (15.03%) for the same time frame. 100 cases (25.64%) of target population had been chosen as our study population as earlier stated. iv. In 44 women (1.06%), the blood loss was recorded as a range of values and therefore the incidence cannot be calculated based on the two figures in the range and thus

Carbetocin versus oxytocin for prevention of postpartum hemorrhage in obese nulliparous women undergoing emergency cesarean delivery

Objective: To assess and compare the effectiveness and safety of single IV polus dose of carbetocin, versus IV oxytocin infusion in the prevention of PPH in obese nulliparous women undergoing emergency Cesarean Delivery.Methods: A double-blinded randomized-controlled trial was conducted on 180 pregnant women with BMI >30. Women were randomized to receive either oxytocin or carbetocin during C.S. The primary outcome measure was major primary PPH >1000 ml within 24 h of delivery as per the definition of PPH by the World Health Organization Secondary outcome measures were hemoglobin and hematocrit changes pre- and post-delivery, use of further ecobolics, uterine tone 2 and 12-h postpartum and adverse effects.Results: A significant difference in the amount of estimated blood loss or the incidence of primary postpartum haemorrhage (>1000 ml) in both groups. Haemoglobin levels before and 24-h postpartum was similar. None from the carbetocin group versus 71.5% in oxytocin group needed additional utrotonics (p < 0.01). The uterine contractility was better in the carbetocin group at 2, and 12-h postpartum (p < 0.05).Conclusions: A single 100-µg IV carbetocin is more effective than IV oxytocin infusion for maintaining adequate uterine tone and preventing postpartum bleeding in obese nulliparous women undergoing emergency cesarean delivery, both has similar safety profile and minor hemodynamic effect.

A Ten-Year Review of Primary Postpartum Haemrrhage at a University Teaching Hospital, Sagamu, Nigeria: A Case-Control Study

Objective: To determine the incidence of primary postpartum haemorrhage, identify risk/aetiological factors contributing to primary postpartum haemorrhage and review the different therapeutic approaches in the management of primary postpartum haemorrhage. Method: A retrospective case-control study of all patients with primary postpartum haemorrhage from January 1, 2001 to December 31, 2010 at Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria. Result: In the period under review, 272 cases of primary postpartum haemorrhage were documented while there were a total of 5929 deliveries, giving an incidence of 1 in 26 (25.6%). The average blood loss in the cases reviewed was 1550 mls whilst in the controls, the average blood loss was 200 mls. There was statistical significant difference between the grandmultiparous cases and grandmultiparous controls (58.4% versus 16.5%, OR = 6.74, p

Primary post partum haemorrhage at the University Of Ilorin Teaching Hospital: a revisit

This study was a retrospective analysis of 545 patients who had primary postpartum haemorrhage (PPH) out of 8,110 patients who delivered spontaneously per vagina at the University of Ilorin Teaching Hospital between 1stJanuary 2001 to 31st December 2003. The incidence of PPH was 6.7% and it accounted for 31% of maternal death during the study period. Uterine atony, cervical laceration, episiotomy and perineal tears were the leading associated aetiologies. The identifiable risk factor for PPH in this study was third stage of labour lasting beyond 30 minutes. Although some factors have been associated with an increased incidence of uterine atony leading to PPH, large proportion of patients who develop PPH had no identifiable risk factors. Therefore every woman in labour is at risk of developing PPH and must be closely monitored after childbirth for signs of haemorrhage and institution of precise measures to address the problem. Keywords: post partum haemorrhage, uterine atony, and third stage of labour The Tropical Journal of Health Sciences Vol. 13(1) 2006: 10-14

B-Lynch sutures for major primary postpartum haemorrhage at caesarean section

SummaryThis was a retrospective observational study of 11 consecutive patients of major primary postpartum haemorrhage (PPH) who had the B-Lynch suture at the time of caesarean section, performed between 1 March 2001 and 31 March 2004 at a teaching hospital in Scotland. Case-note review was performed in 123 patients, who had major primary PPH to identify patients who had B-Lynch sutures at the time of caesarean section. The patient's age, parity, gestation of pregnancy at which the B-Lynch suture was performed, the indication for caesarean section and the cause of primary major PPH were recorded. The operative details, intraoperative and immediate postoperative complications and the need for subsequent hysterectomy were noted. The patients were followed-up with clinic visits at 6 weeks and any further hospital referral for late postoperative complications and whether subsequent successful pregnancy was achieved, were documented. The incidence of major PPH in our centre was 0.5% of the total deliveries, of which 11 cases had the B-Lynch suture applied at the time of caesarean section. The patients were aged between 25 and 38 years old (mean 31 years). Parity ranged from 0 to 1 and the gestational age at which the procedure was performed ranged from 34 to 41 weeks (mean 38 weeks). Ten operations (91%) were performed by senior registrars supervised by the consultant on call and one (9%) case was performed by a consultant on call. All cases had the B-Lynch sutures performed for major primary PPH caused by uterine atony at the time of caesarean section. The weight of the babies delivered ranged between 2,110 – 4,820 g (mean 3,500 g). The total blood loss at surgery ranged from 2,000 – 10,000 ml (mean 3,500 ml). Only three patients (28%) required hysterectomy. All the patients made a good postoperative recovery. The hospital stay ranged from 4 – 24 days (mean 8 days). The patient who remained in hospital for 24 days did so because her baby was admitted into the neonatal unit. All the patients were reviewed 6 weeks postnatally. There was no significant morbidity. A subsequent successful pregnancy has been achieved in one patient.

Primary postpartum haemorrhage in an Australian tertiary hospital: a case‐control study

The present study aimed to determine the incidence of primary postpartum haemorrhage (PPH) after vaginal birth at an Australian tertiary hospital, and to investigate risk factors for primary PPH at this hospital. A case-control study of women delivering vaginally at a tertiary hospital from February to June 2003 was performed. Demographic, antenatal, intrapartum, treatment and outcome data were abstracted from patient records. The study population comprised 125 cases and 125 controls, with a primary PPH rate of 12.1 per 100 vaginal births. Risk factors on multivariate analysis were past history of PPH, second stage labour > 60 min, forceps delivery, and incomplete placenta/ragged membranes.

Analysis of 348 consecutive cases of primary postpartum haemorrhage at a tertiary hospital in Nigeria

A retrospective analysis of 348 cases of primary postpartum haemorrhage (PPH) that occurred at the University of Ilorin Teaching Hospital, Ilorin, Nigeria between 1 January 1993 and 31 December 1996 was carried out. The incidence of PPH was 4.5%. Booking status of the patients had no relation with occurrence of PPH in this study (P > 0.05). The risk of PPH in advanced maternal age (over 35 years) and grandmultiparity (para 5 and over) was twofold higher than low maternal age (< 25 years) and low parity (para 0–1), P < 0.05, respectively. The incidence of PPH was higher in deliveries conducted by midwives than doctors (P < 0.05). Anaemic patients (PCV ⩽ 30%) were more at risk than non-anaemic patients (P < 0.05). Uterine atony, 183 (53.8%) was the most common cause of PPH and a combination of uterotonic agents and uterine massage were effective in controlling PPH in 171 (49.1%) of the cases. Seven (2.0%) patients required hysterectomy. One-third of the patients had a blood transfusion. To reduce the incidence of PPH, we recommend that doctors should supervise the delivery of parturients at risk of PPH and advocate health education against high parity.

A prospective randomised trial to compare the efficacy and safety of Hemabate and Syntometrine for the prevention of primary postpartum haemorrhage

In a prospective, open-label, assessor-blind, randomised parallel group study the efficacy and safety of Hemabate (Pharmacia-Upjohn Pharmaceuticals, Milton Keynes, Buckinghamshire) an analogue of 15-methyl-prostaglandin (PGF2α) analogue was compared with Syntometrine (Alliance Pharmaceuticals, Chippenham, Wilts) the standard combination of ergometrine and syntocinon used for the active management of the third stage of labour and the prevention of primary postpartum haemorrhage (PPH). The study was set in a district general hospital with approximately 4,000 deliveries annually. The study was discontinued at the time of the interim analysis because of unacceptable gastrointestinal side effects. At the time of the interim analysis, a total of 529 women had completed the study with 263 randomised to receive PGF2α and 266 to receive ergometrine and syntocinon. In a pre-specified subgroup analysis, women delivered vaginally were further subdivided into those considered to be at high or low risk of primary PPH. The measured blood loss and incidence of PPH was similar in both treatment groups whether delivered by caesarean section or vaginally independent of whether women were considered to be at high or low risk. Adverse gastrointestinal events were recorded more often in the Hemabate group. The most common symptom was diarrhoea which occurred in 21% of women who received Hemabate compared to only 0.8% of Syntometrine users. PGF2α is as effective as Syntometrine in the prophylaxis of primary PPH in all groups studied but there was a statistically significantly increased risk of diarrhoea among users of PGF2α.

Pregnancy in women with von Willebrand's disease or factor XI deficiency.

To assess the obstetric outcome in women with von Willebrand's disease or factor XI deficiency. Haemophilia Centre and Haemostasis Unit, The Royal Free Hospital. Women with von Willebrand's disease (n = 31) and with factor XI deficiency (n = 11) registered at the Royal Free Hospital Haemophilia Centre who had had a pregnancy within the previous 17 years (1980-1996), including 84 in women with von Willebrand's disease and 28 in women with factor XI deficiency. Women were interviewed and details of the obstetric history were obtained. The records of the Haemophilia Centre and the women's maternity records were also reviewed. Threatened miscarriage occurred in 33% and 14% of pregnancies with von Willebrand's disease and factor XI deficiency, respectively. Excluding recurrent miscarriages, 14/68 (21%) of pregnancies with von Willebrand's disease and one pregnancy with factor XI deficiency miscarried spontaneously. There was an increased incidence of primary and secondary post-abortal bleeding complications. Factor VIII and von Willebrand factor antigen and activity levels increased significantly in pregnancy in all women apart from those with severe von Willebrand's disease. Factor XI, however, did not show any significant change. No neonatal haemorrhagic complications in association with the birth process were reported, although ventouse and difficult forceps deliveries were avoided. Extensive perineal bruising and haematoma was reported in three women with von Willebrand's disease; two of these were associated with forceps delivery. The incidence of primary postpartum haemorrhage was 18.5% in von Willebrand's disease and 16% in factor XI deficiency. Blood transfusion was required in six cases of von Willebrand's disease and two cases of factor XI deficiency. Ten of fourteen instances of primary postpartum haemorrhage occurred when maternal factor levels were < 50 IU/dL with no prophylactic treatment for labour. The incidence of secondary postpartum haemorrhage was 20% in von Willebrand's disease and 24% in factor XI deficiency. None of the women who had prophylactic treatment during labour or the puerperium suffered any significant bleeding complications. There were three neonatal bleeding complications. Pregnancy, labour and the puerperium are associated with significant bleeding problems in women with von Willebrand's disease or factor XI deficiency, but these are largely preventable. Specialist obstetric care in close liaison with the haemophilia centre is essential to minimise maternal and neonatal complications.