Primary Primary Postpartum Haemorrhage Research Articles

Trends, causes and factors associated with primary Postpartum Haemorrhage (PPH) in Ireland: A review of one million hospital childbirths

ObjectiveTo analyse temporal trends for primary Postpartum Haemorrhage (PPH), Major Obstetric Haemorrhage (MOH) between 2005 and 2021 and to examine the causes and factors contributing to the risk of PPH during 2017–2021. MethodsInternational ICD-10-AM diagnostic codes from hospital discharge records were used to identify cases of PPH. Temporal trends in PPH and MOH incidence were illustrated graphically. Poisson regression was used to assess the time trends and to examine factors associated with the risk of PPH during 2017–2021. ResultsA total of 1,003,799 childbirth hospitalisations were recorded; 5.6% included a diagnosis of primary PPH. Risk increased almost fourfold from 2.5% in 2005 to 9.6% in 2021. The ICD-10 AM code for other immediate primary PPH was recorded for 85% of PPH cases in 2017–2021 whereas a diagnosis of uterine inertia/atony was associated with just 3.6% of the cases. Respectively, trauma-related, tissue-related and thrombin-related causes were associated with one third, 4.2% and 0.5% of cases. A wide range of factors relating to the woman including comorbidities, mode of delivery, labour-related interventions and associated traumas increased risk of PPH but placental complications, especially morbidly adherent placenta, were strong risk factors. ConclusionsImprovement in detection and anticipation of placental complications may be effective in addressing the increasing trend of PPH, however, the trends of increasing C-sections and other interventions may also need to be addressed while staff education and quality improvement projects will have a role to play.

Primary postpartum haemorrhage adversely impacts breastfeeding initiation in Victoria, Australia

ProblemBreastfeeding has many important benefits for both mother and baby but sustained breastfeeding is sub-optimal. BackgroundIdentifying women who need increased support to establish breastfeeding has the potential to improve this. Analysis of the relationship between primary postpartum haemorrhage (PPH) and primary severe PPH and breastfeeding may prove informative as PPH has potentially negative impacts on breastfeeding. AimTo determine the relationship between PPH and severe PPH and breastfeeding at postnatal discharge and formula use for breastfed babies in hospital. MethodsPopulation-based retrospective cohort study using the Victorian Perinatal Data Collection for all liveborn singleton births at ≥ 37 weeks’ gestation (n = 339,854) for 2009–13 in Victoria. Estimated blood loss was categorised as PPH ≥ 500 mL and severe PPH ≥ 1500 mL. Descriptive analysis was conducted and multivariable logistic regression was used to determine the adjusted odds ratio for the relationship between PPH/severe PPH and breastfeeding outcomes after adjustment for relevant confounders. FindingsOverall, 94.9% of women initiated breastfeeding. Babies whose mother had a PPH or severe PPH were less likely than others to be exclusively breastfeeding at discharge (aOR 0.88; (95% CI 0.86, 0.90) and aOR 0.57; (95% CI 0.53, 0.61) respectively). Formula – given to 25.9% of all breastfed babies – was more likely for those whose mothers had a PPH or severe PPH (aOR 1.15; (95% CI 1.12, 1.17) and aOR 2.15; (95% CI 2.01, 2.29) respectively. ConclusionsWomen have greater challenges establishing exclusive breastfeeding following PPH and severe PPH. Improving support in hospital for women following PPH may increase breastfeeding success.

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.

Mechanical and surgical interventions for treating primary postpartum haemorrhage.

Mechanical and surgical interventions for treating primary postpartum haemorrhage.

Efficacy of balloon tamponade in control of primary postpartum haemorrhage (PPH).

Objectives: Primary postpartum haemorrhage (PPH) refers to excessive blood loss (>500ml) during 3rd stage of labour in the 1st 24 hours after delivery, thereafter, significant bleeding is referred to as secondary PPH. Its incidence is about 5% of deliveries. This study was conducted to note the efficacy of balloon tamponade in the control of PPH. Study Design: Experimental study. Setting: Department of Obstetrics and Gyne, Civil Hospital, Bahawalpur. Period: 1st January 2018 to 30th June 2018. Material & Methods: A total of 80 cases with Primary PPH after vaginal delivery were considered for this study. Cases with Bleeding disorders, ruptured uterus, retained products of conception, genital tract injuries or on anticoagulant therapy were excluded. All patients received balloon tamponade. Failure of control of bleeding was observed amongst all the patients. Results: Mean age, gestational age and parity were 24.54 years, 37.88 weeks and 3.17 respectively. Mean estimated blood loss was found to be 1125+320 ml, SBP 90.10+20.6 mmHg, DBP 57+7.2 mmHg and pulse 106+9.2 bpm. As far efficacy of balloon tamponade is concerned, it was noted in 71 (88.8%) women. When women were analyzed for maternal age, gestational age and parity status, no significant difference was found (P value > 0.05). Conclusion: Balloon tamponade has good efficacy (88.8%) in controlling PPH. Its ease of use in cases at increased risk of PPH makes it a suitable option.

Active versus expectant management for women in the third stage of labour.

Active versus expectant management for women in the third stage of labour.

Randomized controlled trial of three oxytocic regimens to prevent primary postpartum haemorrhage at caesarean section

The objective of this present study was to compare the efficacy of three oxytocic regimens to prevent primary postpartum haemorrhage (PPH) at caesarean section. A randomized controlled trial including 90 patients who underwent caesarean section were selected according to inclusion and exclusion criteria assigned randomly into three groups (30 patients in each group) was conducted. Group 1 and group 2 were exposure groups and group 3 was control group. All patients were given 10 units intravenous (IV) bolus oxytocin immediately after delivery of baby. Group 1 was given additional 20 units oxytocin in each 1000 ml fluid for 24 hours. Group 2 received additional 1000 microgram misoprostol per rectal. Group 3 did not receive any additional oxytocic drug. Background characteristics of all the three groups were similar. It was observed that 501-1000 ml blood loss was found among 25 (83.3%) cases in group 1, 27 (90.0%) in group 2 and 27 (90.0%) in group 3. The mean (SD) amount of blood loss was found 733 (190) ml in group 1792 (187) ml in group 2 and 818 (14) ml in group 3. Occurrence of PPH and blood transfusion needed among 1 (3.3%) in group 1, 2 (6.7%) in group 2 and 3 (10.0%) in group 3. Side effects occurred in 7 (23.3%) patients of group 1, 18 (60.0%) in group 2, and 6 (20.0%) in group 3. Shivering was found among 4 (13.3%) in group 1, 10 (33.3%) in group 2 and 3 (10%) in group 3. Vomiting was found among 2 (6.7%) in group 1, 4 (13.3%) in group 2, and 2 (6.7%) in group 3. Pyrexia was 1 (3.3%) in group 1, 4 (13.3%) in group 2 and 1 (3.3%) in group 3. Side effects were more in the group where misoprostol was used. Except side effects there was no statistical difference of occurrence of different events among the three groups. Only bolus IV oxytocin appears to be as effective as oxytocin infusion in addition to bolus IV oxytocin or per rectal misoprostol in addition to bolus IV oxytocin to prevent primary PPH at caesarean section. But occurrence of transient side effects such as shivering, pyrexia and vomiting were noted more frequently with the use of misoprostol.Mediscope Vol. 4, No. 2: Jul 2017, Page 5-11

Predictors of the success and failure of emergency pelvic artery embolisation for primary postpartum haemorrhage: a 12-year review.

This study aimed to identify predictors of the outcome and clinical efficacy of emergency pelvic artery embolisation (PAE) for primary postpartum haemorrhage (PPH) and to assess the post-embolisation fertility of PAE patients in a regional hospital setting. A 12-year retrospective study of patients undergoing emergency PAE was conducted at a regional acute general hospital. Clinical and procedural parameters, clinical outcomes and post-embolisation pregnancy success rates were analysed. There were 47,221 deliveries at the hospital during the study period, of which 33 patients required urgent PAE for primary PPH. The technical success rate of embolisation was 97.0% (n = 32). Clinically adequate haemostasis was achieved by a single embolisation procedure in 24 (72.7%) patients; the remaining eight eventually required surgery to achieve cessation of bleeding. Among the parameters studied, multivariate logistic regression analysis showed that pre-embolisation platelet count (p = 0.036) and maternal age (p = 0.019) were the only significant independent predictors of embolisation failure. Only two patients successfully conceived after PAE, although one of them had an ectopic pregnancy. Emergency PAE is an effective measure to arrest life-threatening bleeding in patients with primary PPH. As low pre-embolisation platelet count and advanced maternal age are associated with higher odds of embolisation failure, careful post-embolisation monitoring may be required for such patients. Embolisation also allows subsequent pregnancy. However, further studies are required to assess the outcomes of post-embolisation pregnancies.

Risk factors and surgical interventions associated with primary postpartum haemorrhage unresponsive to first-line therapies

The aim of this study was to investigate risk factors and surgical interventions associated with primary postpartum haemorrhage (PPH) unresponsive to first-line therapies. A retrospective analysis was performed of 212 women who experienced primary PPH (blood loss ≥ 500 ml). Logistic regression analysis identified that caesarean section (odds ratio [OR] 2.745; 95% confidence interval [CI], 1.063–7.085; p = 0.037) and abnormal placental adhesion (OR 3.823; 95% CI, 1.333–10.963; p = 0.013) were risk factors for PPH unresponsive to first-line therapies. There was no significant difference in blood loss, blood transfusion and success rate among intrauterine tamponade, B-Lynch suture and uterine artery ligation. Intrauterine tamponade is the least invasive and most rapid approach, so it should be taken as the first choice for surgical management after unresponsiveness to first-line therapies.

Treatment for primary postpartum haemorrhage.

Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries. To assess the effectiveness and safety of any intervention used for the treatment of primary PPH. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013). Randomised controlled trials comparing any interventions for the treatment of primary PPH. We assessed studies for eligibility and quality and extracted data independently. We contacted authors of the included studies to request more information. Ten randomised clinical trials (RCTs) with a total of 4052 participants fulfilled our inclusion criteria and were included in this review.Four RCTs (1881 participants) compared misoprostol with placebo given in addition to conventional uterotonics. Adjunctive use of misoprostol (in the dose of 600 to 1000 mcg) with simultaneous administration of additional uterotonics did not provide additional benefit for our primary outcomes including maternal mortality (risk ratio (RR) 6.16, 95% confidence interval (CI) 0.75 to 50.85), serious maternal morbidity (RR 0.34, 95% CI 0.01 to 8.31), admission to intensive care (RR 0.79, 95% CI 0.30 to 2.11) or hysterectomy (RR 0.93, 95% CI 0.16 to 5.41). Two RCTs (1787 participants) compared 800 mcg sublingual misoprostol versus oxytocin infusion as primary PPH treatment; one trial included women who had received prophylactic uterotonics, and the other did not. Primary outcomes did not differ between the two groups, although women given sublingual misoprostol were more likely to have additional blood loss of at least 1000 mL (RR 2.65, 95% CI 1.04 to 6.75). Misoprostol was associated with a significant increase in vomiting and shivering.Two trials attempted to test the effectiveness of estrogen and tranexamic acid, respectively, but were too small for any meaningful comparisons of pre-specified outcomes.One study compared lower segment compression but was too small to assess impact on primary outcomes.We did not identify any trials evaluating surgical techniques or radiological interventions for women with primary PPH unresponsive to uterotonics and/or haemostatics. Clinical trials included in the current review were not adequately powered to assess impact on the primary outcome measures. Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first-line therapy for the treatment of primary PPH. When used after prophylactic uterotonics, misoprostol and oxytocin infusion worked similarly. The review suggests that among women who received oxytocin for the treatment of primary PPH, adjunctive use of misoprostol confers no added benefit.The role of tranexamic acid and compression methods requires further evaluation. Furthermore, future studies should focus on the best way to treat women who fail to respond to uterotonic therapy.

PL.06 Treatment for Primary Postpartum Haemorrhage – A Cochrane Systematic Review

AimTo assess the effectiveness and safety of interventions used for the treatment of primary postpartum haemorrhage (PPH).MethodsWe searched the Cochrane Pregnancy and Childbirth Group’s Trials Register for randomised and quasi-randomised...

Efficacy of rusch intrauterine balloon in the management of postpartum haemorrhage – a practical review of a university hospital's experience

ObjectiveTo review the use of Rusch intrauterine balloon catheter in the management of primary postpartum haemorrhage (PPH) to establish efficacy and to allow the development of practical recommendations to guide...

Emotional and physical health outcomes after significant primary post-partum haemorrhage (PPH): A multicentre cohort study

Post-partum haemorrhage (PPH) rates are rising; however, data on the health impact on women are lacking. To describe the emotional and physical health outcomes for women following PPH. A cohort of 206 women with primary PPH of 1500 mL or more, and/or peripartum fall in haemoglobin concentration to 7 g/dL or less, and/or of 4 g/dL or less, was recruited from 17 Australian/New Zealand hospitals. Women completed questionnaires in the first week, and at two and four months post-partum. Obstetric details came from hospital records. Outcomes were anxiety; post-natal depression (PND); fatigue; post-traumatic stress disorder (PTSD); general health (SF-36); physical health problems; post-natal bleeding duration; hospital readmission. Eighty-three percent completed the two-month and 81% the four-month questionnaires; 28% reported bleeding continuously for more than six weeks; 10% required hospital readmission within two months. Anxiety scores were in the medium range; 11 and 13% were at risk of PND at two and four months, respectively; median total fatigue scores were 17 at two and 15 at four months; 5% showed evidence of PTSD at two and 3% at four months; women scored highly in most SF-36 categories and showed improvements over time in all but general and mental health. Physical health concerns were comparable to those reported for general post-natal populations, with the exception of uterine infection (6% at two months). In a cohort of women experiencing PPH, emotional and physical health outcomes were similar to those reported in general post-natal populations, with the exception of post-natal bleeding duration, uterine infection and hospital readmission.

Review of Primary Postpartum Haemorrhage in Sagamu, Nigeria

In the years 2000 to 2005, a total of 2443 booked deliveries were recorded in Olabisi Onabanjo University Teaching Hospital, Sagamu. One thousand seven hundred and seventy one [72.5%] patients delivered vaginally and six hundred and seventy two [27.5%] patients had caesarean section. Out of these deliveries, 76 had primary postpartum haemorrhage (PPH), giving a prevalence of 3.1%. Uterine atony and genital tract trauma were the main causes of the primary PPH. Associated factors were prolonged second and third stages of labour, induction and augmentation of labour with oxytocin and instrumental deliveries. To tackle and prevent the morbidity and mortality associated with PPH, there is need to anticipate it, actively manage third stage of labour, and promptly repair episiotomy sites as well as cervical and vaginal lacerations. The importance of supervised antenatal care and delivery in the hospital should be explained to expectant mothers. Nigerian Medical Practitioner Vol. 52 (3) 2007: pp. 51-54

Is primary postpartum haemorrhage a good predictor of inherited bleeding disorders?

A study was conducted to evaluate the value of screening for inherited bleeding disorders in women with primary postpartum haemorrhage (PPH). Over a 2-year period, women identified to have PPH (defined as >500 mL blood loss for spontaneous vaginal delivery, >700 mL for instrumental deliveries and >1000 mL for caesarean sections within 24 h of delivery) were invited to participate in this study testing for a possible underlying bleeding disorder at 3-9 months post-delivery. Women known to have an inherited bleeding disorder were excluded. Of the 5744 deliveries in our unit during the study period, 152 (3%) fulfilled the criteria for primary PPH and 50 women agreed to participate in the study. Of these, 25 (50%) had a spontaneous vaginal delivery, 8 (16%) had an instrumental delivery and 17 (34%) had a caesarean section. Half of the women were multiparous and five (20%) had PPH in their previous pregnancy. Nineteen (38%) and 12 (24%) reported at least one significant personal and family bleeding history, respectively. One (2%) woman was identified to have von Willebrand disease. In conclusion, primary PPH does not appear to be a strong predictor of inherited bleeding disorders. Further studies are required to assess the prevalence of inherited bleeding disorders among these women.

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.

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.