Risk Of Postpartum Hemorrhage Research Articles

Mild thrombocytopenia and the risk for postpartum hemorrhage in twin pregnancies.

We aimed to investigate the association of mild thrombocytopenia with postpartum hemorrhage (PPH) and blood transfusion among women with twin gestations. A retrospective cohort study (Jan 2015 to May 2019) was performed. Women with twin pregnancies and pre-delivery mild thrombocytopenia were compared to those with normal platelet count. The primary outcome was the rate of PPH, defined as a composite of one or more of the following: (1) need for packed red blood cell transfusion; (2) postpartum hemoglobin decline of ≥3g/dL; and (3) the use of postpartum uterotonics agents in addition to oxytocin. Of 1085 women who were included in final analysis, 315 (30.9%) had mild thrombocytopenia (and 770 (69.1%) served as controls. The rate of PPH was increased in the study group (14% vs. 9.4%, P =0.03), as was the use of uterotonic agents (3.8% vs. 1.3%, respectively, P =0.02). The rate of blood product transfusion and hemoglobin decline >3g/dL was not significantly different between the groups. In multivariate logistic regression analysis, mild thrombocytopenia was associated with a higher risk for PPH (OR 1.55 [95% CI 1.02-2.35], P =0.02). Mild thrombocytopenia in twin pregnancies is associated with an increased risk of interventions such as the use of uterotonic agents.

Analysis of Factors Affecting Postpartum Hemorrhage in Twin Pregnancy

Objective: To explore the factors affecting postpartum hemorrhage in twin pregnancy. Methods: The clinical data of 839 twin pregnancy patients who delivered at the Second Hospital of Shandong University from May 2010 to July 2020 were retrospectively analyzed. According to the amount of postpartum hemorrhage, patients were divided into postpartum hemorrhage group (PPH group) and non- PPH group. The basic population information and clinical data during pregnancy were compared between the two groups. Results: A total of 839 women with twin pregnancy were included in this study, and hemorrhage occurred in 11% (n=96). The Binary logistic regression model predicts the risk of factor of postpartum hemorrhage in twin pregnancy: gestation week of delivery, placenta previa, polyhydramnios, acute delivery, anemia, placental adhesions and DIC (disseminated intravascular coagulation). Conclusions: There are many factors that affect postpartum hemorrhage in twin pregnancy. Choosing the right gestational week for delivery, strengthening pregnancy management, and improving pregnancy complications can reduce the risk of postpartum hemorrhage in twin pregnancy.

Selective Serotonin Reuptake Inhibitor Use in Pregnancy and Risk of Postpartum Hemorrhage.

Selective serotonin reuptake inhibitors (SSRIs) may predispose to postpartum hemorrhage (PPH) by interfering with platelet-mediated hemostasis and serotonin-mediated myometrial contractility. A meta-analysis of 8 observational studies found that, regardless of drug class, gestational exposure to antidepressants was associated with a small (odds ratio, 1.25) but statistically significantly increased risk of PPH; however, this finding was true only when antidepressant exposure was proximal to the date of delivery. A recent, moderately large, nationally representative, Swedish observational study also found that gestational exposure to SSRIs was associated with a significantly increased risk of PPH; the crude number needed to harm was 48. For reasons related to the methodology employed, it is possible that the risk was underestimated in this study. The findings of the meta-analysis and of the observational study are examined with a view to help readers understand how to critically read and interpret the research literature in the field. A reasonable viewpoint is that the increase in risk of PPH associated with gestational exposure to SSRIs is smaller than the increase in risk associated with obstetric risk factors for PPH; nevertheless, following precautionary measures would be wise. Such measures would include the routine administration of a uterotonic agent immediately after delivery to all women who have received serotonin reuptake inhibitor treatment during the month preceding delivery; the choice of uterotonic agent would depend on local hospital protocols. Women at risk should also be closely monitored for continued blood loss during the first 24 hours after delivery.

The Impact of Intravenous Tranexamic Acid on Hemoglobin and Hematocrit Levels after Cesarean Delivery in Women at Low Risk for Postpartum Hemorrhage: A Randomized Controlled Trial

The Impact of Intravenous Tranexamic Acid on Hemoglobin and Hematocrit Levels after Cesarean Delivery in Women at Low Risk for Postpartum Hemorrhage: A Randomized Controlled Trial

A study protocol for the cardiac effects of a single dose of either oxytocin 2.5 IU or carbetocin 100 µg after caesarean delivery: a prospective randomized controlled multi-centre trial in Norway

Background: Both oxytocin and carbetocin are used to prevent uterine atony and post-partum haemorrhage after caesarean delivery in many countries, including Norway. Oxytocin causes dose-dependent ST-depression, troponin release, prolongation of QT-time and arrythmia, but little is known about myocardial effects of carbetocin. We have previously demonstrated comparable vasodilatory effects of oxytocin and carbetocin and are now undertaking a Phase 4 trial to investigate whether carbetocin causes similar changes to myocardial markers compared with oxytocin. Methods: Our randomized controlled trial will be conducted at three obstetrics units at Oslo University Hospital and Akershus University Hospital, Norway. Planned enrolment will be of 240 healthy, singleton pregnant women aged 18 to 50 years undergoing planned caesarean delivery. Based on pilot study data, each participant will receive a one-minute intravenous injection of either oxytocin 2.5 IU or carbetocin 100 µg during caesarean delivery. The prespecified primary outcome is the change from baseline in high-sensitive troponin I plasma concentrations at 6–10 hours after study drug administration. Secondary outcomes include uterine tone grade at 2.5 and five minutes after study drug administration, adverse events for up to 48 hours after study drug administration, estimated blood loss within eight hours of delivery, need for rescue treatment and direct/indirect costs. Enrolment and primary analysis are expected to be completed by the end of 2021. Discussion: Women undergoing caesarean delivery should be assessed for cardiovascular risk particularly as women with an obstetric history of pregnancy induced hypertension, gestational diabetes mellitus, preterm birth, placental abruption, and stillbirth are at increased risk of future cardiovascular disease. Any additional ischaemic myocardial risk from uterotonic agents will need to be balanced with the benefit of reducing the risk of postpartum haemorrhage. Any potential cardiotoxicity difference between oxytocin and carbetocin will help inform treatment decisions for pregnant women. Registration: Clinicaltrials.gov NCT03899961 (02/04/2019).

Maternal and child-health outcomes in different endometrial preparation methods for frozen-thawed embryo transfer: a retrospective study

The purpose of this study was to analyse the obstetric outcome after frozen embryo transfer depending on the protocol used. The endometrial preparation during frozen embryo transfer (FET) was performed in the natural cycle (NC) with timing based on monitoring of the naturally occurring luteinizing hormone (LH) peak or in human chorionic gonadotropin (hCG)-triggered modified natural cycles (MNC), artificial cycle (AC) with hormone replacement therapy cycle and cycle with ovulation induction (OI). A retrospective cohort study was conducted between 2018 and 2020. Pregnancy, perinatal complications and neonatal outcomes were compared among patients treated during AC or MNC or OI protocols. After adjusting for the effect of gravidity, parity, pre-pregnancy body mass index (BMI) and number of miscarriages, the AC group had higher but not significantly different rates of gestational hypertension, preeclampsia and intrahepatic cholestasis of pregnancy (ICP) than women in OI and MNC groups. Significant differences were observed in the rates of placental adherence (15.30% in AC vs. 9.24% in MNC, p = 0.004) and postpartum haemorrhage (PPH) (24.33% in AC vs. 13.07% in OI, p = 0.003, 24.33% in AC vs. 16.24% in MNC, p = 0.002) among the three groups. In singletons, significant differences were observed in the rates of placental adherence (14.09% in AC vs. 8.57% in MNC, p = 0.002), AC and MNC groups had higher risk of PPH compared with OI group (18.36% in AC vs. 12.38% in MNC, p = 0.042 and 7.69% in OI vs. 18.36% in AC, p = 0.013). Neonatal outcomes were similar among the three groups except risk of small for date infants (0.35% in AC vs. 1.44% in MNC, p = 0.008). These findings are important in view of increasing use of frozen cycles and new policy of freeze-all cycles in in vitro fertilization (IVF). The results suggest a link between the absence of corpus luteum and adverse obstetric outcomes.

Image Analysis Application of Motherwort Total Alkaloid Injection in the Treatment of Postabortion Hemorrhage.

In order to reduce the possibility of postabortion hemorrhage leading to maternal death, the author studied the image analysis of postpartum hemorrhage based on Leonurus total alkaloid injection, combining research results, in order to explore the curative effect of Leonurus injection in treating postpartum hemorrhage. After treatment, the time and volume of vaginal bleeding were significantly lower than those in the control group (P < 0.05); it is suggested that the combination of oxytocin and motherwort can effectively reduce the time and volume of vaginal bleeding after medical abortion, conducive to postoperative recovery. The results show that motherwort injection can effectively reduce the amount of bleeding and reduce the risk of postpartum hemorrhage; in addition, adverse reactions have been reduced, and an image analysis consensus has been formed, which is worthy of promotion.

Low Maternal Serum 25-Hydroxyvitamin D Concentration Is Associated With Postpartum Hemorrhage: A Retrospective Observational Study.

ObjectiveThe primary aim of this study is to investigate the relationship between vitamin D serum level and the incidence of postpartum hemorrhage (PPH). The secondary objective is to determine the relative risk of low vitamin D associated with PPH.MethodsThis was a retrospective observational study. A total of 600 women who had delivered their babies in a single tertiary teaching hospital were enrolled. Serum blood test for 25(OH)D was performed at 35 + 0 to 36 + 6 weeks of pregnancy to measure vitamin D. A 25(OH)D level < 20 ng/mL was defined as vitamin D deficient, and a level 21–29 ng/mL as insufficient.ResultsVitamin D levels were deficient in 145 (24.1%) and insufficient in 254 (42.3%) of the women tested. Women with deficient and insufficient vitamin D levels were significantly younger than those with sufficient vitamin D levels (p < 0.001). The overall rates of PPH in the deficient and insufficient groups were 6.9% (10/145) and 6.7% (17/254), respectively, and were significantly higher than the rate of the normal vitamin D group (1.5%, p = 0.009). Women with sufficient vitamin D levels had significantly higher hemoglobin levels than those with low vitamin D levels. Higher vitamin D levels were associated with a significantly low risk of PPH (AOR: 0.93, CI: 0.89–0.98, p = 0.006).ConclusionOur results suggest that a low vitamin D level is a risk factor for PPH. Low vitamin D also related to high risk of low hemoglobin before delivery. Thus, antepartum care should include vitamin D supplements for all women if possible.

Fetal macrosomia: analysis of the maternal and neonatal outcomes and complications

it is well known that the health of the child depends largely on the health of his mother during pregnancy. There are no clear criteria in the available sources and clinical protocols for predicting the risk of macrosomia, which may further adversely affect pregnancy management in general. Our aim was to analyze the maternal and neonatal outcomes and complications in Ukrainian cohort of patients during pregnancy with fetal macrosomia by conducting a prospective analysis of the history of pregnancies and childbirth of adolescent girls’ mothers with gynecological pathology, born with large to gestational age from the reference indicators. This was a retrospective cohort study. 68 histories of pregnancy and childbirth were analyzed. The incidence of maternal and neonatal complications in pregnant women with macrosomia (birth weight greater than 4000 g) was compared with that in pregnancy with normal body weight (2500–4000 g). Macrosomia is associated with significantly higher maternal age and gestational age. In macrosomia, significantly more births were completed by caesarean section. With a fetal weight above 4500 g, the risk of postpartum hemorrhage increased. Macrosomia has been shown to be associated with severe adverse outcomes for both mother and fetus.

Assessment of post-partum haemorrhage risk among women with moderate thrombocytopenia.

SummaryIt is unknown whether moderate thrombocytopenia represents a risk factor for post‐partum haemorrhage (PPH). We assessed PPH risk among women with a platelet count of between 100 and 50 × 109/l and stratified the risk for O/non‐O blood group. We included consecutive women undergoing vaginal delivery or caesarean section with moderate thrombocytopenia. Women with >150 × 109/l platelets at delivery were selected as controls and matched for age, type of birth and ethnicity. Odds ratios (ORs) with their 95% confidence intervals (95% CIs) were calculated as risk estimates. A total of 94 thrombocytopenic women and 94 controls were included in the study. The rate of PPH was significantly higher in thrombocytopenic women than in controls (37% vs. 10%, p < 0.001); there was a higher risk of PPH in the thrombocytopenic group when compared to the control group (adjusted OR 4.7, 95% CI 2.1–10.8, p < 0.01) and this association was stronger in blood group O carriers (adjusted OR 11.0, 95% CI 2.4–49.6, p < 0.01). In conclusion, our study shows that a moderate thrombocytopenia is a risk factor for PPH, especially in blood group O carriers.

Magnitude of postpartum hemorrhage and its associated factors in Ethiopia: a systematic review and meta-analysis

BackgroundPostpartum hemorrhage or postpartum bleeding (PPH) is often defined as loss of > 500 ml of blood after vaginal delivery or > 1000 ml after cesarean delivery within 24 h. Postpartum hemorrhage is a leading direct cause of maternal morbidity and mortality in Ethiopia. Therefore, the main objective of this systematic review and meta-analysis was to estimate the pooled magnitude of postpartum hemorrhage and the pooled effect size of the associated factors in Ethiopia.MethodsPrimary studies were searched from PubMed/MEDLINE online, Science Direct, Hinari, Cochrane Library, CINAHL, African Journals Online, Google and Google Scholars databases. The searching of the primary studies included for this systematic review and meta-analysis was limited by papers published from 2010 to October 10/2021. The data extraction format was prepared in Microsoft Excel and extracted data was exported to Stata Version 16.0 statistical software for analysis. A random effect meta-analysis model was used. Statistical heterogeneity was evaluated by the I2 test and Egger’s weighted regression test was used to assess publication bias.ResultA total of 21 studies were included in this meta-analysis. The pooled magnitude of postpartum hemorrhage in Ethiopia was 8.24% [(95% CI 7.07, 9.40]. Older age [OR = 5.038 (95% CI 2.774, 9.151)], prolonged labor [OR = 4.054 (95% CI 1.484, 11.074)], absence of anti-natal care visits (ANC) [OR = 13.84 (95% CI 5.57, 34.346)], grand-multiparty [OR = 6.584 (95% CI 1.902, 22.795)], and history of postpartum hemorrhage [OR = 4.355 (95% CI 2.347, 8.079)] were factors associated with the occurrence of postpartum hemorrhage.ConclusionsThe pooled magnitude of postpartum hemorrhage among post-natal mothers in Ethiopia was moderately high. The finding of this study will strongly help different stakeholder working in maternal and child health to focus on the main contributors’ factors to reduce post-partum hemorrhage among postnatal mothers. Health professionals attending labor and delivery should give more attention to advanced aged mothers, grand-multipara mothers and mothers who had a history of post-partum hemorrhage due to higher risk for postpartum hemorrhage. Encouraging to continue ANC visit and prevent prolonged labor should also be recommended to decrease postpartum hemorrhage.

2021 Chinese consensus on the diagnosis and management of primary immune thrombocytopenia in pregnancy.

2021 Chinese consensus on the diagnosis and management of primary immune thrombocytopenia in pregnancy.

Exposure to oil pollution and maternal outcomes: The Niger Delta prospective cohort study.

BackgroundMaternal exposure to oil pollution is an important public health concern. However, there is a dearth of literature on the effects of maternal exposure to oil pollution on maternal outcomes in the Niger Delta region of Nigeria. This study was therefore designed to determine the effect of maternal exposure to oil pollution on maternal outcomes in the Niger Delta region of Nigeria.MethodsProspective cohort study design involving 1720 pregnant women followed from pregnancy to delivery was conducted. The participants were 18–45 years old at a gestational age of less than 17 weeks, who attended randomly selected health facilities in the areas with high exposure and low exposure to oil pollution in the Niger Delta, Nigeria. Data were collected using an interviewer-administered questionnaire and review of medical records from April 2018 to April 2019. Multivariate log-binomial model was used to examine the effect of maternal exposure to oil pollution on the risk of adverse maternal outcomes adjusting for sociodemographic, maternal and lifestyle characteristics.ResultsA total of 1418 women completed the follow-up and were included in the analysis. Women in high exposure areas had a higher incidence of premature rupture of membrane (PROM), caesarean section (CS) and postpartum haemorrhage (PPH) compared to women in areas with low exposure to oil pollution. After adjusting for cofounders, women in high exposure areas also had a higher risk of PROM (ARR = 1.96; 95% CI: 1.24–3.10) and PPH (ARR = 2.12; 95% CI: 1.28–3.36) in Model I–III when compared to women in areas with low exposure to oil pollution. However, pregnancy-induced hypertension and CS had no association with maternal exposure area status to oil pollution.ConclusionWomen in high exposure areas are at a higher risk of PROM and PPH. This calls for policies and intervention toward reducing maternal exposure to oil pollution in the Niger Delta region of Nigeria.

469 Is thrombocytopenia a risk factor of postpartum hemorrhage?

Introduction and aims of the study: To assess whether thrombocytopenia is associated to an increased risk of postpartum hemorrhage (PPH) at delivery. Methods: We conducted a retrospective single referral center study from January 1st to March 21th 2020. All patients were assessed for platelets count at the end of pregnancy. Thrombocytopenia was defined as a platelets count <150G/L, and included severe thrombocytopenia. Primary outcome was PPH defined as a blood loss >500ml in the first 24 hours postpartum.

UTEROTONIC USE IN THE ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR (AMTSL): SYSTEMATIC REVIEW

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Maternal mortality rate in Indonesia has decreased from 184/100,000 live birth (LB) (2016) to 177/100,000 LB (2017), but this number is still high enough than SDGs target of 70/100,000 LB. The one of direct cause of maternal death is hemorrhage, especially postpartum hemorrhage (PPH). Causes of PPH are uterine atony, laceration of birth canal, resistant placenta and uterine inversion. PPH prevention method is Active Management of Third Stage of Labor (AMTSL). The objective of this systematic review is to analyze the use of uterotonics in AMTSL.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This systematic review used the PRISMA protocol, articles taken from Google Scholar, Science Direct, and Pub Med. The time span of the research article was 2010 to 2021.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Result:&lt;/strong&gt; The results of the study describe that the use of uterotonics in single use or combination in third stage of labor can reduce the risk of PPH and shorten the time of the stage. The side effects were reported in misoprostol and methyl ergometrine than oxytocin. In addition, combination therapy with oxytocin and misoprostol can reduce the length of the third stage and the potential for a decrease in hemoglobin within 24 hours of delivery. In Indonesia, if oxytocin is not available, maternal nipple stimulation is performed as nonpharmacological therapy or ergometrine 0.2 mg is given to patients without complications of high blood pressure.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; The use of uterotonics is adjusted to its cost-effectiveness, ability to store and refrigerate also the benefits compare to the side effects to the patients.&lt;/p&gt;

Risk factors for postpartum hemorrhage in patients with retained placenta: building a predict model.

Among patients with placenta retention, the risk factors of massive blood loss remain unclear. In this study, a secondary data analysis was conducted to construct a predictive risk model for postpartum hemorrhage (PPH) in this particular population. A prediction model based on the data of 13 hospitals in the UK, Uganda, and Pakistan, from December 2004, to May 2008 was built. A total of 516 patients and 14 potential risk factors were analyzed. The least absolute shrinkage and selection operator regression (LASSO) model was used to optimize feature selection for the PPH risk model. Multivariable logistic regression analysis was applied to build a prediction model incorporating the LASSO model. Discrimination and calibration were assessed using C-index and calibration plot. Among patients with placenta retention, the incidence of PPH was 62.98% (325/526). Risk factors in the model were country, number of past deliveries, previous manual removal of placenta, place of placenta delivery, and how the placenta was delivered. In these factors, patients in the low-income country (i.e.,Uganda) (OR: 1.753, 95% CI=1.055-2.915), retained placentas delivered in thetheater (OR: 2.028, 95% CI=1.016-4.050), and having placentas partially removed by controlled cord traction (cct), completely removed manually (OR: 4.722, 95% CI=1.280-17.417) were independent risk factors. The C-statistics was 0.702. By secondary data analysis, our study constructed a prediction model for PPH in patients with placenta retention, and identified the independent risk factors.

Exploring New Risk Factors for Postpartum Hemorrhage: Time to Consider Gestational Age?

(Anesthesiology. 2021;134:832–834. doi: 10.1097/ALN:0000000000003775) All birthing centers are now required by the Joint Commission to assess postpartum hemorrhage risk before delivery. This predelivery assessment is critical to classify women as being low, medium, or high risk for hemorrhage. Identifying mothers who are at high risk for postpartum hemorrhage can help specialists including anesthesiology, obstetric, and nursing teams closely monitor the mother’s delivery and recovery, prepare blood and medical equipment preventatively, and reduce maternal morbidity and mortality. Unfortunately, postpartum hemorrhage still occurs in women without recognized risk factors.

How Collaborative Position Paper on the Management of Thrombocytopenia in Pregnancy

(Aust N Z J Obstet Gynaecol. 2021;61:195–204) Up to one in 10 pregnant women develop thrombocytopenia (TCP) defined as a platelet (PLT) count of &lt;150×109/L. More severe TCP with PLT &lt;100×109/L, affect 1-2% of pregnant patients, and may increase risk of postpartum hemorrhage (PPH). There are no randomized trials studying this issue and clinicians must use retrospective reviews and guidelines for decision making. This paper by members of the Haematology in Obstetrics and Women’s Health (HOW) Collaborative provides evidence-based guidelines for the management of TCP in Australia and New Zealand. Following independent literature review, all authors reached consensus on the final version. The recommendations are National Health and Medical Research Council grade C as there is a lack of high-quality evidence.

Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity

Addressing severe maternal morbidity (SMM) is a public health priority in the US. Use of labor neuraxial analgesia for vaginal delivery is suggested to reduce the risk of postpartum hemorrhage (PPH), the leading cause of preventable severe maternal morbidity. To assess the association between the use of labor neuraxial analgesia for vaginal delivery and SMM. In this population-based cross-sectional study, women aged 15 to 49 years undergoing their first vaginal delivery were included. Data were taken from hospital discharge records from New York between January 2010 and December 2017. Data were analyzed from November 2020 to November 2021. Neuraxial analgesia (ie, epidural or combined spinal-epidural) vs no neuraxial analgesia. The primary outcome was SMM, as defined by the US Centers for Disease Control and Prevention, and the secondary outcome was PPH. Adjusted odds ratios (aORs) and 95% CIs of SMM associated with neuraxial analgesia were estimated using the inverse propensity score-weighting method and stratified according to race and ethnicity (non-Hispanic White vs racial and ethnic minority women, including non-Hispanic Asian or Pacific Islander, non-Hispanic Black, Hispanic, and other race and ethnicity) and to the comorbidity index for obstetric patients (low-risk vs high-risk women). The proportion of the association of neuraxial analgesia with the risk of SMM mediated through PPH was estimated using mediation analysis. Of 575 524 included women, the mean (SD) age was 28 (6) years, and 46 065 (8.0%) were non-Hispanic Asian or Pacific Islander, 88 577 (15.4%) were non-Hispanic Black, 104 866 (18.2%) were Hispanic, 258 276 (44.9%) were non-Hispanic White, and 74 534 (13.0%) were other race and ethnicity. A total of 400 346 women (69.6%) were in the low-risk group and 175 178 (30.4%) in the high-risk group, and 272 921 women (47.4%) received neuraxial analgesia. SMM occurred in 7712 women (1.3%), of which 2748 (35.6%) had PPH. Before weighting, the incidence of SMM was 1.3% (3486 of 272 291) with neuraxial analgesia compared with 1.4% (4226 of 302 603) without neuraxial analgesia (risk difference, -0.12 per 100; 95% CI, -0.17 to -0.07). After weighting, the aOR of SMM associated with neuraxial analgesia was 0.86 (95% CI, 0.82-0.90). Decreased risk of SMM associated with neuraxial analgesia was similar between non-Hispanic White women and racial and ethnic minority women and between low-risk and high-risk women. More than one-fifth (21%; 95% CI, 14-28) of the observed association of neuraxial analgesia with the risk of SMM was mediated through the decreased risk of PPH. Findings from this study suggest that use of neuraxial analgesia for vaginal delivery is associated with a 14% decrease in the risk of SMM. Increasing access to and utilization of labor neuraxial analgesia may contribute to improving maternal health outcomes.

Risk factors for postpartum haemorrhage in the Northern Province of Rwanda: A case control study.

Postpartum haemorrhage (PPH) remains a major global burden contributing to high maternal mortality and morbidity rates. Assessment of PPH risk factors should be undertaken during antenatal, intrapartum and postpartum periods for timely prevention of maternal morbidity and mortality associated with PPH. The aim of this study is to investigate and model risk factors for primary PPH in Rwanda. We conducted an observational case-control study of 430 (108 cases: 322 controls) pregnant women with gestational age of 32 weeks and above who gave birth in five selected health facilities of Rwanda between January and June 2020. By visual estimation of blood loss, cases of Primary PPH were women who changed the blood-soaked vaginal pads 2 times or more within the first hour after birth, or women requiring a blood transfusion for excessive bleeding after birth. Controls were randomly selected from all deliveries without primary PPH from the same source population. Poisson regression, a generalized linear model with a log link and a Poisson distribution was used to estimate the risk ratio of factors associated with PPH. The overall prevalence of primary PPH was 25.2%. Our findings for the following risk factors were: antepartum haemorrhage (RR 3.36, 95% CI 1.80-6.26, P<0.001); multiple pregnancy (RR 1.83; 95% CI 1.11-3.01, P = 0.02) and haemoglobin level <11 gr/dL (RR 1.51, 95% CI 1.00-2.30, P = 0.05). During the intrapartum and immediate postpartum period, the main causes of primary PPH were: uterine atony (RR 6.70, 95% CI 4.78-9.38, P<0.001), retained tissues (RR 4.32, 95% CI 2.87-6.51, P<0.001); and lacerations of genital organs after birth (RR 2.14, 95% CI 1.49-3.09, P<0.001). Coagulopathy was not prevalent in primary PPH. Based on our findings, uterine atony remains the foremost cause of primary PPH. As well as other established risk factors for PPH, antepartum haemorrhage and intra uterine fetal death should be included as risk factors in the development and validation of prediction models for PPH. Large scale studies are needed to investigate further potential PPH risk factors.