macrosomia with or without polyhydramnios and antepartum hemorrhage followed by preeclampsia

Abstract

PPH, a leading cause of maternal mortality, causes an estimated 140,000 deaths each year globally - this roughly corresponds to one woman dying every 4 minutes. In addition, serious morbidity may follow PPH in the form of various sequels.^{11, 12} Massive PPH is associated with a worse prognosis. Inability to stabilize a patient who is in hemorrhagic shock can eventually result in death.¹¹ The incidence of PPH in this audit was 0.77% of all deliveries in 2019 at DHQ Hospital Rawalpindi, Pakistan. This figure is certainly comparable to that reported in studies conducted at AKUH, Karachi which was 0.64%.¹¹ However other population-based studies where the incidence of massive PPH has been reported to be as high as 1.1%.^13,14 The prevalence of postpartum hemorrhage (PPH) (blood loss ≥500 ml) ranged from 7.2% in Oceania to 25.7% in Africa. The prevalence of severe PPH (blood loss ≥1000 ml) was highest in Africa at 5.1% and the lowest in Asia at 1.9%.¹² In a recent review, PPH was also found to have an increasing trend in the more developed parts of the world.¹⁵ The exact reasons for this rise remain unclear.

In the current study increased incidence of PPH was recorded among non booked patients. The larger percentage of non booked women who had PPH in this study confirmed the importance of quality antenatal care in early recognition of risk and control of complications associated with pregnancy. The age range of presentation at our institution was 22–42 years. Incidence of PPH was reported in similar age group in other studies.^15,16

Multiparas showed an increased incidence of PPH in our study. A study was done in Nigeria by A.E.Olowokere also had more incidences in multiparas.¹³ Whereas in studies conducted by Lill Trine et al and Michael Kramer showed increased incidence in primiparas.^14,15 The NICE guideline on intrapartum care identified eight cross-sectional studies assessing parity as a risk factor for PPH and recommended that grand multiparas (parity 4 or more) should be advised to give birth in an obstetric unit where more emergency treatment options are available.¹⁶ The majority of patients had spontaneous labor followed by augmentation of labor and delivery by cesarean section. Similar results were presented in studies by A.E.Olowokere and Lill Trine et al,^13,14 whereas others showed increased risk with cesarean section and augmentation of labor.¹⁵ A study conducted in Uganda c-section was a risk factor for PPH.¹⁷ Major risk factors identified were high parity, anemia, macrosomia with or without polyhydramnios and antepartum hemorrhage followed by preeclampsia, chorioamnionitis, and malpresentation. Anemia remained a major risk factor in many of the studies followed by the history of PPH in a previous pregnancy, preeclampsia, and increased fetal weight.^18-20

Although active management of the third stage of labor and use of uterotonic drugs helps contract the uterus and hence decreased postpartum blood loss due to relaxed uterine muscles²¹ still Uterine atony remained major etiology in our setup causing PPH in 77% of cases followed by RPOC’s and tears as other main etiologies. Uterine atony remained the major etiology in many reviewed studies. In an Irish study, atony accounted for 76% of the total cases of PPH.²² Incidence of uterine atony was high in the study conducted at AKUH i.e (96%).¹¹

Medical management of PPH with uterotonic drugs was successful in 30% of patients and these patients did not need any mechanical or surgical treatment. Many international articles support the use of tranexamic acid and misoprostol along with oxytocin in the treatment of PPH with significant decreases in rates of acute cases of PPH and mean blood loss.^23-25 Uterine packing was done in 30 (43%) patients and bleeding was successfully arrested in 27 (90%) patients. Similar results were shown in a study conducted in 2008 by Khairunnisa where uterovaginal packing was successful in 89.14% of patients.²⁶