Microsoft word - _7_ original article- dr. nandkishor more

Vol 22, Number 1
Journal of Forensic Medicine, Science and Law
A Journal of Medicolegal Association of Maharashtra
Original Article

A PROSPECTIVE CLINICAL STUDY OF POSTPARTUM HAEMORRHAGE IN
RURAL POPULATION
Dr. N More, Dr. S Vaidya

Authors

Dr. Nandkishor More, Assistant Professor, Department of OBGY, SRT Rural Government
Medical College, Ambajogai, Dist. Beed (MS)
Dr. Shailesh Vaidya, Associate Professor, Department of OBGY, SRT Rural Government
Medical College, Ambajogai, Dist Beed. (MS)
Dr. Nandkishor More, Assistant Professor, Department of OBGY, SRT Rural Government Medical College, Ambajogai, Dist. Beed. (MS) Maharashtra, India. Vol 22, Number 1
Journal of Forensic Medicine, Science and Law
A Journal of Medicolegal Association of Maharashtra
Original Article

A PROSPECTIVE CLINICAL STUDY OF POSTPARTUM HAEMORRHAGE IN
RURAL POPULATION

Abstract:
This study was designed as a hospital based prospective study, carried out at Government Medical College and Hospital, during period of November 2010 to October 2012. In present study maximum number of patients had PPH due to atonicity of uterus & number of PPH patients due to retained placenta is comparable with study carried out by Lumaan Sheikh et al. Overall majority of cases of PPH developed atonicity. In present study incidence of PPH decreased to almost 50% with use of AMTSL (Active Management of Third Stage of Labour). Study of Hope Johnson et al also showed that incidence of PPH decreases significantly after use of AMTSL. So AMTSL significantly reduces the incidence of PPH which is comparable. In present study maternal death rate was 64 per 100000 live births of the diagnosed cases of PPH which is less than the incidence in the studies carried out by Afaf et al. The lower death rate in our study might be due to earlier detection of PPH by using blood drape, to calculate exact amount of blood loss, active intervention and use of Nonpneumatic Anti Shock Garment. Hence, this indicates that early intervention and blood replacement even in compromised setup invariably brightens the chances of survival. So early and accurate detection of blood loss, timely management and use of innovations like Nonpneumatic Anti Shock Garment reduces the risk of maternal death even
in rural Indian setup where more than half of the maternal deaths are still caused by
Postpartum Haemorrhage.
Keywords: AMTSL, PPH, Maternal Mortality.

Introduction:
Postpartum haemorrhage (PPH) is a worldwide problem and one of the three messengers of maternal death2. The exact incidence of obstetric haemorrhage is not known because of its imprecise definition as well as difficulty in its recognition and thus its diagnosis. Postpartum haemorrhage is the excessive loss of blood per vaginum after the delivery of the baby and up to 42 days postpartum. It can either be primary or secondary. Primary PPH is the loss of more than 500 ml of blood in case of vaginal delivery and more than 1000 ml in case of caesarean section within the first 24 hours of delivery. Factors that lead to increased incidence of PPH are mainly multiparity, preeclampsia, eclampsia, multiple gestation, anaemia, abruptio placentae, placenta praevia, polyhdramnios, instrumental vaginal delivery and prolonged labour. Although the presence of one or more of these factors may increase the chances of PPH in women, 2/3rd of PPH cases occur in women with no risk factor which is then termed as idiopathic. Presence of risk factors cannot be used to predict PPH; some studies have sought to determine whether the third stage of labour should be actively managed in all women giving birth to decrease the incidence of uterine atony which is the leading cause of PPH 3. Active Management of Third Stage of Labour (AMTSL) is a three part process intended to augment uterine contraction and prevent PPH due to uterine atony6. The recommended protocol comprises use of uterotonic drug within 1 minute of the delivery of baby, delivery of placenta by applying controlled cord traction with counter traction over uterus and uterine massage after delivery of placenta. When AMTSL is practiced, oxytocin is the preferable prophylactic uterotonic3. Present study is an attempt to Vol 22, Number 1
Journal of Forensic Medicine, Science and Law
A Journal of Medicolegal Association of Maharashtra
evaluate the incidence, prevention, treatment and outcome of PPH by using different modes
of management in rural setup1.

Materials and Methods:
The present prospective study is carried out in Department of Obstetrics and Gynaecology in Rural Government Medical College and Hospital, during the period from November 2010 to October 2012. 20281 cases of labour were studied. In 1023 patients following protocol was carried out, the placenta was delivered by maternal effort aided by gravity or nipple stimulation and the cord was clamped when pulsation ceased. Oxytocin was given after delivery of placenta. Active Management of Third Stage of Labour (AMTSL) was used in 19258 patients with following protocol: Uterotonic drug was given within one minute of the delivery of baby. Placenta was delivered by applying controlled cord traction with counter-traction over uterus. Uterine massage given after delivery of placenta. Diagnosed cases were managed with emergency resuscitative measures, blood transfusion in the form of whole blood or blood components. Uterotonic agents such as inj.
Oxytocin, inj. Ergometrine, inj. Carboprost (15 methyl PG F2α) and Tab. Misoprostol were
used alone or in combination. In some cases surgical procedures like repair of genital
lacerations in cases of traumatic PPH, manual removal of placenta in cases of retained
placenta, selective devascularisation i.e. uterine and/ or ovarian artery ligation and/ or internal
iliac artery ligation, uterine compression suture i.e. B-Lynch suture, and lastly Emergency
Obstetric Hysterectomy were done.

Data analysis:
The data obtained on all PPH patients was tabulated in Microsoft Office Excel software and analyzed using SPSS version 17.0, the chi-square test was used in assessing the
associations between categorical variables; a p-value of 0.05 or less was considered
statistically significant.

Result:
In present study maximum number of patients i.e. 82.76% had PPH due to atonicity of uterus which is comparable with studies carried out by MA Ijaiya et al, Kant Anita et al, Farhana Yusuf et al who also had maximum number of PPH patients due to atonicity3, 4, 5. In present study number of PPH patients due to retained placenta is comparable with study carried out by Lumaan Sheikh et al. Cases of traumatic PPH in present study is comparable with study carried out by Lumaan Sheikh et al6. Overall majority of cases of PPH developed atonicity. Table No. 1: Distribution of Patients According to Causes of PPH Causes In present study incidence of PPH decreased incidence of PPH decreases significantly significantly reduces the incidence of PPH Vol 22, Number 1
Journal of Forensic Medicine, Science and Law
A Journal of Medicolegal Association of Maharashtra Table No. 2: Incidence of PPH in Cases with and without Active Management of Third Incidence In present study out of total 232 intervention, this is comparable with the study carried out by out by HalderAtin et al and Tarik Y et al lesser number of cases were recovered by medical management while surgery was required in larger population which is not comparable with our study. Majority of cases of PPH can be tackled with uterotonics and blood transfusion. Use of newer uterotonics like prostaglandins is responsible for better response to medical management. Table No. 3: Type of Management Required in Cases of PPH Management No. of cases Percentage In present study maternal death rate was 64 per 100000 live births of the diagnosed cases of PPH which is less than the incidence in the studies carried out by Afafet al9. The lower death rate in our study might be due to earlier detection of PPH by using blood drape, to calculate exact amount of blood loss, active intervention and use of Nonpneumatic Anti Shock Garment. Maternal death in present study is comparable with studies carried out by Lumaan et al and Saharabhojanee et al10 at advanced setup of Goa Medical College & Hospital Bombolim Goa, which has got better facilities like blood component separation unit and the study was carried out on emergency obstetric hysterectomy cases only. Hence, this indicates that early intervention and blood replacement even in compromised setup invariably brightens the chances of survival. Table No. 4: Incidence of Maternal Death in Cases of PPH Maternal No. of Per 100000 So early and accurate detection of blood loss, timely management and use of innovations like Nonpneumatic Anti Shock Garment reduces the risk of maternal death11 even in rural Indian setup where more than half of the maternal deaths are still caused by Postpartum Haemorrhage. Table No. 5: Causes of Maternal Mortality during study period Causes Discussion:
that the chief cause of PPH is atonicity of uterus (82.76% of Vol 22, Number 1
Journal of Forensic Medicine, Science and Law
A Journal of Medicolegal Association of Maharashtra AMTSL as a routine protocol significantly brings down incidence of PPH. Table No. 2 shows that out of 1023 deliveries who did not receive AMTSL, 28 patients developed PPH and the incidence was 2.73%. While out of 19258 deliveries who had received AMTSL 204 patients developed PPH and the incidence was 1.06%. This difference in the incidence of PPH was statistically significant (p<0.05). Table No. 3 shows that 176 i.e. 75.86% of cases recovered with medical management and 56 i.e. 24.14% of cases required surgical management for the treatment of PPH. So most of the cases respond to timely management and still maternal mortality is inevitable in some cases like in this study incidence of Maternal Mortality was 64 per 100000 live births. (Table no. 4). During this study period 20281 women delivered in department and there were 13 maternal deaths. Table No. 5 shows that maximum 7 i.e. 53.85% of maternal mortality during study period was due to PPH. Active Management of Third Stage of Labour (AMTSL) significantly reduces chances of atonic PPH by almost 50%. PPH accounts for more than 50% maternal deaths but
early detection and timely intervention improves chances of survival.

References:
M.L. McCormick, H.C.G. Sanghvi, B. Kinzie, N. McIntosh.Preventing postpartum hemorrhage in low-resource settings, International Journal of Gynecology & Obstetrics 77; 2002.267-275. Khan KSW. WHO analysis of causes of maternal death: a systematic review, MA Ijaiya, AP Aboyeji and D Abubakar Analysis of 348 consecutive cases of primary postpartum haemorrhage at a tertiary hospital in Nigeria, Journal of Obstetrics &Gynaecology 2003; 23(4):374-377. FarhanaYusuf, GulfareenHaider, Postpartum hemorrhage: an experience at tertiary care hospital, Journal of Surgery Pakistan (International) 14 (2) April - June 2009. Kant Anita, WadhwaniKavita, Emergency obstetric hysterectomy, J ObstetGynecol India Vol. 55, No. 2 : March/April 2005 Pg 132-134. Lumaan Sheikh, Nadeem F. Zuberi, RubabRiaz, Javed H. Rizvi, Massive primary postpartum haemorrhage: Setting up Standards of Care, J Pak Med Assoc, Vol. 56, No. 1, January 2006, pp 26-31. Hope Johnson, Victor Rhee, Juliana Cuervo, and Manjunath Shankar, Active Management of the Third Stage of Labor, POPPHI, August-September, 2006, page 22. ShamshadBibi, Nargis Danish, AnisaFawad, Muhammad Jamil, An audit of primary postpartum haemorrhage, J Ayub Med Coll Abbottabad; 2006; 19(4), pp 102-106. Afaf R.A. Alsayali; Salah M.A. Baloul, Emergency Obstetric Hysterectomy: 8-Year Review at Taif Maternity Hospital, Saudi Arabia, Annals of Saudi Medicine, Vol 20, Nos 5-6, 2000, 454-456. Sahasrabhojanee Mrinalini, Jindal Manjusha, Kamat Anjali, Obstetric hysterectomy: a life saving emergency, J Obstet Gynecol India Vol. 58, No. 2 : March/April 2008 pg 138-141. Suellen Miller, Carol Camlin, David Nsima, Elizabeth Butrick, Obstetric hemorrhage and shock management: using the low technology Non-pneumatic Anti-Shock Garment in Nigerian and Egyptian tertiary care facilities, BMC Pregnancy and Childbirth 2010, 10:64.

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