By Japheth Mati
Definition
Postpartum haemorrhage (PPH), antepartum haemorrhage (APH), and bleeding following an incomplete abortion are collectively referred to as obstetric haemorrhage. PPH is the single most important cause of maternal deaths worldwide.
The definition of PPH is somewhat arbitrary and problematic[i]. Postpartum haemorrhage is defined as blood loss of more than 500 mL following vaginal delivery or more than 1000 mL following delivery by caesarean section. A loss of these amounts within 24 hours of delivery is termed early or primary PPH, whereas such losses are termed late or secondary PPH if they occur 24 hours after delivery. Estimates of blood loss at delivery are subjective and generally inaccurate. Studies have suggested that caregivers consistently underestimate actual blood loss. Another consideration is the differing capacities of individual parturient to cope with blood loss. A healthy woman has a 30-50% increase in blood volume in a normal singleton pregnancy and is much more tolerant of blood loss than a woman who has pre-existing anemia, or other medical complications. The diagnosis of PPH is usually reserved for pregnancies that have progressed beyond 20 weeks’ gestation, even though bleeding related to spontaneous abortion may have causes and management in common with those for PPH.
Magnitude of the problem
Photo Credit: José Luis Álvarez. http://www.eurekalert.org/multimedia/pub/20270.php?from=154475
United Nations estimates show that more than 500,000 women die each year worldwide due to complications arising from pregnancy and childbirth, which has been expressed as one woman dying every 7 minutes[ii]. In 2008 almost 99 per cent of all maternal deaths occurred in developing regions, with sub-Saharan Africa accounting for 57 per cent of all deaths. According to a UN report[iii] on “Trends in maternal mortality”, the number of maternal deaths globally had decreased by 34 per cent from an estimated 546 000 in 1990 to 358 000 in 2008. However, in sub-Saharan Africa, the decrease in maternal mortality was below average, being 26 per cent. The report concluded that although that progress was notable, the annual rate of decline (i.e. 2.3 per cent) was still less than half of what is needed (i.e. 5.5 per cent) to achieve the MDG 5 target of reducing the maternal mortality ratio by 75 per cent between 1990 and 2015.
In the sub-Saharan Africa, the main direct causes of maternal death are bleeding (34%), infection (10%), pre-eclampsia/ eclampsia (9%) and obstructed labour (4%). In Kenya, a national review of safe motherhood[iv] conducted in 1997, marking the tenth anniversary of the Safe Motherhood Conference held in Nairobi in October 1987, showed that haemorrhage, sepsis, pre-eclampsia/ eclampsia, ruptured uterus and complications of induced abortion were the leading direct causes of maternal mortality. Clearly, prevention and making accessible treatment of postpartum haemorrhage should be highly prioritised in the interventions to reduce maternal mortality.
Causes of and risk factors for PPH
Postpartum haemorrhage has many potential causes, but by far the most frequently encountered is uterine atony, a condition whereby there is failure of the uterine muscle to contract and retract following delivery of the baby. Besides primary uterine atony, other causes of bleeding may include: retained placental tissue; trauma to the birth canal, especially cervical tears; and occasionally bleeding may be associated with clotting failure (coagulation defect) [v]. Although in a large proportion of women experiencing PPH no risk factors can be identified, the following have been identified as significant risk factors for PPH in published data[vi]:
- · Retained placental tissue
- · Prolonged second stage of labour
- · Placenta accrete (morbidly attached placenta)
- · Lacerations of the birth canal
- · Instrumental delivery, especially forceps delivery
- · Large for gestational age (LGA) newborn
- · Hypertensive disorders
- · Induction of labour, and
- · Augmentation of labour with oxytocin
Prevention of PPH
There is ample evidence, based on several randomized controlled trials (RCTs) and a Cochrane meta-analysis involving more than 6000 deliveries, which suggests that active management of the third stage of labour (AMTSL) reduces the incidence and severity of PPH[vii], and should be recommended and offered to all women[viii]. Active management involves interventions to assist in expulsion of the placenta with the intention to prevent or decrease blood loss. It is the combination of uterotonics, clamping of the umbilical cord, and controlled cord traction when the uterus is well contracted. Uterotonics promote uterine contractions and thereby prevent atony and speed up delivery of the placenta. In contrast, with expectant, or physiological, management, spontaneous delivery of the placenta is awaited, with subsequent intervention, if necessary, that involves uterine massage and use of uterotonics.
Generally, uterotonic drugs are used to induce (start) or augment (speed up) labour; facilitate uterine contractions following a spontaneous abortion; prevent postpartum hemorrhage during active management of the third stage of labor; treat hemorrhage following childbirth or abortion; and for other gynecological reasons. The three categories of uterotonic drugs used most frequently are the oxytocins, ergot alkaloids and prostaglandins. Uterotonic drugs may be given intramuscularly (IM), intravenously (IV), and as a tablet that can be given orally, vaginally, rectally, or buccally. The uterotonic agents that are listed in Essential Medicines List, and which are commonly used in East Africa include oxytocin, ergometrine, and Syntometrine (a combination of ergometrine and oxytocin), all of which have to be administered through an injection.
Misoprostol, a prostaglandin E1 analogue with uterotonic activity, is an attractive option for use in AMTSL because it is stable, active orally, and inexpensive[ix]. Besides, whereas ergometrine is contraindicated in women with a history of hypertension, heart disease, preeclampsia, or eclampsia, there are no known contraindications for use of Misoprostol as used in AMTSL. Where skilled attendance is not available, the International Confederation of Midwives (ICM) and International Federation of Gynaecology and Obstetrics (FIGO) recommend that in the context of prevention of PPH, if oxytocin is not available or birth attendants’ skills are limited, misoprostol should be administered orally soon after the birth of the baby[x]. There is sufficient research evidence to support use of misoprostol both for prevention and treatment of PPH, particularly in settings where the majority of births take place away from health facilities, where standard uterotonics are not available. Studies in Tanzania, Afghanistan, Nepal, and Bangladesh have shown that for prevention of PPH, pregnant women delivering at home without a skilled birth attendant can successfully self-administer misoprostol orally as soon as possible after their baby is delivered[xi].
Use of Misoprostol for prevention and treatment of PPH ought to be added to Essential Medicines List
In consideration of the above this author, along with others, recently supported applications[xii] to add misoprostol to the World Health Organization’s (WHO) Essential Medicines List (EML) for prevention and treatment of PPH[xiii]. The addition of misoprostol to the EML for PPH prevention and treatment has potential to contribute significantly to the efforts to achieve MDG5 target. This safe and effective drug has been shown to prevent and control postpartum bleeding suspected to be due to uterine atony. The drug’s wide availability, low cost, stability at room temperature and ease of use make it an ideal candidate to add to the package of interventions available to prevent PPH in low-resource settings. Meanwhile in Kenya, the Kenya Obstetrical and Gynaecological Society (KOGS) is also pushing for the registration of misoprostol, “as an effective intervention in controlling PPH, particularly in limited-resource settings”[xiv]. Currently misoprostol is registered in Kenya for treatment of gastric ulcer, and the fear has been that misoprostol might be used for purposes of procuring abortion. Nigeria, in 2010, became the first African country to register misoprostol, but, ironically, restricted it to obstetric use in medical centres only; this in a context where nearly75 percent of women give birth at home!
[i] John R Smith, Barbara G Brennan, Postpartum hemorrhage http://emedicine.medscape.com/article/275038-overview
[ii] Potts M, Prata N, Sahin-Hodoglugil NN. Maternal mortality: one death every 7 min. Lancet 2010; 375: 1762–63.
[iv]Ministry of Health, Kenya. A Question of Survival? Review of Safe Motherhood, Division of Primary Health Care, June, 1997.
[v] A mnemonic for remembering the causes of PPH is “4 T’s”: tone, tissue, trauma, and thrombosis (coagulation defect).
[vi] Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M. Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. J Matern Fetal Neonatal Med. Sep 2005;18(3):149-54. [Medline].
[vii] Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev. 2000;CD000007. [Medline].
[x]International Confederation of Midwives (ICM), International Federation of Gynaecology and Obstetrics (FIGO). Prevention and Treatment of Post-partum Haemorrhage: New Advances for Low Resource Settings Joint Statement. The Hague: ICM; London: FIGO; 2006. Available at: http://www.figo.org/docs/PPH%20Joint%20Statement%202%20English.pdf. Accessed October 12, 2007.
[xi] Prata N, Mbaruku G, Campbell M, Potts M, Vahidnia F. Controlling postpartum hemorrhage after home births in Tanzania. Int J Gynecol Obstet 2005; 90: 51–55; Rajbhandari S, Hodgins S, Sanghvi H, McPherson R, Pradhan YV, Baqui AH,and Misoprostol Study Group. Expanding uterotonic protection following childbirth through community-based distribution of misoprostol: operations research study in Nepal. Int J Gynecol Obstet 2010; 108: 282–88; Sanghvi H, Ansari N, Prata JVN, Gibson H, Ehsan A, Smith J. Prevention of postpartum hemorrhage at home birth in Afghanistan. Int J Gynecol Obstet 2010; 108: 276–81; Potts M, Prata N, Sahin-Hodoglugil NN. Maternal mortality: one death every 7 min. Lancet 2010; 375: 1762–63.
[xii] http://www.who.int/selection_medicines/committees/expert/18/applications/Rosenhaus_Support_Treatment.pdf; http://www.who.int/selection_medicines/committees/expert/18/applications/Rosenhaus_Support_Prevention.pdf
[xiii] These applications have been submitted by Gynuity Health Projects and Venture Strategies for Innovations.
[xiv] Susan Anyangu-Amu Misoprostol Can’t Shake Bad Reputation http://ipsnews.net/news.asp?idnews=52385
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