Lumaan Sheikh  ( Department of Obstetrics and Gynaecology, The Aga Khan University, Karachi. )
Nadeem F. Zuberi  ( Department of Obstetrics and Gynaecology, The Aga Khan University, Karachi. )
Rubab Riaz  ( Department of Obstetrics and Gynaecology, The Aga Khan University, Karachi. )
Javed H. Rizvi  ( Department of Obstetrics and Gynaecology, The Aga Khan University, Karachi. )

Postpartum Haemorrhage (PPH) is one of the major causes of maternal mortality and morbidity worldwide. It is estimated that 600,000-800,000 women die in childbirth each year. 1 A blood loss up to 500ml at delivery is regarded as 'physiologically normal'. It is part of the normal mechanism that brings the mother's blood parameters to their normal non-pregnant levels and a healthy pregnant woman can cope with it without any difficulty. 2,3 Traditionally, primary PPH is defined as bleeding from the genital tract of 500ml or more in the first 24 hours following delivery of the baby. 4 Incidence of primary PPH has been reported as 5% of all deliveries in the literature. 5 Owing to the relatively low risks with this level of blood loss and lesser clinical relevance, a new definition of massive postpartum haemorrhage has been introduced, being the loss of greater than 1000ml or 1500ml of blood. 6 As estimation of blood loss is usually subjective, severe haemorrhage has been defined as estimated blood loss >1500ml, peripartum fall in hemoglobin concentration >4g/dl or acute transfusion of 4 or more units of blood. 7 The most common consequences of PPH include hypovolaemic shock, disseminated intravascular coagulopathies (DIC), renal failure, hepatic failure and adult respiratory distress syndrome (ARDS). 8 As every woman is potentially at risk of postpartum haemorrhage, active management of the third stage of labour should be offered to women, which includes administration of uterotonic agents; controlled cord traction; and uterine massage after delivery of the placenta. 1 Although risk factors for postpartum haemorrhage are known,9 it is not always possible to successfully prevent it. Therefore it is important to manage this life threatening condition promptly and effectively.

We report review of our experience in managing massive primary postpartum haemorrhage. Furthermore, based upon current best available evidence and our experience, we propose a protocol with 'level of care' and 'time lines' for the management of postpartum haemorrhage.

A cross-sectional study of women delivering at Aga Khan University Hospital, Karachi between January 1, 2003 and July 31, 2004 were included if they were labeled as primary postpartum haemorrhage by ICD-9-CM10 (666.00, 666.02, 666.04, 666.10, 666.12, 666.14) and had blood loss >1000ml. Cases with blood loss between 1000 and 1500ml were labeled as "Massive haemorrhage", whereas those with blood loss of > 1500ml were labeled as "Near miss". In our hospital active management of third stage of labour is offered

to all women. The blood loss is measured by the subjective assessment of soaked swabs, estimation of blood clots, and blood in the suction bottle; along with the objective assessment of drop in haemoglobin levels and need for blood transfusion.

Medical record files of the study patients were reviewed for maternal mortality and morbidity which included, mode of delivery (spontaneous vaginal, instrumental vaginal, elective caesarean section or emergency caesarean section), possible cause of postpartum haemorrhage (uterine atony, vaginal haematoma, adherent placenta, cervical tear, uterine angle extension), supportive and medical interventions (additional uterotonics including oxytocin, ergometrine and / or prostaglandin F2 a, intrauterine Tamponade balloon, blood transfusions, need for care in High Dependency Unit), surgical interventions (examination under anaesthesia, intrauterine packing, caesarean hysterectomy, suturing of vaginal, cervical or uterine angle tears, drainage of vaginal haematoma and manual removal of placenta). Descriptive statistics of study variables are presented for 'Massive haemorrhage' and 'Near miss'.

During the study period, 2.9% (140/4881) of women had 'postpartum haemorrhage' of blood loss >500, while 'massive haemorrhage' of >1000ml was encountered in 0.7% (32/4881) of cases. Two-third of these women had blood loss of >1500 ml and were labeled as 'Near miss.'

Our study patients included 9 (28.1%) spontaneous vaginal deliveries, 9 (28.1%) instrumental vaginal deliveries, 6 (18.7%) elective caesarean sections and 8 (25.1%) emergency caesarean sections. Most common cause of haemorrhage was uterine atony 18 (56.3%), followed by 5 (15.7%) cases of vaginal haematoma, 5 (15.7%) cases of cervical or vaginal tears, 4 (12.5%) cases of adherent placenta, 2 (6.2%) cases of uterine angle extension and only 1 (3.1%) case of retained placenta. As supportive and medical interventions, 28 (87.5%) required admission to 'High Dependency Unit', and 18 (56.3%) required blood transfusions, 8 (25%) required additional uterotonics only. Intra-uterine Balloon Tamponade was used in 2 (6.2%) cases only. As part of surgical interventions, 14 (43.8%) cases were subjected to examination under anaesthesia (EUA). Details of additional interventions are

specified in Tables 1 and 2. Other additional surgical interventions included suturing of vaginal, cervical or uterine-angle tears in 7 (20%) cases, drainage of vaginal haematoma in 5 (15.6 %) cases, intrauterine packing in 4 (12.5% ), caesarean hysterectomy in 4 (12.5% ), B-Lynch sutures in 2 (6.2%) and manual removal of placenta in 1 (3.1%) patient. There was 1 (3.1%) maternal death, 1 (3.1%) case of urinary bladder injury, 5 ( 15.6%) of postpartum fever of >38.5ºC, while no subsequent complication occurred in 25 (78.1%) cases.

In women who had blood loss between 1000-1500ml, 8/12 had vaginal delivery. Uterine-atony and vaginal-haematomas were the most common reasons for haemorrhage. This group required least interventions and there were no subsequent morbidities (Table 1). None of these women required blood transfusion.

In the Near miss cases (blood loss >1500ml) who delivered vaginally, uterine-atony occurred mostly in women who did not have instrumental delivery. Women in whom uterine-atony was the primary cause of bleeding, 3 had intrauterine packing, 2 had Foley catheter Balloon Tamponade and 1 required additional uterotonics only. Fever >38°C occurred in two women who responded to antibiotic therapy (Table 2).

Of women who had blood loss >1500ml after caesarean delivery, 50% had the caesarean section as an elective procedure. In this subgroup, 3-caesarean hysterectomies were done including 1-maternal death and 1-urinary bladder injury. In the emergency caesarean section subgroup, 1 - woman had caesarean hysterectomy and 2 - women responded to modified B-Lynch suture. (Table 3). In the Near miss group 85% (17/20) of women required more than 4-units of packed red cell transfusion. Four of these women also received transfusion of Fresh Frozen Plasma (FFP).

We encountered primary postpartum haemorrhage in 2.9% of women. While significantly higher rates of 5-17% have been reported following deliveries in the UK. 11 Postpartum haemorrhage is a leading cause of maternal mortality and morbidity accounting for approximately 4% of maternal deaths in the developed countries. 12 This figure is higher in the developing world where emergency obstetric care is not universally available. Despite the repeated practice recommendations, the confidential report continues to document substandard care in up to 60% of cases. 13

Prompt resuscitative measures and the cause-directed management is the mainstay of treatment for PPH, and includes fluid and blood administration, use of uterotonics, uterine massage, repair of lacerations, removal of retained products of conception and intrauterine balloon tamponade. If these measures are unsuccessful in controlling the bleeding, the next step is usually surgical either conservative or aggressive like uterine bracing suture application, vessel ligation, or hysterectomy. 14 However, by the time surgery is performed, the patient has usually received multiple transfusions of blood and blood products. This may lead to the development of life threatening systemic complications, such as DIC, ARDS, etc. thereby further increasing the morbidity and mortality of any subsequent surgical procedure. It is therefore evident that in order to manage such acute emergencies there should be clear cut guidelines in every obstetric unit to manage this condition. 15 By strictly adhering to guidelines and practice drills, significant reduction in the incidence of massive haemorrhage from 1.70% to 0.45 % has been reported. 16

In our study, there was underutilization of measures like 'Intrauterine Balloon Tamponade' and 'Uterine Compression Sutures', both being used in 2-patients each. Avoidance of surgery has been reported in 87.5% of cases with 'Tamponade test'17, while less complex forms of B-Lynch suturing technique can provide a simple first surgical step to control bleeding. 18 More aggressive techniques were attempted possibly due to less familiarity and experience with the newer and simpler techniques. Episiotomy haematoma was identified as one of the commoner and avoidable cause of blood loss between 1000 and 1500 ml. Prompt suturing along with better suturing technique would further reduce the rate of massive PPH.

Based upon current best available evidence and our experience, we recommend a protocol with 'level of care' required for various degrees of blood loss. It is indeed extremely difficult to make accurate assessment of blood loss following delivery. At our institute, we encourage estimation of blood loss following delivery. This has enabled them to promptly undertake appropriate additional interventions. We have also described the additional interventions according to the degree of estimated blood loss, along with responsible persons and 'time lines' to standardize management of postpartum haemorrhage (Appendix). Other obstetric units may adopt this protocol to reduce practice variability and rate of postpartum haemorrhage in their setup.

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