Immediate post-partum haemorrhage: Epidemiological aspects and maternal prognosis at South N’djamena District Hospital (Chad)

Abstract

Background: Post-partum haemorrhage defined as blood loss after delivery over 500mls, affects all countries and is the commonest cause of maternal mortality. It is a frequent obstetric emergency in developing countries.

Objective: To identify the causes of post-partum haemorrhage and identify adequate management of immediate post-partum haemorrhage and thus reduce maternal mortality.

Patients and methods: This was a prospective and descriptive study of one year from 1^st January 2014 to 31^stDecember 2014 conducted at South N’Djamena district hospital. Before including a patient in our survey her consent was obtained after explaining to her the need for the survey. All consenting patients with post-partum haemorrhage were included. Data were analyzed using SPSS17.0.

Results: We recorded 100 cases of post-partum haemorrhage among 6815 deliveries giving an incidence of 1.47%. The average age of the women was 25.0 years. The majority of deliveries (90%) were vaginal.  The main cause of immediate post-partum haemorrhage was a third stage of labour bleeding (66%) followed by genital lesions (32%). The management was medical (uterotonic drug, fluid replacement and blood transfusion), obstetric (manual removal of placenta or clot), and surgical (suture of lesions, vascular ligature and hysterectomy).  There were two maternal deaths (2%).

Conclusion: Post-partum haemorrhage is often fatal in our region. Preventive measures and efficient management can help to improve maternal prognosis.

Introduction

More than 90% of maternal deaths worldwide occur in sub-Saharan Africa (SSA) and south Asia. These high maternal and associated neonatal mortality rates persist despite considerable efforts from the World Health Organization, governments, development partners, and others [1,2,3].The majority of these deaths are related to pregnancy complications that are inadequately managed because of a lack of access to emergency health care.

The maternal mortality ratios (MMRs) of Sweden, the United Kingdom, and the United States are 4, 12, and 21 per 100,000 live births, respectively, whereas those of Chad, Nigeria, and Congo are 1099, 630, and 540 respectively. In SSA, the major direct causes of maternal mortality are haemorrhage, pre-eclampsia/eclampsia, obstructed labour, and sepsis [4, 5]. According to previous studies, the main cause of haemorrhage in Chad is immediate post-partum haemorrhage [6]. Post-partum haemorrhage is defined as blood loss after delivery over 500 mls [7]. The management of this problem is hampered by the lack of blood products and often leads to maternal death. This situation is the same in South N’Djamena district hospital.

Our objective was to identify the main causes of post-partum haemorrhage in order to identify adequate management of immediate post-partum haemorrhage and thus reduce maternal mortality.

Materials and methods

This was a prospective and descriptive survey of the epidemiological aspects and prognosis of immediate post-partum haemorrhage. It was carried out for one year from 1^st. January2014 to 31^st. December 2014 at South N’Djamena district hospital.

The survey population included patients who had given birth at South N’Djamena district hospital or had been referred from another hospital because of post-partum haemorrhage. Before including a patient in our survey her consent was obtained after explaining to her the need for the survey.

Studied variables were: age, parity, causes and risk factors, treatment and prognosis. Data were analyzed using SPSS17.0.

Results

Incidence

We recorded 100 cases of immediate post-partum haemorrhage among 6815 delivery giving an incidence 1.47%

Age and parity

Table 1 shows that 33 (33%) of the mothers were aged 20 to 24 years, and 68 (68%) were aged 20 years to 34 years.  The average age was 25.0 years. Multiparity was more represented at 60%, and the average parity was 2.5.

Table 1. Age and parity

Risk factors of immediate post-partum haemorrhage

Table 2 shows that 40% of patients had no risk factors, and that the most common risk factor was multiparity (60%). Six cases of intra-uterine death were recorded which can cause clotting problems.

Table 2. Risk factors

Timing and causes of immediate post-partum haemorrhage

The majority of cases (66 patients) bled during the third stage of labour.  There were 40 cases of uterine atony and 26 cases of placental retention – see Table 3.

Table 3.Causes of post-partum haemorrhage

Treatment of immediate post-partum haemorrhage

We carried out manual removal of a clot from the uterus to check the emptiness of the uterus. The second reason for this maneuver is to eliminate a uterus tear. Thus manual removal of clot from the uterus associated with uterine massage was carried out for all cases. Manual removal of the placenta was associated in three cases.

To ensure uterine contraction, uterotonic drugs were used. In district hospitals of N’Djamena, oxytocin or methylergometrin (if blood pressure is normal) were used. Patients who had received between 60-80 IU could not have more because after this dose, undesirable effects can occur. For these patients we added misoprostol. Removal of a clot from the uterus can allow infection, so we gave antibiotics routinely.

Surgical treatment was carried out in 40 cases, mostly suturing of genital tract lesions (32 patients). We achieved bilateral ligature of the uterine artery in 6 cases, one B-Lynch suture (1%) and one hysterectomy (1%). Twenty five patients (25%) received a blood transfusion. – see Table 4.

Table 4. Treatment

Maternal prognosis

We recorded two cases of maternal death giving a mortality of 2%. These deaths were due to massive haemorrhage exacerbated by the lack of blood available to transfuse.

Discussion

Incidence

According to the World Health Organization post-partum haemorrhage is annually responsible for a quarter of maternal deaths (estimated at 585,000) [8, 9]. In France the incidence is estimated as 2% [5]. In Africa, according to previous studies, the incidence varied from 1.7% to 10.4 % [10, 11].

We report an incidence of 1.47%. Dlinga [12] noted previously an incidence of 1.26% in N’Djamena city. Factors like exemption for medical fees in South N’Djamena district hospital can explain this proportion. The South N’Djamena district hospital receives mostly rural and poor people. The population surrounding N’djamena city is poor and cannot afford treatment in a private hospital. The exemption for medical fees is an opportunity for them to receive free treatment.

Age and parity

A third of the patients (33%) were aged 20 to 24 years, and two thirds (64%) were aged less than 30 years.  Our results confirm a national statistic that reported a high proportion of marriage among young girls [13]. Cultural practices favour early pregnancy and often lead to obstetric complications.

Multiparity was common (60%). This proportion is similar to other data that underlined a predominance of post-partum haemorrhage in this group [14, 15]^. The risk of post-partum haemorrhage increases with parity and may be explained by uterine muscle weakening which cannot ensure uterine retraction allowing good haemostasis. Multiparity and some factors like uterine distention (macrosomia, hydramnios, multiple pregnancies) or uterine myoma are recognized as risk factor of post-partum haemorrhage [6, 12].

Mode and place of delivery

Ninety percent of patients had a vaginal delivery and 10% delivered by Caesarean section. Twenty six patients (26%) delivered at home. Difficulties with home deliveries were linked to problems with access for women in labour to the health centre during the rainy season and at night.

Causes of post-partum haemorrhage

Bleeding occurred in the third stage of labour for the majority of patients with post-partum haemorrhage (66%). This proportion is consistent with those reported by previous surveys that showed the third stage bleeding as the main time of post-partum haemorrhage [15, 16].

The most important and major finding in our study was that the commonest cause of post-partum haemorrhage was uterine atony, which is loss of tone in the uterine musculature. Normally, contraction of the uterine muscle compresses the vessels and reduces flow. This increases the likelihood of coagulation and prevents bleeds. Thus, lack of uterine muscle contraction can cause an acute haemorrhage. These findings were also evident in studies conducted in America and Pakistan [17, 18, 19].

 Cervical and vaginal tears also emerged as one of the causes of post-partum haemorrhage and were seen in 32 % of cases. Many authors have noted a lower proportion than ours. Thus, Ducloy [10], Dreyfus [20], and Chaouki [21], reported respectively proportions of 4%, 9% and 16.3%. A qualified health care provider is required for the management of delivery aiming to prevent complications [14].

Therapeutic aspects and prognoses

All patients received an uterotonic drug by intravenous route (oxytocin), intra muscular (oxytocin or methylergometrin), or rectal route (misoprostol) and antibiotics. Manual removal of clot from uterus was systematically done beforehand. These treatments aimed to insure uterine retraction and prevent infection. Like Armide and al [22], these treatments were instituted as the two first steps of the treatment.

Surgical treatment concerned 40 patients (40%). In the majority of cases this treatment was the suture of genital lesions (32%). Chaouki [21] in his series reported a higher proportion (83.3%).

For complicated cases we did six vascular ligatures, and insertion of B-Lynch (1 case) all as recommended by the Society of Obstetricians and Gynecologists of Canada [23] and B Lynch [24].. 

One hysterectomy (1%) was permitted in order to save a patient who had a massive haemorrhage. This proportion is less than that noted by Chaouki [21] in his series (5.4%). Recourse to hysterectomy was the final solution to stop bleeding. Our attitude was conservative that is why we carried out more vascular ligatures aiming to reduce or stop blood loss.

Maternal prognosis

Post-partum haemorrhage is the main cause of maternal death in the world. We registered two cases of maternal death (2%). This mortality rate is lower than that reported by Dlinga [12].The maternal deaths noted in this survey were due to massive blood loss that led to hypovolemic shock. We didn’t get time to carry out any surgical treatment for these patients that died.

Conclusion

Post-partum haemorrhage is the most common cause of maternal mortality. Oxytocics given to contract the uterus is the most common prevention and treatment. Preventive measures and efficient curative treatments are useful to improve maternal prognosis.

Authors approval

All authors approve the submission of this work.

Conflict of interest

All authors have declared that there is no conflict of interest.

Funding

No financial assistance or grants were solicited or obtained during the course of preparing this article.

Consent

For this survey we got the consent of patients and the agreement of the director of South N’Djamena district hospital.

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