Management of Immediate Postpartum Hemorrhage at the University Hospital Center of the Sino-Central African Friendship ()
1. Introduction
Postpartum hemorrhage is loss of blood from the genital tract, in quantities greater than 500 ml in the case of vaginal delivery or greater than or equal to 1000 ml in the case of cesarean section and/or having an impact on the mother’s condition [1] [2] [3] [4] . There are two types:
➢ Immediate postpartum hemorrhages which include hemorrhages during delivery and hemorrhages contemporary with delivery which occur within 24 hours following delivery;
➢ And late postpartum hemorrhages which occur beyond 24 hours after delivery and within 45 days following delivery.
The most common cause regardless of the route of delivery is uterine atony, representing up to 70% of cases of postpartum hemorrhage (PPH), followed by retained placentas, wounds of the genital tract, abnormalities of placental insertion (placenta previa and placenta accreta), and primary or secondary coagulation abnormalities [5] [6] [7] [8] .
In recent years, new techniques and therapies have been adopted in developed countries to deal with it; which has made it possible to considerably reduce its frequency in these countries.
However, in sub-Saharan Africa in general and in the Central African Republic (CAR) in particular, the situation remains very worrying [9] with little data on the issue, hence the objective of our study which is to contribute to improving the intake in charge of immediate postpartum hemorrhages with a view to reducing maternal mortality in our country.
2. Patients and Methods
We conducted a retrospective descriptive analytical study over a period of 12 months from January 1st to December 31st, 2020 at the maternity ward of the University Hospital Center of the Sino-Central African Friendship. Our study population consisted on the one hand of all patients who gave birth in the department and then presented blood loss of more than 500 cc with repercussions on the general condition following childbirth and, on the other hand, of those referred from neighboring health centers or from home for the same reason. All women giving birth with hemorrhages less than 500 cc without repercussions on the general condition were systematically excluded from the study. Information collected from a pre-established questionnaire was collected in the delivery room from partogram cards, patient files and operating room registers. The results were processed by Epi Info 7.2.5.0.
3. Results
3.1. Frequency
We collected a total of 109 files on a total of 4,360 deliveries. The frequency of immediate postpartum hemorrhages was around 2.5%.
3.2. Age Group
The most represented age group was 20 to 24 years old 31.5% (Table 1).
3.3. Parity
Nearly 75% of patients were pauciparous (Table 2).
3.4. Educational Level
The study population consisted largely of uneducated women 64.5% (Table 3).
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Table 1. Distribution of cases according to age group.
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Table 2. Distribution of patients according to parity.
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Table 3. Distribution of patients according to educational levels.
3.5. Birthing Places
63.8% of postpartum hemorrhages occurred in parturients who gave birth outside the service (maternity wards or peripheral practices, home, road, fields, others) (Table 4).
3.6. Main Causes
The main causes of immediate postpartum hemorrhage were represented in our study by cervical tears with 56 cases or 51.2% followed by partial retained placentas with 33 cases or 30.7% (Table 5).
3.7. Providers Profile
48.8% of these deliveries were carried out by midwives and 33.2% by assistant midwives (Table 6).
3.8. Management
Active Management of the Third Period of Delivery (AMTPD) was systematic and immediate followed by the valve examination supplemented by Oxytocin infusion in the event of uterine atony; tranexamic acid and misoprostole intra-rectally. If the hemorrhage persists, suture the cervical lesions; ligation of the cervical vessels or even laparotomy either for selective ligation of the uterine vessels or for hemostasis hysterectomy were performed. Some cases required blood transfusions. We do not have a Nalador, nor a Bakry balloon, nor an Interventional Radiology service for embolization of the uterine arteries.
3.9. Death
We deplored 1.3% of deaths following coagulation disorders (Table 7).
4. Discussion
Our study was limited by the fact that it was not multicenter. Additionally, this was a retrospective study. However, it took place in a reference center and offers us the possibility of understanding the causes and management of immediate postpartum hemorrhage in our context as well as the related difficulties.
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Table 4. Distribution of patients according to place of delivery.
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Table 5. Distribution of patients according to the causes of immediate postpartum hemorrhage.
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Table 6. Distribution of patients according to the status of the providers who carried out the deliveries.
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Table 7. Distribution of patients according to the number of deaths.
4.1. Frequency
Out of a total of 4,360 deliveries in 12 months, we recorded 109 cases of immediat postpartum hemorrhage, representing a frequency of around 2.5%. Our data are superior to those of Keita S [10] and Ongoiba I.H. [11] in Bamako in Mali who found frequencies of 1.38% and 1.85% respectively.
4.2. Age
In our study, the most represented age group was 20 to 24 years old, i.e. 31.5%. This age group corresponds to that where obstetric activity is intense in the CAR, as demonstrated by previous work carried out in the country by Sepou and colleagues [12] .
4.3. Parity
Nearly 75% of patients were pauciparous (2 to 3 deliveries). Alihonou E et al. found 36.7% of pauciparians [13] .
4.4. Educational Level
The study population consisted largely of uneducated women 64.5%. This could be explained by the fact that uneducated women hardly carry out prenatal follow-up and are therefore exposed to risk factors. Our results are similar to those of Coulibaly [14] in Bamako, Mali.
4.5. Main Causes
With a frequency of 51.2%, cervical lesions represented the first cause of immediate postpartum hemorrhages in our series. Nguembi et al. [15] found a rate of 59.7%. Retained placenta constitutes the second cause with 30.7%. It was also highlighted by Pambou et al. [16] in Brazzaville in Congo and Akpadza [17] in Lome in Togo.
4.6. Medical Care
It depends on the etiologies. The cervical lesions representing the first etiology in our series were sutured. In the case of retained placenta, artificial delivery and/or uterine revision were performed. Additional measures were also taken such as the administration of uterotonics and misoprostol and blood transfusion. We deplore the lack of Nalador, Bakry balloon and interventional radiology service.
4.7. Death
We recorded a death rate of 1.3%. Akpadza in Lomé, Togo [17] had 3.8%. Our case of death was linked to the onset of coagulation disorders in a parturient referred late.
5. Conclusion
Ultimately, the proportion of immediate postpartum hemorrhages is not high in our health facility compared to other health facilities in the country. The rapid handling of cases on arrival would probably be the main reason. The faster it is, the better results we obtain. Improving the quality of services offered to women during childbirth can further reduce the frequency of these hemorrhages.