Abstract
Background:
This study aims to find the correlation between risk factors and the incidence of postpartum hemorrhage (PPH) in normal vaginal deliveries.
Materials and Methods:
The present research is an observational cohort study. Two hundred and thirty-nine women undergoing normal labor who delivered vaginally were given 0.2 mg of Ergometrine or 600 μg of Misoprostol at the delivery of the anterior shoulder, as a prophylaxis to prevent PPH. The blood loss was estimated by the use of blood collection drapes during delivery. All statistical analyses were conducted through SPSS version 27. The risk factors were compared between the groups with or without PPH.
Results:
The majority 87 (36.4%) of the participants were in the 25–29 years’ age group, 113 were nullipara (47.3%), and 93 (38.9%) were primigravida. The prevalence of PPH was 4.6% (11/239). Almost half of the cases of PPH (5/11, 45.5%) had no risk factors, whereas those with risk factors had twin pregnancy (25%), low-lying placenta (50%), grand multipara (33.3%), and previous history of PPH (33.3%). Furthermore, a moderate positive correlation between the risk factors and the incidence of PPH was observed (R = 0.512).
Conclusions:
In this study, women with risk factors such as twin pregnancy, low-lying placenta, grand multipara, and previous history of PPH developed PPH despite prophylaxis and close monitoring. However, almost half of the cases of PPH occurred in people where there was no risk factor. It is recommended that vigilance for the early detection and appropriate preparation for the management of PPH should be followed even in low-risk women undergoing vaginal delivery.
Keywords: Postpartum hemorrhage, risk factors, vaginal delivery
Résumé
Contexte:
Cette étude vise à établir la corrélation entre les facteurs de risque et l’incidence de l’hémorragie du postpartum (HPP) lors des accouchements par voie vaginale normale.
Matériels et Méthodes:
La présente recherche est une étude de cohorte observationnelle. Deux cent trente-neuf femmes ayant accouché par voie vaginale ont reçu 0,2 mg d’ergométrine ou 600 μg de misoprostol lors de la délivrance de l’épaule antérieure, à titre prophylactique pour prévenir l’HPP. La perte sanguine a été estimée à l’aide de draps de collecte de sang pendant l’accouchement. Toutes les analyses statistiques ont été effectuées à l’aide de SPSS version 27. Les facteurs de risque ont été comparés entre les groupes avec ou sans HPP.
Résultats:
La majorité des participantes, soit 87 (36,4 %), étaient âgées de 25 à 29 ans, 113 étaient nullipares (47,3 %) et 93 (38,9 %) étaient primigestes. La prévalence de l’HPP était de 4,6 % (11/239). Près de la moitié des cas d’HPP (5/11, 45,5 %) ne présentaient aucun facteur de risque, tandis que les autres avaient une grossesse gémellaire (25 %), un placenta bas inséré (50 %), une grande multiparité (33,3 %) ou des antécédents d’HPP (33,3 %). De plus, une corrélation positive modérée entre les facteurs de risque et l’incidence de l’HPP a été observée (R = 0,512).
Conclusions:
Dans cette étude, les femmes présentant des facteurs de risque tels qu’une grossesse gémellaire, un placenta bas inséré, une grande multiparité et des antécédents d’HPP ont développé une HPP malgré la prophylaxie et une surveillance étroite. Cependant, près de la moitié des cas d’HPP sont survenus chez des femmes sans facteur de risque apparent. Il est donc recommandé de maintenir une vigilance accrue pour la détection précoce et une préparation adéquate à la prise en charge de l’HPP, même chez les femmes à faible risque accouchant par voie vaginale.
Mots-clés: Accouchement par voie vaginale, facteurs de risque, hémorragie du postpartum
INTRODUCTION
Worldwide, the major cause of peripartum and maternal mortality is postpartum hemorrhage (PPH).[1] The highest burden of this is among women in low-income countries.[2] PPH is the cause of mortality in >50% of the 140,000 maternal mortality cases every year, and most of these occur within a day of delivery i.e. due to primary PPH.[3,4] There is a PPH-related mortality every 4 min. Despite the prevalence, there is the limited knowledge about the risk factors and extent of PPH. PPH can be caused by inadequate blood coagulation system, injury in the genital tract, retained tissues inside the uterus, and majorly due to uterine atony.[5] Uterine atony is defined as the failure of myometrial cells in the corpus uteri to contract after delivery, which is normally induced by the release of endogenous oxytocin, making it the principal cause of PPH and among the top five causes of maternal mortality.[6,7] Some of the common risk factors identified include intrauterine fetal death, cesarean births, induction of labor, not using prophylaxis for PPH (such as uterotonics), genital tract injuries, preterm births, advanced maternal age, grand multiparity, being primigravida, fetal macrosomia, multiple pregnancies, and a history of PPH.[8,9,10]
The traditional definition of PPH is the loss of blood after vaginal delivery which exceeds 500 ml or 1,000 ml in cesarean sections.[11] In most of the studies,[8,9,10] the estimation of blood loss is the main indicator of PPH, however, they used the method of visually evaluating blood loss which has a huge margin of human error and inaccuracy.[12] According to a systematic review,[13] this visual evaluation of PPH has advantages such as the absence of cost, real-time results, and feasibility. However, the disadvantages include its inaccuracy when severe PPH occurs. This is critical as it leads to the under detection of PPH and has severe clinical implications. PPH is responsible for more than 85,000 deaths per year and it is suggested that an alternate definition of PPH should be followed for appropriate recognition of cases.[14]
PPH can be prevented given proper measures have been taken by identifying the risk factors in the early stage of pregnancy.[10] Knowledge regarding these risk factors will also help identify needed public health interventions.[6] Therefore, this study aims to find the correlation between the risk factors of PPH and the incidence of PPH in vaginal deliveries. The significance of this study is that it will promote preventive measures undertaken by healthcare providers in the antenatal and intrapartum periods so that early prophylaxis can be started. This in turn will prevent maternal morbidity and mortality.
MATERIALS AND METHODS
The present study is an observational and cohort study. The study was conducted in the Department of Obstetrics and Gynecology at Jagannath Hospital, Bhubaneswar, between March 2020 and October 2021. The sample size was calculated to be 239 in the study. After providing information and obtaining informed consent, 239 women with normal vaginal delivery were included in the study. Women with contraindications to either Ergometrine or Misoprostol were excluded. The study further used various exclusion criteria to remove potential bias due to any underlying disease. Exclusion criteria were:
Obstetrics (gestational age <32 weeks, preeclampsia, eclampsia, induction of labor, use of oxytocin for augmentation of labor, prolonged labor, precipitate labor, and vaginal instrumental deliveries)
Nonobstetrics (H/o Asthma, H/o Epilepsy, H/o Heart disease, H/o Kidney disease, H/o Jaundice, and Coagulation disorder).
All women received active management of the third stage of labor where they were given either 0.2 mg intravenous ergometrine or 600 μg of Misoprostol as a prophylaxis to prevent PPH immediately after the birth of the baby. Women with any contraindication to these drugs were also excluded. Furthermore, the side effects of these drugs were also noted. Following this, controlled cord traction was performed after the signs of placental separation were observed, and the uterine fundus was massaged.
The blood loss was estimated by using the gravimetric method wherein all blood-soaked drapes were collected in a plastic tray during labor. After the bleeding stopped, the tray and its contents were weighed using an analytical balance. For this experiment, the mean weight of 1 ml of blood was considered 1.06 g.
Detailed past medical history of these patients was obtained to identify the occurrence of past PPH in previous pregnancies, systematic diseases such as heart disease, hypertension, bronchial asthma, and other risk factors. The amount of blood loss, length of the third stage of labor, laboratory parameters such as Hb%, packed cell volume (PCV), etc., and general clinical conditions were obtained in the participants. The incidence of PPH was also noted and recorded in the prepared performa. The amount of blood loss was estimated from the readings in the blood collection drape, clinically, and also by comparing the values of hemoglobin (Hb%) and hematocrit (PCV) from the second postdelivery day blood sample with the values in late pregnancy or at admission. In addition, a record of the vitals such as blood pressure, temperature, and pulse were obtained just before the birth of the baby, every 15 min (till 1 h), at 30 min (till 2 h), and then after 4, 8, 12, 16, and 24 h.
The statistical analysis of the study included a Chi-square test for finding an association between the risk factors and the occurrence of PPH in women with vaginal delivery. Furthermore, the frequency and descriptive statistics of all the observed variables were estimated. The statistical software used was Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY) version 27 and the significant value was taken at <0.05. Linear regression was run to study the relationship between the incidence of PPH and its risk factors.
RESULTS
There were a total of 239 patients recruited out of which, only 2 (<1%) were above 40 years, 6 (2.5%) were below 20 years and the majority 87 (36.4%) were between 25 and 29 years. Based on gravidity status, the majority of them 93 (38.9%) were primigravida, followed by 48 (20.1%) second gravida, and the least 3 (1.3%) were seventh and 3 (1.3%) were eighth gravida and above. Based on parity, majority 113 (47.3%) were nullipara, whereas, the least 2 (<1%) had parity more than 5. These findings are shown in Table 1. It also demonstrates the risk factors for PPH found in the patients across all age groups. Among the risk factors, the most common was anemia 32 (13.4%). Other common factors were grand multiparity 9 (3.8%) and hypotension 8 (3.4%).
Table 1.
Demographics
| Variables | n (%) |
|---|---|
| Age (years) | |
| 15–19 | 6 (2.5) |
| 20–24 | 48 (20.1) |
| 25–29 | 87 (36.4) |
| 30–34 | 70 (29.2) |
| 35–39 | 26 (10.9) |
| >40 | 2 (0.84) |
| Gravidity status | |
| Primigravida | 93 (38.9) |
| Second gravida | 48 (20.1) |
| Third gravida | 44 (18.4) |
| Fourth gravida | 26 (10.9) |
| Fifth gravida | 13 (5.4) |
| Sixth gravida | 9 (3.7) |
| Seventh gravida | 3 (1.3) |
| Eighth gravida and above | 3 (1.3) |
| Parity | |
| 0 | 113 (47.3) |
| 1 | 71 (29.7) |
| 2 | 32 (13.4) |
| 3 | 14 (5.9) |
| 4 | 4 (1.7) |
| 5 | 3 (1.2) |
| >5 | 2 (0.8) |
| Risk factors | |
| Twin pregnancy | 4 (1.7) |
| Polyhydramnios | 6 (2.5) |
| Grand multipara | 9 (3.8) |
| History of previous PPH | 3 (1.2) |
| Anemia | 32 (13.4) |
| Low-lying placenta | 2 (0.8) |
| Hypotension | 8 (3.4) |
| Chorioamnionitis | 1 (0.4) |
| IUFD | 5 (2.1) |
| GDM | 5 (2.1) |
| Macrosomia | 2 (0.8) |
GDM=Gestational diabetes mellitus, IUFD=Intra-uterine fetal death, PPH=Postpartum hemorrhage
The amount of blood loss was also calculated among the patients [Figure 1]. Here, the majority of the patients 45 (18.9%) had blood loss between 100 and 150 ml, whereas, the least number of patients (4 [1.7%]) had blood loss between 0 and 49 ml. However, 11 (4.6%) patients had blood loss of more than 500 ml, i.e. postpartum hemorrhage.
Figure 1.
Blood loss in patients measured in ml
Figure 2 demonstrates the length of the 3rd stage of labor. The majority of the patients 74 (31%) had 120–149 s length of the third stage of labor, while none had less than 60 s. The majority of the patients (67.3%) had 3rd stage of the labor period between 90 and 209 s.
Figure 2.
Length of 3rd stage of labor in seconds
Change in HB was majorly seen to be 0–0.5 gm% in 161 (67.4%). Whereas, 15 (6.2%) patients had more than 1 to more than 5 gm% change. Change in PCV was the highest seen in 177 (74%) patients that had 1%–2% change. More than 5% change was seen in 10 (4.2%) patients [Table 2].
Table 2.
Change in hemoglobin and packed cell volume after delivery
| Variables | n (%) |
|---|---|
| Change in HB | |
| 0–0.5 | 161 (67.4) |
| 0.6–1.0 | 63 (26.4) |
| 1.1–2 | 11 (4.6) |
| 2.1–5 | 3 (1.2) |
| >5 | 1 (0.4) |
| Change in PCV | |
| <1 | 8 (3.4) |
| 1–2 | 177 (74.0) |
| 3–4 | 44 (18.4) |
| >5 | 10 (4.2) |
HB=Hemoglobin, PCV=Packed cell volume
Table 3 reports the frequency and percentage of risk factors and occurrence of PPH. Grand multipara women had an incidence of PPH in 33.33% of cases, and one-third of women with a previous history of PPH also had PPH during delivery. The highest incidence was seen in patients with a risk factor of low-lying placenta, where, 50% (1 in 2) developed PPH. A total of 11 patients had PPH, and almost half of them 5 (45.5%) had no risk factor.
Table 3.
Frequency of risk factors and occurrence of postpartum hemorrhage
| Risk factor | Total | PPH | Percentage |
|---|---|---|---|
| Twin pregnancy | 4 | 1 | 25.0 |
| Low-lying placenta | 2 | 1 | 50 |
| Previous history of PPH | 3 | 1 | 33.33 |
| Grand multipara | 9 | 3 | 33.33 |
| Others | 62 | 0 | 0 |
| + No risk factors | 159 | 5 | 3.1 |
PPH=Postpartum hemorrhage
The occurrence of PPH when compared between the groups of women with and without any risk factors, was statistically significant (P = 0.012) [Table 4].
Table 4.
Association between risk factors and occurrence of postpartum hemorrhage
| PPH (n=11), n (%) | No PPH (n=228), n (%) | Pearson Chi-square P value (χ2, Df) | Yates corrected Chi-square P value (χ2, Df) | |
|---|---|---|---|---|
| 33.4% with risk factors (n=80) | 6 (7.5%) (54.54% of PPH) | 74 (92.5) 0.07 | 0.012 (2.299, 1) | 0.234 (1.414, 1) |
| 66.5% without risk factors (n=159) | 5 (3.14%) (45.45% of PPH) | 154 (96.8) 0.04 |
PPH=Postpartum hemorrhage
The linear regression analysis reveals that the risk factors have a statistically significant, moderate positive effect on the incidence of PPH, with a correlation coefficient (R) of 0.512 [Table 5]. This suggests that as the risk factors increase, there is a moderate increase in the incidence of PPH. The model’s explanatory power, indicated by the R2 = 0.262, shows that approximately 26.2% of the variance in PPH incidence can be accounted for by the included risk factors.
Table 5.
Linear regression analysis predicting postpartum hemorrhage incidence based on risk factors
| R | R 2 | Adjusted R2 | SE of the estimate |
|---|---|---|---|
| 0.512a | 0.262 | 0.226 | 0.159 |
SE=Standard error
Table 6 provides the ANOVA results, demonstrating the overall fit of the linear regression model. The F-statistic of 7.298, accompanied by a significance level (P value) of 0.000, indicates that the regression model is statistically significant. This means that the risk factors together have a significant impact on the incidence of PPH.
Table 6.
ANOVA table demonstrating the overall fit of the linear regression model
| Sum of squares | df | Mean square | F | Significant | |
|---|---|---|---|---|---|
| Regression | 2.026 | 11 | 0.184 | 7.298 | 0.000b |
| Residual | 5.705 | 226 | 0.025 | ||
| Total | 7.731 | 237 |
bThe table presents the overall fit of the linear regression model. A significant F-statistic (P < 0.001) indicates that the independent variables collectively explain a significant portion of the variance in the dependent variable
DISCUSSION
This study aimed to find a correlation between risk factors and incidence of PPH in normal vaginal deliveries. The majority of the participants were in the 25–29 years’ age group and were primigravida. Complications during pregnancy and labor can affect the outcomes and lead to complications in mother and baby.[15,16,17,18,19] The majority of PPH cases had no risk factors, whereas those with risk factors, twin pregnancy, low-lying placenta, grand multipara, and previous history of PPH were notable, despite the use of uterotonics such as Ergometrine and Misoprostol.
The results of this study are similar to one conducted in Uganda between 2013 and 2014 where PPH was seen with multiple pregnancies which had an adjusted odds ratio (OR) of 7.66, macrosomia had an adjusted OR of 2.14 and HIV had an adjusted OR of 2.26 all at 95% confidence interval (CI).[6] However, as in this study, none of the participants were diagnosed with HIV-positive serostatus, and no correlation between HIV and PPH could be assessed. Twin pregnancy is more associated with peripartum factors leading to PPH compared to singleton pregnancies.[20] During twin pregnancy, the uterus is overdistended which leads to impairment in postpartum myometrial contractility and can enhance uterine atony. In addition, uterine blood flow and maternal blood volume also increase in multiple gestation for the provision of additional fetal, uterine, and placental tissues.[21,22] However, despite these factors, clinically significant PPH occurs in only among few cases with multiple or twin pregnancies, making it unclear to determine how to correctly identify high-risk patients with certainty in this population. According to Blitz et al.[23] decreasing the cesarean delivery, optimizing PPH parameters and comorbid conditions in mothers can decrease the risk of PPH.
According to a systematic review conducted by Fan et al.,[24] 5146 pregnancies were identified with placenta previa (minor) of which 22.3% had PPH (95% CI 15.8%–28.7%). Comparatively, in this study, the incidence was higher; however, as there were very few cases with low-lying placenta, this could have led to an increased incidence rate. The low-lying placental edge reaches up to the endocervical opening, where vaginal delivery is still possible but leads to fetal-neonatal and maternal complications.[25] PPH is usually atonic due to the inability of the lower segment to contract and provide myotamponade, but may be due to antepartum hemorrhage or trauma during delivery in the presence of soft and vascular lower segment. The placenta previa may be caused by uterine scarring due to endometrial damage, which can become complicated by incursion of villi outside the decidua basalis and lead to placenta increta or accrete.[26] Placenta increta often leads to unexpected complications, increased blood loss, or maternal mortality.[27] Therefore, there is an increased chance of PPH in expecting mothers with low-lying placenta. However, in this study, there were no placenta accrete, or increta.
In a study by Akhtar et al.,[28] PPH was found in 5.44% of women with grand multipara, where the leading cause found was atonic uterus. Comparatively, only 3.7% of women in this study were grand multipara and 33.33% among them had PPH. Women who have delivered 5 or more term babies (after 28 weeks) with a weight of more than 500 g are characterized as grand multipara or even “dangerous multipara,” as it has been linked with multiple complications in pregnancy and delivery.[29] Previous studies indicate that its incidence is very high in developing countries (18.5%) compared to developed countries (2%–4%).[30]
However, PPH was also found in patients with low-risk factors. This indicates that PPH can occur in the absence of high-risk factors. To combat that, the attending staff should be vigilant and equipped to handle the cases of unexpected PPH incidents. This safety precaution can decrease the maternal mortality rate. In this study, PPH was found in patients with risk factors of twin pregnancy, placenta previa, grand multipara, and previous history of PPH despite giving prophylaxis and uterotonics. This warrants the need for a thorough investigation of risk factors to provide adequate management and monitoring to prevent PPH and maternal mortality. However, almost half the cases occurred in women without any risk factors. The occurrence of PPH when compared between groups of women with risk factors and groups without risk factors, was not statistically significant. Therefore, there is a need for the identification of all possible risk factors as well as better predictive models for the occurrence of PPH. Maternity units should be vigilant for the occurrence of PPH and prepared for appropriate timely management, irrespective of the presence or absence of known risk factors and the type of prophylaxis used.
The limitations of the study were a limited sample size and a small number of patients with PPH. Also, it only included women undergoing vaginal delivery. However, strengths include this being conducted over a long period increasing its generalizability factor. Furthermore, women with most of the known risk factors were excluded. This is the reason for a smaller sample size.
CONCLUSIONS
Postpartum hemorrhage is the leading cause of maternal and peripartum deaths worldwide. The highest burden of this is among women in low-income countries. This study highlights that while certain risk factors such as twin pregnancy, low-lying placenta, grand multiparity, and previous history of PPH are significantly associated with the occurrence of PPH, a substantial proportion of cases occur in the absence of identifiable risk factors. Future studies on a large sample size should be conducted over a targeted population of women with risk factors to further understand its mechanism and true incidence rate in the targeted population. Additionally, the skill level of the healthcare providers should also be assessed so that variability as a result of this confounder can be controlled. This underscores the importance of universal vigilance and preparedness in managing normal vaginal deliveries to mitigate the risk of PPH, regardless of the presence of known risk factors.
Ethical statement
The study was conducted in accordance with Declaration of Helsinki, and approved by institutional review board. Informed consent was obtained from all subjects involved in the study.
Data availability statement
The raw data is available with the corresponding author and can be provided after reasonable request.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The raw data is available with the corresponding author and can be provided after reasonable request.
