Obstetrics and Gynaecology Forum - Volume 20, Issue 3, 2010
Volume 20, Issue 3, 2010
Author J. MoodleySource: Obstetrics and Gynaecology Forum 20 (2010)More Less
Obstetric haemorrhage is a major direct cause of maternal deaths in South Africa and the rest of the African Continent. Moreover, postpartum haemorrhage (PPH), the major component of obstetric haemorrhage, is increasing in other parts of the world due to increasing rates of PPH associated with caesarean sections. In South Africa, the latest Saving Mothers Report (2005-2007) indicates that there has not been a decline in deaths from obstetric haemorrhage since the first comprehensive report (Table 1).
Source: Obstetrics and Gynaecology Forum 20, pp 77 –79 (2010)More Less
Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality in under-resourced settings. It is also a major cause of severe acute morbidity in well-resourced settings.
The maternal mortality ratio for PPH in South Africa in the years 2005-2007 was 18.8 deaths per 100,000 live births; there were 491 deaths in 3 years. It should be noted that although the known causes of PPH are uterine atony, genital tract trauma (including ruptured uteri), retained placenta inverted uterus, bleeding following abruptio placenta and placenta praevia, and maternal bleeding disorders, there can be more than 1 cause for PPH for an individual patient. All causes can be complicated by a coagulopathy which results from massive blood loss and PPH can occur at and after caesarean section.
The majority of deaths attributed to PPH in South Africa were preventable. It is vital that all levels of health care can deal with the emergency management of PPH and are also aware of the preventable factors.
Source: Obstetrics and Gynaecology Forum 20, pp 81 –83 (2010)More Less
The occurrence of PPH can be minimised by addressing preventable factors that lead to haemorrhage and the appropriate management of the third stage of labour.
The antenatal detection and treatment of anaemia plays a critical role in decreasing morbidity and mortality from PPH. Other factors placing women at risk of PPH include increased parity, increased maternal age, obesity, polyhydramnios, multiple pregnancy, known placenta praevia and abruptio placenta. Women identified with such factors should be delivered in hospitals with 24 hour caesarean section services. Their labours should have a skilled attendant, active management of the third stage and close observation in the first 4 hours after birth. All attempts must be made to prevent haemorrhage, detect it early and prevent it from becoming massive by aggressive use of uterotonic agents and early recourse to surgical measures to arrest haemorrhage.
Author G.J. HofmeyrSource: Obstetrics and Gynaecology Forum 20, pp 90 –92 (2010)More Less
Postpartum haemorrhage (PPH) may occur unexpectedly in any woman who has given birth. All birth attendants must have the skills and knowledge to manage PPH quickly and effectively. This may include rubbing up the uterus and bimanual compression, resuscitation, removal of retained placental tissue and surgical procedures.
The use of drugs to contract the uterus, and to enhance coagulation, are one element in the holistic management. The following sequence of drugs may be used :
Used by midwife :
1. If not recently given as prophylaxis and drip not yet up, oxytocin 10u im
2. Iv infusion oxytocin 20u in 1000ml Ringers lactate or saline at 120-240 mL/hour
3. Ergometrine 0.5mg or syntometrine 1 amp IMI provided no hypertension or cardiac disease [repeat once if needed]
Used by medical officer :
4. In women with hypertension or cardiac disease who continue to bleed with atonic uterus despite oxytocin, the risks versus benefits of ergometrine need to be weighed up.
5. Prostaglandin F2α 5mg in 10ml saline, inject 1ml into myometrium, checking carefully that not injecting into a blood vessel
6. Cyclokapron 1g slowly intravenously
7. Misoprostol 400µg sublingually or 600µg per rectum may be considered in the following circumstances :
1. When no oxytocin or ergometrine is available (eg unplanned home birth)
2. When all other methods have failed (although there is no evidence of benefit when injectable uterotonics have been given)
Source: Obstetrics and Gynaecology Forum 20, pp 94 –96 (2010)More Less
Estimation of blood loss can be difficult. Loss is usually underestimated as it may remain unobserved or concealed (e.g. broad ligament haematoma). Also, physiological changes of pregnancy may mask its severity. A pregnant patient may lose large volumes of blood without showing any clinical signs (masked shock).
Source: Obstetrics and Gynaecology Forum 20, pp 98 –100 (2010)More Less
Patient identifiable factors have been identified in maternal deaths and in the main, these are related to antenatal care. There is a need to support family-centred maternity care. This can be done by promoting antenatal care, preventing harmful practices, providing complete information on a birth plan including transport arrangements and home-based life-saving skills. Moreover, if health care workers and families are to work as a team to minimise complications associated with pregnancy, women and their families should be treated with respect and care.
Source: Obstetrics and Gynaecology Forum 20, pp 102 –105 (2010)More Less
Hypertensive disorders in pregnancy are responsible for significant mortality and morbidity of which pre-eclampsia is the greatest contributor. More than half of these deaths can be avoided by better understanding the important epidemiology of this disease. By intelligent revision of the final causes of hypertensive death, it is evident that there are only two significant contributory causes, namely cerebral haemorrhage and cardio-respiratory failure, usually manifesting in pulmonary oedema. Accurate measurement and appropriate treatment of blood pressure, seizure prevention, early recognition and referral of women in respiratory distress and monitoring of pulmonary capillary wedge pressure are effective interventions aimed at reducing mortality.The belief that morbidity or mortality associated with pre-eclampsia is confined to the reproductive years is no longer legitimate. The long-term risks of cardiovascular disease, stroke, end-stage renal disease and cognitive decline are increased in women having had one or more pregnancies complicated by this disease. These risks need to be appreciated and addressed by health professionals.
Source: Obstetrics and Gynaecology Forum 20, pp 107 –108 (2010)More Less
Background : Chorioamniotic membrane separation (CAS) is an uncommon sonographic finding, but its presence is associated with significant perinatal morbidity and mortality. This condition usually occurs following fetal invasive procedures. Apart from the association with Down syndrome, other complications include preterm labour, premature rupture of membranes, IUGR, fetal malformation and fetal death. Such pregnancies require close fetal surveillance and occasionally inpatient management. Case : We present a case of spontaneous complete CAS and preterm amniorrhexis, and review the current literature on the topic. Conclusion : Spontaneous complete chorioamniotic membrane separation is associated with pregnancy complications and must be monitored as high risk.