Introduction

Postpartum haemorrhage (PPH) describes excessive bleeding after

delivery of a foetus. It is the leading cause of maternal death, responsible for
approximately 68,500 deaths a year, 99.7% occurring in developing regions. It
occurs in approximately 6% of deliveries when defined as a blood loss equal to
or greater than 500 ml, or 1–2% when a 1000 ml is used. It therefore represents
a significant global health burden, disproportionately affecting those in the world's
poorest countries.
An individual's risk of excessive blood loss will be influenced by numerous
pre-existing, pregnancy-related and obstetric factors. Risk factors for PPH
include: Asian ethnicity; obesity; previous PPH; multiple pregnancy; anaemia;
large baby; placenta praevia; age over 40 years; induction of labour; prolonged
labour; intrapartum pyrexia; placental abruption; episiotomy; operative vaginal
delivery; retained placenta; and delivery by caesarean section. Incidence and
severity of PPH will therefore vary widely depending on the population studied
and the obstetric practice. PPH-related adverse clinical events will also vary
depending on the individual. For example the same blood loss could have no
clinical consequence in a healthy woman, but be a life-threatening event for in a
woman with severe anaemia.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139805/
According to the World Health Organization (WHO), Postpartum
haemorrhage (PPH) is the leading cause of maternal mortality, accounting for
about 35% of all maternal deaths.1 These deaths have a major impact on the
lives and health of the families affected. Between 1990 and 2010, there was a
global reduction in maternal deaths and the maternal mortality ratio (MMR) from
543 000 and 400 per 100 000 live births to 287 000 and 210 per 100 000 live
births respectively. However, developing countries continue to experience higher
numbers of maternal deaths compared to developed countries.2 In 2010, the
MMR in developing countries was 240 per 100 000 live births (284 000 maternal
deaths) compared to 16 (2 200 maternal deaths) in developed countries. Thirty-
five countries have been identified as either making insufficient or no progress
towards achieving the Fifth Millennium Development Goal (MDG5), which aims to
reduce the global maternal mortality rate by 75% from 2000 to 2015.
Every year about 14 million women around the world suffer from PPH.3
The risk of maternal mortality from haemorrhage is 1 in 1 000 deliveries in
developing countries (100 per 100 000 live births). Most deaths (about 99%) from
PPH occur in low- and middle-income countries compared with only 1% in
industrialized nations.4 However, recent studies have shown an increase in the
incidence of PPH in developed countries as well.5 Therefore, in order to reduce
the MMR and achieve MDG5, it is essential to achieve a major reduction in the
incidence of PPH. The WHO and professional bodies recommend active
management of the third stage of labour (AMTSL) for all vaginal births in order to
prevent PPH.6 This involves prophylactic administration of uterotonic medicines
before delivery of the placenta in addition to other non-pharmacological
interventions, such as late cord clamping and controlled cord traction of the
umbilical cord (in settings where skilled birth attendants are available). Although
AMTSL reduces postpartum blood loss, about 3% to 16.5% of women will still go
on to experience PPH and will require treatment.
Oxytocin injection is the recommended first line uterotonic medicine for
preventing and treating PPH because it is more effective than ergometrine and
other uterotonics and has relatively fewer side-effects. However, oxytocin is
unstable at room temperature and requires special temperature storage
conditions to remain effective. The cold chain storage required to transport and
store oxytocin is unreliable in resource-constrained countries. In addition, the fact
that oxytocin must be administered parenterally requires the involvement of
skilled health personnel.
https://www.who.int/medicines/areas/priority_medicines/Ch6_16PPH.pdf
The need of further studies and researches regarding Postpartum
Hemorrhage is really needed and important since one of the goals of Millennium
Development Goal (MDG) is to reduce global maternal mortality rate, and
Postpartum Hemorrhage is of the leading cause of maternal death, since almost
of the etiology of pregnancy complications are still unknown, there are risk
factors that contributes in pregnancy complications, by studying the case we can
prevent those complications by studying its risk factors. It can be prevented if we
are knowledgeable enough regarding those cases. Studying this case help us
generate ideas and relate each aspect.
Patient X is a 22-year-old woman (G1P1), Patient X delivered via Normal
Spontaneous Vaginal Delivery and was re-admitted due to post-partum bleeding,
cervix is 2cm open upon assessment. Vaginal bleeding was noted since 24hours
after birth, and simply thought it was lochia for succeeding days but on the day of
admission patient experienced heavy bleeding that soaked her perineal pads,
and experienced body malaise. Since admission Patient X received three units of
whole fresh blood, medications such as Methergine, Methronidazole, Hemorate,
Co-Amoxiclav, and Mefenamic Acid. Obstetric team performed completion
curettage and repair of laceration as the cause of bleeding.