Risk factors for postpartum haemorrhage in the Northern Province of Rwanda: A case control study

The profile of patients with postpartum hemorrhage admitted to the obstetric intensive care: a cross-sectional study

Objective

In Brazil, postpartum hemorrhage (PPH) is a major cause of maternal morbidity and mortality. Data on the profile of women and risk factors associated with PPH are sparse. This study aimed to describe the profile and management of patients with PPH, and the association of risk factors for PPH with severe maternal outcomes (SMO).

Methods

A cross-sectional study was conducted in Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) obstetric intensive care unit (ICU) between January 2012 and March 2020, including patients who gave birth at the hospital and that were admitted with PPH to the ICU.

Results

The study included 358 patients, of whom 245 (68.4%) delivered in the IMIP maternity, and 113 (31.6%) in other maternity. The mean age of the patients was 26.7 years, with up to eight years of education (46.1%) and a mean of six prenatal care. Uterine atony (72.9%) was the most common cause, 1.6% estimated blood loss, 2% calculated shock index (SI), 63.9% of patients received hemotransfusion, and 27% underwent hysterectomy. 136 cases of SMO were identified, 35.5% were classified as maternal near miss and 3.0% maternal deaths. Multiparity was associated with SMO as an antepartum risk factor (RR=1.83, 95% CI1.42-2.36). Regarding intrapartum risk factors, abruptio placentae abruption was associated with SMO (RR=2.2 95% CI1.75-2.81). Among those who had hypertension (49.6%) there was a lower risk of developing SMO.

Conclusion

The principal factors associated with poor maternal outcome were being multiparous and placental abruption.

Predictive Modelling of Postpartum Haemorrhage Using Early Risk Factors: A Comparative Analysis of Statistical and Machine Learning Models

Postpartum haemorrhage (PPH) is a significant cause of maternal morbidity and mortality worldwide, particularly in low-resource settings. This study aimed to develop a predictive model for PPH using early risk factors and rank their importance in terms of predictive ability. The dataset was obtained from an observational case-control study in northern Rwanda. Various statistical models and machine learning techniques were evaluated, including logistic regression, logistic regression with elastic-net regularisation, Random Forests, Extremely Randomised Trees, and gradient-boosted trees with XGBoost. The Random Forest model, with an average sensitivity of 80.7%, specificity of 71.3%, and a misclassification rate of 12.19%, outperformed the other models, demonstrating its potential as a reliable tool for predicting PPH. The important predictors identified in this study were haemoglobin level during labour and maternal age. However, there were differences in PPH risk factor importance in different data partitions, highlighting the need for further investigation. These findings contribute to understanding PPH risk factors, highlight the importance of considering different data partitions and implementing cross-validation in predictive modelling, and emphasise the value of identifying the appropriate prediction model for the application. Effective PPH prediction models are essential for improving maternal health outcomes on a global scale. This study provides valuable insights for healthcare providers to develop predictive models for PPH to identify high-risk women and implement targeted interventions.

Predictors of postpartum hemorrhage at public hospitals in Addis Ababa, Ethiopia: A case-control study

Introduction

Postpartum hemorrhage (PPH) is responsible for half of all maternal deaths during childbirth. Despite being preventable and curable, PPH remains the leading cause of maternal death in Ethiopia. Therefore, the aim of this study was to identify the determinants of PPH among women delivered at public hospitals in Addis Ababa, Ethiopia, in 2022.

Methods

A facility-based, unmatched case control study with 378 study participants was carried out in selected public hospitals in Addis Ababa, Ethiopia. Women who gave birth and developed PPH were considered cases, while women who gave birth in public hospitals in Addis Ababa and did not develop PPH were controls. Binary and multivariable logistic regression analyses were used to identify independent predictors of PPH. Variables was considered statistically significant in the final model if their p-value was less than 0.05.

Results

The result of this study identified that antenatal care follow-up (AOR: 2.58; 95% CI: 1.12, 5.96), history of cesarean delivery (AOR: 3.47; 95% CI: 1.40, 8.58), prolonged labor (AOR: 5.14; CI: 2.07, 12.75), and genital trauma apart from episiotomy (AOR: 4.39; CI: 1.51, 12.81) were determinants of PPH.

Conclusion

According to the finding of this study duration of labor, history of cesarean section, antenatal care follow-up, and genital trauma other than episiotomy were independent determinants of PPH. Therefore, it is crucial to screen and closely monitor high-risk mothers during antepartum care visit, including those who have a history of cesarean delivery.

Prenatal hypertension as the risk of eclampsia, HELLP syndrome, and critical obstetric hemorrhage

Critical bleeding is a common cause of maternal mortality in obstetric patients. However, the non-obstetric factors underlying critical obstetric bleeding remain uncertain. Therefore, this study aimed to clarify the impact of chronic hypertension on obstetric hemorrhage by evaluating a nationwide administrative database in Japan. Women who gave birth between 2018 and 2022 were enrolled. The primary outcome was critical hemorrhage requiring massive red blood cell (RBC) transfusion during childbirth. In total, 354, 299 eligible women were selected from the database. The maternal mortality rate was >1.0% among those who received a massive RBC transfusion (≥4000 cc), and this amount was used as the cutoff of the outcome. Critical hemorrhage was less frequent with elective Caesarean section (CS) compared with vaginal childbirth or emergent CS (odds ratio [OR], 0.38; 95% confidence interval, 0.30-0.47). Multiple logistic regression analysis adjusting for these obstetric risks revealed that a higher maternal age (adjusted OR [aOR] per 1 year, 1.07 [1.05-1.09]); oral medications with prednisolone (aOR, 2.5 [1.4-4.4]), anti-coagulants (aOR, 10 [5.4-19]), and anti-platelets (aOR, 2.9 [1.3-6.4]); and a prenatal history of hypertension (aOR, 2.5 [1.5-4.4]) and hypoproteinemia (aOR, 5.8 [1.7-20]) are the risks underlying critical obstetric hemorrhage. Prenatal history of hypertension was significantly associated with obstetric disseminated intravascular coagulation (OR, 1.9 [1.5-2.4]); Hemolysis, Elevated Liver enzymes, and Low platelet count (HELLP) syndrome (OR, 3.3 [2.7-4.2]); and eclampsia (OR, 6.1 [4.6-8.1]). In conclusion, a maternal prenatal history of hypertension is associated with the development of HELLP syndrome, eclampsia, and resultant critical hemorrhage. The incidence of HELLP syndrome and eclampsia increased more than fivefold in the presence of prenatal hypertension. However, the likelihood of subsequently developing DIC or experiencing critical bleeding did not change by the presence of prenatal hypertension.

Frequency of Maternal Anemia in Patients Presenting With Preterm Premature Rupture of Membranes

BACKGROUND

Preterm premature rupture of membranes (PPROM) is the rupture of fetal membranes before 38 weeks of gestation. The etiology is multifactorial. Maternal anemia is one of the factors leading to PPROM. This study aims to determine the frequency of maternal anemia in patients presenting with PPROM.

MATERIALS AND METHODS

This cross-sectional study was carried out at the Department of Obstetrics and Gynecology, Lady Reading Hospital, Peshawar. This study was conducted from July 1 to December 31, 2021. One hundred and twenty two patients with PPROM presenting to the Department of Obstetrics and Gynecology were included. The diagnosis of PPROM was made based on the history of the PV leak, followed by confirmation with the nitrazine litmus test, microscopic fern test, and ultrasonographic amniotic fluid index measurement. Anemia was determined by examination of hemoglobin levels in the maternal blood samples. Hb <11gm/dl was labeled as anemia. IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. was used for statistical analysis.

RESULTS

 The age of the patients ranged from 20 to 40 years. The mean age was 29.14 ± 6.194 years. 63 patients (51.6%) were multiparous (parity 2 to 4). Maternal anemia was observed in 39 patients (32.0%). A significant association (p = 0.005) was observed between maternal anemia and grand multiparity (parity 2 to 4).

CONCLUSION

 Maternal anemia significantly contributes to PPROM, especially in multiple pregnancies. Meticulous family planning and consistent obstetrical monitoring throughout pregnancy are key to addressing this, potentially reducing both maternal anemia risk and PPROM complications.

Hemostatic biomarkers associated with postpartum hemorrhage: a systematic review and meta-analysis

Postpartum hemorrhage (PPH) is a leading cause of maternal morbi-mortality. Although obstetric risk factors are well described, the impact of predelivery hematologic and hemostatic biomarkers remains incompletely understood. In this systematic review, we aimed to summarize the available literature on the association between predelivery hemostatic biomarkers and PPH/severe PPH. Searching MEDLINE, EMBASE, and CENTRAL databases from inception to October 2022, we included observational studies on unselected pregnant women without bleeding disorder reporting on PPH and on predelivery hemostatic biomarkers. Two review authors independently performed title, abstract and full-text screening, upon which quantitative syntheses of studies reporting on the same hemostatic biomarker were conducted, calculating the mean difference (MD) between women with PPH/severe PPH and controls. A search on 18 October 2022 yielded 81 articles fitting our inclusion criteria. The heterogeneity between studies was considerable. With regard to PPH, the estimated average MD in the investigated biomarkers (platelets, fibrinogen, hemoglobin, Ddimer, activated partial thromboplastin time, and prothrombin time) were not statistically significant. Women who developed severe PPH had lower predelivery platelets than controls (MD = -26.0 109/L; 95% confidence interval, -35.8 to -16.1), whereas differences in predelivery fibrinogen concentration (MD = -0.31 g/L; 95% confidence interval, -0.75 to 0.13) and levels of factor XIII or hemoglobin were not statistically significant in women with and without severe PPH. Predelivery platelet counts were, on average, lower in women with severe PPH compared with controls, suggesting the potential usefulness of this biomarker for predicting severe PPH. This trial was registered at the International Prospective Register of Systematic Reviews as CRD42022368075.

Abnormal Uterine Involution May Lead to Atony and Postpartum Hemorrhage: A Hypothesis, With Review of the Evidence

Uterine involution has 2 major components-(1) involution of vessels; and (2) involution of myometrium. Involution of vessels was addressed by Rutherford and Hertig in 1945; however, involution of myometrium has received little attention in the modern literature. We suggest that the pathophysiology of myometrial involution may lead to uterine atony and postpartum hemorrhage. The myometrium dramatically enlarges due to gestational hyperplasia and hypertrophy of myocytes, caused by hormonal influences of the fetal adrenal cortex and the placenta. After delivery, uterine weight drops rapidly, with physiologic involution of myometrium associated with massive destruction of myometrial tissue. The resulting histopathology, supported by scientific evidence, may be termed "postpartum metropathy," and may explain the delay of postpartum menstrual periods until the completion of involution. When uterine atony causes uncontrolled hemorrhage, postpartum hysterectomy examination may be the responsibility of the perinatal pathologist.Postpartum metropathy may be initiated when delivery of the baby terminates exposure to the hormonal influence of the fetal adrenal cortex, and may be accelerated when placental delivery terminates exposure to human chorionic gonadotrophin (HCG). This hypothesis may explain why a prolonged third stage of labor, and delays in management, are risk factors for severe hemorrhage due to uterine atony.

Determinants of postpartum uterine atony in urban South Ethiopia: a community-based unmatched nested case-control study

BACKGROUND

Uterine atony is the most common cause of postpartum hemorrhage, which is the leading preventable cause of maternal morbidity and mortality. Despite several interventions uterine atony-related postpartum hemorrhage remains a global challenge. Identifying risk factors of uterine atony helps to reduce the risk of postpartum hemorrhage and subsequent maternal death. However, evidence about risk factors of uterine atony is limited in the study areas to suggest interventions. This study aimed to assess determinants of postpartum uterine atony in urban South Ethiopia.

METHODS

A community-based unmatched nested case-control study was conducted from a cohort of 2548 pregnant women who were followed-up until delivery. All women with postpartum uterine atony (n = 93) were taken as cases. Women who were randomly selected from those without postpartum uterine atony (n = 372) were taken as controls. Using a case to control ratio of 1:4, the total sample size was 465. An unconditional logistic regression analysis was done using R version 4.2.2 software. In the binary unconditional logistic regression model variables that have shown association at p < 0.20 were recruited for multivariable model adjustment. In the multivariable unconditional logistic regression model, statistically significant association was declared using 95% CI and p < 0.05. Adjusted odds ratio (AOR) used to measure the strength of association. Attributable fraction (AF) and population attributable fraction (PAF) were used to interpret the public health impacts of the determinants of uterine atony.

RESULTS

In this study, short inter-pregnancy interval < 24 months (AOR = 2.13, 95% CI: 1.26, 3.61), prolonged labor (AOR = 2.35, 95% CI: 1.15, 4.83), and multiple birth (AOR = 3.46, 95% CI: 1.25, 9.56) were determinants of postpartum uterine atony. The findings suggest that 38%, 14%, and 6% of uterine atony in the study population was attributed to short inter-pregnancy interval, prolonged labor, and multiple birth, respectively, which could be prevented if those factors did not exist in the study population.

CONCLUSIONS

Postpartum uterine atony was related to mostly modifiable conditions that could be improved by increasing the utilization of maternal health services such as modern contraceptive methods, antenatal care and skilled birth attendance in the community.

Utilisation of modern contraceptives by sexually active adolescent girls in Rwanda: a nationwide cross-sectional study

Background

Modern contraceptive use has been shown to influence population growth, protect women’s health and rights, as well as prevent sexually transmitted infections (STIs) for barrier contraceptive methods such as condoms. The present study aimed at assessing the level of utilization and factors associated with modern contraceptive use among sexually active adolescent girls in Rwanda.

Methods

We used secondary data from the Rwanda Demographic and Health Survey (RDHS) 2020 data of 539 sexually active adolescent girls (aged 15 to 19 years). Multistage stratified sampling was used to select study participants. We conducted multivariable logistic regression to assess the association between various socio-demographics and modern contraceptive use using SPSS version 25. Modern contraception included the use of products or medical procedures that interfere with reproduction from acts of sexual intercourse.

Results

Of the 539 sexually active girls, only 94 (17.4%, 95% CI: 13.8–20.1) were using modern contraceptives. Implants (69.1%) and male condoms (12.8%) were the most used options. Modern contraceptive use was positively associated with older age (AOR = 10.28, 95% CI: 1.34–78.70), higher educational level (AOR = 6.98, 95% CI: 1.08–45.07), history of having a sexually transmitted infection (AOR = 8.27, 95% CI: 2.54–26.99), working status (AOR = 1.72, 95% CI: 1.03–2.88) and being from a female-headed household (AOR = 1.96, 95% CI: 1.12–3.43). However, not being in a union (AOR = 0.18, 95% CI: 0.10–0.35) and region (AOR = 0.28, 95% CI: 0.10–0.80) had negative associations.

Conclusions

To promote utilisation of modern contraceptives, family planning campaigns need to place more emphasis on the younger, unmarried adolescents, as well as those with lower educational levels. Consideration of household and regional dynamics is also highlighted.