Study of analysis of post-partum hemorrhage (PPH) in cesarean section

Abstract

Introduction: Postpartum hemorrhage is defined as a blood loss of more than 500 mL, estimated with a vaginal birth or more than 1000 mL estimated with a caesarean delivery (PPH)¹. Atonicity of the uterus is the most common cause of PPH. Primary postpartum hemorrhage (PPH) can occur in any pregnant woman without any risk factors^3,4 including in prepartum anemia⁵, prolonged labor^6,7, induction of labor⁸, delivery by Caesarean section^8,9 history of severe PPH¹⁰, multiple pregnancies¹⁰, preeclampsia¹⁰, mothers with older ages⁹, fetal macrosomia⁹, and multiparity. Secondary consequences of bleeding include shock, adult respiratory distress syndrome, disseminated intravascular coagulation, acute renal failure, loss of fertility, and pituitary necrosis. Presebt study was planned with an objective to assess clinical profile, incidence, risk factors & outcome of caesarean section patients associated with PPH. Materials and Methods: With Ethics Committee approval and participant consent, 990 patients of LSCS were included in the study over a period of 6 months. A proforma was used to collect data. 990 participants enrolled in this study out of which 98 landed in PPH during LSCS, over a period of 6 months (oct 2023-march 2024). Out of 990 participants, data sub-groups were studied. After the patient underwent LSCS, management of PPH was analyzed. Maternal outcomes were further analyzed. Incidence calculation according to pre-operative history (demographic details, high risk factors, stage of labour and preceding antenatal factors). Observations and Results: The incidence of PPH was more in the age group 26-35 (62%) and least in the age group of >35(5%). Multipara (61%) were found at more risk for PPH compared to primipara (29%) and grandmultipara (10%). Incidence is found to be higher in singleton pregnancy (92%) than multiple gestation (8%) due to this study including more number of singleton pregnancies. PPH incidence is found to be highest in patients with pre-ecclampsia (43%) as compared to maternal anemia (41%), placenta previa (9%), Previous history of PPH (5%) and PAS (placenta accreta spectrum) (2%). antenatal risk factors such as previous caesarean section (46%), fetal macrosomia (9%), Polyhydramnios(8%), maternal obesity (morbid and class III ( 7%) were identified. 19% cases of induced labour resulted PPH. Whereas 10% of these cases had a prolonged second stage whereas 1% of cases were due to obstructed labour As more number of cases were performed under spinal anaesthesia , more was the reported incidence of PPH in these cases (95%) compared to general anaesthesia (5%). 81% cases of PPH had a blood loss of 1000 – 1500ml, whereas 16% cases had a blood loss of 1500 – 2000ml and only 1% of cases had a blood loss of >2000ml. 71% of cases required only PCV transfusion whereas 6% of cases required PCV, FFP and platelet transfusion. All cases of post-partum haemorrhage were managed medically (uterotonic agents) out of which 19% patients required surgical interventions including stepwise devascularisation (12%), bilateral uterine artery ligation (3%), uterine haemostatic sutures (2%) and obstetric hysterectomy (2%). 92% cases of PPH were managed in the ward, 6 % cases needed ICU admission, out of which 5 cases had a prolonged ICU stay and 1 case needed ventilatory support. 2% of cases had post-operative wound infection which required re-suturing. Conclusion: This study lays emphasis on the incidence, associated antenatal, intrapartum and postpartum risk factors as well as the management of PPH. Through this study it was concluded that the incidence of PPH in our tertiary care institute was approximately 9.9%. Most of the cases were managed successfully with medical management. Many of these cases needed PCV transfusions. Nearly 1/10^th of these cases were managed in the ICU. Although most of the cases of PPH were managed only with medical management, a few of these cases needed surgical intervention with only 2 cases needing Obstetric hysterectomy.

Keywords: caesarean delivery (CD), PPH, fetal macrosomia