GROUP C5

WEJE CHITURU .C.

OPARANOZIE EMMANUEL
OMUKORO FRED ETERIGHO-IKELEGBE .O.

BIRABE .L. HADDY

SOMIARI ABIYE AYERITE ABRAHAM .L.

U2005/4710398 U2005/4710368 U2005/4710356 U2004/4710345 U2000/4710336 U2005/4710380 U2001/4710243

Outline
Case Presentation Introduction/Terminologies Epidemiology Causes/Risk Factors Management of PPH Complications Prevention Recommendations/Conclusion References

Case Presentation
I present Mrs RC, a 28 year old trader with primary level of

education, who resides at Deeper-life compound Umuopara village. She is Igbo and a Christian of the Pentecostal denomination. She is Para 6+0 (6 alive). She presented to the unbooked labour ward 5 days ago, with a 7 hour history of retained placenta and bleeding par vagina, following the delivery of a live female baby at a TBAs home. There was inability to deliver the placenta and concurrent vaginal bleeding. There was associated dizziness, weakness and fast breathing. The attendant TBA gave intramuscular injections , abdominal massage and intravenous fluids( names unknown), all to no avail, hence she was rushed to UPTH for expert management.

 Index pregnancy was not registered for antenatal care,

uneventful and carried to term. Labour was prolonged and outcome was a live female baby of an unknown birth weight, who is alive and well. There is no previous history of retained placenta. She has had 5 previous confinements between 2003 and 2009. All pregnancies were uncomplicated and carried to term, deliveries were by spontaneous vertex and the outcomes were 2 males and 3 females. Puerperium was normal. The age at which she attained menarche was unknown. She has a 4 day menstrual flow in a regular 28 day menstrual cycle. There is no history of menorrhagia or dysmenorrhoea. She has not had any termination of pregnancy. She is aware of contraceptives but dose not use any. She is not aware of papanicoloau smear .

 Past medical and surgical history were not

contributory. She is the only wife of a 40 year old taxi driver in a monogamous setting. There is no family history of diabetes mellitus, sickle cell anaemia , hypertension, bronchial asthma nor twinning. She does not take alcoholic beverages or tobacco product in any form. The review of her systems was essentially normal.

 On examination, she was anxious, severely pale, febrile with

temperature of 37.4c, anicteric, acyanosed, severely dehydrated and had bilateral pedal oedema up to the level of the ankle. Pulse rate was 118bpm (low volume and thready), BP was 90/40mmHg. Heart sounds 1 and 2 only were heard. Respiratory rate was 26cpm. Chest was clinically clear. Abdomen was enlarged, moved with respiration and tender. Uterine size was 26 weeks and tonically contracted. There was no associated organomegaly. On Vaginal examination, vulva was smeared with blood and the umbilical cord was seen at the introitus , clamped with a thread. Placenta tissue was at the vault occluding the cervical os which was about 4cm dilated. An impression of primary PPH secondary to retained placenta was made.

 The following investigations were done and revealed; PCV

of 18%, urinalysis-NAD, and 4 units of whole blood was grouped and cross matched. She was resuscitated with 2 litres of normal saline infusion and 40 IU of oxytocin in 1 litre of N/saline at 30dpm. She was placed on intravenous antibiotics, analgesics and transfused with 2 units of whole blood. Subsequently, the placenta was delivered manually in the theatre and she was later placed on oral medications. She is currently in the unbooked lying in ward with her baby, and has been counselled on the need for contraception.

CASE SUMMARY
In summary, I have presented Mrs. RC, a 28 year

unbooked para 6 +0 (6 alive), who was admitted and still being managed as a case of primay PPH secondary to retained placenta.

INTRODUCTION

The joy of motherhood . Many women have died while searching

for this joy especially in developing countries as maternal morbidity and mortality continues to rise . Photo ; cesr.org

TERMINOLOGIES
MATERNAL MORTALITY : It is the death of a woman while pregnant or

within 42 days of delivery or termination of pregnancy, regardless of the site or duration of the pregnancy from any cause related to or aggravated by the pregnancy or its management (10th Revision of the ICD) but not from accidental or incidental causes.
Maternal mortality ratio: It is the number of maternal deaths during a

given year per 100,000 live births during the same period. The appropriate denominator for the maternal mortality ratio would be the total number of pregnancies (live births, still births, abortions, ectopic and molar pregnancies). These figures are seldom available especially in the developing countries where most births take place, so the number of live births is generally used as the denominator. Here we use deliveries (live +still births).

 Maternal mortality rate: Measures both the

obstetric risk and the frequency with which women are exposed to this risk. It is the number of maternal deaths in a given period per 100,000 women of reproductive age (15-49yrs). Often used interchangeably (i.e. rate and ratio). It is essential for the sake of clarity to specify the denominator used when referring to either of these measures.

Major causes of maternal mortality world wide.

Indirect causes include

Hepatitis Heart diseases TB HIV/AIDS Pulmonary embolism Sequestration crisis Jaundice in pregnancy Anaesthesia Ruptured ectopic pregnancy Acute renal failure Blood transfusion reaction Diabetic coma Broncho pneumonia Abdominal massage

 In UPTH in 12yrs (ranking) Severe pre-eclampsia/eclampsia 22% Obstructed labour 14% Abortions/ 14% Haemorrhage 11% Sepsis 10% Ruptured uterus 11% Others are: Hepatitis Heart diseases TB HIV/AIDS

INTRODUCTION 4
POSTPARTUM HAEMORRHAGE
as primary or secondary
Primary PPH is traditionally defined as
Blood loss from the genital tract in excess of of 500ml

Excessive bleeding following delivery and is described

following vaginal delivery or 1000ml or more following a caesarean section within 24 hours of delivery. OR
Any amount of blood that can cause haemodynamic or

cardiovascular instability within 24 hours of delivery.

Secondary PPH is defined as abnormal vaginal

bleeding from 24 hours after delivery until 6 weeks postpartum.

 An estimated 600,000 women die each year throughout the

EPIDEMIOLOGY

world from complications of pregnancy and childbirth

55,000 of these deaths occur in Nigeria Nigeria is only two percent of the worlds population but

accounts for over 10% of the worlds maternal deaths in childbirth

Ranks second globally (to India) in number of maternal

deaths. Most occur in developing countries mm ratio (developed countries) =27/100,000livebirths. mm ratio in developing countries: 20 x or more (480/ 100,000 live births and in some areas may be as high as 1,000/ 100,000 live births.

MATERNAL MORTALITY RATIOS IN NIGERIA

NATIONAL RURAL URBAN SOUTH WEST SOUTH EAST NORTH WEST
NORTH EAST 351

704 828

165 286 1025 1549 0 500 1000 1500 2000

OTHER INDICATORS OF MATERNAL MORBIDITY AND MORTALITY

Risk of a woman dying from child birth is 1 in 18 in
Nigeria, compared to 1 in 61 for all developing countries, and 1 in 29, 800 for Sweden

For every woman who dies from childbirth in Nigeria,

another 30 women suffer long term chronic illhealth(morbidity)

EPIDEMIOLOGY OF PPH
14 million cases of obstetric haemorrhage occur annually.

128,000 maternal deaths are caused by PPH annually (25% of MM)

Tops the list of causes of maternal deaths Major cause of postpartum morbidity worldwide Incidence varies. In developed countries 5 12 % of all deliveries. In Britain, the risk of maternal death from PPH is around 1 in

100,000 deliveries
In developing countries the risk is 1 in 1,000 deliveries.

UPTH 2011
From Jan 2011 June 2011 Unbooked Labour Ward admissions.
Month(s)
Jan Feb Mar Apr May June

Admissions
52 26 42 74 58 75

Cases of PPH
3 2 1 2 -

327

Making up a percentage of 2.45%

 Booked Labour Ward Admissions (Jan-June 2011)

Month(s) Jan Feb Mar Apr May June Admissions 199 126 236 287 333 161 1342 Cases of PPH 1 1 I 1 4

Making up a percentage of 0.3%

CAUSES/RISK FACTORS
Medical
Social MEDICAL

Tonicity(uterine atony) Commonest

Trauma Tissue(placental tissue) Thrombopathy

UTERINE ATONY
Previous history of PPH Overdistension of the uterus multiple gestation, fetal

macrosomia, polyhydramnios
Antepartum haemorrhage placenta praevia, abruptio placenta Precipitate labour Prolonged labour (Uterine Inertia) Grandmultiparity fibrosis in uterine muscle

Chorioamnionitis
Uterine fibroids Drugs halothane, magnesium sulphate etc

GENITAL TRACT LACERATION

Episiotomies Instrumental vaginal deliveries Forceps, vacuum extraction Manipulative deliveries especially in shoulder dystocia, vaginal

breech deliveries
Precipitate labour / bearing down before full cervical dilatation Destructive vaginal operations craniotomy, decapitation,

cleidotomy
Injudicious use of oxytocics

RETAINED PLACENTAL TISSUE

Poor management of third stage of labour e.g.

overzealous CCT
Abnormal placenta e.g. succenturiate lobe Morbidly adherent placenta accreta, increta and

percreta

COAGULOPATHY
Abruptio placenta Pre-eclampsia Amniotic fluid embolism Septicaemia / Intrauterine sepsis Retained dead fetus Hypovolaemia

Hydatidiform mole
Intravascular haemolysis Incompatible blood transfusion

SOCIAL RISK FACTORS

Type I Delay -when a woman with a pregnancy complication
fails to get to a hospital in time Type II Delay -when the delay is due to difficulty with transportation Type III Delay -when there is delay in treatment after the patient has reached the hospital

Contribution of Delays to Maternal

Mortality in Nigeria
No delay Type I Delay Type II Delay Type III Delay 10% 30% 20% 40%

Causes of Type III Delay

Non-affordability of antenatal costs, delivery costs
and post-natal costs Delays in seeing staff in health facilities Incessant strikes and lockouts Delays due to poor supplies and consumables Delay in referral of patients Basic essential obstetrics care not available in most facilities Systemic problems doctors and midwives refusing rural postings External brain drain

MANAGEMENT
Medical management

PPH is an obstetric emergency Call for help Rub up contraction Empty the bladder Assess blood loss and resuscitate Use of oxytocics Evacuate the uterus(for retained placenta)

MANAGEMENT CONTD
Surgical Repair of genital tract lacerations / ruptured uterus Application of sutures(B-Lynch suture) Systematic devascularization Hysterectomy Interventional radiology Uterine artery embolization

COMPLICATIONS
MEDICAL Anaemia Hypovolaemic shock Adult respiratory distress syndrome Pulmonary oedema Acute Renal Failure Hypopituitarism (sheehan`s syndrome) Uterine synechiae Sepsis. Death

COMPLICATIONS 2
SOCIAL (SOCIETAL IMPLICATIONS)
Postpartum depression Social withdrawal Financial burden Prostitution Increased chance of u5m of surviving

offsprings Psycho-social implications on surviving offsprings

Millennium Development Goals, UN (2000) how far?

Goal 4: Reduced child mortality - To reduce
mortality rate among children under 5 by two thirds by the year 2015 Goal 5: Improved maternal health - To reduce by 75%, the maternal mortality rate by the year 2015 Eleven(11) years into the 15 years deadline for achieving these goals, there is no clear evidence that Nigeria has yet achieved any remarkable achievements.

PREVENTION
PRIMARY SECONDARY

TERTIARY

PRIMARY PREVENTION
PUBLIC HEALTH EDUCATION ENLIGHTMENT CAMPAIGNS. SEMINARS/TALK. PUBLIC LEGISLATURE. FEMALE EMPOWERMENT. GIRL CHILD EDUCATION. FREE ANTENATAL SERVICES. PROVISION OF HOSPITAL,HEALTH CENTRES AND

DRUG. TRAINING AND RETRAINING OF HEALTH WORKERS/TBAs IMPROVED BLOOD BANKING SERVICES FAMILY PLANNING SERVICES

Antenatal anticipation
Previous history Other risk factors Prevent anaemia

Haematinics Treatment of malaria and intercurrent infections Blood transfusion Ensure blood is available for delivery

Secondary prevention

SECONDARY PREVENTION
ACTIVE MANAGEMENT OF THIRD STAGE OF

LABOUR
Obstetric emergency Uterine atony Rub up contractions Empty bladder Administer oxytocics Bimanual compression Evacuate uterus Internal uterine tamponade

 Genital tract lacerations

Examine under good light source Repair episiotomy promptly Repair of vaginal lacerations Examine cervix and repair any lacerations Laparotomy for uterine rupture Retained placenta Evaluation and resuscitation Antibiotics Attempt removal by CCT Manual removal in theatre under general anaesthesia Umbilical vein infusion

TERTIARY PREVENTION
Adoption
Psychological support Establishment of support groups

NGO intervention
Care for surviving infants Limitation of disabilities Recuperation into society Rehabilitation

 Of great importance but often neglected are:

reporting, record keeping, analysis of POST PARTUM HEMORRHAGE. and near misses on a case-by-case basis (auditing) to increase our understanding of the pathway of survival and death, make local improvements, identify substandard care and avoidable factors. That is the use of health information to improve quality of care.

Recommendations

Political leadership is neededThe Presidency should personally speak to the problem of the high rate of maternal mortality morbidity in Nigeria, just like he has done for HIV/AIDS Executive Governors and Local Government Council chairmen should do the same in their States and LGAs
A multi-sectorial approach should be adopted whereby all sectors (Legislative Assemblies, Information, Education, Women Affairs etc) should include MCH programming in their portfolios

Costs alleviation for women seeking antenatal care and delivery services. Such a policy has been successful in reducing maternal mortality in Kano State
A more effective National Institute for maternal and child health

National Institute of Maternal and Child Health

Will provide an avenue through which

government will providing funding for MCH Will reduce donor dependency on MCH programming Will provide an avenue for research and data collation on matters related to MCH Will develop guidelines, policies and strategies for reducing maternal and child mortality in Nigeria Will provide a forum for capacity building and resource mobilization for MCH

Programs to reduce post partum haemorrhage in Nigeria

1.
2.

Provision of information and services about family planning and contraception

Programs to encourage all pregnant women to receive antenatal care and to be delivered by skill birth attendant Improvement of antenatal and delivery services in hospitals, especially emergency obstetrics care Government should address the problem of women dying from poorly performed abortions The government should ensure the legislation for the registration of all maternal deaths in Nigeria, as been already legislated in Edo State.

3. 4. 5.

What the federal Government is currently doing

Maternal Mortality : Agency deploys 3500 midwives to rural

communities June 14, 2011 By nigerianhealthjournal By Hassan Ibrahim, Kaduna The National Primary Healthcare Development Agency (NPHCDA), has so far deployed 3,500 midwives to rural communities across the country to reduce the current high rate of maternal mortality in Nigeria, the NPHCDA Executive Secretary, Dr. Muhammad Ali Pate, has said. Speaking in Kaduna during the orientation of midwives under the MSS scheme, Pate said adequate security arrangements had been put in place for the fresh batch of 441 basic midwives who recently graduated from 25 schools of midwifery and were now being deployed to various communities in Nigeria.

 U.N. Secretary-General Ban Addresses Maternal Mortality

In Nigeria. Monday, May 23, 2011 As part of a four-country tour, U.N. Secretary-General Ban Kimoon on Sunday arrived in Nigeria, where he highlighted the importance of fighting maternal and child mortality in the country, which has one of the highest maternal mortality rates in Africa, Agence France-Presse reports (5/22). He "commended the Nigerian authorities for integrating services for maternal, newborn and child health, with programmes on HIV/AIDS, tuberculosis, malaria and nutrition," according to the U.N. News Centre (5/22). Ban, along with Jeffrey Sachs, his special adviser on the Millennium Development Goals (MDGs), met with Nigerian President Goodluck Jonathan, The Nation reports

CONCLUSION
Postpartum haemorrhage has remained an important

cause of maternal morbidity and mortality especially in developing countries like ours. Therefore the need for education of all stake-holders on the proper understanding of the aetiopathology cannot be overemphasized, as this may ultimately form the template for improved safe motherhood in Nigeria.

References
WHO mortality database Geneva;WHO;2007

(http://who.int/health info/morttables) A publication on maternal and child health in Nigeria, by Prof. Friday Okonofua.(FIGO) Provost, College of medical science, University of Benin. Executive Director of Obstetrics and Gynaecology A publication on maternal mortality by Prof. S. A. Uzoigwe. MD,FWACS, FICS. Head of department of Obstetrics and Gynaecology. College of Health Sciences, University of Port Harcourt UNICEF Maternal Health database (http://www.childinfo.org/eddb/maternalhtn)

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