- Academic Editor
Background: Postpartum hemorrhage (PPH) is the most common cause of
maternal mortality in low-and middle-incomes countries (LMICs). It is treated
surgically when first line treatments fail. The goal of the sutdy is to report
the results of surgical management of PPH at a University Hospital in the Capital
of Côte d’Ivoire from 2015–2017. Methods: This was a retrospective
study of all cases of PPH surgically managed at the university hospital of Cocody
over two years. We did not include cases of maternal soft tissue injuries such as
cervical, vaginal, vulvar and perineal lacerations. We studied the
sociodemographic characteristics, surgical method performed and outcome of 54
cases who were operated on for PPH. Surgical management was either Radical
Uterine Surgery (RUS): postpartum hysterectomy or Conservatice Uterine Surgery
(CUS): hysterography, tsirulnikov triple ligation and bilateral hypogastric
artery ligation (BHAL). No embolization was performed because it is not available
in our country. Data were analyzed using Stata 13.1 software 2013, StataCorp,
College Station-Texas, USA. Results: Of 23,730 deliveries there were 971
cases of PPH (4.1%) 54 of which (5.6% of PPH cases) were managed surgically. Of
these, 34 were after cesarean and 20 after vaginal delivery. The mean age was 30
years and the mean parity was 3. Referred patients after PPH comprised 75.9% of
cases. The average time elapsed from delivery to postpartum surgery was 133
minutes
Postpartum hemorrhage (PPH) is a major cause of maternal death worldwide, particularly in low-and middle-incomes countries (LMICs) [1, 2, 3, 4, 5, 6, 7, 8, 9, 10]. It is a common complication of childbirth that occurs in approximately 2% to 4% of vaginal deliveries and 6% of cesarean sections [1, 2, 3, 4, 5, 6]. Uterine atony is one of the main etiologies (50%) followed by tissue retention, traumatic soft tissue injury, coagulation disorders, and uterine rupture [2, 7, 8]. A multidisciplinary surgical management is often essential for uterine atony and severe traumatic maternal soft tissue injury [1, 2, 3, 4, 5, 8, 9, 10]. It can be managed by radical uterine surgery (RUS) (postpartum hysterectomy) or conservative uterine surgery (CUS), such as, intrauterine tamponade, bilateral uterine artery ligation (BUAL) and bilateral hypogastric artery ligation (BHAL) [10, 11]. The efficacity of CUS has been well described in the Western literature [7, 10, 12] but not yet well studied in underdeveloped countries [8, 9, 11]. New techniques for CUS have recently been incorporated, including arterial embolization and uterine devascularization methods [10, 12, 13, 14]. Failure of these conservative methods resulted in further bleeding in the short term [1, 2, 5, 15]. In our daily practice, where intensive care units, blood products and operating rooms are not available, we wanted to determine, through this study, the surgical data on the management of PPH in a sub-Saharan African country.
We undertook a retrospective descriptive study for 24 months (January 2015 to December 2017) at the university hospital of Cocody (Côte d’Ivoire). All PPH cases that were surgically managed in the department were included. We did not include maternal lower genital tract soft tissue injuries (cervical, vaginal, vulvar and perineal lacerations). Sociodemographic data, surgical method performed and its results were studied. The surgical management was either RUS (postpartum hysterectomy) or CUS (hysterorraphy, Tsirulnikov triple ligation and BHAL). No embolization was performed because it is not available in our country. Data were analyzed using Stata 13.1 software 2013 (StataCorp, College Station-Texas, College Station, TX, USA).
We recorded 23,730 deliveries. Of these 971 were PPH cases (4.1%). The mean age of women giving birth was 30 years with extremes of 15 and 44 years. The average parity was 3 with extremes of 0 and 9. The sociodemographic and admission data of the patients are summarized in Table 1.
Data | n = 54 | % |
Age (years) | ||
6 | 11.1 | |
25 | 46.3 | |
16 | 29.7 | |
7 | 12.9 | |
Parity | ||
8 | 14.8 | |
5 | 9.3 | |
27 | 50 | |
14 | 25.9 | |
Admission mode | ||
13 | 24.1 | |
41 | 75.9 | |
Origin of referral | ||
40 | 74.1 | |
9 | 16.7 | |
5 | 9.3 | |
Reason of admission | ||
15 | 22.2 | |
9 | ||
23 | 25.9 | |
2 | 3.7 | |
3 | 5.6 | |
2 | 3.7 |
24% of deliveries took place at Cocody hospital and 76% were referred from
outside the hospital. These referrals arrived by cab (57%), 43% arrived on foot
or by ambulance or other means of transportation. Delivery and postpartum
parameters are presented in Table 2. The mean time from delivery to postpartum
surgery was 133 minutes
Features | n | % |
Mode of delivery | ||
30 | 55.5 | |
24 | 44.4 | |
Etiology of PPH | ||
34 | 63.0 | |
13 | 24.1 | |
7 | 13.0 | |
Time from admission to diagnosis (min) | ||
22 | 46.8 | |
25 | 53.2 | |
Time from delivery to PPH surgery (min) | ||
12 | 25.5 | |
35 | 74.5 | |
Time from diagnosis to surgery (min) | ||
19 | 40.4 | |
28 | 59.6 | |
Scheduled cesarean section (n = 4) and Emergency caesarean section (n = 26). |
Data on surgical management of PPH and postoperative outcome (Tables 3,4).
Data | n = 54 | % |
Radical uterine surgery (RUS) | 34 | 63.0 |
20 | 58.8 | |
14 | 41.2 | |
Conservative uterine surgery (CUS) | 20 | 37.0 |
8 | 60.0 | |
6 | 20.0 | |
6 | 20.0 | |
Operative indications for RUS | n = 34 | |
22 | 64.7 | |
10 | 29.4 | |
2 | 5.9 | |
Operative indications for CUS | n = 20 | |
12 | 60.0 | |
5 | 25.0 | |
3 | 15.0 | |
Postoperative outcome | n = 54 | |
44 | 81.5 | |
10 | 18.5 | |
34/44 | 77.3 | |
7/44 | 15.9 | |
3/44 | 6.8 |
BHAL, bilateral hypogastric artery ligation.
Deceased women risk factors | n = 10 | % |
Age (years) | ||
2 | 20.0 | |
8 | 80.0 | |
Parity | ||
3 | 30.0 | |
7 | 70.0 | |
Reason for admission or PPH etiology | ||
4 | 40.0 | |
4 | 40.0 | |
2 | 20.0 | |
Method of delivery | ||
5 | 50.0 | |
5 | 50.0 | |
Time from vaginal birth until surgery for PPH | ||
2 | 20.0 | |
8 | 80.0 | |
Type of surgery | ||
3 | 30.0 | |
7 | 70.0 | |
Time from surgery until death | ||
3 | 30.0 | |
7 | 70.0 |
Surgical management of PPH accounted for 5.6% of cases (n = 54) including RUS (n = 34 or 63.0%) and CUS (n = 20 or 37.0%). We recorded a high case fatality rate of 18.5% (n = 10 MD (maternal deaths)). MDs occurred within 120 minutes after the procedure (70%). One woman who waited 225 minutes for surgery obviously died. Overall maternal morbidity was high (77.3%) with postoperative anemia being the dominant etiology (68.2%) followed by surgical site-infection (15.9%) and endometritis (6.8%).
We conducted a retrospective study that had the classic limitations of this type of study. Indeed, some essential data were not found in the patients’ medical records, and some records were not found because of poor archiving in our hospital. However, we believe it is unlikely that this generated too much bias in data quality and conclusions.
PPH is the leading cause of maternal death worldwide, particularly in LMICs [1, 3]. Most maternal deaths (MD) occur in the first 24 hours after delivery and can
be prevented in vaginal deliveries with proper management of the third stage of
labor [16, 17, 18]. The incidence of PPH was significant in this study (4.1% of
deliveries) as reported in the African [3, 4, 8, 11] and Western literature [10, 12, 18]. There are some divergent data that can be attributed to the methodology
of the study and subjectivity of PPH diagnosis. Indeed, in underdeveloped
countries [3, 4, 8, 11], PPH diagnosis is based on blood loss via visual
estimation and maternal repercussions, while in developed countries it is much
more objective, as assessed with a measuring bag [15, 16]. We describe a young
population of women (30
Surgical results were satisfactory in this study with high rate of cessation of bleeding (81.5%). Nevertheless, maternal lethality related to PPH was significantly high (18.51%). Maternal deaths (MD) were mainly related to multiparous women over 30 years of age, with placenta acreta. In the literature, observations have been described with the risk of MD increasing from an odds ratio (OR) = 1 in those under 20 years to an OR = 2.15 after 35 years of age [7, 21, 22, 23, 24, 25, 26]. The profile of MDs was consistent with the socio-demographic findings of LMICs. In this study, most MDs were rapidly seen within 30 minutes of admission because these patients were hemodynamically unstable and did not receive effective resuscitative care. This was illustrated by the predominance of MDs (70%) in placenta acreta despite the small number (n = 7) because they were seen two hours after surgery. Due to a more favorable prognosis, many authors propose radical management, in case of morbid placental insertion [6, 7, 8, 9, 10, 11]. These MDs may not be related to surgery but exacerbating factors such as poor maternal hemodynamic status on admission, late referral after prolonged hemorrhage. Regarding the evaluation of the effectiveness of surgical methods, there was no significant association with the mode of delivery or the etiology of PPH and surgical technique used. This is similar to many authors who show that surgical outcome is better when performed promptly by competent surgeons [9, 14, 18]. MDs are more likely due to uncompensated blood loss than as a consequence of surgery. Implementation of guidelines is needed to improve surgeon selection for surgical treatment of PPH, as hospital-based shifts are often performed by resident physicians. Surgical failure and poor prognostic factors may include prolonged vaginal bleeding, hemorrhagic shock, severe anemia, and unmet transfusion needs. Most of these factors are interrelated and are found in underdeveloped countries [10, 23, 24, 25]. Further operational research would effectively evaluate the choice of surgical method for the management in our LMICs. Prompt initiation of these therapeutic measures in first-contact health care setting facilities is essential to improve maternal prognosis [24, 26, 27, 28]. Implementation of these actions is essential in choosing the type of surgery to minimize patient risks and ensure surgical success.
Postpartum hemorrhage (PPH) is the predominant severe complication of childbirth. Surgical management remains the last resort to stop hemorrhage but is the first line of defense in underdeveloped countries for safety reasons. No surgical method has been shown to be superior to the other; however, the small size of our population does not allow us to generalize these observations. The choice of a surgical method must take into account the preservation of women’s lives as determined by maternal status on admission, surgeon kill, availability of operating rooms, and resuscitation options.
Data supporting the results of this study are available from the corresponding author, but restrictions apply to their availability. The data were used under license for the current study, and are therefore not publicly available. However, the data are available from the authors upon reasonable request and with permission from Dehi Boston Mian.
DBM, FT, VA, AY, CB, KNG and SB have contributed to the conception of the work, the acquisition, analysis and interpretation of data collected during this survey. DBM, FT, VA, AY and CB have contributed in extraction of data. DBM, VA, KNG, SB have made the final manuscript draft, reviewed it critically for important intellectual content and achieved the published version. All authors contributed to editorial changes in manuscript. All authors read and approved this final manuscript, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
We have obtained the approval of the National Committee of Ethics of Health and Life (N 255451-CI/2020) of the Felix Houphouet Boigny University for the publication of this manuscript. The informed consent of the patient was obtained for this study.
We acknowledge any support provided that is not covered by the authors’ contribution.
This research received no external funding.
The authors declare no conflict of interest.
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