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Postpartum Haemorrhage
in the Developing World
A Review of Clinical Management Strategies
ABSTRACT: The developing world is disproportionately burdened with high rates of maternal
mortality. Despite widespread reduction in maternal deaths due to improved antepartum, intrapartum,
and postpartum care in developed nations, mortality rates are persistently high in many countries
unable to provide advanced medical care. Postpartum haemorrhage accounts for a substantial
proportion of maternal deaths in developing countries. This review addresses the clinical management
strategies aimed at the prevention and treatment of postpartum haemorrhage that are effective in low-
resource settings. The review was conducted by searching the English-language medical literature
using MEDlINE (1950 - Feb 2009) and the online search engine Google Scholar. Four relevant
strategies were identified in the literature: active management of the third stage of labour (AMSTl),
the use of uterotonic agents including misoprostol, accurate measurement of blood loss, and internal
and external compression techniques. Despite known intervention options, additional research on
effective management strategies and their implementation is needed to address postpartum
haemorrhage in countries of the developing world.

INTRODUCTION
nations disproportionately burdened by maternal Healthy mothers are the focus of United Nations’ Fifth Millennium Development Goal, with the aim of Maternal mortality can be conceptualised as a direct lowering maternal mortality ratios by 75% between result of obstetrical complication leading to death, or 1990 and 2015 (1). Despite reduction in maternal indirectly from a previously existing disease for which deaths amongst transitional and developed countries, pregnancy exacerbates the pathology or contributes to maternal mortality remains a significant cause of death increased severity of illness. Direct causes account for for women of reproductive age in the developing world.
the great majority of maternal deaths in the developing This fact is exemplified by statistics collected by the world (3). A systematic review conducted by the WHO WHO, which show that 99% of the world’s half-million found that postpartum haemorrhage is the leading cause annual maternal deaths occur in developing countries of maternal mortality in Africa and Asia, accounting for (2). Lifetime risk of maternal death is as high as one in up to half of the total number of deaths in these regions six for women living in the world’s poorest nations, a (4). Overall, postpartum haemorrhage accounts for an figure in sharp contrast to a risk of one in 30,000 for estimated 25% of maternal mortality worldwide (2).
women in Northern Europe (3). Substantial progress is Hypertensive disorders such as eclampsia were required before the targets of Goal No. 5 are met, and identified as the leading causes of death in Latin increasingly this progress must be seen within the America and the Caribbean; other prevalent causes ofmaternal mortality include sepsis, obstructed labour,and complications with abortion (2). *To whom correspondence should be addressed:John W. Snelgrove This review addresses the question of which clinical management strategies are effective in treating postpartum haemorrhage in the developing world.
Relevance of management options to the low-resource settings characteristic of developing countries is and accurate blood loss estimation, and compression especially considered. While equally important health infrastructure and policy interventions are necessary todecrease maternal mortality in developing countries Active Management of the Third Stage of Labour (2,3), these are not the focus of this review. Active management of the third stage of labour pharmacological treatment directed at reducing the risk A search of the available English-language medical of postpartum haemorrhage. This management strategy literature was undertaken using MEDLINE (1950-Feb.
is in contrast to “expectant” management of the third 2009) and an online search engine, Google Scholar.
stage of labour, whereby therapeutic intervention to aid Terms used in searches included combinations of in the expulsion of the placenta is not performed.
“maternal mortality”, “postpartum haemorrhage/ Modalities of treatment in AMTSL include the hemorrhage”, “labor/labour complications”, and administration of a uterotonic agent, umbilical cord “developing countries.” Abstracts from potentially traction, fundal massage, and may or may not include relevant publications were read for content and included early cord clamping (10). A large randomised in the review if they addressed the clinical management controlled trial found evidence that AMSTL reduced the of postpartum haemorrhage in a developing country or odds of postpartum haemorrhage by half compared to non-active delivery of the placenta (OR=0.50, 95%CI0.34-0.73) (11). These findings were reflected in a ClINICAl MANAGEMENT OF POSTPARTUM
retrospective cohort study with historical controls HAEMORRHAGE
conducted in a developing country, which found a Postpartum haemorrhage is defined as blood loss of significant reduction in incidence of postpartum more than 500 mL within 24 hours of vaginal delivery.
haemorrhage after implementation of AMSTL Blood loss may be associated with retained or adherent management (10). The evidence is in favour of AMTSL placenta, trauma to tissue and vessels during delivery, as a relatively inexpensive and effective management uterine atony, or coagulopathies such as fibrinolysis and modality for controlling postpartum haemorrhage in afibrinogenaemia (5). The known risk factors for developing countries, providing the technique is postpartum haemorrhage include prolonged third stage performed appropriately. Evidence from a Cochrane of labour, multiple delivery, fetal macrosomia, Review (12) on active versus expectant management is episiotomy, and previous history of postpartum consistent with this recommendation: significantly haemorrhage (6,7). Postpartum haemorrhage may have reduced odds of postpartum haemorrhage were a predilection toward certain ethnicities; however, this observed with the use of AMSTL in the meta-analysis is not a consistent finding. In a low-resource setting, of Khan and colleagues (11), which focussed on the advanced maternal age and low parity have been shown developing world. Side effects of nausea, vomiting, and to associate with a higher risk of haemorrhage (8).
raised blood pressure were more strongly associated Importantly, postpartum haemorrhage may occur in with AMSTL than expectant management, though these obstetrical patients with an absence of known risk were considered less adverse than the higher risk of postpartum haemorrhage found with expectant The clinical management of postpartum haemorrhage has not been systematically assessed with respect to thereduction of maternal mortality in the context of developing countries. Indeed, maternal mortality has Uterotonic agents are administered during active been used as a primary outcome in only a few management of the third stage of labour to promote randomised controlled trials, largely because of the uterine contractions and the expulsion of placental unethical nature of withholding care that is obviously tissue (10,12,13,15,19). Regarding the appropriate life-saving, but also as a result of the necessary sample choice of uterotonic agent, oxytocin is favoured for the size requirements to show an effect on mortality (9).
medical management of postpartum haemorrhage, Fortunately, clinical management strategies to prevent based on a large, multicentre randomised controlled or reduce blood loss due to postpartum haemorrhage trial conducted by the WHO (13). This study showed have been more broadly considered in the literature (9- that oxytocin is associated with significantly less risk of 27). This review identified four management strategies haemorrhage (3% versus 4% incidence in the oxytocin relevant to the topic of postpartum haemorrhage in and misoprostol groups respectively, p<0.001) and developing countries: the active management of the fewer side effects than misoprostol (13). This result is third stage of labour, the use of uterotonic agents, early consistent with a Cochrane systematic review, which assessed 37 trials from both developed and developing similar collection system used in Tanzania provides a nations and concluded that oxytocin is more effective consistent measure of blood loss with the use of kanga, than misoprostol against postpartum haemorrhage and a type of blanket with standard dimensions that is used associated sequelae (14). Smaller randomised regionally in East Africa and holds approximately 250 controlled trials conducted specifically in developing mL of blood when soaked (23). The effectiveness of countries found significant evidence of reduced blood loss estimation using these techniques has not postpartum haemorrhage risk with misoprostol been established empirically with respect to postpartum compared to placebo (15,16), and some reported no haemorrhage outcomes. However, standardised, difference when compared to oxytocin (17,18). The accurate measurement tools would theoretically allow above studies concluded that misoprostol is effective as birth attendants to more easily recognise postpartum a uterotonic agent to prevent and treat postpartum haemorrhage in a systematic way, resulting in opportunities for intervention and appropriate The choice of uterotonic agent for treatment of management. Although these approaches have been postpartum haemorrhage in developing countries must described in only a handful of studies, they demonstrate be considered in the context of both expense and the importance of solutions that are regionally thermostability. Costly or heat-labile preparations acceptable and relevant—such as calibrated measures in requiring refrigeration may be difficult or impossible to Tanzania based on the amount of blood absorbed by a use in low-resource settings (17,18). Misoprostol is a relatively inexpensive, thermostable uterotonic agentwhich can be administered orally, rectally, or vaginally External and Internal Compression (16-19). This makes it a likely candidate for effective Blood loss resulting from postpartum haemorrhage medical prevention and management of postpartum may be managed with the use of compression haemorrhage in the developing world despite the techniques suited or adapted to use in low-resource therapeutic advantage provided by oxytocin, which is settings. Abdominal compression of the aorta may more expensive, heat-labile, and requires IV or IM decrease blood loss in severe postpartum haemorrhage administration (19). Given that oxytocin may provide if performed correctly (24). This manoeuvre is easy to an advantage over misoprostol and is associated with perform and requires little equipment, thus it would fewer side-effects, its use in areas with refrigeration present fewer barriers to implementation in developing capability and adequate financing is favoured over countries than many other therapies. However, there is misoprostol in settings where AMSTL is the norm a dearth of evidence showing that abdominal (13,14,19). However, in low-resource settings, compression of the aorta significantly reduces negative misoprostol should be considered as an alternative outcomes associated with postpartum haemorrhage primary treatment for postpartum haemorrhage.
specifically. Intrauterine tamponade with the use of acondom and rubber catheter has been suggested as an Early and Accurate Estimation of Blood Loss affordable alternative to blood loss management in Not surprisingly, the severity of clinical outcomes for severe postpartum haemorrhage refractory to uterotonic postpartum haemorrhage correlates with the amount of therapy. The evidence for this technique is based on blood lost, and for this reason, the early and accurate several series of case reports, the largest of which estimation of blood loss is vitally important to the involved 23 obstetric patients and was conducted in clinical management of the postpartum bleeding patient (20). Low-resource settings may not have access tostandardised blood collection tools, however, novel DISCUSSION
approaches developed to estimate blood loss may The proper management of postpartum haemorrhage provide effective alternatives. For example, Patel and is an essential component of obstetric care and a colleagues describe the effectiveness of an inexpensive necessary step in the goal to reduce worldwide maternal blood collection drape used in India to estimate blood mortality. The literature is replete with evidence for loss against visual assessment alone. Estimates based best practices and appropriate therapies, particularly on the drape correlated well with photospectrometry with respect to uterotonic agents and active and were more accurate than visual assessment alone, management of the third stage of labour. However, the which tended to underestimate the amount of blood lost interventions predominantly identified in the research (21). This suggests the tool provides an appropriate and clinical settings of developed countries may not be measurement that can be easily and inexpensively made feasible in the low-resource settings characteristic of the in low-resource settings. Geller and colleagues indicate developing world (9, 22, 26). Strategies that prevent that this system is now used in eight countries (22). A and treat postpartum haemorrhage must be readily accessible, affordable, and have uncomplicated storage mothers experiencing complications with pregnancy requirements in order to be effective in countries with and delivery. The authors describe three potential limited healthcare financing and infrastructure. A ready delays to treatment, the first being a delay in the example of this phenomenon is the suggested use of patient’s or family’s recognition of the need to seek care misoprostol as a uterotonic agent in the absence of (3). This can be further explained as discordance resources that make the provision of the superior between actual and perceived risk, the latter being therapy (oxytocin) possible. An urgent need for the partly constituted by attitudes and cultural beliefs such uptake of technologies proven to work in developing as, for example, the benefit or normalcy of bleeding countries has been identified. Furthermore, continued during delivery (29). Added to this “first delay” would research into the effectiveness of postpartum be a family’s inability to afford care in settings that lack haemorrhage interventions in the context of low- publically funded healthcare. Uncoordinated referral resource settings is required to better understand the systems and barriers at the community level—including clinical management of this obstetrical complication.
physical, financial, or cultural—comprise the second These needs extend beyond postpartum haemorrhage to delay, while delay in receiving effective interventions is include the other direct and indirect causes of maternal cited as the third (3). As mentioned previously, this mortality in the developing world. Contextually review focuses on clinical management strategies, akin appropriate strategies to manage hypertensive disorders to the interventions necessary to avoid the “third delay”.
(e.g. eclampsia), sepsis, obstructed labour, and Nonetheless, the extent to which appropriate complications related to abortion have been identified management may improve clinical outcomes is limited but still require implementation to be effective against by factors described by delays “one” and “two”.
Socioeconomic inequalities predispose women from This review identified four clinical management poorer backgrounds to increased risk of death during strategies for postpartum haemorrhage, however a fifth childbirth, as does the lower social status women hold clinical consideration needs also to be addressed, in many communities of the developing world (3, 29).
although it is not specific to reduced postpartum Additionally, healthcare systems in developing haemorrhage alone: the presence of skilled birth countries may not be able to provide comprehensive attendants during delivery. These healthcare workers care to patients as a result of limited access to resources.
and midwives possess (at least theoretically) a In an ecological analysis of Latin American and minimum skill set necessary to take a detailed history, Caribbean countries, Cruz found an inverse association provide antenatal care, perform a vaginal exam, time between donor blood availability and both maternal and assess uterine contractions, and otherwise manage mortality ratios and risk of death due to postpartum normal labour and recognise the need to refer in the haemorrhage (30). Social and cultural inequalities, presence of complications (27). The availability of along with issues concerning the accessibility and skilled birth attendants during delivery may be an comprehensiveness of healthcare, are the antecedents of important step toward maternal mortality reduction, as maternal mortality in developing nations. These suggested by ecological data from the WHO (28).
upstream factors need to be considered alongside clinical management and intervention in the pursuit of recommendations regarding skilled attendance at birth.
Intrapartum care is largely dependent on setting,transportation, and the availability of referral networks SUMMARy OF RECOMMENDATIONS
to manage complications (9). Additionally, the lack of This review identified several evidence-based a clear definition regarding the practice scope of skilled recommendations for the prevention and management birth attendants continues to confuse their role in of postpartum haemorrhage in developing countries.
providing healthcare. Despite these areas of ambiguity, Broadly, these recommendations relate to AMSTL,the Graham and colleagues note the positive impact use of uterotonic therapy, the use of compression attendants may have on reducing maternal mortality, so techniques, and the accurate measurement of blood loss.
long as specific skill sets are mastered and adequate These recommendations and their level of evidence are access to equipment and referral services is available Recommendations Based on Level A Evidence In considering only the clinical management of 1. AMTSL should be practised by clinicians to reduce risk postpartum haemorrhage, this review necessarily takes a narrow view of the causes of maternal mortality.
2. Oxytocin should be used as a uterotonic agent in settings Ronsmans and colleagues describe the other levels at where the appropriate storage and administration of this which delays in access to care can prove fatal to 3. In the absence of available oxytocin, misoprostol is an 14. Gülmezoglu AM, Forna F, Villar J, Hofmeyr GJ. Prostaglandins effective uterotonic agent and should be used to help for preventing postpartum haemorrhage. Cochrane Database of prevent postpartum haemorrhage (17-19).
15. Walraven G, Blum J, Dampha Y, Sowe M, Morison L, Winikoff Recommendations Based on Level B Evidence B, et al. Misoprostol in the management of the third stage of 1. Intrauterine tamponade with condom and catheter may be labour in the home delivery setting in rural Gambia: Arandomised controlled trial. BJOG: Int J Obstet Gynaecol.
used to control severe postpartum haemorrhage refractory Derman RJ, Kodkany BS, Goudar SS, Geller SE, Naik VA, Recommendations Based on Level C Evidence Bellad MB, et al. Oral misoprostol in preventing postpartumhaemorrhage in resource-poor communities: a randomised 1. Accurate estimation of blood loss should be standardised controlled trial. Lancet. 2006;368:1248-1253.
using a blood collection drape (21-23).
17. Lokugamage AU, Sullivan KR, Niculescu I, Tigere P, 2. Abdominal compression of the aorta may decrease blood Onyangunga F, El-Refaey H, et al. A randomized study loss in severe postpartum haemorrhage (24).
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at McMaster University in the Bachelor of Health Sciences program and holds a MSc in social epidemiology from University College London in the U.K.

Source: http://www.mjm.mcgill.ca/review12022.pdf

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