Preventing Mortality from Postpartum Hemorrhage
Harshad Sanghvi Patricia Stephenson
MAQ 2005 Mini University, 14th October 2005
Session Objectives
Magnitude & epidemiology of PPH Evidence-based approaches to prevention & treatment Challenges to program implementation
Magnitude of the Problem & Epidemiology of PPH
PPH is the most common cause of maternal death worldwide. At least 25% of all maternal deaths worldwide are due to PPH.
Definition of PPH
PPH : Blood loss greater than 500 ml Severe PPH: Blood loss greater than 1000 ml
Any blood loss that causes a physiologic change that threatens a woman’s life
Incidence of PPH
Blood Loss (n = 434) Mean + SE 265.18 + 10.95
Range Median Mode Acute PPH Acute severe PPH Goudar, Eldavitch, Bellad, 2003
20 - 1600 200 100 57 (13.2 %) 8 (1.8 %)
Etiology of PPH
• Uterine atony (~3/4 cases)
• Other
• Episiotomy • Retained placenta • Trauma - uterine rupture, inversion, cervical laceration, vaginal hematoma • Postpartum infections • Rarely : Coagulopathy
Risk Factors for PPH
Up to 90% of women who experience PPH have no identifiable risk factors
Preeclampsia, previous PPH, multiple gestation, arrest of descent, maternal hypotension, coagulation disorder, Asian or Hispanic, delivery with forceps or vacuum, augmented labor, nulliparity, multiparity, polyhydramnios, underlying anemia
Lightning Round Points
• PPH accounts for more maternal deaths than any other cause.
• We cannot predict who will experience PPH on the basis of risk factors.
• PPH can be difficult to recognize and blood loss difficult to measure. • The primary cause of PPH is uterine atony.
Prevention of PPH
Active management of third stage of labor (AMSTL) • Uterotonic after birth of baby • Controlled cord traction • Fundal massage
Restricting episiotomy & unnecessary obstetric interventions
Prevention & treatment of anemia due to iron deficiency, hook worm, malaria
Active vs. Expectant Management
Management of third stage of labor Expectant (n=3126)
Blood Loss > 500 mls
Blood loss > 1000 mls
13.6% 5.2% 0.38 (0.32-0.46)
2.6% 1.7% 0.33(0.21-0.51) 57(42-89)
Active (n=3158) Relative risk
Number needed 12 (10-15) to treat
Prendiville, Elbourne, McDonald, The Cochrane Library issue 3, 2003
Comparison of Uterotonics
Consideration for PPH prevention
Oxytocin +++ yes no
Ergometrine(inj) -/? yes no
Misoprostol ++ no yes
Effectiveness Need skilled provider Preparation suitable for home birth
Serious side effects
rare
common
rare
Contraindications
Heat stability Cost
0%
no $.80
15%
no ?
0%
yes $0.35–0.80
Misoprostol: Mounting Evidence
• Clinical demonstration study 1 – Oral Misoprostol reduced PPH incidence to 6% • Double-blind placebo controlled study 2 – Oral Misoprostol reduced need for treatment of PPH from 8.4% 2.8% • Rectal Misoprostol vs. Syntometrin for 3rd stage 3 – Similar reduction in length of 3rd stage, postpartum blood loss and postpartum hemglobin; Higher BP with Syntometrin • Oral Misoprostol vs. Placebo 4 – PPH: 7% vs 15% – Need for therapeutic Oxytocin: 16% vs. 38%
1: El-Refaey, 1997; 2: Hofmeyr, 1998; 3: Bamigboye, 1998; 4: Surbek, 1999
More Evidence
• Double-blind placebo controlled WHO multicenter study : Oxytocin vs. Misoprostol in hospital 1 – 8 countries – N=9266 – Oxytocin; N=9264 – oral Misoprostol • Severe PPH (1000cc): 3% vs. 4% • Misoprostol – higher incidence of shivering – Conclusion: Oxytocin preferred over Misoprostol in a hospital when both available • Double blind placebo controlled RCT in rural HCs in Guinea Bissau of Misoprostol vs. placebo – Misoprostol alone reduces severe PPH (1000mls+) 11% vs. 17% RR 0.66 (0.44-0.98)
1: Gulmezoglu,et al., Lancet 2001, lars Hors BMJ 2005
Preventing PPH at Homebirth with Misoprostol
Completed programs • Indonesia, Gambia, Guinea Bissau New programs underway • Pakistan, Nepal, Bangladesh, Kenya, Uganda, Afghanistan
INDONESIA PROGRAM
Safety: No women took medication at wrong time
Acceptability: users said they would recommend it and purchase drug for future births
Feasibility: 94% coverage with PPH prevention method achieved Effectiveness:
• 25% reduction in perceived excessive bleeding OR 0.76 ( 0.55 1.05)
• 45% reduction in need for referral for PPH 0.53 (0.24-1.12)
Lightning Round Points
• Active management of third stage of labor • Is recommended for all women • Requires a skilled birth attendant, consistent supplies of uterotonics, and supply chain logistics. • Injectable oxytocin is the drug of choice • Ergometrine has many important disadvantages over other uterotonics but is still in widespread use. • Misoprostol is a highly promising alternative to Oxytocin for use at homebirth. • Nipple stimulation does not produce sufficient oxytocin to qualify as a uterotonic.
Treatment of PPH
Even under the best circumstances, all PPH is not preventable Once severe PPH occurs, death can follow very rapidly
Clinical Interventions
Basic EmOC
• • • • • • Management of shock Uterotonics Bimanual compression Suturing of lacerations Aortic compression Manual removal of placenta
Comprehensive EmOC
• • • • Uterine artery ligation B-lynch procedure Hysterectomy Blood transfusion
Met Need for EmOC Services
Africa % NEED MET FOR
Asia %
LAC %
Basic EmOC Facilities 4 facilities per 500000 population Comprehensive EmOC 1 facility per 500,000 population
% Met need for obstetric complication MMR per 100,000
6-35
5-76
0-53
122-193
31-304
164-242
8-23 690-1100
5-19 380-740
19-92 150-450
AMDD supported country assessments IJGO 2002-4
Home-Based Life Savings Skills
HBLSS: family & community focused program to increase life saving skills at homebirth. HBLSS interventions addressing PPH at homebirth: – Call for help, squat, pass urine, rub womb, roll nipples, two hand hold, pad firmly between legs, refer. Result: – Better recognition of PPH. – Increased response according to protocol. – Impact on mortality / morbidity not reported. Conclusions: A promising approach, consider adding Misoprostol. Main concern: the effectiveness of several of the HBLSS interventions has not been demonstrated.
Source: Sibley et al 2004
Innovative Treatment Approaches at Homebirth
Study: controlling PPH at homebirth in Tanzania Intervention : TBAs trained to recognize PPH, administer Misoprostol 1000mcg rectally & refer if bleeding persists, n=454 Control : TBAs trained to recognize PPH and refer. N=395 Results: • PPH rates 24% vs. 18%, OR 1.3 (.0-1.7) • Referrals reduced in intervention area (1.8% vs. 19%) • Reduced need for blood transfusion, fluids, MRP (1% vs 9.5%) • One death not related to PPH in control area Conclusion: TBAs can detect PPH and effectively treat PPH at homebirth Main concern: large proportion of homebirths conducted by occasional TBAs
Prata et al IJGO, 2005
Tamponade Using Condom
Sayeba et al 2004
Lightning Round Points
• Once PPH occurs, death can follow very rapidly. • Expanding quality basic emergency obstetric care services will reduce unmet need for PPH treatment. • Women, their support persons, TBAs and community health volunteers can be taught to recognize PPH. • Misoprostol has much promise for prevention and treatment of PPH at homebirth, but more to come…
Policy and Supportive Environment
• • • • Clinical practice standards Pre- and in-service curricula Supportive supervision Appropriate uterotonics on essential drugs lists and registered in-country • Policy allows mid- and lowerlevel skilled birth attendants to administer uterotonics and perform manual techniques • Professional associations take an active role
Supply Chain Logistics
• Oxytocin is drug of choice and must be available in sufficient quantities for routine use • Alternative uterotonics for settings without a cold chain • Cold chain and storage conditions • Safe injection equipment
Human Capacity and Training
Key Skills Gaps: % of Ugandan EmOC mid level providers who say they are not confident or have not performed this skill)
EmOC skill Birth preparedness & complication readiness counseling Perform AMTSL
% Not confident or never performed 53% 38%
Management of shock
Bimanual compression
53%
47%
Manual removal of placenta Repair of cervical tear
33% 47%
Community Mobilization & Involvement
Birth Preparedness/Complication Readiness (BPCR)
Interventions that address PPH: • Recognition of danger signs, arrangements for transport, funds, walking donor, designated use of skilled provide through multiple community interventions Results: • Better recognition of PPH • Increased arrangements for complications • Impact on morbidity/mortality unknown Conclusion: substantial investment necessary; Services need to be in place before generating demand
Referral Links
Examples: radio call, air, road and sea ambulances, bicycle ambulance. Results: • Increased staff morale. • Rapid transfer possible. • Significant morbidity and mortality reductions. Main concern: – Most such programs have not been sustained beyond external support. – Link with BPCR programs.
Letterman’s “Top 10 Signs” your PPH program is taking off
You know your program is taking off when…. • Medical and midwifery students understand AMTSL to be a routine lifesaving practice rather than something that comes out of a keg. • Policy makers stop asking why we offer beer to women who have just given birth. • Clinical protocols recommend AMTSL not AMSTEL light. • Oxytocin is stored in the cool chain and not next to the autoclave. • Ergometrine no longer used for AMTSL; becomes much sought after ingredient for fertilizer. • It becomes possible to purchase Misoprostol with USAID funds. • Heads of hospital housekeeping departments rejoice in support of PPH prevention programs because laundry bills cut by half. • Like dominos, professional midwifery and obstetrical associations worldwide endorse AMTSL for prevention of PPH. • Governments decide to make home birth safer before the research is completed. • We no longer have to give this mini-u course because everybody knows how to set up a PPH prevention and treatment program.