Immediate Postpartum Haemorrhage at the Libreville University Hospital Centre: Epidemiological Prole of Women

Methods


Introduction
Immediate postpartum hemorrhage (IPPH) is de ned as the loss of 500 mL or more of blood within 24 hours of delivery (1)(2)(3). In developing countries and sub-Saharan Africa, it is the leading direct cause of maternal death (2,4,5,6,7). In Gabon, the frequency of maternal deaths directly related to IPPH is clearly increasing at the Libreville University Hospital Centre. It increased from 15-25% between 2013 and 2015 (8), despite the various means that WHO has made available to EmONC providers such as the implementation of recommended protocols on the management of postpartum haemorrhage. Some of these deaths were preventable (9)(10)(11). The objective of this study was to determine the prevalence and epidemiological characteristics of IPPH at Libreville University Hospital Centre with the aim of improving its management and reducing the rate of maternal deaths.

Purpose and type of study
This was an analytical retrospective study over a 5-year period from January 1, 2010 to December 31, 2014, based on the systematic collection of immediate postpartum hemorrhage case les that occurred during this period. The study took place in the Department of Gynecology and Obstetrics of the University Hospital Centre of Libreville.

Study Population And Sampling
The study population is represented by all parturients admitted to the Department of Gynaecology and Obstetrics during the study period, n = 42728. Included were all vaginal deliveries and cesarean deliveries with immediate postpartum hemorrhage. Not included were deliveries with late postpartum hemorrhage, postabortion hemorrhage, and rectorrhage or hematuria. All the records of parturients admitted to the Gynaecology and Obstetrics Department of the University Hospital Centre of Libreville who had presented an immediate postpartum haemorrhage and who were registered were collected. The data were collected Page 4/17 using a collection form. The form was lled in on the basis of information contained in partogrammes, birth registers, operative report registers, anaesthesia and reanimation registers and hospitalization registers.

The Variables
The variables studied were sociodemographic characteristics, obstetric and gynecological history of the woman, characteristics of the pregnancy, the conduct of delivery, and the etiologies of hemorrhage.

Data Analysis
The data was entered into an Excel database and analyzed using SPSS version 22. The sample is described using numbers and proportions. The relationship between the etiologies of IPPH and certain characteristics of the women was established using the ORs with their 95% con dence intervals. The difference was signi cant if p < 0.05.

Ethical Considerations
The study has received the approval of the ethics committee and an authorization from the Direction of the University Hospital of Libreville.

Results
During the study period, 42,728 birth records were collected, with a prevalence of immediate postpartum hemorrhage of 1.6% (n = 671).

Socio-demographic Characteristics Of Women
The age of parturients ranged from 14 to 46 years with a mean age of 26.9 ± 6.6 years. The 20-39 age group was the most represented with just over half of the parturients (n = 337). The majority of patients were housewives or women without paid employment (n = 293) and students (n = 156/202). Other characteristics of the women are presented in Table 1. Women's Gynecological-obstetric History Table 2 presents the participants' gynecological and obstetrical history. Slightly more than half (n = 341/671) of the parturients (50.8%) had no gynecological history at all. In the other half, abortion (n = 301/330) was found in the majority, followed by extrauterine pregnancy and in utero fetal death.

Characteristics Of Pregnancy And Childbirth
Prenatal follow-up was carried out by 647 parturients, or 96.4%. Among those who had performed prenatal follow-up and whose records mentioned it, near ¾ (n = 478/647) had performed at least 4 prenatal visits, or 73.9%. The remaining quarter (n = 169 or 26.1%) had made between 1 and 3 prenatal visits.
Of those who had completed prenatal follow-up, more than three-quarters (n = 498/647) had been followed by a midwife for prenatal visits, or 77%. Of the remainder, some (n = 139 or 21.5%) had been followed by a gynecologist, while the records of the others did not specify the provider of the antenatal visits. Among the records studied, twin pregnancies (n = 17) concerned 2.5% of parturients, while monofetal pregnancies (n = 654) concerned 97.5% ( Table 2).
The majority of parturients (n = 584/671) had arrived at the University Hospital Centre on their own and by their own efforts, 87%. The remaining patients (n = 8) or 13% had been referred from other facilities. More than half of the parturients (n = 345) were not in labour when they were admitted, 51.4%. The other half (n = 326) had been in labour for an average of three hours. Extended work of at least 13 hours was found in 5.2% of parturients (n = 17).

Etiologies Of Immediate Postpartum Hemorrhage
The main etiology of this study was hemorrhage of delivery in 65.5% of parturients, the majority of whom had a placental insertion defect (n = 311/439). Genital tract trauma was found as a second etiology (n = 402), with cervical lacerations (n = 176/402) being the main cause. No pathology of haemostasis had been identi ed (Table 3). The etiologies of immediate postpartum hemorrhages were delivery hemorrhages and genital tract trauma.
We observed that primigravidae such as primiparous (p < 0.001), multigravidae (p < 0.001) as well as multiparous (p = 0.047) women had a lower risk of IPPH compared to women with 2-3 pregnancies or 2-3 children. Women with preterm (p = 0.005) and postterm (p < 0.001) births were more likely to have IPPH than women with full-term births. This was similarly the case for women with children weighing < 2500 g and at 4000 g. In contrast, women with duration of labour more than 12 hours had signi cantly more IPPH than women with less than 12 hours (Table 4). Factors associated with genital tract trauma were being 14-19 years of age (p < 0.001), pauciparum (p < 0.001), full-term delivery (p < 0.001) and having a child weighing between 2500-4000 g (p < 0.001). On the contrary, multiparous women were less likely (p < 0.001) to have a genital tract trauma (Table 4).

Discussion
During data collection, we were confronted with the inherent limitations of any retrospective study: incomplete anamnestic information; non-exhaustive paraclinical explorations; missing medical dossiers (poor management of archives). In spite of these constraints, we feel that we have determined the epidemiological aspects of immediate postpartum hemorrhage at the University Hospital Centre (UHC). This hospital and mono-centric survey does not re ect the epidemiological reality at the level of the whole country. However, it is an advocacy tool to improve the lling out and maintenance of admission and follow-up records in the delivery room.

Prevalence Of Ipph
The prevalence of immediate postpartum hemorrhage was 1.6%. While this prevalence varies from 0.86-9.0% according to studies reported in some countries (5, 7, 12, 13, 14, 15, 16, 17, 18). In population-based studies, the incidence of PPH is around 5% of deliveries when blood loss is not accurately measured, and around 10% when blood loss is accurately measured (19). The variation in prevalence for our case during these years could be explained by the fact that not all cases of hemorrhage were reported in the registries.
This was due to some low-level hemorrhages that went unnoticed and the fact that this notion had not always been reported in the obstetrical records of the patients because of the burden of work. In addition, the census of maternal deaths at the hospital did not begin until 2014.

Socio-demographic Characteristics
The sociodemographic characteristics studied were age, occupation, marital status and educational level of women.
Women between the ages of 20 and 39 were more represented with more than 80% of the workforce.
However, there are variations in age frequency noted in Norway, Tunisia, France and Chad (5,13,14,15,20). In a general review Deneux-Thenaux noted the same results (19). The high frequency of IPPH in this age group in our context could be explained by the fact that it corresponds to the period of increased female genital activity and fertility in the subregion. Any woman in the period of genital activity may be affected by immediate postpartum hemorrhage. Housewives and high school students were the most affected class with 45.0% and 84.5% respectively. This result could be explained by the fact that unemployment affects women almost twice as much as men in Gabon : 20 per cent compared to 11 per cent. The unemployment rate for young people under 30 years of age is 31% (21). IPPH seems to be more common among the disadvantaged strata, because of the inaccessibility of prenatal care and the management of the factors that contribute to it. And since the marital status of women aged 15-49 in Gabon is dominated by single and cohabiting couples (21), the study found that 92.7% of parturients were single.

Women's Gynecological History
The proportion of women with a history of cicatricial uterus was minimal, 1%, in contrast to that reported by Chouaki in the Democratic Congo, 30.4% (15). However, the proportion of women with a history of abortion was 45.6%. It has been recognized that curettage and Caesarean section are causes of placenta previa and placental retention, which are risk factors for IPPH (12,13). The absence of a history of IPPH or toxemia gravidarum in the records reviewed is to be deplored. In the partograms there is no entry mentioning these antecedents, which may be the reason for their absence. Nevertheless, Firmin et al. mentioned a signi cance between the history of IPPH and its occurrence (17). Partograms also do not show the estimated amount of blood loss. A new method for estimating blood loss should be adopted, as Andrikopoulou has pointed out (22). We noted a frequency of IPPH in pauciparum and primiparum with respectively 37.7% and 32.8% against 25.6% in multiparum. The same trend has been observed by some authors where IPPH was more frequent in paucipares (13,18). Higher frequencies of IPPH in primiparous women have been observed in some studies while they have also been observed in multiparous women as shown in studies in Madagascar and Norway (12,13). These results show that the frequency of IPPH is as high in pauci pares as in primipares. This could be explained by the overuse of uterotonics in these parturients in order to speed up labour ; the use of indigenous oxytocics at home, fetopelvic disproportions or prolonged labour in primiparous women are also incriminated.

Characteristics Of Current Pregnancy And Childbirth
There was no information on the modes and conditions of evacuation of these parturients, factors that may in uence maternal and fetal management and prognosis. Pregnancies considered at term were the most observed and accounted for 53.1% and one third of deliveries were premature. In contrast to data from studies conducted in Madagascar and France, which found a higher frequency of full-term pregnancies than ours (14,18). There is evidence that premature delivery can lead to placental retention complicated by delivery hemorrhage due to a cleavage defect between the placenta and the myometrium (23).
More than half of the parturients were not in labour when admitted. The other half had been in labour for an average of three hours and 5.2% of parturients had been in labour for at least 13 hours. In the dossiers explored, there was a lack of information concerning the pro le of the staff who had taken immediate care of the parturients, as more than ¾ of women had gone directly to the hospital. Rakotozanany et al.
showed that late referral and late management of parturients with IPPH are risk factors for maternal death (12). The majority of parturients had given birth by Caesarean section. In 2.2% of cases the extraction is done by forceps and an arti cial delivery is done in 57.5% of cases. The frequency of these three procedures seems high since they are performed in the only reference hospital in the city that has an adequate technical platform.

Etiologies And Risk Factors For Immediate Postpartum Hemorrhage
Delivery haemorrhages accounted for 65.5% of IPPH, while genital traumas accounted for 59.9%. These delivery haemorrhages are dominated by retroplacental haematoma, placenta previa and uterine atony. Some patients presented with one or two selected causes at the same time. These results are almost similar to the results obtained by some authors who have noted that uterine atony is the main cause of IPPH and that genital tract wounds are responsible for about 1 in 5 cases of IPPH (19). Thus, three of the three can be associated. They may be associated with: a pathology of delivery mainly represented by uterine inertia and placental retention; a uterine or vaginal genital lesion or a pathology of haemostasis (24,25).

The Hemorrhages Of Deliverance
The main risk factors for IPPH in the most recent population-based studies vary from one author to another (19). In our study, primigravida and multi-gestations on the one side and primiparous and multiparous on the other appeared to have a lower risk of developing delivery hemorrhage. While women with preterm and postterm births, those with more than 12 hours of labor and those with a birth weight of less than 2500 grammes and more than 4000 grammes had a higher risk of developing IPPH. Multiparity, a factor contributing to uterine atony, has a non-negligible proportion in our study. Also, the use of oxytocics in our environment is very common, which could explain the frequency of uterine atony. In the occurrence of postpartum hemorrhages after vaginal delivery, the role of placenta previa is classic. The haemorrhage can be explained by the di culties of uteroplacental cleavage and above all by the di culties of spontaneous haemostasis. Also, the women's records did not allow us to note a history of IPPH.

Trauma Of The Genital Tract
In contrast to delivery bleeding, women aged 14-19 years are more likely to have genital tract trauma. These results are similar to those found in several studies (19). Indeed, this young age is exposed to lacerations of the cervix and perineum. We have also noted that women who have given birth at term, those who have children with a birth weight between 2500-4000 grammes and women who have given birth more than twice are more likely to have genital tract trauma. Still, in this study we have a proportion of 98.7% of women who underwent an arti cial and assisted delivery; 51.6% of women had a caesarean section. These two factors are recognized as soft tissue tearing factors (26).

Conclusions
Immediate postpartum haemorrhage remains the most feared obstetric emergency in the delivery room, despite the existence of multiple management methods. The prevalence of immediate postpartum haemorrhage was 1.6%. The parturients with the highest risk of IPPH were young women aged between 20 and 39 years, unmarried and from an unfavourable socioeconomic background as housewives or schoolchildren, with a secondary school education and having had at least one abortion and given birth at least once. The most common etiology was hemorrhage from the delivery due to a placental defect.
Trauma to the genital tract was the second etiology. Multiparity remains the most common risk factor. IPPH is still the leading cause of maternal mortality in Gabon and the rest of the world. This is why it is important to improve management by better assessment of blood loss in the immediate postpartum period with the use of collection bags, saving time in diagnosis and management, close monitoring of the parturient and systematic delivery. The three aspects of treatment are inseparable, justifying adapted multidisciplinary care (obstetrician, anaesthetist, resuscitator, biologist): hence the interest in strengthening the capacities of health providers in terms of EmONC. Availability of data and materials The datasets used and analysed during the current study available from the corresponding author on reasonable request. The datasets generated and/or analysed during the current study are not publicly available due to the promise made to health staff to keep the data con dential when they are questioned, but are available from the corresponding author on reasonable request.
Competing interests : The authors declare no con ict of interest Fundings : None Authors' contributions : NAL and SHW designed the study, wrote the protocol and text and supervised the data analysis. LAOO, FEYM, VNST and EOA participated in the drafting of the protocol, data analysis and text writing. AJK participed in text writing and proofreading. All authors have read and approved the manuscript and contributed equally.