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 reflect the epidemiological reality at the level of the whole country. However, it is an advocacy tool to improve the filling 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% to 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 significance 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 influence 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 profile 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 artificial 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 difficulties of uteroplacental cleavage and above all by the difficulties 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 artificial and assisted delivery; 51.6% of women had a caesarean section. These two factors are recognized as soft tissue tearing factors (26).