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Research Article | Volume 15 Issue 1 (Jan - Feb, 2025) | Pages 210 - 215
Prevalence and Risk Factors of Postpartum Hemorrhage in a Tertiary Care Hospital: An Observational Analysis
1
Associate Professor, Department of Obstetrics and Gynecology, Late Smt. Indira Gandhi Memorial Government Medical College (LSIGMGMC), North Bastar, Kanker, Chhattisgarh, India
Under a Creative Commons license
Open Access
Received
Nov. 23, 2024
Revised
Dec. 5, 2024
Accepted
Dec. 30, 2024
Published
Jan. 18, 2025
Abstract

Background: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality globally. This study aimed to determine the prevalence, associated risk factors, severity, and management outcomes of PPH in a tertiary care hospital. Methods: An observational analysis was conducted on 100 postpartum cases. Data on demographics, obstetric history, labor characteristics, and management approaches were collected. The prevalence and risk factors of PPH were analyzed, and the severity of cases was categorized based on blood loss volume. Management strategies were evaluated for their effectiveness. Results: The prevalence of PPH was 23%. Significant risk factors included maternal age ≥35 years (65%), grand multiparity (48%), cesarean delivery (56%), prolonged labor (>12 hours, 60%), antepartum anemia (67%), placenta previa/placental abruption (30%), macrosomia (5%), and pre-eclampsia (70%). Mild PPH (500–1000 mL) accounted for 65% of cases, moderate PPH (1001–1500 mL) for 26%, and severe PPH (>1500 mL) for 9%. Management was primarily medical, effectively controlling 83% of cases, while surgical interventions were required in 17%. Conclusion: PPH remains a significant obstetric challenge, with multiple risk factors contributing to its occurrence and severity. Effective management, predominantly through medical interventions, is critical in reducing complications. Preventive measures focusing on high-risk groups, such as those with antepartum anemia or pre-eclampsia, may mitigate PPH prevalence and severity.

Keywords
INTRODUCTION

Postpartum hemorrhage (PPH) is a critical obstetric emergency and a leading cause of maternal morbidity and mortality worldwide, accounting for approximately 27% of maternal deaths globally1. Defined as blood loss exceeding 500 mL following vaginal delivery or 1000 mL following cesarean delivery, PPH poses significant challenges in both high-resource and low-resource settings2,3. Its multifactorial etiology encompasses uterine atony, retained placenta, obstetric trauma, and coagulation disorders, making early identification and management crucial.

 

The burden of PPH varies across regions, influenced by socioeconomic factors, healthcare access, and obstetric practices4,5. In low- and middle-income countries, the prevalence is significantly higher due to delayed access to skilled obstetric care and inadequate management of predisposing conditions such as anemia and hypertensive disorders6. Risk factors such as advanced maternal age, multiparity, mode of delivery, and labor duration further compound the complexity of PPH prevention and treatment7.

 

Despite advancements in obstetric care, PPH remains a significant public health challenge, highlighting the need for continuous monitoring and evidence-based interventions. Understanding the prevalence, associated risk factors, and effective management strategies is essential for formulating targeted policies and improving maternal outcomes.

 

This study aims to assess the prevalence of PPH, identify key risk factors, and evaluate the severity and management outcomes in a tertiary care hospital. By addressing these objectives, the study seeks to contribute to the growing body of knowledge required for effective prevention and treatment of this life-threatening condition.

MATERIALS AND METHODS

Study Design and Setting:

This observational study was conducted in the Department of Obstetrics and Gynecology at Late Smt. Indira Gandhi Memorial Government Medical College, North Bastar, Kanker, Chhattisgarh. This tertiary care institution caters to a diverse patient population from rural and semi-urban areas of the region.

 

Study Period:

The study was conducted over one year, from  April 2022 to March 2024.

 

Study Population:

The study included 100 postpartum cases admitted to the hospital during the study period. Participants were selected using a convenience sampling method. All postpartum women who experienced blood loss during delivery were screened for inclusion. Cases of postpartum hemorrhage (PPH) were identified based on the criteria of blood loss >500 mL following vaginal delivery or >1000 mL following cesarean delivery.

 

Data Collection:

Data were collected using structured case records and participant interviews. Information on demographic characteristics, obstetric history, labor details, mode of delivery, and underlying medical conditions was documented. Clinical assessments and laboratory investigations, including hemoglobin levels, were performed for all participants to evaluate predisposing factors and outcomes.

 

Outcome Measures:

The primary outcome measure was the prevalence of PPH. Secondary outcomes included the identification of associated risk factors, the severity of PPH (categorized as mild, moderate, or severe based on estimated blood loss), and the effectiveness of management strategies (medical or surgical interventions).

 

Data Analysis:

Descriptive statistics were employed to calculate the prevalence and proportions of risk factors. The severity and management outcomes of PPH were analyzed as percentages of affected cases. Results were presented in tabular and graphical formats for clarity.

 

Ethical Considerations:

The study was conducted in accordance with ethical guidelines and approved by the Institutional Ethics Committee of Late Smt. Indira Gandhi Memorial Government Medical College, Kanker. Written informed consent was obtained from all participants prior to their inclusion in the study.

RESULTS

The prevalence of postpartum hemorrhage (PPH) in this study was found to be 23%, as 23 out of 100 total cases were identified with PPH (Table 1).

 

Table 1: Prevalence of Postpartum Hemorrhage (PPH)

Total Cases

Cases of PPH

Prevalence (%)

100

23

23

 

Figure No:1. Prevalence of Postpartum Hemorrhage

 

Risk Factors Associated with PPH

The analysis of risk factors revealed that maternal age, parity, mode of delivery, labor duration, and underlying conditions significantly influenced the prevalence of PPH. Maternal age ≥35 years was associated with a higher prevalence of PPH (65%) compared to maternal age <35 years (35%). Regarding parity, grand multiparity (≥5 pregnancies) showed a prevalence of 48%, while primiparity exhibited a lower prevalence of 18%, and multiparity was associated with a prevalence of 34%.

Mode of delivery also played a critical role, with cesarean delivery being associated with a higher prevalence of PPH (56%) compared to vaginal delivery (44%). Labor characteristics further underscored their importance, with prolonged labor (>12 hours) showing a prevalence of 60%, whereas normal labor duration had a much lower prevalence of 40%.

 

Among underlying conditions, pre-eclampsia emerged as the highest risk factor, with a prevalence of 70%. Antepartum anemia (Hb <10 g/dL) followed as the second highest risk factor, with a prevalence of 67%, in contrast to 33% among non-anemic patients. Other notable contributors included placenta previa/placental abruption, with a prevalence of 30%, and macrosomia (birth weight >4 kg), which showed a prevalence of 5% (Table 2).

 

Table 2: Risk Factors Associated with PPH

Risk Factor

Prevalence (%)

Maternal Age ≥35 years

65

Maternal Age <35 years

35

Multiparity

34

Primiparity

18

Grand Multiparity (≥5 pregnancies)

48

Vaginal Delivery

44

Cesarean Delivery

56

Prolonged Labor (>12 hours)

60

Normal Labor Duration

40

Antepartum Anemia (Hb <10 g/dL)

67

No Anemia

33

Placenta Previa/Placental Abruption

30

Macrosomia (Birth Weight >4 kg)

5

Pre-eclampsia

70

Overall, this analysis highlights the significant impact of maternal and obstetric factors on the risk of PPH, with pre-eclampsia and anemia standing out as the most critical risk factors.

 

Severity of PPH

Among the PPH cases, the majority were classified as mild (500–1000 mL), accounting for 65% of the cases, followed by moderate severity (1001–1500 mL) at 26%. Severe cases (>1500 mL) were less common, comprising 9% of PPH cases (Table 3).

 

Table 3: Severity of PPH

Severity of PPH

Number of Cases

Percentage of PPH Cases (%)

Mild (500–1000 mL)

15

65

Moderate (1001–1500 mL)

6

26

Severe (>1500 mL)

2

9

 

Figure No:2. Severity of Postpartum Hemorrhage (PPH)

 

Management of PPH

The management of PPH predominantly involved medical interventions, which were effective in 83% of cases. Surgical interventions, including procedures such as Uterine artery ligation and B Lynch compression suture, were required in 17% of cases, highlighting their role in managing more severe instances of PPH (Table 4).

 

Table 4: Management of PPH

Management Type

Number of Cases

Percentage of PPH Cases (%)

Medical Management

19

83

Surgical Interventions

4

17

 

Figure No:3. Management of Postpartum Hemorrhage (PPH).

DISCUSSION

Postpartum hemorrhage (PPH) remains a significant challenge in obstetric care, with a prevalence of 23% observed in this study. This aligns with findings by Liu et al8. (2021), who reported PPH prevalence influenced by socioeconomic and healthcare factors, particularly in low- and middle-income countries. The study's findings highlight key risk factors and underscore the importance of targeted interventions to mitigate PPH risk.

 

Risk Factors Associated with PPH

Maternal age ≥35 years demonstrated a higher prevalence of PPH (65%), consistent with the observations of Taylor et al9. (2022), who linked advanced maternal age to increased risks of uterine atony and obstetric complications. Grand multiparity (≥5 pregnancies) showed a strong association with PPH (48%), echoing findings by Mitta et al10. (2023), who highlighted uterine overdistension as a significant contributing factor.

Cesarean deliveries were associated with a higher prevalence of PPH (56%) compared to vaginal deliveries (44%), supporting previous findings by Guasch et al11. (2009) regarding the surgical and anesthetic complications inherent to cesarean procedures. Similarly, prolonged labor (>12 hours) emerged as a significant risk factor (60%), aligning with results from Miller et al12. (2017), who emphasized the impact of uterine exhaustion on PPH risk.

Antepartum anemia (67%) was another critical contributor to PPH, underscoring the importance of antenatal anemia correction, as suggested by Bazirete et al13. (2022). Placenta previa/placental abruption (30%) and macrosomia (5%) were also strongly associated with increased PPH risk. These findings are consistent with those of Prapawichar et al14. (2020), who linked placental abnormalities and high birth weight to higher blood loss during delivery.

 

Notably, pre-eclampsia emerged as the highest risk factor (70%), highlighting its significant impact on PPH prevalence. Liu et al8. (2021) similarly identified pre-eclampsia and antepartum anemia as critical risk factors in their study on severe postpartum hemorrhage, further supporting the need for targeted antenatal interventions to address these conditions and minimize associated risks.

 

Severity and Management of PPH

Most cases of PPH in this study were mild (65%), effectively managed with medical interventions, primarily uterotonics such as oxytocin. This is in line with the observations of Taylor et al9. (2022) and Liu et al8. (2021), who reported high success rates with medical management. Moderate (26%) and severe cases (9%) required surgical interventions, such as Uterine artery ligation and B Lynch compression suture, emphasizing the importance of skilled surgical expertise, as highlighted by Mitta et al10. (2023) and Miller et al12. (2017).

 

Implications for Practice

The findings underscore the critical importance of proactive antenatal care, including anemia screening and correction, as well as early identification of high-risk pregnancies such as pre-eclampsia. Effective labor management, particularly for cases of prolonged labor, can significantly reduce the risk of PPH. Strategies such as active management of the third stage of labor (AMTSL) and timely surgical interventions are vital, as suggested by Guasch et al11. (2009) and Bazirete et al13. (2022). Training healthcare providers in PPH management and ensuring the availability of medications and blood products are crucial, consistent with the recommendations of Prapawichar et al14. (2020) and Liu et al8. (2021).

 

Limitations

This study was conducted in a single tertiary care center, limiting the generalizability of findings to other settings. Additionally, the sample size of 100 cases may not capture the full spectrum of PPH risk factors and management outcomes. Future multicentric studies with larger cohorts are recommended to validate these findings.

CONCLUSION

This study highlights a PPH prevalence of 23% in a tertiary care hospital, emphasizing its significant impact on maternal health. Key risk factors identified include maternal age ≥35 years, grand multiparity, prolonged labor, cesarean delivery, antepartum anemia, pre-eclampsia  and conditions such as placenta previa and macrosomia. The majority of cases were mild (65%) and effectively managed with medical interventions (83%), while severe cases required surgical procedures (17%). These findings underscore the need for focused antenatal care, including anemia correction and high-risk pregnancy monitoring, along with timely labor management and institutional deliveries. Strengthening healthcare facilities with adequate resources and trained personnel is critical for reducing PPH-related morbidity and mortality.

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