Introduction

• Anemia in pregnancy Hb below 11g/dl (WHO)

• WHO : prevalence of anemia during pregnancy in developing
countries exceeds 50%
• In pregnancy, anemia is mainly due to nutritional – deficiency of iron
and folates. Other factors are impaired absorption, charonic blood
loss, increase requirement, malaria.
• Anemia increase risk of PPH and the two conditions together
contribute to 40-43% of maternal deaths in Afrika and Asia.
Introduction
• Small studies demonstrated casual-relationship between severe
anemia and uterine atony which is the main cause of PPH.
• In less developing countries, anemia is prevalent in remote setting
which accessibility to antenatal care services is difficult.
• It is common to see women at time of labor with moderate to severe
anemia.
• Aim of this study is to find out the rate of PPH among women with
low Hb concentration (Hb<10) during cesarean delivery and to acess
the Hb level at which cesarean hysterectomy is needed.
Patients and methods
• Cross-sectional observational trial conducted from August 2012 to
July 2013 in Al Thawra General Hospital.
• Anemia is defined according to WHO criteria :
- Mild (Hb 10-10.9g/dl)
- Moderate (Hb 7-9.9g/dl)
- Severe (Hb<7g/dl)
Patients and methods
Inclusive criteria
• all singleton pregnant women
• 38 weeks gestational age or
more (based on early first
trimester USG and/or LMP)
• delivered by cesarean section
• having moderate to severe
anemia (Hb<10g/dl) at
admission.
Exclusive criteria
• Women with risk factor of
uterine atony
- Overdistended uterus
- Parity >5
- History of previous PPH
- Bleeding tendency
Patients and methods
• 53 women meet the criteria in this study
• The hospital protocol for prevention of PPH was followed which relies
on administration of 600mcg misoprostol (3 tablets) rectally at time
of scrubbing, in addition to oxytoxin (20units in 500ml normal saline
solution infused over 30 minutes).
• Circumstances which additional uterogenis agents are
required,injection of methyl ergometrine, increasing of oxytoxin
infused doses, local injection of either or both drugs are used as
appropriate.
Patients and methods
• Cesarean section was performed as standard by senior in charge and
one of resident doctor, under spinal anesthesia wirh Pfannelstiel skin
and lower uterine segment transverse incisions.
• The intraoperative blood loss was estimated by using the calibrated
Steri-Drape TM Loban TM 2 for all cases.
• Collected blood within the drape was added to the content of suction
bottle and counted.
Patients and methods
• All patients receive prophylactic antibiotics and blood transfusion.
• Hysterectomy was performed by senior in charge and on call consultant
after conservative measures failed to restore uterine tonus – bimanual
uterine massage, use of uterotonic agents, compression sutures and
uterine artery ligation.
• Then outcome measures :
- Level of Hb among women who needed hysterectomy
- Estimation of blood loss
- Amount of blood transfused the interval from delivery till completing the
hysterectomy
- Type of hysterectomy
Statistical analysis
• Analysis using
SPSS version 21
• Odds ratio and
95% confidence
interval (CI)
were calculated
• P <0.5 was
considered
statically
significant
Results
• Total of deliveries – 11,680
• 182 – Hb < 11g/dl at the time of admission
• Of these, 53 women (29.1%) were developed PPH due ti uterine atony
during cesarean section.
• Of 53 women, 32 cases were successfully managed by conservative
measures : 26 cases additional uterotonic drugs, 4 cases by B-lynch
compression sutures, 4 cases by uterine artery ligation, 1 case of internal
iliac artery
• Severe bleeding that require emergency hysterectomy was developed in
21/53 cases.
• The difference was statically significant (p<0.03)
Results
• Majority of hysterotomized women (17/21) had Hb < 7 and non
hysterotomized patients had Hb>7. The difference was significant.
• The amount of bleeding (>1500ml) was significantly higher in
hysteroromized than in non hysterotomized women.
• 90 women had cesarean hysterectomy while in 2 cases, hysterectomy
was performed after abdominal closure due to persistent vaginal
bleeding.
• Common type of operation –subtotal hysterectomy
Discussion
• 29.1% anemic women developed PPH during cesarean delivery due to
uterine atony.
• Prior study – severe anemia may impair myometrial contractility
resulting from impaired transport of Hb and oxygen to uterus causing
tissue enzymes and cellular disfunction.
• In this study, severe uterine atony required emergency hysterectomy
was occurred in 32/53 of women who had severe anemia (Hb<7 g/dl).
• This findings indicated that patients with Hb 7or less, the likehood of
having PPH due to uterine atony increases greatly compared to
patients with Hb 7.1-10.
Discussion
• All women in this study received rectal misoprostol and ocytoxin
intraoperatively.
• Combination of these agents may be responsible for reduction of
hemorrhage and better outcome.
• This suggests the importance of active management of the third stage of
labor in reducing blood loss.
• Elbourrne et al reported significant reduction of amount of blood loss
when prophylactic administration of uterotonic agents during the third
stage of labor.
• Badejoko et al reported effect of rectal misoprostol 600 mcg in prevention
of PPH comparable with oxytoxin infusion.
Discussion
• The correlation between Hb values and blood loss was inversely
signifanct, indicating the more severe the anemia, the more likely of
greater blood loss.
• This result highlights the need to increase the population awareness
to utilize the available maternity case services along with the
promotion of iron and folates supplementation for all pregnant
women.
• Specific cause of nemia was not considered in this study.
• Cesarean – hysterectomy was done in 39.6% of cases with uterine
atony.
Discussion
• Total abdominal hysterectomy was performed in 4 cases. Although
there is no consensus as the appropriate time for resorting to
hysterotomy in atonic uterus, the patient’s general condition, the
severity of blodd loss, and effectiveness of the conservative measures
should direct the decision-making process.
• According to the result, they proposed that severe anemia, Hb 7 and
less combined with ongoing bleeding despite other conservative
measures is predicators of persistent myometrial contractility failure,
and warrant early hysterectomy.
• Mild anemia is common and tends to have less significant impact on
labor and delivery complications.
Conclusion
• The finding of this study support the link between low hb levels at
delivery and the potential risk of PPH.
• Futher study with larger sample size to confirm these findings are
reuired.
• When other measures are ineffective, early decision of hysterectomy
is needed in this subgroup of anemic women who develop severe PPH
due to uterine atony.