Incidence, Management, and Outcome of Refractory Postpartum Hemorrhage at Kenyatta National Hospital in the Year 2015 to 2020

Abstract

Hemorrhage is among the top five direct leading causes of maternal deaths worldwide with post-partum hemorrhage accounting for two-thirds of these deaths. Refractory PPH is bleeding that persists despite instituting what is considered first-line interventions in its management. The incidence of postpartum hemorrhage is known and the existing recommendations by WHO are based on atony being the commonest cause of PPH. However, little is known about refractory PPH and there may be a different pattern of causes and risk factors associated with it. This study aims to identify its incidence in our region, the different managements instituted and their outcome and help come up with recommendations that can be implemented and help lower maternal mortality and morbidity. This will ultimately help us in reaching the SDG goal of less than 70 maternal deaths. Objectives: To determine the incidence, management, and outcome of refractory PPH among obstetric patients in Kenyatta national hospital from the year 2015 to 2020. Study methodology A retrospective descriptive cohort study with an analytical component looking at files of all the women who were managed for PPH at KNH from January 2015 to December 2020. We identified the files of all the patients who had primary PPH and were managed at KNH. From these, we identified the patients who had refractory PPH, their management, and outcome as our population of interest. The maternal and clinical characteristics of those with refractory PPH were assessed as a secondary outcome. Consecutive sampling was used to identify 540 files of those with PPH from records and from there we identified those with refractory PPH. Mean and standard deviation was computed for numerical variables while frequencies(n) and percentages were computed for categorical variables. Data collected was entered, cleaned, and analyzed using Statistical Package for Social Sciences(SPSS)version 26. Results: From a total of 1238 files screened,540 patients had refractory PPH. The mean age was 29 (S.D ±5.74). The majority of the patients were aged between 25-35 years, (66%)., multipara 201(66%), married 262(86%), unemployed 195(64%), and had attained secondary level education at 120(39%) Incidence of refractory PPH was seen to be 56% with,257(85%) of the patients receiving additional uterotonics. Up to 102(34%) received tranexamic acid, 245(81%) of the patients received a blood transfusion and 179(59%) had a EUA. Among those that had a surgical intervention done 89(29%)had a uterine artery ligation done, a B lynch suture at 70(23%), and a hysterectomy at 68(22%). Only 38(13%) had a 3rd and 4th-degree tear repaired while the least surgical intervention used was an internal iliac artery ligation at 7(2%). A UBT was done in only 55(18%) while a bimanual uterine compression 43(14%) and an abdominal aorta compression were the least done accounting for only 3(1%). There was a statistically significant association between refractory PPH with maternal death occurring (9.2%), renal failure, febrile (11.8%), Transfusion (81%), neurological (10.9%),Urological morbidity(2%)and Respiratory morbidity(7.9%). The only clinical factor found that can be used to predict the odds of refractory PPH occurring was the mode of the delivery being a cesarean section which had a 3 –fold increased odds of being associated with refractory PPH. Conclusion: There was a high incidence of refractory PPH in our setting at 56%. It was associated with severe maternal outcomes. However, apart from the mode of delivery, there are no clinical and sociodemographic factors that were found to be statistically significant to be used to predict the odds of developing refractory PPH. Recommendations: Seeing that refractory PPH has a high incidence in our setting, we need to be more vigilant in the management of any PPH case we come across. We need a more objective measurement of blood loss. Implementing the use of MEOW charts in monitoring our patients. Training and frequent drills on PPH management could be implemented to keep the health providers vigilant. Skills training on surgical interventions for the management of refractory PPH and ensuring antibiotics are used after PPH cases to reduce sepsis.