Objectives

1. A STUDY OF CLINICAL PROFILE OF SECONDARY POSTPARTUM HAEMORRHAGE IN CENTRAL WOMEN HOSPITAL (YANGON) SOE SOE,NWE MAR TUN,WIN WIN MYA University Of Medicine (1), Yangon, Myanmar Results Objectives Results Results • Proportion of secondary PPH in CWH(Yangon) during study period • Age distribution of secondary PPH cases according to mode of delivery • Parity distribution of secondary PPH cases • Distribution of secondary PPH cases according to level of ANC • Antenatal risk factors and secondary PPH cases • Distribution of secondary PPH cases according to place of birth 1. To determine the proportion of secondary postpartum haemorrhage in CWH (Yangon) within the study period (1st January 2009 to 31st December 2009) . .  2. To describe the causes of secondary postpartum haemorrhage. 3. To describe the clinical presentations of secondary postpartum haemorrhage. 4. To describe the factors associated with secondary postpartum haemorrhage. 5. To describe the management patterns of secondary postpartum haemorrhage. • Interval between delivery and secondary PPH according to mode of delivery. • History of PPH • Among 4 women(16%) with • history of PPH in previous • delivery, one women had primary PPH and 3 women • had secondary PPH. • Puerperium complications - Five patients had puerperium complications and twenty had no perperium complications. Among women with complications, 3 had puerperial pyrexia, one had episiotomy wound complications and one had abdominal wound sepsis. • Condition of patients on admission • Size of uterus on admission • Results of ultrasound examination • Type and duration of antibiotics used • Eighty percent of patients • were respond to ceftrizone • and metronidazole. • Oxytocics - Uterotonic agents such as injection oxytocin, ergometrine and prostaglandin were given to all women. • Surgical evacuation – Although uterotic agents were given, ten patients require surgical evacuation. Half of the patients who underwent surgical evacuation were sent histopathological examination from curettage tissues. Confirmation of placental tissues was shown in two of six (33%) undergoing evacuation without pre-operative scan compared with one of four (25%) following scan. Laparotomy - Only one patient require laparotomy i.e., subtotal hystetrectomy to control bleeding. She presenting with secondary PPH, nine days after emergency caesarean section for previous one scar in labour. There was no history of primary PPH and retained placenta. The uterotonic agents given were not control haemorrhage. Urgent laparotomy was done and found that uterus was necrotic and friable. Subtotal hysterectomy was done. Histological report revealed retained placental tissues. Total blood 11 units were transfused. Blood transfusion Duration of hospital stay Methods Conclusions • Operational definitions • Secondary postpartum haemorrhage : Blood loss from the genital tract of a volume greater than expected (her usual menstrual blood loss) after the first 24 hours but within the first 6 weeks of delivery . • Place of study • The study was carried out at Obstetrics and Gynaecological wards of CWH (Yangon). • Study design • This study was a hospital- based cross-sectional descriptive study. • Study population • All women with secondary postpartum haemorrhage cases during 1st January 2009 to 31st December 2009 in CWH( Yangon). • Study Procedure • The patient presenting with secondary postpartum haemorrhage was assessed. The on duty MO and on duty on call team were give the management of women with secondary postpartum haemorrhage. • The secondary postpartum haemorrhage cases were recorded in the pro forma according to the following steps. • History taking was done including relevant past medical history, past gynecological history, past obstetric history such as parity, past history of PPH, history regarding delivery of present baby such as date and time of delivery, place of delivery, mode of delivery, and 3rd stage events. • General examination - temperature, BP, PR, anaemia, cardiovascular and respiratory system examinations were recorded. • Abdominal examination was done and size of uterus was recorded. Any genital tract trauma was observed and recorded. • Investigations such as haemoglobin concentration, ultrasound finding and other results of the case were recorded. • Management of the cases was studied and recorded. CAlexander J, Thomas PW, Sanghera J (2002). Treatments for secondary postpartum haemorrhage. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD002867. DOI: 10.1002/14651858.CD002867. Brace V, Penny G, Hall M (2004).Quantifying severe maternal morbidity: a Scottish population study. Br J Obstet Gynaecol 111(5):481-484. Dewhurst CJ (1966). Secondary postpartum haemorrhage. J Obstet Gynaecol Br Comnwlt 73:53-58 Hoveyda F, MacKenzie IZ (2001). Secondary postpartum haemorrhage: incidence, morbidity and current management. Br J Obstet Gynaecol 108:927-930. Kaul V, Bagga R, Jain V, Gopalan S (2006). The impact of primary postpartum hemorrhage in "Near-Miss" morbidity and mortality in a tertiary care hospital in North India. Indian J of Medical Sciences 60(6): 233-240. King PA, Duthie SJ, Dong ZG, Ma HK(1989). Secondary postpartum haemorrhage. Aust N Z J Obstet Gynaecol 29: 394-398. Rome M.R(1975). Secondary post partum haemorrhage. Br J Obstet Gynaecol 82: 289– 292. Ronmans C, Graham WJ (2006). Maternal Mortality: who, when and why. Lancet 368:1189-1200. World Health Organization (WHO) (1996). Postpartum Haemorrhage Module. Notes for students. In: Maternal health and safe motherhood programme, Division of Family Health, Geneva: WHO 27-28. Zhang W-H, Alexander S, Bouvier Colle M-H, Macfailance A, the MOMS-B Group (2005). Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European based study. Br J Obstet Gynaecol 112:89-96. The secondary PPH cases admitted to CWH (Yangon) were studied during the one year period from 1st January to 31st December 2009. There were 25 cases of secondary PPH admitted to CWH (Yangon) of which 12 cases were delivered at CWH (Yangon). There was no clear association between APH, PE, PROM, ANC and history of PPH. Ultrasound examination of uterine cavity to identify retained placental tissues was not accurate. The management of secondary PPH remains unclear. Antibiotics were commonly given to treat superimposed infection, thought to precipitate the haemorrhage, but the evidence to support this was limited. Uterine evacuation in this situation was had therapeutic benefit although products of conception were often not identified. More aggressive surgical options such as laparotomy and hysterectomy may also necessary. The mean days of puerperium at the time of presentation were 17.4 days at that time most of patients were discharged from hospital. Mean duration of hospital stay was 7.2 days. The proportion of secondary PPH in this study was 0.205 per 100 deliveries and was resulted in significant maternal morbidity such as hospital admission, blood transfusion, uterine evacuation and more aggressive surgical interventions. These problems deserve more attention than it received in recent years. References