Trend and outcomes of postpartum hemorrhage among women attending CHUK from 2016 to 2020: A retrospective cross-sectional study

Abstract

Background: Postpartum hemorrhage (PPH) is one of the major causes of maternal morbidity and mortality worldwide, especially in Low and middle income countries. Objectives: The study assessed the overall prevalence of PPH, trends of yearly prevalence of PPH and outcomes of PPH among women who attended CHUK from 2016 to 2020. Methods: A retrospective cross-sectional study that compared the periodic proportions of postpartum hemorrhage among women attending the gynecology and obstetrics of Centre Hospitalier Universitaire de Kigali (CHUK) from 2016 to 2020. The data were collected from the Archives of Centre Hospitalier Universitairede Kigali using a questionnaire. Chi-square for trend and logistic regression analysis (binary and multivariable analysis) were used to study the relationships between variables. Results: Of 415 patients who were managed for PPH at CHUK from 2016 to 2020, 80.5% of them were transferred from district and provincial hospitals while 19.5% of them delivered at CHUK. The overall prevalence of PPH was ranging from 6.0% to 2.65%. The highest overall prevalence of PPH was observed in 2016 at 6.0% followed by 3.74% in 2017, then 3.0% in 2018, then 2.84% in 2019 and lastly the lowest prevalence was observed in 2020 at 2.65%. The overall prevalence of PPH among patients who have delivered at CHUK was 0.7% ranging from 0.89% in 2016 to 0.57% in 2018. The majority of the patients (83%) have been transfused where34.8% of them received massive transfusion. Considering the complications of PPH among our patients, about 34% had haemostatic hysterectomy, 36 patients (8.67%) were admitted in the ICU, 36 patients (8.67%) had maternal cardiac arrest, 34 patients (8.19%) had coagulopathy, 22 patients (5.3%) had sepsis and 3.13% developed acute kidney injury. Two patients developed venous thromboembolism and 1 patient developed pulmonary emboli. Mortality rate of PPH was 9.16%(38/415) with only one of 81 patients died from patients who delivered from CHUK (1.23%) compared to 37 of 334 patients (11%) who have been transferred from secondary level hospitals died. Transferred patients were 10 times more likely to die as those who delivered at CHUK (OR=9.96; 95% CI=1.34-73.75; p=0.024). The most common cause of death was hemorrhagic shock at 52.63% followed by coagulopathy (DIC) at 26.32%, multi-organ failure and pulmonary edema were identified as the cause of death in 3 patients for each. Patients with multiple pregnancies, placenta previa and history of induction of labor were more likely to die. Patients with history of induction of labor were more likely to be massively transfused compared to those without induction of labor (p=0.041). Conclusion: Generally, the prevalence of PPH has consistently decreased over time from 2016 to 2020. However, postpartum hemorrhage remains one of the leading causes of maternal morbidity and mortality in our setting. Delays associated with transfers from a secondary level hospital to tertiary level are major contributing factor to adverse maternal outcomes. There is a need for further investment in prevention, early recognition and prompt full package management of PPH patients at delivery site.