77 Anaemia and Obstetric Haemorrhage

Helen 08/11/18

77.1 Anaemia

Defn’s

Anaemia < 11 Mild < 11 Mod < 9 Severe < 7

Half of pregnant women in low income countries with anaemia. In Chad only 10% of these receive iron/folic acid supplementation.

Strong association with death and morbidity. Change of death 2x higher in women in severe anaemia

77.1.1 Causes

  • Dietary deficiencies (Iron mainly, but others also) This is the main cause
  • Short inter-pregnancy intervals
  • Haemoglobinopathies
  • Infections (Malaria, HIV, Hookworm)
  • Menstural loss/Fibroids
  • Increased need for iron in pregnancy

WHO Recommendation: Daily oral iron and folic acid supplementation in pregnancy

But the problem is that lots of women do not have their malaria and anaemia, or their post partum haemorrhage identified.

77.2 Haemorrhage

Grand multips - People with more than 4 children are more likely to bleed postpartum

1/4 of deaths of mothers in developing countries are due to haemorrhage.

Uterine blood flow at term is 700mls/minute! An untreated health woman may die from haemorrhage within 2 hours!

How do you prevent these deaths?

  • Prevent anaemia,
  • Stop bleeding,
  • Replace blood

Stopping this is:

  • Access to care (physically, affordable, available)
  • Skilled birth attendants in an enabling environment (setting with the correct resources)

oxytocin is a uterotonic, to contract it to stop bleeding

But it’s not the haemorrhage alone that kills women. PPH is 1/4 maternal deaths, anaemia is 1/5 deaths, antepartum in india is 1/20 deaths.

9/10 women who died of obstetric haemorrhage in Kenya, received sub-optimal care and were potentially avoidable deaths.

In UK, one preganacy will die every 200,000 from haemorrhage

77.2.1 Causes

77.2.1.1 Ante Partum

  • Ectopic
  • Termination (unsafe abortion)
  • Placental abruption
  • Placenta praevia
  • Cervical tumour

77.2.1.2 Intra Partum

  • Abruption
  • Placenta Praevia

77.2.1.3 Post Partum

This is the biggest contributor to deaths from haemorrhage

4 T’s

  • Tone (uterine atony) - 70% of PPH
  • Tissue (retained products)
  • Trauma (tears)
  • Thrombin (consumption coagulopathy)

These four causes are not mutually exclusive, you can have all four!

77.2.2 C Sections

There is a worrying upward trend in C sections globally (1/5 of all deliveries), this matters in places where maternal mortality is high, and matters more with second pregnancies and beyond. 50% in some hospitals in Rwanda.

Up to around 19% C sections you see improvement in maternal and neonatal mortality.

After that you start getting disadvantaged by rates of deaths by increased bleeding: either in c-section, or abnormal placentation due to scar in uterus (more placenta praevia after c-sections), or due to tears in uterus.

77.2.3 Prevent haemorrhage

  • Treat anaemia
  • Avoid unneccesry c sections
  • US to know placenta
  • Good surgical technique
  • Ensure uterine cavity
  • Management of third stage (oxytocic - carbitocin is a heat stable alternative to oxytocin that needs a cold chain, and is an injection rather than an infusion)
  • Examine carefully for tears

77.2.4 Detecting haemorrhage

Shock Index = HR / Systolic BP

Good predictor of outcome of PPH

77.2.5 Stopping Bleeding

TXA: 1 gram IV was conducted in the Woman Trial. Hugh difference in maternal mortality. Now part of WHO guidelines.

Uterine Balloon Tamponade: Use a foley catheter and a condom

Surgical: B Lynch Suture

Anti Shock Garment in PPH

77.2.6 Replacing Blood

Blood bank service are not available everywhere.

So what about cell salvage. Doesn’t work if the patient is already anaemic!