Postpartum hemorrhage (PPH) is the common cause of maternal death worldwide. It is
interesting to note that PPH is the most common cause of death in developing country.
Additionally, PPH is the common cause of maternal cardiac arrest. PPH defined as the
amount of bleeding more than or equal to 500 ml after vaginal delivery and bleeding of
more than or equal to 1,000 ml after cesarean delivery. The rate of PPH regardless any
route of delivery was 2.9-3.2%. Rate of PPH in patients undergoing cesarean delivery was
approximately 0.6% - 3.1%.
The difference in anesthetic techniques influence the rate of postpartum hemorrhage.
Numerous studies showed the association between general anesthesia and postpartum
hemorrhage in patient undergoing cesarean delivery. The outcome showed the odds of PPH in
women who had cesarean delivery with general anesthesia were 8.15 times higher (95% CI
6.43-10.33) than for those who had CS with epidural anesthesia. Likewise, systematic
review and meta-analysis revealed general anesthesia associated with higher amount of
blood loss, but not the transfusion rate comparing with regional anesthesia. The
decreasing of myometrial uterine tone from the usage of inhalational agents (halothane,
enflurane, isofurane, sevoflurane, and desflurane) from general anesthesia explains this
consequence.
Guidelines recommended the management of PPH after cesarean delivery were launched. World
Health Organization (WHO) recommendation reported both surgical together with medical
management (non-surgical) in patients with PPH, which published in the year 2012. The
major role of anesthesiologists involving in treatment of PPH is medical treatment and
blood and blood component administration. The novel medical treatment of PPH has been
described in several literatures including the usage of tranexamic acid and fibrinogen
concentrate. The World Maternal Antifibrinolytic trial (WOMAN trial) is the large-sample
size randomized controlled trial publishing in the Lancet in the year 2017. WOMAN trial
revealed the administration of tranexamic acid in patients with PPH after vaginal or
cesarean delivery significantly reduced blood loss and decreased maternal mortality rate
from bleeding. Likewise, Cochrane database systematic review concluded in the year 2018
that intravenous tranexamic acid reduced mortality rate due to bleeding in women with
PPH, irrespective of mode of delivery. The WHO collaborator subsequently launched the
update of recommendation including the administration of tranexamic acid 1 gram in PPH
patients within 3 hours after birth.
Moreover, the rate of ICU admission after postpartum hemorrhage was studied revealing 15
of 21 patients (71.4%). Of which, 12 patients presented disseminated intravascular
coagulation (DIC) and 2 cases death (9%). Critically-ill patients deriving from massive
hemorrhage from PPH also transfusion-related acute lungs injury (TRALI), congestive heart
failure, acute kidney injury and multiorgan failure.
In this study, we emphasize in patients underwent cesarean delivery with PPH
(intraoperative estimated blood loss > 1,000 ml). The primary purpose is to identify the
maternal outcomes after PPH. The highlighted outcome is the anesthetic management
including rate of blood transfusion and incidence of patient experiencing massive blood
transfusion. The secondary purposes of this study are amount of blood loss, causes of PPH
and other outcomes that related to PPH such as the rate of hysterectomy and postoperative
outcome eg. congestive heart failure, acute kidney injury and TRALI etc. Additionally,
incidence of PPH will be studied. Data collection will be made to identify the cause of
PPH, anesthetic techniques that may related to the amount of hemorrhage, medical
treatment for PPH and neonatal outcomes. We also aim to obtain the rate of ICU admission
and revealed the factors involving the ICU admission in PPH patients underwent cesarean
delivery.
The detail of outcomes of PPH in cesarean delivered patients in Siriraj hospital is
scared; and it has not yet been described in the literature. Therefore, the authors aim
to collected the data and analyzed the outcomes associated with PPH, in order to report
in the literatures as well as improving the anesthetic management of intraoperative PPH
in our institute.