Incidence and outcome of severe ante-partum hemorrhage at the Teaching Hospital Yalgado Ouédraogo in Burkina Faso

Background Hemorrhage is the main cause of maternal death during pregnancy. This study aims to evaluate incidence and outcomes of Severe Ante Partum Hemorrhage (SAPH) during the third trimester of pregnancy prior to delivery. Methods Analytical cross-sectional study with prospective data collection during 12 months in Yalgado Ouedraogo Hospital, Ouagadougou, Burkina Faso. In this context SAPH is specifically referring to Ante Partum Hemorrhage (APH) and Intra Partum Hemorrhage (IPH) in the 3rd trimester. Postpartum Hemorrhage (PPH) was not included. Results During our study 7,469 women were admitted in obstetrics and 122 cases of SAPH were recorded. SAPH represented 1.6% (n = 122) of hospitalizations causes and 14.5% (n = 1083) of hemorrhages during pregnancy. Mean age was 27.8 ± 6.9 years, mean parity 2.8 ± 1.3 and mean duration of pregnancy was 37 Weeks Amenorrhea (WA). Evacuation from other facilities was the main mode of admission (91.8%, n = 112) and blood transfusion was the essence of resuscitation. Complications were observed in 80.3% (n = 98). During the study, 118 maternal deaths were reported of which 15.6% (n = 19) related to SAPH. Among SAPH cases who died (n = 19) majority (n = 16) had severe anemia (n = 16; 82.6%, p = 0.004). Ten women (8.19%) were admitted in Intensive Care Unit (ICU). Fifteen premature births (12.3%) and 22 perinatal deaths (18.1%) were recorded. Evacuation (p = 0.04), critical clinical condition during admission (p = 0.004), and Uterine Rupture (UR) (p = 0.002) were associated with poor outcome. The Retroplacental Hemorrhage (RPH) (40.9%) was the most common cause of fetal death (p = 0.005) and was associated with High Blood Pressure (HBP) and pre-eclampsia. Conclusion APH is a complication associated with significant maternal and fetal morbidity and mortality.


Background
Worldwide approximately 830 women die every day from preventable causes related to pregnancy and childbirth; 99% of those 830 daily deaths are women from developing countries. [1] Direct obstetrical complications are the main causes of maternal deaths, with bleeding [2] identified as the first cause. In Burkina Faso maternal mortality remains high, with 2,700 deaths per 100,000 deliveries [1]. Hemorrhage is the leading cause of maternal mortality globally, accounting for approximately 27% of deaths worldwide; this includes postpartum, intrapartum and antepartum hemorrhage [3]. In developed countries, hemorrhage prior to delivery accounts for only 16.3% of maternal deaths, while Sub-Saharan Africa remains high at 24.5%. Antepartum Hemorrhage (APH) is defined as bleeding from the vagina after 24 weeks [4]. In France [5] Serious Obstetrical Hemorrhage (SOH) represented 19% of admissions to the Intensive Care Unit (ICU). Worldwide postpartum hemorrhage (PPH) has been well studied, but APH and intrapartum hemorrhage (IPH) are less well-documented. APH is an obstetric emergency significantly contributing to perinatal and maternal morbidity and mortality. PPH yields mainly maternal complications and may be in itself a complication of APH. However, during APH, complications can be fetal as well as maternal. The maternal complications are malpresentation, premature labor, PPH, sepsis, shock and retained placenta [6]. Various fetal complications are prematurity, low birth weight, intrauterine death, congenital malformation and birth asphyxia [7].
The obstetric department of Ouagadougou is the main and sole national reference center. Patients are generally referred from health facilities at least 150 km from Ouagadougou. The obstetric department has 81 beds plus 9 intensive care beds. It is poorly equipped in material, and drug supply is scarce. Specialized personnel consist of 13 obstetricians, 17 nurses specialized in anesthesia, 38 midwifes, and one anesthesiologist. Our study aims to evaluate the incidence and outcome of severe APH in the third trimester of pregnancy prior to delivery in Yalgado Ouedraogo Hospital in Burkina Faso.

Methods
This was an analytical cross-sectional study with prospective collection of data during 12 consecutive months (1 st of February 2012 to 31 st of January 2013). Informed written consent was obtained from each participant or her guardian, and confidentiality was assured. Patients who refused to participate were thanked without any further pressure to change or explain their refusal. The study included women admitted in the obstetric service during their third trimester of pregnancy with hemorrhage. To qualify as "Severe Ante-Partum Hemorrhage" in this study, the hemorrhage had to satisfy at least one of the following criteria: a blood loss above 2000 ml, a loss of 150 ml/min, a loss of 50% of blood volume within 3 h, a decrease of maternal hemoglobin concentration of 4 g/dl, transfusion needs greater than 4 units, [8] maternal hemoglobin concentration less than 6 g/dl at any point of time, bleeding with vital signs instability (maternal pulse less than 50 or higher than 100 bpm, systolic blood pressure less than 100 mmHg and diastolic pressure ≤ 50 mmHg) or hemorrhagic shock. In our study, serious obstetrical hemorrhage is specifically referring to APH and IPH in the 3 rd trimester. Patients who met at least one of these criteria were included. Our center already published its results about PPH, which results are therefore not included in the present study. Data collection was based on the clinical review, interview, admission register and ultrasound archives. Causes of hemorrhage were diagnosed by ultrasound, clinical assessment or intra-operative findings. Socio-demographic data, causes for hemorrhage, case management, maternal and fetal outcomes were reviewed and analyzed. Delay to transfusion was defined as the time elapsed from the decision to transfuse to actual blood transfusion. Definitions: A transfer is the referral of a patient from another service in the same hospital. A reference is the non-emergency transfer of a patient from a health facility to another high performance facility. An evacuation is an emergency referral of a patient from a health facility to another high performance facility. Data were analyzed with EPI Info 3.5 and results expressed as a mean for quantitative values, median, extremes and a percentage for qualitative values. Association between variables was investigated by the Chi2 test, and a p value less than 0.05 was considered as statistically significant. The present study was approved by National Center of Scientific Reseach and Technologic (NCSRT) committee of Burkina Faso. Strict confidentiality was ensured for all personal data.

Results
During our study, 7,469 women were admitted in obstetrics. Among them, 3,645 women experienced a hemorrhage, and from that group again 122 (1.6%) women experienced SAPH. Seventy-nine patients live inside Ouagadougou. Demographic, obstetrical and clinical data are illustrated in Tables 1 and 2 below. Table 2 focuses on clinical data and the causes of hemorrhage.
Our study showed SAPH mortality rate was 16.1%. The average age of deceased patients was 27.2 years and the majority of them were evacuated. Reference (p = 0,001) and not transfusion (p = 0,002) were risks factors associated with maternal mortality. Patients died because of multiple organ failures in eight cases, and coagulopathy (n = 6) or lack of blood products. Preterm delivery occurred in 12.3% (n =15). Twenty-two perinatal deaths (18.1%; n = 22) were recorded, including 12 apparent stillborn and 10 macerated stillborn. Retro placental hematoma was associated with a 25% fetal mortality rate (n = 10/40 cases), significantly higher than placenta praevia (n = 7 cases on 52, 13.5%) and uterine rupture (n = 6/30, 20%) (p = 0.005) as indicated in Table 4 below.    3 . SAPH is more frequent in developing countries than in developed countries [3,11] In fact, data must be analyzed cautiously; our study is limited to severe hemorrhage while most publications concern all types of hemorrhage. The average age of our patients was 27.8 years. In Burkina Faso, half of women marry before 17.5 years old, and the majority of women give birth to their first child before 20 years old [12]. This young age is reported by other authors, [13,14] Women living outside Ouagadougou represented 35.2% of total patient our study. These patients were referred which contributed to a delay in decision making and increased maternal morbidity and mortality. During admission, severe clinical anemia (≤6 g/dl) was observed in 101 patients (82.8%).
The majority of women were referred form other facilities (91.8%). Pregnancies had been relatively well attended with 3 antenatal consultations for 65% of them. Burkina Faso has a pyramidal organization of health care facilities. The obstetric department of Ouagadougou is the main and only national reference center. Patients are generally referred from health care facilities located more than 150 km from Ouagadougou. In our study, 112 (91.8%) patients were referred. During reference, 65% of all women referred were accompanied by a nurse, none by a doctor. Women coming outside Ouagadougou (43,7%) were assisted by nurse only (18%) and others came themselves (4.5%). Ouattara and al [15] reported that the reference process accounted for 43% of admissions in the same service where we conducted our study. The insufficiency of heath service and poorly maintained or low availability of equipment are some of explanations of this situation. Women were relatively followed up during pregnancy in our study like some other study [12].
There was a delay in the management of pregnant patients' bleeding and patients were often previously anemic. Rhesus blood grouping and hemoglobin measurement were performed in emergency as described in the literature [9,16] Given the excellent results of ultrasound examination, any suspicion of obstetric pathology justifies its use, but because of unavailability, it was performed only for 6 patients (5%), identifying 4 cases of Placental Previa (PP) and 2 cases of Retroplacental hematoma (RPH) in our study. The main causes of SAPH are PP, followed by RPH and Uterine Rupture (UR). These three pathologies are common in Africa [9,14] The PP incidence accounted for 41.80% of severe APH (n = 51) in our series. In the literature, abnormal placental insertions were responsible of 5 to 10% of SAPH [10,17] In our study, RPH caused 32.8% (n = 40) of SAPH. Takpara et al. [9] in Benin reported that RPH was responsible of 5.8% of serious obstetrical hemorrhage. RPH occurred in 0.5% of all pregnancies, and complicate 0.2 to 0.4% of these pregnancies with a perinatal mortality about 20.2% related to hemorrhage [17,18] Obstetric hemorrhage was due to UR in 42% (n = 31) in our study from which 2 cases (6.5%) occurred on a scarred uterus and other ¾ on healthy uterus. In our study, the high proportion of UR on healthy uterus may be related to multiparty, lack of support for pregnancy, fetal and pelvic disproportion, unfavorable socio-economic status, prolonged labor, and delayed consultation. SAPH was responsible of 8.2% of intensive care unit admissions in our study. All cases of SAPH must be admitted in intensive care, but the lack of health insurance is an obstacle to their admission unlike in others countries [5,18,19] Despite the availability of Emergency Obstetric and Neonatal Care (EmONC), there was no protocol for hemorrhage management in this service. Measures such as the left lateral position, oxygen supplement were effective for 77 patients (63.4%). Volume expansion with saline (n = 122) and gelofusin (n = 88; 72%) were implemented. Thirteen percent (n = 16) of women did not receive oxygen due to lack of supplies (oxygen mask, nasal prongs). Like in others' Africans studies, maternal resuscitation was hampered by the lack of blood products [20]. In our studied population, uncovered transfusion needs were reported for 18 patients (14.8%), but no patient needed massive transfusion. The average waiting time for transfusion was long (3.8 h) and Bonkoungou [21] in the same service reported 5.2 h delay to transfusion. In our series, one of the ten women died because of the lack of blood products. The transfusion products were mainly erythrocytes. Two patients received fresh frozen plasma for clotting disorders. There are no publications on stock-outs of supplies and blood in this Hospital and data are unavailable. A further research information is needed to establish the no covered rate of blood transfusion. Oxytocin and antibiotics were used in our study like in others studies [9].
A Cesarean section was performed for 79 patients (64.8%). This rates are similar to Beninese data [9]. Eight woman who gave birth vaginally could have been cared in a peripheral clinic and this raises questions about the qualification of agents that referred women. A hysterectomy was performed in 2 cases (1.6%) after failure of conservative treatment. In the study of Nayama et al. [22] in Niger 18,934 deliveries had been registered from which 154 patients had benefited from obstetric hysterectomy (0.8%). Despite this radical rescue surgery, a patient died in post-operative period. The decision to perform a hysterectomy remains difficult, especially in the African socio-cultural context [13] and among young women. The delay in management explains the high mortality reported both in our study and in the Takpara [9] study.
The major morbidity was anemia (73.4%) in our study as described in the literature [14]. Anemia is often part of the continuum of pregnancy. The second cause of morbidity was infection. Maternal death rate in our study was 15.6%. Hemorrhage is responsible for 27,1% of maternal deaths according to Say and al [3]. The mortality rate in our series is comparable to what Cissé [23] reported (16.4%). UR was the deadliest (29%) (p = 0.06) in  [17,18]. The need of patients to be referred (p = 0.04), critical condition during admission (p = 0.004), and uterine rupture (p = 0.002) were poor outcome factors in our study. In Africa, the insufficiency of equipment, drugs for resuscitation and delay to health care utilization increase the mortality rate. So delay can be attributed to poor access to supplies and to blood products. Despite resuscitation and Cesarean section practice, fetal outcome remained severe. Fifteen premature births (12.3%) and 22 perinatal deaths (18.1%) were recorded in our study. This rate of stillbirths was comparable to Takpara [9] data (14.7%). RPH remained the most feticide (27.3%) in our study. According to Mercier and al [24] RPH was responsible of 20.2% perinatal mortality. During pregnancy, high blood pressure, pre-eclampsia must be researched and managed in order to reduce risk of placenta abruption.

Conclusion
APH is serious obstetric complication. Young women were concerned. SOH is associated with significant maternal and fetal morbidity and mortality. It is a frequent reason for consultation, and its outcome can be fatal without early and appropriate management. The lack of blood products, insufficient equipment, poor medical condition upon transfer from health facilities, and delayed resuscitation each impacted the effectiveness of the APH management. Since April 2016 with the establish 43,7%) ent of general health insurance for obstetric and pediatric care in our country, we hope that pregnancy will have more attention and good care. However, some effort must be done to improve availability of skilled resources.