Postpartum haemorrhage remains a global challenge in maternal health - Experts

KUALA LUMPUR - The desire to have children is deeply personal and holds great significance for many families. Parenthood is a multifaceted journey involving biological, emotional, social, and cultural factors that profoundly shape the human experience.

While childbirth is a transformative experience for mothers, it is also fraught with challenges, including postpartum haemorrhage (PPH), a critical obstetrical emergency characterised by excessive bleeding following childbirth.

PPH is defined as blood loss exceeding 500 millilitres (mL) after vaginal delivery or 1,000 mL after caesarean delivery, posing significant risks to maternal health on a global scale.

An estimated 14 million women worldwide suffer from PPH annually. If not promptly treated, PPH can lead to maternal death within hours.

The World Health Organisation (WHO) reports that PPH accounts for 25 per cent of all maternal deaths globally, underscoring its critical impact on maternal mortality rates (MMR) when inadequately managed.

IMPACT ON NATIONAL MMR

According to Datuk Dr Harlina Halizah Siraj, Visiting Consultant Obstetrician and Gynaecologist at An-Nur Specialist Hospital, PPH is not only one of the most common obstetrical emergencies but also a leading cause of maternal morbidity and mortality worldwide.

It ranks among the top three causes of direct maternal deaths in both developing and developed countries. Primary and secondary PPH occur within 24 hours and beyond 24 hours up to 12 weeks post-delivery, respectively.

In Malaysia, despite advancements in healthcare infrastructure and maternal care, PPH remains a significant concern. The maternal mortality ratio (MMR) has declined historically but remains a challenge, with persistent rates over recent decades.

Historically, MMR has steadily declined from 1080.0 per cent of deaths per 100,000 births in 1933 to 21.1 per cent deaths per 100,000 births in 2019, according to data from the Family Health Development Division, Ministry of Health Malaysia (MOH).

"However, the number of cases has been persistent in recent times, with a significant increase during the Covid-19 pandemic due to various reasons,” she said.

Citing MOH data, she said the percentage of MMR cases increased from around 21 per cent in 2019 (103 deaths) to 24.8 per cent in 2020 (117 deaths) and further to 68.2 per cent in 2021 (300 deaths).

"The swift intervention by MOH resulted in a decrease to 26 per cent MMR in 2022 (110 maternal deaths). Despite these improvements, achieving WHO’s MMR target of fewer than 70 deaths per 100,000 births by 2030 remains a challenge," she said when met recently at a private event organised by Organon Malaysia, a global healthcare company focused on improving women’s health.

UNDERSTANDING THE 4Ts

Dr Harlina, who is also Founding Director of Akademi Dr Har, emphasises the importance of understanding the underlying causes of Postpartum Haemorrhage (PPH) for timely intervention and improved maternal outcomes.

PPH is often classified using the mnemonic ‘4Ts’: Tissue, Tone, Trauma, and Thrombin or Coagulopathy.

One primary cause of PPH is retained placenta or retained products of conception, where placental tissue or blood clots remain in the uterus after childbirth. This prevents proper uterine contraction and increases the risk of ongoing bleeding.

Uterine atony is another major cause, accounting for approximately 70-80 per cent of PPH cases. It occurs when the uterus fails to contract adequately after delivery, keeping uterine blood vessels dilated and resulting in persistent bleeding. Factors contributing to uterine atony include prolonged labour or a large foetal size.

"Genital tract trauma refers to injuries in the female reproductive system, such as cuts in the cervix or vagina. These tears can occur accidentally during childbirth or intentionally through episiotomy to aid delivery. Trauma disrupts blood vessel integrity in the birth canal, leading to significant bleeding if not promptly treated.

"Coagulopathy refers to blood clotting disorders that predispose women to PPH. Pre-existing conditions like Von Willebrand disease or liver disease can impair clot formation. PPH itself can further deplete clotting factors, worsening bleeding and complicating management," she explained.

Therefore, vigilance for symptoms of uterine atony during childbirth is crucial to recognise PPH early. Normally, uterine muscles contract after childbirth, ensuring controlled bleeding.

"However, abnormal postpartum bleeding can occur in cases of uterine atony. According to the American College of Obstetricians and Gynecologists (ACOG), postpartum blood loss exceeding 500 mL after vaginal delivery is considered abnormal and should be investigated promptly.

"This highlights the urgent need for effective management of blood loss to prevent serious complications," she added.

PROMOTING HEALTHY PREGNANCIES

Meanwhile, Prof Dr Jamiyah Hassan, Consultant Obstetrician and Fetomaternal Specialist at the Department of Obstetrics and Gynaecology, Hospital Al-Sultan Abdullah, Universiti Teknologi Mara (UiTM) Puncak Alam, said that the best approach to prevent PPH is to avoid high-risk pregnancies.

Public awareness should highlight that several factors increase the risk of PPH, such as being overweight or obese, which can lead to conditions like diabetes, high cholesterol and hypertension.

According to the 2023 Vital Statistics by the Department of Statistics Malaysia (DOSM), approximately 1.7 million people in Malaysia have all three major risk factors.

Additionally, about one in two adults in Malaysia have abdominal obesity, and one in five adults have diabetes, further contributing to high-risk pregnancies. Women with such conditions face increased risks of adverse maternal outcomes due to underlying health issues.

"Thus, by identifying and closely monitoring high-risk pregnancies and focusing on preconception care, we can safeguard maternal health and minimise severe PPH events that lead to maternal mortality," Dr Jamiyah said.

"Addressing underlying health conditions, reducing the need for obstetric interventions, optimising maternal health and uterine function are crucial in combating PPH cases,” she added.

Furthermore, the practice of Active Management of the Third Stage of Labour (AMTSL) in the delivery room significantly aids in placental delivery by enhancing uterine contractions, thereby preventing PPH due to uterine atony.

This approach involves the use of uterotonic agents such as oxytocin, which induce or enhance uterine contractions, crucial for controlling postpartum bleeding and reducing excessive blood loss.

"In addition, the Controlled Cord Traction technique involves gently pulling on the umbilical cord while applying counter-pressure on the lower abdomen to guide the placenta downward through the birth canal, promoting swift delivery and minimising postpartum bleeding," she explained, emphasising the importance of developing medical devices to aid in childbirth and address PPH-related challenges in the future.

MEDICAL INNOVATION

The Jada System represents a significant medical advancement developed by Organon to manage and treat abnormal postpartum uterine bleeding.

Bilal Somra, Executive Director and Country Lead of Organon Malaysia, highlighted the device's importance in addressing the urgent global health challenge of postpartum haemorrhage, affecting one in ten mothers in Malaysia.

The device is an intrauterine vacuum-induced haemorrhage-control system designed to promptly and effectively manage abnormal postpartum uterine bleeding. It includes an intrauterine loop, cervical seal, seal valve, and vacuum connector, and can be deployed as soon as abnormal bleeding is detected.

"The Jada System utilises a low-level vacuum to stimulate uterine contraction following delivery, efficiently controlling bleeding within an average of three minutes after treatment initiation," Somra said.

"In the pivotal PEARLE study involving 107 subjects across the United States, it successfully controlled uterine bleeding in 94 per cent of patients without further intervention," he added.

Organon plans to introduce the Jada System in Malaysian hospitals by the end of the month, prioritising awareness campaigns and healthcare professional training.

Additionally, the company will collaborate with local stakeholders to assess its implementation and cost-effectiveness within the healthcare system, aligning with the WHO’s strategic roadmap to reduce maternal mortality related to PPH. - BERNAMA