OBSTETRIC HEAMORRHAGE

 Obstetric Haemorrhage is the leading cause of maternal morbidity and mortality worldwide. It is defined as excessive bleeding during pregnancy, childbirth, or the postpartum period. It is difficult to quantify the volume of blood loss. Still, most references suggest excessive bleeding of more than 500 ml after a vaginal delivery and more than 1000 ml after a caesarean section is significant. It also depends on how the mother has been optimized during the antenatal period to cope with bleeding. Anemia in pregnancy can on its own predispose pregnant women to postpartum haemorrhage.

We have made good progress in terms of training staff concerning the acute management of haemorrhage, maternal resuscitation, and the use of uterotonic agents. We believe that in the twenty-first century, we should not lose any woman with obstetric haemorrhage. Most of us know the tragic story of Mumtaz Mahal in 1631 who gave birth to her fourteenth child. Shah Jahan was devastated by her death and decided to build a magnificent mausoleum in her memory which is named the Taj Mahal in Agra, India. It took 22 years to be completed, and it is considered one of the seven wonders of the modern world. It is a testament to Shah Jahan's and Mumtaz Mahal's eternal love.

In the modern world, we have easy access to birth control. Most births occur in a level of health care facility. In our regional hospital, we still struggle to have access to a blood bank after 4pm, which is not ideal considering it is a mother-and-child hospital with about 1000 births per month. The other day we prioritized an elective caesarean section with a known placenta praevia to be done first thing in the morning while the senior doctors are on duty and the blood bank is available. We started the case with 2 units of blood in theatre and we also had the senior anesthetic consultant available. The fetal medicine unit had not found any ultrasound evidence of the anterior and low-lying placenta being morbidly adherent to the uterus. Intraoperatively the placenta was morbidly adherent and we had an obstetric haemorrhage and proceeded with a caesarean hysterectomy! The mom ended up in the ICU with a massive transfusion.

We try our best every day to decrease the incidence of obstetric haemorrhage and the morbidity and mortality that comes with it. A morbidly adherent placenta or a placenta accrete spectrum is on the rise due to a rise in caesarean section rate. We hope with recent advances in antenatal imaging we will be able to identify such cases and manage them appropriately in a tertiary-level hospital with experienced surgeons and, an anesthesiology team.