Postpartum bleeding and shock in women giving birth with severe anaemia

Abstract

Abstract Background Each year, about 70,000 women die from bleeding after childbirth. Maternal anaemia increases the risk of postpartum bleeding. WHO recommends that treatment for postpartum haemorrhage should begin if there is blood loss ≥300 ml with abnormal haemodynamic signs (including elevated shock index) or blood loss ≥500 ml within 24 hours of birth. The prevalence of anaemia is highest in Sub-Saharan Africa and South Asia and these regions also have the highest maternal death rates. We examine the effect of severe anaemia (haemoglobin <70 g/L) compared to moderate anaemia (haemoglobin 70-99 g/L) on shock in 15066 women giving birth in Nigeria, Pakistan, Tanzania and Zambia. Methods We conducted a cohort analysis of data from the WOMAN-2 trial. We report mean and median estimated blood loss and the number of women with blood loss ≥1L, stratified by anaemia severity. We defined shock as post birth shock index >1.3. We define shock index as heart rate ÷ systolic blood pressure. We use multivariable logistic regression to calculate an odds ratio for the effect of severe anaemia on shock, adjusting for estimated blood loss, antepartum haemorrhage or placenta abnormalities, infection and hypertension. Results Mean (SD) estimated blood loss was 306 (177) ml in women with moderate anaemia compared to 339 (269) ml for severe anaemia. Median (IQR) estimated blood loss was 280 (200-350) ml for moderate anaemia versus 290 (200-360) ml for severe anaemia. Blood loss ≥1L occurred in 1.2% (156/12982) of women with moderate anaemia versus 2.9% (60/2076) with severe anaemia (OR=2.45 95%CI 1.81-3.31). Shock occurred in 0.8% (103/12,974) of women with moderate anaemia versus 2.3% (48/2,070) with severe anaemia. Severe anaemia tripled the odds of shock (OR=3.35, 95%CI 2.34-4.81). After adjusting for blood loss and other factors, severe anaemia more than doubled the odds of shock (aOR=2.39, 95%CI 1.59-3.58). Conclusions For any given blood loss, women with severe anaemia are more likely to become shocked. Preventing and treating anaemia in women of reproductive age must be a public health priority.