Obstetric Hemorrhage during the Third Trimester of Pregnancy: Experience in a University Hospital in Guinea

Aims: Obstetric hemorrhage, especially during the 3rd trimester of pregnancy, causes maternal, fetal and neonatal mortality and morbidity. We attempted to characterize its clinical features in Guinea. The objectives of this study were to describe the socio-demographic characteristics of the patients, identify the causes and contributing factors, describe the management and evaluate the maternal-fetal prognosis in such patients. Methods: We retrieved and analyzed patients with 3rd trimester hemorrhage whom we managed at Ignace Deen National Hospital, Guinea during 1-year period (1 st of December 2019-30 th of November 2020). Results: We experienced recorded 401 patients with 3rd trimester obstetric hemorrhage out of 5468 deliveries during the corresponding period; the rate being 7.33%. The main causes were as follows: placental hematoma (65.33%), placenta previa (27.68%) and uterine rupture (6.99%). The socio-demographic profiles were as follows: the age group of 25 - 29 years (28.42%), married (94.51%), uneducated (50.12%), and with a liberal profession. (43.64%) and pauciparous (30.42%). The conditions were considered to be preventable by managing risk factors during the prenatal consultation (PNC): 7.73% underwent no PNC. Cesarean accounted for 84.78% of patients. Prognosis was as follows: 14 maternal deaths (3.45% of a fatality), 34.66% of anemia, and 16.95% of hemorrhagic shock. Fetal/neonatal prog-noses were poor. Conclusion: Obstetric hemorrhage during 3rd trimester remains the main cause of poor outcomes in Guinea. This study identified that this type of hemorrhage still represents an important cause of maternal and fetal morbidity and mortality in developing countries.


Introduction
Obstetric hemorrhage during the third trimester corresponds to external bleeding through the vagina during the third trimester of pregnancy from 28 WA, and constitutes an obstetric emergency with a risk of maternal and fetal morbidity and mortality. They complicate 2% to 5% of pregnancies [1]. Whatever their etiologies, hemorrhages prenatal can have deplorable consequences. Indeed, for Mercier et al., antenatal hemorrhages, with a low incidence (about 5 to 6%), constitute an important cause of maternal and perinatal mortality [2].
In the 21st century, the drama of maternal mortality still remains the same. It is a scourge that strikes hard in developing countries and particularly in Africa where socio-economic, environmental and health conditions expose women to dreadful complications of pregnancy and childbirth [3].
According to WHO statistics between 1990 and 2015, the global maternal mortality rate decreased by only 2.5%. Approximately 500,000 women die each year worldwide during pregnancy or in the immediate postpartum period and 99% of these deaths occur in developing countries [2].
In developed countries, maternal mortality linked to hemorrhages has become rare, even in severe forms, thanks to rapid and appropriate treatment. Thus in France, severe obstetric hemorrhage accounted for 19% of intensive care admissions [4].
In Africa, obstetric hemorrhage remains the leading cause of maternal death today [5]. Among them, those of the third trimester constitute a daily concern in current practice, encompassing a range of obstetric pathologies whose delay in management could be detrimental to the mother and the fetus [6].
In Cameroon, according to Fumulu, placenta previa, abruption placenta and uterine rupture represent 40.9% of the causes of maternal death related to hemorrhage [7].
In Senegal, Biaye B et al. reported that PRH represents 7% of the causes of maternal death linked to hemorrhage [8].
In Guinea, Barry KM had found a 2.2% frequency of hemorrhage in the last trimester of pregnancy at the Ignace Deen National Hospital with maternal and fetal mortality rates, which were 7.62% and 61.90%. [9].
The scarcity of previous data on this subject at the Ignace Deen National Hospital and the seriousness of maternal and fetal complications related to obstetric hemorrhage during the third trimester of pregnancy motivated the realization of this study. Thus, we set ourselves the following objectives: to determine the frequency of obstetric hemorrhage during the third trimester, to describe the socio-demographic characteristics of the patients, to identify the causes and contributing factors, to describe the management and to evaluate the maternal-fetal

Patients and Methods
This was a descriptive and analytical cross-sectional prospective study lasting twelve (12)   Where appropriate, Filer's exact test was used. The research protocol was approved by the national ethics committee with informed consent. During the realization of this work we encountered some difficulties namely: the absence of an ultrasound in the delivery room, the difficulty in estimating the blood losses, the difficult access to blood products, the ignorance of the date of the last menstrual period and not performing of an early ultrasound.

Frequency
During the study period, we recorded 401 cases of obstetric hemorrhage during the third trimester of pregnancy out of 5468 deliveries, i.e. a frequency of 7.33%.
The main etiologies responsible for bleeding in the third trimester of pregnancy were retro placental hematoma (65.33%), placenta previa (27.68%) and Open Journal of Obstetrics and Gynecology uterine rupture (6.99%).

Clinical Appearance
Mode of admission: More than half of the patients were evacuated for all etiologies with an average of 66.33%.

Maternal Mortality
In our series, we recorded 14 cases of maternal death, i.e. a lethality of 3.5% for all etiologies and a ratio of 291.7/100,000 live births. These maternal deaths were related to retroplacental hematoma in 10 cases (9 cases of hemorrhagic shock and 1 case of eclamptic coma) and to uterine rupture in 4 cases (3 cases of hemorrhagic shock and 1 case of septic shock).

State of the Newborn
On average we recorded a rate of 47.6% of stillbirths for all etiologies with specifically 59.5% of stillbirths in RPH and 67.9% in rupture uterine. In placenta previa, the newborn was alive in the majority of cases.

Birth Weight
We recorded 52.4% of newborns with a birth weight of <2500 g for all etiologies.
This low birth weight was more frequent in RPH (60.7%). Birth weight ≥2500 g was more frequently found in cases of placenta previa and uterine rupture with respective frequencies of 57.0% and 89.3%.

Frequency
Our study reveals a higher frequency than that reported 10 years ago in the same department (2.2%) by Barry  Regarding uterine rupture, our frequency (7%) is significantly lower than that of Lankoande M in Burkina Faso (24.6%) [11], and much higher than that of Mbongo JF in Brazzaville (5.1%) [10]. Our frequency could be explained by multiparity, obstructed labor in these parturient, and the unfavorable socioeconomic status of the patients.

Sociodemographic Characteristics
Bleeding in the third trimester of pregnancy occurs at any age. Pregnant women in the 25 -29 age group were the most affected overall with 28.4%. Our result is comparable to that of Nisar S et al. who found 54.1% for the age group of 20 -30 years [13].
The incidence in relation to age also reveals that the 25 -29 and 30 -34 age groups are age groups at high risk of bleeding in the third trimester with respectively 8.79% and 8.84% of incidence compared to patients who did not experience bleeding (91.21% and 91.16%). These observed differences were statistically significant (P < 0.001).
This result could be explained by the frequent association of these age groups with multiparity, which is also a proven risk factor.
The majority of patients were married (94.5%) in our series. Results identical to those of Lankoande M who found that more than half of the patients were housewives (67.2%) [11]. This high frequency of married women would be explained by socio-cultural and religious reasons in our society that do not allow procreation outside the marital home. Unschooled women paid the highest price for all etiologies with an average of 50.1%. This result could be explained by the level of education of the Guinean population with 57% illiterate, 69% of whom are female, with an enrollment rate of 31% against 55% among boys according to EDS Guinea 2018 [14].
Women with a liberal profession were the most affected (43.6%). Reaching this socio-professional category could be linked to illiteracy and the effect of a Open Journal of Obstetrics and Gynecology low socio-economic level, as Rabarikoto HFF et al. in Madagascar [15]. Retroplacental hematoma and placenta previa more frequently concerned pauciparae with respectively 28.7% and 35.1%; and as for uterine rupture, multiparous women were the most represented (35.7%). It follows from the study that the incidence of bleeding in the third trimester increases with parity. The most exposed patients were multiparous and grand multiparous with respectively 10.9% and 13.2% for those who presented bleeding and 89.1% for those who did not present bleeding. These observed differences were statistically significant (P < 0.001). Multiparity is a factor of procreation ingrained in our societies with low levels of education and information and the difficulty of accessing family planning care. This predominance of uterine rupture in multiparas has been reported by various authors [16] [17].

Clinical Aspect
Regarding the mode of admission, the majority of patients were evacuated (66.3%). Our result is significantly lower than that of Lankoande M in Burkina Faso who reported 91.8% of evacuees [11].
The management of patients with peripheral third trimester obstetric hemorrhages often poses problems. Our rate could be explained by the fact that our service is a center of last resort receiving obstetrical evacuations from peripheral maternities in the city of Conakry and certain neighboring prefectures.
In our series, 56.6% of patients bled between 37 and 42 weeks. Results contrary to those of Samal SK et al. reporting 73% occurrence of bleeding in the third trimester between 34 -36 weeks and 6 days [18]. Our result could be explained by the fact that most of these hemorrhages were triggered by uterine contractions at the end of pregnancy.
Regarding the number of prenatal consultations, the follow-up was not of good quality. The required number of prenatal consultations according to the WHO was only reached in a proportion of 21.5% for all the pathologies in question. A well-monitored pregnancy could reduce the risk of bleeding during the third trimester of pregnancy. It also allows rapid treatment before any dramatic complications, in order to reduce the maternal-fetal death rate and to provide advice on family planning [19].
In our series 11.5% of patients had had previous bleeding. This rate is lower than that of Sépou A et Coll. in Central Africa which reported 20.5% [12]. of cases [17]. Two (2) cases of hysterectomy were performed by Lankoande M after failure of conservative treatment [11]. In the study by Bambara M in Burkina Faso, a haemostat hysterectomy was performed for most cases of uterine rupture (67%) [22].
Our result could be explained by the fact that the caesarean performed in time prevents complications. Furthermore, our caesarean section rate could be explained by the fact that this operation is free and the availability of emergency kits, the introduction of which into our practice had enabled rapid management of cases of hemorrhage in the third trimester before hemodynamic complications do not set in.

Aspect Prognosis
Maternal prognosis: The major morbidity was anemia (34.6%) in our study as described in the literature by various authors [10] [11] [23].
The problem of maternal mortality arises mainly in developing countries. Ignorance, illiteracy and poverty are implicated factors [24].  [11]. Bleeding in the third trimester of pregnancy remains very feticidal. This very high mortality is mainly linked to the delay in treatment but also to the etiology.
We recorded 52.4% of newborns with a birth weight of <2500 g for all etiologies. This could be explained on the one hand by the abundance of hemorrhage which may require urgent uterine evacuation whatever the gestational age and on the other hand by the action of arterial hypertension and anemia on fetal development means that third trimester hemorrhages are pathologies that cause a high rate of prematurity and intrauterine growth retardation.
Limits: Sonogo SD in its study in Mali had reported the same difficulties with the absence of an ultrasound scanner in the delivery room as well as the problem of providing emergency products and blood which were a serious handicap for the management rapid and adequate charging [25]. As for Nayama M in Niger, the technical platform leaves something to be desired with insufficient availability of blood products [26].

Conclusion
Bleeding in the third trimester of pregnancy remains one of the main emergencies in obstetric practice with 7.3% of deliveries in the department. It is a serious and dreadful accident, especially since it is unpredictable and represents a major cause of maternal mortality and morbidity in the absence of rapid and adequate treatment. Among the different causes of these hemorrhages, retroplacental hematoma remains the most feticidal cause. They therefore require precise and rapid diagnosis, early, multidisciplinary management and close collaboration among obstetricians, neonatologists, anesthetist-resuscitator and biologists, to improve the maternal-fetal prognosis. Reducing maternal mortality would go through the availability of blood products, the central barometer for care in our context.

Conflicts of Interest
The authors declare that they have no conflict of interest.