POSTPARTUM HAEMORRHAGE (PPH) is one of the top causes of maternal death in Malaysia, but a condition that's not commonly discussed.
PPH is a severe obstetric emergency marked by excessive bleeding after childbirth and it remains one of the leading causes of maternal death globally, especially in low- and middle-income countries.
PPH, defined as blood loss exceeding 500ml after vaginal delivery or 1000ml after a C-section, can occur suddenly and unpredictably, often leading to severe complications or death.
Fetomaternal medicine consultant Professor Dr Jamiyah Hassan says the "rule of 30" is crucial in assessing and responding to PPH effectively.
"If we don't address blood loss within 30 minutes, the woman's condition will deteriorate rapidly, highlighting the critical need for swift and vigilant acute management," she explains.
Consultant obstetrician and gynaecologist Datuk Dr Harlina Halizah Siraj agrees that women experiencing PPH are at high risk of death within a few hours if not given proper treatment.
Although health technology has vastly improved in Malaysia, PPH is still the number one threat in childbirth, she adds.
"PPH remains a critical concern, particularly in low- and middle-income countries. Mothers, especially in these regions, are metaphorically sitting on a time bomb during pregnancy."
The World Health Organisation has set a target to reduce maternal mortality, aiming for less than 70 deaths per 100,000 live births by 2030, but we still have a long way to go in achieving this, she explains.
In Malaysia, the maternal mortality rate has improved significantly since the early 20th century, but recent challenges, including the Covid-19 pandemic, have hindered further progress. Dr Harlina says the pandemic led to a rise in the number of cases.
According to the Department of Statistics Malaysia (DOSM) the maternal mortality rate in 2022 was 26 per 100,000 live births, with 110 maternal deaths recorded.
Dr Harlina says PPH also continues to be a significant threat to mothers worldwide with one in six women affected.
PPH results from any one or a combination of four processes (4T) which are tone, tissue, trauma and thrombin (coagulation).
Uterine atony is the most prevalent cause of PPH, accounting for 70 to 80 per cent of primary cases.
"This condition occurs when the uterus fails to contract effectively after childbirth, leading to abnormal bleeding," she says.
Risk factors include increased maternal blood volume, multiple pregnancies, pre-eclampsia, placenta previa, induction or augmentation of labour, prolonged second stage of labour, and maternal anaemia.
Dr Harlina said bleeding may also result from retained placental tissue or blood clots that hinder proper uterine contraction.
Such retained products can lead to continuous bleeding if not addressed properly.
Meanwhile, trauma to the genital tract, whether spontaneous or due to medical interventions like an episiotomy, can also lead to PPH.
This includes lacerations in the cervix, vagina, perineum, or complications from caesarean sections.
Coagulation disorders, whether congenital or acquired, can cause abnormal bleeding too.
"Conditions that diminish clotting factors or increase fibrinolytic activity are significant contributors to PPH."
Thus, effective management of blood loss is crucial as is continuous vigilance of mums affected by PPH.
"One maternal death is one too many. We must keep this in mind and strive to prevent PPH in all deliveries."
The health of the mother also plays a role. Dr Jamiyah says over half a million Malaysians are grappling with all four major non-communicable diseases (NCDs) — diabetes, hypertension, high cholesterol, and obesity.
Women aiming for pregnancy should seek preconception care to address these issues effectively, she says.
"A modest weight reduction of even five kilograms before conception can have substantial benefits."
In fact, women with all the above mentioned NCDs should consider delaying pregnancy to allow doctors to optimise their health, including managing diabetes, for a safer pregnancy and delivery.