Uterine atony, retained placenta, and blood clotting issues are the main causes of postpartum hemorrhage (PPH), the leading cause of maternal mortality worldwide. A study conducted questionnaires on PPH prevalence, causes, and treatments among Egyptian university students. Most participants knew someone who experienced PPH. The most common reported causes were anemia, uterine atony, and clotting problems. Blood transfusion was the most common reported treatment. The study concluded there is low PPH awareness and an increasing trend, calling for better education and healthcare to manage risks and reduce mortality.

1. Postpartum Hemorrhage: Causes and First-Line Therapy in Australia
The Number 1 Cause of Maternal Mortality
Norseen H. Lotfy
Department Of Pharmacy, Galala University
LAN023: Academic Writing
Dr. Maram El-Saadany
Jan 2, 2023

2. Outline
I. Etiology 3
A. Causes of PPH 4
1. Uterine atony 4
2. Uterine trauma 4
3. Retained placenta 4
4. Blood clotting condition (thrombin) 4
II. First-line therapy 5
A. Physiological Approaches 5
1. Blood transfusion 5
2. Surgical interference 5
B. Pharmacological Therapy 5
1. Oxytocin 5
2. Methylergonovine 5
3. Misoprostol 5
C. Prevention strategies 5
III. Methodology 6
A. Description of the study 6
B. Participants 6
C. Sample questionnaire 7
D. Data grid 12
E. Results and Data Interpretation 14
IV. Conclusion 19
V. References 20

3. Abstract
Postpartum hemorrhage (PPH) is a most abundant cause of global maternal mortality and
morbidity. The trend of incidents was noted by the international PPH collaboration to be
increasing by time. Most of these deaths can be avoided through the use of uterotonics or
prophylactic therapies that is taken in the third trimester of pregnancy along with an appropriate
management. In addition to providing a good health care for women during pregnancy for
prevention and treatment of postpartum hemorrhage (PPH), which is an important step of the
Millennium Development targets. We review available data sources on the incidence of PPH
over time in Egypt, where information is available, the incidence of PPH is recognized by causes
that participants get introduced to. A quantitative questionnaire was conducted to examine the
prevalence, causes and treatment of case. Results showed an increasing trend in PPH, using
heterogeneous definitions in Egypt, low awareness of PPH was noted. Conclusions were around
enhancing the awareness of case among young women and their families, encourage women to
look and fix early symptoms and get checked if needed and provide health care for themselves
throughout their lives, especially throughout their pregnancy.

4. Introduction
Do you know what is the reason for the death of one quarter of all women giving birth
around the world? Postpartum Hemorrhage (PPH) is considered to be leading cause of maternal
mortality, holding an account for 25–43% of maternal deaths. PPH occurs approximately
8.7 million times and causes 44,000 to 86,000 deaths per year. It occurs commonly when there is
a blood loss after birth with a more susceptibility with a c-section delivery.
The implications and managements of some second handed fatal causes of maternal death
such as Puerperal sepsis (childbed fever) are robustly researched, despite this, a poor attention is
given to the primary cause and management of Postpartum hemorrhage have yet to be actively
explored. The target of this guideline is to give a proper foundation for the updated reasons of
PPH and the programmed management needed to provide an ensured sustainable application of
effective therapy for reducing the worldwide burden of PPH. This study shows the most possible
reasons of PPH and the most worldwide used first-line therapy. What are the causes and the first-
line therapy of postpartum hemorrhage?
Etiology
Postpartum Hemorrhage (PPH) occurs commonly when there is loss of blood of 500 ml
to 1000 ml within the first 24 hours after birth followed by the death of the mother, the ratio of
incidence is higher with a c-section. PPH may occur without risk factors for hemorrhage, but not
commonly, PPH usually happens when there’s an error during placenta delivery, mostly when
the operation is rushed, but there are other factors that affect the hemorrhage even with the
proper placenta delivery such as uterine atony (soft weak uterus causing lack of contraction) or

5. the mother’s anemia, most commonly the uterine atony, followed by retained tissue, genital tract
tear, coagulation problem, and uterine rupture.
Causes of PPH
Top 4 causes are known as the four Ts (tone, trauma, tissue and thrombin)
Uterine atony: considered to be the primary cause of PPH, holds account for 70% to 80% of all
hemorrhage. Uterine atony refers to the weakness of the uterus after delivery, when the muscle
can't contract enough to clamp the placental blood vessel shunt and this leads to steady blood
hemorrhage.
Uterine trauma: Bleeding due to a damage to your vagina, cervix, uterus or perineum (area
between your genitals and anus), also due to laceration (a deep cut or tear in skin or flesh),
hematoma (clotted blood that forms in an organ or tissue). The risk of the trauma can be
increased when using a vacuum extraction or forceps (smooth metal instruments used to deliver
the baby) during delivery.
Retained placental tissue: This happens when the placenta does not separate from the uterine
wall (invasive placenta), usually from a hormonal cause that and it usually affects the ability of
contraction.
Blood clotting condition (thrombin): This is when there is reduced body clotting ability due to
coagulation problem like eclampsia (disorder that can make even a tiny bleed uncontrollable)

6. First-line therapy
Physiological Approaches
Blood transfusion: Fastest and most effective physiological method to prevent further
complications like coma or death, often used along with pharmacological treatments.
Surgical interference: Often used with retained placenta, along with blood transfusion and
pharmacological anesthetics and antibiotics.
Pharmacological Therapy (Uterotonics)
Oxytocin (10UI, IM/IV): Oxytocin is considered to be the first-line agent. It’s a hormone
naturally produced by the posterior pituitary works rapidly to cause uterine contraction with no
contraindications and minimal side effects. It’s often used when hemorrhage is due uterine atony.
Choosing second-line agents is based on problems the patient may have with the treatment if it
has contraindications. Recommended drug for prevention of PPH in caesarean section.
Methylergonovine (0.2mg, IM): where oxytocin is not available, second-line agents is used.
Methylergonovine is a semi-synthetic ergot alkaloid. It works rapidly for sustained uterine
contraction. It is contraindicated in patients with hypertension.
Misoprostol (600mcg Orally): Prostaglandin E1 analog. Used for its delayed onset than the
above medications. Oxytocin is more effective than misoprostol for prevention and treatment of
uterine atony and has fewer adverse effects
Prevention Strategies
Active management of the third stage of labor (AMTSL) is the most effective prevention method
for all women. It also decreases the risk of PPH. AMTSL takes place in last stage of labor
(placenta delivery). The use of uterotonics is recommended for all births. If third-stage labor

7. takes more than 30mintues, IV/IM oxytocin 10IU should be used to manage retained placenta
and if the placenta is retained and bleeding, a manual removal should be applied along with a use
of prophylactic antibiotics.
Methodology
Description of The Study
The data gathered for this study was a quantitative questionnaire investigating prevalence, most
common causes and treatment of PPH, it was conducted among university students and their
families in Egypt
Questions were:
1-Age 17 to 18 / 19 to 20 / 21 to 22/ 22 or more
2-Gender Male / Female
3-Have you ever heard of a woman who died while giving birth? Yes / No
4-Do you a woman who had hemorrhage after giving birth? Yes / No
5-Did they have signs during pregnancy such as anemia? Yes / No
6-Did they have general muscle weakness? Yes / No
7-Did they have clotting problems such as prolonged scar healing? Yes / No
8-Did they have an accident such as a car crash before giving birth? Yes / No
9-What was the treatment needed for this case? Blood transfusion Injections Surgical interference
10-Do you think there's enough awareness of postpartum hemorrhage in your city? Yes / No
Participants
A total number of 63, 10 Males and 53 females, age group: 17 to 22 of private university
students

8. Data Grid
Table 1.
Grid of 7 questionnaire answers
Resp.
3
Resp.
4 Resp.
5
Resp.
6
Resp.
7
Resp.
8
Resp.
9
Resp.
10
Yes Yes No No No Yes
Blood transfusion, Surgical
interference No
Yes Yes Yes Yes Yes Yes Injections Yes
Yes No Yes Yes Yes No
Blood transfusion, Injections,
Surgical interference No
Yes Yes Yes Yes Yes Yes Injections No
Yes No No No No No No
Yes Yes Yes No Yes No Blood transfusion Yes
Yes Yes No Yes Yes No
Blood transfusion, Surgical
interference No
Yes Yes Yes No No No Blood transfusion No
No Yes No Yes Yes No Injections No
No No Yes Yes No No Blood transfusion No
Yes No Yes Yes Yes No
Blood transfusion, Injections,
Surgical interference No
No No No No No No Yes
Yes Yes Yes Yes Yes No
Blood transfusion, Injections,
Surgical interference No
Yes Yes Yes Yes No No Blood transfusion, Injections No
Yes No Yes Yes Yes No Blood transfusion Yes
Yes Yes Yes Yes Yes No
Blood transfusion, Surgical
interference No
Yes Yes Yes No No Yes Surgical interference Yes
Yes Yes Yes Yes Yes No
Blood transfusion, Surgical
interference No
Yes No No Yes Yes No
Blood transfusion, Injections,
Surgical interference No
Yes No Yes No Yes No Blood transfusion Yes
No Yes No Yes No Yes Injections No
Yes No Yes No No No Blood transfusion, Injections No
Yes No Yes Yes Yes No Blood transfusion No
Yes Yes Yes Yes Yes Yes
Blood transfusion, Injections,
Surgical interference Yes
Yes No Yes Yes Yes No
Blood transfusion, Surgical
interference No
Yes No Yes Yes Yes No Blood transfusion No
Yes No Yes Yes No No Blood transfusion Yes
Yes Yes No Yes No No
Blood transfusion, Surgical
interference No
No No Yes Yes No Yes Injections Yes
Yes No No No No No
Blood transfusion, Injections,
Surgical interference No
Yes Yes Yes Yes No Yes Surgical interference No
Yes No Yes Yes Yes No Injections No

9. Yes Yes Yes Yes Yes Yes Blood transfusion Yes
No No No No No No Yes
Yes Yes Yes Yes No No Blood transfusion Yes
Yes No Yes Yes Yes Yes
Blood transfusion, Injections,
Surgical interference No
Yes No No No No No Surgical interference Yes
Yes Yes No Yes Yes Yes Blood transfusion No
Yes Yes No Yes Yes Yes Surgical interference No
Yes No Yes Yes Yes No Blood transfusion No
Yes Yes Yes Yes No No Blood transfusion No
Yes Yes Yes Yes Yes No Blood transfusion, Injections No
Yes No No No No No Blood transfusion No
Yes No Yes Yes Yes No Blood transfusion No
Yes No No No No No Blood transfusion No
Yes No Yes Yes Yes No Blood transfusion No
Yes No No No No No Blood transfusion Yes
Yes Yes No No Yes No
Blood transfusion, Surgical
interference No
Yes Yes Yes Yes Yes Yes
Blood transfusion, Injections,
Surgical interference No
Yes Yes Yes Yes Yes Yes
Blood transfusion, Injections,
Surgical interference No
Yes Yes Yes No No Yes
Blood transfusion, Surgical
interference No
No Yes No No No No
Blood transfusion, Injections,
Surgical interference Yes
Yes No Yes Yes Yes Surgical interference Yes
Yes Yes Yes Yes Yes Yes
Blood transfusion, Surgical
interference No
Yes Yes No Yes No No Blood transfusion Yes
Yes Yes Yes Yes Yes No
Blood transfusion, Injections,
Surgical interference No
Yes Yes Yes Yes No No Injections Yes
Yes Yes No No No Yes
Blood transfusion, Injections,
Surgical interference No
Yes Yes Yes Yes Yes No
Blood transfusion, Injections,
Surgical interference No
Yes Yes Yes No No No Surgical interference Yes
Yes No No No No No Blood transfusion No
Yes Yes Yes Yes Yes No Injections No
No No No No No No Surgical interference Yes

10. Results and Data Interpretation
Figure 1.
Respond 1 on: Gender
Most of answers were by females. Which indicates more relative results of the case.
Figure 2.
Respond 2 on: Age
Most age group was from 19 to 20 years old, specifically 2nd
and 3rd
level of college in Galala
university

11. Figure 3.
Respond 3 on: Have you ever heard of a woman who died while giving birth
55 of 63 participants happen to be familiar with PPH which indicates the high prevalence of PPH
in Egypt.
Figure 4.
Respond 4 on: Do you a woman who had hemorrhage after giving birth

12. More than half of participants know someone had PPH, as participants do not know about the
case itself, they know the incidence of it, this still indicate the high prevalence of case and
provide a faster lifestyle management after awareness.
Figure 5.
Respond 5 on: Did they have signs during pregnancy such as anemia
A high count of 41 of participants refer to the cause of the hemorrhage of the PPH cases they
know was anemia.
Figure 6.
Respond 6 on: Did they have general muscle weakness

13. Highest count in questionnaire answers about causes of PPH was 42 of participants that refer to
the cause of the hemorrhage of the PPH cases they know was general muscle weakness, which
indicates that Uterine atony (lack of uterine muscle contractions) is still the most common reason
for postpartum hemorrhage.
Figure 7.
Respond 7 on: Did they have clotting problems such as prolonged scar healing
This data indicates a nearly equal answers of clotting problems as a common cause of
postpartum hemorrhage. Encourage clinicians to put a more focused criteria on more effective
reasons other than clotting problems; moreover, manage the case faster and reduce mortality.
Figure 8.
Respond 8 on: Did they have an accident such as a car crash before giving birth

14. Lowest count in responds about causes of PPH of only 28%, indicates the very low frequency.
Figure 9.
Respond 9 on: What was the treatment needed for this case
Highest responses of best working treatment for the cases were in the favor of blood transfusion.
Figure 10.

15. Respond 10 on: Do you think there's enough awareness of postpartum hemorrhage in
your city
72% of participants agree on the fact that there’s no enough awareness of the case itself,
although many have confirmed knowing the incidence of bleeding, most of them didn’t know
about PPH as a case with treatment, codes and management strategies. Which states the
importance of awareness for prevention of upcoming cases.
Conclusion
The previous chapters emphasize the increasing prevalence of PPH and will have to address the
requirements of fast proper treatments and challenging complications could worsen the situation,
if there were no preparations and cautions during pregnancy or delivery. Definitions of PPH
should be unified; where Oxytocin and other uterotonics were found to be the best solutions for
this case, further research is required to investigate practicing of the management and coding of
data. Doctors should be more vigilant given the possibility that the frequency and severity of
PPH has in fact increased. This applies particularly to the small hospitals with relatively few
deliveries where management protocols may not be defined adequately and drugs or equipment
may not be on hand to deal with unexpected severe PPH. A high prevalence of case was noticed

16. in Egypt according to participants answers, uterine atony is still the most common cause for
postpartum hemorrhage. Results have been showing an increasing trend in PPH. A low level of
PPH awareness has been noted. There is a growing demand for effective education and
awareness enhancement within the context of local and global imperatives of case, also to
encourage women to look for early symptoms and get checked if needed and provide health care
for themselves throughout their lives, especially throughout their pregnancy.

17. References
Evensen, A., Anderson, J. M., & Fontaine, P. (2017). Postpartum Hemorrhage:
Prevention and Treatment. American family physician, 95(7), 442–449.
World Health Organization. WHO recommendations for the prevention and treatment of
postpartum hemorrhage. Geneva: WHO; 2012. Available from:
https://apps.who.int/iris/bitstream/handle/10665/75411/9789241548502_eng.pdf
Wormer KC, Jamil RT, Bryant SB. Acute Postpartum Hemorrhage. [Updated 2022 May 8]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK499988/