Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241119EnglishN2019May21HealthcareAn Overview on the Cause and Management of Postpartum Hemorrhage English0106Jaanam Altaf KhanEnglish Shu ZhuEnglish Xiuli WangEnglishPostpartum hemorrhage is a potentially lethal, hazardous whilst preventable condition making it the significant cause of maternal mortality. It is defined as loss of blood greater than 500ml in a normal delivery and more than 1000ml in C-section in the first 24 hours. One third and one fourth of the death that occurs is due to postpartum hemorrhage, Among the various causes of Postpartum hemorrhage (PPH), uterine atony is the most common cause involved in 80% of the cases. Hypovolemic shock, DIC, hepatorenal syndrome and acute distress syndrome are some of the complications in women who encounter massive postpartum hemorrhage. Death occurs in women in whom timely adequate emergency measures were not taken. Life can be saved when immediate measures are taken. When uterine atony is observed administration of utero tonic drugs such as oxytocin and prostaglandin, uterine massage, uterine compression technique and intrauterine balloon tamponade is used. When hemostasis is not achieved by conservative method then, TAE or surgical management including (vessel ligation, bilateral ligation of the uterine or internal iliac arteries), uterine compression suture, and hysterectomy is implemented in refractive cases without any further delay. EnglishPostpartum hemorrhage, Uterine atony, Obstetric hemorrhage, Hysterectomy Introduction Postpartum hemorrhage (PPH) is of utmost concern because of the mortality it causes in pregnant women and as an estimation every year, the rate of death recorded is around five thousand of which 1/4th of the women population die due to PPH[1]. It is believed that in both developed and underdeveloped countries it is one of the most common causes of maternal mortality affecting about 1-5 % of deliveries by this[2]. A blood loss greater than 500ml in 24 hours following a vaginal delivery or more than 1000ml after a Caesarean section is considered as PPH. On the basis of classification, primary and secondary are the two classification of it.PPH that occurs in the first 24 hours following delivery is known as the primary PPH and the secondary PPH is considered when it appears from more than one day up to 12th week postpartum[3]. A blood transfusion of 4 units of Blood is required, when there is blood loss of more than 1500ml it can be regarded as primary “massive” postpartum hemorrhage resulting in the down regulation of hemoglobin concentration to more than 4g/dB postpartum[4]. Formation of capillary hemorrhage which leads to expulsion and shrinking of placenta due to the strong uterine contraction enables the restriction of hemorrhage due to the activation of the coagulation system and uterine contractions[5]. Among the causes of PPH, Uterine atony by far remains the most common etiological factor resulting in PPH. This is generally regarded as the primary cause of postpartum hemorrhage, involving the other potential causes too like laceration, retained tissue or placenta and coagulation defects. Secondary postpartum hemorrhage is due to congenital or Inherited defect in the coagulation, endometritis and the failure of the placenta to come back to its normal position after birth. The study involving the risk factor for PPH includes hemorrhage due to prolonged labor particularly the third stage of labor (where the delivery of placenta takes more than 30mins, after the delivery of baby), prior PPH (due to placenta accrete, Increta or percreta), preeclampsia, multiparty, twin gestation, arrest of labor, deliveries using forceps or vacuum-assisted deliveries, laceration of soft tissues and polyhydraminos[6]. The amount of blood loss can roughly be associated by the visual Inspection or by directly weighing the amount of blood in the suction canister, this report will further demonstrate the conservative and surgical technique used in the management of PPH in an obstetric field to overcome the potentially lethal cause of mortality in these women.  The etiology of postpartum hemorrhage causing potentially lethal mortality 1)Uterine Atony (Over-distended uterus, muscle floppiness)- Uterine atony is most common etiological factor in aiding postpartum hemorrhage, In the third stage of labor where the delivery of placenta takes place, the prevention of uterine atony has led to significant decline in the rate of postpartum hemorrhage[7]. 2) Retained Placenta Products (accrete, increta, percreta)- The second most common cause of PPH after uterine atony is said to be Retained placenta, It has risk factors including maternal age more than 35 years, a prior dilatation and curettage, placenta weighing less than 500g and multiparty making it a major Indicator in the requirement of blood transfusion protocol in the stage of labor where the delivery of placenta takes place, after the delivery of the baby[8]. 3) Multiple gestation – Multiple Gestation has led to the two fold increase in the rate of mortality as compared to primipara. 4)Laceration of soft tissues (perineum, vagina, cervix due to fetal malpresentation or forceps and vacuum-assisted deliveries) – Trans catheter arterial embolization (TAE) is an effective method in patients, who bleed due to laceration in genital tract or inpatient with forceps-assisted deliveries ,TAE helps in evacuation of Para vaginal hematoma in these patient [9]. 5)Coagulation defect (Acquired Congenital defect – hemophilia and Von Willebrand disease, Inherited Congenital defect – DIC, low fibrinogen level, and hyperfibrinolysis)- The early indicator in the severity of bleeding in postpartum hemorrhage is assumed to be the low levels of fibrinogen, fibrinogen value less than 2g/L is 100% for positive predictive value[10]. 6) Uterine rupture – A woman’s chance of uterine rupture increases among those with prior Cesarean section and also in women whom labor is induced with prostaglandins confers the greatest risk of uterine rupture [11]. 7) Prolonged third stage labor – The stage of labor where the delivery of placenta takes more than 30minutes the risk of having postpartum hemorrhage is Increased to Six folds than before 30minutes[12]. Diagnosis – Diagnosis can be achieved by following ways depending upon the type of postpartum hemorrhage, If it’s a primary postpartum hemorrhage, the patient or the caregiver may notice excessive bleeding, which will prompt them to use more than one pads in 5 minutes due to increased saturation of the pad, patient may also become light-headed, nauseated, clammy  or dyspneic due to the excessive amount of blood loss. Excessive pain and hematoma occur at the site when there is bleeding in the soft tissues. Inpatient with secondary postpartum hemorrhage, the patient will note abrupt escalation of vaginal bleeding, In cases where the placenta is retained or the product of conception is retained, bloody discharge may be characterized by a foul odor and patient may experience severe cramping sensation and low abdominal pain. The patient also have similar symptoms of anemia.  Clinical Manifestation in a patient with postpartum hemorrhage  Prolonged and excessive bleeding due to hemorrhage can cause hemodynamic instability resulting in volume depletion thus known as hypovolemic Shock. Hypovolemia can cause circulatory collapse, end-organ damage and finally death due to depletion in a large amount of blood volume as a compensatory mechanism of the body, patients have increased heart rate and Increased breath rate (Reflex Tachycardia and Tachypnea)[13]. Based on the classification of postpartum hemorrhage in accordance with the class, It is divided into four classes, when the amount of blood loss is 1000ml with loss in blood volume of 15% it is regarded as Class 1, the clinical symptoms are characterized by  palpitations, feeling of dizziness  and a certain decrease in the amount of blood pressure. When the blood loss is estimated to be around 1500ml that is (20-25%) loss it is Class 2, symptoms of increased heart rate, Increased breath rate, excessive sweating, weakness, and narrowed pulse pressure is observed, for the Class 3 it is the volume of blood loss of 2000ml (30-35%) it is manifested by significant increased in heart rate, increased in breath rate, agitation, pallor and cool extremities, the last stage which is class 4 it is the volume loss of 2500ml or more (40% or more) It is associated with shock, air hunger and decreased urine output. According to the severity of shock, a Volume loss of less than 20% can result in symptoms of excessive sweating, increased capillary refill, cool extremities and anxiety which can be regarded as Mild Shock.  However, when there is volume loss of approximately 20-40% symptoms of Tachycardia, tachypnea, postural hypotension and oliguria can be seen which is regarded as the moderate degree of shock. In severe degree of Shock, there is blood loss greater than 40% resulting in agitation, hypo tension and hemodynamic Instability. Conservative and surgical approach in the management of postpartum hemorrhage in a patient with postpartum hemorrhage. The treatment option for the early management of primary postpartum hemorrhage is to maintain the fluid loss by replacing the amount of both blood loss and fluid loss, also to control the site and cause of bleeding and look for the coagulopathy if present. It should be ensured that the airway is clear without any obstruction and there is proper ventilation taking place. If the respiration is compromised and there is an altered level of consciousness then Intubation is considered with an adequate amount of oxygen supplementation. IV access should be obtained with the help of large bore cannula and also a urinary catheter should be placed and to monitor the urine output (greater than 30ml/hour). Postpartum hemorrhage has been the leading cause of maternal death. A variety of approaches have been used in dealing with the most lethal cause of maternal mortality during the postpartum period which Includes the Active management of the third stage of labor (AMTSL) which has three components 1) use of utero tonic agents like misoprostol(prostaglandins PGE1), methergine, carbetocin(oxytocin) immediately after birth of the baby 2) Control cord traction for the delivery of placenta and early clamping of umbilical cord 3) Continuous uterine massage[14]. Uterine tamponade such as Balloon tamponade, Bi manual compression and tight intrauterine packing under anesthesia surgical approach has also been used in achieving hemostasis, surgical technique which include, uterine devascularization procedure which are as follows B-Lynch Compression and suture, Ligation of uterine artery, Ligation of anterior division of Internal Iliac artery, arterial embolization, If these procedures are not adequate enough to achieve arrest of bleeding then Hysterectomy is performed as an ultimate resort[15]. Hysterectomy has two types the total and the subtotal which is different for each individual depending on the situation. Utero tonic Agents – If  Uterine atony is suspected then utero tonic agents should be used as soon as possible Oxytocin – It is the first line choice for the prevention of PPH because of the lesser side effect as compared to the drugs with similar efficacy, Oxytocin can be administered in two ways Intravenously and Intramuscularly, the prior has an instant effect at a concentration of 10IU IVat 30 minutes which plays a significant role in reducing the risk of PPH, however the latter takes about 3-7 minute for the drug to show its effect and it persists for 30-60minutes. Intravenous administration has been associated with adverse effect including increased heart rate, hypo-tension, and CVS side effects[16]. Oxytocin 10IU, IV/IM is recommended, continuous infusion of 10-40 units in 1L of crystalloid solution. When oxytocin is not available other drugs like Methergine 0.2mg by IV/IM as the first line and PO as the second line is used in every 2-4 hours, however, caution must be taken in patients with the hypertensive disorder as it is contraindicated in those patient[17]. To prevent the degradation and ineffectiveness of oxytocin drug, World Health Organization recommend that the drug should be stored between 2-8 C° [18]. Misoprostol –  Prostaglandin E1 is a potent vasodilator, Misoprostol is an E1 derivative of synthetic prostaglandin, It is a low-cost drug, which can be stored easily, 600ug PO of misoprostol(PGE1) proved as an effective drug in the prevention of PPH but there is an adverse effect of this drug including Fever, tachycardia and face flushing[19]. Misoprostol is used as an alternative when other parenteral prostaglandins are either contraindicated or unavailable for the treatment of Postpartum hemorrhage[20]. In countries with low socioeconomic status, misoprostol is the first drug of choice because of the reasonable cost and easy availability, it can be used both orally, sublingually and rectally as a prophylactic measure in a woman who prefers to deliver at home[21]. As by the International Federation of Obstetric and Gynecology (FIGO) guidelines when 40 IU IV oxytocin is unavailable, administration of single dose of 800μg of misoprostol is Indicated for the treatment of PPH[22]. Misoprostol is also used prophylactically in the third stage of labor, it can be administered by different routes like orally, sublingually by vaginal route and also rectally[23]. Carbetocin-  Where Oxytocin and other utero tonic drugs including ergometrine, misoprostol degrades in response to heat or light, the efficacy of the drug diminishes making it less effective in the use of the management of PPH [24]. On contrary Carbetocin has met the requirement of the International Council for Harmonization (ICH) to be used in hot and humid climates (Zone IVA and B) for the period of two years at 30 °C and half a year at 40 °C[25]. Inpatient with elective C-section Carbetocin 100ug of IV, bolus should be preferred over continuous oxytocin infusion to prevent PPH[26]. The use of 100ug IM of carbetocin in women delivered vaginally with a prior risk factor of PPH showed the decrease in the need of a uterine massage to prevent PPH as compared to continuous oxytocin infusion[27]. Tranexamic acid – when bleeding still persists then Tranexamic acid is given, It is an anti-fibrinolytic agent which works by activating the plasminogen to plasma to achieve hemostasis [28]. It is known to reduce maternal mortality and the requirement for surgery with the use of 1g of Intravenous Tranexamic acid (TA) which is given within 3 hours following a PPH [29]. Its ability to reduce bleeding and decrease the need for transfusion has been well known in different elective surgeries[30]. TA has also helped in reducing hemorrhage in diseases where there is heavy bleeding (menorrhagia), hysterectomy and myomectomy. It should be avoided in renal failure patients because it is excreted through urine; it has an adverse effect including feeling nauseated along with dizziness and hypo tension. When hemostasis is not achieved after the use of utero tonic agent, other technologies such as uterine artery ligation, hypo gastric artery ligation, B-Lynch sutures or Balloon Tamponade should be considered. Balloon Tamponade – If bleeding still persists after the use of utero tonic agent then consider balloon tamponade, the success rate in achieving hemostasis by using balloon tamponade has increased from 71 to 87% and the use of it has been reported for the last 20 years in the management of a patient with obstetric hemorrhage. In this procedure the uterine cavity is filled with pressure to control bleeding, the balloon is inserted in the uterine cavity, it is made up of silicone or rubber, It is inflated with normal saline[31]. There is various kind of balloon depending on the cost which includes the Sengstaken – Blakemore tube, Foley catheter, Condom catheter, the Bakri balloon and the Rusch Balloon[32]. These catheters can be inserted in the Delivery room or the operating room, however, there are cases where the failure of Balloon Tamponade has taken place[33]. Uterus preserving Surgery (UPS)-  When conservative therapy fails before performing Hysterectomy,  ligation technique is used to decrease the blood flow to the uterus, to achieve hemostasis and to prevent the ongoing life-threatening condition. It involves ligation of pelvic arteries for example bilateral hypo gastric artery ligation, Uterine artery ligation or application of B lynch Uterine compression sutures, Tsirulnikov triple ligation, and Hysterography to achieve hemostasis[34]. 90% of the blood supply to the uterus comes from the bilateral uterine artery, ligation of this artery can prevent hemorrhage , If this step is unsuccessful then the next step is the Ligation of the ovarian artery, which arises from abdominal aorta and form an anastomosis called utero-ovarian anastomosis, a suture is placed in mesovarium, however if this fails too, Internal iliac artery ligation is done which can cause reduction in pulse pressure by 85%. It needs a professional to do this to avoid unwanted complications involving the injury to vessel and ureter [35]. B- lynch compression suture involves the procedure in which the opening is made in the transverse lower segment of the uterus also known as transverse hysterectomy or involves the application of bilateral uterine brace sutures to stop the bleeding[36]. Uterine compression sutures work as a mechanical compressor of the vascular sinuses of the uterus without blocking the uterine vessels and uterine cavity. Introduction of compression sutures by B-Lynch has made a significant decline in the rate of hysterectomy for patients who have severe postpartum Hemorrhage and thus avoiding the rate of blood loss in a patient with peripartum hysterectomy[37]. Trans arterial Embolization- The ability of TAE to preserve uterus and make future fertility possible has made it a widely accepted modality in the treatment of PPH [38]. It has an advantage of being quick and being performed without the use of general anesthesia. TAE usage is attainable to the patient where TAE is available. The earlier the use of TAE the higher chances of reducing blood loss and easy consequent surgery with a clear field of vision [39]. Hysterectomy-  when hemostasis is difficult to establish despite all the trials including bimanual uterine compression, administration of utero tonic agent, B-Lynch compression sutures, Emergency Hysterectomy is performed to save women from death, placenta accrete is the most common Indication for hysterectomy[40] PPH related hysterectomy was 3.87 times higher in those women who already had a prior C-section than those who didn’t have prior C-section[41]. The psychological trauma of not being able to bear a child , loss of fertility and many short term and long term complications such as injury of other organs, poor wound healing, Infection still makes Hysterectomy as the ultimate and the most common procedure to save life and to achieve arrest of bleeding from severe postpartum hemorrhage [42]. Discussion - Postpartum hemorrhage(PPH) is an obstetric emergency and the leading cause of maternal mortality, potentially life threatening whilst preventable condition when timely actions are taken. It is defined as loss of blood above 500 ml in a normal delivery and greater than 1000ml following a cesarean delivery. Uterine atony is the leading cause of it. Signs and symptoms  varies with the degree of blood loss, circulatory collapse may occur in cases, where there is massive hemorrhage followed with tachycardia, tachypnea, postural hypo tension and oliguria. Management of PPH includes, use of utero tonic agents, balloon tamponade, use of ligation technique, uterine compression sutures, If hemostasis is still not achieved despite these techniques, hysterectomy is the last resort for such patients. Conclusion – Postpartum hemorrhage is a life-threatening, hazardous, whilst preventable condition when correct measures and management are taken at the right time. Emergency measures are taken to save the patient's life from this lethal cause of death and to prevent ongoing long-term complications. Although the newer drug requires more studies, experiments, and trials, it gives us an encouragement to use them in everyday practice, In this review the new advancement in the treatment of postpartum hemorrhage have been enlightened based on the research outcomes and also the effectiveness to achieve homeostasis based on the previous trials and research outcomes have been discussed. More scientific trials and experiments are necessary to confirm the efficacy and effectiveness of these newer drugs before its application on patients. Acknowledgments This work was supported by the Scientific Research Project of Jiangsu Provincial Health Commission (H2018017), the second phase of Maternal and Child Health Key Talent Project of Jiangsu Province (FRC201709), the first phase of Maternal and Child Health Project of Jiangsu Province (F201619), the fifth phase of the "333 project" of Jiangsu Province (LGY2016003). Authors acknowledge the immense help received from the scholars whose articles are cited and included in the references of this manuscript. The authors are also grateful to authors/ editors/ publishers of all those articles, journals and book from where the literature for this article has been reviewed and discussed. Declaration of Interests  The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported. Englishhttp://ijcrr.com/abstract.php?article_id=2597http://ijcrr.com/article_html.php?did=2597 Knight M, Callaghan W, Berg C, Alexander S, Bouvier-Colle M-H, Ford J, Joseph K, Lewis G, Liston R, Roberts C: Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth. 2009, 9 (1): 55-10.1186/1471-2393-9-55 2) Weisbrod AB, Sheppard FR, Chernofsky MR, Blankenship CL, Gage F, Wind G, Elster EA, Liston WA: Emergent management of postpartum hemorrhage for the general and acute care surgeon. World J Emerg Surg. 2009, 4: 43-10.1186/1749-7922-4-43. 3) Bibi S, Danish N, Fawad A, Jamil M: An audit of primary post partum haemorrhage. J Ayub Med Coll Abbottabad. 2007, 19: 102-106 4)  Sheikh L, Zuberi NF, Riaz R, Rizvi JH: Massive primary postpartum haemorrhage: setting up standards of care. J-Pakistan Med Assoc. 2006, 56 (1): 26- 5)   Rath WH. Postpartum hemorrhage- update on problems of definitions and diagnosis. Acta Obstet Gynecol Scand. 2011;90:421–28.  6) Royal College of Obstetrician and Gynaecologists. Postpartum Hemorrhage: Prevention and Management. 2011 7) Elbourne DR, Prendiville WJ, Carroli G, Wood J, McDonald S., Prophylactic use of oxytocin in the third stage of labour. Cochrane Database Syst Rev. 2001;(4):CD001808.  8) Owolabi AT, Dare FO, Fasubaa OB. Risk factors for retained placenta in South-Western Nijeria Singapore. Med J 2008; 49(7): 532-7. 9) Yamashita Y, Takahashi M, Ito M, Okamura H (1991) Transcatheter arterial embolization in the management of postpartum hemorrhage due to genital tract injury. Obstet Gynecol 77:160–163. 10)  Ayaka Nakashima, Kazuhide Ogita, Masaya Chita and Takeshi Yokoi, Serum fibrinogen levels could be an index of successful use of balloon tamponade in postpartum hemorrhage, Journal of Perinatal Medicine, 10.1515/jpm-2016-0238, 46, 1, (53-57), (2018). 11) Caughey AB, Shipp TD, Repke JT, Zelop CM, Cohen A, Lieberman E. Rate of uterine rupture during a trial of labor in women with one or two prior cesarean deliveries. Am J Obstet Gynecol 1999;181:872-876. 12) Dombrowski MP, Bottoms SF, Saleh AA, Hurd WW, Romero R. Third stage of labor: analysis of duration and clinical practice. Am J Obstet Gynecol 1995;172:1279–84. 13) Maier RV. Approach to the patient with shock. In: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s principles of internal medicine. 16th ed. New York: McGraw-Hill;2004:1600–6. 14)  World Health Organization. WHO recommendations for the prevention of postpartum haemorrhage. Geneva: WHO; 2007. Available from: http://whqlibdoc. who.int/hq/2007/WHO_MPS_07.06_eng.pdf 15)  ept. of Reproductive Health and Research . World Health Organization, dept. of reproductive health and research, World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization Press; 2012. 16) Choy CM, Lau WC, Tam WH, Yuen PM BJOG.A randomised controlled trial of intramuscular syntometrine and intravenous oxytocin in the management of the third stage of labour.2002 Feb; 109(2):173-7. 17) McDonald SJ, Abbott JM, Higgins SP. Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour. Cochrane Database Syst Rev. 2004:CD000201. 18) WHO. Oxytocin: Adopted text for the international pharmacopoeia: final text for addition to the International Pharmacopoeia (June 2010) 4. Geneva: World Health Organization; 2010. 19) Gulmezoglu AM, Villar J, Ngoc NT, Piaggio G, Carroli G, Adetoro L, et al. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. Lancet. 2001;358:689–95. 20) Green-top Guideline No 52. Prevention and Management of Postpartum Haemorrhage. London: RCOG; 2009. Royal College of Obstetricians and Gynaecologists. 21) WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage .Geneva: World Health Organization. 2012 22) International Federation of Gynecology, Obstetrics Treatment of postpartum hemorrhage with misoprostol. Int J Gynecol Obstet. 2012;119(3):215–216. 23) Gulmezoglu AM, Forna F, Villar J, Hofmeyr GJ. Prostaglandins for prevention of postpartum haemorrhage. Cochrane Database Syst Rev.2004;(1):CD000494. 24) Hogerzeil HV, GJA W, de Goeje MJ. Stability of injectable oxytocics in tropical climates: WHO report; 1993. WHO/AP93.6. Available from: http://apps.who.int/iris/handle/10665/59411 25) Malm M, Madsen I, Kjellström J. Development and stability of a heat-stable formulation of carbetocin for the prevention of postpartum haemorrhage for use in low and middle-income countries. J Pep Sci. 2018:e3082. Available from: 10.1002/psc.3082 26) Bibi S, Danish N, Fawad A, Jamil M: An audit of primary post partum haemorrhage. J Ayub Med Coll Abbottabad. 2007, 19: 102-106 27) Gulmezoglu AM, Villar J, Ngoc NT, Piaggio G, Carroli G, Adetoro L, et al. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. Lancet. 2001;358:689–95. 28) Pau LM. Tranexamic acid: a review of its use in the treatment of hyperfibrinolysis. Drugs 2012;72:585–61. 29) Hinshaw K. Tranexamic acid for post-partum haemorrhage in the WOMAN trial. Lancet. 2017;390:1582–3. 30) Naoulou B, Tsai MC. Efficacy of tranexamic acid in the treatment of idiopathic and non-functional heavy menstrual bleeding: a systematic review. Acta Obstet Gynecol Scand 2012;91:529–37. 31)  Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloon for obstetrical bleeding. Int J Gynecol Obstet 2001;74:139-42. 32)  Dabelea V, Schultze PM, McDuffie RS. Intrauterine balloon tamponade in the management of postpartum hemorrhage. Am J Perinatol 2007;24:359–64.) 33) Brace V, Kernaghan D, Penney G. Learning from adverse outcomes: major obstetric haemorrhage in Scotland, 2003?05. BJOG 2007;114:1388–96. 34) Tsirulnikov MS.Ligation of the uterine vessels during obstetrical hemorrhages. Immediate and long-term results (author's transl)].J Gynecol Obstet Biol Reprod (Paris). 1979; 8(8):751-3. 35) Salvat J, Schmidt MH, Guilbert M, Martino A. Vascular ligation for severe obstetrical haemorrhage: Review of the literature. J Gynecol Obstet Biol Reprod. 2002;31:629–39. 36) B -Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ, Br J Obstet Gynaecol. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: An alternative to hysterectomy? Five cases reported.1997 Mar; 104(3):372-5. 37) Matsubara S, Yano H, Ohkuchi A, Kuwata T, Usui R, Suzuki M. Uterine compression sutures for postpartum haemorrhage: an overview. Acta Obstet Gynecol Scand. 2013;92:378–85. 38) Gonsalves M, Belli A. The role of interventional radiology in obstetric hemorrhage. Cardiovasc Intervent Radiol. 2010 Oct; 33(5):887-95. 39) Ko HK, Shin JH, Ko GY, Gwon DI, Kim JH, Han K, Lee SW. Korean J Radiol. Efficacy of Prophylactic Uterine Artery Embolization before Obstetrical Procedures with High Risk for Massive Bleeding.2017 Mar-Apr; 18(2):355-360. 40) de la Cruz CZ, Thompson EL, O'Rourke K, Nembhard WN. Cesarean section and the risk of emergency peripartum hysterectomy in high-income countries: a systematic review. Arch Gynecol Obstet. 2015 Dec; 292(6):1201-15. 41) Flood KM, Said S, Geary M, Robson M, Fitzpatrick C, Malone FD. Changing trends in peripartum hysterectomy over the last four decades. Am J Obstet Gynecol. 2009 Jun; 200(6):632.e1-6. 42) Michelet D, Ricbourg A, Gosme C, et al. Emergency hysterectomy for life-threatening postpartum haemorrhage: Risk factors and psychological impact. Gynecol Obstet Fertil 2015;43:773–9.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241119EnglishN2019May21HealthcareAnalysing Potential Health Impacts of Drinking Water: A Case Study of Delhi Slums English0711Ritika PrasadEnglishNew Delhi is home to about 17 million people. It is the largest Indian city in terms of area, and has the highest population density in the country. New Delhi has housed about 6,343 slums with approximately 1 million households. While the census indicates that 83% used treatedtap water as a primary potable water source, only half of the slum households have any water source within their housepremises, which reflects the insufficient availability and overreliance on unreliable shared sources. Provision of clean drinking water is vital to improving people’s health and reducing the incidence of diseases and deaths. This drudgery is not only undesirable in itself but it also takes away other opportunities for self-development, productivity and income generation. Broken hand pumps and lack of piped connections results in women having to travel long distances to fetch water. The aim of the paper is to examine the drinking water related health issues which are often faced by slum dwellers due to lack of sanitation facilities. The analysis of the paper has been carried out using primary survey of 100 respondents, 25 respondents from each surveyed slum and gathering secondary data from Delhi Jal Board and Central Pollution Control Board. The water from hand-pumps is considered non-potable and it is not recommended to be used for drinking and cooking purposes. This implies that the poor people in the slums, often without knowledge and ability to filter the supplied water, are the most vulnerable to receiving non-potable water and, hence, most vulnerable to water-borne diseases. EnglishDrinking water, Slums, Diseases, Health, Water borneINTRODUCTION Delhi, capital of India, is home to about 3 million people living in slums and it is estimated that 45% of its population lives in unauthorized colonies, JhughiJhopri (JJ) and urban villages.(Slum & JJ Department, Municipal Corporation of Delhi, 2009 Fact Sheet.)  As per the UN-HABITAT definition states ‘a slum household is a group of individuals living under the same roof in an urban area that lack one or more of the following Durable housing of a permanent nature that protects against extreme climate conditions;  Sufficient living space which means not more than three people sharing the same room; Easy access to safe water in sufficient amounts at an affordable price; Access to adequate sanitation in the form of a private or public toilet shared by a reasonable number of people; Security of tenure that prevents forced evictions. Many of the health problems in urban slums stem from the lack of access to or demand for basic amenities. Basic service provisions are either absent or inadequate in slums. Poor living conditions, lack of income and scarce education contribute to serious health problems that would otherwise be preventable. Maternal health is poor, and death associated with pregnancy and childbirth is common as women have no access to suitable facilities or trained midwives. The provision of a reliable supply of potable water must go hand-in-hand with the provision of a waterborne system of sewage disposal if there is to be any significant improvement in the health of the urban poor in the cities of the developing world. In the past, investment in urban sanitation lagged behind the provision of water supply and there was a tendency to promote the use of appropriate technological solutions in the form of on-site sanitation. In densely populated urban areas this is inappropriate because their discarded sludges, effluents and leachates will bring about gross pollution of groundwater and surface water resulting in conditions that pose a severe threat to health. (Reference: 'And Not a Drop to Drink': Water and Sanitation Services to the Urban Poor in the Developing World, Harry Giles and Bryan Brown). Provision of clean drinking water is vital to improving people’s health and reducing the incidence of diseases and deaths. Women and girls spend hours fetching water. This drudgery is not only undesirable in itself but it also takes away other opportunities for self-development, productivity and income generation. (Reference:Examining Water Quantity and Quality in Delhi, India, Dr. David MaidmentNishtha Mehta) It is commonly found that the drinking water quality in the slums are bad after the water quality analysis, and the water supply, none to very sporadic. Broken hand pumps and lack of piped connections results in women having to travel long distances to fetch water. The water from hand-pumps is considered non-potable and it is not recommended to be used for drinking and cooking purposes. This implies that the poor people in the slums, often without knowledge and ability to filter the supplied water, are the most vulnerable to receiving non-potable water and, hence, most vulnerable to water-borne diseases. Water-borne diseases are "dirty-water" diseases those caused by water that has been contaminated by human, animal, or chemical wastes. Water-borne diseases include cholera, typhoid, polio, meningitis, and hepatitis A and E. Human beings and animals can act as hosts to the bacterial, viral, or protozoal organisms that cause these diseases. Where proper sanitation facilities are lacking, water-borne diseases can spread rapidly. Untreated excreta carrying disease organisms wash or leach into freshwater sources, contaminating drinking water and food. Diarrheal disease, the major water-borne disease, is prevalent in many slum areas of the world where sewage treatment is inadequate. Using contaminated sewage for fertilizer can result in epidemics of such diseases as cholera. These diseases can even become chronic where clean water supplies are lacking.These kinds of health problems in adults and children though considered to common ailments lead to physical (pain, suffering, fatigue) mental (agony, distress and distraction) and financial losses (in terms of livelihood/ employment days and expenses on treatment). This disease burden is borne disproportionately by the slum dwellers. The water in slums was often stored in open buckets kept on the floor without a ladle to draw it .This implies that the storage conditions can result in severe contamination and health risks. This also indicates a lack of access to safe water and water storage facilities affects the urban poor in slums significantly.  The pollution is not simply restricted to the stored water but is a large part of the water source – river Yamuna. THE STUDY AREA Delhi, with a population of 17 million, is the third largest, fastest growing and most densely populated city in India. It has over 3 million living in slum colonies or slum like conditions, proliferating rapidly and lacking even the most basic amenities like water and sanitation. Migration has roughly averaged 1.3 times the natural growth in Delhi. The city has witnessed an increase of population at a phenomenal rate of 4.6% annually, double of the national average of 2.34% and more than the urban growth rate of any city of the country. The density of population, 11,297 persons per sq. km., as per Census 2011, is the highest in the country. As Delhi swells due to a large influx of migrants from smaller cities, towns and rural areas, with unmatched provision of housing and basic amenities, ‘informal settlement’ increases in numbers, sizes and densities. Within Delhi four slum areas have been studied, Jagdamba slum camp in the south of Delhi, Lalbagh Jhuggi in the north of Delhi, Seelampur slums in the east and Amar Park Jhuggi in the west of Delhi. (Reference: A report on Basic Services in Urban Slums of Delhi, March 2008.) RESEARCH METHODOLOGY The analysis of the paper is based on both primary and secondary data. Primary data was gathered by interviewing the slum respondents and government officials using structured questionnaire. The entire study has conducted a primary survey of 100 respondents selected randomly, 25 each from the four slums of Delhi. Questions were also prepared for the nearby government hospitals/clinics that the respondents visit when they suffer from health problems. In the survey it was the females who were mostly questioned. They were mostly between the age group of 18-35 years. Secondary data was gathered from Central Pollution Control Board (CPCB) and Delhi Jal Board. CPCB is a statutory organisation under the Ministry of Environment, Forest and Climate Change (MoEF& CC). It was constituted in September, 1974 under the Water (Prevention and Control of Pollution) Act, 1974. Further, CPCB was entrusted with the powers and functions under the Air (Prevention and Control of Pollution) Act, 1981. The principal functions of CPCB is to promote cleanliness of streams and wells in different areas of the states by prevention, control and abatement of water pollution, and to improve the quality of air and to prevent, control or abate air pollution in the country The Delhi Jal Board (DJB) is entrusted with the responsibility of procurement and distribution of water as well as treatment and disposal of sewage in study area of Delhi.DJB serves a total population of nearly 14 million through 1.47 million water connections. Delhi Jal Board was constituted through an Act of Delhi Legislative Assembly on 6th April 1998. RESULTS AND DISCUSSION Water Borne Diseases in the Slums Looking into the slum wise water related diseases, all the sampled slums had almost the same health problems. In the Jagdamda slum camp of south Delhi the health problems which mainly prevailed due to unsafe drinking water were, diarrhoea, typhoid and jaundice. The irregular arrival of water tanker was mainly common in the Lalbagh slum of north Delhi. When the tank of water does not arrive the drinking water is stored for 2-3 days as a result of which the water gets contaminated and giving rise to the health problems. The people of Lalbagh slum also suffered with the same health problems related to drinking water as in case of Jagdamba slum. In the Seelampur slum and Amar Park jhuggi there was incidences of diarrhoeal diseases the most. Water in these two slums had bacteriological contamination as the ground water is hard. Usually the respondents told us the symptoms of the disease like fatigue, fever and cough. The diseases were confirmed from the nearby hospital which the slum people visited. There were 2-3 cases of deaths in Seelampur slums due to water borne diseases four years back. There were few also cases of cholera reported from the slum of Lalbagh. In order to confirm the data on health issues the study also collected information from the nearby hospitals and clinics which the slum dwellers visited when they suffer from the above given diseases. In the Jagdamba slum most of the slum dweller went to the nearby Madan Mohan Malviya government hospital for their treatment and private doctors. Though coming from the lower income group they had to get themselves treated by private doctors because some respondents say that they did not get proper attention in government hospital and had to wait long hours for their turn. In Seelampur slum the people went to the nearby Bhim Sen government hospital in Shastri Park. Some of them were also treated by private doctors in their locality. In Lalbagh slum there was a bangali doctor in the area where some of the people got themselves treated it was mainly because it costs less and was not far away rather located in the slum itself. Some respondents told that they also went to the Hindu Rao government hospital. In the Amarpark jhuggi, the slum people go to charitable dispensary in Motinagar. Fig 6: The health scenario shows that around 67 percent of the slum households go to government doctors/hospitals for treatment while 26 percent refer private practitioners/hospitals. Some of them also prefer Bangali Doctor and dispensary. Study also made an effort to assess the frequency of treatment. Overall, in the slums around 10 percent of the cases respondents reported visiting the doctor 2-3 times a month and in around 25 percent of the households respondents reported visiting the doctor only once a month and 55 percent of the respondents did not visit the doctor often. Fig 7: Frequency of visits by the slum dwellers to the doctors. In the study it was also found that cases of water-borne diseases are reported throughout the year in the hospitals but during rains, people are more prone to these water borne diseases. At this time of the year, one can find contaminated water all around. Monsoons may have brought relief from Delhi's scorching heat, but on the flipside temperatures are rising with the onset of various diseases. Most hospitals witness a sudden rise in number of patients complaining of problems like diarrhoea, typhoid, jaundice etc.  CONCLUSION The drinking water health issues mainly resulted from to contamination of water due to inadequate storage facilities, storing water for a longer period and not adopting various purification methods. In the sampled slums it was observed that diarrhoea was common disease in all the slums followed by cholera typhoid and jaundice. The incidences of diarrhoea are maximum due to lack of clean potable water especially in monsoons. Partly can be the reasons such as open drains and improper sewage facilities. Other water borne diseases result from also occur due to lack of access to safe water and water storage facilities and where sewage treatment is minimal. The slum dwellers visit the nearby health centres for their check-up there was no health centre and medical shop located within the slum area. This is one the main reasons which can be attributed to less frequent visits to the doctors when fallen ill as people have to devote almost their entire day. In the study it was also found that cases of water-borne diseases are reported throughout the year in the hospitals but during rains, people are more prone to these water borne diseases. Having understood the gravity of the situation and the worldwide phenomenon of depleting water resources, it is imperative to put into practice strategies and activities for water management. Management of water not only requires a community based approach but also practices at individual level. ACKNOWLEDGMENT  The author acknowledges the immense help received from the scholars whose articles are cited and included in references of this article. The author isalso grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Englishhttp://ijcrr.com/abstract.php?article_id=2598http://ijcrr.com/article_html.php?did=2598 R. N. Sharma and K. Sita. Cities, Slums and Government. Economic and Political Weekly, Vol. 35, No. 42 (Oct. 14-20, 2000), pp. 3733-3735 Rajiv Bahl, Pratima Ray, Swati Subodh, Prashant Shambharkar, Manju Saxena,Umesh Parashar, Jon Gentsch, Roger Glass, M. K. Bhan. The Journal of Infectious Diseases, Vol. 192, Supplement 1. Rotavirus in Asia: Epidemiology, Burden of Disease, and Current Status of Vaccines (Sep. 1, 2005), pp. S114-S119 How the 'Other Side' of Delhi Lives. Economic and Political Weekly, Vol. 23, No. 43 (Oct. 22, 1988), p. 2193 Statement on National Health Policy: Ministry of Health and Family Welfare, Government of India, New Delhi, 1982. Journal of Public Health Policy, Vol. 7, No. 2 (Summer, 1986), pp. 248-264. Harry Giles and Bryan Brown.  'And Not a Drop to Drink': Water and Sanitation Services to the Urban Poor in the Developing World. Geography, Vol. 82, No. 2 (April 1997), pp. 97-109. Planning Commission 2002, Water Supply and Sanitation – a WHO_UNICEF sponsored study, India-Assessment 2002, Planning Commission, Government of India, New Delhi, November 200, p 37. Anon 2003, Health Information of India, 2000 and 2001, Central Bureau of Health Intelligence, Ministry of Health and Family Welfare, Government of India, p 182 Pande Suchi. Background note on health in urban slums in Delhi. Ensuring public accountability through community action 2005 Institute of Social Studies Trust, New Delhi A Report - Drinking water and Sanitation status in India – Coverage Financing and Emerging Concerns, Water Aid India, 2005. Sabir Ali (2003), Environmental Situation of Slums in India; especially Chapter 3 on the ‘Magnitude of Slum Problem in Delhi’. Uppal Publishing House, New Delhi. Gita DewanVerma (2002): ‘Slumming India—A Chronicle of Slums and Their Saviours’. Penguin Books, India Justin DeNormandie and Janette Sunita. Combating diarrhoeal disease in India through safe drinking water. Population Services International (PSI) Delhi, India November 2002. Zerah, M. H. (2000). Water: Unreliable Supply in Delhi. New Delhi: Manohar Publishers. Lal, P; et al., (1996). Incidence of diarrhoea and some related environmental and behavioural factors in Jhuggis of Delhi. Indian Journal of Public Health. Vol 40 (2). Rehman, A and Netzband, M. 2007. An assessment of urban environmental issues using remote sensing and GIS techniques an integrated approach: A case study: Delhi, India. Paper presented in PRIPODE Conference - Urban Population, Development and Environment Dynamics in Developing Countries, Nairobi.  11th to 13th June, 2007. Slum & JJ Department, Municipal Corporation of Delhi. (2009). Fact Sheet. A report on Basic Services in Urban Slums of Delhi, March 2008. Water Quality of Sub-standard Settlements in Delhi Hazards Centre 2006

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241119EnglishN2019May21HealthcareAssessment of Nutritional Status of the HIV Infected Children Attending ART Centre and its Relation with Immunodeficiency - A Hospital Based Study English1217Raghavendra N.English R. G. VivekiEnglishIntroduction: Malnutrition is a common complication among HIV-infected children. HIV impairs the immune system, making the body vulnerable to various infections. Infections leads to malnutrition which further contributes to a weakened immune system making a vicious cycle. This leads to a rapid progression to AIDS. Objectives: To assess the burden of malnutrition and to know its effect on immune status of HIV infected children attending Anti-Retro viral Therapy (ART) Centre. Methodology: The study was conducted among HIV positive children aged 0-14 years, attending ART Centre of Belagavi Institute of Medical Sciences (BIMS) Hospital, Belagavi. Anthropometric measurements and CD4 counts were recorded. Anthropometric indicators were expressed in Z-scores. Three types of malnutrition were defined: acute malnutrition (WHZ/BAZ < -2 SD and HAZ ≥ -2SD), chronic malnutrition (HAZ < -2 SD and WHZ/BAZ ≥ -2 SD) and mixed malnutrition (WHZ/BAZ < -2 SD and HAZ < -2SD). Results: The study included 180 HIV infected children (112 boys, 68 girls). The prevalence of malnutrition was 78.3%. Acute, chronic and mixed malnutrition was seen in 17 (9.4%), 106 (58.9%), 18 (10.0%) of the study participants respectively. Immunodeficiency was seen in 42% of them. The presence of malnutrition in the study participants was significantly associated with immunodeficiency. Conclusion: There was high prevalence of malnutrition among the HIV infected children. HIV acts as an independent risk factor for malnutrition. Malnutrition should be treated and prevented to ensure optimal response to ART and reduce early mortality. EnglishART, Children, CD4 count, HIV, MalnutritionINTRODUCTION:             According to world health organization (WHO), by 2017 an estimated 36.9 million people were living with Human Immunodeficiency Virus(HIV) worldwide, 1.8 million People were newly infected with HIV and 9, 40,000 people died from Acquired Immune Deficiency Syndrome (AIDS) related illnesses. Children (Englishhttp://ijcrr.com/abstract.php?article_id=2599http://ijcrr.com/article_html.php?did=2599 WHO: Summary of the global HIV epidemic. Available at: http://www.who.int/hiv/data/2017_summary-global-hiv-epidemic.png?ua=1. Retrieved on: 12/08/2018 India HIV estimations 2015. Technical report. NACO & NIMS ICMR, Ministry of Health & Family Welfare. Gov`t of India. Available at: http://www.naco.gov.in/sites/default/files/India%20HIV%20Estimations%202015.pdf Retrieved on: 12/08/2018. Nutrition Guidelines for HIV-Exposed and Infected Children (0-14 Years Of Age) NACO. Ministry of Health & Family Welfare. Gov`t of India. Available at: http://www.naco.gov.in/sites/default/files/Paedia%20Nutrition%20national%20guidelines%20NACO.pdf Retrieved on: 02/08/18 Dundigalla C, Chidugulla SK, Ashwani N, Divya BP, Dundigalla P. Study of Prevalence Of Malnutrition In HIV Positive Children and Its Correlation With Cd4 Count. IOSR J of Denl and Med Sci. 2015; 14(12):50-57. Ambey R, Sahu S, Sharma A, Gupta R, Goyal B. Assessment of Nutritional Status of HIV Positive Children in Antiretroviral Therapy Center: A Study from Central India. Int J of Pediatr Res and Pract. 2015; 1(1):7-11. Jesson J, Masson D, Adonon A, Tran C, Habarugira C, Zio R et.al. Prevalence of malnutrition among HIV-infected children in Central and West-African HIV-care programmes supported by the Growing up Programme in 2011: A cross-sectional study. BMC Infectious Dis. 2015; 15(216):1-12. Kishore J. National Health Programs of India, National Policies and Legislations related to Health. 11th ed. Century Publications. 2014: 289-343. WHO case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children. WHO 2007. Available at: http://www.who.int/hiv/pub/guidelines/HIVstaging150307.pdf Retrieved on: 16/08/18 Gupta M, K.J.P.S. Puri1, Singh K, Malhotra S. The road less travelled: A social and demographic profile of HIV- infected children accessing care at tertiary care centre in North India. Egyptian Dermatology Online Journal. 2013; 9(4):1-10. Madiba S, Mokwena K. Profile and HIV diagnosis disclosure status of children enrolled in a pediatric antiretroviral program in Gauteng province, South Africa. Southeast Asian J Trop Med Pub Health. 2013; 44(6):1010-1020. Chauhan RC, Singh N. Socio-demographic profile of HIV infected children accessing care at pediatric clinic of a tertiary level hospital in North India. Int J ContempPediatr. 2014; 1(1):20-23. S. Rajasekaran, L. Jeyaseelan, K. Raja, N. Ravichandran. Demographic & clinical profile of HIV infected children accessing care at Tambaram, Chennai, India. Indian J Med Res. 2009; 129:42-49. Bhattacharya M, Rajeshwari K, Saxena R. Demographic and Clinical Features of Orphans and Nonorphans at a Pediatric HIV Centre in North India. Ind J Ped. 2010; 77:627-631. Solunke VN, Kamble MB, Suryawanshi AR, Saple P, Tiwari MM, Bhete SB et.al, Clinical Profile and Prevalence of Opportunistic Infection in HIV Patients Attending Pediatric Department. Int Med J. 2014; 1(2):69-74. Oladokun R, Brown B, Aiyetan P, Ayodele O, Osinusi K. Comparison of socio-demographic and clinical characteristics of orphans and non-orphans among HIV-positive children in Ibadan, Nigeria. Int J Inf Dis. 2009; 13:462-468. Adedemy JD, Zohoun L, Alihonou F, d&#39;Almeida M, Couringa Y, Agossou J et.al. Screening for malnutrition and nutritional care in HIV-infected children followed up in the pediatric unit of CNHU-HKM in Cotonou. MaternPediatrNutr. 2016; 2(2):1-7. Rakholia R, Bano M, Rawat V.  Malnutrition among HIV- infected Children by Anthropometric Measures in Poor Outreach Area of a Developing Country and its Relationship with CD4 Counts. Int J Pediatr. 2016; 4(4):1643-1654. Gomber S, Kaushik JS, Chandra J, Anand R. Profile of HIV infected children from Delhi and their response to antiretroviral treatment. Indian Pediatrics. 2011; 48:703-707. Agarwal D, Chakravarty J, Sundar S, Gupta V, Bhatia BD. Correlation between Clinical Features and Degree of Immunosuppression in HIV Infected Children. Indian Pediatrics. 2008; 45(17): 140-143. Lodha R, Upadhyay A, Kapoor V, Kabra SK. Clinical Profile and Natural History of Children with HIV Infection. Ind J of Ped. 2006; 73: 201-204. Sanjeeva GN, Sukanya V, Govindaraj M, Shivananda. Clinical profile, treatment response, and outcome of HIV-TB co-infected children. Pediatric Infectious Dis. 2013(5):3-8.