To assess the quantity and duration of lochia in women with or without inherited bleeding disorders and to identify factors that influence lochial loss.
Pictorial blood assessment chart was completed by 115 pregnant women (21 with or carriers of inherited bleeding disorder and 94 without bleeding disorder) using standardized sanitary products.
The median duration of lochia was significantly longer in women with (or carriers of) inherited bleeding disorder (39 days; range 21–58) compared with women without bleeding disorder (31 days; range, 10–62; P = .03); however, the median lochial loss were similar (441 mL; range, 135–1290 vs 429 mL; range, 112–1295; P = .59). Long labor and instrumental delivery were associated with heavier lochia.
Pictorial blood assessment chart is potentially a useful tool in the assessment of lochia. Women with inherited bleeding disorders experience longer period of lochia compared with women without bleeding disorder. Labor duration and mode of delivery influence lochial loss.
Despite being experienced by all women after childbirth, puerperal loss (lochia), like many aspects of postnatal health, remains an underresearched topic. There is a paucity of information in the medical literature on the characteristics of lochia. In addition, the textbook descriptions are often conflicting and lack support from research evidence. The total duration of lochia described in textbooks ranges from 18 days up to 6 weeks. However, several studies have showed that lochia not uncommonly lasts longer than 6 weeks. Information on the normal duration and amount of lochia can help identify excessive and/or prolonged postpartum bleeding, which is an important cause of maternal morbidity. The diagnosis of secondary postpartum hemorrhage (PPH) is purely based on subjective assessment as there is no quantitative definition. This intensifies the need to be aware of the normal parameters for puerperal loss. Women who are carriers or have an inherited bleeding disorder are at increased risk of PPH. They may also be more likely to experience heavier or longer puerperal loss. However, there is currently lack of data in the literature on lochial loss in these women.
A common problem in the determination of lochial loss arises from the lack of a standard method for assessment. In clinical situations, weighing pads is impractical and simple visual estimation is unlikely to be accurate without the implementation of a standardized method of assessment. In this study, we used the pictorial blood assessment chart (PBAC) to quantify semiobjectively the amount of lochia. Several groups have demonstrated a positive correlation between the objective measurements of menstrual blood loss and self-assessed pictorial chart scores. The objectives of this study were to assess and compare the quantity and duration of lochia between women with and without inherited bleeding disorders and to evaluate factors that may influence the amount or duration of lochia.
Materials and Methods
Pregnant women with (or carriers of) inherited bleeding disorders registered at the Royal Free Haemophilia Centre and Thrombosis Unit were invited to participate in the study between June 1, 2005, and June 1, 2006. Pregnant women who were not known to have an inherited bleeding disorder and who were receiving antenatal care at the Royal Free Hospital during this period were approached and recruited into the study as controls. Women with other hematologic disorders or on anticoagulants were excluded from the study. This prospective study was approved by the local research ethics committee. All participants gave informed written consent. They were provided with standardized sanitary towels (Kotex ultra normal plus, ultra super plus, and maxi nighttime pads; Kimberly Clark, Aylesford, Kent, UK) to use exclusively during the postpartum period. They were given a booklet that was comprised of weekly modified PBACs ( Figure 1 , A), and an explanation to complete the charts from 24 hours after delivery until the cessation of lochia. They were advised to contact 1 of the authors if they had any queries or required further supply of sanitary towels. A stamped addressed envelope was provided for the return of the booklet after completion.
The PBAC chart and the scoring system ( Figure 1 , A and B) used in this study were based on that devised by Wyatt et al, which had been shown to correlate with the amount of blood loss measured by the alkaline hematin method. An extra type of sanitary towels (Kotex ultra normal plus) was included in this study to give the women more choices because the duration of lochia is usually longer than menstruation. The scoring system was subsequently modified by adding known amounts of expired venous blood to the same types of towels to create the appearances as illustrated on the chart and was comparable to that reported by Wyatt et al.
This enabled an estimation of the amount of lochial loss on each towel used. The total score also took into consideration the amount and size of the clots lost and the number of flooding episodes experienced by the women ( Figure 1 , B).
A questionnaire was included at the end of the PBAC booklet to assess their experience and expectation toward puerperal blood loss and to inquire on the method of feeding. The questions included are shown in Table 4 .
Demographic and obstetric details were obtained from the case notes. They included age, booking weight, parity, gestational age at delivery, length of labor, mode of delivery, birthweight, estimated blood loss at delivery, and perineal tear or episiotomy. All carriers or women with inherited bleeding disorders in this study received prophylactic cover with tranexamic acid in the first 7-10 days postdelivery. Those with relevant low clotting factor levels during pregnancy received additional prophylactic cover for labor and delivery.
Comparison of the duration and total amount of lochia between women with and without inherited bleeding disorders were made using Mann-Whitney test. Relationships between the duration or amount of lochia and the various obstetric factors examined in this study were tested for significance using the Mann-Whitney test, Kruskal-Wallis test, or Spearman’s rank correlation coefficient, where appropriate. The χ 2 test was performed to compare the experience and attitudes of primiparous and multiparous women toward their lochia. P < .05 was considered to be statistically significant.
In total, 180 women (22 with and 158 without an inherited bleeding disorder) were approached; 170 gave informed consent and 10 declined to participate in the study. The PBAC booklet was completed and returned by 115 (68%) women. They included 94 women without a bleeding disorder and 21 women who were either carriers or had an inherited bleeding disorder (12 carriers of hemophilia, 5 factor XI deficiency, 2 factor VII deficiency, and 2 von Willebrand disease).
Overall, the duration of lochia varied widely between 10 and 62 days postdelivery and the total amount of lochial loss estimated from PBAC ranged from 112–1295 mL ( Table 1 ). The median duration of lochia among women with inherited bleeding disorders (39 days; range, 21–58) was significantly longer compared with women without a bleeding disorder (31 days; range, 10–62) ( P = .03). However, the total amount of lochial loss estimated from PBAC was similar in both groups. Overall, the women experienced on average the highest amount of lochial loss in the first week postdelivery ( Table 2 ). About a third of the women (40/115) had lochia lasting longer than 6 weeks postdelivery.
|Characteristic||Women with IBD||Women without IBD||P value a|
|Median (range)||30 (19–39)||32 (22–41)||.12|
|Duration of lochia, d|
|Median (range)||39 (21–58)||31 (10–62)||.03|
|Amount of lochia, mL|
|Median (range)||441 (135–1290)||429 (112–1295)||.59|