252: Postpartum hemorrhage: Enhanced recognition and response during implementation of an obstetric hemorrhage bundle

Abstract

Postpartum hemorrhage (PPH) is a leading cause of mortality and severe maternal morbidity (SMM). Research evidence demonstrates increasing risk for PPH, PPH severity, and associated morbidity. In response, the New York State Safe Motherhood Initiative (SMI) supported implementation of a bundle to improve management of PPH. We sought to assess (i) trends in PPH utilizing a novel multi-severity-level framework and (ii) hemorrhage-associated morbidity during PPH bundle implementation. This study analyzed PPH at a large, multi-site academic medical center from 7/2014 to 7/ 2017 during SMI hemorrhage bundle implementation. A novel framework was developed to track PPH risk factors, PPH severity, and indicators of PPH under-treatment. We analyzed changes in PPH levels over time using logistic regression accounting for PPH risk factors. Low fibrinogen levels were analyzed as a proxy for coagulopathy as an indicator for under-treatment. For these analyses, patients with no PPH were compared to patients with PPH based on severity within our framework. Using a framework of PPH that includes 4 severity levels (Figure 1A), we found variation across time in incidence of PPH and treatment patterns (Figure 1B). PPH did not change over time according to ICD coding (“Coded PPH” in Figure 2A). However, usage of uterotonics other than Pitocin increased significantly (“PPH1” in Figure 2A), as did usage of Bakri Balloons and small volume (1-3 unit) red blood cell (RBC) transfusions (“PPH3” in Figure 2A). Hysterectomy and/or RBC transfusion ≥4 units did not increase significantly (“PPH4” in Figure 2A). Cases with fibrinogen<=200, an under-treatment indicator, did not increase significantly over time (p=0.10 in logistic regression) and there were no PPH related maternal mortalities during hospitalization in the study period. Based on trends in uterotonic use, transfusion <4 units RBCs and Bakri use, PPH incidence and risk appeared to increase. This risk was not captured in routine billing data. Hemorrhage bundles call for early recognition of PPH with stage-based response including uterotonic medication, tamponade, and transfusion. Clinical uptake of these recommendations occurred over the study period. Despite increases in PPH risk and severity, key measures of SMM, including hysterectomy and coagulopathy, did not increase.View Large Image Figure ViewerDownload Hi-res image Download (PPT)