Abstract
BackgroundThe absence of a uniform and clinically relevant definition of severe postpartum haemorrhage hampers comparative studies and optimization of clinical management. The concept of persistent postpartum haemorrhage, based on refractoriness to initial first-line treatment, was proposed as an alternative to common definitions that are either based on estimations of blood loss or transfused units of packed red blood cells (RBC). We compared characteristics and outcomes of women with severe postpartum haemorrhage captured by these three types of definitions.MethodsIn this large retrospective cohort study in 61 hospitals in the Netherlands we included 1391 consecutive women with postpartum haemorrhage who received either ≥4 units of RBC or a multicomponent transfusion. Clinical characteristics and outcomes of women with severe postpartum haemorrhage defined as persistent postpartum haemorrhage were compared to definitions based on estimated blood loss or transfused units of RBC within 24 h following birth. Adverse maternal outcome was a composite of maternal mortality, hysterectomy, arterial embolisation and intensive care unit admission.ResultsOne thousand two hundred sixty out of 1391 women (90.6%) with postpartum haemorrhage fulfilled the definition of persistent postpartum haemorrhage. The majority, 820/1260 (65.1%), fulfilled this definition within 1 h following birth, compared to 819/1391 (58.7%) applying the definition of ≥1 L blood loss and 37/845 (4.4%) applying the definition of ≥4 units of RBC. The definition persistent postpartum haemorrhage captured 430/471 adverse maternal outcomes (91.3%), compared to 471/471 (100%) for ≥1 L blood loss and 383/471 (81.3%) for ≥4 units of RBC. Persistent postpartum haemorrhage did not capture all adverse outcomes because of missing data on timing of initial, first-line treatment.ConclusionThe definition persistent postpartum haemorrhage identified women with severe postpartum haemorrhage at an early stage of haemorrhage, unlike definitions based on blood transfusion. It also captured a large majority of adverse maternal outcomes, almost as large as the definition of ≥1 L blood loss, which is commonly applied as a definition of postpartum haemorrhage rather than severe haemorrhage.
Highlights
The absence of a uniform and clinically relevant definition of severe postpartum haemorrhage hampers comparative studies and optimization of clinical management
In order to gain knowledge on the case-mix of women captured by persistent postpartum haemorrhage as a definition of severe postpartum haemorrhage, we aimed to describe clinical characteristics and outcomes of women selected by this definition, as compared to definitions based on estimations of blood loss and transfused red blood cells (RBC)
When defining severe postpartum haemorrhage based on estimated blood loss, time from birth to the moment she reached 1 L of blood loss was less than 1 h in 819 out of 1391 women (58.7%)
Summary
The absence of a uniform and clinically relevant definition of severe postpartum haemorrhage hampers comparative studies and optimization of clinical management. Used definitions of postpartum haemorrhage and its severity are based on estimations of blood loss or the need of transfusion of packed red blood cells (RBC) within 24 h following birth [11,12,13,14,15,16,17,18,19]. Depends on volume, and on the rate of blood loss, physiological response to bleeding and response to treatment [11, 20, 21] Such characteristics of bleeding are important determinants of clinical management during the dynamic process of ongoing haemorrhage [20]. The need for transfusion on the other hand, reflects an intermediary state during ongoing bleeding or the end stage of haemorrhage, and is unsuitable when it comes to decisions regarding when to start more aggressive interventions to prevent adverse maternal outcome in women with severe postpartum haemorrhage
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