Abstract
ObjectiveDeveloping and validating nomogram to predict severe postpartum hemorrhage (SPPH) in women with placenta previa (PP) undergoing cesarean delivery.MethodsWe conducted a multicenter retrospective case-control study in five hospitals. In this study, 865 patients from January, 2018 to June, 2020 were enrolled in the development cohort, and 307 patients from July, 2020 to June, 2021 were enrolled in the validation cohort. Independent risk factors for SPPH were obtained by using the multivariate logistic regression, and preoperative nomogram and intraoperative nomogram were developed, respectively. We compared the discrimination, calibration, and net benefit of the two nomograms in the development cohort and validation cohort. Then, we tested whether the intraoperative nomogram could be used before operation.ResultsThere were 204 patients (23.58%) in development cohort and 80 patients (26.06%) in validation cohort experienced SPPH. In development cohort, the areas under the receiver operating characteristic (ROC) curve (AUC) of the preoperative nomogram and intraoperative nomogram were 0.831 (95% CI, 0.804, 0.855) and 0.880 (95% CI, 0.854, 0.905), respectively. In validation cohort, the AUC of the preoperative nomogram and intraoperative nomogram were 0.825 (95% CI, 0.772, 0.877) and 0.853 (95% CI, 0.808, 0.898), respectively. In the validation cohort, the AUC was 0.839 (95% CI, 0.789, 0.888) when the intraoperative nomogram was used before operation.ConclusionWe developed the preoperative nomogram and intraoperative nomogram to predict the risk of SPPH in women with PP undergoing cesarean delivery. By comparing the discrimination, calibration, and net benefit of the two nomograms in the development cohort and validation cohort, we think that the intraoperative nomogram performed better. Moreover, application of the intraoperative nomogram before operation can still achieve good prediction effect, which can be improved if the severity of placenta accreta spectrum (PAS) can be accurately distinguished preoperatively. We expect to conduct further prospective external validation studies on the intraoperative nomogram to evaluate its application value.
Highlights
The placenta previa (PP) is defined as placenta complete or partial covering the internal orifice of cervix [1], the prevalence of Placenta previa (PP) in obstetrics is about 0.3–1.5% [2]
Between the development and validation cohort, there were statistical differences in the proportion of PP (p = 0.022), preoperative HGB < 90 g/L (p = 0.012), Preoperative bleeding (PB) (p = 0.048), the anterior wall of the uterus adheres to the surrounding tissue (p = 0.044) and the severity of Placenta accreta spectrum (PAS) found during operation (p = 0.009), and there were no statistical differences in other factors
There were no statistical differences in the rate of transfer to ICU (p = 0.067) and postoperative bleeding (p = 0.167) between the severe postpartum hemorrhage (SPPH) and non-SPPH group in the validation cohort, we considered that might be related to the small sample size in validation cohort
Summary
The placenta previa (PP) is defined as placenta complete or partial covering the internal orifice of cervix [1], the prevalence of PP in obstetrics is about 0.3–1.5% [2]. In the United States, SPPH accounts for 11% of maternal deaths [3, 5]. The risk prediction tools for SPPH have been established based on previous research of risk factors [8], and researchers developed prediction models for SPPH in women with PP [9,10,11,12]. They cannot be recommended for clinical at present due to lack of studies on the performance, impact, and effectiveness of these models [13]. We aim to develop and validate a new nomogram to predict SPPH in women with PP undergoing cesarean delivery by a multicenter retrospective case-control study
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