Abstract
Obstetric hemorrhage is one of the leading preventable causes of maternal mortality in the United States. Although hemorrhage risk-prediction models exist, there remains a gap in literature describing if these risk-prediction tools can identify composite maternal morbidity. We investigate how well an established obstetric hemorrhage risk-assessment tool predicts composite hemorrhage-associated morbidity. We conducted a retrospective cohort analysis of a multicenter database including women admitted to Labor and Delivery from 2016 to 2018, at centers implementing the Association of Women’s Health, Obstetric, and Neonatal Nurses risk assessment tool on admission. A composite morbidity score incorporated factors including obstetric hemorrhage (estimated blood loss ≥ 1000 mL), blood transfusion, or ICU admission. Out of 56,903 women, 14,803 (26%) were categorized as low-risk, 26,163 (46%) as medium-risk and 15,937 (28%) as high-risk for obstetric hemorrhage. Composite morbidity occurred at a rate of 2.2%, 8.0% and 11.9% within these groups, respectively. Medium- and high-risk groups had an increased combined risk of composite morbidity (diagnostic OR 4.58; 4.09–5.13) compared to the low-risk group. This established hemorrhage risk-assessment tool predicts clinically-relevant composite morbidity. Future randomized trials in obstetric hemorrhage can incorporate these tools for screening patients at highest risk for composite morbidity.
Highlights
No previous uterine incision ≤ 4 Previous vaginal births No known bleeding disorder No history of PPH Singleton pregnancy
Understanding the relationship between hemorrhage-risk score and hemorrhage-associated morbidity may be critical in identifying patient populations who could benefit from additional risk-reducing interventions at the time of delivery, such as tranexamic acid
Obstetric hemorrhage occurred at a rate of 2.1%, 7.6% and 11.4% within the low, medium- and high-risk groups, respectively
Summary
No previous uterine incision ≤ 4 Previous vaginal births No known bleeding disorder No history of PPH Singleton pregnancy. Induction of labor > 4 Prior vaginal births Prior cesarean birth or prior uterine incision Large uterine fibroids History of one previous PPH Chorioamnionitis Fetal demise Morbid obesity (BMI > 35) Estimated fetal weight > 4 kg Family history in first degree relative who experienced PPH Polyhydraminos. Active bleeding more than bloody show Suspected accreta or percreta Placenta previa, low lying placenta Known coagulopathy History of more than one previous PPH Hematocrit < 30 and other risk factors Platelets < 100 k (hysterectomy, dilation and curettage). Understanding the relationship between hemorrhage-risk score and hemorrhage-associated morbidity may be critical in identifying patient populations who could benefit from additional risk-reducing interventions at the time of delivery, such as tranexamic acid
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