Strategy for Reducing Postpartum Hemorrhage Incidence Through the Implementation of Digital-Based Admission Screening: An Action Study in Hospitals

A double centre retrospective study into rates of postpartum haemorrhage in women on low molecular weight heparin

Hemorrhage remains the leading cause of maternal death and accounts for approximately 34% of the 350,000 maternal deaths annually worldwide. About 120,000 deaths annually are attributed to hemorrhage. Overall worldwide, the maternal mortality ratio (MMR) is 260/100,000, with a range from less than five in developed regions to more than 1,200 /100,000 in nations with very low income. In low-income countries, hemorrhage is the leading cause of maternal death; however, the problem remains in developed countries. From 2008-2010, there were 7.8 maternal deaths per 100,000 deliveries annually in Canada. Postpartum hemorrhage (PPH) is currently the third leading cause of maternal death in Canada, with a MMR of 1.6/100,000. In the USA, the MMR is much higher at 21/100,000 deliveries in 2010, up from 13.1 in 2006. In the USA, embolic disease, preeclampsia, and hemorrhage remain leading causes of maternal death. There are many causes of postpartum hemorrhage; however, the most prevalent cause is uterine atony. It is thought to be the etiology in over 70% of all events of postpartum hemorrhage. It is difficult to determine the contribution that uterine atony makes to maternal death from hemorrhage. In a recent study in the USA reporting a large cohort of patient data from 1995-2004 (876,641 hospital admission for delivery), 25,654 cases of PPH were identified, with uterine atony accounting for 79% of these cases. The investigators of this study found a strong association between PPH and a number of serious complications, including acute renal failure, coagulopathy, and acute respiratory failure. All of these complications were likely a consequence of hypovolemia and subsequent massive transfusion. In this cohort, PPH, secondary to uterine atony, was also a significant source of maternal mortality, accounting for approximately one-fifth of all deaths in delivering patients. When evaluating trends in PPH attributable to uterine atony, these investigators identified a 27% increase in the rate of PPH from atony from 1995-2004. Disturbingly, they were unable to identify antenatal risk factors for this trend, as the increase in PPH could not be accounted for by adjusting for changes in maternal demographics, maternal comorbidity, or delivery mode. Also noteworthy in this cohort was the observation that the rates of PPH from other causes, including retained placenta and coagulopathy, remained relatively stable during the study. The investigators also noted that PPH is more common among patients delivering at hospitals in the bottom quartile for delivery volume compared with those delivering at hospitals in the top quartile, which may be a factor with overall management of hemorrhage situations. In an 11-year population-based cohort study from Ireland, similar results were found. This group reported an overall increase in the rate of PPH from 1.5% in 1999 to 4.1% in 2009; with atonic PPH increasing from 1.0% in 1999 to 3.4% in 2009. These increasing trends in rates of atonic PPH were observed across all modes of delivery, i.e., vaginal, instrumental, and emergency and elective Cesarean deliveries. In their cohort, data were collected on 649,019 childbirth hospitalizations, with a 2.6% incidence of PPH. In the patients with PPH, 75.7% were attributed to uterine atony, a number very similar to that found in the USA-based study. They noted that the incidence of atony as a cause for PPH was consistently higher among deliveries that involved induction. The lowest rates of atonic PPH were among non-induced vaginal deliveries, H. A. Muir, MD (&) Department of Anesthesiology, Duke University Hospital, Durham, NC 27710, USA e-mail: holly.muir@duke.edu

BackgroundPostpartum haemorrhage (PPH) remains a leading cause of maternal mortality. Many trials assessing interventions to prevent PPH base their data on low risk women. It is important to consider the impact data collection methods may have on these results. This review aims to assess trials of PPH prophylaxis by grading trials according to the degree of risk status of the population enrolled in these trials and identify differences in the PPH rates of low risk and high risk populations.MethodsSystematic review and meta-analysis using a random-effects model. Trials were identified through CENTRAL. Trials were assessed for eligibility then graded according to antenatal risk factors and method of birth into five grades. The main outcomes were overall trial rate of minor PPH (blood loss ≥500 ml) and major PPH (> 1000 ml) and method of determining blood loss (estimated/measured).ResultsThere was no relationship between minor or major PPH rate and risk grade (Kruskal-Wallis: minor - T = 0.92, p = 0.82; major - T = 0.91, p = 0.92). There was no difference in minor or major PPH rates when comparing estimation or measurement methods (Mann-Whitney: minor - U = 67, p = 0.75; major - U = 35, p = 0.72). There was however a correlation between % operative births and minor PPH rate, but not major PPH (Spearman r = 0.32 v. Spearman r = 0.098).ConclusionsUsing data from trials using low risk women to generalise best practice guidelines might not be appropriate for all births, particularly complex births. Although complex births contribute disproportionately to PPH rates, this review showed they are often underrepresented in trials. Despite this, there was no difference in reported PPH rates between studies conducted in high and low risk groups. Method of birth was shown to be an important risk factor for minor PPH and may be a better predictor of PPH than antenatal risk factors. Women with operative births are often excluded from trials meaning a lack of data supporting interventions in these women. More focus on complex births is needed to ensure the evidence base is relevant to the target population.

Worldwide obstetric hemorrhage remains the leading cause of maternal mortality, accounting for over one quarter of maternal deaths. Over half of these deaths occur in Sub-Saharan Africa with mortality rates of 500 - 1000 per 100,000 births, compared to approximately 5 - 10 in developed countries. Over decades in Sub Saharan Africa preventive measures and treatment protocols have been made to reduce maternal mortality caused by PPH. While rates of postpartum hemorrhage have continued to rise, there is a need to evaluate if its etiology and patterns have changed over time. Broad Objective: This study aims at describing trends in incidence, causes and maternal outcomes of Postpartum Hemorrhage at Muhimbili National Hospital for a period of 7 years. Methodology: This is a retrospective descriptive hospital-based study that has included all cases of postpartum hemorrhage at Muhimbili National Hospital, a tertiary hospital in Tanzania from 2014 to 2020. The data was analyzed using SPSS Version 26 and presented using frequency tables, figures and percentages. The trends of postpartum hemorrhage over time were determined using chi-square test and P-value where less than 0.05 was considered statistically significant. Results: Overall, the incidence of postpartum hemorrhage has been fluctuating over the years with minimum of 1.78% and maximum of 2.87% with no statistical significance. Out of 1113 enrolled cases of PPH, 422 (37.9%) were attributed to genital tears followed by uterine atony 285 (25.6%). A statistically significant increase in linear trend was observed in the postpartum hemorrhage cases due to uterine atony, uterine rupture and sub analysis on genital tears (cervical tear). Overall, there was a statistically significant change in trend of maternal outcomes throughout the years, with a P-value time. Conclusion: The trend in the incidence of postpartum hemorrhage has been fluctuating over the years during the study period. The leading cause of postpartum hemorrhage was genital tears, followed by uterine atony with a significant increase in adverse maternal outcomes over the years. Continuous health education to medical personnel to improve timely and proper diagnosis of women in danger of PPH and timely referral, thus improve maternal morbidity and mortality.

Postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. The purpose of this study was to evaluate if meconium-stained amniotic fluid (MSAF) is a risk factor for PPH after vaginal delivery. We retrospectively analyzed medical records of all patients who had a vaginal delivery at Fujian Provincial Maternity and Children's Hospital, between 1st January 2013 to 31st December 2018. Women with cesarean deliveries, multiple pregnancies, abnormal coagulation profile, and those with concomitant liver or kidney disorders were excluded. Patients were classified into MSAF (n=13686) and clear amniotic fluid (AF) (n=41511) groups. The incidence of PPH was significantly higher at 2.7% (370/13686) in the MSAF group as compared to 2.18% (904/41511) in the clear AF group (p=0.0004). There was no difference in the incidence of severe PPH between the two groups. Statistically significant difference in the incidence of PPH between MSAF and clear AF was seen in the maternal age groups of 30-34 and 35-39 years, gestational age>40weeks and >3 gravidity (p<0.05). Our study demonstrates that MSAF is a significant risk factor for minor and moderate PPH. Presence of meconium could therefore alert clinicians to expect PPH and make arrangements for further patient management. Further basic research is required to evaluate the mechanism by which meconium influences the incidence of PPH.

INTRODUCTION: Postpartum hemorrhage is the leading cause of maternal mortality. Oxytocin is routinely used to prevent postpartum hemorrhage in the United States but dosing is based on limited evidence. Standardized postpartum oxytocin administration is lacking in many facilities. We hypothesized that a standardized postpartum oxytocin administration protocol would prevent postpartum hemorrhage. METHODS: A retrospective quality improvement assessment compared postpartum hemorrhage rates at one level III urban perinatal center for 6 months preprotocol implementation and 6 months postprotocol implementation (60 units of oxytocin over 5 hours). Postpartum hemorrhage was defined as postpartum hemorrhage treatment by pharmaceutical, mechanical, or surgical methods. Inclusion criteria included all deliveries at greater than 23 weeks of gestation from April 2012 to March 2013. RESULTS: The preprotocol group (n=1,267) and postprotocol group (n=1,440) were similar for race, age, parity, gestational age, delivery type, and neonatal weights. The postpartum hemorrhage rate decreased 37% after protocol implementation (adjusted relative risk 0.63, 95% confidence interval 0.46–0.91). Administration of misoprostol, carboprost, methylergonovine maleate, and blood products decreased postprotocol implementation by 36%, 38%, 32%, and 22%, respectively. The postpartum hemorrhage rate for women with a vaginal delivery lowered significantly after protocol implementation (5.9% compared with 3.8%, P=.03). The postpartum hemorrhage rate for women with a cesarean delivery increased but not significantly after protocol implementation (6.9% compared with 8.6%, P=.34). CONCLUSION: Implementation of a standardized oxytocin administration protocol reduced the overall incidence of postpartum hemorrhage. Although we did not control for some postpartum hemorrhage risk factors, our postpartum hemorrhage rate for women delivered by cesarean remains lower than other published rates. This protocol warrants further study.

Incidence, treatment and outcomes of postpartum haemorrhage among women admitted at a large regional referral hospital in Eastern Uganda: a one-year prospective observational study.

Objective To explore the trend of postpartum hemorrhage after two-child policy and to analyze the high-risk risks of postpartum hemorrhage so as to put forward intervention measures to reduce the postpartum hemorrhage. Methods We retrospectively selected 8 784 delivery women with routine production inspection and hospitalized at a ClassⅢ Grade A hospital from 2014 to 2018. We collected the general information, record of production inspection, delivery record and analyzed the trend of postpartum hemorrhage rate, blood loss and related high-risk factors. Results From 2014 to 2018, there were statistical differences in the postpartum hemorrhage rate, serious postpartum hemorrhage rate and blood loss (P<0.05) . The trend showed an increasing trend. In 2017, the postpartum hemorrhage rate, serious postpartum hemorrhage rate and blood loss were 16.9%, 6.1% and (540.1±758.2) ml respectively highest in those years. From 2014 to 2018, the percentage of delivery women with advanced ages, multiple pregnancy, pregnancy times≥2, history of cesarean section≥2 were increasing; delivery women with the prenatal hemoglobin≤110 g/L and percentage of natural labor were decreasing with a statistical difference (P<0.05) ; the percentage of emergency cesarean section was on the rise; the percentage of placental expulsion time from 15 to 30 minutes declined with statistical differences (P<0.05) ; the percentage of placental expulsion time≥30 minutes and above was no significant trend. Conclusions From 2014 to 2018, the postpartum hemorrhage rate, serious postpartum hemorrhage rate and blood loss did not show an increasing trend. However, the percentage of high-risk pregnant and delivery women increased gradually. Therefore, we should carry out the pregnancy risk assessment rating for pregnant and delivery women and formulate a suitable high-risk assessment tool for postpartum hemorrhage so as to reduce the incidence of postpartum hemorrhage. Key words: Postpartum hemorrhage; Puerpera; Blood loss; Change trend; High-risk factors

Postpartum hemorrhage is a significant contributor to maternal morbidity and mortality. We evaluated maternal and perinatal outcome of primary massive postpartum hemorrhage. In a restrospective case analysis of 33 women with intractable postpartum hemorrhage initially managed either by hysterectomy or a conservative approach in a tertiary referral center between January 1, 1991 to December 30, 1998, we reviewed the procedures used as a primary or secondary attempt to arrest the hemorrhage. Medical and surgical measures were successful in controlling hemorrhage in 21 (63.6%) of the 33 women. Hemorrhage was successfully arrested by conservative surgery in 13 cases, and by medical management in 8 cases. Emergency hysterectomy was performed in 12 cases (0.7 per 1000 deliveries) No maternal deaths occurred, but there were 2 early neonatal deaths (6.1 %). Atony of the uterus was the main cause of hemorrhage (n=15). Genital tract laceration was associated with a worse prognosis, but the time lapse between delivery and surgery appears to be the main prognostic factor. Uterine atony and morbid adherent placenta are major causes of massive obstetric hemorrhage. In our series, morbidity was high, but there was no mortality. Obstetricians should identify women at risk which is especially associated with a prior cesarean delivery, a current placenta previa and high parity. Early intervention and proper procedure could minimize the complications.

To quantify the contribution of placenta accreta to the rate of postpartum hemorrhage and severe postpartum hemorrhage. All hospital deliveries in Canada (excluding Quebec) for the years 2009 and 2010 (N=570,637) were included in a retrospective cohort study using data from the Canadian Institute for Health Information. Placenta accreta included placental adhesion to the uterine wall, musculature, and surrounding organs (accreta, increta, or percreta). Severe postpartum hemorrhage included postpartum hemorrhage with blood transfusion, hysterectomy, or other procedures to control bleeding (including uterine suturing and ligation or embolization of pelvic arteries). Rates, rate ratios, population-attributable fractions (ie, incidence of postpartum hemorrhage attributable to placenta accreta), and 95% confidence intervals (CIs) were estimated. Logistic regression was used to quantify associations between placenta accreta and risk factors. The incidence of placenta accreta was 14.4 (95% CI 13.4-15.4) per 10,000 deliveries (819 cases among 570,637 deliveries), whereas the incidence of placenta accreta with postpartum hemorrhage was 7.2 (95% CI 6.5-8.0) per 10,000 deliveries. Postpartum hemorrhage among women with placenta accreta was predominantly third-stage hemorrhage (41% of all cases). Although placenta accreta was strongly associated with postpartum hemorrhage (rate ratio 8.3, 95% CI 7.7-8.9), its low frequency resulted in a small population-attributable fraction (1.0%, 95% CI 0.93-1.16). However, the strong association between placenta accreta and postpartum hemorrhage with hysterectomy (rate ratio 286, 95% CI 226-361) resulted in a population-attributable fraction of 29.0% (95% CI 24.3-34.3). Placenta accreta is too infrequent to account for the recent temporal increase in postpartum hemorrhage but contributes substantially to the proportion of postpartum hemorrhage with hysterectomy.

Low-dose asprin use during pregnancy may be a potential risk for postpartum hemorrhage and increased blood loss: a systematic review and meta-analysis.

Background: The cause of AKI in DIY 2018, 11% of post-partum hemorrhage, with a gap in MMR target and achievement &lt;102 / 100,000 live births, MMR in 2018: 111.5 / 100,000 live births, indicating an increase in MMR. In the same year at Panti Rapih Hospital, there was an increase in the incidence of post-partum hemorrhage by 6%, with 62.8% of parity at risk, 53.5% of age at risk.&#x0D; Objective: of the study was to determine the relationship between parity and maternal age with the incidence of primary post-partum hemorrhage at Panti Rapih Hospital in 2017-2018.&#x0D; Methods: observational, cross sectional design, sample 43 people. Chi Square Test data analysis.&#x0D; Results: There was a significant relationship between parity and the incidence of primary post partum hemorrhage (p-value = 0.011). There was a significant relationship between age and the incidence of primary post-partum hemorrhage at Panti Rapih Hospital (p-value = 0.014).&#x0D; Conclusion: There is a significant relationship between parity, maternal age &lt;20 years or&gt; 35 years with the incidence of primary post partum hemorrhage at Panti Rapih Hospital in 2017-2018.

Active management of the third stage of labour (AMTSL) using oxytocin substantially reduces postpartum haemorrhage (PPH), a leading cause of maternal mortality. An economic analysis of the use of AMTSL was conducted as part of an intervention study in Thanh Hoa Province, Vietnam. A spreadsheet was used to calculate various scenarios and estimate the costs and outcomes of the routine use of AMTSL with oxytocin in Uniject compared with oxytocin in ampoules, and AMTSL compared with no AMTSL. We estimated the health outcomes from probabilities that were generated from the effectiveness portion of the AMTSL intervention project. The study also estimates the costs of treating PPH and the net incremental costs of AMTSL (costs and savings); examines the impact of different scenarios of PPH rate and Uniject cost; and estimates the potential cost per PPH case and PPH death averted. The additional net cost per woman of providing AMTSL with ampoules was just US dollar 0.20 in the base case; using Uniject devices added only US dollar 0.08 more per woman to the ampoule cost. Varying the rate of PPH had the biggest effect; if the underlying PPH rate were 8%, the incremental cost of AMTSL drops to just US dollar 0.07 per woman with ampoules and the cost to avert a case of PPH is US dollar 2.10 with ampoules and US dollar 4.52 with Uniject. The low net incremental cost of AMTSL suggests that the introduction of AMTSL in primary-level facilities in Vietnam can reduce the incidence of PPH and benefit women's health without adding much to national health care costs.

ObjectiveTo derive population-based incidence rates of postpartum haemorrhage (PPH) and to investigate trends associated with method of delivery and blood transfusion. Specific focus was given to PPH due to atonic...

IntroductionPostpartum hemorrhage remains a leading cause of maternal morbidity and mortality worldwide. Therefore, cumulative incidence of postpartum hemorrhage and severe postpartum hemorrhage are commonly monitored within and compared across maternity hospitals or countries for obstetrical safety improvement. These indicators are usually based on hospital discharge data though their accuracy is seldom assessed. We aimed to measure postpartum hemorrhage and severe postpartum hemorrhage using electronic health records and hospital discharge data separately and compare the detection accuracy of these methods to manual chart review, and to examine the temporal trends in cumulative incidence of these potentially avoidable adverse outcomes.Materials and methodsWe analyzed routinely collected data of 7904 singleton deliveries from a large Swiss university hospital for a three year period (2014–2016). We identified postpartum hemorrhage and severe postpartum hemorrhage in electronic health records by text mining discharge letters and operative reports and calculating drop in hemoglobin from laboratory tests. Diagnostic and procedure codes were used to identify cases in hospital discharge data. A sample of 334 charts was reviewed manually to provide a reference-standard and evaluate the accuracy of the other detection methods.ResultsSensitivities of detection algorithms based on electronic health records and hospital discharge data were 95.2% (95% CI: 92.6% 97.8%) and 38.2% (33.3% to 43.0%), respectively for postpartum hemorrhage, and 87.5% (85.2% to 89.8%) and 36.2% (26.3% to 46.1%) for severe postpartum hemorrhage. Postpartum hemorrhage cumulative incidence based on electronic health records decreased from 15.6% (13.1% to 18.2%) to 8.5% (6.7% to 10.5%) from the beginning of 2014 to the end of 2016, with an average of 12.5% (11.8% to 13.3%). The cumulative incidence of severe postpartum hemorrhage remained at approximately 4% (3.5% to 4.4%). Hospital discharge data-based algorithms provided significantly underestimated incidences.ConclusionsHospital discharge data is not accurate enough to assess the incidence of postpartum hemorrhage at hospital or national level. Instead, automated algorithms based on structured and textual data from electronic health records should be considered, as they provide accurate and timely estimates for monitoring and improvement in obstetrical safety. Furthermore, they have the potential to better code for postpartum hemorrhage thus improving hospital reimbursement.