Increase In Postpartum Haemorrhage Research Articles

Postpartum haemorrhage trends in Sweden using the Robson ten group classification system: a population-based cohort study.

To examine postpartum haemorrhage (PPH) trends in Sweden using the Robson classification system. Population-based cohort study. Sweden. Deliveries in 2000-2016, classified as Robson groups 1-5 (singleton pregnancies in vertex presentation, from gestational weeks 37+0; n = 1 590 178). We examined temporal trends in PPH between 2000 and 2016 overall, and within each Robson group, and performed logistic regression to examine the influence of changes in risk factors (maternal, comorbidity, obstetric practice and infant factors) over time. Postpartum haemorrhage, defined as an estimated blood loss of >1000 ml. The overall PPH rate increased from 5.4 to 7.3%, corresponding to a 37% (OR 1.37, 95% CI 1.32-1.42) increase over time. Rates varied between Robson groups, ranging from 4.5% in group 3 to 14.3% in group 4b. Increasing trends in PPH were found in all Robson groups except for groups 2b and 4b (prelabour caesarean deliveries). In the unstratified analysis, adjusting for maternal, comorbidity and obstetric practice factors slightly attenuated the risk of PPH in the later period (2013-2016), compared with the reference period (2000-2004; crude OR 1.26, 95% CI 1.24-1.29, adjusted OR 1.22, 95% CI 1.20-1.25). Within individual Robson groups, changes in risk factors did not explain increasing rates of PPH. Postpartum haemorrhage rates varied between Robson groups. Changes in risk factors could not explain the 37% increase in PPH for women in Robson groups 1-5 in Sweden, 2000-2016. Changes in risk factors could not explain the increasing trend of PPH in Sweden, and rates of PPH varied widely between Robson groups.

1153 Influence of race on adverse perinatal outcomes in women undergoing TOLAC

To examine the association between race and adverse maternal and neonatal outcomes in women who undergo Trial of Labor after Cesarean (TOLAC). This is a retrospective cohort study of singleton non-anomalous pregnancies between 2007 and 2011 using linked vital statistics and discharge data. Chi-square tests were used to compare rates of adverse outcomes for women who underwent TOLAC categorized by race. Multivariable logistic regression was used to control for several factors including race. Race was categorized into six categories of White (Non-Hispanic), Black, Hispanic, Asian, American Native, and Other. The adverse maternal outcomes examined were postpartum hemorrhage (PPH), perineal lacerations, chorioamnionitis, maternal blood transfusion, placental abruption, severe maternal morbidity (SMM), and endomyometritis. The neonatal outcomes examined were infant death, neonatal death (NND), intrauterine fetal death (IUFD), Neonatal Intensive Care Unit (NICU) admission, birth injuries, brachial plexus injury (BPI), hypoxic ischemic encephalopathy (HIE), clavicle fracture, and skull fracture. The cohort consisted of 362,270 pregnancies with a prior CD, 29,628 pregnancies resulted in TOLAC. The cohort of 2,699,312 women consisted of 36,195 TOLAC, 29,638 of which were singleton non-anomalous pregnancies. After controlling for several confounders of interest there was a statistically significant increase in PPH, lacerations, chorioamnionitis, maternal blood transfusions, SMM, endomyometritis, infant death and birth injuries in Asian Women. There was a statistically significant increase in chorioamnionitis and HIE as well as a decrease in lacerations in Black Women. There was a statistically significant increase in chorioamnionitis and endomyometritis in Hispanic women as well as a decrease in infant death (Table 1). Different racial backgrounds increase the risk of maternal and neonatal complications in the settings TOLAC. Practitioners should exercise heightened awareness of the effect of race on these potential adverse outcomes when managing TOLAC.

Major obstetric haemorrhage: Incidence, management and quality of care in Irish maternity units

ObjectiveTo assess major obstetric haemorrhage incidence, management and quality of care in Irish maternity units. DesignIn collaboration with Irish maternity units the National Perinatal Epidemiology Centre (Leitao et al., 2020) carried out a national clinical audit and surveillance of major obstetric haemorrhage (MOH). MethodsMOH was defined as blood loss of at least 2500 ml, transfusion of five or more units of blood or documented treatment for coagulopathy. Co-ordinators in maternity units completed detailed case assessment forms. The denominator data obtained from the individual units was restricted to live births and stillbirths of babies weighing at least 500 g. International Classification of Diseases diagnostic codes from hospital discharge records were used to identify cases of postpartum haemorrhage (PPH) and blood transfusion. ResultsDuring the time period, 2011–2018, there was a 54 % increase in MOH, a 60 % increase in PPH and a 54 % increase in blood transfusion. For 497 reported cases of MOH in 2011–2013, the median estimated blood loss was 3000 ml (range: 600-13,000 ml) and uterine atony was the most common cause. At least one uterotonic agent was used to arrest the bleeding in 94 % of the 477 MOH cases associated with a vaginal or caesarean delivery. A blood transfusion was received in 93 % of cases. Regarding quality of care, the vast majority of reported cases were described as receiving appropriate care and were well managed. ConclusionInternationally, obstetric haemorrhage and especially PPH and its increasing trend remains a major challenge for service providers and clinical staff. A standardisation of definitions of PPH/severe PPH/MOH and agreed approaches to quantitation of blood loss would be valuable developments to allow better investigation and shared learning. Reducing the burden of this morbidity through improvements in care should be a real focus of maternity services.

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

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

Trends and outcomes of postpartum haemorrhage, 2003-2011.

BackgroundWhile rates of postpartum haemorrhage (PPH) have continued to rise, it is not clear if the association with other morbidity and transfusion has changed over time. This study explores the recent trend in postpartum haemorrhage and whether postpartum haemorrhage is associated with increased transfusions or adverse outcomes over time.MethodsLinked birth and hospital data were used to examine ICD-10 AM coded PPH and outcomes in maternal birth admission records, 2003-–2011 in hospitals in New South Wales (NSW), Australia (N = 818,965 pregnancies). Trends were calculated on the whole population, and among subgroups, and tested using the Cochran Armitage test for trend. Logistic regression models were developed separately for vaginal and caesarean births, and for a maternal morbidity composite indicator (excluding transfusion) and red cell transfusion. Adjusted odds ratios (aOR) for each year relative to 2003 and 95 % confidence intervals (CI) are presented with adjustment for maternal (eg. age, country of birth) and pregnancy factors (eg. parity, interventions, pregnancy complications).ResultsOverall, there was a significant increase in the PPH rate, from 6.1 % in 2003 to 8.3 % in 2011 (p < 0.0001). Crude rates of postpartum haemorrhage with transfusion increased from 0.75 % (n = 636) to 1.21 % (n = 1145) (p < 0.0001) while crude rates of postpartum haemorrhage with maternal morbidity increased from 0.18 % (n = 149) to 0.23 % (n = 221) (p = 0.02). Having accounted for maternal and pregnancy factors, there were significant overall decreases in the odds of morbidity among women with a PPH delivering vaginally (in 2006, 2007 and 2010, aORs were 0.70 (95 % CI 0.52, 0.96) 0.69 (0.51, 0.94) and 0.64 (0.47, 0.87) relative to 2003; p < 0.05), and no significant decrease among women delivered by caesarean section (aOR 0.87 (0.58, 1.29) in 2011; p = 0.37). Among women with a PPH delivering vaginally, there was a trend towards a non-linear increase in the adjusted odds of transfusion by birth year. Compared to women who had vaginal births with PPH in 2003, the adjusted odds for transfusion was between 1.1 and 1.2 fold higher for those with a PPH delivering vaginally in 2007, 2009, 2010 and 2011. However there was no significant trend amongst caesarean births (aOR 0.84 (0.66, 1.06) in 2011; p = 0.29).ConclusionsPPH has become more frequent, however this has not been associated with a clear pattern of increased severe maternal morbidity. This suggests that the increase in PPH may represent fewer severe haemorrhages, better management of severe haemorrhage or better recording of PPH. The increase in transfusions following vaginal births with PPH warrants further investigation.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0788-5) contains supplementary material, which is available to authorized users.

Pharmacologic intervention for managing uterine atony and related maternal hemorrhage: what is the most effective drug dose?

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

Does magnesium sulfate increase the incidence of postpartum hemorrhage? A systematic review

The incidence of Postpartum Hemorrhage (PPH) is increasing in the western world. We hypothesize that magnesium sulfate (MgSO4) could be a contributing factor. MgSO4 might increase the incidence of PPH by induction of vasodilation, tocolytic effects, and effects on the blood like red cell deformity, platelet activity inhibition and a prolonged bleeding time. Based on these effects of MgSO4 a correlation with PPH is suspected. MgSO4 is widely used in the prevention of eclampsia. However, the working mechanism of this effective drug is largely unknown. We performed a systematic search to find all Randomized Controlled trials (RCTs) containing MgSO4 in preeclamsia as well as all MgSO4 studies with information on PPH. Titles, abstracts and references of publications were evaluated for appropriateness and whether they met the inclusion criteria. RCTs about MgSO4 with original data on PPH prevalence were included in our systematic review. We calculated the relative risk of PPH in every study as well as an overall relative risk. Four relevant and valid RCTs were found, totalling 11,621 relevant patients. The relative risk of PPH in women treated with MgSO4 is 0.964 (95% CI 0.886 - 1.050) In this systematic review we found no significant increase in PPH in women treated with MgSO4. However, there is still room for discussion due to the heterogeneity in methods (dosage and duration of treatment), results, and tertiary outcomes, as well as the small number of studies found with respect to this important issue.

A new perspective on VBAC: A retrospective cohort study

Previous studies assessing the safety of vaginal birth after caesarean section (VBAC) have compared VBAC to elective repeat caesarean section (ERCS), despite the fact that the risks posed by each are considerably different. Explaining the complications of VBAC in a way that is meaningful to women can be challenging, and thus a comparison to a similar group of women who have also not undergone previous vaginal delivery may be a more relevant comparison. When counselling women undergoing planned VBAC, should a comparison of outcomes be made to women undergoing ERCS, or is a comparison to other nulliparous women undergoing vaginal birth a more valid comparison in terms of risk outcomes? A retrospective cohort study was undertaken comprising a consecutive cohort of 21,389 women who delivered, stratified by Robson's criteria into Robson groups 1-5. Those in Robson groups 6-10 were not included. Demographic data and maternal/neonatal outcomes were reviewed, with main outcome measures comprising uterine rupture, post-partum haemorrhage (PPH), 3rd/4th degree tears and neonatal morbidity. There was no increase in PPH, vaginal tears or neonatal complications in the VBAC group when compared to Robson groups 1 and 2 (nulliparous women in spontaneous or induced labour, respectively). Uterine rupture rates were low in all groups, with no correlation identified. The maternal and neonatal morbidity associated with VBAC is comparable to primiparous women undergoing a vaginal birth. In demonstrating the low relative morbidity in this comparison, these outcomes may aid in counselling women faced with the choice of VBAC versus ERCS.

Trends in postpartum hemorrhage: United States, 1994–2006

The purpose of this study was to estimate the incidence of postpartum hemorrhage (PPH) in the United States and to assess trends. Population-based data from the 1994-2006 National Inpatient Sample were used to identify women who were hospitalized with postpartum hemorrhage. Data for each year were plotted, and trends were assessed. Multivariable logistic regression was used in an attempt to explain the difference in PPH incidence between 1994 and 2006. PPH increased 26% between 1994 and 2006 from 2.3% (n = 85,954) to 2.9% (n = 124,708; P < .001). The increase primarily was due to an increase in uterine atony, from 1.6% (n = 58,597) to 2.4% (n = 99,904; P < .001). The increase in PPH could not be explained by changes in rates of cesarean delivery, vaginal birth after cesarean delivery, maternal age, multiple birth, hypertension, or diabetes mellitus. Population-based surveillance data signal an apparent increase in PPH caused by uterine atony. More nuanced clinical data are needed to understand the factors that are associated with this trend.