Is the increase in postpartum hemorrhage after vaginal birth because of altered clinical practice?: A register-based cohort study

Postpartum hemorrhage: risk factors for severe blood loss, surgical intervention and peripartum hysterectomy

PURPOSE

To evaluate risk factors in patients presenting with postpartum hemorrhage (PPH) associated with severe blood loss (BL), surgical intervention or peripartum hysterectomy.

METHODS

This retrospective cohort study included all patients who gave birth at the Hannover Medical School between January 2013 and August 2022 with PPH, defined as BL ≥ 500 ml after vaginal delivery and ≥ 1000 ml after cesarean section. The threshold for severe PPH was set at BL ≥ 1500 ml. Operative management included manual placental removal and/or aspiration/curettage, need for intrauterine balloon tamponade, uterine packing with a chitosan covered gauze or compression sutures. Hysterectomy as ultima ratio was observed separately.

RESULTS

In total 20.9% of 1038 patients with PPH developed severe BL. Several risk factors were identified such as nicotine abuse (aOR 3.45, 95% CI 1.57-7.59, p = 0.002), multiparity (aOR 2.12, 95% CI 1.10-4.10, p = 0.03), uterine malformation (aOR 5.09, 95% CI 1.22-21.16, p = 0.03), c-section (aOR 3.92, 95% CI 2.59-5.92, p < 0.001), placenta praevia (aOR 2.82, 95% CI 1.2-6.63, p = 0.02), abnormal placentation (aOR 9.76, 95% CI 4.22-22.56, p < 0.001) and inversion of the uterus (aOR 16.89, 95% CI 1.62-176.12, p = 0.02). More than one third of the women had a surgical intervention. Independent risk factors for an operative management of PPH were uterus malformation (aOR 5.04, 95% CI 1.22-20.91, p = 0.03), placenta praevia (aOR 2.84, 95% CI 1.23-6.53, p = 0.01), abnormal placentation (aOR 9.78, 95% CI 4.30-22.27, p < 0.001) and c-section (aOR 4.65, 95% CI 3.14-6.89, p < 0.001). Peripartum hysterectomy occurred in 1.9% of the cases and was in addition independently associated wih preeclampsia (aOR 7.50, 95% CI 1.29-43.81, p = 0.03) and amniotic infection syndrome (aOR 12.22, 95% CI 1.92-77.90, p = 0.01).

CONCLUSION

PPH is a common complication in modern obstetrics and one in five patients with pathological bleeding after birth develops severe BL. There are specific risk factors associated with a BL ≥ 1500 ml, surgical intervention and peripartum hysterectomy in PPH that should be assessed by health professionals and taken into account in the management of this postpartum complication.

Postpartum hemorrhage and postpartum depression: A systematic review and meta-analysis of observational studies

OBJECTIVE

To assess the postpartum depression (PPD) risk in women with postpartum hemorrhage (PPH) and moderators.

METHODS

We identified observational studies of PPD rates in women with versus without PPH in Embase/Medline/PsychInfo/Cinhail in 09/2022. Study quality was evaluated using the Newcastle-Ottawa-Scale. Our primary outcome was the odds ratio (OR, 95% confidence intervals [95%CI]) of PPD in women with versus without PPH. Meta-regression analyses included the effects of age, body mass index, marital status, education, history of depression/anxiety, preeclampsia, antenatal anemia and C-section; subgroup analyses were based on PPH and PPD assessment methods, samples with versus without history of depression/anxiety, from low-/middle- versus high-income countries. We performed sensitivity analyses after excluding poor-quality studies, cross-sectional studies and sequentially each study.

RESULTS

One, five and three studies were rated as good-, fair- and poor-quality respectively. In nine studies (k = 10 cohorts, n = 934,432), women with PPH were at increased PPD risk compared to women without PPH (OR = 1.28, 95% CI = 1.13 to 1.44, p < 0.001), with substantial heterogeneity (I2 = 98.9%). Higher PPH-related PPD ORs were estimated in samples with versus without history of depression/anxiety or antidepressant exposure (OR = 1.37, 95%CI = 1.18 to 1.60, k = 6, n = 55,212, versus 1.06, 95%CI = 1.04 to 1.09, k = 3, n = 879,220, p < 0.001) and in cohorts from low-/middle- versus high-income countries (OR = 1.49, 95%CI = 1.37 to 1.61, k = 4, n = 9197, versus 1.13, 95%CI = 1.04 to 1.23, k = 6, n = 925,235, p < 0.001). After excluding low-quality studies the PPD OR dropped (1.14, 95%CI = 1.02 to 1.29, k = 6, n = 929,671, p = 0.02).

CONCLUSIONS

Women with PPH had increased PPD risk amplified by history of depression/anxiety, whereas more data from low-/middle-income countries are required.

Trends in postpartum hemorrhage and manual removal of the placenta and the association with childbirth interventions: A Dutch nationwide cohort study

BACKGROUND

Because the cause of increasing rates of postpartum hemorrhage (PPH) and manual placental removal (MROP) is still unknown, we described trends in PPH, MROP, and childbirth interventions and examined factors associated with changes in rates of PPH and MROP.

METHODS

This nationwide cohort study used national perinatal registry data from 2000 to 2014 (n = 2,332,005). We included births of women who gave birth to a term singleton child in obstetrician-led care or midwife-led care. Multivariable logistic regression analyses were used to examine associations between characteristics and interventions, and PPH ≥ 1000 mL and MROP.

RESULTS

PPH rates increased from 4.3% to 6.6% in obstetrician-led care and from 2.5% to 4.8% in midwife-led care. MROP rates increased from 2.4% to 3.4% and from 1.0% to 1.4%, respectively. A rising trend was found for rates of induction and augmentation of labor, pain medication, and cesarean section, while rates of episiotomy and assisted vaginal birth declined. Adjustments for characteristics and childbirth interventions did not result in large changes in the trends of PPH and MROP. After adjustments for childbirth interventions, in obstetrician-led care, the odds ratio (OR) of PPH in 2014 compared with the reference year 2000 changed from 1.66 (95% CI 1.57-1.76) to 1.64 (1.55-1.73) among nulliparous women and from 1.56 (1.47-1.66) to 1.52 (1.44-1.62) among multiparous women. For MROP, the ORs changed from 1.51 (1.38-1.64) to 1.36 (1.25-1.49) and from 1.56 (1.42-1.71) to 1.45 (1.33-1.59), respectively.

CONCLUSIONS

Rising PPH trends were not associated with changes in population characteristics and rising childbirth intervention rates. The rising MROP was to some extent associated with rising intervention rates.

The infection, cervical and perineal lacerations in relation to postpartum hemorrhage following vaginal delivery induced by Cook balloon catheter

OBJECTIVE

To identify whether infection, cervical laceration and perineal laceration are associated with postpartum hemorrhage in the setting of vaginal delivery induced by Cook balloon catheter.

MATERIALS AND METHODS

The retrospective study included 362 women who gave birth vaginally at or beyond 37 weeks of gestation with a diagnosis of postpartum hemorrhage between February 2021 to May 2022, of which including 216 women with induction of labor (Cook balloon catheter followed by oxytocin or oxytocin) and 146 women with spontaneous delivery. Risk factors for postpartum hemorrhage were collected and compared.

RESULTS

362 women were divided into three groups, group 1 with spontaneous delivery, group 2 with oxytocin, group 3 with Cook balloon catheter followed by oxytocin. There was no significant difference in incidence of infection within three groups (P > 0.05). The rate of cervical laceration and perineal laceration was significantly higher in group 3 compared with groups 2 and 1 (P < 0.05); Multivariate logistic regression analysis found that compared with group 1, either group 3 or group 2 was associated with increased risks of cervical laceration and perineal laceration (P < 0.05), and compared with group 2, group 3 was not associated with increased risks of cervical laceration and perineal laceration (P > 0.05).

CONCLUSION

Infection, cervical laceration and perineal laceration are identified not to be independent risk factors for postpartum hemorrhage for women undergoing labor with Cook balloon catheter; Cervical laceration and perineal laceration increase the risk of postpartum hemorrhage in women with labor induction.

Analysis of risk factors associated with different degrees of postpartum hemorrhage in patients with pregnancy-induced hypertension and construction of a prediction model using line graph

OBJECTIVE

This study aims to analyze the risk factors associated with different degrees of postpartum hemorrhage in patients with pregnancy-induced hypertension and construct a prediction model using line graph.

METHODS

The patients who were treated in our hospital for pregnancy-induced hypertension from January 2021 to December 2022 were enrolled as the study subjects. Their clinical data were collected, and the risk factors associated with postpartum hemorrhage in patients with pregnancy-induced hypertension were analyzed by single-factor and multi-factor logistic regression. The nomogram prediction model was constructed and validated internally, and the discrimination and consistency of the model were verified by the ROC curve and calibration graph.

RESULTS

In this experiment, 125 out of the 482 patients with hypertensive disorder complicating pregnancy experienced different degrees of postpartum hemorrhage, with an incidence of 25.93%. Multivariate Logistic regression analysis showed that patients with severe disease (OR = 2.454), the degree of proteinuria +++ or ++++ (OR = 6.754, 7.206), fetal body mass ≥4000 g (OR = 5.972), uterine atony (OR = 11.789), abnormal HDL-C (OR = 3.174), abnormal LDL-C (OR = 8.812), and abnormal VEGF (OR = 7.702) had a higher risk of postpartum hemorrhage (p < .05). The risk of postpartum hemorrhage was lower in patients with onset gestational week ≥28 weeks (OR = 0.158, 0.025) and delivery gestational week ≥28 weeks (OR = 0.085, 0.152) (p < .05). Columnar line graph models for postpartum hemorrhage in patients with gestational hypertension were constructed based on nine independent risk factors, and the model differentiation (AUC 0.912 and 0.919, respectively) and precision (goodness of fit HL χ2 = 8.441, p = .392, χ2 = 7.741, p = .459) were better in the modeling and validation groups.

CONCLUSION

The severity of disease, the gestational week upon onset, the gestational week upon delivery, the degree of proteinuria, systolic blood pressure, diastolic blood pressure, uterine atony, HDL-C, LDL-C, VEGF are factors affecting the incidence of postpartum hemorrhage in patients with hypertensive disorder complicating pregnancy. The prediction model based on the above factors can accurately evaluate the risk of different degrees of postpartum hemorrhage in patients with hypertensive disorder complicating pregnancy.

Family history of postpartum hemorrhage is a risk factor for postpartum hemorrhage after vaginal delivery: results from the French prospective multicenter Haemorrhages and Thromboembolic Venous Disease of the Postpartum cohort study

BACKGROUND

Postpartum hemorrhage is a major component of perinatal morbidity and mortality that affects young women worldwide and is still often unpredictable. Reducing the incidence of postpartum hemorrhage is a major health issue and identifying women at risk for postpartum hemorrhage is a key element in preventing this complication.

OBJECTIVE

This study aimed to estimate postpartum hemorrhage prevalence after vaginal delivery and to identify postpartum hemorrhage risk factors.

STUDY DESIGN

Unselected pregnant women ≥16 years of age admitted to 1 of 6 maternity wards in Brittany (France) for vaginal birth after 15 weeks of gestation were recruited in this prospective, multicenter cohort study between June 1, 2015, and January 31, 2019. Postpartum hemorrhage was defined as blood loss ≥500 mL in the 24 hours following delivery. Independent risk factors for postpartum hemorrhage were determined using logistic regression. Missing data were imputed using the Multivariate Imputation by Chained Equations method.

RESULTS

Among 16,382 included women, the postpartum hemorrhage prevalence was 5.37%. A first-degree family history of postpartum hemorrhage (adjusted odds ratio, 1.63; 95% confidence interval, 1.24-2.14) and a personal transfusion history (adjusted odds ratio, 1.90; 95% confidence interval, 1.23-2.92) were significantly associated with postpartum hemorrhage. The use of oxytocin during labor was also a risk factor for postpartum hemorrhage (adjusted odds ratio, 1.24; 95% confidence interval, 1.06-1.44). Inversely, smoking during pregnancy and intrauterine growth restriction were associated with a reduced risk for postpartum hemorrhage (adjusted odds ratio, 0.76; 95% confidence interval, 0.63-0.91, and 0.34; 95% confidence interval, 0.13-0.87, respectively).

CONCLUSION

In addition to classical risk factors, this study identified a family history of postpartum hemorrhage and personal transfusion history as new characteristics associated with postpartum hemorrhage after vaginal delivery. The association of postpartum hemorrhage with a family history of postpartum hemorrhage suggests a hereditary hemorrhagic phenotype and calls for genetic studies. Identifying women at risk for postpartum hemorrhage is a key element of being prepared for this complication.

A prolonged latent phase: An early career in oxytocin during birth

•The author, a nurse-midwife scientist, shares her path to the study of the causes and consequences of clinical oxytocin use.•This paper highlights mentors and key research that informed new thinking about the role of oxytocin during parturition.•Future directions for improving maternal care during childbirth are presented, including genetic and epigenetic perspectives.

Patterns in Second Stage Labor Care Practices Associated With Genital Tract Injury and Postpartum Hemorrhage During Physiologic Birth: A Latent Mixture Model Analysis

INTRODUCTION

Genital tract injury during childbirth contributes to short and long-term problems, including postpartum hemorrhage, incontinence, and pelvic organ prolapse. The purpose of this study was to examine which sets of second stage management techniques employed by midwives attending births in the community setting are associated with genital tract injury and subsequent postpartum hemorrhage.

METHODS

Data from primiparous individuals within the Midwives Alliance of North America (MANA) Stats 2.0 (2004–2009) database were used for this analysis. Latent mixture modeling identified classes (groups) within the sample that are most similar based on 11 different characteristics of second stage management as noted by midwives in their birth notes, including hands-on management techniques during birth, maternal positioning at birth, and water birth.

RESULTS

Three classes of second stage management techniques best fit this complex dataset. The patterns of techniques used by midwives were only marginally associated with better or worse genital tract outcomes independent of other factors. Two covariables, however, advanced maternal age (OR1.60, 95% CI 1.09–2.34) and births with low fetal heart rate during second stage (OR2.82, 95% CI 1.93–4.10)—were associated with severe genital tract injury. Postpartum hemorrhage was more likely for the two classes where midwives used more hands-on management during second stage, even when considering presence of genital tract injury (OR1.33, 95% CI 1.09–1.63). This study highlights the complex second stage circumstances that interact with management techniques, which together shape or contribute to both genital tissue and hemorrhage outcomes.

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

OBJECTIVE

To examine postpartum haemorrhage (PPH) trends in Sweden using the Robson classification system.

DESIGN

Population-based cohort study.

SETTING

Sweden.

POPULATION

Deliveries in 2000-2016, classified as Robson groups 1-5 (singleton pregnancies in vertex presentation, from gestational weeks 37+0; n = 1 590 178).

METHODS

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.

MAIN OUTCOME MEASURES

Postpartum haemorrhage, defined as an estimated blood loss of >1000 ml.

RESULTS

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.

CONCLUSIONS

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.

TWEETABLE ABSTRACT

Changes in risk factors could not explain the increasing trend of PPH in Sweden, and rates of PPH varied widely between Robson groups.