Objective
Because the diagnosis of postpartum hemorrhage (PPH) depends on the accoucheur's subjective
estimate of blood loss and varies according to mode of delivery, we examined temporal
trends in severe PPH, defined as PPH plus receipt of a blood transfusion, hysterectomy,
and/or surgical repair of the uterus.
Study Design
We analyzed 8.5 million hospital deliveries in the US Nationwide Inpatient Sample
from 1999 to 2008 for temporal trends in, and risk factors for, severe PPH, based
on International Classification of Diseases, 9th revision, clinical modification diagnosis and procedure codes. Sequential logistic
regression models that account for the stratified random sampling design were used
to assess the extent to which changes in risk factors explain the trend in severe
PPH.
Results
Of the total 8,571,209 deliveries, 25,906 (3.0 per 1000) were complicated by severe
PPH. The rate rose from 1.9 to 4.2 per 1000 from 1999 to 2008 (P for yearly trend < .0001), with increases in severe atonic and nonatonic PPH, due
especially to PPH with transfusion, but also PPH with hysterectomy. Significant risk
factors included maternal age ≥35 years (adjusted odds ratio [aOR], 1.5; 95% confidence
interval [CI], 1.5–1.6), multiple pregnancy (aOR, 2.8; 95% CI, 2.6–3.0), fibroids
(aOR, 2.0; 95% CI, 1.8–2.2), preeclampsia (aOR, 3.1; 95% CI, 2.9–3.3), amnionitis
(aOR, 2.9; 95% CI, 2.5–3.4), placenta previa or abruption (aOR, 7.0; 95% CI, 6.6–7.3),
cervical laceration (aOR, 94.0; 95% CI, 87.3–101.2), uterine rupture (aOR, 11.6; 95%
CI, 9.7–13.8), instrumental vaginal delivery (aOR, 1.5; 95% CI, 1.4–1.6), and cesarean
delivery (aOR, 1.4; 95% CI, 1.3–1.5). Changes in risk factors, however, accounted
for only 5.6% of the increase in severe PPH.
Conclusion
A doubling in incidence of severe PPH over 10 years was not explained by contemporaneous
changes in studied risk factors.
Key words
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References
- The World Health Report: 2005: Make every mother and child count.World Health Organization, Geneva2005
- Deaths: final data for 2004.Natl Vital Stat Rep. 2007; 55: 1-119
- Increased postpartum hemorrhage rates in Australia.Int J Gynecol Obstet. 2007; 98: 237-243
- Investigation of an increase in postpartum haemorrhage in Canada.BJOG. 2007; 114: 751-759
- Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group.BMC Pregnancy and Childbirth. 2009; 9: 55
- Trends in postpartum hemorrhage: United States, 1994-2006.Am J Obstet Gynecol. 2010; 202: 353.e1-353.e6
- The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries.Anesth Analg. 2010; 110: 1368-1373
- Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions?.Obstet Gynecol Surv. 2012; 66: 18-20
- Risk factors for postpartum hemorrhage: can we explain the recent temporal increase?.J Obstet Gynaecol Can. 2011; 33: 810-819
- Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study.BJOG. 2012; 119: 306-314
- Visually estimated and calculated blood loss in vaginal and cesarean delivery.Am J Obstet Gynecol. 2008; 199: 519.e1-519.e7
- Hospital data reporting on postpartum hemorrhage: under-estimates recurrence and over-estimates the contribution of uterine atony.Matern Child Health J. 2012; 16: 1542-1548
Bingham D, Lyndon A, Lagrew D, Main EK. A state-wide obstetric hemorrhage quality improvement initiative. Philadelphia, PA: Lippincott Williams & Wilkins, vol. 36, no. 5, September/October 2011.
- Reducing maternal deaths through state maternal mortality review.J Women's Health. 2012; 21: 905-909
- Health advisory: prevention of maternal deaths through improved management of hemorrhage.State of New York Department of Health,. Aug. 12, 2004;
- How we treat: management of life-threatening primary postpartum hemorrhage with a standardized massive transfusion protocol.Transfusion. 2007; 47: 1564-1572
- Trends and morbidity associated with oxytocin use in labour in nulliparas at term.Aus N Z J Obstet Gynaecol. 2012; 52: 173-178
- Oxytocin exposure during labor among women with postpartum hemorrhage secondary to uterine atony.Am J Obstet Gynecol. 2011; 204: 56.e1-56.e6
- Validity of using ICD-9-CM codes to identify selected categories of obstetric complications, procedures and co-morbidities.Paediatr Perinat Epidemiol. 2012; 26: 421-429
- The changing specter of uterine rupture.Am J Obstet Gynecol. 2009; 200: 269.e1-269.e4
Article Info
Publication History
Published online: July 18, 2013
Accepted:
July 10,
2013
Received in revised form:
May 17,
2013
Received:
January 17,
2013
Footnotes
Supported by a grant from the Canadian Institutes of Health Research .
The authors report no conflict of interest.
Reprints are not available from the authors.
Cite this article as: Kramer MS, Berg C, Abenhaim H, et al. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol 2013;209:449.e1-7.
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Copyright
© 2013 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
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- Secondary analyses from a randomized clinical trial: age as the key prognostic factor in endometrial carcinomaAmerican Journal of Obstetrics & GynecologyVol. 210Issue 6
- PreviewKramer et al1 reported a doubling of the incidence of severe postpartum hemorrhage (PPH) over recent years (1999-2008), although were unable to explain the overall temporal trend despite analyzing traditional risk factors. An audit of 2 UK units, delivering more than 4000 babies per year, showed increases in PPH greater than 1000 mL, and PPH greater than 2000 mL, of greater than 500% (2003-2012).
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