Postpartum haemorrhage: prevention and treatment

In this study, we sought to (1) define trends in the incidence of postpartum hemorrhage (PPH), and (2) elucidate the contemporary epidemiology of PPH focusing on risk factors and maternal outcomes related to this delivery complication. Hospital admissions for delivery were extracted from the Nationwide Inpatient Sample, the largest discharge dataset in the United States. Using International Classification of Diseases, Clinical Modification (ninth revision) codes, deliveries complicated by PPH were identified, as were comorbid conditions that may be risk factors for PPH. Temporal trends in the incidence of PPH from 1995 to 2004 were assessed. Logistic regression was used to identify risk factors for the most common etiology of PPH-uterine atony. In 2004, PPH complicated 2.9% of all deliveries; uterine atony accounted for 79% of the cases of PPH. PPH was associated with 19.1% of all in-hospital deaths after delivery. The overall rate of PPH increased 27.5% from 1995 to 2004, primarily because of an increase in the incidence of uterine atony; the rates of PPH from other causes including retained placenta and coagulopathy remained relatively stable during the study period. Logistic regression modeling identified age or =40 years, cesarean delivery, hypertensive diseases of pregnancy, polyhydramnios, chorioamnionitis, multiple gestation, retained placenta, and antepartum hemorrhage as independent risk factors for PPH from uterine atony that resulted in transfusion. Excluding maternal age and cesarean delivery, one or more of these risk factors were present in only 38.8% of these patients. PPH is a relatively common complication of delivery and is associated with substantial maternal morbidity and mortality. It is increasing in frequency in the United States. PPH caused by uterine atony resulting in transfusion often occurs in the absence of recognized risk factors.

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. 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. 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. A doubling in incidence of severe PPH over 10 years was not explained by contemporaneous changes in studied risk factors. Copyright © 2013 Mosby, Inc. All rights reserved.

Postpartum haemorrhage (PPH) is an important cause of maternal mortality. We conducted a systematic review of the prevalence of PPH with the objective of evaluating its magnitude both globally and in different regions and settings: global figures, as well as regional, country and provincial variations, are likely to exist but are currently unknown. We used prespecified criteria to select databases, recorded the database characteristics and assessed their methodological quality. After establishing PPH (>or=500 mL blood loss) and severe PPH (SSPH) (>or=1000 mL blood loss) as main outcomes, we found 120 datasets (involving a total of 3,815,034 women) that reported PPH and 70 datasets (505,379 women) that reported SPPH in the primary analysis. The prevalence of PPH and SPPH is approximately 6% and 1.86% of all deliveries, respectively, with a wide variation across regions of the world. The figures we obtained give a rough estimate of the prevalence of PPH and suggest the existence of some variations. For a reliable picture of PPH worldwide - its magnitude, distribution and consequences - a global survey tackling this condition is necessary.