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CME / ABIM MOC / CE

Are Postpartum Hemorrhage Rates and Risk Factors Rising?

  • Authors: MDEdge News Author: Heidi Splete; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 2/3/2023
  • Valid for credit through: 2/3/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for obstetricians/gynecologists/women’s health clinicians, family medicine/primary care clinicians, internists, nurses, physician assistants, and other members of the health care team caring for patients with or at risk for postpartum hemorrhage.

The goal of this activity is for healthcare team members to be better able to describe temporal trends in and risk factors for postpartum hemorrhage and the association of risk factors with postpartum hemorrhage-related interventions such as blood transfusion and peripartum hysterectomy.

Upon completion of this activity, participants will:

  • Assess temporal trends in and risk factors for postpartum hemorrhage and the association of risk factors with postpartum hemorrhage-related interventions, based on a repeated cross-sectional study analyzing delivery hospitalizations from 2000 to 2019 in the National (Nationwide) Inpatient Sample
  • Evaluate the clinical implications of temporal trends in and risk factors for postpartum hemorrhage and the association of risk factors with postpartum hemorrhage-related interventions, based on a repeated cross-sectional study analyzing delivery hospitalizations from 2000 to 2019 in the National (Nationwide) Inpatient Sample
  • Outline implications for the healthcare team


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Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


MDEdge News Author

  • Heidi Splete

    Disclosures

    Heidi Splete has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / ABIM MOC / CE

Are Postpartum Hemorrhage Rates and Risk Factors Rising?

Authors: MDEdge News Author: Heidi Splete; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 2/3/2023

Valid for credit through: 2/3/2024, 11:59 PM EST

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Clinical Context

Postpartum hemorrhage is the leading cause of maternal mortality globally and a significant cause of US maternal morbidity and mortality. Risk factors include clinical factors causing uterine atony, uterine overdistention, cesarean delivery, uterine fibroids, and advanced age.

Many of these risk factors appear to be increasing in the population. Recent US population trends in postpartum hemorrhage risk and outcomes in the setting of recent clinical management changes are poorly characterized.

Study Synopsis and Perspective

The rate of postpartum hemorrhage for hospital deliveries in the United States increased significantly over the course of a 20-year period, according to data from more than 76 million delivery hospitalizations from the National Inpatient Sample.

Postpartum hemorrhage remains the leading cause of maternal morbidity and mortality worldwide, and many clinical- and patient-level risk factors appear to be on the rise, write Chiara M. Corbetta-Rastelli, MD, from the University of California, San Francisco, and colleagues.

Although practice changes have been introduced to reduce postpartum hemorrhage, recent trends in postpartum hemorrhage risk and outcomes in the context of such changes as hemorrhage safety bundles have not been examined, they said.

In a study published in Obstetrics & Gynecology, the researchers reviewed data from hospitalizations for females aged 15 to 54 years for deliveries between 2000 and 2019, using the National Inpatient Sample.[1] They used a regression analysis to estimate average annual percentage changes (AAPC). Their objectives were to characterize trends and to assess the association between risk factors and the occurrence of postpartum hemorrhage and related interventions. Demographics, clinical factors, and hospital characteristics were mainly similar between the group of patients with postpartum hemorrhage and those with no postpartum hemorrhage.

Approximately 3% (2.3 million) of 76.7 million hospitalizations for delivery were complicated by postpartum hemorrhage during the study period, and the annual rate increased from 2.7% to 4.3%.

Overall, 21.4% of individuals with delivery hospitalizations complicated by postpartum hemorrhage had 1 postpartum risk factor and 1.4% had 2 or more risk factors. The number of individuals with at least 1 risk factor for postpartum hemorrhage increased significantly, from 18.6% to 26.9%, during the study period, with an annual percentage change of 1.9%.

Compared with deliveries in individuals without risk factors, individuals with 1 risk factor had slightly higher odds of postpartum hemorrhage (odds ratio, 1.14), but those with 2 or more risk factors were more than twice as likely to experience postpartum hemorrhage as those with no risk factors (odds ratio, 2.31).

The researchers also examined the association of specific risk factors and interventions related to hemorrhage--notably, blood transfusion and peripartum hysterectomy. Blood transfusions in individuals with postpartum hemorrhage increased from 5.4% to 16.7% between 2000 and 2011 (AAPC, 10.2%) and then decreased from 16.7% to 12.6% from 2011 to 2019 (AAPC, −3.9%).

Peripartum hysterectomy in the study population increased from 1.4% to 2.4% from 2000 to 2009 (AAPC 5.0%), remained steady from 2009 to 2016, and then decreased from 2.1% to 0.9% from 2016 to 2019 (AAPC, −27%).

Other risk factors associated with postpartum hemorrhage itself and with blood transfusion and hysterectomy in the setting of postpartum hemorrhage included prior cesarean delivery with placenta previa or accreta, placenta previa without prior cesarean delivery, and antepartum hemorrhage or placental abruption, the researchers note.

“In addition to placental abnormalities, risk factors such as preeclampsia with severe features, polyhydramnios, and uterine leiomyomas demonstrated the highest rates of increase in our data,” they write in their discussion. These trends may lead to continuing increases in postpartum hemorrhage risk, which was not fully explained by the increase in risk factors seen in the current study, the researchers said.

The study findings were limited by several factors, including the use of billing codes that could lead to misclassification of diagnoses, as well as possible differences in the definition and coding for postpartum hemorrhage among hospitals, the researchers note. Other limitations were the exclusion of cases of readmission for postpartum hemorrhage and lack of clinical details involving use of medications or nonoperative interventions, they said.

Notably, the study finding of stable to decreasing peripartum hysterectomy rates in hospitalized patients with postpartum hemorrhage conflicts with another recent study showing an increase in peripartum hysterectomy from 2009 to 2020, but this difference may reflect changes in billing, indications for hysterectomy, or study modeling, they note.[2]

The current study was strengthened by the use of a large database to analyze population trends, a contemporary study period, and the inclusion of meaningful outcomes such as peripartum hysterectomy.

The shift in blood transfusion and peripartum hysterectomy may reflect the implementation of protocols to promote early intervention and identification of postpartum hemorrhage, they conclude.

Interventions can have an effect

“Hemorrhage remains a leading cause of maternal mortality in the United States, and blood transfusion is the most common severe maternal morbidity,” Catherine M. Albright, MD, associate professor of maternal-fetal medicine at the University of Washington, Seattle, said in an interview. “It is important to understand the current state, especially given that many hospitals have implemented policies and procedures to better identify and treat postpartum hemorrhage,” she said.

Dr Albright added, “I was pleased to see that they did not just look at a diagnosis of postpartum hemorrhage but rather also looked at complications arising from postpartum hemorrhage, such as blood transfusion or hysterectomy.”

Postpartum hemorrhage is often a clinical diagnosis that uses estimated blood loss, which is a notoriously inaccurate measure, said Dr Albright. “Additionally, the definitions of postpartum hemorrhage, as well as the [International Classification of Diseases] codes, changed during the time period of the study,” she noted. “These factors all could lead to both underreporting and overreporting of the true incidence of postpartum hemorrhage. Blood transfusion and hysterectomy are more objective outcomes and demonstrate true morbidity,” she said.

“Most of the risk factors that are listed in the article are not modifiable during that pregnancy,” said Dr Albright. For example, a history of a prior cesarean or having a twin pregnancy is not something that can be changed, she said. “Many of the other risk factors or associated clinical factors, such as obesity, chronic hypertension, and pregestational diabetes, are modifiable, but before pregnancy. Universal and easy access to primary medical care prior to and between pregnancies may help to mitigate some of these factors,” she noted.

Looking ahead, “It would be helpful to ensure that these types of data are available at the state and hospital level; this will allow for local evaluation of programs that are in place to reduce postpartum hemorrhage risk and improve identification and treatment,” Dr Albright said.

The study received no outside funding. Dr Corbetta-Rastelli and Dr Albright have disclosed no relevant financial relationships.

Obstet Gynecol. 2023;141(1):152-161

Study Highlights

  • This repeated cross-sectional study analyzed National Inpatient Sample delivery hospitalizations from 2000 to 2019.
  • Trends analyses used joinpoint regression to estimate AAPCs.
  • Unadjusted/adjusted logistic regression assessed relationships between postpartum hemorrhage risk factors and likelihood of postpartum hemorrhage, postpartum hemorrhage requiring blood transfusion, and peripartum hysterectomy for postpartum hemorrhage.
  • 2.3 million (3.0%) of approximately 76.7 million delivery hospitalizations had postpartum hemorrhage.
  • From 2000 to 2019 postpartum hemorrhage rate increased from 2.7% to 4.3% (AAPC, 2.6%; 94% CI, 1.7%-3.5%).
  • 21.4% of women with postpartum hemorrhage had 1 risk factor and 1.4% had 2 or more risk factors.
  • Proportion of deliveries to women with at least 1 postpartum hemorrhage risk factor increased from 18.6% to 26.9% (AAPC, 1.9%; 95% CI, 1.7%-2.0%).
  • Odds of postpartum hemorrhage were slightly higher in women with 1 risk factor vs those without risk factors (odds ratio [OR], 1.14) and more than double in those with 2 or more risk factors (OR, 2.31), with similar estimates after adjustment for demographic and clinical factors.
  • The number of postpartum hemorrhage risk factors was also associated with higher odds of transfusion (1 factor: OR, 3.51; 2 or more factors: OR, 2.29) and peripartum hysterectomy.
  • Among deliveries with postpartum hemorrhage, blood transfusions rose from 5.4% to 16.7% from 2000 to 2011 (AAPC, 10.2%) and then fell from 16.7% to 12.6% from 2011 to 2019 (AAPC, −3.9%).
  • Peripartum hysterectomy among hospitalized individuals with postpartum hemorrhage increased from 1.4% to 2.4% from 2000 to 2009 (AAPC, 5.0%), remained stable from 2009 to 2016, and then decreased significantly from 2.1% to 0.9% from 2016 to 2019 (AAPC, −27.0%; 95% CI, −35.2% to −17.6%).
  • Risk factors for postpartum hemorrhage and associated transfusion and hysterectomy included prior cesarean with previa or placenta accreta, placenta previa without prior cesarean, and antepartum hemorrhage or placental abruption.
  • The greatest risk factor increases were in placental abnormalities, such as preeclampsia with severe features, polyhydramnios, and uterine leiomyomas.
  • The investigators concluded that postpartum hemorrhage and related risk factors increased during a 20-year period, but despite this, blood transfusions and hysterectomy rates recently decreased.
  • Stable-to-decreasing peripartum hysterectomy rates conflict with another recent study showing increased peripartum hysterectomy from 2009 to 2020, which may reflect changes in billing, hysterectomy indications, or study modeling.
  • Increase in risk factors may contribute to, but not fully explain, continuing increases in postpartum hemorrhage risk, as 73.8% of deliveries with postpartum hemorrhage had no known risk factors.
  • Most risk factors, such as twin pregnancy or prior cesarean, are not modifiable, but low-dose aspirin may help prevent preeclampsia.
  • Universal, easy health care access before and between pregnancies may help lessen the effect of modifiable risk factors such as obesity, chronic hypertension, and pregestational diabetes.
  • Improved postpartum hemorrhage diagnosis and national quality efforts to improve identification and management may help explain recent decreases in blood transfusions and hysterectomies.
  • Study limitations included potential diagnosis misclassification from use of billing codes, possible differences in postpartum hemorrhage definition and coding among hospitals, exclusion of cases of postpartum hemorrhage readmission, and lack of data regarding medications or nonoperative interventions.
  • In addition, changes in postpartum hemorrhage definitions and International Classification of Diseases codes during the study could cause underreporting or overreporting of true incidence.
  • Future availability of similar data at state and hospital levels should facilitate local assessment of programs intended to reduce postpartum hemorrhage risk and improve identification and treatment.

Clinical Implications

  • Postpartum hemorrhage and related risk factors increased over the course of 2 decades, but blood transfusions and hysterectomies recently decreased.
  • Increase in risk factors may contribute to, but not fully explain, continuing increases in postpartum hemorrhage risk.
  • Implications for the Health Care Team: The care team should consider the use of standardized protocols or safety bundles, for early recognition and more timely medical management of modifiable risk factors.

 

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