Incidence, risk factors, and temporal trends in severe postpartum hemorrhage
01 Nov 2013-American Journal of Obstetrics and Gynecology (Am J Obstet Gynecol)-Vol. 209, Iss: 5, pp 4-9
TL;DR: A doubling in incidence of severe PPH over 10 years was not explained by contemporaneous changes in studied risk factors, as well as changes in risk factors themselves.
About: This article is published in American Journal of Obstetrics and Gynecology.The article was published on 2013-11-01. It has received 394 citations till now.
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862 citations
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TL;DR: Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle.
Abstract: Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.
256 citations
Cites background from "Incidence, risk factors, and tempor..."
...Typically these tools identify 25% of women to be at higher risk who will then develop 60% of the severe hemorrhages (requiring transfusion).(26,27) Therefore, because approximately 40% of postpartum hemorrhages occur in low-risk women, every birth has to be considered to have risk, reinforcing the need for universal vigilance....
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TL;DR: Substantial variation exists in PPH prevention and management guidelines among 4 national organizations that highlights the need for better evidence and more consistent synthesis of the available evidence with regard to a leading cause of maternal death.
206 citations
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TL;DR: Women with a history of severe PPH should be included as a risk factor in the development and validation of prediction models for PPH, based on the findings of this case-control study.
Abstract: In high-income countries, the incidence of severe postpartum hemorrhage (PPH) has increased. This has important public health relevance because severe PPH is a leading cause of major maternal morbidity. However, few studies have identified risk factors for severe PPH within a contemporary obstetric cohort. We performed a case-control study to identify risk factors for severe PPH among a cohort of women who delivered at one of three hospitals in Norway between 2008 and 2011. A case (severe PPH) was classified by an estimated blood loss ≥1500 mL or the need for blood transfusion for excessive postpartum bleeding. Using logistic regression, we applied a pragmatic strategy to identify independent risk factors for severe PPH. Among a total of 43,105 deliveries occurring between 2008 and 2011, we identified 1064 cases and 2059 random controls. The frequency of severe PPH was 2.5% (95% confidence interval (CI): 2.32–2.62). The most common etiologies for severe PPH were uterine atony (60%) and placental complications (36%). The strongest risk factors were a history of severe PPH (adjusted OR (aOR) = 8.97, 95% CI: 5.25–15.33), anticoagulant medication (aOR = 4.79, 95% CI: 2.72–8.41), anemia at booking (aOR = 4.27, 95% CI: 2.79–6.54), severe pre-eclampsia or HELLP syndrome (aOR = 3.03, 95% CI: 1.74–5.27), uterine fibromas (aOR = 2.71, 95% CI: 1.69–4.35), multiple pregnancy (aOR = 2.11, 95% CI: 1.39–3.22) and assisted reproductive technologies (aOR = 1.88, 95% CI: 1.33–2.65). Based on our findings, women with a history of severe PPH are at highest risk of severe PPH. As well as other established clinical risk factors for PPH, a history of severe PPH should be included as a risk factor in the development and validation of prediction models for PPH.
175 citations
Cites background from "Incidence, risk factors, and tempor..."
...Retained placental tissue, including abnormal placentation, has been estimated to cause approximately 10% of all PPHs [8, 24]....
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TL;DR: Pre-specified subgroup analyses suggest that fibrinogen replacement is not required if the Fibtem A5 is > 12 mm or Clauss fibr inogen >2 g litre -1, but an effect below these levels cannot be excluded, and the raised fibrInogen at term appears to be a physiological buffer rather than required for haemostasis.
Abstract: Background: Postpartum haemorrhage (PPH) can be exacerbated by haemostatic failure. We hypothesized that early fibrinogen replacement, guided by viscoelastometric testing, reduces blood product usage and bleed size. Methods: Women with PPH 1000–1500 ml were enrolled. If Fibtem A5 was ≤15 mm and bleeding continued, subjects were randomized to fibrinogen concentrate or placebo. The primary outcome compared the number of units of red blood cells, plasma, cryoprecipitate and platelets transfused. Results: Of 663 women enrolled 55 were randomized. The adjusted incidence rate ratio (IRR) (95% CI) for the number of allogeneic units transfused in the fibrinogen group compared with placebo was 0.72 (0.3–1.7), P=0.45. In pre-specified subgroup analyses, subjects who had a Fibtem A5 ≤12 mm at the time of randomization and who received fibrinogen concentrate received a median (25th–75th centile) of 1 (0–4.5) unit of allogeneic blood products and had an additional 300 (100–350) ml blood loss whereas those who received placebo also received 3 (0–6) units of allogeneic blood products and had 700 (200–1550) ml additional blood loss; these differences were not statistically significantly different. There was one thrombotic event in each group. Conclusions: Infusion of fibrinogen concentrate triggered by Fibtem A5 ≤15 mm did not improve outcomes in PPH. Pre-specified subgroup analyses suggest that fibrinogen replacement is not required if the Fibtem A5 is > 12 mm or Clauss fibrinogen >2 g litre−1, but an effect below these levels cannot be excluded. The raised fibrinogen at term appears to be a physiological buffer rather than required for haemostasis
136 citations
References
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01 Jan 2005
TL;DR: The World Health Report 2005 – Make Every Mother and Child Count, says that this year almost 11 million children under five years of age will die from causes that are largely preventable.
Abstract: The World Health Report 2005 – Make Every Mother and Child Count, says that this year almost 11 million children under five years of age will die from causes that are largely preventable. Among them are 4 million babies who will not survive the first month of life. At the same time, more than half a million women will die in pregnancy, childbirth or soon after. The report says that reducing this toll in line with the Millennium Development Goals depends largely on every mother and every child having the right to access to health care from pregnancy through childbirth, the neonatal period and childhood.
986 citations
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TL;DR: Clinicians should be more vigilant given the possibility that the frequency and severity of PPH has in fact increased, and training should be provided to all staff involved in maternity care concerning assessment of blood loss and the monitoring of women after childbirth.
Abstract: BACKGROUND: Postpartum hemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Several recent publications have noted an increasing trend in incidence over time. The international PPH collaboration was convened to explore the observed trends and to set out actions to address the factors identified. METHODS: We reviewed available data sources on the incidence of PPH over time in Australia, Belgium, Canada, France, the United Kingdom and the USA. Where information was available, the incidence of PPH was stratified by cause. RESULTS: We observed an increasing trend in PPH, using heterogeneous definitions, in Australia, Canada, the UK and the USA. The observed increase in PPH in Australia, Canada and the USA was limited solely to immediate/atonic PPH. We noted increasing rates of severe adverse outcomes due to hemorrhage in Australia, Canada, the UK and the USA. CONCLUSION: Key Recommendations 1. Future revisions of the International Classification of Diseases should include separate codes for atonic PPH and PPH immediately following childbirth that is due to other causes. Also, additional codes are required for placenta accreta/percreta/increta. 2. Definitions of PPH should be unified; further research is required to investigate how definitions are applied in practice to the coding of data. 3. Additional improvement in the collection of data concerning PPH is required, specifically including a measure of severity. 4. Further research is required to determine whether an increased rate of reported PPH is also observed in other countries, and to further investigate potential risk factors including increased duration of labor, obesity and changes in second and third stage management practice. 5. Training should be provided to all staff involved in maternity care concerning assessment of blood loss and the monitoring of women after childbirth. This is key to reducing the severity of PPH and preventing any adverse outcomes. 6. Clinicians should be more vigilant given the possibility that the frequency and severity of PPH has in fact increased. This applies particularly to small hospitals with relatively few deliveries where management protocols may not be defined adequately and drugs or equipment may not be on hand to deal with unexpected severe PPH.
574 citations
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TL;DR: PPH caused by uterine atony resulting in transfusion often occurs in the absence of recognized risk factors and is associated with substantial maternal morbidity and mortality.
Abstract: BACKGROUND: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.METHODS:Hospital admissions for delivery were extracte
511 citations
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TL;DR: In this article, a study was conducted to estimate the incidence of postpartum hemorrhage in the United States and to assess trends, showing an apparent increase in PPH caused by uterine atony.
471 citations
21 Aug 2007
TL;DR: Mortality patterns in 2004 were consistent with long-term trends, and life expectancy in 2004 increased again to a new record level and the age-adjusted death rate declined to a record low historical figure.
Abstract: OBJECTIVES: This report presents final 2004 data on U.S. deaths; death rates; life expectancy; infant and maternal mortality; and trends by selected characteristics such as age, sex, Hispanic origin, race, marital status, educational attainment, injury at work, state of residence, and cause of death. Previous reports presented preliminary mortality data for 2004 and summarized key findings in the final data for 2004. METHODS: This report presents descriptive tabulations of information reported on death certificates, which are completed by funeral directors, attending physicians, medical examiners, and coroners. The original records are filed in the state registration offices. Statistical information is compiled into a national database through the Vital Statistics Cooperative Program of the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS). Causes of death are processed in accordance with the International Classification of Diseases, Tenth Revision (ICD-10). RESULTS: In 2004, a total of 2,397,615 deaths were reported in the United States. The age-adjusted death rate was 800.8 deaths per 100,000 standard population, representing a decrease of 3.8 percent from the 2003 rate and a record low historical figure. Life expectancy at birth rose by 0.4 year to a record high of 77.8 years. Age-specific death rates decreased for all age groups. (The decrease for children aged 5-14 years was not statistically significant.) The 15 leading causes of death in 2004 remained the same as in 2003. Heart disease and cancer continued to be the leading and second leading causes of death, together accounting for over one-half of all deaths. In 2004, Alzheimer's disease surpassed and swapped positions with Influenza, relative to their previous placements in 2003. The infant mortality rate in 2004 was 6.79 per 1000 births. CONCLUSIONS: Generally, mortality patterns in 2004 were consistent with long-term trends. Life expectancy in 2004 increased again to a new record level. The age-adjusted death rate declined to a record low historical figure. Although not statistically significant, the decrease in the infant mortality rate is typical of recent trends; except for 2002, the infant mortality rate has either decreased or remained level each successive year from 1958 to 2004. Language: en
442 citations