Incidence, trends and severity of primary postpartum haemorrhage in Australia: A population-based study using Victorian Perinatal Data Collection data for 764 244 births.

BACKGROUND: Increasing incidence and severity of postpartum haemorrhage, together with postpartum haemorrhage-associated morbidities, have been reported in many high-resource countries. In-depth analysis of such factors in Victorian births since 2002 was lacking. AIMS: Our aim was to determine the incidence and trends for primary postpartum haemorrhage (World Health Organization and International Classification of Diseases 10th revision, Australian Modification definitions) for all confinements in Victoria, Australia, for the years 2003-2013 and the incidence and trends for severe postpartum haemorrhage (≥1500 mL) for 2009-2013. MATERIALS AND METHODS: In this population-based cross-sectional study de-identified data from the Victorian Perinatal Data Collection were analysed for confinements (excluding terminations) from 2003 to 2013 (n = 764 244). Perinatal information for all births ≥20 weeks (or of at least 400 g birthweight if gestation was unknown) were prospectively collected. RESULTS: One in five women (21.8%) who gave birth between 2009 and 2013 experienced a primary postpartum haemorrhage and one in 71 women (1.4%) experienced a severe primary postpartum haemorrhage. The increasing trends in incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage, blood transfusion, admission to an intensive care or high dependency unit and peripartum hysterectomy were significant (P < 0.001). Women who had an unassisted vaginal birth had the lowest incidence of primary postpartum haemorrhage. The highest incidence was experienced by women who had an unplanned caesarean section birth. Women who had a forceps birth had the highest incidence of severe primary postpartum haemorrhage. CONCLUSIONS: The incidence of primary postpartum haemorrhage, severe primary postpartum haemorrhage and associated maternal morbidities have increased significantly over time in Victoria.

Analyses of severe acute maternal morbidity in Slovakia during years 2012-2016.

AIM: Severe acute maternal morbidity (SAMM) is a state of the woman, when she nearly died, but survived. The aim of study was to find out the exact incidence of SAMM in Slovakia, establishment of functional surveillance system and improve quality of health care. MATERIALS AND METHODS: The regular annual analyses of SAMM cases in Slovakia from January 1st 2012 to December 31st 2016. Observed SAMM included: peripartum haemorrhage, peripartum hysterectomy, uterine rupture, abnormally invasive placenta, HELLP syndrome, eclampsia, sepsis, transport to intensive care unit or anaesthesiology and non-fatal amniotic fluid embolism. RESULTS: The response rate of questionnaires was 84.8 %. The overall confirmed incidence of SAMM was 6.35/1,000 births (95% CI 6.03-6.67). The most often causes of SAMM were: peripartum haemorrhage (2.1/1,000 births), transport to intensive care unit or anaesthesiology (1.46/1,000 births), peripartum hysterectomy (0.84/1,000 births) and HELLP syndrome (0.63/1,000 births). The average age of women with SAMM was 30.3 years (14-46) and average parity was 1.16 (0-15). CONCLUSION: The incidence of SAMM and especially incidence of peripartum haemorrhage and peripartum hysterectomy in Slovakia is one of the highest in Europe. To decrease incidence and improve management and outcome of patients, regular audit of SAMM is needed (Tab. 3, Fig. 2, Ref. 30).

Prevention of postpartum haemorrhage: a distributional approach for analysis.

BACKGROUND: There is empirical evidence that measured postpartum blood loss has a lognormal distribution. This feature can be used to analyze events of the type 'blood loss greater than a certain cutoff point' using a lognormal approach, which takes into account all the quantitative observations, as opposed to dichotomizing the variable blood loss volume into two categories. This lognormal approach uses all the information contained in the data and is expected to provide more efficient estimates of proportions and relative risk when comparing treatments to prevent postpartum haemorrhage. As a consequence, sample size can be reduced in clinical trials, while keeping the statistical precision requirements. METHODS: The authors illustrate how a lognormal approach can be used in this situation, using data from a clinical trial and the event 'blood loss greater than 1000 mL'. RESULTS: Estimates of the proportions of this event for each treatment, and relative risks obtained with this method are presented and compared with the standard estimates obtained by dichotomizing measured blood loss volume. An example of how the blood loss distributions of two treatments can be compared is also presented. Different scenarios of the sample size needed to compare two treatments or interventions are presented to illustrate how with the lognormal approach the size of a clinical trial can be reduced. CONCLUSIONS: A distributional approach for postpartum blood loss using the lognormal distribution fitted to the data results in more precise estimates of risks of events and relative risks, compared to the use of binomial proportions of events. It also results in reduced required sample size for clinical trials. TRIAL REGISTRATION: This paper reports a secondary analysis for a trial that was registered at clinicaltrials.gov ( NCT00781066 ).

Assisted reproductive technology and severe postpartum haemorrhage: a case-control study.

OBJECTIVE: To investigate the association between assisted reproductive technology and severe postpartum haemorrhage. DESIGN: Case-control study. SETTING: The study was conducted in Norway; Division of Gynaecology and Obstetrics at Oslo University Hospital and Department of Obstetrics and Gynaecology at Drammen Hospital. POPULATION: A source population including all women admitted for delivery at Oslo University Hospital and Drammen Hospital during the time period 1 January 2008 to 31 December 2011. The study population consisted of all cases of severe postpartum haemorrhage (n = 1064) and a random sample of controls (n = 2059). METHODS: We used an explanatory strategy in the analysis, with multivariable logistic regression. MAIN OUTCOME MEASURES: Severe postpartum haemorrhage; defined as blood loss ≥1500 ml or need for blood transfusion. RESULTS: Assisted reproductive technology was associated with an increased risk of severe postpartum haemorrhage (crude OR = 2.92; 95% CI 2.18-3.92, P < 0.001). Mode of delivery and anticoagulant medication had significant confounding effects. Strong interaction was found for multiple pregnancies. After adjusting for confounding and interaction, an increased risk was observed both in the strata of multiple pregnancies (adjusted OR = 7.00, 95% CI 2.70-18.12, P < 0.001), and in the strata of single gestation (adjusted OR = 1.58, 95% CI 1.12-2.24, P = 0.010). CONCLUSIONS: Our findings warrant an increased awareness of the risk of severe postpartum haemorrhage in women conceiving with assisted reproductive technology. Furthermore, the high risk of severe postpartum haemorrhage in the presence of a twin or triplet pregnancy is an additional argument for single embryo transfer. TWEETABLE ABSTRACT: Assisted reproductive technology is associated with an increased risk of severe postpartum haemorrhage.

Primary postpartum haemorrhage adversely impacts breastfeeding initiation in Victoria, Australia.

PROBLEM: Breastfeeding has many important benefits for both mother and baby but sustained breastfeeding is sub-optimal. BACKGROUND: Identifying women who need increased support to establish breastfeeding has the potential to improve this. Analysis of the relationship between primary postpartum haemorrhage (PPH) and primary severe PPH and breastfeeding may prove informative as PPH has potentially negative impacts on breastfeeding. AIM: To determine the relationship between PPH and severe PPH and breastfeeding at postnatal discharge and formula use for breastfed babies in hospital. METHODS: Population-based retrospective cohort study using the Victorian Perinatal Data Collection for all liveborn singleton births at ≥ 37 weeks' gestation (n = 339,854) for 2009-13 in Victoria. Estimated blood loss was categorised as PPH ≥ 500 mL and severe PPH ≥ 1500 mL. Descriptive analysis was conducted and multivariable logistic regression was used to determine the adjusted odds ratio for the relationship between PPH/severe PPH and breastfeeding outcomes after adjustment for relevant confounders. FINDINGS: Overall, 94.9% of women initiated breastfeeding. Babies whose mother had a PPH or severe PPH were less likely than others to be exclusively breastfeeding at discharge (aOR 0.88; (95% CI 0.86, 0.90) and aOR 0.57; (95% CI 0.53, 0.61) respectively). Formula - given to 25.9% of all breastfed babies - was more likely for those whose mothers had a PPH or severe PPH (aOR 1.15; (95% CI 1.12, 1.17) and aOR 2.15; (95% CI 2.01, 2.29) respectively. CONCLUSIONS: Women have greater challenges establishing exclusive breastfeeding following PPH and severe PPH. Improving support in hospital for women following PPH may increase breastfeeding success.

Posttraumatic stress disorder in partners following severe postpartum haemorrhage: A prospective cohort study.

BACKGROUND: Partners of women are increasingly present during childbirth and may be exposed to a traumatic experience. Since parents' mental health issues (i.e. posttraumatic stress disorder) have been shown to increase the risk of problems in the child's development, it is important to identify these risk factors. Partners often describe severe postpartum haemorrhage as traumatic. AIM: Whether witnessing severe postpartum haemorrhage is a risk factor for developing posttraumatic stress disorder in partners. METHODS: In this prospective cohort study, we compared partners of women with severe postpartum haemorrhage (≥2000 mL) and partners of women with ≤500 mL of blood loss (controls). Four weeks after birth partners were screened for posttraumatic stress disorder symptoms with a self-report questionnaire. Scores ≥11 were followed by a gold standard clinical interview to diagnose posttraumatic stress disorder. FINDINGS: We included 123 severe postpartum haemorrhage partners and 62 control partners. Partners of women with severe postpartum haemorrhage reported higher scores than control partners (median 3.0 (0.0-7.0) vs 2.0 (0.0-4.0), p = 0.04) on symptoms of posttraumatic stress, but no significant difference in probable posttraumatic stress disorder diagnosis according to the self-report questionnaire was found. According to the clinical interview no partners were diagnosed with posttraumatic stress disorder. Severe postpartum haemorrhage was experienced as traumatic by the partners who felt excluded. CONCLUSION: None of the partners developed posttraumatic stress disorder, revealing the resilience of young fathers. Because some partners reported severe postpartum haemorrhage as traumatic, we recommend sufficient information and support is provided during childbirth.

Severe postpartum haemorrhage after vaginal delivery: a statistical process control chart to report seven years of continuous quality improvement.

UNLABELLED: Severe postpartum haemorrhage after vaginal delivery: a statistical process control chart to report seven years of continuous quality improvement OBJECTIVE: To use statistical process control charts to describe trends in the prevalence of severe postpartum haemorrhage after vaginal delivery. This assessment was performed 7 years after we initiated a continuous quality improvement programme that began with regular criteria-based audits STUDY DESIGN: Observational descriptive study, in a French maternity unit in the Rhône-Alpes region. INTERVENTION: Quarterly clinical audit meetings to analyse all cases of severe postpartum haemorrhage after vaginal delivery and provide feedback on quality of care with statistical process control tools. MAIN OUTCOME MEASURES: The primary outcomes were the prevalence of severe PPH after vaginal delivery and its quarterly monitoring with a control chart. The secondary outcomes included the global quality of care for women with severe postpartum haemorrhage, including the performance rate of each recommended procedure. Differences in these variables between 2005 and 2012 were tested. RESULTS: From 2005 to 2012, the prevalence of severe postpartum haemorrhage declined significantly, from 1.2% to 0.6% of vaginal deliveries (p<0.001). Since 2010, the quarterly rate of severe PPH has not exceeded the upper control limits, that is, been out of statistical control. The proportion of cases that were managed consistently with the guidelines increased for all of their main components. CONCLUSION: Implementation of continuous quality improvement efforts began seven years ago and used, among other tools, statistical process control charts. During this period, the prevalence of severe postpartum haemorrhage after vaginal delivery has been reduced by 50%.

[Objective severity markers in women with severe postpartum haemorrhage: a 310-case series]. / Critères objectifs de gravité en cas d'hémorragie grave du post-partum: à propos de 310 cas.

OBJECTIVES: Postpartum haemorrhage (PPH) is a major contributor to maternal morbidity and mortality in France. The objective of our study was to reveal predictive factors of severity or cure, allowing an adapted management as less invasive as possible, in case of severe PPH. PATIENTS AND METHODS: This retrospective study included 310 patients, who had been treated for a severe PPH in Lariboisière university hospital from April 2007 to April 2009. RESULTS: The predictive factors found for an invasive management (surgery or embolization) are: at clinical examination, heart rate (88 versus 100 pulses per minute), importance of bleeding and the tonicity of the uterine globe. At biological examination, they are haemoglobin level (9 versus 8.2g/dL) and clotting factors, especially fibrinogen (3 versus 2g/L) and prothrombin time (PT) (76 versus 63%). The identified cure factors are the same ones as severity factors. With multivariate analysis, initial independent predictive factors about an invasive management were: the tonicity of the uterine globe (OR=0.14), heart frequency (OR=1.3) and PT (OR=0.76). DISCUSSION AND CONCLUSION: In case of severe haemorrhage, there may be the question of transfer of the patient. The difficulty is to avoid unnecessary transport, without delay for the future care. Very few studies searched predictive factors of severity or cure. Our study found, as predictive factors of invasive treatment, elements of physical examination (heart rate and the tonicity of the uterine globe) and biological factors (hemoglobin level and clotting factors).