Outcomes and prognosis of postpartum hemorrhage according to management protocol: A 11-year retrospective study from two referral centers

doi:10.21203/rs.3.rs-4336664/v1

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Research Article

Outcomes and prognosis of postpartum hemorrhage according to management protocol: A 11-year retrospective study from two referral centers

https://doi.org/10.21203/rs.3.rs-4336664/v1

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Journal Publication

published 01 Aug, 2024

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Background

No standard treatment guidelines have been established for postpartum hemorrhage (PPH). We aimed to assess the differences in outcomes between patients with PPH who underwent surgical and non-surgical treatments.

Methods

This retrospective study included 230 patients diagnosed with PPH at two referral hospitals between August 2013 and October 2023. The patients were divided into non-surgical intervention (group 1, n = 159), surgical intervention (group 2, n = 45), and surgical intervention after failure of non-surgical intervention (group 3, n = 26) groups.

Results

In each group, the initial heart rate and body temperature were significantly different (92.2 ± 20.7, 112.6 ± 30.4, and 102.1 ± 23.3 beats per minute, p < 0.001 and 37.3 ± 0.8°, 36.9 ± 0.9°, and 37.2 ± 0.9°, p = 0.016, in groups 1–3, respectively). Among the causes of PPH, uterine atony combined with other causes showed a significant difference among the three groups (32 cases (20.1%), 8 cases (17.8%), and 14 cases (53.8%), p = 0.003 in groups 1–3, respectively). Mean duration of hospitalization and intensive care unit admission rate were significantly different between the groups (4.1 ± 1.7, 8.7 ± 10.3, and 10.4 ± 13.6 days, p < 0.001 and 6 cases (3.8%), 17 cases (37.8%), and 12 cases (46.2%), p < 0.001 in groups 1–3, respectively). Hysterectomy and disseminated intravascular coagulopathy rates were significantly higher in group 3 than in group 2 [(19 cases (73.1%) and 23 cases (51.1%), x² = 3.291, p = 0.047); 18 cases (69.2%) and 19 cases (42.2%), x² = 4.817, p = 0.028), respectively].

Conclusions

In patients with PPH and an initial increased heart rate or decreased body temperature and in those with causes combined with uterine atony, immediate surgical intervention improves the prognosis. Postoperative complications increased when surgery was performed after failure of non-surgical interventions.

Postpartum Hemorrhage

Uterine Atony

Hysterectomy

Disseminated Intravascular Coagulation

Uterine Artery Embolization

Postpartum hemorrhage (PPH) is a serious obstetric complication that accounts for 27% of maternal deaths worldwide [1]. It is the fourth leading cause of maternal mortality in the United States and the leading cause of maternal mortality and morbidity worldwide [2]. PPH can be divided into two types: primary PPH, which occurs within 24 hours of delivery, and secondary PPH, which occurs between 24 hours and 12 weeks after delivery. Currently, the definition of PPH across countries varies; blood loss exceeding 500 mL after vaginal delivery or exceeding 1000 mL after cesarean section has been defined as PPH by the Society of Obstetricians and Gynecologists of Canada (SOGC) [3], while the World Health Organization (WHO) defines PPH as blood loss exceeding 500 mL, regardless of the mode of delivery [4]. In 2017, the American College of Obstetricians and Gynecologists (ACOG) redefined PPH as 1000 mL of blood loss accompanied by signs or symptoms of hypovolemia, regardless of the route of delivery [5]. PPH is the result of several factors that can occur alone or in combination, such as uterine atony, retained placental tissue, trauma including genital tract injuries, and coagulation dysfunction (the “4Ts”: tone, tissue, trauma, and thrombin) [6]. Uterine atony was responsible in most cases (75%) of PPH [7].

When PPH occurs, the treatment method is chosen based on the amount of bleeding, the patient's vital signs, and the cause of the bleeding. Unless the condition is life threatening, conservative treatment is usually administered before peripartum hysterectomy to preserve fertility. The first-line treatments for PPH include uterine massage, manual removal of residual placental tissue, bimanual compression maneuvers, gauze packing, application of uterotonics and hemostasis, and volume replacement. If unsuccessful, second-line treatments for PPH, such as a uterine sandwich (B-Lynch suture and Bakri balloon tamponade [BBT]), uterine arterial ligation, and uterine arterial embolization (UAE), should be performed [8, 9]. Among these, BBT has been recommended by the ACOG and WHO as a second-line conservative treatment for PPH [10], and UAE has been proposed as a standard treatment option for PPH because of its low invasiveness and high success rates [11]. An appropriate second-line procedure may achieve hemostasis for intractable hemorrhage and prevent the need for more severe surgical procedures, including peripartum hysterectomy.

Peripartum hysterectomy is usually performed in patients with severe bleeding that cannot be conservatively controlled. To date, no optimal approach has been established to treat PPH with 100% success, and the decision to perform a hysterectomy is challenging, particularly in young women and those with low parity. However, choosing an appropriate initial treatment method is important because it can indicate the vitality of a patient. Most studies have investigated the risk factors and prognosis of peripartum hysterectomy for PPH by dividing patients into groups that underwent peripartum hysterectomy and those that did not [12–14]. In addition, some studies have shown that UAE is highly effective in preventing peripartum hysterectomy [15], while other studies have shown the effectiveness of UAE and BBT and that these methods can lower the incidence of peripartum hysterectomy [10, 16, 17]. However, few studies have analyzed cases in which surgery was performed after failure of second-line treatments, such as BBT or UAE that were performed first.

Therefore, this study investigated the causes of PPH and the differences in outcomes between surgical and non-surgical intervention groups. The surgical group was further divided into a group that underwent surgery immediately and a group that underwent surgery due to failure of BBT or UAE. This study aimed to assess the differences in outcomes between patients with PPH who underwent non-surgical, surgical, and surgical treatment after failure of non-surgical intervention.

Between August 2013 and October 2023, this retrospective study was conducted in the department of Obstetrics and Gynecology of Chungnam National University Hospital and Chungnam National University Sejong Hospital, tertiary referral centers for high-risk pregnancies. This study was approved by the Ethics Committee of the Chungnam National University Sejong Hospital (IRP No. 2023-12-004). PPH was defined as blood loss of > 500 mL, regardless of the mode of delivery (vaginal or cesarean section), according to the WHO definition of PPH. Cases of primary PPH occurring within 24 hours of delivery and secondary PPH occurring between 24 hours and 12 weeks after delivery were included.

Figure 1 shows the selection of the study participants. Women diagnosed with PPH were included in the study. Of the 272 patients recruited for PPH, 42 were excluded because their estimated blood loss (EBL) was < 500 mL or no blood transfusion was performed. The 230 patients were divided into three groups: non-surgical intervention (group 1, n = 159), surgical intervention (group 2, n = 45), and surgical intervention after non-surgical intervention failure (group 3, n = 26). First-line treatments included the application of uterotonics, hemostasis, uterine massage, manual removal of residual placental tissue, gauze packing, and a bimanual compression maneuver. Second-line treatments included Bakri balloon tamponade (BBT) and uterine artery embolization (UAE). Surgical interventions included B-Lynch suturing, uterine artery ligation, surgical bleeding control or laceration repair, surgical placental removal, and hysterectomy. Failure of non-surgical intervention refers to the failure of second-line treatment.

The decision-making on undertaking surgery was based on the institutional criteria. When patients with PPH visited the hospital, only first-line treatment was administered if their vital signs were stable, EBL was < 1 L, or vaginal bleeding required 1–2 pads/h. If the EBL was 1–2 L or > 2 pads/h, the second-line treatment was performed simultaneously with the first-line treatment. Surgery was performed immediately in cases of EBL > 2 L, clinically severe and persistent uncontrollable hemorrhage, or unstable vital signs.

The baseline characteristics of women with PPH, such as age, body mass index (BMI), parity, multiple or singleton pregnancies, gestational age at delivery, type of delivery (vaginal delivery vs. cesarean section), delivery location (inborn vs. outborn), weight of the newborn, and previous uterine surgery, including a history of cesarean section and myomectomy, were obtained from the records.

Basic information on PPH, such as the time of PPH onset (< 24 h after delivery or > 24 h after delivery to 12 weeks), time taken for transfer, time from admission to surgery, cause of PPH, initial laboratory results, and initial vital signs, were obtained from the records. The causes of PPH were classified according to the 4Ts; “Tone” includes uterine atony, “Trauma” includes uterine wall rupture and genital tract injury, “Tissue” includes retained placenta and clots and abnormal placentation, and “Thrombin” includes placental abruption, preeclampsia, and coagulation abnormalities. Abnormal placentation includes placenta previa and placenta accreta syndrome; genital tract injuries include perineal, cervical, and vaginal lacerations; and extrauterine bleeding includes bleeding in the abdominal wall, intraperitoneal cavity, and surrounding organs. Initial laboratory tests included white blood cell (WBC) count, hemoglobin level, hematocrit (Hct), and platelet count, and initial vital signs included systolic blood pressure (BP), diastolic BP, heart rate, and body temperature.

Data on PPH and morbidity outcomes were also analyzed. Survey items included mean duration of hospitalization, intensive care unit (ICU) admission rate, total EBL, total number of blood transfusion packs, mortality, and complications. Total EBL was estimated by measuring the weight of the blood-soaked pad, weight of the gauze used before and after the procedure, and the amount of blood contained in the irrigation bottle used during the surgery. Complications included hysterectomy; disseminated intravascular coagulopathy (DIC); fever; hypertension; wound infection; acute renal failure (ARF); bladder injury; ureteral injury; intestinal complications such as paralytic ileus; pulmonary complications such as pulmonary edema and pulmonary effusion; cardiac complications such as heart failure and arrhythmia; cerebral complications such as cerebral hemorrhage, stroke, and headache; deep vein thrombosis (DVT); and Sheehan syndrome.

Statistical Analysis

Quantitative variables were described as mean ± standard deviation. Qualitative variables were described as frequency (n) and proportion (%). Analysis of variance was used to compare the means of quantitative variables among the three groups. Post-hoc analysis was performed using the least significant difference method when homogeneity of variance was satisfied and the Dunnett T3 method was used when homogeneity of variance was not satisfied. Chi-squared test was used to compare the nominal variables among the three groups. Through these analyses, items that showed significant differences between the surgical intervention group (Group 2) and the surgical intervention group after non-surgical intervention (Group 3) were selected. Statistical significance was defined as p < 0.05. The statistical program SPSS (IBM SPSS Version 22.0) was used for analysis.

No significant differences in obstetric variables, including age, BMI, parity, number of fetuses, gestational age, delivery location, and baby weight, were observed. Age showed no significant difference among groups 1–3 (33.1 ± 4.0, 33.0 ± 4.4, and 34.7 ± 3.7 years, respectively; p = 0.189). BMI showed no significant difference among groups 1–3 (24.2 ± 3.0, 25.5 ± 4.8, and 23.7 ± 3.3 kg/m², respectively; p = 0.071). The parity among groups 1–3 showed no significant differences; 67 (42.1%), 24 (53.3%), and 24 (53.8%) women were multiparous, respectively (p = 0.280). Additional details are presented in Table 1. The initial blood test values (WBC, hemoglobin, Hct, and platelet levels) and systolic and diastolic BP showed no significant differences between the groups. However, the initial heart rate showed a significant difference among groups 1–3 (92.2 ± 20.7, 112.6 ± 30.4, and 102.1 ± 23.3 beats per minute, respectively; p < 0.001), and the initial body temperature showed a significant difference among groups 1–3 (37.3 ± 0.8°, 36.9 ± 0.9°, and 37.2 ± 0.9°, respectively; p = 0.016).

Table 1

Obstetric and baseline characteristics of patients with postpartum hemorrhage (n = 230)
Variable	Group 1 (n = 159)	Group 2 (n = 45)	Group 3 (n = 26)	P-value
Age	33.1 ± 4.0	33.0 ± 4.4	34.7 ± 3.7	0.189
BMI (kg/m²)	24.2 ± 3.0	25.5 ± 4.8	23.7 ± 3.3	0.071
Parity (Primipara: Multipara)	92:67 (57.9:42.1)	21:24 (46.7:53.3)	12:24(46.2:53.8)	0.280
Number of fetuses (Singleton: Multiple)	148:11 (93.1:6.9)	43:2 (95.6:4.4)	26:0 (100:0)	0.343
Gestational age (Full term: Preterm)	153:6 (96.2:3.8)	43:2(95.6:4.4)	26:0 (100:0)	0.579
Type of delivery (Vaginal delivery: C/S)	98:61 (61.6:38.4)	26:19 (57.8:42.2)	14:12 (53.8:46.2)	0.715
Delivery location (Inborn: Outborn)	20:139 (11.9:86.8)	2:43 (4.4:95.6)	1:25 (3.8:96.2)	0.177
Baby weight (kg)	3.2 ± 0.4	3.2 ± 0.5	3.1 ± 1.0	0.869
Previous uterine surgery	18 (11.3)	7 (15.6)	2 (7.7)	0.514
PPH onset (Primary: Secondary)	119:40 (74.8:25.2)	37:8 (82.2:17.8)	21:5 (80.8:19.2)	0.507
From transfer to Operation time (min)	None	204 ± 248	306 ± 236	0.109
Initial Blood test
WBC (10³/L)	17.5 ± 6.9	18.6 ± 7.9	18.3 ± 7.3	0.555
Hb (g/dL)	9.4 ± 2.2	9.1 ± 2.9	9.3 ± 2.1	0.643
Hct (%)	27.8 ± 6.5	27.3 ± 7.6	26.2 ± 7.7	0.515
Platelet (K)	188.1 ± 87.3	176.2 ± 100.0	143.2 ± 61.0	0.051
Initial vital signs
Systolic BP (mmHg)	121.4 ± 81.7	111.4 ± 25.9	101.8 ± 22.8	0.342
Diastolic BP (mmHg)	69.4 ± 16.5	66.5 ± 19.0	62.4 ± 15.2	0.118
HR (beat/min)	92.2 ± 20.7	112.6 ± 30.4	102.1 ± 23.3	< 0.001
BT (°C)	37.3 ± 0.8	36.9 ± 0.9	37.2 ± 0.9	0.016
Cause of PPH
Tone	123 (77.4)	24 (53.3)	20 (76.9)	< 0.001
Trauma	40 (25.2)	17 (37.8)	15 (57.7)	0.189
Tissue	31 (19.5)	15 (33.3)	6 (23.1)	0.315
Tone + other causes	32 (20.1)	8 (17.8)	14 (53.8)	0.003
All data presented as mean ± standard deviation or number (%)
Group 1, non-surgical intervention group, Group 2, surgical intervention group, Group 3, surgical intervention after non-surgical intervention group, BMI, body mass index, C/S, cesarean section, PPH, postpartum hemorrhage, Hb, hemoglobin, Hct, hematocrit, BP, blood pressure, HR, heart rate, BT, body temperature, Tone, uterine atony, Trauma, uterine rupture, genital tract injury, tissue, retained placenta and clots, abnormal placentation, Thrombin, placental abruption, preeclampsia, existing coagulation abnormalities.

Among the causes of PPH (Table 1), uterine atony was significantly different among groups 1–3 (123 (77.4%), 24 (53.3%), and 20 (76.9%), respectively; p < 0.001). When uterine atony was combined with other causes, a significant difference among groups 1–3 was observed (32 cases [20.1%], 8 cases [17.8%], and 14 cases [53.8%], respectively; p = 0.003). The causes of PPH in all patients are shown in Table 2.

Table 2

Causes of postpartum hemorrhage (n = 230)
Cause of PPH	n (%)
Tone Uterine atony	110 (47.8)
Trauma Uterine rupture Genital tract injury	30 (13.0)
Tissue Retained placenta Abnormal placentation	28 (12.2)
Multifactorial
Tone + Trauma	34 (14.8)
Tone + Tissue	15 (6.6)
Tone + Trauma + Tissue	3 (1.3)
Trauma + Tissue	4 (1.7)
Thrombin (placental abruption or preeclampsia or existing coagulopathy) ± tone ± trauma ± tissue	6 (2.6)
Total	230 (100)

Data are presented as number (%).

PPH, postpartum hemorrhage; Tone, uterine atony; Trauma, uterine rupture; Genital tract injury; Tissue, retained placenta and clots, abnormal placentation; Thrombin, placental abruption, pre-eclampsia, existing coagulation abnormalities

Among the sole causes of PPH, uterine atony accounted for the highest rate at 47.8%. The proportions of trauma and tissue as the sole causes were similar, at 13% and 12.2%, respectively. A combination of atony and other causes was observed in 52 (22.6%) patients. Uterine atony accounted for 70.4% of all PPH cases. Thrombin-related causes did not exist alone but were combined with other causes, accounting for six (2.6%) cases.

The PPH and morbidity outcomes are presented in Table 3.

Table 3

Postpartum hemorrhage and morbidity outcomes (n = 230)
Variables	Group 1 (n = 159)	Group 2 (n = 45)	Group 3 (n = 26)	P-value
Mean duration of hospitalization (days)	4.1 ± 1.7	8.7 ± 10.3	10.4 ± 13.6	< 0.001
ICU admission rate	6 (3.8)	17 (37.8)	12 (46.2)	< 0.001
Total EBL (mL)				< 0.001
>500 to < 1000	85 (53.5)	12 (26.7)	4 (15.4)
≥1000 to < 2000	64 (40.3)	10 (22.2)	4 (15.4)
≥2000	10 (6.3)	23 (51.1)	18 (69.2)
Blood transfusion
RBC (pack)	4.2 ± 3.0	13.4 ± 18.2	13.7 ± 11.6	< 0.001
FFP (pack)	2.6 ± 2.9	11.7 ± 23.4	12.3 ± 10.9	< 0.001
Platelets (pack)	1.0 ± 3.3	17.3 ± 31.2	12.2 ± 15.7	< 0.001
Mortality	0	2 (4.4)	0	0.016
Complications
Hysterectomy done	-	23 (51.1)	19 (73.1)	< 0.001
DIC	14 (8.8)	19 (42.2)	18 (69.2)	< 0.001
Fever	19 (11.9)	10 (22.2)	8 (30.8)	0.024
Hypertension	2 (1.3)	1 (2.2)	3 (11.5)	0.009
Wound infection	0	2 (4.4)	1 (3.8)	0.033
ARF	0	3 (6.7)	3 (11.5)	< 0.001
Bladder injury	1 (0.6)	2 (4.4)	2 (7.7)	0.037
Ureter injury	0	0	1 (3.8)	0.019
Intestinal complications	0	1 (2.2)	1 (3.8)	0.081
Pulmonary complications	4 (2.5)	11 (24.4)	10 (38.5)	< 0.001
Cardiac complications	2 (1.3)	2 (4.4)	4 (15.4)	0.001
Cerebral complications	2 (1.3)	3 (6.7)	4 (15.4)	0.002
DVT	1 (0.6)	2 (4.4)	0	0.113
Sheehan syndrome	0	3 (6.7)	0	0.002

All data presented as mean ± standard deviation or number (%)

Group 1, non-surgical intervention group; Group 2, surgical intervention group; Group 3, surgical intervention after non-surgical intervention group; ICU, intensive care unit; RBC, red blood cell; FFP, fresh frozen plasma; EBL, estimated blood loss; DIC, disseminated intravascular coagulation; ARF, acute renal failure; DVT, deep vein thrombosis

Mean duration of hospitalization showed a significant difference among groups 1–3 (4.1 ± 1.7, 8.7 ± 10.3, and 10.4 ± 13.6 days, respectively; p < 0.001). The ICU admission rate was significantly different among groups 1–3 (6 [3.8%], 17 [37.8%], and 12 [46.2%] cases, respectively; p < 0.001]. The total EBL and total number of blood transfusion packs also showed significant differences among the three groups (p < 0.001 and p < 0.001, respectively). All complications investigated, including hysterectomy (p < 0.001), DIC (p < 0.001), fever (p = 0.024), hypertension (p = 0.009), wound infection (p = 0.033), ARF (p < 0.001), bladder injury (p = 0.037), ureter injury (p = 0.019), pulmonary complication (p < 0.001), cardiac complication (p = 0.001), cerebral complication (p = 0.002), and Sheehan syndrome (p = 0.002), except intestinal complications (p = 0.081) and DVT (p = 0.113), showed significant differences.

According to the post-hoc analysis in Table 4, body temperature decreased significantly in group 2 compared to group 1 (p = 0.012), and heart rate increased significantly in group 2 compared to group 1 (p < 0.001).

Table 4

Post hoc analysis of items showing significant differences among the three groups
Variables	Group	Mean difference	Std Error	P-value
Initial heart rate	1*2	-20.45	3.91	< 0.001
	1*3	-9.89	4.91	0.111
	2*3	10.57	5.71	0.156
Initial body temperature	1*2	0.41	0.14	0.012
	1*3	0.12	0.18	0.795
	2*3	-0.30	0.21	0.327
Mean hospital day	1*2	-4.61	1.11	< 0.001
	1*3	-6.35	1.39	< 0.001
	2*3	-1.73	1.62	0.531
RBC transfusion	1*2	-9.25	1.56	< 0.001
	1*3	-9.58	1.95	< 0.001
	2*3	-0.33	2.28	0.988
FFP transfusion	1*2	-9.10	1.90	< 0.001
	1*3	-9.64	2.37	< 0.001
	2*3	-0.54	2.76	0.979
Platelet transfusion	1*2	-16.31	2.53	< 0.001
	1*3	-11.27	3.17	0.001
	2*3	5.04	3.69	0.360

1*2 Comparison between groups 1 and 2; 1*3 Comparison between groups 2 and 3; 2*3 Comparison between groups 2 and 3

RBC, red blood cell; FFP, fresh frozen plasma

The mean duration of hospitalization increased significantly in groups 2 and 3 compared to group 1 (p < 0.001 and p < 0.001, respectively). According to the chi-squared test between the nominal variables in Table 5, the rate of uterine atony and the rate of uterine atony combined with other causes were significantly higher in group 3 than in group 2 (20 [76.9%] vs. 24 [53.3%] cases, p = 0.049; and 14 [53.8%] vs. 8 [17.8%] cases, p = 0.006, respectively).

Table 5

Chi-squared test for comparison of nominal variables showing significant differences between Groups 2 and 3.
Complication	Group 2 (n = 42)	Group 3 (n = 26)	Total	x² (P-value)
Mortality	2 (4.4)	0	2 (2.8)	1.189 (0.276)
ICU admission rate	17 (37.8)	12 (46.2)	29 (40.8)	0.478 (0.489)
Uterine atony	24 (53.3)	20 (76.9)	44 (62.0)	3.891 (0.049)
Uterine atony + other causes +	8 (17.8)	14 (53.8)	22 (31.0)	10.158 (0.006)
Hysterectomy	23 (51.1)	19 (73.1)	42 (59.2)	3.291 (0.047)
DIC	19 (42.2)	18 (69.2)	37 (52.1)	4.817 (0.028)
Fever	10 (22.2)	8 (30.8)	18 (25.4)	0.636 (0.425)
Hypertension	1 (2.2)	3 (11.5)	4 (5.6)	2.690 (0.101)
Wound infection	2 (4.4)	1 (3.8)	3 (4.2)	0.015 (0.904)
ARF	3 (6.7)	3 (11.5)	6 (8.5)	0.506 (0.477)
Bladder injury	2 (4.4)	2 (7.7)	4 (5.6)	0.327 (0.567)
Ureter injury	0	1 (3.8)	1 (1.4)	1.755 (0.185)
Pulmonary complications	11 (24.4)	10 (38.5)	21 (29.6)	1.554 (0.212)
Cardiac complications	2 (4.4)	4 (15.4)	6 (8.5)	2.549 (0.110)
Cerebral complications	3 (6.7)	4 (15.4)	7 (9.9)	1.409 (0.235)
Sheehan syndrome	3 (6.7)	0	3 (4.2)	1.810 (0.179)
Total	45 (63.4)	26 (36.6)	71 (100)

Data are presented as number (%).

Group 2, surgical intervention group; Group 3, surgical intervention after non-surgical intervention group; ICU, intensive care unit; DIC, disseminated intravascular coagulation; ARF, acute renal failure; x², Pearson’s chi-squared test

The hysterectomy rate was significantly higher in group 3 than in group 2 (19 [73.1%] vs. 23 [51.1%], x² = 3.291, p = 0.047). The DIC rate was significantly higher in group 3 than in group 2 (18 [69.2%] vs. 19 [42.2%] cases, x² = 4.817, p = 0.028).

The current study showed that in patients with PPH, changes in heart rate and body temperature can be important initial criteria for determining the severity of PPH and deciding on surgery. In group 2, the heart rate significantly increased and the body temperature decreased compared to the other groups. According to the American College of Surgeons Advanced Trauma Life Support hemorrhagic shock classification, when class II hemorrhage (blood loss of 15–30%) is present, clinical symptoms include BP in the normal range, but the heart rate rises above 100 beats per minute [18]. Based on this classification method, no significant differences in BP and laboratory values were observed among the three groups in our study. However, a large amount of blood loss occurred in a short period through an increase in heart rate. Hypothermia is commonly accompanied by hemorrhagic shock [19]. According to a study on hemorrhagic shocked rats, hypothermia is related to survival time; if hypothermia is not corrected, survival time is reduced [20]. Therefore, when PPH occurs, careful monitoring of the increase in heart rate or decrease in body temperature is necessary to prevent worsening of conditions, such as hemorrhagic shock or DIC and to immediately decide on surgery.

We observed that the most common cause of PPH was uterine atony alone; in multifactorial cases, the rate of accompanying atony was also the cause of PPH (Table 2). Uterine atony ranked first as the sole cause at 47.8%, and when combined with uterine atony and other causes at 22.7%, the proportion of uterine atony reached approximately 70%. This finding is consistent with previous reports showing that the most common cause of PPH is uterine atony [21]. However, as a result of dividing the entire group into three groups and comparing the causes of PPH between the groups in Table 1, the proportion of cases with uterine atony and other causes in groups 1 and 2 was similar to that in the overall group; however, in group 3, the ratio increased significantly to 53.8%. The other causes, such as genital tract laceration and remnant placenta, could be the main causes of PPH; however, these were not resolved, and bleeding continued to occur over time, leading to secondary uterine atony. Placenta-related factors are known to contribute to the failure of non-surgical treatment. PPH due to placenta accreta, either unanticipated or after failure of conservative management, has an independent and significant impact on the risk of the procedure [22, 23]. Additionally, the leading cause of emergency peripartum hysterectomy in PPH in a previous study was abnormal placentation, especially placenta accreta [24, 25]. Based on the results of this study, in cases with causes other than isolated uterine atony, especially those related to the placenta, it would be helpful to improve the prognosis by considering surgical methods that can directly and quickly resolve the cause of PPH.

This study showed that in patients with PPH, complications vary depending on the failure of non-surgical intervention. We observed that group 3 had a higher incidence of hysterectomy, DIC, abnormal massive bleeding, and ICU admission than group 2. Complications such as fever, hypertension, and ARF, and pulmonary, cardiac, and cerebral complications also tended to increase in group 3 compared to group 2, despite no significant difference between the two groups. This might be because of the time required to attempt non-surgical interventions, which might lead to a delay in performing surgery. A previous study showed that every 5 minutes of delay in the appropriate application of therapeutic uterotonics in patients with primary PPH resulted in a 26% higher rate of hypotension and increased blood transfusions [26]. The lack of blood transfusion before surgery and prolonged surgery were significantly associated with complications [27]. In the present study, the time from transfer to surgery differed by an average of 100 minutes between groups 2 and 3. This might be explained by the increasing rates of hysterectomy and DIC in group 3 compared to those in group 2. Therefore, selecting patients in whom non-surgical treatment is likely to fail and quickly deciding whether to undergo surgery will help improve the prognosis of patients with PPH. Further research on this topic is required.

Most complications had a higher incidence in group 3; however, Sheehan syndrome had a higher incidence in group 2 than in the other groups. The pituitary gland is physiologically enlarged during pregnancy and is therefore very sensitive to decreased blood flow caused by massive hemorrhage and hypovolemic shock. The initial insult is caused by massive PPH, which leads to impaired blood supply to the pituitary gland [28]. In the present study, this result was due to the fact that in group 2, many patients were of class II (blood loss 15–30%) or higher in the American College of Surgeons Advanced Trauma Life Support hemorrhagic shock classification, and many showed signs of massive blood loss and hypovolemic shock in a short period.

This study has several limitations. First, because this was a retrospective study, various variables could not be standardized; therefore, selection bias and other confounding factors may have been present. Second, failure of non-surgical treatment methods was defined as failure of BBT or UAE, which are second-line treatments. However, non-surgical treatment methods for PPH are diverse and limitations in establishing selection criteria exist because of no clearly established treatment steps. Third, the number of complications was small; therefore, statistical significance could not be confirmed. Further studies are required to increase the number of such cases. Despite these limitations, the main strengths of our study are that it was a large-scale study spanning over 10 years at a single institution and meaningful results were obtained by dividing the surgery groups according to the treatment procedures performed before surgery. In addition, prognosis and postoperative complications were carefully investigated.

Immediate surgical intervention was considered for patients with PPH with an increased heart rate or decreased body temperature. In addition, in cases of PPH accompanied by uterine atony with other causes, the probability of failure of non-surgical intervention is high; therefore, immediate surgical intervention would be effective in improving prognosis. When surgery was performed after the failure of non-surgical intervention, the overall postoperative complications, including the rate of hysterectomy and DIC, were significantly higher. Therefore, predicting non-surgical failure and carefully selecting cases that require immediate surgical intervention will improve the prognosis of patients with PPH.

PPH

Postpartum hemorrhage

WHO

World Health Organization

ACOG

American College of Obstetricians and Gynecology

BBR

Bakri balloon tamponade

UAE

uterine arterial embolization

EBL

estimated blood loss

BMI

body mass index

WBC

white blood cell

Hct

hematocrit

blood pressure

RBC

red blood cell

FFP

fresh frozen plasma

ICU

intensive care unit

DIC

disseminated intravascular coagulopathy

ARF

acute renal failure

DVT

deep vein thrombosis

Ethics approval and consent to participate

All data were anonymously analyzed without individual patient consent owing to the retrospective nature of the study. This study was approved by the institutional review board of the Ethics Committee of Chungnam National University Sejong Hospital. (approval no. 2023-12-004).

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable

Authors’ contributions

Conceptualization: YWJ, and HJY; investigation: YWJ, JK, and WKS; writing—original draft preparation: YWJ, JK and HJY; writing—review and editing: YWJ, WKS, SYS, JSC, SHH, JHM, YNI, SMJ, SKO, and HJY; supervision: YWJ, JK, WKS, SYS, JSC, SHH, JHM, YNI, SMJ, SKO, and HJY. All authors have read and agreed to the published version of the manuscript.

Acknowledgements

Not applicable

Authors’ information

Author notes

Ye Won Jungand Jin Kim contributed equally to this work.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Outcomes and prognosis of postpartum hemorrhage according to management protocol: A 11-year retrospective study from two referral centers

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