CLINIC SCIENCE SESSION

 POSTPARTUM HEMORRHAGERESULTING FROM UTERINE

ATONY AFTER VAGINAL DELIVERY

OLEHIKA TRESNI

PEMBIMBINGDr. FIRMANSYAH, SPOG

To identify factors associated with severity of postpartum hemorrhage→characteristics of women & theirdelivery, the components of initial postpartum hemorrhage management,

and the organizational characteristics of maternity units.

OBJECTIVE

Cohort study included women with postpartum hemorrhage →uterine atony

after vaginal delivery in 106 French hospitals between December 2004 & November 2006 (N4,550).

METHODS

Severe postpartum hemorrhage →peripartum change in hemoglobin of 4 g/dL or more.

A multivariable logistic model rhage severity

Severe postpartum hemorrhage occurred in 952 women (20.9%).

factors independently→ primiparity; previous postpartum hemorrhage; previous cesarean delivery; cervical ripening; prolonged labor; and episiotomy; and delay in initial care for postpartum hemorrhage.

RESULTS

Also associated with severity was 1 Administration of oxytocin2 Manual examination of the uterine cavity 3 Call for additional assistance4 delivery in a public nonuniversity

hospital.

Aspects of labor, delivery, and their management; delay in initial care; and place of Delivery are independent risk factors for severe blood loss in women with postpartum hemorrhage caused by

atony.

CONCLUSION

Postpartum hemorrhage→ maternal mortality worldwide & the main component of severe maternal morbidity in Western countries.

Most postpartum hemorrhages are the result of uterine atony.

Two categories of explanatory factors can beconsidered: 1. The individual characteristics of women

and deliveries.

2. Factors related to medical care, that is, both

the content of care and the organization of healthcare services.

The Pithagore6 trial→ all cases ofPostpartum hemorrhage in 106 French Maternity units during 1 year and collected detailed data onthem→severity in postpartumhemorrhage related maternal morbidity.

The study population →a cohort of women with postpartum hemorrhage selected from the Pithagore6 trial population.

The Pithagore6 trial was a cluster randomized

controlled trial in 106 French maternity units operating as six perinatal networks.

MATERIALS AND METHODS

Data were collected→ December 2004 through

November 2005 in the Aurore network andfrom December 2005 through November

2006 in the other five.

Postpartum hemorrhage was clinically assessed

by the caregivers if the estimated postpartum blood loss was greater than 500 mL or

defined by a peripartum change in hemoglobin (Hb) greater than 2 g/dL (considered equivalent tothe loss of more than 500 mL of blood).

Prepartum Hb was collected as part of routinePrenatal care during the last weeks of pregnancy; Postpartum Hb was the lowest

Hblevel found in the 3 days after delivery. Birth attendants in each unit Prospectively

identified all deliveries with postpartum hemorrhage

and reported them to the research team.

Fig. 1. Study population.

The outcome was severe postpartum hemorrhage→peripartum change in Hb of 4 g/dL or more (considered equivalent to the loss of 1,000 mL or more of blood).

Three groups of potential risk factors for severe postpartum hemorrhage

1. Characteristics of the women and aspects of labor and delivery before postpartum hemorrhage

2. Components of initial postpartum hemorrhage management.

3. Organizational characteristics of the units.

The crude associations of severe postpartum hemorrhage with these variables → chi square statistics and quantified with unadjusted odds ratios and their 95% Confidence intervals.

Multivariable logistic regression modeling was used to assess the independent effect of each variable.

1. In a first step, a logistic regression analysis → characteristics of women, labor, and delivery before postpartum hemorrhage was performed to determine whether these characteristics were independently associated with postpartum hemorrhage severity.

2.Separate multilevel models tested the association of each component of initial postpartum hemorrhage care with postpartum hemorrhage severity after adjustment for the significant characteristics of women, labor, and delivery

3. Finally, the association of each organizational characteristic with postpartum hemorrhage severity was examined after adjustment for characteristics of women, labor, delivery, and components of initial care.

Among 4,550 women with postpartum hemorrhage in the study population, 952 (20.9%) had severe postpartum hemorrhage.

RESULTS

Table 1. Characteristics of Women, Labor, and Delivery: Distribution in the Cohort of Postpartum Hemorrhage and Risk of Severe Postpartum Hemorrhage,Univariable and Multivariable Analyses

Table 2. Initial Management of Postpartum Hemorrhage andCharacteristics of the Units: Distribution in the Cohort of Postpartum Hemorrhage and Risk of Severe Postpartum Hemorrhage, univariable Analysis

Table 3. Initial Management of Postpartum Hemorrhage and Risk of Severe Postpartum Hemorrhage, Multivariable Analysis*

Table 4. Characteristics of the Units and Risk of Severe Postpartum Hemorrhage, Multivariable Analysis*

These include the woman’s obstetric history, aspects of delivery before postpartum hemorrhage, delay in initial care for postpartum hemorrhage, and hospital status.

DISCUSSION

Our study shows that some aspects of the management of labor and delivery as well asdelayed initial care for postpartum

hemorrhageand place of delivery increase the risk of

heavypostpartum bleeding caused by atony.

More specifically, it provides evidence suggesting that reducing use cervical

ripening, episiotomy, or cesarean delivery, in particular in situations in which these interventions do not provide clear benefits as well improving

the rapidity of first care once postpartum hemorrhage has occurred, may reduce theincidence of severe postpartum hemorrhage.

TERIMA KASIH