Investigation of an increase in postpartum haemorrhage in Canada

BJOG An International Journal of Obstetrics & Gynaecology (Impact Factor: 3.76). 05/2007; 114(6):751 - 759. DOI: 10.1111/j.1471-0528.2007.01316.x

ABSTRACT Objective To investigate the cause of a recent increase in hysterectomies for postpartum haemorrhage in Canada.Design Retrospective cohort study.Setting Canada between 1991 and 2004.Population All hospital deliveries in Canada as documented in the database of the Canadian Institute for Health Information (excluding incomplete data from Quebec, Manitoba and Nova Scotia).Methods Deliveries with postpartum haemorrhage by subtype were identified using International Classification of Diseases codes, while hysterectomies were identified using procedure codes. Changes in determinants of postpartum haemorrhage (all postpartum haemorrhage and that requiring hysterectomy) were examined, and crude and adjusted period changes were assessed using logistic models.Main outcome measures Postpartum haemorrhage, postpartum haemorrhage with hysterectomy, postpartum haemorrhage with blood transfusion and postpartum haemorrhage by subtype.Results Rates of postpartum haemorrhage increased from 4.1% in 1991 to 5.1% in 2004 (23% increase, 95% CI 20–26%), while rates of postpartum haemorrhage with hysterectomy increased from 24.0 in 1991 to 41.7 per 100 000 deliveries in 2004 (73% increase, 95% CI 27–137%). These increases were because of an increase in atonic postpartum haemorrhage, from 29.4 per 1000 deliveries in 1991 to 39.5 per 1000 deliveries in 2004 (34% increase, 95% CI 31–38%). Adjustment for temporal changes in risk factors did not explain the increase in atonic postpartum haemorrhage but attenuated the increase in atonic postpartum haemorrhage with hysterectomy.Conclusions There has been a recent, unexplained increase in the frequency, and possibly the severity, of atonic postpartum haemorrhage in Canada.

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    ABSTRACT: Objective To assess whether postpartum hemorrhage (PPH) can be predicted in women with gestational hypertension or mild preeclampsia at term. Design A cohort study in which we used data from our multicentre randomized controlled trial (HYPITAT-trial). SettingThe study was conducted in 38 hospitals in the Netherlands between 2005 and 2008. Population Women with gestational hypertension or mild preeclampsia at term (n=1,132). Methods An antepartum model (model A) and an antepartum/ intrapartum model (model B) were created using logistic regression. The predictive capacity of the models was assessed with receiver-operating-characteristic (ROC) analysis and calibration. Main outcome measurePPH, defined as blood loss >1000 ml within 24h after delivery. ResultsPPH occurred in 118 (10.4%) women. Maternal age (OR 1.03), pre-pregnancy body mass index (OR 0.96) and women with preeclampsia (OR 1.5) were independent antepartum prognostic variables of PPH. Intrapartum variables incorporated in the model were gestational age at delivery (OR 1.2), duration of dilatation stage (OR 1.1) and episiotomy (OR 1.5). Model A and model B showed moderate discrimination, with an area under the ROC-curve of 0.59 (95% CI 0.53-0.64) and 0.64 (95% CI 0.59-0.70). Calibration was moderate for model A (Hosmer-Lemeshow p-value=0.26) but better for model B (Hosmer-Lemeshow p-value=0.36). The rates of PPH ranged from 4% (lowest 10 percent) to 22% (highest 10 percent). Conclusion In the assessment of performance of a prediction model, calibration is more important than discriminative capacity. Our prediction model shows that for women with gestational hypertension or mild preeclampsia at term distinction between low and high risk of developing PPH is possible when antepartum and intrapartum variables are combined.This article is protected by copyright. All rights reserved
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