Investigation of an increase in postpartum haemorrhage in Canada
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 reservedActa Obstetricia Et Gynecologica Scandinavica 01/2010; 1. · 1.85 Impact Factor
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ABSTRACT: This study aimed to explore whether recording of a prior adverse pregnancy outcome (postpartum hemorrhage) in a medical record increases the likelihood that recurrence of the same event is reported in hospital data. Using a sample of 588 pregnancies [2 consecutive pregnancies for 294 randomly selected women with at least one postpartum hemorrhage (PPH)], we compared 'coded' recurrence rates in hospital data with those obtained from medical record audit. 'Coded' recurrence in a second pregnancy was also compared for women with or without a documented history of prior PPH. We found a 'coded' recurrence rate of 18.5% and an 'audited' recurrence rate of 28.4%. The 'coded' rate of recurrence among women who had a documented history of PPH was 27.4% compared to 19.1% when the previous PPH was not noted in the second pregnancy medical record. Medical record reporting of uterine atony as the cause for postpartum hemorrhages in first and second births was 37.9 and 34.0% while 'coded' hospital data reporting attributed 79.8 and 73.9% respectively to atony. Our study results indicate that a history of postpartum hemorrhage may be a stronger risk factor for subsequent PPH than previously demonstrated. A recorded history of PPH was associated with an increased likelihood of reporting a subsequent PPH, and in such cases recurrence rates approximate true recurrence. The contribution of uterine atony as a cause of postpartum hemorrhage is over-estimated using hospital data.Maternal and Child Health Journal 11/2011; 16(7):1542-8. · 2.24 Impact Factor
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ABSTRACT: There is considerable evidence for increasing trends in the incidence of postpartum hemorrhage (PPH) over time. The aim of the present study was to investigate trends in the frequency and the severity of PPH in developed countries, and to assess potential causes for any observed trends. There was an increasing trend in PPH in Australia, Canada, the United Kingdom, and the United States. The increased incidence of PPH was limited solely to immediate/atonic PPH in Australia, Canada, and the United States. Increasing rates of severe adverse outcomes due to PPH were found in Australia, Canada, the United Kingdom, and the United States. The key recommendations of the Collaborative Group are as follows: in future revisions of the International Classification of Diseases, there should be separate codes for atonic PPH and other forms of PPH that occur in the first 24 hours after delivery of the placenta. Separate codes are also required for morbidly adherent placenta including placenta accreta, increta, and percreta. A standardized definition of PPH should be used in all countries. Research is needed to determine how current definitions are applied in practice to the coding of data. Improved methods of data collection are required including assessment of severity. Additional studies are required to determine whether increases in rate of PPH have occurred in other countries, and to evaluate the role of potential risk factors of PPH including obesity, increased duration of labor, and changes in management of the second and third stage. A key to reducing the severity of PPH and preventing adverse outcomes is enhanced training of maternity care staff in the assessment of blood loss and the monitoring of women following childbirth. Physicians should be more aware of the likelihood that the frequency and severity of PPH has increased and be more vigilant. The reported increased incidence of PPH is especially a problem in small hospitals with few deliveries. Such hospitals have limited access to equipment or drugs and lack adequate management protocols to treat women with unexpected severe PPH.Obstetrical and Gynecological Survey 03/2010; 65(4):211-212. · 2.51 Impact Factor