Management of postpartum hemorrhage at a level 1 perinatal center : A retrospective analysis over a period of 18 years.

Abstract

Background: Postpartum hemorrhage (PPH) remains a clinically significant cause of maternal complications and death. Due to the increasing incidence, international recommendations have been implemented, such as the D‑A-CH algorithm, an interdisciplinary and transnational treatment algorithm for Germany, Austria and Switzerland. This study aims to evaluate both the impact of implementing a hemostaseology working group and adopting the internationally recognized D‑A-CH algorithm on the clinical management of PPH in a university hospital.

Methods: In this single-center retrospective observational study, patient records were reviewed from all patients treated for PPH between March 2003 and July 2021 at the University Hospital Ulm, Germany (n = 341). Data were divided into three groups: (I) patients treated before the implementation of a working group for hemostaseology (n = 40), (II) patients treated after the implementation of a working group for hemostaseology and before the clinical application of the D‑A-CH-algorithm (n = 103) and (III) patients treated after the clinical application of the D‑A-CH algorithm (n = 198).

Results: After the implementation of the D‑A-CH-algorithm, a significantly higher amount of fibrinogen (2.0 g, interquartile range, IQR, 0.0-3.0 g in group III vs. 0.0 g, IQR 0.0-2.0 g in group II and 0.0 g, IQR 0.0-0.0 g in group I ; p < 0.0001) and tranexamic acid (1.0 g, IQR 1.0-1.5 g in group III vs. 1.0 g, IQR 0.0-1.0 g in group II and 0.0 g, IQR 0.0-0.0 g in group I; p < 0.0001) was administered. Additionally, transfusion of allogeneic blood products (units of concentrated red cells: 2.0, IQR 0.0-4.0 in group III vs. 3.0, IQR 2.0-5.0 in group II and 3.0, IQR 0.0-7.8 in group I; p = 0.0036), intensive care unit (ICU) stay (3.0 days, IQR 2.0-4.0 days in group III vs. 3.0 days, IQR 2.0-5.0 days in group II and 3.0 days, IQR 2.0-4.3 days in group I; p = 0.0195) and hospital stay (5.0 days, IQR 3.0-7.0 days in group III vs. 7.0 days, IQR 5.0-9.0 days in group II and 7.0 days, IQR 5.0-9.0 days in group I; p < 0.0001) was significantly reduced. Implementation of a hemostaseology working group alone was only associated with increased fibrinogen and tranexamic acid administration.

Conclusion: In this retrospective study, application of the D‑A-CH algorithm was associated with improved targeted hemostatic therapy and reduced transfusion requirements as well as shorter ICU and hospital stays, whereas implementation of a hemostaseology working group alone was only associated with increased fibrinogen and tranexamic acid administration. Due to the retrospective design of the study and inherent limitations therein, we were unable to draw a causative effect relationship. Nonetheless, our results warrant further study.