Obstetric Interventions and Maternal Morbidity Among Women Who Experience Severe Postpartum Hemorrhage During Caesarean Delivery

Abstract

Postpartum hemorrhage (PPH) causes severe maternal morbidity and mortality in women undergoing cesarean delivery (CD) compared to women undergoing vaginal delivery. The planning and management of PPH varies according to whether PPH occurs during prelabor CD or intrapartum CD. This study examined the rates of blood product utilization, medical and surgical intervention and maternal morbidity after severe PPH in the prelabor CD and intrapartum CD populations. The study was a retrospective analysis of data from cesarean deliveries at a tertiary obstetric center between 2002 and 2012. Rate of blood product utilization was the primary outcome of this study, and the secondary outcomes were medical and surgical interventions and hemorrhage-related maternal morbidity. The study population was divided into two CD cohorts: prelabor CD and intrapartum CD that experienced severe PPH. Patients were identified as suffering from severe PPH if the documented estimated blood loss (EBL) was ≥1500 mL or if a red blood cell (RBC) transfusion was administered during CD or within 48 h after CD. Blood component use, medical and surgical intervention and maternal morbidity were reviewed. Statistical analyses were performed using STATA (statistical software package) version 12 and a P <0.05 was considered statistically significant. The study data comprised of 269 prelabor women and 278 intrapartum CD women. For the prelabor cohort, RBC transfusion was used intraoperatively or within 48 h post-CD in 148 (55%) patients. Prelabor CD cases had higher rates of morbidity, including hysterectomy (18%) and the need for ICU admission (16%). For the prelabor CD group with severe PPH, abnormal placentation was contributing in 72% of cesarean hysterectomies and 49% of ICU admissions. In the intrapartum CD cohort, a lower proportion of women received RBCs during the intraoperative period compared to the postoperative period (18.3% vs. 43.9%, respectively; P < 0.001). In this review, methylergonovine was the most commonly used second line uterotonic in both groups. In conclusion, the transfusion rates were relatively high for women with severe PPH during prelabor or intrapartum CD. This data is reflective of current transfusion and surgical practices for management of severe PPH during prelabor and intrapartum CD. Large pragmatic studies are essential for comparing the effects of different PPH interventions on maternal outcomes.