Incidence, management and outcome of women requiring massive transfusion after childbirth in the Netherlands: secondary analysis of a nationwide cohort study between 2004 and 2006

Abstract

BackgroundPostpartum hemorrhage remains the leading cause of maternal morbidity and mortality worldwide. Few population-based studies have examined the epidemiology of massive transfusion for postpartum hemorrhage. The aim of this study was to determine the incidence, management, and outcomes of women with postpartum hemorrhage who required massive transfusion in the Netherlands between 2004 and 2006.MethodsData for all women from a gestational age of 20 weeks onwards who had postpartum hemorrhage requiring eight or more red blood cell concentrates were obtained from a nationwide population-based cohort study including all 98 hospitals with a maternity unit in the Netherlands.ResultsThree hundred twenty-seven women who had postpartum hemorrhage requiring massive transfusion were identified (massive transfusion rate 91 per 100,000 deliveries (95% confidence interval: 81–101)). The median blood loss was 4500 mL (interquartile range 3250–6000 mL) and the median number of red blood cell concentrates transfused was 11 units (interquartile range 9–16 units). Among women receiving massive transfusion, the most common cause of hemorrhage was uterine atony. Eighty-three women (25%) underwent hysterectomy, 227 (69%) were admitted to an intensive care unit, and three women died (case fatality rate 0,9%).ConclusionThe number of women in the Netherlands who had postpartum hemorrhage treated with massive transfusion was relatively high compared to other comparable settings. Evidence-based uniform management guidelines are necessary.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-017-1384-7) contains supplementary material, which is available to authorized users.

Women receiving massive transfusion due to postpartum hemorrhage: A comparison over time between two nationwide cohort studies

“…The TeMpOH‐1 source population comprised 270 101 births (including births under guidance of primary care) in the Netherlands during the 2‐year inclusion period. A total of 176 women experienced PPH and received transfusion of 8 or more units of packed red blood cells, making the incidence of massive transfusion due to PPH in the Netherlands 65 per 100 000 births (95% CI 56‐75) (Figure ) …”

“…Massive transfusion was defined as 8 or more units of packed red blood cells transfused within the first 24 h after childbirth. All results were compared with our previous observations from the LEMMoN cohort (Landelijke studie naar Etnische determinanten van Maternale Morbiditeit in Nederland) between 2004 and 2006; nationwide statistics obtained from the Netherlands Perinatal Registry (PRN, 2012) were used as national reference values …”

“…We recorded the following parameters: maternal age at time of birth, body mass index (BMI) at beginning of pregnancy, parity, ethnicity (Caucasian/non‐Caucasian), obstetric history (previous cesarean section and/or previous PPH), gestational age, mode of birth (vaginal birth, instrumental vaginal birth, elective cesarean section or emergency cesarean section), induction of labor, multiple pregnancy, preeclampsia in current pregnancy, blood loss (measured by weighing gauzes and by use of a suction system in the operating theater), number of packed red blood cells transfused, cause of hemorrhage (uterine atony, uterine rupture, placental pathology [including retained placenta, placental remnants, placenta previa, abnormally invasive placenta and placental abruption], laceration of the birth canal, uterine inversion and clotting disorder with or without amniotic fluid embolism) and management of hemorrhage (uterotonic agents [oxytocin, sulprostone, ergometrine, misoprostol], non‐uterotonic agents [tranexamic acid], intrauterine balloon tamponade, surgical interventions [B‐Lynch sutures, uterine artery ligation, hysterectomy] and uterine artery embolization). Furthermore, as major PPH can be the result of concurrent causes, we re‐examined all cases of massive transfusion due to PPH within the TeMpOH‐1 cohort, and only included multiple causes for an individual woman if those causes contributed significantly to the bleeding, as was previously done in the LEMMoN study . Causes of PPH in women who received massive transfusion were further analyzed by mode of birth and the number of packed red blood cells transfused, using the same cut‐off points described by Green et al in the UK: “moderate” (8‐12 units of packed red blood cells), “high” (13‐20 units of packed red blood cells) and “immense” (> 20 units of packed red blood cells).…”

“…Its incidence seems to be increasing in high‐income countries accompanied by increasing rates of severe adverse outcomes . In obstetrics, massive transfusion (defined as 8 or more units of packed red blood cells transfused) after birth is associated with high rates of morbidity and hysterectomy . Incidence of massive transfusion due to PPH was notably high in the Netherlands between 2004 and 2006 (91 per 100 000 births) compared with the United Kingdom between 2012 and 2013 (23 per 100 000 births) and with the state of New York between 1998 and 2007 (60 per 100 000 births) …”

“…The aim of this study was to describe incidence, causes, management and outcome of women who received massive transfusion due to PPH in the Netherlands between 2011 and 2012 and compare these with the same parameters previously described in the Netherlands between 2004 and 2006 and with the Dutch general pregnant population of 2012 …”