Obstetric Hemorrhage Outcomes by Intrapartum Risk Stratification at a Single Tertiary Care Center

Hussain, Sabahat; Guarini, Carla B; Blosser, Colleen; Poole, Aaron

doi:10.7759/cureus.6456

Cited by 11 publications

(17 citation statements)

References 11 publications

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“…Previous studies that examined OBH risk assessment tools have showed significantly higher sensitives of the tools in predicting OBH and OBH-T in patients categorized as high risk. [8][9][10][11][12] This is consistent with our study, which has comparable accuracy data, including PPV and likelihood ratios. In a recent review of OBH risk assessment tools completed by Ende and Butwick, 13 the PPV ranges for OBH (defined as 1,000 mL of blood loss or greater) and OBH-T were 9-11 and 1-23, respectively.…”

Section: Discussionsupporting

confidence: 91%

“…Notably, previous validation studies have not examined this population and hospital setting. [8][9][10][11][12] It is important to recognize the complexity in collecting race and ethnicity data; however, it is also worthwhile to express that this data increases our data collection on groups traditionally excluded or aggregated into larger population groups. 20 Secondly, by incorporating accuracy data in statistical analysis, both pre-and post-inclusion of intrapartum risk factors, this study allows for more robust data with regards to the possible efficacy of identifying high-risk patients with repeated risk assessment after labor floor admission.…”

Section: Accepted Manuscriptmentioning

confidence: 99%

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Intrapartum Risk Factors and Prediction of Obstetric Hemorrhage–Related Morbidity

et al. 2022

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OBJECTIVE: Assess whether inclusion of intrapartum risk factors improves our obstetric hemorrhage risk stratification tool in predicting obstetric hemorrhage, transfusion, and related severe morbidity. STUDY DESIGN: This is a retrospective cohort study using all live deliveries at a single institution over a two-year period (n = 5,332). Obstetric hemorrhage risk factors, hemorrhage burden, and severe maternal morbidity index outcomes were assessed through chart abstraction. Hemorrhage risk was assessed at: 1. “Time of Admission” through chart abstraction and 2. “Pre-delivery” by calculation after inclusion of all abstracted intrapartum risk factors. Admission high-risk was compared to pre-delivery high-risk for sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio in predicting obstetric hemorrhage, obstetric hemorrhage requiring transfusion, and obstetric hemorrhage related severe morbidity. Significance levels were calculated using descriptive statistical methods including chi-squared tests and McNemar tests. RESULTS: The sensitivities of the risk assessment tool using admission risk classification for high-risk patients is: 25% for obstetric hemorrhage, 37% for obstetric hemorrhage requiring transfusion, and 22% for obstetric hemorrhage related severe morbidity. After intrapartum factor inclusion, the sensitivities increase to: 55% for obstetric hemorrhage, 59% for obstetric hemorrhage requiring transfusion, and 47% for obstetric hemorrhage related severe morbidity. This “pre-delivery” risk assessment is significantly more sensitive across all three end points (p < 0.001 for all three outcomes). While the positive likelihood ratios for obstetric hemorrhage are equal on admission and pre-delivery (2.10 on admission and pre-delivery), they increase after intrapartum factor inclusion for obstetric hemorrhage requiring transfusion and obstetric hemorrhage related severe morbidity (on admission, 2.74 and 1.6, respectively, and pre-delivery: 4.57 and 3.58, respectively). CONCLUSION: Inclusion of intrapartum risk factors increases the accuracy of this obstetric hemorrhage risk stratification tool in predicting patients requiring hemorrhage management with transfusion and obstetric hemorrhage related severe morbidity.

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Section: Discussionsupporting

confidence: 91%

Section: Accepted Manuscriptmentioning

confidence: 99%

Intrapartum Risk Factors and Prediction of Obstetric Hemorrhage–Related Morbidity

et al. 2022

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“…This is comparable to other studies such as Ruppel et al and Hussain et al, who respectively noted that 48 and 43% of hemorrhages occurred in women categorized as low risk. 9 13 This firmly supports the need for hemorrhage risk assessment tool improvement. Clinicians should execute caution and have persistent clinical vigilance even with a score of low risk using a hemorrhage risk prediction tool and ensure utilization of all aspects of an OBH safety bundle.…”

Section: Discussionsupporting

confidence: 53%

Comparative Analysis of Obstetric Hemorrhage Risk Prediction Tools

et al. 2021

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Objective Hemorrhage risk prediction tools were developed in response to rising rates of obstetric hemorrhage (OBH). The California Maternal Quality Care Collaborative (CMQCC) risk prediction tool classifies patients as low, medium, and high risk for OBH based on individual risk factors. At our institution, Magee-Womens Hospital (MWH), a unique OBH risk prediction tool was derived from the CMQCC tool that differs through its use of weighted risk factors and distinctive laboratory value cutoffs. Our objective is to compare this enhanced institution-specific tool to the CMQCC tool. Study Design This study was a retrospective cohort analysis of delivery admissions from a single health care network. Admission OBH risk scores were assigned to each patient using both the MWH and CMQCC scores. Cohen's kappa estimated agreement. Scoring systems and maternal outcomes were compared using chi-square test. Composite morbidity included transfusion, hysterectomy, uterine artery embolization, and intensive care unit admission. Results A total of 21,843 delivery admissions were included. A moderate association was observed between scoring systems (kappa 0.41, p < 0.001). The CMQCC tool categorized 16,184 (74%) patients as low risk, 4,664 (21%) as medium risk, and 995 (5%) as high risk. The MWH tool categorized 13,137 (60%) patients as low risk, 8,113 (37%) as medium risk, and 593 (3%) as high risk. The MWH score recategorized CMQCC low-risk patients to a higher stratum 26% of the time. CMQCC high-risk patients were recategorized to a lower stratum 82% of the time. Both the MWH and CMQCC tools were able to differentiate OBH-related morbidity across risk strata. The MWH tool independently predicted risk of composite morbidity within each stratum of the CMQCC score. Conclusion Both the MWH and CMQCC tools independently distinguish risk of composite morbidity. Adding weighted values to individual risk factors further discriminates risk of morbidity. This suggests it may be reasonable to adapt the CMQCC tool to reflect institutional populations and resources. Key Points

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“…While risk factors are well-documented from descriptive studies (i.e. longer second stage labor, infant macrosomia, oxytocin administration during labor); an estimated 40% of PPH occurs during births without these commonly-noted risk factors [ 8 , 19 , 61 – 64 ] as assessed with available screening tools. A reason for this inaccuracy in risk assessment is due to the fact that PPH is a diagnosis only made after a high cumulative blood loss has occurred.…”

Section: Discussionmentioning

confidence: 99%

“…statistics listed Table Left denotes GG participants and increased positive correlation between greater oxytocin administration and higher blood loss. Right denotes AG/AA participants (larger red circles = AA) and a diminished effect of greater exposure to intrapartum oxytocin on eventual total blood loss labor); an estimated 40% of PPH occurs during births without these commonly-noted risk factors [8,19,[61][62][63][64] as assessed with available screening tools. A reason for this inaccuracy in risk assessment is due to the fact that PPH is a diagnosis only made after a high cumulative blood loss has occurred.…”

Section: Discussionmentioning

confidence: 99%

Oxytocin receptor single nucleotide polymorphism predicts atony-related postpartum hemorrhage

Erickson

Krol

Perkeybile

et al. 2022

BMC Pregnancy Childbirth

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Background Postpartum hemorrhage remains a key contributor to overall maternal morbidity in the United States. Current clinical assessment methods used to predict postpartum hemorrhage are unable to prospectively identify about 40% of hemorrhage cases. Oxytocin is a first-line pharmaceutical for preventing and treating postpartum hemorrhage, which acts through oxytocin receptors on uterine myocytes. Existing research indicates that oxytocin function is subject to variation, influenced in part by differences in the DNA sequence within the oxytocin receptor gene. One variant, rs53576, has been shown to be associated with variable responses to exogenous oxytocin when administered during psychological research studies. How this variant may influence myometrial oxytocin response in the setting of third stage labor has not been studied. We tested for differences in the frequency of the oxytocin receptor genotype at rs53576 in relationship to the severity of blood loss among a sample of individuals who experienced vaginal birth. Methods A case–control prospective design was used to enroll 119 postpartum participants who underwent vaginal birth who were at least 37 weeks of gestation. Cases were defined by either a 1000 mL or greater blood loss or instances of heavier bleeding where parturients were given additional uterotonic treatment due to uterine atony. Controls were matched to cases on primiparity and labor induction status. Genotype was measured from a maternal blood sample obtained during the 2nd postpartum month from 95 participants. Statistical analysis included bivariate tests and generalized linear and Poisson regression modeling. Results The distribution of the genotype across the sample of 95 participants was 40% GG (n = 38), 50.5% AG (n = 48) and 9.5% AA (n = 9). Blood loss of 1000 mL or greater occurred at a rate of 7.9% for GG, 12.5% for AG and 55.6% for AA participants (p = 0.005). Multivariable models demonstrated A-carriers (versus GG) had 275.2 mL higher blood loss (95% CI 96.9–453.4, p < 0.01) controlling for parity, intrapartum oxytocin, self-reported ancestry, active management of third stage or genital tract lacerations. Furthermore, A-carrier individuals had a 79% higher risk for needing at least one second-line treatment (RR = 1.79, 95% CI = 1.08–2.95) controlling for covariates. Interaction models revealed that A-carriers who required no oxytocin for labor stimulation experienced 371.4 mL greater blood loss (95% CI 196.6–546.2 mL). Conclusions We provide evidence of a risk allele in the oxytocin receptor gene that may be involved in the development of postpartum hemorrhage among participants undergoing vaginal birth, particularly among those with fewer risk factors. The findings, if reproducible, could be useful in studying pharmacogenomic strategies for predicting, preventing or treating postpartum hemorrhage.

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Obstetric Hemorrhage Outcomes by Intrapartum Risk Stratification at a Single Tertiary Care Center

Abstract: Open Access Original Article

Cited by 11 publications

References 11 publications

Intrapartum Risk Factors and Prediction of Obstetric Hemorrhage–Related Morbidity

Intrapartum Risk Factors and Prediction of Obstetric Hemorrhage–Related Morbidity

Comparative Analysis of Obstetric Hemorrhage Risk Prediction Tools

Oxytocin receptor single nucleotide polymorphism predicts atony-related postpartum hemorrhage

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