Hemorrhage Risk Assessment on Admission: Utility for Prediction of Maternal Morbidity

Abstract

Objective Hemorrhage is a major cause of maternal morbidity and mortality prompting creation of innovative risk assessment tools to identify patients at highest risk. We aimed to investigate the association of hemorrhage risk assessment with maternal morbidity and to evaluate maternal outcomes after implementation of the risk assessment across hospital sites.

Study Design We conducted a retrospective cohort analysis of a multicenter database including women admitted to labor and delivery from January 2015 to June 2018. The Association of Women's Health, Obstetric and Neonatal Nurses risk assessment tool was used to categorize patients as low, medium, or high risk for hemorrhage. Multivariate logistic regression was used to describe the association between hemorrhage risk score and markers of maternal morbidity and evaluate maternal outcomes before and after standardized implementations of the risk assessment tool.

Results In this study, 14,861 women were categorized as low risk (26%), 26,080 (46%) moderate risk, and 15,730 (28%) high risk (N = 56,671 births). For women with high-risk scores, the relative risk (RR) ratio compared with low-risk women was 4.9 (RR: 95% confidence interval [CI]: 3.2–7.4) for blood transfusion and 5.2 (RR: 95% CI: 4.6–5.9) for estimated blood loss (EBL) ≥ 1,000 mL. For the second objective, 110,633 women were available for pre- and postimplementation analyses (39,027 and 71,606, respectively). A 20% reduction in rates of blood transfusion (0.5–0.4%, p = 0.02) and EBL ≥ 1,000 mL (6.3–5.9%, p = 0.014) was observed between pre- and postimplementations of the admission hemorrhage risk assessment tool.

Conclusion Women who were deemed high risk for hemorrhage using a hemorrhage risk assessment tool had five times higher risk for blood transfusion and EBL ≥ 1,000 mL compared with low-risk women. Given the low incidence of the outcomes explored, the hemorrhage risk assessment works moderately well to identify patients at risk for peripartum morbidity.

Key Points

• This study aimed to understand the utility of the AWOHNN hemorrhage risk assessment tool for predicting hemorrhage-related morbidity and to evaluate maternal outcomes before and after tool implementations.

• A high score using a hemorrhage risk assessment tool on admission is associated with five times higher risk for blood transfusion and/or estimated blood loss ≥ 1,000 mL, compared with a low score.

• Use of a hemorrhage risk assessment tool works moderately well to identify patients at highest risk for hemorrhage-related morbidity.

Keywords

hemorrhage risk assessment - maternal morbidity - obstetric hemorrhage - transfusion

Note

Findings were presented at the 39th Annual SMFM Meeting, February 13–16, 2019.

Publication History

Received: 04 March 2020

Accepted: 05 April 2020

Article published online:
23 May 2020

• References

• 1 Grobman WA, Bailit JL, Rice MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Frequency of and factors associated with severe maternal morbidity. Obstet Gynecol 2014; 123 (04) 804-810
• 2 World Health Organization. WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage. 2017 . Accessed March 17, 2019 at: https://www.who.int/reproductivehealth/publications/tranexamic-acid-pph-treatment/en/
• 3 Knight M, Callaghan WM, Berg C. et al. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth 2009; 9: 55
• 4 Kramer MS, Berg C, Abenhaim H. et al. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol 2013; 209 (05) 449.e1-449.e7
• 5 Lappen JR, Seidman D, Burke C, Goetz K, Grobman WA. Changes in care associated with the introduction of a postpartum hemorrhage patient safety program. Am J Perinatol 2013; 30 (10) 833-838
• 6 Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol 2015; 212 (03) 272-280
• 7 Main EK, Goffman D, Scavone BM. et al; National Partnership for Maternal Safety; Council on Patient Safety in Women's Health Care. National Partnership for Maternal Safety: consensus bundle on obstetric hemorrhage. Obstet Gynecol 2015; 126 (01) 155-162
• 8 Ahmadzia HK, Phillips JM, James AH, Rice MM, Amdur RL. Correction: predicting peripartum blood transfusion in women undergoing cesarean delivery: a risk prediction model. PLoS One 2019; 14 (01) e0211360
• 9 Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg 2010; 110 (05) 1368-1373
• 10 Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B. Prevalence and risk factors of severe obstetric haemorrhage. BJOG 2008; 115 (10) 1265-1272
• 11 Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Postpartum Hemorrhage Project: A Multi-Hospital Quality Improvement Program. 2017. Accessed March 17, 2019 at: http://www.pphproject.org
• 12 The American College of Obstetricians and Gynecologists. Safe Motherhood Initiative. Maternal Safety Bundle for Obstetric Hemorrhage. 2015. Accessed March 17, 2019 at: https://www.acog.org/community/districts-and-sections/district-ii/programs-and-resources/safe-motherhood-initiative/obstetric-hemorrhage
• 13 Bingham D, Melsop K, Main E. CMQCC Obstetric Hemorrhage Hospital Level Implementation Guide. Palo Alto, CA: The California Maternal Quality Care Collaborative (CMQCC); 2010
• 14 Dilla AJ, Waters JH, Yazer MH. Clinical validation of risk stratification criteria for peripartum hemorrhage. Obstet Gynecol 2013; 122 (01) 120-126
• 15 Gordis L. Epidemiology. Philadelphia, PA: Elsevier; 2009
• 16 Callaghan WM, Grobman WA, Kilpatrick SJ, Main EK, D'Alton M. Facility-based identification of women with severe maternal morbidity: it is time to start. Obstet Gynecol 2014; 123 (05) 978-981
• 17 Oyelese Y, Ananth CV. Postpartum hemorrhage: epidemiology, risk factors, and causes. Clin Obstet Gynecol 2010; 53 (01) 147-156
• 18 Kacmar RM, Mhyre JM, Scavone BM, Fuller AJ, Toledo P. The use of postpartum hemorrhage protocols in United States academic obstetric anesthesia units. Anesth Analg 2014; 119 (04) 906-910