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Am J Perinatol
DOI: 10.1055/a-2297-8790
Original Article

Risk of Postpartum Hemorrhage in Hypertensive Disorders of Pregnancy: Stratified by Severity

Kristen A. Cagino 
1   Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
,
Rachel L. Wiley
1   Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
,
Ipsita Ghose 
1   Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
,
Hailie N. Ciomperlik
1   Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
,
Baha M. Sibai
1   Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
,
Hector Mendez-Figueroa
1   Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
,
Suneet P. Chauhan
1   Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
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Abstract

Objective We aimed to determine the composite maternal hemorrhagic outcome (CMHO) among individuals with and without hypertensive disorders of pregnancy (HDP), stratified by disease severity. Additionally, we investigated the composite neonatal adverse outcome (CNAO) among individuals with HDP who had postpartum hemorrhage (PPH) versus did not have PPH.

Study Design Our retrospective cohort study included all singletons who delivered at a Level IV center over two consecutive years. The primary outcome was the rate of CMHO, defined as blood loss ≥1,000 mL, use of uterotonics, mechanical tamponade, surgical techniques for atony, transfusion, venous thromboembolism, intensive care unit admission, hysterectomy, or maternal death. A subgroup analysis was performed to investigate the primary outcome stratified by (1) chronic hypertension, (2) gestational hypertension and preeclampsia without severe features, and (3) preeclampsia with severe features. A multivariable regression analysis was performed to investigate the association of HDP with and without PPH on a CNAO which included APGAR <7 at 5 minutes, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, seizures, neonatal sepsis, meconium aspiration syndrome, ventilation >6 hours, hypoxic–ischemic encephalopathy, or neonatal death.

Results Of 8,357 singletons, 2,827 (34%) had HDP. Preterm delivery <37 weeks, induction of labor, prolonged oxytocin use, and magnesium sulfate usage were more common in those with versus without HDP (p < 0.001). CMHO was higher among individuals with HDP than those without HDP (26 vs. 19%; adjusted relative risk [aRR] 1.11, 95% CI 1.01–1.22). In the subgroup analysis, only individuals with preeclampsia with severe features were associated with higher CMHO (n = 802; aRR 1.52, 95% CI 1.32–1.75). There was a higher likelihood of CNAO in individuals with both HDP and PPH compared to those with HDP without PPH (aRR 1.49, 95% CI 1.06–2.09).

Conclusion CMHO was higher among those with HDP. After stratification, only those with preeclampsia with severe features had an increased risk of CMHO. Among individuals with HDP, those who also had a PPH had worse neonatal outcomes than those without hemorrhage.

Key Points

  • Individuals with HDP had an 11% higher likelihood of CMHO.

  • After stratification, increased CMHO was limited to those with preeclampsia with severe features.

  • There was a higher likelihood of CNAO in those with both HDP and PPH compared to HDP without PPH.

Keywords

blood loss - coagulopathy - hysterectomy - maternal morbidity - preeclampsia


Publication History

Received: 06 February 2024

Accepted: 24 March 2024

Accepted Manuscript online:
02 April 2024

Article published online:
25 April 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Ford ND, Cox S, Ko JY. et al. Hypertensive disorders in pregnancy and mortality at delivery hospitalization - United States, 2017-2019. MMWR Morb Mortal Wkly Rep 2022; 71 (17) 585-591
    CrossrefPubMedGoogle Scholar
  • 2 Hoyert DL, Miniño AM. Maternal mortality in the United States: changes in coding, publication, and data release, 2018. Natl Vital Stat Rep 2020; 69 (02) 1-18
    PubMedGoogle Scholar
  • 3 American College of Obstetricians and Gynecologists. ACOG Practice Bulletin, Number 222: Gestational hypertension and preeclampsia. Obstet Gynecol 2020; 135 (06) e237-e260
    CrossrefPubMedGoogle Scholar
  • 4 von Schmidt auf Altenstadt JF, Hukkelhoven CWPM, van Roosmalen J, Bloemenkamp KWM. Pre-eclampsia increases the risk of postpartum haemorrhage: a nationwide cohort study in the Netherlands. PLoS ONE 2013; 8 (12) e81959
    CrossrefPubMedGoogle Scholar
  • 5 Lertbunnaphong T. Risk factors of primary postpartum hemorrhage in Siriraj Hospital. Siriraj Medical Journal 2010;62(05):
    PubMedGoogle Scholar
  • 6 Koopmans CM, van der Tuuk K, Groen H. et al; HYPITAT study group. Prediction of postpartum hemorrhage in women with gestational hypertension or mild preeclampsia at term. Acta Obstet Gynecol Scand 2014; 93 (04) 399-407
    CrossrefPubMedGoogle Scholar
  • 7 Combs CA, Murphy EL, Laros Jr RK. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991; 77 (01) 69-76
    PubMedGoogle Scholar
  • 8 Eskild A, Vatten LJ. Abnormal bleeding associated with preeclampsia: a population study of 315,085 pregnancies. Acta Obstet Gynecol Scand 2009; 88 (02) 154-158
    CrossrefPubMedGoogle Scholar
  • 9 Fein A, Wen T, Wright JD. et al. Postpartum hemorrhage and risk for postpartum readmission. J Matern Fetal Neonatal Med 2021; 34 (02) 187-194
    CrossrefPubMedGoogle Scholar
  • 10 Young BC, Levine RJ, Karumanchi SA. Pathogenesis of preeclampsia. Annu Rev Pathol 2010; 5 (01) 173-192
    CrossrefPubMedGoogle Scholar
  • 11 Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M. Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. J Matern Fetal Neonatal Med 2005; 18 (03) 149-154
    CrossrefPubMedGoogle Scholar
  • 12 Tica VI, Tica AA, Carlig V, Banica OS. Magnesium ion inhibits spontaneous and induced contractions of isolated uterine muscle. Gynecol Endocrinol 2007; 23 (07) 368-372
    CrossrefPubMedGoogle Scholar
  • 13 Colvin Z, Feng M, Pan A, Palatnik A. Duration of labor induction in nulliparous women with hypertensive disorders of pregnancy and maternal and neonatal outcomes. J Matern Fetal Neonatal Med 2022; 35 (20) 3964-3971
    CrossrefPubMedGoogle Scholar
  • 14 Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum hemorrhage. Obstet Gynecol 2017; 130 (04) e168-e186
    CrossrefPubMedGoogle Scholar
  • 15 Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit. . Accessed November 18, 2023 at: https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit
    PubMedGoogle Scholar
  • 16 Zhong X, Zhang P. Analysis of risk factors associated with different degrees of postpartum hemorrhage in patients with pregnancy-induced hypertension and construction of a prediction model using line graph. J Matern Fetal Neonatal Med 2023; 36 (02) 2239983
    CrossrefPubMedGoogle Scholar
  • 17 Wang C, Zhang C. Meta-analysis to assess the role of maternal characteristics and risk factors on postpartum hemorrhage. Adv Clin Exp Med 2023; 32 (07) 723-731
    CrossrefPubMedGoogle Scholar
  • 18 Baker AM, Haeri S. Estimating risk factors for development of preeclampsia in teen mothers. Arch Gynecol Obstet 2012; 286 (05) 1093-1096
    CrossrefPubMedGoogle Scholar
  • 19 Durmaz A, Komurcu N. Relationship between maternal characteristics and postpartum hemorrhage: a meta-analysis study. J Nurs Res 2018; 26 (05) 362-372
    CrossrefPubMedGoogle Scholar
  • 20 Ende HB, Lozada MJ, Chestnut DH. et al. Risk factors for atonic postpartum hemorrhage: a systematic review and meta-analysis. Obstet Gynecol 2021; 137 (02) 305-323
    CrossrefPubMedGoogle Scholar
  • 21 Ngwenya S. Postpartum hemorrhage: incidence, risk factors, and outcomes in a low-resource setting. Int J Womens Health 2016; 8: 647-650
    CrossrefPubMedGoogle Scholar
  • 22 Suzuki S, Kikuchi F, Ouchi N. et al. Risk factors for postpartum hemorrhage after vaginal delivery of twins. J Nippon Med Sch 2007; 74 (06) 414-417
    CrossrefPubMedGoogle Scholar
  • 23 Ford JB, Roberts CL, Simpson JM, Vaughan J, Cameron CA. Increased postpartum hemorrhage rates in Australia. Int J Gynaecol Obstet 2007; 98 (03) 237-243
    CrossrefPubMedGoogle Scholar
  • 24 Gofton EN, Capewell V, Natale R, Gratton RJ. Obstetrical intervention rates and maternal and neonatal outcomes of women with gestational hypertension. Am J Obstet Gynecol 2001; 185 (04) 798-803
    CrossrefPubMedGoogle Scholar
  • 25 Ghose I, Wiley RL, Ciomperlik HN. et al. Association of adverse outcomes with three-tiered risk assessment tool for obstetrical hemorrhage. Am J Obstet Gynecol MFM 2023; 5 (10) 101106
    CrossrefPubMedGoogle Scholar
  • 26 Lyndon A, Lagrew D, Shields L, Main E, Cape V. eds. Improving Health Care Response to Obstetric Hemorrhage Version 2.0. A California quality improvement toolkit. Stamford, CT: California Maternal Quality Care Collaborative; 2015
    Google Scholar
  • 27 Chahin L, Ghose I, Wiley RL, Ciomperlik HN, Chauhan SP, Mendez-Figueroa H. Medium risk factors for postpartum hemorrhage: multiple versus single risk factor.
    PubMedGoogle Scholar
  • 28 Ibarra CJ, Wiley RL, Chen HY. et al. Validation of calculator for cesarean delivery during induction of labor. Am J Obstet Gynecol 2018; 218 (02) 254
    PubMedGoogle Scholar
  • 29 Schwartzenburg C, Wiley RL, Ghose I, Ciomperlik HN, Chauhan SP, Mendez-Figueroa H. Post-partum hemorrhage risk stratification: association of adverse outcomes with and without documentation. Am J Obstet Gynecol MFM 2024; 230 (01) S421-S422
    PubMedGoogle Scholar
  • 30 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Epidemiology 2007; 18 (06) 800-804
    CrossrefPubMedGoogle Scholar
  • 31 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
    CrossrefPubMedGoogle Scholar
  • 32 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 203: Chronic hypertension in pregnancy. Obstet Gynecol 2019; 133 (01) e26-e50
    CrossrefPubMedGoogle Scholar
  • 33 Vanek M, Sheiner E, Levy A, Mazor M. Chronic hypertension and the risk for adverse pregnancy outcome after superimposed pre-eclampsia. Int J Gynaecol Obstet 2004; 86 (01) 7-11
    CrossrefPubMedGoogle Scholar
  • 34 Aslan H, Gul A, Cebeci A. Neonatal outcome in pregnancies after preterm delivery for HELLP syndrome. Gynecol Obstet Invest 2004; 58 (02) 96-99
    CrossrefPubMedGoogle Scholar
  • 35 Buchbinder A, Sibai BM, Caritis S. et al; National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Adverse perinatal outcomes are significantly higher in severe gestational hypertension than in mild preeclampsia. Am J Obstet Gynecol 2002; 186 (01) 66-71
    CrossrefPubMedGoogle Scholar
  • 36 Habli M, Levine RJ, Qian C, Sibai B. Neonatal outcomes in pregnancies with preeclampsia or gestational hypertension and in normotensive pregnancies that delivered at 35, 36, or 37 weeks of gestation. Am J Obstet Gynecol 2007; 197 (04) 406.e1-406.e7
    CrossrefPubMedGoogle Scholar
  • 37 Razak A, Florendo-Chin A, Banfield L. et al. Pregnancy-induced hypertension and neonatal outcomes: a systematic review and meta-analysis. J Perinatol 2018; 38 (01) 46-53
    CrossrefPubMedGoogle Scholar
  • 38 Long SY, Yang Q, Chi R, Luo L, Xiong X, Chen ZQ. Maternal and neonatal outcomes resulting from antepartum hemorrhage in women with placenta previa and its associated risk factors: a single-center retrospective study. Ther Clin Risk Manag 2021; 17: 31-38
    CrossrefPubMedGoogle Scholar
  • 39 Fan D, Wu S, Liu L. et al. Prevalence of antepartum hemorrhage in women with placenta previa: a systematic review and meta-analysis. Sci Rep 2017; 7 (01) 40320
    CrossrefPubMedGoogle Scholar
  • 40 Wu E, Jolley JA, Hargrove BA, Caughey AB, Chung JH. Implementation of an obstetric hemorrhage risk assessment: validation and evaluation of its impact on pretransfusion testing and hemorrhage outcomes. J Matern Fetal Neonatal Med 2015; 28 (01) 71-76
    CrossrefPubMedGoogle Scholar
  • 41 Dilla AJ, Waters JH, Yazer MH. Clinical validation of risk stratification criteria for peripartum hemorrhage. Obstet Gynecol 2013; 122 (01) 120-126
    CrossrefPubMedGoogle Scholar
  • 42 Ruppel H, Liu VX, Gupta NR, Soltesz L, Escobar GJ. Validation of postpartum hemorrhage admission risk factor stratification in a large obstetrics population. Am J Perinatol 2021; 38 (11) 1192-1200
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Ende HB, Butwick AJ. Current state and future direction of postpartum hemorrhage risk assessment. Obstet Gynecol 2021; 138 (06) 924-930
    CrossrefPubMedGoogle Scholar
  • 44 Miller EC. Preeclampsia and cerebrovascular disease. Hypertension 2019; 74 (01) 5-13
    CrossrefPubMedGoogle Scholar
  • 45 Say L, Chou D, Gemmill A. et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2 (06) e323-e333
    CrossrefPubMedGoogle Scholar
  • 46 Cipparone CW, Withiam-Leitch M, Kimminau KS, Fox CH, Singh R, Kahn L. Inaccuracy of ICD-9 Codes for chronic kidney disease: a study from Two Practice-based Research Networks (PBRNs). J Am Board Fam Med 2015; 28 (05) 678-682
    CrossrefPubMedGoogle Scholar
  • 47 Benesch C, Witter Jr DM, Wilder AL, Duncan PW, Samsa GP, Matchar DB. Inaccuracy of the International Classification of Diseases (ICD-9-CM) in identifying the diagnosis of ischemic cerebrovascular disease. Neurology 1997; 49 (03) 660-664
    CrossrefPubMedGoogle Scholar
  • 48 Pressly MA, Parker RS, Waters JH, Beck SL, Jeyabalan A, Clermont G. Improvements and limitations in developing multivariate models of hemorrhage and transfusion risk for the obstetric population. Transfusion 2021; 61 (02) 423-434
    CrossrefPubMedGoogle Scholar
  • 49 Main EK, Cape V, Abreo A. et al. Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative. Am J Obstet Gynecol 2017; 216 (03) 298.e1-298.e11
    CrossrefPubMedGoogle Scholar
  • 50 Hussain SA, Guarini CB, Blosser C, Poole AT. Obstetric hemorrhage outcomes by intrapartum risk stratification at a single tertiary care center. Cureus 2019; 11 (12) e6456
    PubMedGoogle Scholar
  • 51 Kawakita T, Mokhtari N, Huang JC, Landy HJ. Evaluation of risk-assessment tools for severe postpartum hemorrhage in women undergoing cesarean delivery. Obstet Gynecol 2019; 134 (06) 1308-1316
    CrossrefPubMedGoogle Scholar
  • 52 Phillips JM, Hacker F, Lemon L, Simhan HN. Correlation between hemorrhage risk prediction score and severe maternal morbidity. Am J Obstet Gynecol MFM 2021; 3 (05) 100416
    CrossrefPubMedGoogle Scholar
  • 53 Fleishon HB, Itri JN, Boland GW, Duszak Jr R. Academic medical centers and community hospitals integration: trends and strategies. J Am Coll Radiol 2017; 14 (01) 45-51
    CrossrefPubMedGoogle Scholar