The rate of postpartum hemorrhage for hospital deliveries in the United States increased significantly over a 20-year period, according to data from more than 76 million delivery hospitalizations from the National Inpatient Sample.
Postpartum hemorrhage remains the leading cause of maternal morbidity and mortality worldwide, and many clinical and patient-level risk factors appear to be on the rise, wrote Chiara M. Corbetta-Rastelli, MD, of the University of California, San Francisco, and colleagues.
Although practice changes have been introduced to reduce postpartum hemorrhage, recent trends in postpartum hemorrhage risk and outcomes in the context of such changes as hemorrhage safety bundles have not been examined, they said.
In a study published in Obstetrics & Gynecology, the researchers reviewed data from hospitalizations for females aged 15-54 years for deliveries between 2000 and 2019 using the National Inpatient Sample. They used a regression analysis to estimate average annual percentage changes (AAPC). Their objectives were to characterize trends and also to assess the association between risk factors and the occurrence of postpartum hemorrhage and related interventions. Demographics, clinical factors, and hospital characteristics were mainly similar between the group of patients with postpartum hemorrhage and those with no postpartum hemorrhage.
Approximately 3% (2.3 million) of 76.7 million hospitalizations for delivery were complicated by postpartum hemorrhage during the study period, and the annual rate increased from 2.7% to 4.3%.
Overall, 21.4% of individuals with delivery hospitalizations complicated by postpartum hemorrhage had one postpartum risk factor, and 1.4% had two or more risk factors. The number of individuals with at least one risk factor for postpartum hemorrhage increased significantly, from 18.6% to 26.9%, during the study period, with an annual percentage change of 1.9%.
Compared with deliveries in individuals without risk factors, individuals with one risk factor had slightly higher odds of postpartum hemorrhage (odds ratio, 1.14), but those with two or more risk factors were more than twice as likely to experience postpartum hemorrhage as those with no risk factors (OR, 2.31).
The researchers also examined the association of specific risk factors and interventions related to hemorrhage, notably blood transfusion and peripartum hysterectomy. Blood transfusions in individuals with postpartum hemorrhage increased from 5.4% to 16.7% between 2000 and 2011, (AAPC, 10.2%) then decreased from 16.7% to 12.6% from 2011 to 2019 (AAPC, –3.9%).
Peripartum hysterectomy in the study population increased from 1.4% to 2.4% from 2000 to 2009 (AAPC 5.0%), remained steady from 2009 to 2016, and then decreased from 2.1% to 0.9% from 2016 to 2019 (AAPC –27%).
Other risk factors associated with postpartum hemorrhage itself and with blood transfusion and hysterectomy in the setting of postpartum hemorrhage included prior cesarean delivery with placenta previa or accreta, placenta previa without prior cesarean delivery, and antepartum hemorrhage or placental abruption, the researchers noted.
“In addition to placental abnormalities, risk factors such as preeclampsia with severe features, polyhydramnios, and uterine leiomyomas demonstrated the highest rates of increase in our data,” they wrote in their discussion. These trends may lead to continuing increases in postpartum hemorrhage risk, which was not fully explained by the increase in risk factors seen in the current study, the researchers said.
The study findings were limited by several factors, including the use of billing codes that could lead to misclassification of diagnoses, as well as possible differences in the definition and coding for postpartum hemorrhage among hospitals, the researchers noted. Other limitations were the exclusion of cases of readmission for postpartum hemorrhage and lack of clinical details involving use of medications or nonoperative interventions, they said.
Notably, the study finding of stable to decreasing peripartum hysterectomy rates in hospitalized patients with postpartum hemorrhage conflicts with another recent study showing an increase in peripartum hysterectomy from 2009 to 2020, but this difference may reflect changes in billing, indications for hysterectomy, or study modeling, they said.
The current study was strengthened by the use of a large database to analyze population trends, a contemporary study period, and the inclusion of meaningful outcomes such as peripartum hysterectomy, the researchers wrote.
The shift in blood transfusion and peripartum hysterectomy may reflect the implementation of protocols to promote early intervention and identification of postpartum hemorrhage, they concluded.