Risk Factors for Postpartum Hemorrhage and its Severe Forms with Blood Loss Evaluated Objectively - A Prospective Cohort Study

Borovac-Pinheiro, Anderson; Ribeiro, Filipe Moraes; Pacagnella, Rodolfo Carvalho

doi:10.1055/s-0040-1718439

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Original Article • Rev. Bras. Ginecol. Obstet. 43 (02) • Feb 2021 • https://doi.org/10.1055/s-0040-1718439 copy

Risk Factors for Postpartum Hemorrhage and its Severe Forms with Blood Loss Evaluated Objectively - A Prospective Cohort Study

Fatores de risco para hemorragia pós-parto e suas formas graves com perda sanguínea avaliada objetivamente - Um estudo de coorte prospectivo

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To identify risk factors related to postpartum hemorrhage (PPH) and severe PPH with blood loss quantified objectively.

Methods

This is a complementary analysis of a prospective cohort study that included pregnant women delivering vaginally. The total blood loss was obtained through the sum of the volume collected from the drape with the weight of gauzes, compresses and pads used by women within 2 hours. Exploratory data analysis was performed to assess mean, standard deviation (SD), frequency, percentage and percentiles. The risk factors for postpartum bleeding were evaluated using linear and logistic regression.

Results

We included 270 women. Themean blood loss at 120 minutes was 427.49 mL (±335.57 mL). Thirty-one percent (84 women) bled > 500mL and 8.2% (22 women) bled > 1,000 mL within 2 hours. Episiotomy, longer second stage of labor and forceps delivery were related to blood loss > 500mL within 2 hours, in the univariate analysis. In the multivariate analysis, only forceps remained associated with bleeding > 500 mL within 2 hours (odds ratio [OR] = 9.5 [2.85-31.53]). Previous anemia and episiotomy were also related to blood loss > 1,000mL.

Conclusion

Prolonged second stage of labor, forceps and episiotomy are related to increased incidence of PPH, and should be used as an alert for the delivery assistants for early recognition and prompt treatment for PPH.

Keywords:
risk factors; postpartum hemorrhage; maternal mortality

Characteristics	n	Mean ± SD
Age (years old)	270	24.67 ± 6.2
BMI (antepartum) ^a	244	28.85 ± 4.6
Parity	270	0.80 ± 1.10
Gestational age (in weeks)	270	38.93 ± 1.47
Education (in years) ^b	231	9.91 ± 2.5
Time to second stage (in minutes) ^c	223	32.47 ± 34.7
Initial Hb (in g/dL) ^d	260	11.45 ± 0.1
Ethnicity - white ^e	178 (67%)
Previous C-Section	42 (15.5%)
Spontaneous onset of labor	203 (75.2%)
Anesthesia/analgesia (yes)	170 (63%)
Mode of delivery
vaginal	247 (91.5%)
forceps	23 (8.5%)
Episiotomy (yes)	96 (36%)
Laceration (≥ grade 2)	155 (57.1%)
Blood loss within 120 minutes
≥ 500 mL	84 (31%)
≥ 1000 mL	22 (8.2%)

		500 mL within 2 hours		1,000 mL within 2 hours
	n	OR	p-value	OR	p-value
	n	(95%CI)	p-value	(95%CI)	p-value
Univariate analysis
Age
≤ 19 years old	63	1.51	0.172	1.60	0.329
≤ 19 years old	63	(0.83 - 2.71)	0.172	(0.62 - 4.11)	0.329
20–35 years old	191	Ref.
≥ 35 years old	16	1.00	0.990	1.67	0.516
≥ 35 years old	16	(0.34 - 2.99)	0.990	(0.35 - 7.87)	0.516
Ethnicity
white	178	Ref.
non-white	85	0.83	0.534	2.24	0.085
non-white	85	(0.47 - 1.47)	0.534	(0.89 - 5.61)	0.085
Schooling (mean in years)	231	1.04	0.431	0.97	0.813
Schooling (mean in years)	231	(0.93 - 1.17)	0.431	(0.80 - 1.18)	0.813
Overweight (BMI^a ≥25)	104	1.36	0.272	0.94	0.900
Overweight (BMI^a ≥25)	104	(0.78 - 2.36)	0.272	(0.34 - 2.55)	0.900
Obesity (BMI^a ≥ 30)	89	1.03	0.913	1.60	0.350
Obesity (BMI^a ≥ 30)	89	(0.58 - 1.82)	0.913	(0.59 - 4.31)	0.350
Multiparity (two or more previous deliveries)	53	0.65	0.227	0.87	0.817
Multiparity (two or more previous deliveries)	53	(0.32 - 1.30)	0.227	(0.28 - 2.70)	0.817
Gestational age
34–40 weeks	146	0.92	0.764	1.64	0.277
34–40 weeks	146	(0.53 - 1.59)	0.764	(0.67 - 4.03)	0.277
40 weeks	102	Ref.
Previous C-section	42	1.13	0.731	1.65	0.351
Previous C-section	42	(0.56 - 2.28)	0.731	(0.57 - 4.75)	0.351
Anemia (hemoglobin ≤ 11 g/dl)	43	1.60	0.175	2.82	0.037
Anemia (hemoglobin ≤ 11 g/dl)	43	(0.81 - 3.15)	0.175	(1.06 - 7.47)	0.037
Spontaneous labor	203	0.58	0.062	0.87	0.780
Spontaneous labor	203	(0.32 - 1.03)	0.062	(0.32 - 2.32)	0.780
Duration of second-stage of labor ≥ 30 minutes	223	1.88	0.032	1.90	0.230
Duration of second-stage of labor ≥ 30 minutes	223	(1.05–3.37)	0.032	(0.66–5.45)	0.230
Anesthesia (yes)	168	1.225	0.458	1.068	0.886
Anesthesia (yes)	168	(0.71–2.09)	0.458	(0.43–2.64)	0.886
Episiotomy (yes)	96	2.39	0.001	3.05	0.017
Episiotomy (yes)	96	(1.39 - 4.10)	0.001	(1.12 - 7.66)	0.017
Laceration (≥ grade 2)	144	1.03	0.924	1.64	0.300
Laceration (≥ grade 2)	144	(0.60 - 1.74)	0.924	(0.64 - 4.22)	0.300
Forceps (yes)	23	9.87	<0.001	2.68	0.101
Forceps (yes)	23	(3.53 - 27.65)	<0.001	(0.82 - 8.72)	0.101
Multivariate analysis
Forceps (yes)	260	9.48	<0.001
Forceps (yes)	260	(2.85 - 31.53)	<0.001
Duration of second stage of labor ≥ 30 minutes	260	1.05	0.883
Duration of second stage of labor ≥ 30 minutes	260	(0.57–2.10)
Episiotomy (yes)	260	1.49	0.25
Episiotomy (yes)	260	(0.75–2.96)

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[1] Address for correspondence Anderson Borovac-Pinheiro, MD, PhD, Cidade Universitária Zeferino Vaz, Barão Geraldo, Campinas, SP, 13083-970, Brazil (e-mail: andersonpinheiro.unicamp@gmail.com).