Postpartum hemorrhage in electronic health records: risk factors at admission and in-hospital occurrence

Martins, Raíssa Isabelle Leão; Novais, Jussara de Souza Mayrink; Reis, Zilma Silveira Nogueira

doi:10.61622/rbgo/2024AO14

Raíssa Isabelle Leão Martins Corresponding author Raíssa Isabelle Leão Martins Email: raissailmartins@ufmg.br

involved in the design and interpretation of the analysis

contributed to the writing of the manuscript

read and approved the final manuscript

Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.

https://orcid.org/0000-0002-3909-0117

Jussara de Souza Mayrink Novais

involved in the design and interpretation of the analysis

contributed to the writing of the manuscript

read and approved the final manuscript

Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.

https://orcid.org/0000-0001-5957-4365

Zilma Silveira Nogueira Reis

involved in the design and interpretation of the analysis

contributed to the writing of the manuscript

read and approved the final manuscript

Department of Gynecology and Obstetrics, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.

https://orcid.org/0000-0001-6374-9295

Corresponding author Raíssa Isabelle Leão Martins Email: raissailmartins@ufmg.br

Associate Editor Sue Yazaki Sun (https://orcid.org/0000-0001-6573-7386) Universidade Federal de São Paulo, São Paulo, SP, Brazil

Conflicts to interest: none to declare.

Figures (1)
Tables (5)

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Figure 1
Flowchart of patient allocation according to eligibility criteria

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Chart 1
Grades of PPH risk according to the introduced prevention program (at least one factor)

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Table 1
Demographic profile of participants with PPH and without PPH, at maternity admission

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Table 2
Delivery, obstetric interventions and intrapartum complications, compared between participants with and without PPH

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Table 3
Risk factors of PPH in a multivariate analysis

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ID_HOSPITALIZATION PATIENT IDENTIFICATION INTEGER AGE WOMEN MOTHER'S AGE INTEGER PPH YES / NO PREGNANCY INT 1 -SINGLE, 2 - TWINS, 3 - TRIPLETS, 4 - QUADRIGEMINS, 5 - QUINTUPLES INTEGER FETAL PRESENTATION 1 - CEPHALIC, 2 - BREECH, 3 - ANOMALOUS (TRANSVERSE OR OBLIQUE)) INTEGER LABOR ON ADMISSION 1- SPONTANEOUS, 2- INDUCED, 3- OUT OF LABOR INTEGER PARITY 1 - NULIPAROUS, 2 - MULTIPAROUS INTEGER PREVIOUS C-SECTIONS NUMBER INTEGER GA_WEEKS GESTATIONAL AGE (WEEKS) INTEGER GA_DAYS GESTATIONAL AGE (DAYS) INTEGER HEMORRHAGE RISK 1 - LOW RISK, 2 - MEDIUM RISK, 3 - HIGH RISK INTEGER ACTIVE BLEEDING ON ADMISSION 1- YES, 2 - NO YES / NO GESTATIONAL HYPERTENSION 1- YES, 2 - NO YES / NO CHRONIC HYPERTENSION 1- YES, 2 - NO YES / NO PREECLAMPSIA O - NO 1- MILD, 2 - SEVERE INTEGER ECLAMPSIA 1- YES, 2 - NO YES/ NO THROMBOCYTOPENIA 1- YES, 2 - NO YES / NO USE OF ANTICOAGULANTS 1- YES, 2 - NO YES / NO PLACENTA_ACCRETA 1- YES, 2 - NO YES / NO PLACENTA PREVIA 1-YES, 2-NO YES/ NO DIABETES 1- YES, 2 - NO YES / NO MED_OXYTOCIN_1ST 1- YES, 2 - NO YES / NO MED_OXYTOCIN_2ST 1- YES, 2 - NO YES / NO MODE OF DELIVERY 1 - VAGINAL BIRTH, 2 - C-SECTION YES / NO RETAINED PLACENTA 1- YES, 2 - NO YES / NO PLACENTAL ABRUPTION 1- YES, 2 - NO YES / NO PERINEAL LACERATIONS 0 - NONE, 1 - 1° DEGREE, 2 - 2° DEGREE, 3 - 3° DEGREE, 4 - 4° DEGREE INTEGER FORCEPS 0 - NO, 1 - YES YES / NO ANALGESIA 1- YES, 2 - NO YES / NO NEWBORN_BIRTHWEIGHT BIRTH WEIGHT (G) 300 - 6000

Low-risk	Medium-risk	High-risk
Absent of uterine scar	Previous C-section or uterine scar	Placenta previa
Single pregnancy	Mild preeclampsia	Severe preeclampsia
Equal to or less than three vaginal births	Uterine overdistension^a a Multiple gestations, polyhydramnios, fetal macrosomia; PPH - postpartum hemorrhage; BMI - body mass index	Hematocrit below 30%
Absent clotting disorder	Equal to or more than four vaginal births	Platelets below 100,000/mm³
No previous PPH	Chorioamnionitis	Active vaginal bleeding at admission
	Previous uterine atony or any obstetric hemorrhage	Coagulopathy
	Obesity (BMI> 35kg/m²)	Using anticoagulant
		Placental abruption
		Placenta accreta
		Two or more medium risk factors

Variables	Total (n=1936) n(%)	PPH (n=131) n(%)	Without PPH (n=1805) n(%)	p-value
Age, years, mean (SD)	29.7(7.0)	30.4(7.1)	29.6(7.0)	0.792^* * Mean-t Test.
Nulliparous	724(40.3)	47(35.9)	677(40.6)	0.817^ Qui-square Test
Previous C-section				0.176^ Qui-square Test
0	1535(79.3)	112(85.5)	1423(78.8)
1	275(14.2)	14(10.7)	261(14.5)
2 or more	126(6.5)	5(3.8)	121(6.7)
Previous uterine scar	404(20.6)	19(14.5)	385(21.6)	0.063^ Qui-square Test
Multiple pregnancy	57(3.3)	9(6.9)	48(3.0)	0.019^ Qui-square Test
Hypertensive disorders of pregnancy	384(19.8)	33(25.2)	351(19.4)	0.111^ Qui-square Test
Diabetes	298(16.7)	20(15.3)	278(16.8)	0.657^ Qui-square Test
Thrombocytopenia	16(0.9)	3(2.3)	13(0.8)	0.078^ Qui-square Test
Use of anticoagulant	29(1.6)	2(1.5)	27(1.6)	0.927^ Qui-square Test

Variables	Total (n=1936) n(%)	PPH (n=131) n(%)	Without PPH (n=1805) n(%)	p-value
Gestational age, weeks, median (IQR)	37.6(2.0)	37.2(3.0)	38.0 (2.0)	0.137^* * Mann-Whitney Test;
Birth weight, grams, median (IQR)^a a In case of multiple gestation, only the first twin;	2947(657)	2910(712)	2950 (653)	0.510^* * Mann-Whitney Test;
Labor^** ****** 137 missing data;				0.342^ Qui-square Test;
Spontaneous	721(40.1)	45(34.3)	676(40.5)
Induced	489(27.2)	41(31.3)	448(26.9)
Without labor	589(32.7)	45(34.4)	544(32.6)
Active bleeding on admission	11(0.6)	5(3.8)	6(0.4)	0.001^ Qui-square Test;
Non-cephalic presentation	133(7.4)	15(11.5)	118(7.1)	0.067^ Qui-square Test;
Oxytocin during first and/or second stages of labor	305(17.2)	35(26.7)	270(16.4)	0.003^ Qui-square Test;
Analgesia during labor	382(21.4)	42(32.1)	340(20.6)	0.002^ Qui-square Test;
Retained placenta^b b The placenta is not delivered within 30 minutes of childbirth;	15(0.8)	7(5.3)	8(0.4)	<0.001^ Qui-square Test;
Placenta previa	11(0.6)	2(1.5)	9(0.5)	0.160^ Qui-square Test;
Placenta accreta	5(0.3)	2(1.5)	3(0.2)	0.046^* ***** Fisher Exact Test;
Placental abruption	19(1.0)	7(5.3)	12(0.7)	<0.001^ Qui-square Test;
Vaginal delivery^*** *** 21 missing data;	1125(58.7)	89(67.9)	1036(58.1)	0.027^ Qui-square Test;
C-section	790(41.3)	42(32.1)	748(41.9)
Forceps during vaginal birth	39(2.2)	7(5.3)	32(1.9)	0.010^ Qui-square Test;
Vacuum-extractor	44(2.5)	8(9.0)	35(2.1)	0.001^ Qui-square Test;
OASIS^c c Third and fourth-degree tear of perineum, considering only vaginal deliveries	29(2.6)	3(3.4)	26(2.5)	0.624^ Qui-square Test;

Risk factor	Crude OR (95%CI)	Adjusted OR (95%CI)
Previous uterine scar	0.63 (0.38 to 1.03)	0.84 (0.46 to 1.53)
Multiple pregnancy	2.35 (1.13 to 4.90)	2.84 (1.26 to 6.42)
Thrombocytopenia	2.97 (0.83 to 10.54)	3.05 (0.78 to 11.99)
Active bleeding on admission	10.9 (3.28 to 36.23)	5.81 (1.29 to 26.17)
Fetal presentation, non-cephalic	1.69 (0.96 to 2.99)	2.40 (1.23 to 4.74)
Oxytocin during first and/or second stages of labor	1.86 (1.24 to 2.80)	1.38 (0.85 to 2.25)
Analgesia during labor	1.82 (1.24 to 2.68)	1.29 (0.80 to 2.09)
Vaginal delivery	1.53 (1.05 to 2.24)	0.58 (0.34 to 0.98)
Instrumental delivery ^a	3.03 (1.61 to 5.68)	2.14 (1.08 to 4.25)
Retained placenta	12.68 (4.52 to 35.54)	9.46 (2.90 to 30.81)
Placenta accreta at admission	8.54 (1.41 to 51.55)	2.53 (0.29 to 22.46)
Placental abruption	8.44 (3.26 to 21.81)	6.85 (2.03 to 23.15)

ID_HOSPITALIZATION	PATIENT IDENTIFICATION	INTEGER
AGE WOMEN	MOTHER'S AGE	INTEGER
PPH		YES / NO
PREGNANCY	INT 1 -SINGLE, 2 - TWINS, 3 - TRIPLETS, 4 - QUADRIGEMINS, 5 - QUINTUPLES	INTEGER
FETAL PRESENTATION	1 - CEPHALIC, 2 - BREECH, 3 - ANOMALOUS (TRANSVERSE OR OBLIQUE))	INTEGER
LABOR ON ADMISSION	1- SPONTANEOUS, 2- INDUCED, 3- OUT OF LABOR	INTEGER
PARITY	1 - NULIPAROUS, 2 - MULTIPAROUS	INTEGER
PREVIOUS C-SECTIONS	NUMBER	INTEGER
GA_WEEKS	GESTATIONAL AGE (WEEKS)	INTEGER
GA_DAYS	GESTATIONAL AGE (DAYS)	INTEGER
HEMORRHAGE RISK	1 - LOW RISK, 2 - MEDIUM RISK, 3 - HIGH RISK	INTEGER
ACTIVE BLEEDING ON ADMISSION	1- YES, 2 - NO	YES / NO
GESTATIONAL HYPERTENSION	1- YES, 2 - NO	YES / NO
CHRONIC HYPERTENSION	1- YES, 2 - NO	YES / NO
PREECLAMPSIA	O - NO 1- MILD, 2 - SEVERE	INTEGER
ECLAMPSIA	1- YES, 2 - NO	YES/ NO
THROMBOCYTOPENIA	1- YES, 2 - NO	YES / NO
USE OF ANTICOAGULANTS	1- YES, 2 - NO	YES / NO
PLACENTA_ACCRETA	1- YES, 2 - NO	YES / NO
PLACENTA PREVIA	1-YES, 2-NO	YES/ NO
DIABETES	1- YES, 2 - NO	YES / NO
MED_OXYTOCIN_1ST	1- YES, 2 - NO	YES / NO
MED_OXYTOCIN_2ST	1- YES, 2 - NO	YES / NO
MODE OF DELIVERY	1 - VAGINAL BIRTH, 2 - C-SECTION	YES / NO
RETAINED PLACENTA	1- YES, 2 - NO	YES / NO
PLACENTAL ABRUPTION	1- YES, 2 - NO	YES / NO
PERINEAL LACERATIONS	0 - NONE, 1 - 1° DEGREE, 2 - 2° DEGREE, 3 - 3° DEGREE, 4 - 4° DEGREE	INTEGER
FORCEPS	0 - NO, 1 - YES	YES / NO
ANALGESIA	1- YES, 2 - NO	YES / NO
NEWBORN_BIRTHWEIGHT	BIRTH WEIGHT (G)	300 - 6000

[1] Corresponding author Raíssa Isabelle Leão Martins Email: raissailmartins@ufmg.br

Brasil

Brasil

Postpartum hemorrhage in electronic health records: risk factors at admission and in-hospital occurrence

Abstract

Objective:

Methods:

Results:

Conclusion: