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1873-233X13462019DecObstetrics and gynecologyObstet GynecolEvaluation of Risk-Assessment Tools for Severe Postpartum Hemorrhage in Women Undergoing Cesarean Delivery.130813161308-131610.1097/AOG.0000000000003574To examine and compare the validity of three known risk-assessment tools (CMQCC [California Maternal Quality Care Collaborative], AWHONN [Association of Women's Health, Obstetric and Neonatal Nurses], and NYSBOH [New York Safety Bundle for Obstetric Hemorrhage]) in women undergoing cesarean delivery.We conducted a retrospective cohort study that evaluated all women undergoing cesarean delivery at 23 weeks of gestation or longer from 2012 to 2017 at an urban hospital with average of 1,200 cesarean deliveries per year. Data were obtained by chart review. Severe postpartum hemorrhage was defined as transfusion of at least four units of packed red blood cells during the intrapartum or postpartum period. For each risk-assessment tool, women were stratified into low-risk, medium-risk, and high-risk groups. Risk factors were examined using multivariable logistic regression.Of 6,301 women who underwent cesarean delivery, a total of 76 (1.2%) had severe postpartum hemorrhage. Women classified as low- or medium-risk had lower rates of severe postpartum hemorrhage (0.4-0.6%) compared with women classified as high-risk (1.8-5.1%) (P<.001). Risk factors that were included in all three tools that were associated with severe postpartum hemorrhage included placenta accreta, placenta previa or low-lying placenta, placental abruption, hematocrit less than 30%, and prior uterine scar. Factors included in only one or two tools that were associated with severe postpartum hemorrhage included having more than four previous vaginal deliveries (CMQCC and AWHONN), stillbirth (AWHONN), and more than four prior births (NYSBOH). Area under the curve and 95% CI for CMQCC, AWHONN, and NYSBOH were all moderate-CMQCC 0.77 (0.71-0.84), AWHONN 0.69 (0.65-0.74), and NYSBOH 0.73 (0.67-0.79), respectively (AWHONN being most sensitive [88% with high-risk as cut-off] and CMQCC being most specific [87% with high-risk as cut-off]).Risk-assessment tools had moderate prediction to identify high-risk groups at risk for severe postpartum hemorrhage after cesarean delivery.KawakitaTetsuyaTDepartment of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC; the Department of Biostatistics and Epidemiology, MedStar Health Research Institute, Hyattsville, Maryland; and the Georgetown-Howard Universities Center for Clinical and Translational Science and the Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital, Washington, DC.MokhtariNegginNHuangJim CJCLandyHelain JHJengUL1 TR001409TRNCATS NIH HHSUnited StatesEvaluation StudyJournal ArticleResearch Support, N.I.H., Extramural
United StatesObstet Gynecol04011010029-7844IMAdultCesarean SectionCohort StudiesFemaleHumansPostpartum HemorrhagediagnosisetiologypathologyPredictive Value of TestsPregnancyPrenatal DiagnosisRetrospective StudiesRisk AssessmentSeverity of Illness Index2019112660201911266020204460ppublish3176474410.1097/AOG.000000000000357400006250-201912000-00025Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014;2:e323–33.Centers for Disease Control and Prevention. Pregnancy mortality surveillance system. Available at: http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html. Retrieved July 21, 2019.Mehrabadi A, Hutcheon JA, Lee L, Kramer MS, Liston RM, Joseph KS. Epidemiological investigation of a temporal increase in atonic postpartum haemorrhage: a population-based retrospective cohort study. BJOG 2013;120:853–62.American Congress of Obstetricians and Gynecologists. Maternal safety bundle for obstetric hemorrhage. Available at: https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/HEMSlideSetNov2015.pdf?dmc=1&ts=20190820T2308033042. Retrieved August 20, 2019.The AWHONN Postpartum Hemorrhage Project. Postpartum hemorrhage (PPH) risk assessment table 1.0. Available at: https://mygnosis.com/Content/Chunks/3504/assets/pdfs/PPH_Risk_Assessment_Table-7-17-15.pdf. Retrieved September 18, 2019.Bingham D, Melsop K, Main E. CMQCC obstetric hemorrhage hospital level implementation guide. Available at: https://www.cmqcc.org/resource/1489/download. Retrieved August 11, 2019.Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B. Prevalence and risk factors of severe obstetric haemorrhage. BJOG 2008;115:1265–72.Helman S, Drukker L, Fruchtman H, Ioscovich A, Farkash R, Avitan T, et al. Revisit of risk factors for major obstetric hemorrhage: insights from a large medical center. Arch Gynecol Obstet 2015;292:819–28.Dilla AJ, Waters JH, Yazer MH. Clinical validation of risk stratification criteria for peripartum hemorrhage. Obstet Gynecol 2013;122:120–6.Kramer MS, Berg C, Abenhaim H, et al. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol 2013;209:449.e1–7.Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77:69–76.Driessen M, Bouvier-Colle MH, Dupont C, Khoshnood B, Rudigoz RC, Deneux-Tharaux C. Postpartum hemorrhage resulting from uterine atony after vaginal delivery: factors associated with severity. Obstet Gynecol 2011;117:21–31.Sosa CG, Althabe F, Belizán JM, Buekens P. Risk factors for postpartum hemorrhage in vaginal deliveries in a Latin-American population. Obstet Gynecol 2009;113:1313–9.Wetta LA, Szychowski JM, Seals S, Mancuso MS, Biggio JR, Tita AT. Risk factors for uterine atony/postpartum hemorrhage requiring treatment after vaginal delivery. Am J Obstet Gynecol 2013;209:51.e1–6.Combs CA, Murphy EL, Laros RK Jr. Factors associated with hemorrhage in cesarean deliveries. Obstet Gynecol 1991;77:77–82.Naef RW III, Chauhan SP, Chevalier SP, Roberts WE, Meydrech EF, Morrison JC. Prediction of hemorrhage at cesarean delivery. Obstet Gynecol 1994;83:923–6.Rouse DJ, MacPherson C, Landon M, Varner MW, Leveno KJ, Moawad AH, et al. Blood transfusion and cesarean delivery. Obstet Gynecol 2006;108:891–7.Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian J Anaesth 2014;58:590–5.American College of Obstetricians and Gynecologists. Severe maternal morbidity: screening and review. Obstetric Care Consensus No. 5. Obstet Gynecol 2016;128:e54–60.Higgins RD, Saade G, Polin RA, Grobman WA, Buhimschi IA, Watterberg K, et al. Evaluation and management of women and newborns with a maternal diagnosis of chorioamnionitis: summary of a workshop. Obstet Gynecol 2016;127:426–36.Steyerberg EW, Harrell FE Jr, Borsboom GJ, Eijkemans MJ, Vergouwe Y, Habbema JD. Internal validation of predictive models: efficiency of some procedures for logistic regression analysis. J Clin Epidemiol 2001;54:774–81.Main EK, Goffman D, Scavone BM, Low LK, Bingham D, Fontaine PL, et al. National Partnership for Maternal Safety: consensus bundle on obstetric hemorrhage. Obstet Gynecol 2015;126:155–62.The AWHONN postpartum hemorrhage project. Available at: http://www.pphproject.org/focus-states.asp. Retrieved July 21, 2019.trying2...
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Evaluation of Risk-Assessment Tools for Severe Postpartum Hemorrhage in Women Undergoing Cesarean Delivery. | LitMetric
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Evaluation of Risk-Assessment Tools for Severe Postpartum Hemorrhage in Women Undergoing Cesarean Delivery.

Tetsuya Kawakita Neggin Mokhtari Jim C Huang Helain J Landy

Obstet Gynecol

Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC; the Department of Biostatistics and Epidemiology, MedStar Health Research Institute, Hyattsville, Maryland; and the Georgetown-Howard Universities Center for Clinical and Translational Science and the Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital, Washington, DC.

Published: December 2019

Objective: To examine and compare the validity of three known risk-assessment tools (CMQCC [California Maternal Quality Care Collaborative], AWHONN [Association of Women's Health, Obstetric and Neonatal Nurses], and NYSBOH [New York Safety Bundle for Obstetric Hemorrhage]) in women undergoing cesarean delivery.

Methods: We conducted a retrospective cohort study that evaluated all women undergoing cesarean delivery at 23 weeks of gestation or longer from 2012 to 2017 at an urban hospital with average of 1,200 cesarean deliveries per year. Data were obtained by chart review. Severe postpartum hemorrhage was defined as transfusion of at least four units of packed red blood cells during the intrapartum or postpartum period. For each risk-assessment tool, women were stratified into low-risk, medium-risk, and high-risk groups. Risk factors were examined using multivariable logistic regression.

Results: Of 6,301 women who underwent cesarean delivery, a total of 76 (1.2%) had severe postpartum hemorrhage. Women classified as low- or medium-risk had lower rates of severe postpartum hemorrhage (0.4-0.6%) compared with women classified as high-risk (1.8-5.1%) (P<.001). Risk factors that were included in all three tools that were associated with severe postpartum hemorrhage included placenta accreta, placenta previa or low-lying placenta, placental abruption, hematocrit less than 30%, and prior uterine scar. Factors included in only one or two tools that were associated with severe postpartum hemorrhage included having more than four previous vaginal deliveries (CMQCC and AWHONN), stillbirth (AWHONN), and more than four prior births (NYSBOH). Area under the curve and 95% CI for CMQCC, AWHONN, and NYSBOH were all moderate-CMQCC 0.77 (0.71-0.84), AWHONN 0.69 (0.65-0.74), and NYSBOH 0.73 (0.67-0.79), respectively (AWHONN being most sensitive [88% with high-risk as cut-off] and CMQCC being most specific [87% with high-risk as cut-off]).

Conclusions: Risk-assessment tools had moderate prediction to identify high-risk groups at risk for severe postpartum hemorrhage after cesarean delivery.

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http://dx.doi.org/10.1097/AOG.0000000000003574DOI Listing

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