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Risk Factors for Severe Hemorrhage-Related Morbidity in Patients Diagnosed With Uterine Atony Undergoing Cesarean Delivery
Abstract Number: F 1
Abstract Type: Original Research
Introduction: Rates of postpartum hemorrhage (PPH) due to uterine atony (UA) have increased in the US.(1) Although severe maternal morbidity can result from PPH,(2) risk factors for severe hemorrhage-related morbidity (HRM) associated with UA are unclear. We performed an observational study to investigate risk factors for severe HRM among women diagnosed with UA undergoing cesarean delivery (CD).
Methods: 2294 women with a diagnosis of UA were identified from the NICHD MFMU Network prospective study registry of 57182 patients who underwent CD between 1999-2002. UA was defined by administration of methylergonovine and/or carboprost. A composite outcome for HRM was defined by ≥1 of the following events: intraoperative or postpartum transfusion, uterine artery or hypogastric artery ligation, ICU admission for pulmonary edema, coagulopathy, ARDS, postoperative ventilation, or hemodynamic monitoring. Multivariate logistic regression was used to identify clinical predictors for severe HRM. Internal validation was performed using 10-fold cross-validation.
Results: The frequency of severe HRM in the cohort with diagnosed UA was 19.6%. The most common complication and perioperative intervention was postpartum transfusion (13.7%) and uterine artery ligation (5.1%) respectively. Based on multivariable analysis, predictors significantly associated with an increased risk of severe HRM were: African-American or Hispanic race (vs. Caucasian); multiple gestation; placenta previa; placental abruption; ≥2 prior CD; ASA class 3 or 4 (vs. ASA class 2); general anesthesia ± regional anesthesia (vs. spinal anesthesia) [Table]. Interestingly, pre-pregnancy BMI of 30-34.9 and ≥35 were significantly associated with a decreased risk of severe HRM (vs. BMI<25: referent group) [Table].
Conclusion: Our results confirm that established risk factors for severe PPH are associated with UA-related HRM (e.g., placenta previa, placental abruption, general anesthesia, African-American or Hispanic, ≥2 prior CDs). Surprisingly, overweight and obese patients were at decreased risk of severe HRM, which may be explained by hospital-level factors (e.g., more experienced physicians managing obese patients during CD) or clinical factors (e.g., better physiologic compensation to blood loss in obese patients compared to non-obese patients; non-linear decreases in blood volume with increasing weight).
References: (1) Am J Obstet Gynecol 2010;202:353 e1-6. (2) Obstet Gynecol 2009;113:293-9.