1
|
Lengerich BJ, Caruana R, Painter I, Weeks WB, Sitcov K, Souter V. Interpretable machine learning predicts postpartum hemorrhage with severe maternal morbidity in a lower-risk laboring obstetric population. Am J Obstet Gynecol MFM 2024:101391. [PMID: 38851393 DOI: 10.1016/j.ajogmf.2024.101391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 05/12/2024] [Accepted: 05/20/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Early identification of patients at increased risk for postpartum hemorrhage (PPH) associated with severe maternal morbidity (SMM) is critical for preparation and preventative intervention. However, prediction is challenging in patients without obvious risk factors for postpartum hemorrhage with severe maternal morbidity. Current tools for hemorrhage risk assessment use lists of risk factors rather than predictive models. OBJECTIVE To develop, validate (internally and externally), and compare a machine learning model for predicting PPH associated with SMM against a standard hemorrhage risk assessment tool in a lower risk laboring obstetric population. STUDY DESIGN This retrospective cross-sectional study included clinical data from singleton, term births (>=37 weeks' gestation) at 19 US hospitals (2016-2021) using data from 58,023 births at 11 hospitals to train a generalized additive model (GAM) and 27,743 births at 8 held-out hospitals to externally validate the model. The outcome of interest was PPH with severe maternal morbidity (blood transfusion, hysterectomy, vascular embolization, intrauterine balloon tamponade, uterine artery ligation suture, uterine compression suture, or admission to intensive care). Cesarean birth without a trial of vaginal birth and patients with a history of cesarean were excluded. We compared the model performance to that of the California Maternal Quality Care Collaborative (CMQCC) Obstetric Hemorrhage Risk Factor Assessment Screen. RESULTS The GAM predicted PPH with an area under the receiver-operating characteristic curve (AUROC) of 0.67 (95% CI 0.64-0.68) on external validation, significantly outperforming the CMQCC risk screen AUROC of 0.52 (95% CI 0.50-0.53). Additionally, the GAM had better sensitivity of 36.9% (95% CI 33.01-41.02) than the CMQCC screen sensitivity of 20.30% (95% CI 17.40-22.52) at the CMQCC screen positive rate of 16.8%. The GAM identified in-vitro fertilization as a risk factor (adjusted OR 1.5; 95% CI 1.2-1.8) and nulliparous births as the highest PPH risk factor (adjusted OR 1.5; 95% CI 1.4-1.6). CONCLUSION Our model identified almost twice as many cases of PPH as the CMQCC rules-based approach for the same screen positive rate and identified in-vitro fertilization and first-time births as risk factors for PPH. Adopting predictive models over traditional screens can enhance PPH prediction.
Collapse
Affiliation(s)
| | | | - Ian Painter
- Foundation for Health Care Quality, Seattle, WA (Painter, Sitcov and Souter)
| | | | - Kristin Sitcov
- Foundation for Health Care Quality, Seattle, WA (Painter, Sitcov and Souter)
| | - Vivienne Souter
- Foundation for Health Care Quality, Seattle, WA (Painter, Sitcov and Souter)
| |
Collapse
|
2
|
Wu Y, Xin B, Wan Q, Ren Y, Jiang W. Risk factors and prediction models for cardiovascular complications of hypertension in older adults with machine learning: A cross-sectional study. Heliyon 2024; 10:e27941. [PMID: 38509942 PMCID: PMC10950703 DOI: 10.1016/j.heliyon.2024.e27941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 03/08/2024] [Accepted: 03/08/2024] [Indexed: 03/22/2024] Open
Abstract
Background Hypertension has emerged as a chronic disease prevalent worldwide that may cause severe cardiovascular complications, particularly in older patients. However, there is a paucity of studies that use risk factors and prediction models for cardiovascular complications associated with hypertension in older adults. Objectives To identify the risk factors and develop prediction models for cardiovascular complications among older patients with hypertension. Methods A convenience sample of 476 older patients with hypertension was recruited from a university-affiliated hospital in China. Demographic data, clinical physiological indicators, regulatory emotional self-efficacy, medication adherence, and lifestyle information were collected from participants. Binary logistic regression analysis was performed to screen for preliminary risk factors associated with cardiovascular complications. Two machine learning methods, Back-Propagation neural network, and random forest were applied to develop prediction models for cardiovascular complications among the study cohort. The sensitivity, specificity, accuracy, receiver operating characteristic curve, and area under the curve (AUC) values were used to assess the performance of the prediction models. Results Binary logistic regression identified nine risk factors for cardiovascular complications among older patients with hypertension. The machine learning models displayed excellent performance in predicting cardiovascular complications, with the random forest model (AUC 0.954) outperforming the Back-Propagation neural network model (AUC 0.811), as confirmed by model comparison analysis. The sensitivity, specificity and accuracy of the Back-Propagation neural network model compared to the random forest model were 74.2% vs. 86.5%, 75.2% vs. 94.3%, and 74.7% vs. 90.4%, respectively. Conclusion The machine learning methods employed in this study demonstrated feasibility in predicting cardiovascular complications among older patients with hypertension, with the random forest model based on nine risk factors exhibiting excellent prediction performance. These models could be used to identify high-risk populations and suggest early interventions aimed at preventing cardiovascular complications in such cohorts.
Collapse
Affiliation(s)
- Yixin Wu
- School of Nursing, Health Science Center, Xian Jiaotong University, Xi'an, Shaanxi Province, 710061, China
| | - Bo Xin
- School of Nursing, Health Science Center, Xian Jiaotong University, Xi'an, Shaanxi Province, 710061, China
| | - Qiuyuan Wan
- School of Nursing, Health Science Center, Xian Jiaotong University, Xi'an, Shaanxi Province, 710061, China
- Department of Obstetrics and Gynecology, Xi'an Jiaotong University Second Affiliated Hospital, Xi'an, Shaanxi Province, 710004, China
| | - Yanping Ren
- Department of Geriatrics, Xi'an Jiaotong University Medical College First Affiliated Hospital, Xi'an, Shaanxi Province, 710061, China
| | - Wenhui Jiang
- School of Nursing, Health Science Center, Xian Jiaotong University, Xi'an, Shaanxi Province, 710061, China
| |
Collapse
|
3
|
de Moreuil C, Mehic D, Nopp S, Kraemmer D, Gebhart J, Schramm T, Couturaud F, Ay C, Pabinger I. Hemostatic biomarkers associated with postpartum hemorrhage: a systematic review and meta-analysis. Blood Adv 2023; 7:5954-5967. [PMID: 37307172 PMCID: PMC10562765 DOI: 10.1182/bloodadvances.2023010143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/09/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023] Open
Abstract
Postpartum hemorrhage (PPH) is a leading cause of maternal morbi-mortality. Although obstetric risk factors are well described, the impact of predelivery hematologic and hemostatic biomarkers remains incompletely understood. In this systematic review, we aimed to summarize the available literature on the association between predelivery hemostatic biomarkers and PPH/severe PPH. Searching MEDLINE, EMBASE, and CENTRAL databases from inception to October 2022, we included observational studies on unselected pregnant women without bleeding disorder reporting on PPH and on predelivery hemostatic biomarkers. Two review authors independently performed title, abstract and full-text screening, upon which quantitative syntheses of studies reporting on the same hemostatic biomarker were conducted, calculating the mean difference (MD) between women with PPH/severe PPH and controls. A search on 18 October 2022 yielded 81 articles fitting our inclusion criteria. The heterogeneity between studies was considerable. With regard to PPH, the estimated average MD in the investigated biomarkers (platelets, fibrinogen, hemoglobin, Ddimer, activated partial thromboplastin time, and prothrombin time) were not statistically significant. Women who developed severe PPH had lower predelivery platelets than controls (MD = -26.0 109/L; 95% confidence interval, -35.8 to -16.1), whereas differences in predelivery fibrinogen concentration (MD = -0.31 g/L; 95% confidence interval, -0.75 to 0.13) and levels of factor XIII or hemoglobin were not statistically significant in women with and without severe PPH. Predelivery platelet counts were, on average, lower in women with severe PPH compared with controls, suggesting the potential usefulness of this biomarker for predicting severe PPH. This trial was registered at the International Prospective Register of Systematic Reviews as CRD42022368075.
Collapse
Affiliation(s)
- Claire de Moreuil
- UMR 1304, Groupe d'Etude de la Thrombose de Bretagne Occidentale, Université de Bretagne Occidentale, Brest, France
- Internal Medicine, Vascular Medicine and Pneumology Department, Brest University Hospital, Brest, France
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Dino Mehic
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Stephan Nopp
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Daniel Kraemmer
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Theresa Schramm
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Francis Couturaud
- UMR 1304, Groupe d'Etude de la Thrombose de Bretagne Occidentale, Université de Bretagne Occidentale, Brest, France
- Internal Medicine, Vascular Medicine and Pneumology Department, Brest University Hospital, Brest, France
| | - Cihan Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
4
|
Anouilh F, de Moreuil C, Trémouilhac C, Jacquot M, Salnelle G, Bellec V, Touffet N, Cornec C, Muller M, Dupré PF, Bellot C, Morcel K, Joliff DL, Drugmanne G, Gelebart E, Lucier S, Nowak E, Bihan L, Couturaud F, Tromeur C, Moigne EL, Pan-Petesch B. Family history of postpartum hemorrhage is a risk factor for postpartum hemorrhage after vaginal delivery: results from the French prospective multicenter Haemorrhages and Thromboembolic Venous Disease of the Postpartum cohort study. Am J Obstet Gynecol MFM 2023; 5:101062. [PMID: 37343695 DOI: 10.1016/j.ajogmf.2023.101062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/08/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Postpartum hemorrhage is a major component of perinatal morbidity and mortality that affects young women worldwide and is still often unpredictable. Reducing the incidence of postpartum hemorrhage is a major health issue and identifying women at risk for postpartum hemorrhage is a key element in preventing this complication. OBJECTIVE This study aimed to estimate postpartum hemorrhage prevalence after vaginal delivery and to identify postpartum hemorrhage risk factors. STUDY DESIGN Unselected pregnant women ≥16 years of age admitted to 1 of 6 maternity wards in Brittany (France) for vaginal birth after 15 weeks of gestation were recruited in this prospective, multicenter cohort study between June 1, 2015, and January 31, 2019. Postpartum hemorrhage was defined as blood loss ≥500 mL in the 24 hours following delivery. Independent risk factors for postpartum hemorrhage were determined using logistic regression. Missing data were imputed using the Multivariate Imputation by Chained Equations method. RESULTS Among 16,382 included women, the postpartum hemorrhage prevalence was 5.37%. A first-degree family history of postpartum hemorrhage (adjusted odds ratio, 1.63; 95% confidence interval, 1.24-2.14) and a personal transfusion history (adjusted odds ratio, 1.90; 95% confidence interval, 1.23-2.92) were significantly associated with postpartum hemorrhage. The use of oxytocin during labor was also a risk factor for postpartum hemorrhage (adjusted odds ratio, 1.24; 95% confidence interval, 1.06-1.44). Inversely, smoking during pregnancy and intrauterine growth restriction were associated with a reduced risk for postpartum hemorrhage (adjusted odds ratio, 0.76; 95% confidence interval, 0.63-0.91, and 0.34; 95% confidence interval, 0.13-0.87, respectively). CONCLUSION In addition to classical risk factors, this study identified a family history of postpartum hemorrhage and personal transfusion history as new characteristics associated with postpartum hemorrhage after vaginal delivery. The association of postpartum hemorrhage with a family history of postpartum hemorrhage suggests a hereditary hemorrhagic phenotype and calls for genetic studies. Identifying women at risk for postpartum hemorrhage is a key element of being prepared for this complication.
Collapse
Affiliation(s)
- François Anouilh
- Ecole Universitaire de Maïeutique de Brest, UFR Santé - Brest, Brest, France (Mr Anouilh); UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), Brest, France (Mr Anouilh, Drs de Moreuil, Trémouilhac, Morcel, Couturaud, Tromeur, Le Moigne, and Pan-Petesch)
| | - Claire de Moreuil
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), Brest, France (Mr Anouilh, Drs de Moreuil, Trémouilhac, Morcel, Couturaud, Tromeur, Le Moigne, and Pan-Petesch); Département de Médecine Interne, Médecine Vasculaire et Pneumologie, Centre Hospitalier Universitaire Brest, Brest, France (Drs Moreuil, Couturaud, Tromeur, and Le Moigne).
| | - Christophe Trémouilhac
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), Brest, France (Mr Anouilh, Drs de Moreuil, Trémouilhac, Morcel, Couturaud, Tromeur, Le Moigne, and Pan-Petesch); Service de Gynécologie Obstétrique, Centre Hospitalier Universitaire Brest, Brest, France (Dr Trémouilhac, Ms Cornec, and Drs Dupré and Morcel)
| | - Matthieu Jacquot
- Service de Gynécologie Obstétrique, CHIC de Quimper, Quimper, France (Drs Jacquot, Bellot, and Le Joliff)
| | - Gilles Salnelle
- Service de Gynécologie Obstétrique, CH des Pays de Morlaix, Morlaix, France (Drs Salnelle and Muller)
| | - Violaine Bellec
- Service de Gynécologie Obstétrique, Centre Hospitalier Privé de Brest - Keraudren, Brest, France (Dr Bellec)
| | - Nathalie Touffet
- Service de Gynécologie Obstétrique, CH de Landerneau, Landerneau, France (Dr Touffet)
| | - Caroline Cornec
- Service de Gynécologie Obstétrique, Centre Hospitalier Universitaire Brest, Brest, France (Dr Trémouilhac, Ms Cornec, and Drs Dupré and Morcel)
| | - Matthieu Muller
- Service de Gynécologie Obstétrique, CH des Pays de Morlaix, Morlaix, France (Drs Salnelle and Muller)
| | - Pierre-François Dupré
- Service de Gynécologie Obstétrique, Centre Hospitalier Universitaire Brest, Brest, France (Dr Trémouilhac, Ms Cornec, and Drs Dupré and Morcel)
| | - Charles Bellot
- Service de Gynécologie Obstétrique, CHIC de Quimper, Quimper, France (Drs Jacquot, Bellot, and Le Joliff)
| | - Karine Morcel
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), Brest, France (Mr Anouilh, Drs de Moreuil, Trémouilhac, Morcel, Couturaud, Tromeur, Le Moigne, and Pan-Petesch); Service de Gynécologie Obstétrique, Centre Hospitalier Universitaire Brest, Brest, France (Dr Trémouilhac, Ms Cornec, and Drs Dupré and Morcel)
| | - Delphine Le Joliff
- Service de Gynécologie Obstétrique, CHIC de Quimper, Quimper, France (Drs Jacquot, Bellot, and Le Joliff)
| | - Guillaume Drugmanne
- CIC1412, Institut National de la Sante et de la Recherche Medicale, Brest, France (Mr Drugmanne, Ms Gelebart, Ms Lucier, Dr Nowak, and Ms Bihan)
| | - Elodie Gelebart
- CIC1412, Institut National de la Sante et de la Recherche Medicale, Brest, France (Mr Drugmanne, Ms Gelebart, Ms Lucier, Dr Nowak, and Ms Bihan)
| | - Sandy Lucier
- CIC1412, Institut National de la Sante et de la Recherche Medicale, Brest, France (Mr Drugmanne, Ms Gelebart, Ms Lucier, Dr Nowak, and Ms Bihan)
| | - Emmanuel Nowak
- CIC1412, Institut National de la Sante et de la Recherche Medicale, Brest, France (Mr Drugmanne, Ms Gelebart, Ms Lucier, Dr Nowak, and Ms Bihan)
| | - Line Bihan
- CIC1412, Institut National de la Sante et de la Recherche Medicale, Brest, France (Mr Drugmanne, Ms Gelebart, Ms Lucier, Dr Nowak, and Ms Bihan)
| | - Francis Couturaud
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), Brest, France (Mr Anouilh, Drs de Moreuil, Trémouilhac, Morcel, Couturaud, Tromeur, Le Moigne, and Pan-Petesch); Département de Médecine Interne, Médecine Vasculaire et Pneumologie, Centre Hospitalier Universitaire Brest, Brest, France (Drs Moreuil, Couturaud, Tromeur, and Le Moigne)
| | - Cécile Tromeur
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), Brest, France (Mr Anouilh, Drs de Moreuil, Trémouilhac, Morcel, Couturaud, Tromeur, Le Moigne, and Pan-Petesch); Département de Médecine Interne, Médecine Vasculaire et Pneumologie, Centre Hospitalier Universitaire Brest, Brest, France (Drs Moreuil, Couturaud, Tromeur, and Le Moigne)
| | - Emmanuelle Le Moigne
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), Brest, France (Mr Anouilh, Drs de Moreuil, Trémouilhac, Morcel, Couturaud, Tromeur, Le Moigne, and Pan-Petesch); Département de Médecine Interne, Médecine Vasculaire et Pneumologie, Centre Hospitalier Universitaire Brest, Brest, France (Drs Moreuil, Couturaud, Tromeur, and Le Moigne)
| | - Brigitte Pan-Petesch
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), Brest, France (Mr Anouilh, Drs de Moreuil, Trémouilhac, Morcel, Couturaud, Tromeur, Le Moigne, and Pan-Petesch); Centre de Ressources et de Compétence des Maladies Hémorragiques, Centre de Ressources et de Compétence des Maladies Hémorragiques, Hémostase, Service Hématologie, Centre Hospitalier Universitaire Brest, Brest, France (Dr Pan-Petesch)
| |
Collapse
|
5
|
Zheng F, Wen H, Shi L, Wen C, Wang Q, Yao S. Incidence of postpartum hemorrhage based on the improved combined method in evaluating blood loss: A retrospective cohort study. PLoS One 2023; 18:e0289271. [PMID: 37506099 PMCID: PMC10381060 DOI: 10.1371/journal.pone.0289271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 07/16/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE In view of the current clinical inaccuracies and underestimations of postpartum hemorrhage amount, this study aims to investigate the incidence, etiology, clinical characteristics of postpartum hemorrhage in different modes of delivery based on the combination of volumetric method, gravimetric method and area method in evaluating blood loss. DESIGN This retrospective cohort study was conducted in Hangzhou Women's Hospital from January 2020 to June 2021, including 725 cases of postpartum hemorrhage among 18,977 parturients. Based on different modes of delivery, the participants were divided into three groups: vaginal delivery, forceps delivery, and cesarean section, for comparison. METHODS Using an improved combined assessment method for blood loss, we retrospectively analyzed a cohort of parturients with postpartum hemorrhage who underwent vaginal delivery, forceps delivery, or cesarean section and were hospitalized in Hangzhou Women's Hospital from January 2020 to June 2021. RESULTS (1) Among the 18,977 parturients, 725 cases of postpartum hemorrhage occurred, with an incidence rate of 3.8%, and severe postpartum hemorrhage accounted for 0.4% of the cases. (2) The incidence of postpartum hemorrhage was significantly higher in the forceps delivery group than in the vaginal delivery group (χ2 = 19.27, P<0.001), while the incidence of severe postpartum hemorrhage was significantly higher in the cesarean section group than in the vaginal delivery group (χ2 = 8.71, P = 0.003). (3) The causes of postpartum hemorrhage were statistically different among the different delivery modes, with varying underlying factors (P<0.001). (4) Patients with postpartum hemorrhage in different delivery modes showed statistically significant differences in age, body mass index (BMI), birth weight, gestational age, gravidity, parity, the decline of postpartum peripheral blood hemoglobin concentration, and estimated blood loss (P<0.05). (5) The proportion of blood transfusion was significantly higher in the cesarean section group than in the vaginal delivery and forceps delivery groups (χ2 = 231.03, P<0.001). LIMITATIONS This study is a single-center retrospective study, which may have led to selection bias in case selection. Additionally, the implementation of the combined three blood loss assessment methods may not have been strictly followed in all cases. Moreover, due to the mixing of bleeding with amniotic and irrigation fluids, the accuracy of evaluation may have been affected, leading to the possibility of inaccuracy of blood loss. CONCLUSIONS Forceps delivery and cesarean section increase the risk of postpartum hemorrhage, but forceps delivery does not significantly increase the incidence of severe postpartum hemorrhage. Uterine atony remains the leading cause of postpartum hemorrhage, while birth canal laceration and placental factors are the second most common causes of postpartum hemorrhage in forceps delivery and cesarean section, respectively. In this study, the volumetric method, gravimetric method and area method were combined to quantitatively assess postpartum hemorrhage amount. The combined method has strong clinical practicability and is less affected by subjective factors, although it also has limitations. In the future, we still need to focus on the early prediction and identification of postpartum hemorrhage, and further improve the quantitative assessment of postpartum blood loss.
Collapse
Affiliation(s)
- Fangyuan Zheng
- Department of Obstetrics, Hangzhou Women's Hospital, Hangzhou, China
| | - Haiyan Wen
- Department of Obstetrics, Hangzhou Women's Hospital, Hangzhou, China
| | - Lan Shi
- Department of Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Caihe Wen
- Department of Obstetrics, Hangzhou Women's Hospital, Hangzhou, China
| | - Qiumeng Wang
- Department of Obstetrics, Hangzhou Women's Hospital, Hangzhou, China
| | - Shouzhen Yao
- Department of Obstetrics, Hangzhou Women's Hospital, Hangzhou, China
| |
Collapse
|
6
|
Glonnegger H, Glenzer MM, Lancaster L, Barnes RF, von Drygalski A. Prepartum Anemia and Risk of Postpartum Hemorrhage: A Meta-Analysis and Brief Review. Clin Appl Thromb Hemost 2023; 29:10760296231214536. [PMID: 37968861 PMCID: PMC10655792 DOI: 10.1177/10760296231214536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Postpartum hemorrhage (PPH) is responsible for 30% to 50% of maternal deaths. There is conflicting evidence if prepartum anemia facilitates PPH. A comprehensive analysis of studies describing their relation is missing. An extensive database search was conducted applying the terms "anemia" OR "hemoglobin" AND "postpartum hemorrhage." We used a random-effects meta-analysis model to estimate an overall odds ratio (OR) for PPH and prepartum anemia, separating studies that were conformant and non-conformant with the World Health Organization (WHO) definitions for anemia. The search yielded 2519 studies, and 46 were appropriate for analysis. The meta-analyses of WHO-conformant (n = 22) and non-conformant (n = 24) studies showed that the risk of PPH was increased when anemia was present. The ORs were 1.45 (CL: 1.23-1.71) for WHO-conformant studies, 2.88 (CL: 1.38-6.02) for studies applying lower thresholds for anemia, and 3.28 (CL: 2.08-5.19) for undefined anemia thresholds. PPH risk appeared to increase with lower anemia thresholds. Prepartum anemia is associated with an increased risk of PPH, an observation that is important regarding improved anemia correction strategies such as iron supplementation.
Collapse
Affiliation(s)
- Hannah Glonnegger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center-University of Freiburg, Freiburg, Germany
| | - Michael M. Glenzer
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, CA, USA
| | - Lian Lancaster
- Department of Emergency Medicine, The George Washington University Washington DC, Washington DC, USA
| | - Richard F.W. Barnes
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, CA, USA
| | - Annette von Drygalski
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, CA, USA
| |
Collapse
|
7
|
Angarita AM, Cochrane E, Bianco A, Berghella V. Prevention of postpartum hemorrhage in vaginal deliveries. Eur J Obstet Gynecol Reprod Biol 2023; 280:112-119. [PMID: 36455391 DOI: 10.1016/j.ejogrb.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/07/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
Identification of patients at risk for postpartum hemorrhage (PPH) may allow for prompt diagnosis and intervention. Individual risk factors, risk assessment tools and prediction models have been used for determining a patient's risk of PPH. Measures for the prevention of PPH include identification and management of iron deficiency anemia, unit readiness and preparedness through performing regular simulations and having a PPH cart or medication kit readily available, prophylactic uterotonic - carbetocin alone or dual agents such as oxytocin and misoprostol or oxytocin and methylergometrine or antifibrinolytic (oxytocin and tranexamic acid) use in the third stage of labor immediately after fetal head delivery, and controlled cord traction.
Collapse
Affiliation(s)
- Ana M Angarita
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Elizabeth Cochrane
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Angela Bianco
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States.
| |
Collapse
|
8
|
Bihan L, Nowak E, Anouilh F, Tremouilhac C, Merviel P, Tromeur C, Robin S, Drugmanne G, Le Roux L, Couturaud F, Le Moigne E, Abgrall JF, Pan-Petesch B, de Moreuil C. Development and Validation of a Predictive Tool for Postpartum Hemorrhage after Vaginal Delivery: A Prospective Cohort Study. BIOLOGY 2022; 12:biology12010054. [PMID: 36671746 PMCID: PMC9855728 DOI: 10.3390/biology12010054] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/19/2022] [Accepted: 12/26/2022] [Indexed: 12/30/2022]
Abstract
Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity worldwide. This study aimed to develop and validate a predictive model for PPH after vaginal deliveries, based on routinely available clinical and biological data. The derivation monocentric cohort included pregnant women with vaginal delivery at Brest University Hospital (France) between April 2013 and May 2015. Immediate PPH was defined as a blood loss of ≥500 mL in the first 24 h after delivery and measured with a graduated collector bag. A logistic model, using a combination of multiple imputation and variable selection with bootstrap, was used to construct a predictive model and a score for PPH. An external validation was performed on a prospective cohort of women who delivered between 2015 and 2019 at Brest University Hospital. Among 2742 deliveries, PPH occurred in 141 (5.1%) women. Eight factors were independently associated with PPH: pre-eclampsia (aOR 6.25, 95% CI 2.35−16.65), antepartum bleeding (aOR 2.36, 95% CI 1.43−3.91), multiple pregnancy (aOR 3.24, 95% CI 1.52−6.92), labor duration ≥ 8 h (aOR 1.81, 95% CI 1.20−2.73), macrosomia (aOR 2.33, 95% CI 1.36−4.00), episiotomy (aOR 2.02, 95% CI 1.40−2.93), platelet count < 150 Giga/L (aOR 2.59, 95% CI 1.47−4.55) and aPTT ratio ≥ 1.1 (aOR 2.01, 95% CI 1.25−3.23). The derived predictive score, ranging from 0 to 10 (woman at risk if score ≥ 1), demonstrated a good discriminant power (AUROC 0.69; 95% CI 0.65−0.74) and calibration. The external validation cohort was composed of 3061 vaginal deliveries. The predictive score on this independent cohort showed an acceptable ability to discriminate (AUROC 0.66; 95% CI 0.62−0.70). We derived and validated a robust predictive model identifying women at risk for PPH using in-depth statistical methodology. This score has the potential to improve the care of pregnant women and to take preventive actions on them.
Collapse
Affiliation(s)
| | | | - François Anouilh
- UMR1304, INSERM, GETBO, Université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
- Ecole de Sage-Femmes, UFR Santé, 29200 Brest, France
| | - Christophe Tremouilhac
- UMR1304, INSERM, GETBO, Université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
- Service de Gynécologie Obstétrique, CHU Brest, 29200 Brest, France
| | - Philippe Merviel
- UMR1304, INSERM, GETBO, Université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
- Service de Gynécologie Obstétrique, CHU Brest, 29200 Brest, France
| | - Cécile Tromeur
- UMR1304, INSERM, GETBO, Université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
- Département de Médecine Vasculaire, Médecine Interne et Pneumologie, CHU Brest, 29200 Brest, France
| | - Sara Robin
- UMR1304, INSERM, GETBO, Université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
- Département de Médecine Vasculaire, Médecine Interne et Pneumologie, CHU Brest, 29200 Brest, France
| | | | - Liana Le Roux
- CIC1412, INSERM, 29200 Brest, France
- CIC-RB Ressources Biologiques (UF 0827), CHU Brest, 29200 Brest, France
| | - Francis Couturaud
- UMR1304, INSERM, GETBO, Université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
- Département de Médecine Vasculaire, Médecine Interne et Pneumologie, CHU Brest, 29200 Brest, France
| | - Emmanuelle Le Moigne
- UMR1304, INSERM, GETBO, Université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
- Département de Médecine Vasculaire, Médecine Interne et Pneumologie, CHU Brest, 29200 Brest, France
| | | | - Brigitte Pan-Petesch
- UMR1304, INSERM, GETBO, Université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
- Centre de Traitement de L’hémophilie, Hématologie, CHU Brest, 29200 Brest, France
| | - Claire de Moreuil
- UMR1304, INSERM, GETBO, Université de Bretagne Occidentale, CHRU de Brest, 29200 Brest, France
- Département de Médecine Vasculaire, Médecine Interne et Pneumologie, CHU Brest, 29200 Brest, France
- Correspondence:
| |
Collapse
|
9
|
Carr BL, Jahangirifar M, Nicholson AE, Li W, Mol BW, Licqurish S. Predicting postpartum haemorrhage: A systematic review of prognostic models. Aust N Z J Obstet Gynaecol 2022; 62:813-825. [PMID: 35918188 PMCID: PMC10087871 DOI: 10.1111/ajo.13599] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 07/10/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Postpartum haemorrhage (PPH) remains a leading cause of maternal mortality and morbidity worldwide, and the rate is increasing. Using a reliable predictive model could identify those at risk, support management and treatment, and improve maternal outcomes. AIMS To systematically identify and appraise existing prognostic models for PPH and ascertain suitability for clinical use. MATERIALS AND METHODS MEDLINE, CINAHL, Embase, and the Cochrane Library were searched using combinations of terms and synonyms, including 'postpartum haemorrhage', 'prognostic model', and 'risk factors'. Observational or experimental studies describing a prognostic model for risk of PPH, published in English, were included. The Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist informed data extraction and the Prediction Model Risk of Bias Assessment Tool guided analysis. RESULTS Sixteen studies met the inclusion criteria after screening 1612 records. All studies were hospital settings from eight different countries. Models were developed for women who experienced vaginal birth (n = 7), caesarean birth (n = 2), any type of birth (n = 2), hypertensive disorders (n = 1) and those with placental abnormalities (n = 4). All studies were at high risk of bias due to use of inappropriate analysis methods or omission of important statistical considerations or suboptimal validation. CONCLUSIONS No existing prognostic models for PPH are ready for clinical application. Future research is needed to externally validate existing models and potentially develop a new model that is reliable and applicable to clinical practice.
Collapse
Affiliation(s)
- Bethany L Carr
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
| | - Maryam Jahangirifar
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia
| | - Ann E Nicholson
- Faculty of Information Technology, Monash University, Melbourne, Victoria, Australia
| | - Wentao Li
- Department of Obstetrics and Gynaecology, The School of Clinical Sciences, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, The School of Clinical Sciences, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Sharon Licqurish
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia.,Monash Centre for Health Research & Implementation, Monash Health, Melbourne, Victoria, Australia
| |
Collapse
|
10
|
Westcott JM, Hughes F, Liu W, Grivainis M, Hoskins I, Fenyo D. Prediction of Maternal Hemorrhage Using Machine Learning: Retrospective Cohort Study. J Med Internet Res 2022; 24:e34108. [PMID: 35849436 PMCID: PMC9345059 DOI: 10.2196/34108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 02/24/2022] [Accepted: 06/13/2022] [Indexed: 12/03/2022] Open
Abstract
Background Postpartum hemorrhage remains one of the largest causes of maternal morbidity and mortality in the United States. Objective The aim of this paper is to use machine learning techniques to identify patients at risk for postpartum hemorrhage at obstetric delivery. Methods Women aged 18 to 55 years delivering at a major academic center from July 2013 to October 2018 were included for analysis (N=30,867). A total of 497 variables were collected from the electronic medical record including the following: demographic information; obstetric, medical, surgical, and family history; vital signs; laboratory results; labor medication exposures; and delivery outcomes. Postpartum hemorrhage was defined as a blood loss of ≥1000 mL at the time of delivery, regardless of delivery method, with 2179 (7.1%) positive cases observed.
Supervised learning with regression-, tree-, and kernel-based machine learning methods was used to create classification models based upon training (21,606/30,867, 70%) and validation (4630/30,867, 15%) cohorts. Models were tuned using feature selection algorithms and domain knowledge. An independent test cohort (4631/30,867, 15%) determined final performance by assessing for accuracy, area under the receiver operating curve (AUROC), and sensitivity for proper classification of postpartum hemorrhage. Separate models were created using all collected data versus models limited to data available prior to the second stage of labor or at the time of decision to proceed with cesarean delivery. Additional models examined patients by mode of delivery. Results Gradient boosted decision trees achieved the best discrimination in the overall model. The model including all data mildly outperformed the second stage model (AUROC 0.979, 95% CI 0.971-0.986 vs AUROC 0.955, 95% CI 0.939-0.970). Optimal model accuracy was 98.1% with a sensitivity of 0.763 for positive prediction of postpartum hemorrhage. The second stage model achieved an accuracy of 98.0% with a sensitivity of 0.737. Other selected algorithms returned models that performed with decreased discrimination. Models stratified by mode of delivery achieved good to excellent discrimination but lacked the sensitivity necessary for clinical applicability. Conclusions Machine learning methods can be used to identify women at risk for postpartum hemorrhage who may benefit from individualized preventative measures. Models limited to data available prior to delivery perform nearly as well as those with more complete data sets, supporting their potential utility in the clinical setting. Further work is necessary to create successful models based upon mode of delivery and to validate the findings of this study. An unbiased approach to hemorrhage risk prediction may be superior to human risk assessment and represents an area for future research.
Collapse
Affiliation(s)
- Jill M Westcott
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY, United States
| | - Francine Hughes
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Wenke Liu
- Institute for Systems Genetics, New York University Grossman School of Medicine, New York, NY, United States.,Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, NY, United States
| | - Mark Grivainis
- Institute for Systems Genetics, New York University Grossman School of Medicine, New York, NY, United States.,Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, NY, United States
| | - Iffath Hoskins
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY, United States
| | - David Fenyo
- Institute for Systems Genetics, New York University Grossman School of Medicine, New York, NY, United States.,Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, NY, United States
| |
Collapse
|
11
|
Machine learning-based prediction of postpartum hemorrhage after vaginal delivery: combining bleeding high risk factors and uterine contraction curve. Arch Gynecol Obstet 2022; 306:1015-1025. [PMID: 35171347 DOI: 10.1007/s00404-021-06377-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/22/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE This work used a machine learning model to improve the accuracy of predicting postpartum hemorrhage in vaginal delivery. METHODS Among the 25,098 deliveries in the obstetrics department of the First Hospital of Jinan University recorded from 2016 to 2020, 10,520 were vaginal deliveries with complete study data. Further review selected 850 cases of postpartum hemorrhage (amount of bleeding > 500 mL) and 54 cases of severe postpartum hemorrhage (amount of bleeding > 1000 mL). Indicators of clinical risk factors for postpartum hemorrhage were retrieved from electronic medical records. Features of the uterine contraction curve were extracted 2 h prior to vaginal delivery and modeled using a 49-variable machine learning with 90% of study cases used in the training set and 10% of study cases used in the test set. Accuracy was compared among the assessment table, classical statistical models, and machine learning models used to predict postpartum hemorrhage to assess their clinical use. The assessment table contained 16 high-risk factor scores to predict postpartum hemorrhage. The classical statistical model used was Logistic Regression (LR). The machine learning models were Random Forest (RF), K Nearest Neighbor (KNN), and the one integrated with Lightgbm (LGB) and LR. The effect of model prediction was evaluated by area under the receiver operating characteristic curve (AUC), namely, C-static, calibration curve Brier score, decision curve, F-measure, sensitivity (SE), and specificity (SP). RESULTS 1: Among the tested tools, the machine learning model LGB + LR has the best performance in predicting postpartum hemorrhage. Its Brier, AUC, and F-measure scores are better than those of other models in each group, and its SE and SP reach 0.694 and 0.800, respectively. The predictive performance of the classical statistical model LR is AUC: 0.729, 95%CI [0.702-0.756]). 2: Verification on the testing set reveals that the features of uterine contraction contribute to the improved accuracy of the model prediction. 3: LGB + LR model suggested that among the 49 indicators for predicting severe postpartum hemorrhage, the importance of the first 10 characteristics in descending order is as follows: hematocrit (%), shock index, frequency of contractions (min-1), white blood cell count, gestational hypertension, neonatal weight (kg), time of second labor (min), mean area of contractions (mmHg s), total amniotic fluid (mL), and body mass index (BMI). The prediction effect is close to that of the model after training with all 49 features. The predictive effect was close to that of the model after training using all 49 features. 4: Contraction frequency and intensity Mean_Area (representing effective contractions) have a high predictive value for severe postpartum hemorrhage. 5: Blood loss amount within 2 h has a high warning effect on postpartum hemorrhage, and the increase in AUC to 0.95 indicates that postpartum bleeding mostly occurs within 2 h after delivery. CONCLUSION Machine learning models incorporated with uterine contraction features can further improve the accuracy of postpartum hemorrhage prediction in vaginal delivery and provide a reference for clinicians to intervene early and reduce adverse pregnancy outcomes.
Collapse
|
12
|
The effects of rectal suppositories of Plantago major and Anetheum Graveolens on postpartum hemorrhage: A randomized triple blinded clinical trial. J Herb Med 2022. [DOI: 10.1016/j.hermed.2021.100526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
13
|
Patterson J, Randall D, Isbister J, Peek M, Nippita T, Torvaldsen S. Place of birth and outcomes associated with large volume transfusion: an observational study. BMC Pregnancy Childbirth 2021; 21:620. [PMID: 34517834 PMCID: PMC8439088 DOI: 10.1186/s12884-021-04091-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Guidelines recommend that women at high risk of postpartum haemorrhage deliver at facilities able to handle heavy bleeding. However postpartum haemorrhage is often unexpected. This study aims to compare outcomes and health service use related to transfusion of ≥4 units of red blood cells between women delivering in tertiary and lower level hospitals. METHODS The study population was women giving birth in public hospitals in New South Wales, Australia, between July 2006 and December 2010. Data were obtained from linked hospital, birth and blood bank databases. The exposure of interest was transfusion of four or more units of red cells during admission for delivery. Outcomes included maternal morbidity, length of stay, neonatal morbidity and need for other blood products or transfer to higher care. Multivariable regression models were developed to predict need of transfusion of ≥4 units of red cells using variables known early in pregnancy and those known by the birth admission. RESULTS Data were available for 231,603 births, of which 4309 involved a blood transfusion, with 1011 (0.4%) receiving 4 or more units. Women giving birth in lower level and/or smaller hospitals were more likely to receive ≥4 units of red cells. Women receiving ≥4 units in tertiary settings were more likely to receive other blood products and have longer hospital stays, but morbidity, readmission and hysterectomy rates were similar. Although 46% of women had no identifiable risk factors early in pregnancy, 20% of transfusions of ≥4 units occurred within this group. By the birth admission 70% of women had at least one risk factor for requiring ≥4 units of red cells. CONCLUSIONS Overall outcomes for women receiving ≥4 units of red cells were comparable between tertiary and non-tertiary facilities. This is important given the inability of known risk factors to predict many instances of postpartum haemorrhage.
Collapse
Affiliation(s)
- Jillian Patterson
- The University of Sydney Northern Clinical School, Women and Babies Research, St Leonards, New South Wales, Australia.
- Northern Sydney Local Health District, Kolling Institute, St Leonards, New South Wales, Australia.
- Women and Babies Research, c/o University Department of O&G, Level 5, Douglas Building, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia.
| | - Deborah Randall
- The University of Sydney Northern Clinical School, Women and Babies Research, St Leonards, New South Wales, Australia
- Northern Sydney Local Health District, Kolling Institute, St Leonards, New South Wales, Australia
- Women and Babies Research, c/o University Department of O&G, Level 5, Douglas Building, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia
| | - James Isbister
- The University of Sydney Northern Clinical School, St Leonards, New South Wales, Australia
| | - Michael Peek
- Australian National University Medical School, ANU, Garran, Australian Capital Territory, Australia
| | - Tanya Nippita
- The University of Sydney Northern Clinical School, Women and Babies Research, St Leonards, New South Wales, Australia
- Northern Sydney Local Health District, Kolling Institute, St Leonards, New South Wales, Australia
- Women and Babies Research, c/o University Department of O&G, Level 5, Douglas Building, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Siranda Torvaldsen
- The University of Sydney Northern Clinical School, Women and Babies Research, St Leonards, New South Wales, Australia
- Northern Sydney Local Health District, Kolling Institute, St Leonards, New South Wales, Australia
- Women and Babies Research, c/o University Department of O&G, Level 5, Douglas Building, Royal North Shore Hospital, St Leonards, New South Wales, 2065, Australia
- School of Population Health, UNSW, Sydney, Australia
| |
Collapse
|
14
|
Li S, Gao J, Liu J, Hu J, Chen X, He J, Tang Y, Liu X, Cao Y, Liu X, Wang X. Incidence and Risk Factors of Postpartum Hemorrhage in China: A Multicenter Retrospective Study. Front Med (Lausanne) 2021; 8:673500. [PMID: 34497812 PMCID: PMC8419315 DOI: 10.3389/fmed.2021.673500] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 07/31/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide but the incidence and its risk factors in China is limited. The objective of this study is to investigate the incidence and the risk factors of PPH in Chinese women. Methods: A multi-center retrospective study of pregnant women at ≥28 weeks of gestation was conducted. Logistic regression was used to identify potential risk factors of PPH and receiver operating characteristic curve was used to evaluate the predictive performance of the identified risk factors. Subgroup analysis focusing on the number of fetus and the mode of delivery was conducted. Results: A total of 99,253 pregnant women were enrolled and 804 (0.81%) experienced PPH. The subgroup analysis revealed that the incidence of PPH was 0.75, 2.65, 1.40, and 0.31% in singletons, twin pregnancies, cesarean sections, and vaginal deliveries, respectively. Placenta previa and placenta accreta were the predominant risk factors of PPH in the overall population and all subgroups. A twin pregnancy was a risk factor for PPH regardless of the mode of delivery. Obesity, and multiparity were risk factors for PPH in both singletons and cesarean section cases, but the latter predicted a reduced probability of PPH in vaginal deliveries. Macrosomia was associated with increased risk of PPH in singletons or vaginal deliveries. In women who delivered vaginally, preeclampsia was associated with a higher risk of PPH. The areas under the curve for the overall cohort, singletons, twin pregnancies, cesarean section cases, and vaginal deliveries were 0.832 (95% confidence interval [CI] 0.813–0.851), 0.824 (95% CI 0.803–0.845), 0.686 (95% CI 0.617–0.755), 0.854 (95% CI 0.834–0.874), and 0.690 (95% CI 0.646–0.735), respectively. Conclusions: The risk factors of PPH varied slightly based on the number of fetuses and the mode of delivery, while placenta previa and placenta accreta were the two major risk factors. A combination of the identified risk factors yielded a satisfactory predictive performance in determining PPH in the overall cohort, singletons pregnancies, and women who delivered by cesarean section, whereas the performance was moderate in twin pregnancies and in women delivering vaginally.
Collapse
Affiliation(s)
- Sijian Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Jinsong Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Jing Hu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Xiaoxu Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Jing He
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Yabing Tang
- Department of Obstetrics and Gynecology, Hunan Maternal and Child Health Care Hospital, Changsha, China
| | - Xinghui Liu
- Department of Obstetrics and Gynecology, Sichuan University West China Second Hospital, Chengdu, China
| | - Yinli Cao
- Department of Obstetrics and Gynecology, Northwest Women and Children's Hospital, Xi'an, China
| | - Xiaowei Liu
- Department of Obstetrics and Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Xietong Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| |
Collapse
|
15
|
Development and validation of a prediction model for postpartum hemorrhage at a single safety net tertiary care center. Am J Obstet Gynecol MFM 2021; 3:100404. [PMID: 34048966 DOI: 10.1016/j.ajogmf.2021.100404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postpartum hemorrhage is a leading cause of pregnancy-related morbidity and mortality; however, there is limited ability to identify women at risk of this obstetrical complication. OBJECTIVE This study aimed to develop and validate a prediction model for postpartum hemorrhage based on antenatal and intrapartum risk factors. STUDY DESIGN This was a retrospective cohort study of women who delivered between April 2016 and March 2019 at a single safety net hospital. The prevalence of postpartum hemorrhage, defined as blood loss of ≥1000 mL at the time of delivery, was determined, and characteristics were compared between women with and without postpartum hemorrhage. Women were randomly assigned to a prediction or a validation cohort. The selection of predictors to be included in the model was based on known antenatal and intrapartum risk factors for postpartum hemorrhage. A multivariable logistic regression with a backward stepwise approach was used to create a prediction model. Area under the receiver operating characteristic curve and 95% bootstrap confidence intervals were calculated. Using the final model, a single threshold for classifying postpartum hemorrhage was chosen, and the resulting sensitivity, specificity, and false-negative and false-positive rates were explored. RESULTS The prevalence rates of postpartum hemorrhage in the prediction and validation cohorts were 6.3% (377 of 6000 cases) and 6.4% (241 of 3774 cases), respectively (P=.83). The following predictors were selected for the final model: maternal body mass index (kg/m2), number of fetuses, history of postpartum hemorrhage, admission platelets of <100,000/µL, chorioamnionitis, arrest of descent, placental abruption, and active labor duration. The predictive model had an area under the receiver operating characteristic curve of 0.82 (95% confidence interval, 0.81-0.84). When applied to the validation cohort, the model had an area under the receiver operating characteristic curve of 0.81 (95% confidence interval, 0.78-0.83), a sensitivity of 86.9%, a specificity of 74.2%, a positive predictive value of 18.6%, a negative predictive value of 98.8%, a false-negative rate of 13.1%, and a false-positive rate of 25.9%. CONCLUSION The model performed reasonably well in identifying women at risk of postpartum hemorrhage. Further studies are necessary to evaluate the model in clinical practice and its effect on decreasing the prevalence of postpartum hemorrhage and associated maternal morbidity.
Collapse
|
16
|
Salomon C, de Moreuil C, Hannigsberg J, Trémouilhac C, Drugmanne G, Gatineau F, Nowak E, Anouilh F, Briend D, Moigne EL, Merviel P, Abgrall JF, Lacut K, Petesch BP. Haematological parameters associated with postpartum haemorrhage after vaginal delivery: Results from a French cohort study. J Gynecol Obstet Hum Reprod 2021; 50:102168. [PMID: 34033967 DOI: 10.1016/j.jogoh.2021.102168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/11/2021] [Accepted: 05/19/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immediate postpartum haemorrhage (PPH) is a major, feared and often unpredictable issue. Besides many clinical risk factors, some biological parameters could also be predictive of PPH. OBJECTIVE To study simple and easily accessible haematological parameters as potential risk factors for PPH after vaginal delivery. METHODS All women who had a vaginal delivery between April 1, 2013 and May 29, 2015 in the maternity ward of Brest University Hospital (France) were included, after oral informed consent obtained. Clinical data were collected by obstetricians or midwives during antenatal care visits, labour and delivery, and recorded by trained research assistants. Haematological variables, including immature platelet fraction, were measured from a blood sample systematically collected at the entrance in the delivery room. PPH, measured with a graduated collector bag, was defined as blood loss of at least 500 ml. RESULTS 2742 women were included. PPH occurred in 141 (5%) women. Seven clinical factors were independently associated with PPH: pre-eclampsia (OR 5.85, 95%CI 2.02, 16.90), multiple pregnancy (OR 3.28, 95%CI 1.21, 8.91), assisted reproduction (OR 2.75, 95%CI 1.45, 5.20), antepartum bleeding (OR 2.15, 95%CI 1.24,3.73), post-term delivery (OR 1.93, 95%CI 1.17, 3.17), obesity (OR 2.95, 95%CI 1.76, 4.93) and episiotomy (OR 2.51, 95%CI 1.63, 3.74). Three haematological factors were additionally identified as independent risk factors for PPH: platelets < 150 Giga/L (OR 2.98, 95%CI 1.63, 5.46), fibrinogen < 4.5 g/l (OR 1.86, 95%CI 1.21, 2.87) and APTT ratio ≥ 1.1 (OR 2.16, 95%CI 1.31, 3.57). Immature platelet fraction was not associated with PPH. CONCLUSION Besides classical clinical risk factors, this study identifies simple haematological parameters as risk factors for PPH.
Collapse
Affiliation(s)
- C Salomon
- EA3878, Université de Bretagne Occidentale - Brest,France
| | - C de Moreuil
- EA3878, Université de Bretagne Occidentale - Brest,France; Département de médecine interne, médecine vasculaire et pneumologie, CHU Brest - Brest, France.
| | - J Hannigsberg
- EA3878, Université de Bretagne Occidentale - Brest,France; Service de Gynécologie Obstétrique, CHU Brest - Brest, France
| | - C Trémouilhac
- EA3878, Université de Bretagne Occidentale - Brest,France; Service de Gynécologie Obstétrique, CHU Brest - Brest, France
| | | | | | - E Nowak
- CIC1412, INSERM - Brest, France
| | - F Anouilh
- Ecole de Sage-femmes, UFR Santé - Brest, France
| | - D Briend
- Service de Gynécologie Obstétrique, CHU Brest - Brest, France
| | - E Le Moigne
- EA3878, Université de Bretagne Occidentale - Brest,France; Département de médecine interne, médecine vasculaire et pneumologie, CHU Brest - Brest, France
| | - P Merviel
- EA3878, Université de Bretagne Occidentale - Brest,France; Service de Gynécologie Obstétrique, CHU Brest - Brest, France
| | - J F Abgrall
- Centre de traitement de l'hémophilie, Hématologie, CHU Brest - Brest,France
| | - K Lacut
- EA3878, Université de Bretagne Occidentale - Brest,France; Département de médecine interne, médecine vasculaire et pneumologie, CHU Brest - Brest, France
| | - B Pan Petesch
- EA3878, Université de Bretagne Occidentale - Brest,France; Centre de traitement de l'hémophilie, Hématologie, CHU Brest - Brest,France
| |
Collapse
|
17
|
Huang Q, Zhu X, Qu Q, Liu X, Zhang G, Su Y, Chen Q, Liu F, Sun X, Liang M, Liu Y, Jiang M, Liu H, Feng R, Yao H, Zhang L, Qian S, Yang T, Zhang J, Shen X, Yang L, Hu J, Huang R, Jiang Z, Wang J, Zhang H, Xiao Z, Zhan S, Liu H, Chang Y, Jiang Q, Jiang H, Lu J, Xu L, Zhang X, Yin C, Wang J, Huang X, Zhang X. Prediction of postpartum hemorrhage in pregnant women with immune thrombocytopenia: Development and validation of the MONITOR model in a nationwide multicenter study. Am J Hematol 2021; 96:561-570. [PMID: 33606900 DOI: 10.1002/ajh.26134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 01/06/2023]
Abstract
Globally, postpartum hemorrhage (PPH) is the leading cause of maternal death. Women with immune thrombocytopenia (ITP) are at increased risk of developing PPH. Early identification of PPH helps to prevent adverse outcomes, but is underused because clinicians do not have a tool to predict PPH for women with ITP. We therefore conducted a nationwide multicenter retrospective study to develop and validate a prediction model of PPH in patients with ITP. We included 432 pregnant women (677 pregnancies) with primary ITP from 18 academic tertiary centers in China from January 2008 to August 2018. A total of 157 (23.2%) pregnancies experienced PPH. The derivation cohort included 450 pregnancies. For the validation cohort, we included 117 pregnancies in the temporal validation cohort and 110 pregnancies in the geographical validation cohort. We assessed 25 clinical parameters as candidate predictors and used multivariable logistic regression to develop our prediction model. The final model included seven variables and was named MONITOR (maternal complication, WHO bleeding score, antepartum platelet transfusion, placental abnormalities, platelet count, previous uterine surgery, and primiparity). We established an easy-to-use risk heatmap and risk score of PPH based on the seven risk factors. We externally validated this model using both a temporal validation cohort and a geographical validation cohort. The MONITOR model had an AUC of 0.868 (95% CI 0.828-0.909) in internal validation, 0.869 (95% CI 0.802-0.937) in the temporal validation, and 0.811 (95% CI 0.713-0.908) in the geographical validation. Calibration plots demonstrated good agreement between MONITOR-predicted probability and actual observation in both internal validation and external validation. Therefore, we developed and validated a very accurate prediction model for PPH. We hope that the model will contribute to more precise clinical care, decreased adverse outcomes, and better health care resource allocation.
Collapse
Affiliation(s)
- Qiu‐Sha Huang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Xiao‐Lu Zhu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Qing‐Yuan Qu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Xiao Liu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Gao‐Chao Zhang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Yan Su
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Qi Chen
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Feng‐Qi Liu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Xue‐Yan Sun
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Mei‐Ying Liang
- Department of Obstetrics and Gynecology Peking University People's Hospital Beijing China
| | - Yi Liu
- Department of Hematology Navy General Hospital Beijing China
| | - Ming Jiang
- Center of Hematologic Diseases First Affiliated Hospital of Xinjiang Medical University Urumqi China
| | - Hui Liu
- Department of Hematology Beijing Hospital Beijing China
| | - Ru Feng
- Department of Hematology Beijing Hospital Beijing China
| | - Hong‐Xia Yao
- Department of Hematology People's Hospital of Hainan Province Haikou China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Tianjin China
| | - Shen‐Xian Qian
- Department of Hematology First People's Hospital of Hangzhou Hangzhou China
| | - Tong‐Hua Yang
- Department of Hematology First People's Hospital of Yunnan Province Kunming China
| | - Jing‐Yu Zhang
- Department of Hematology Hebei Institute of Hematology, The Second Hospital of Hebei Medical University Shijiazhuang China
| | - Xu‐Liang Shen
- Department of Hematology He Ping Central Hospital of the Changzhi Medical College Changzhi China
| | - Lin‐Hua Yang
- Department of Hematology Second Hospital of Shanxi Medical University Taiyuan China
| | - Jian‐Da Hu
- Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital Fuzhou China
| | - Ren‐Wei Huang
- Department of Hematology Third Affiliated Hospital of Southern Medical University Guangzhou China
| | - Zhong‐Xing Jiang
- Department of Hematology First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Jing‐Wen Wang
- Department of Hematology Beijing Tongren Hospital Beijing China
| | - Hong‐Yu Zhang
- Department of Hematology Peking University Shenzhen Hospital Shenzhen China
| | - Zhen Xiao
- Department of Hematology Affiliated Hospital of Inner Mongolia Medical University Hohhot China
| | - Si‐Yan Zhan
- Department of Epidemiology and Biostatistics School of Public Health, Peking University Health Science Center Beijing China
| | - Hui‐Xin Liu
- Department of Clinical Epidemiology Peking University People's Hospital Beijing China
| | - Ying‐Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Qian Jiang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Hao Jiang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Jin Lu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Lan‐Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Xiao‐Hong Zhang
- Department of Obstetrics and Gynecology Peking University People's Hospital Beijing China
| | - Cheng‐Hong Yin
- Department of Internal Medicine Beijing Obstetrics and Gynecology Hospital, Capital Medical University Beijing China
| | - Jian‐Liu Wang
- Department of Obstetrics and Gynecology Peking University People's Hospital Beijing China
| | - Xiao‐Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Xiao‐Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| |
Collapse
|
18
|
Ballesta-Castillejos A, Gómez-Salgado J, Rodríguez-Almagro J, Hernández-Martínez A. Development and validation of a predictive model of exclusive breastfeeding at hospital discharge: Retrospective cohort study. Int J Nurs Stud 2021; 117:103898. [PMID: 33636452 DOI: 10.1016/j.ijnurstu.2021.103898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The benefits of breastfeeding for both mother and newborn have been widely demonstrated. However, breastfeeding rates at discharge are lower than recommended, so being able to identify women at risk of not breastfeeding at discharge could allow professionals to prioritise care. OBJECTIVE To develop and validate a predictive model of exclusive breastfeeding at hospital discharge. DESIGN Retrospective cohort study on women who gave birth between 2014 and 2019 in Spain. DATA SOURCES The data source was a questionnaire distributed through the Spanish breastfeeding associations. The development of the predictive model was made on a cohort of 3387 women and was validated on a cohort of 1694 women. A multivariate analysis was performed by means of logistic regression, and predictive ability was determined by areas under the ROC curve (AUC). RESULTS 80.2% (2717) women exclusively breastfed at discharge in the derivation cohort, and 82.1% (1390) in the validation cohort. The predictive factors in the final model were: maternal age at birth; BMI; number of children; previous breastfeeding; birth plan; induced birth; epidural analgesia; type of birth; prematurity; multiple pregnancy; macrosomia; onset of breastfeeding within the first hour; and skin-to-skin contact. The predictive ability (ROC AUC) in the derivation cohort was 0.76 (CI 95%: 0.74-0.78), while in the validation cohort it was 0.74 (CI 95%: 0.71-0.77). CONCLUSIONS A predictive model of exclusive maternal breastfeeding at hospital discharge has been developed, based on thirteen variables, with satisfactory predictive ability in both the derivation cohort and the validation cohort according to the Swets' criteria. This model can identify women who are at high risk of not breastfeeding at hospital discharge.
Collapse
Affiliation(s)
| | - Juan Gómez-Salgado
- PhD.Department of Sociology, Social Work and Public Health, University of Huelva, 21071 Huelva, Spain; Safety and Health Posgrade Program, Universidad Espíritu Santo, Guayaquil 091650, Ecuador.
| | - Julián Rodríguez-Almagro
- PhD. Department of Nursing. Ciudad Real School of Nursing, University of Castilla La-Mancha, Ciudad Real, Spain.
| | - Antonio Hernández-Martínez
- Msc. Department of Obstetrics & Gynaecology, Alcázar de San Juan, Ciudad Real, Spain; Safety and Health Posgrade Program, Universidad Espíritu Santo, Guayaquil 091650, Ecuador.
| |
Collapse
|
19
|
Pressly MA, Parker RS, Waters JH, Beck SL, Jeyabalan A, Clermont G. Improvements and limitations in developing multivariate models of hemorrhage and transfusion risk for the obstetric population. Transfusion 2020; 61:423-434. [PMID: 33305364 DOI: 10.1111/trf.16216] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/06/2020] [Accepted: 11/07/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Maternal hemorrhage protocols involve risk screening. These protocols prepare clinicians for potential hemorrhage and transfusion in individual patients. Patient-specific estimation and stratification of risk may improve maternal outcomes. STUDY DESIGN AND METHODS Prediction models for hemorrhage and transfusion were trained and tested in a data set of 74 variables from 63 973 deliveries (97.6% of the source population of 65 560 deliveries included in a perinatal database from an academic urban delivery center) with sufficient data at pertinent time points: antepartum, peripartum, and postpartum. Hemorrhage and transfusion were present in 6% and 1.6% of deliveries, respectively. Model performance was evaluated with the receiver operating characteristic (ROC), precision-recall curves, and the Hosmer-Lemeshow calibration statistic. RESULTS For hemorrhage risk prediction, logistic regression model discrimination showed ROCs of 0.633, 0.643, and 0.661 for the antepartum, peripartum, and postpartum models, respectively. These improve upon the California Maternal Quality Care Collaborative (CMQCC) accuracy of 0.613 for hemorrhage. Predictions of transfusion resulted in ROCs of 0.806, 0.822, and 0.854 for the antepartum, peripartum, and postpartum models, respectively. Previously described and new risk factors were identified. Models were not well calibrated with Hosmer-Lemeshow statistic P values between .001 and .6. CONCLUSIONS Our models improve on existing risk assessment; however, further enhancement might require the inclusion of more granular, dynamic data. With the goal of increasing translatability, this work was distilled to an online open-source repository, including a form allowing risk factor inputs and outputs of CMQCC risk, alongside our numerical risk estimation and stratification of hemorrhage and transfusion.
Collapse
Affiliation(s)
- Michelle A Pressly
- Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert S Parker
- Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jonathan H Waters
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Stacy L Beck
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Arundhathi Jeyabalan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Clinical and Translational Sciences Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gilles Clermont
- Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
20
|
Nishida K, Sairenchi T, Uchiyama K, Haruyama Y, Watanabe M, Hamada H, Satoh T, Miyashita S, Fukasawa I, Kobashi G. Poor uterine contractility and postpartum hemorrhage among low-risk women: A case-control study of a large-scale database from Japan. Int J Gynaecol Obstet 2020; 154:17-23. [PMID: 33156517 DOI: 10.1002/ijgo.13474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/11/2020] [Accepted: 11/05/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To examine the association between the risk of postpartum hemorrhage (PPH) and poor uterine contractility, which is suggested by the characteristics of labor. METHODS This case-control study used cases recorded in the Japan Perinatal Registry database during the period 2013-2016. After exclusion of women with specified known risk factors for PPH, we enrolled 174 082 primiparas who had a full-term live singleton vaginal birth. Participants were classified into four classes according to the diagnosis of abnormal labor patterns and use of uterotonics. χ2 tests were used to compare PPH cases with controls, and odds ratios (OR) were calculated by univariate and multivariate analyses. RESULTS Among the enrolled women, 10 508 (6.0%) had PPH. Abnormal labor patterns were significantly associated with an increased risk of PPH. Compared with women without any abnormal labor patterns who had not used uterotonics, women with abnormal labor patterns were at a significantly increased risk for PPH regardless of whether they had used uterotonics (adjusted OR 1.23, 95% confidence interval [CI] 1.10-1.37) or not (adjusted OR 1.30, 95% CI 1.23-1.37). CONCLUSION Our study suggests that among low-risk women with PPH, poor uterine contractility in labor could be a significant predisposing risk factor for PPH.
Collapse
Affiliation(s)
- Keiko Nishida
- Department of Public Health, Dokkyo Medical University School of Medicine, Mibu, Japan.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Toshimi Sairenchi
- Department of Public Health, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Koji Uchiyama
- Department of Public Health, Dokkyo Medical University School of Medicine, Mibu, Japan.,Laboratory of International Environmental Health, Center for International Cooperation, Dokkyo Medical University, Mibu, Japan
| | - Yasuo Haruyama
- Department of Public Health, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Mariko Watanabe
- Department of Obstetrics and Gynecology, Dokkyo Medical University, Mibu, Japan
| | - Hiromi Hamada
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Toyomi Satoh
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Susumu Miyashita
- Department of Obstetrics and Gynecology, Dokkyo Medical University, Mibu, Japan
| | - Ichio Fukasawa
- Department of Obstetrics and Gynecology, Dokkyo Medical University, Mibu, Japan
| | - Gen Kobashi
- Department of Public Health, Dokkyo Medical University School of Medicine, Mibu, Japan
| |
Collapse
|
21
|
Neary C, Naheed S, McLernon DJ, Black M. Predicting risk of postpartum haemorrhage: a systematic review. BJOG 2020; 128:46-53. [DOI: 10.1111/1471-0528.16379] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2020] [Indexed: 12/23/2022]
Affiliation(s)
- C Neary
- Paediatric Surgery NHS Greater Glasgow and Clyde Royal Hospital for Children in Glasgow Glasgow UK
| | - S Naheed
- Department of Obstetrics and Gynaecology NHS Grampian Aberdeen Maternity Hospital Aberdeen UK
| | - DJ McLernon
- Medical Statistics Team Institute of Applied Health Sciences University of Aberdeen Aberdeen UK
| | - M Black
- Aberdeen Centre for Women's Health Research Aberdeen Maternity Hospital University of Aberdeen Aberdeen UK
| |
Collapse
|
22
|
Betts KS, Kisely S, Alati R. Predicting common maternal postpartum complications: leveraging health administrative data and machine learning. BJOG 2019; 126:702-709. [DOI: 10.1111/1471-0528.15607] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2018] [Indexed: 12/29/2022]
Affiliation(s)
- KS Betts
- School of Public Health Curtin University Bentley WA Australia
| | - S Kisely
- School of Medicine University of Queensland Brisbane QLD Australia
| | - R Alati
- School of Public Health Curtin University Bentley WA Australia
| |
Collapse
|
23
|
Kearney L, Kynn M, Reed R, Davenport L, Young J, Schafer K. Identifying the risk: a prospective cohort study examining postpartum haemorrhage in a regional Australian health service. BMC Pregnancy Childbirth 2018; 18:214. [PMID: 29879945 PMCID: PMC5992874 DOI: 10.1186/s12884-018-1852-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/25/2018] [Indexed: 11/11/2022] Open
Abstract
Background In industrialised countries the incidence of postpartum haemorrhage (PPH) is increasing, for which exact etiology is not well understood. Studies have relied upon retrospective data with estimated blood loss as the primary outcome, known to be underestimated by clinicians. This study aimed to explore variables associated with PPH in a cohort of women birthing vaginally in coastal Queensland, Australia, using the gravimetric method to measure blood loss. Methods Women were prospectively recruited to participate using an opt-out consent process. Maternal demographics; pregnancy history; model of care; mode of birth; third stage management practices; antenatal, intrapartum and immediate postpartum complications; gravimetric and estimated blood loss; and haematological laboratory data, were collected via a pre-designed data collection instrument. Descriptive statistics were used for demographic, intrapartum and birthing practices. A General Linear Model was used for multivariate analysis to examine relationship between gravimetric blood loss and demographic, birthing practices and intrapartum variables. The primary outcome was a postpartum haemorrhage (blood loss > 500 ml). Results 522 singleton births were included in the analysis. Maternal mean age was 29 years; 58% were multiparous. Most participants received active (291, 55.7%) or modified active management of third stage (191, 36.6%). Of 451 births with valid gravimetric blood loss recorded, 35% (n = 159) recorded a loss of 500 ml or more and 111 (70%) of these were recorded as PPH. Gravimetric blood loss was strongly correlated with estimated blood loss (r = 0.88; p < 0.001). On average, the estimated blood loss was lower than the gravimetric blood loss, about 78% of the measured value. High neonatal weight, perineal injury, complications during labour, separation of mother and baby, and observation of a gush of blood were associated with PPH. Nulliparity, labour induction and augmentation, syntocinon use were not associated with PPH. Conclusions In contrast to previous study findings, nulliparity, labour induction and augmentation were not associated with PPH. Estimation of blood loss was relatively accurate in comparison to gravimetric assessment; raising questions about routine gravimetric assessment of blood loss following uncomplicated births. Further research is required to investigate type and speed of blood loss associated with PPH.
Collapse
Affiliation(s)
- Lauren Kearney
- Women and Families Service Group, Sunshine Coast Hospital and Health Service, Sunshine Coast University Hospital, 6 Doherty St, Birtinya, Qld, Birtinya, 4575, Australia. .,University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Qld, 4558, Australia.
| | - Mary Kynn
- University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Qld, 4558, Australia
| | - Rachel Reed
- University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Qld, 4558, Australia
| | - Lisa Davenport
- Women and Families Service Group, Sunshine Coast Hospital and Health Service, Sunshine Coast University Hospital, 6 Doherty St, Birtinya, Qld, Birtinya, 4575, Australia
| | - Jeanine Young
- University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Qld, 4558, Australia.,Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
| | - Keppel Schafer
- Women and Families Service Group, Sunshine Coast Hospital and Health Service, Sunshine Coast University Hospital, 6 Doherty St, Birtinya, Qld, Birtinya, 4575, Australia
| |
Collapse
|
24
|
Césarienne après déclenchement du travail : facteurs de risque et score de prédiction. ACTA ACUST UNITED AC 2018; 46:458-465. [DOI: 10.1016/j.gofs.2018.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Indexed: 11/19/2022]
|