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#Grand Rounds

What are the Possible Causes of a PPH that is Unresponsive to First Line Uterotonics?

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BACKGROUND AND PURPOSE:

  • A better understanding of maternal characteristics associated with refractory PPH (unresponsive to first line uterotonics) may help improve treatment
  • Widmer et al. (BJOG, 2019) examined the maternal characteristics and causes associated with refractory postpartum hemorrhage (PPH)

METHODS:

  • Secondary analysis of the WHO CHAMPION trial data
    • CHAMPION trial: double blind, noninferiority RCT comparing the effectiveness of prophylactic IM carbetocin with oxytocin administered immediately after vaginal birth
  • Setting
    • 23 hospitals in 10 countries
  • Participants
    • Women from the CHAMPION trial who received uterotonics as first-line treatment of PPH
  • Study design
    • Data collected: Sociodemographic factors | Pregnancy and childbirth factors
    • Causes of PPH: Uterine atony | Vaginal/perineal/cervical tear | Retained placenta | Coagulopathy
    • Compared women with refractory PPH (unresponsive to first-line uterotonics for PPH) to women who were responsive to first-line PPH treatment
    • Multivariate analysis
  • Primary outcome
    • Maternal characteristics
    • Causes of PPH

RESULTS:

  • 29,539 women randomized in the CHAMPION trial
    • 3061 (10.4%) received additional uterotonics for PPH
    • 16.2% were in the refractory group (did not respond to first-line treatment) | 83.8% responded to initial first-line treatment
  • Higher odds of refractory PPH vs responsive for the following
    • Patient induced or augmented with uterotonics
      • Adjusted odds ratio (aOR) 1.35 (95% CI, 1.07 to 1.72)
    • Episiotomy or tears requiring suturing
      • aOR 1.82 (95% CI, 1.34 to 2.48)
    • Babies with birthweights ≥3500 g
      • aOR 1.33 (95% CI 1.04 to 1.69)
  • 3 maternal deaths were reported, all in the refractory group
    • Placental abruption | Placental retention | Uterine atony

PPH ≥1000 ml

  • Atony was the sole PPH cause in
    • Responsive group: 53.2%
    • Refractory group: 31.5%
  • Tears were the sole cause in
    • Responsive group: 12.8%
    • Refractory group: 28%
  • A placental problem was the sole cause in
    • Responsive group: 11%
    • Refractory group: 5.6%

CONCLUSION:

  • Refractory PPH vs responsive to uterotonics show different causal patterns
  • Induction with uterotonics, episiotomies or tears requiring suturing, and babies ≥3500 g are associated with refractory PPH
  • Women who respond to first-line uterotonics are more likely to have atony vs trauma as the sole cause of PPH | In refractory PPH cases, both atony and trauma showed similar causal rates

Learn More – Primary Sources:

Maternal characteristics and causes associated with refractory postpartum haemorrhage after vaginal birth: a secondary analysis of the WHO CHAMPION trial data

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Related ObG Topics:

Postpartum Hemorrhage – Medications to Treat Uterine Atony 
Postpartum Hemorrhage Prophylaxis: The World Health Organization Recommendations
How Effective is Intrauterine Balloon Tamponade for Severe Postpartum Hemorrhage
Latest Cochrane Review: What is the Most Effective Prophylactic Treatment for Postpartum Hemorrhage?
WOMAN Trial Secondary Analysis: Do Invasive Treatments for PPH Increase Sepsis Risk?

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