What Are the Risk Factors for Postpartum Hemorrhage Due to Uterine Atony?
BACKGROUND AND PURPOSE:
The most common cause of postpartum hemorrhage (PPH) is uterine atony
Several risk assessment tools, recognized by professional bodies, are used for PPH but have moderate predictive value
“This limitation may be partly due to the tools’ development via expert consensus opinion and a lack of systematically reviewed evidence to support or refute the included risk factors”
Ende et al. (Obstetrics & Gynecology, 2021) sought to identify and quantify the risk factors for atonic PPH
Systematic review and meta-analysis
RCTs, prospective or retrospective cohort studies, and case-control studies
Studies of pregnant patients who developed atonic PPH and reported at least one risk factor
Low and moderate risk of bias studies
Qualitative synthesis: Each risk factor was classified as definite, likely, unclear, or not a risk factor
Quantitative meta-analysis: Used for risk factors with homogenous definitions and references ranges
Risk factors associated specifically with atonic PPH
There were 47 potential risk factors for atonic PPH that were identified
6 definite risk factors
Prior postpartum hemorrhage
Preexisting or gestational diabetes mellitus
Genital tract trauma sustained during delivery
9 likely risk factors
Hypertensive diseases of pregnancy
Predelivery oxytocin exposure
Induction of labor
Instrumented vaginal delivery
The remaining 32 assessed risk factors, including obesity and magnesium exposure, were not associated with atonic PPH or had conflicting or unclear evidence
Many risk factors for atonic postpartum hemorrhage are included in current risk-assessment tools
Factors with the greatest impact included prior PPH, placenta previa, placental abruption, uterine rupture, and multiple gestation
Novel risk factors included hypertension, diabetes, and ethnicity
Obesity and magnesium exposure were not associated with atonic PPH
The authors conclude:
By more narrowly defining our focus to only atonic postpartum hemorrhage, we aimed to provide more definitive evidence supporting or refuting presumed risk factors, given that each etiology of postpartum hemorrhage likely has a unique set of contributing factors
Ende et al. (Obstetrics & Gynecology, 2021)
These findings should lead researchers and clinicians to refine current risk-assessment tools further
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