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

Abstract

Objective To assess the maternal characteristics and causes associated with refractory postpartum haemorrhage (PPH). Design Secondary analysis of the WHO CHAMPION trial data. Setting Twenty‐three hospitals in ten countries. Population Women from the CHAMPION trial who received uterotonics as first‐line treatment of PPH. Methods We assessed the association between sociodemographic, pregnancy and childbirth factors and refractory PPH, and compared the causes of PPH between women with refractory PPH and women responsive to first‐line PPH treatment. Main outcome measures Maternal characteristics; causes of PPH. Results Women with labour induced or augmented with uterotonics (adjusted odds ratio [aOR] 1.35; 95% CI 1.07–1.72), with episiotomy or tears requiring suturing (aOR 1.82; 95% CI 1.34–2.48) and who had babies with birthweights ≥3500 g (aOR 1.33; 95% CI 1.04–1.69) showed significantly higher odds of refractory PPH compared with the reference categories in the multivariate analysis adjusted by centre and trial arm. While atony was the sole PPH cause in 53.2% (116/218) of the women in the responsive PPH group, it accounted for only 31.5% (45/143) of the causes in the refractory PPH group. Conversely, tears were the sole cause in 12.8% (28/218) and 28% (40/143) of the responsive PPH and refractory PPH groups, respectively. Placental problems were the sole cause in 11 and 5.6% in the responsive and refractory PPH groups, respectively. Conclusion Women with refractory PPH showed a different pattern of maternal characteristics and PPH causes compared with those with first‐line treatment responsive PPH. Tweetable abstract Women with refractory postpartum haemorrhage are different from those with first‐line treatment responsive PPH.

Prenatal anemia and postpartum hemorrhage risk: A systematic review and meta‐analysis

“…While AMSTL is estimated to prevent over half of PPH cases, there are many cases of pregnant women who lose potentially deleterious amounts of blood despite AMSTL, warranting therapeutic administration of uterotonics 7 . In a subset of women with PPH, uterine atony and bleeding remains refractory despite uterotonic administration, warranting surgical or other invasive interventions 8 . It is plausible that the underlying cause and pathogenesis of PPH in this subset of women might differ from those due to atony, responsive to uterotonics.…”

Circular suture of the uterine serosa and myometrium layer around placental attachment site for refractory postpartum hemorrhage

“…The major causes of refractory PPH include uterine inertia, placental factors, soft birth canal laceration, and coagulation dysfunction, among which uterine inertia is the most common factor 13–15 . Refractory PPH was often influenced by multiple independent risk factors and various clinical factors affected each other.…”

“…[10][11][12] The major causes of refractory PPH include uterine inertia, placental factors, soft birth canal laceration, and coagulation dysfunction, among which uterine inertia is the most common factor. [13][14][15] Refractory PPH was often influenced by multiple independent risk factors and various clinical factors affected each other. Uterine compression sutures, bleeding artery ligation, and embolization should be applied when noninvasive first-line measures could not control the uterine bleeding.…”

Effectiveness of uterine tamponade devices for refractory postpartum haemorrhage after vaginal birth: a systematic review

“…Most women with postpartum haemorrhage (PPH) respond well to first‐line interventions (uterotonics, uterine massage, tranexamic acid). However, 10–20% are unresponsive to these interventions – a subgroup (denoted as ‘refractory PPH’) where most of the PPH‐related morbidity and mortality are concentrated 3 . Between one‐third and one‐half of refractory PPH cases are due to uterine atony.…”