Atonic Postpartum Hemorrhage: Blood Loss, Risk Factors, and Third Stage Management

AbstractObjectiveAtonic postpartum hemorrhage rates have increased in many industrialized countries in recent years. We examined the blood loss, risk factors, and management of the third stage of labour associated with atonic postpartum hemorrhage.MethodsWe carried out a case-control study of patients in eight tertiary care hospitals in Canada between January 2011 and December 2013. Cases were defined as women with a diagnosis of atonic postpartum hemorrhage, and controls (without postpartum hemorrhage) were matched with cases by hospital and date of delivery. Estimated blood loss, risk factors, and management of the third stage labour were compared between cases and controls. Conditional logistic regression was used to adjust for confounding.ResultsThe study included 383 cases and 383 controls. Cases had significantly higher mean estimated blood loss than controls. However, 16.7% of cases who delivered vaginally and 34.1% of cases who delivered by Caesarean section (CS) had a blood loss of < 500 mL and < 1000 mL, respectively; 8.2% of controls who delivered vaginally and 6.7% of controls who delivered by CS had blood loss consistent with a diagnosis of postpartum hemorrhage. Factors associated with atonic postpartum hemorrhage included known protective factors (e.g., delivery by CS) and risk factors (e.g., nulliparity, vaginal birth after CS). Uterotonic use was more common in cases than in controls (97.6% vs. 92.9%, P < 0.001). Delayed cord clamping was only used among those who delivered vaginally (7.7% cases vs. 14.6% controls, P = 0.06).ConclusionThere is substantial misclassification in the diagnosis of atonic postpartum hemorrhage, and this could potentially explain the observed temporal increase in postpartum hemorrhage rates

Supplemental material for Canadian Stroke Best Practice Consensus Statement: <i>Acute Stroke Management during pregnancy</i>

<p>Supplemental material for Canadian Stroke Best Practice Consensus Statement: <i>Acute Stroke Management during pregnancy</i> by Noor Niyar N Ladhani, Richard H Swartz, Norine Foley, Kara Nerenberg, Eric E Smith, Gord Gubitz, Dariush Dowlatshahi, Jayson Potts, Joel G Ray, Jon Barrett, Cheryl Bushnell, Simerpreet Bal, Wee-Shian Chan, Radha Chari, Meryem El Amrani, Shital Gandhi, Michael D Hill, Andra James, Thomas Jeerakathil, Albert Jin, Adam Kirton, Sylvain Lanthier, Andrea Lausman, Lisa Rae Leffert, Jennifer Mandzia, Bijoy Menon, Aleksandra Pikula, Alexandre Poppe, Gustavo Saposnik, Mukul Sharma, Sanjit Bhogal, Elisabeth Smitko and M Patrice Lindsay; on behalf of the Heart and Stroke Foundation Canadian Stroke Best Practice and Quality Advisory Committees; in collaboration with the Canadian Stroke Consortium in International Journal of Stroke</p