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Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study
J E Lutomski1, B M Byrne, D Devane
1National Perinatal Epidemiology Centre, Cork University Maternity Hospital, Wilton, Cork, Ireland. j.lutomski@ucc.ie
Insights
Postpartum haemorrhage (PPH) rates significantly increased from 1999 to 2009, particularly atonic PPH, necessitating urgent research and clinical review. Morbidly adherent placenta also showed a higher risk of PPH.
Area of Science:
- Obstetrics and Gynecology
- Maternal Health
- Epidemiology
Background:
- Postpartum haemorrhage (PPH) remains a leading cause of maternal morbidity and mortality globally.
- Understanding trends in PPH incidence and associated risk factors is crucial for improving obstetric care.
Purpose of the Study:
- To determine national incidence rates of PPH in the Republic of Ireland from 1999-2009.
- To analyze trends in PPH related to delivery method, blood transfusion, and morbidly adherent placenta.
Main Methods:
- Population-based retrospective cohort study utilizing hospital discharge records (1999-2009).
- International Classification of Diseases (ICD) codes identified PPH, uterine atony, and morbidly adherent placenta.
- Cochrane-Armitage tests and log-binomial regression analyzed incidence trends and risk factors.
Main Results:
- Overall PPH incidence rose from 1.5% to 4.1%, with atonic PPH increasing from 1.0% to 3.4% between 1999 and 2009.
- Significant upward trends in atonic PPH were observed across all delivery methods and with blood transfusions.
- The risk of atonic PPH more than tripled by 2009 compared to 1999 (aRR 3.03).
- Morbidly adherent placenta was associated with a substantially higher risk of PPH (uRR 13.14).
Conclusions:
- The rising incidence of atonic PPH underscores an urgent need for research into its causes.
- Clinical audits focusing on preventative strategies and quality of care are essential to address these increasing rates.
- Further investigation into the link between morbidly adherent placenta and PPH is warranted.
Objective:
To derive nationally representative incidence rates of postpartum haemorrhage (PPH), and to investigate trends associated with method of delivery, blood transfusion and morbidly adherent placenta (accreta, percreta and increta).
Design:
Population-based retrospective cohort study.
Setting:
Republic of Ireland.
Population:
Childbirth hospitalisations during the period 1999-2009.
Methods:
International Classification of Diseases (ICD)-9-CM and ICD-10-AM diagnostic codes from hospital discharge records were used to identify cases of PPH. Significant temporal trends in PPH incidence were determined using Cochrane-Armitage tests for trend. Log-binomial regression was conducted to assess annual changes in the risk of PPH diagnosis, with adjustment for potential confounding factors.
Main Outcome Measures:
PPH, uterine atony, blood transfusion and morbidly adherent placenta.
Results:
A total of 649,019 childbirth hospitalisations were recorded; 2.6% (n = 16,909) included a diagnosis of PPH. The overall PPH rate increased from 1.5% in 1999 to 4.1% in 2009; atonic PPH rose from 1.0% in 1999 to 3.4% in 2009. Significant increasing trends in atonic PPH rates were observed across vaginal, instrumental, and emergency and elective caesarean deliveries (P < 0.001). The rate of atonic PPH co-diagnosed with blood transfusion also significantly increased (P < 0.001). Relative to 1999, the risk of atonic PPH in 2009 was three-fold increased (adjusted RR 3.03; 95% CI 2.76-3.34). Women diagnosed with a morbidly adherent placenta had a markedly higher risk of total PPH (unadjusted RR 13.14; 95% CI 11.43-15.11).
Conclusions:
Increasing rates of atonic PPH highlight the pressing need for research and for clinical audit focusing on aetiological factors, preventative measures and quality of care, to guide current clinical practice.
