Surveillance of different methods of treating obstetric haemorrhage

Summary

Haemorrhage is the second most common cause of direct maternal death in the UK as identified in the most recent report of the Confidential Enquiry into Maternal Deaths. 17 deaths in the last triennium were reported to be directly due to haemorrhage, with a striking increase in the number of deaths from postpartum haemorrhage compared with the previous three years. The report notes the lack of denominator data to enable outcomes to be assessed with respect to particular management strategies. The basic treatment of major peripartum haemorrhage consists of surgery and/or medical management with transfusion and uterotonic drugs. There are now a number of reports of the use of other therapies, including activated factor VIIa, B-Lynch or brace sutures, arterial ligation and embolisation. This UK-wide descriptive study collected information on the timing of use of these therapies, subsequent haemorrhage and requirement for additional management strategies such as hysterectomy.

Key findings

• 211 women who had a uterine compression suture to treat a postpartum haemorrhage were reported over the 19 months of the study. 37% had a B-Lynch procedure, 23% a modified B-Lynch with two vertical sutures; 15% other specific techniques; and for 25% the technique was not specified.
• The overall rate of failure, leading to hysterectomy, was 25% (95% confidence interval(CI) 19–31%); there were no significant differences in failure rates among B-Lynch sutures, modified B-Lynch sutures, and other suture techniques.
• Women were more likely to have a hysterectomy if they were older (adjusted odds ratio (aOR) 2.77, 95%CI 1.13-6.77), multiparous (aOR 2.83, 95%CI 1.00-8.00), of non-managerial socioeconomic status (aOR 3.54, 95%CI 1.20-10.4) or had a vaginal delivery (aOR 6.08, 95%CI 1.33-27.8).
• A prolonged delay of two to six hours between delivery and uterine compression suture was independently associated with a fourfold increase in the odds of hysterectomy (aOR 4.60, 95%CI 1.62-13.1).
• These data emphasise the need for a careful evaluation of blood loss after delivery to avoid any prolonged delay in recognition of haemorrhage.

Publications

Journal Articles

• Knight M, Callaghan WM, Berg C, Alexander S, Bouvier-Colle MH, Ford JB, Joseph KS, Lewis G, Liston RM, Roberts CL, Oats J, Walker J. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth. 2009;9:55.
• Kayem G, Kurinczuk JJ, Alfirevic Z, Spark P, Brocklehurst P, Knight M, UKOSS. Uterine compression sutures for the management of severe postpartum hemorrage. Obstet Gynecol. 2011;117(1):14-20.
• Kayem G, Kurinczuk JJ, Alfirevic Z, Spark P, Brocklehurst P, Knight M. Specific second-line therapies for postpartum haemorrhage: a national cohort study. Br J Obstet Gynaecol. 2011;118(7):856-64.