Treatment Patterns in Abnormal Postpartum Uterine Bleeding or Hemorrhage (2016–2022)

Kara M. Rood¹, Candice Yong², Patricia I. Carney², Brian Seal², Seungyoung Hwang², Roy M. Brooks³

¹The Ohio State University-Wexner Medical Center, Columbus, OH;²Organon & Co., Jersey City, NJ; ³Capital Women’s Care, Laurel, MD & Holy Cross Hospital, Silver Spring, MD

Background

• Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality worldwide accounting for ~25% of the deaths annually¹
• Although PPH is largely deemed preventable with timely recognition and treatment, the rate of PPH in the US has increased from 2.7% in the year 2000 to 4.3% in 2019²
• Uterotonic (UT) medications are the first-line of treatment to reduce the blood loss during childbirth involving PPH, and uterine balloon tamponade (UBT) is often used in patients who do not respond to UTs^3,4,5
• WHO guidelines for use of tranexamic acid (TXA) in PPH management were updated after the 2017 publication of the WOMAN trial^6,7

Study Aim, Design, and Outcomes

• This retrospective, observational study aimed to describe rates of abnormal postpartum uterine bleeding/PPH over time and treatment patterns for UTs, TXA, and other interventions among hospital births involving abnormal postpartum uterine bleeding or PPH
• Data for all births in patients ≥15 years old associated with abnormal postpartum uterine bleeding or PPH in the US Premier Hospital Database (Jan 2016–Mar 2022) were included
• Abnormal bleeding or PPH was defined as follows
  - Second-line use of UT beyond oxytocin (i.e., carboprost, methylergonovine, misoprostol ≥800 μg), or TXA was a proxy for abnormal postpartum uterine bleeding
  - PPH was defined by ≥1 International Classification of Diseases (ICD) 10 code
• Descriptive results for diagnosis rates, treatment patterns, and combination therapy over time are presented

Study Population

• A total of 787,964 patients (14.7%) were diagnosed with PPH and/or received second-line UTs
• Patients had a mean age±SD of 29.0±6.0 years and 50.7% were non-Hispanic White; 34.1% underwent a cesarean section
  
  
• Among the 14.7% of patients with PPH or second-line UT usage, most were treated with UTs/TXA without a PPH diagnosis code
• The rate of abnormal postpartum uterine bleeding or PPH increased over time, from 12.1% in 2016 to 19.7% in 2022
• Increased use of the PPH ICD-10 diagnosis code contributed to the observed increase in abnormal postpartum uterine bleeding/PPH during the observation period
• Among patients who received both UBT and pharmacologic therapy, combination therapy with 3 or more UTs/TXA increased from 26.6% in 2016 to 52.4% in 2022

Conclusions

• Factoring both the diagnosis codes and second-line UT use, the observed rate of abnormal postpartum uterine bleeding or PPH was higher than previously reported in the literature and increased from 12% in 2016 to 20% in 2022
• Treatment patterns evolved during the observation period, with decreasing use of methylergonovine and increasing use of TXA and combination therapy; increased TXA use coincided with the WOMAN trial and guideline updates

Additional Results

• Use of TXA increased substantially over time, from 0.3% in 2016 to 27.8% in 2022
• Methylergonovine showed a pattern of decreasing use over time, from 53.3% in 2016 to 46.1% in 2022
• Use of misoprostol ≥800 μg (48.9% in 2016, 46.2% in 2022) and carboprost (14.6% in 2016, 15.0% in 2022) remained relatively stable over the study period
• Combination therapy with 2 or more UTs/TXA increased over the time, from 19.6% in 2016 to 28.9% in 2022
• Nonsurgical treatment with uterine balloon tamponade was relatively stable during the observation period, ranging from 2.4% in 2016-2017 to 2.9% in 2019 and 2021
• Rates of hysterectomy were 0.6% in 2016-2020, and 0.5% in 2021-2022