Objective: To identify the characteristics and treatment approaches for Severe Postpartum Hemorrhage (SPPH) patients in various midwifery institutions in one district in Beijing, especially those without identifiable antenatal PPH risk factors, to improve regional SPPH rescue capacity.

Design: Retrospective cohort study

Setting: This study was conducted at nine tertiary-level hospitals and ten secondary-level hospitals in Haidian district of Beijing from January 2019 to December 2022.

Participants: The major inclusion criterion was SPPH cases with blood loss ≥1500 ml or needing a packed blood product transfusion ≥1000 ml within 24 h after birth. A total of 324 mothers suffering from SPPH were reported to the Regional Obstetric Quality Control Office from 19 midwifery hospitals.

Outcome measures: The pregnancy characteristics collected included: age at delivery, gestational weeks at delivery, height, parity, delivery mode, antenatal PPH risks, etiology of PPH, bleeding amount, PPH complications, transfusion amount, and PPH management. SPPH characteristics were compared between two levels of midwifery hospitals and their association with antenatal PPH high-risk factors was determined.

Results: SPPH was observed in 324 mothers out of 106697 mothers in the four years. There were 74.4% and 23.9% cases of SPPH without detectable antenatal PPH high-risk factors in secondary and tertiary midwifery hospitals, respectively. Primary uterine atony was the leading cause of SPPH in secondary midwifery hospitals, whereas placental-associated disorders were the leading causes in tertiary institutions, accounting for over 50% of cases. In all SPPH cases, the rates of red blood cell transfusion over 10U, unscheduled returns to the operating room, and adverse PPH complications were higher in patients without antenatal PPH risk factors. Secondary hospitals had significantly higher rates of trauma compared with tertiary institutions.

Conclusion: Examining SPPH cases at various institutional levels offers a more comprehensive view of regional SPPH management and enhances targeted training in this area.

Study area

The Haidian district is 431 square kilometers in area, accounting for about 2.6% of Beijing’s landmass. At the end of 2021, the district had 3.130 million permanent residents, making it the second most populous in Beijing. The district has 19 midwifery institutions, nine tertiary facilities (three serving as regional transferal centers), and ten secondary facilities. Primary midwifery institutions are mostly distributed in rural areas, and there are no primary midwifery institutions in this region.

Study design and time frame

A retrospective cohort study was conducted from January 2019 to December 2022.

Participants

The Beijing maternal management policy requires all midwifery institutions to prepare and submit monthly reports about severe perinatal complications to the Reginal Obstetric Quality Control Office (ROQCO). Such complications include abnormal vital signs (eclampsia, cyanosis, oliguria or anuria, coagulation disorders, and shock), abnormal laboratory inspections (lower oxygenation index, thrombocytopenia, abnormal liver, and renal functions), and incidences of specialized care (use of vasoactive agents, mechanical ventilation, hemofiltration, massive transfusion, and unplanned hysterectomy).

All SPPH cases reported to ROQCO were selected. The inclusion criteria were: blood loss ≥1500 ml or the need for a packed blood product transfusion ≥1000 ml within 24 h after childbirth and gestational periods >20 weeks. Figure 1 shows the flowchart.

Data collection

Data were collected and abstracted from case summaries submitted by 19 midwifery institutions to ROQCO in Beijing’s Haidian district. These summaries provide comprehensive information on cases of postpartum hemorrhage (PPH), including detailed demographics, pregnancy history, delivery outcomes, and emergency interventions. In detail, pregnancy variables such as age at delivery, gestational weeks, height, parity, delivery mode, antenatal PPH risks, etiology of PPH, bleeding amount, SPPH complications, transfusion amount, and PPH management were obtained. The word count ranges from 2000 to 4000 Chinese characters.

Antenatal PPH risks

The Antenatal PPH risks considered were as outlined in the global PPH guidelines (7, 17-19). The classification of these risks was based on PPH etiology or assessment on admission, labor or perinatal. The most important antenatal factors were summarized as follows: 1. Placenta previa/placenta accreta; 2. Previous surgical procedures (more than two Cesarean Section (CS) surgeries or myomectomy); 3. Intramural fibroid (≥5cm); 4. Multiple pregnancies; 5. Macrosomia; 6. History of PPH; 7. Anticoagulant medication/coagulation disorders (Fib/platelet reduction); 8. Severe preeclampsia/ HELLP syndrome; 9. Anemia (Hb≤9.0 g/dL).

Statistical analysis

All statistical analyses were performed using GraphPad Prism 9 (GraphPad Software, San Diego, CA). The SPPH characteristics were expressed as means, standard deviation, number (n), and percentage (%). The qualitative variables were compared using the chi-square test, Fisher’s exact test, or an Unpaired t-test, as appropriate. The P-value<0.05 was considered statistically significant.