Early detection, bundled treatment may lower risk from postpartum bleeding

Key takeaways:

• Severe postpartum bleeding occurred among 1.6% of women in an early detection intervention group vs. 4.3% in usual care.
• Early detection and use of a WHO first-response treatment bundle limited severe bleeding.

Among women in Africa with vaginal deliveries, early postpartum hemorrhage detection and use of a bundled treatment intervention lowered risk for severe postpartum bleeding and laparotomy or death from bleeding vs. usual care, data show.

“The WHO has published and updated several evidence-informed recommendations for the prevention and treatment of postpartum hemorrhage,” Ioannis Gallos, DMS, MD, honorary professor at the Institute of Metabolism and Systems Research at the University of Birmingham, U.K., and colleagues wrote. “Despite strong efforts to adopt and scale up the use of these recommendations, postpartum hemorrhage remains the leading cause of maternal complications and death worldwide.”

In the E-MOTIVE trial, an international, parallel cluster-randomized trial published in The New England Journal of Medicine, Gallos and colleagues evaluated a multicomponent clinical intervention for postpartum hemorrhage among 210,132 women with vaginal deliveries at 80 secondary-level hospitals across Kenya, Nigeria, South Africa and Tanzania. The women were randomly assigned to usual care (n = 40) or the E-MOTIVE intervention (n = 40), which included a calibrated blood-collection drape for early postpartum hemorrhage detection and the WHO first-response bundle — uterine massage, oxytocic drugs, tranexamic acid, IV fluids, examination and escalation — supported by an implementation strategy. One hospital in both the usual care and intervention groups did not have data for analysis; researchers analyzed data from 99,659 women from the implementation phase.

The primary outcome was a composite of severe postpartum hemorrhage with blood loss of 1,000 mL or more, laparotomy for bleeding or maternal death due to bleeding. Secondary outcomes were postpartum hemorrhage detection and adherence to the treatment bundle.

Overall, 1.6% of women in the intervention group had severe postpartum hemorrhage compared with 4.3% of women who received usual care (RR = 0.4; 95% CI, 0.32-0.5; P < .001). Hospitals detected postpartum hemorrhage among 93.1% of women in the intervention group and 51.1% of women who received usual care (RR = 1.58; 95% CI, 1.41-1.76). In addition, the WHO treatment bundle was utilized for 91.2% of women in the intervention group and 19.4% of women who received usual care (RR = 4.94; 95% CI, 3.88-6.28). Risk for postpartum hemorrhage decreased with time following randomization, from 3.8% at baseline to 1.1% by the last month.

Researchers observed 17 maternal deaths among women in the intervention group and 28 deaths among women in the usual care group (RR = 0.73; 95% CI, 0.4-1.31). Of these, 12 deaths in the intervention group and 18 in the usual care group were attributed to postpartum bleeding.

“The E-MOTIVE intervention resulted in a 60% lower risk of the primary outcome,” the researchers wrote. “This benefit was presumably attributable to observed improvements in the detection of postpartum hemorrhage and the use of the WHO first-response bundle in the hospitals in the intervention group,”