背景:指南促进产妇产后出血(PPH)风险分层,尽管在已发表的报告中,各组之间相关发病率差异的证据仍然不一致。
目的:使用美国妇产科学院(ACOG)修改的加利福尼亚产妇优质护理合作(CMQCC)模式,我们比较了研究人员在分娩后分类为低的单胎中的复合母体出血结局和复合新生儿不良结局,PPH的中等或高风险。我们假设在三层类别中的个体之间,综合结果会有很大不同。
方法:这是一项回顾性队列研究,研究对象是所有至少14周的单胎产妇,这些产妇在1年内在一个地点分娩。复合母体出血性结局(CMHO)包括以下任何一项:估计失血量≥1,000mL,使用子宫收缩(不包括预防性催产素)或Bakri球囊,PPH的外科治疗,输血,子宫切除术,血栓栓塞,入住重症监护室,或产妇死亡。新生儿复合不良结局(CNAO)为5minApgar评分<7分,出生伤害,支气管肺发育不良,脑室内出血,新生儿癫痫,脓毒症,通风>6小时。,臂丛神经麻痹,缺氧缺血性脑病,或新生儿死亡。使用具有稳健误差方差的多变量泊松回归模型以95%置信区间(CI)估计调整后相对风险(aRR)。
结果:在研究期间的4,544次分娩中,4404(96.7%)符合纳入标准,其中,1,745(39.6%)被归类为低,1,376(31.2%)为中等风险,1,283(29.1%)为高风险。总的来说,941(21.4%)的参与者有CMHO;其中285(16.4%)在低收入人群中,中组319例(23.2%),高危组337例(26.3%)。在所有的产妇中,95.7%在低,中组89.4%,高危组中85.3%的EBL/QBL≥1,000mL,也没有输血。经过多变量调整后,与低风险组相比,在中等风险组(aRR1.23;95%CI1.05-1.43)和高风险组(aRR1.51;95%CI1.31-1.75)中,CMHO的风险显著增高.总的来说,366名新生儿(8.4%)发展为CNAO,低风险组76人(4.2%),中组153人(11.3%),高风险组140人(11.1%)。经过多变量调整后,与低风险组相比,CNAO与中(aRR1.27;95%CI0.97-1.68)或与高风险组(aRR1.29;95%CI0.98-1.68)没有显着差异。
结论:尽管被归类为“高危”的10名产妇中有8名既没有失血≥1,000毫升也没有接受输血,危险分层提供了有关复合孕产妇出血结局的信息.
Guidelines promote stratification for the risk for postpartum hemorrhage among parturients, although the evidence for the associated differential morbidity among the groups remains inconsistent among published reports.
Using the California Maternal Quality Care Collaborative schema modified by the American College of Obstetrics and Gynecology, we compared the composite maternal hemorrhagic outcome and the composite neonatal adverse outcome among singletons who were categorized after delivery by the researchers as low-, medium-, or high-risk for postpartum hemorrhage. We hypothesized that the composite outcomes would be significantly different among the individuals in the different 3-tiered categories.
This was a retrospective cohort study of all singleton parturients with a gestational age of at least 14 weeks who delivered at a single site within 1 year. The composite maternal hemorrhagic outcome included any of the following: estimated blood loss ≥1000 mL, use of
uterotonics (excluding prophylactic oxytocin) or Bakri balloon, surgical management of postpartum hemorrhage, blood transfusion, hysterectomy, thromboembolism, admission to the intensive care unit, or maternal death. The composite neonatal adverse outcome included Apgar score <7 at 5 minutes, birth injury, bronchopulmonary dysplasia, intraventricular hemorrhage, neonatal seizure, sepsis, ventilation > 6 hrs., brachial plexus palsy, hypoxic-ischemic encephalopathy, or neonatal death. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted relative risks with 95% confidence intervals.
Of the 4544 deliveries in the study period, 4404 (96.7%) met the inclusion criteria, and among them, 1745 (39.6%) were categorized as low, 1376 (31.2%) as medium, and 1283 (29.1%) as high risk. Overall, 941 (21.4%) participants experienced the composite maternal hemorrhagic outcome with 285 (16.4%) of those being in the low-risk group, 319 (23.2%) in the medium-risk group, and 337 (26.3%) in the high-risk group. Among all parturients, 95.7% in the low-, 89.4% in the medium-, and 85.3% in the high-risk group neither had an estimated blood loss or a quantified blood loss ≥1000 mL nor were transfused. After multivariable adjustment and when compared with the low-risk group, there was a significantly higher risk for the composite maternal hemorrhagic outcome in the medium-risk group (adjusted relative risk, 1.23; 95% confidence interval, 1.05-1.43) and in the high-risk group (adjusted relative risk, 1.51; 95% confidence interval, 1.31-1.75). Overall, 366 newborns (8.4%) developed the composite neonatal adverse outcome with 76 (4.2%) in of those being in the low-risk group, 153 (11.3%) in the medium-risk group, and 140 (11.1%) in the high-risk group. After multivariable adjustment and when compared with the low-risk group, there were no significant differences in the composite neonatal adverse outcome in the medium- (adjusted relative risk, 1.27; 95% confidence interval, 0.97-1.68) or the high-risk group (adjusted relative risk, 1.29; 95% confidence interval, 0.98-1.68).
Although 8 of 10 parturients categorized as high risk neither had blood loss ≥1000 mL nor underwent transfusion, the risk stratification provides information regarding the composite maternal hemorrhagic outcome.