Risk factors for postpartum hemorrhage after elective cesarean deliveries for twin pregnancies
Abstract
Objectives: To identify the high-risk factors associated with postpartum hemorrhage (PPH) after an elective cesarean delivery of twins. Material and methods: This retrospective cohort study included all women with twin gestations who chose to have an elective cesarean delivery after 28 weeks of gestation at at the Women’s Hospital, School of Medicine, Zhejiang University between September 2014 and April 2019. Women with an intrauterine fetal demise of one or both twins were excluded. PPH was defined as an estimated blood loss of ≥ 1,000 mL within 24 h of birth. A total of 532 women were analyzed and classified into the PPH group (n = 70) and the no-PPH group (n = 462). Univariate and multivariate logistic regression analyses were performed to assess the independent risk factors. Results: Among the 532 women pregnant with twins, PPH occurred in 13.2% women (n = 70). There were statistically significant differences in preeclampsia (p = 0.005), premature rupture of membrane (PROM, p < 0.001), placenta previa (p < 0.001), anemia [hemoglobin (Hb) < 100 g/L; p = 0.003], and antenatal magnesium sulfate (MgSO4) use (p < 0.001) between the two groups. However, the following were the independent risk factors for PPH after an elective cesarean delivery for a twin pregnancy: preeclampsia [odds ratio (OR): 2.91; 95% confidence interval (CI): 1.33–6.36], PROM (OR: 8.57; 95% CI: 2.54–28.89), placenta previa (OR: 9.46; 95% CI: 3.59–24.89), antenatal MgSO4 use (OR: 7.64; 95% CI; 3.18–18.41), and anemia (Hb < 100 g/L; OR: 2.68; 95% CI: 1.42–5.06). Conclusions: Preeclampsia, PROM, placenta previa,and antenatal MgSO4 use were the risk factors for PPH after an elective cesarean delivery for twin pregnancies. Risk factor identification and prevention should be a priority.
Keywords: elective cesarean deliverypostpartum hemorrhagerisk factorstwin pregnancies
References
- Slattery MM, Morrison JJ. Preterm delivery. Lancet. 2002; 360(9344): 1489–1497.
- Homola W, Florjański J, Królak-Olejnik B, et al. The impact of chorionicity and the type of twin growth on the early neonatal outcome in twin pregnancies - 20 years of experience from one tertiary perinatal center. Taiwan J Obstet Gynecol. 2019; 58(4): 482–486.
- Madar H, Goffinet F, Seco A, et al. EPIMOMS (EPIdémiologie de la MOrbidité Maternelle Sévère) Study Group. Severe acute maternal morbidity in twin compared with singleton pregnancies. Obstet Gynecol. 2019; 133(6): 1141–1150.
- Bateman BT, Berman MF, Riley LE, et al. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg. 2010; 110(5): 1368–1373.
- Santana DS, Cecatti JG, Surita FG, et al. WHO Multicountry Survey on Maternal and Newborn Health Research Network. Twin pregnancy and severe maternal outcomes: the World Health Organization multicountry survey on maternal and newborn health. Obstet Gynecol. 2016; 127(4): 631–641.
- Ekin A, Gezer C, Solmaz U, et al. Predictors of severity in primary postpartum hemorrhage. Arch Gynecol Obstet. 2015; 292(6): 1247–1254.
- Wikkelsø AJ, Hjortøe S, Gerds TA, et al. Prediction of postpartum blood transfusion — risk factors and recurrence. J Matern Fetal Neonatal Med. 2014; 27(16): 1661–1667.
- Suzuki S, Hiraizumi Y, Miyake H. Risk factors for postpartum hemorrhage requiring transfusion in cesarean deliveries for Japanese twins: comparison with those for singletons. Arch Gynecol Obstet. 2012; 286(6): 1363–1367.
- Suzuki S, Inde Y, Igarashi M, et al. Elective cesarean as a risk factor for transfusion after delivery of twins. J Nippon Med Sch. 2008; 75(4): 247–249.
- Suzuki S, Kikuchi F, Ouchi N, et al. Risk factors for postpartum hemorrhage after vaginal delivery of twins. J Nippon Med Sch. 2007; 74(6): 414–417.
- Lee HC, Gould JB, Boscardin WJ, et al. Trends in cesarean delivery for twin births in the United States: 1995-2008. Obstet Gynecol. 2011; 118(5): 1095–1101.
- Arabin B, Kyvernitakis I, Liao A, et al. Trends in cesarean delivery for twin births in the United States: 1995-2008. Obstet Gynecol. 2012; 119(3): 657–8; author reply 658.
- Minakami H, Watanabe T, Izumi A, et al. Association of a decrease in antithrombin III activity with a perinatal elevation in aspartate aminotransferase in women with twin pregnancies: relevance to the HELLP syndrome. J Hepatol. 1999; 30(4): 603–611.
- Taguchi T, Ishii K, Hayashi S, et al. Clinical features and prenatal risk factors for hypertensive disorders in twin pregnancies. J Obstet Gynaecol Res. 2014; 40(6): 1584–1591.
- Chen CL, Cheng Y, Wang PH, et al. Review of pre-eclampsia in Taiwan: a multi-institutional study. Zhonghua Yi Xue Za Zhi (Taipei). 2000; 63(12): 869–875.
- Baumfeld Y, Herskovitz R, Niv ZB, et al. Placenta associated pregnancy complications in pregnancies complicated with placenta previa. Taiwan J Obstet Gynecol. 2017; 56(3): 331–335.
- Ononge S, Mirembe F, Wandabwa J, et al. Incidence and risk factors for postpartum hemorrhage in Uganda. Reprod Health. 2016; 13: 38.
- Liu CN, Yu FB, Xu YZ, et al. Prevalence and risk factors of severe postpartum hemorrhage: a retrospective cohort study. BMC Pregnancy Childbirth. 2021; 21(1): 332.
- Miller EMS, Sakowicz A, Leger E, et al. Association between receipt of intrapartum magnesium sulfate and postpartum hemorrhage. AJP Rep. 2021; 11(1): e21–e25.
- Hunter LA, Gibbins KJ. Magnesium sulfate: past, present, and future. J Midwifery Womens Health. 2011; 56(6): 566–574.
- Pergialiotis V, Bellos I, Constantinou T, et al. Magnesium sulfate and risk of postpartum uterine atony and hemorrhage: A meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2021; 256: 158–164.
- Rukuni R, Bhattacharya S, Murphy MF, et al. Maternal and neonatal outcomes of antenatal anemia in a Scottish population: a retrospective cohort study. Acta Obstet Gynecol Scand. 2016; 95(5): 555–564.
- Omotayo MO, Abioye AI, Kuyebi M, et al. Prenatal anemia and postpartum hemorrhage risk: A systematic review and meta-analysis. J Obstet Gynaecol Res. 2021; 47(8): 2565–2576.
