Maternal obesity and postpartum haemorrhage after vaginal and caesarean delivery among nulliparous women at term: a retrospective cohort study
Increasing rates of postpartum haemorrhage in developed countries over the past two decades are not explained by corresponding changes in risk factors and conjecture has been raised that maternal obesity may be responsible. Few studies investigating risk factors for PPH have included BMI or investigated PPH risk among nulliparous women. The aim of this study was to determine in a cohort of nulliparous women delivering at term whether overweight and obesity are independent risk factors for major postpartum haemorrhage (PPH ≥1000ml) after vaginal and caesarean section delivery.
The study population was nulliparous singleton pregnancies delivered at term at National Women’s Hospital, Auckland, New Zealand from 2006 to 2009 (N=11,363). Multivariable logistic regression was adjusted for risk factors for major PPH.
There were 7238 (63.7%) women of normal BMI, 2631 (23.2%) overweight and 1494 (13.1%) obese. Overall, PPH rates were increased in overweight and obese compared with normal-weight women (n=255 [9.7%], n=233 [15.6%]), n=524 [7.2%], p <.001) respectively. There was an approximate twofold increase in risk in obese nulliparous women that was independent of confounders, adjusted odds ratio [aOR (95% CI)] for all deliveries 1.86 (1.51-2.28). Being obese was a risk factor for major PPH following both caesarean 1.73 (1.32-2.28) and vaginal delivery 2.11 (1.54-2.89) and the latter risk was similar after exclusion of women with major perineal trauma and retained placentae. Three additional factors were consistently associated with risk for major PPH regardless of mode of delivery: increasing infant birthweight, antepartum haemorrhage and Asian ethnicity.
Nulliparous obese women have a twofold increase in risk of major PPH compared to women with normal BMI regardless of mode of delivery. Higher rates of PPH among obese women are not attributable to their higher rates of caesarean delivery. Obesity is an important high risk factor for PPH, and the risk following vaginal delivery is emphasised. We recommend in addition to standard practice of active management of third stage of labour, there should be increased vigilance and preparation for PPH management in obese women.
- Rossen J, Okland I, Nilsen OB, Eggebo TM: Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions? Acta Obstet Gynecol Scand 2010,89(10):1248–1255. CrossRef
- Callaghan WM, Kuklina EV, Berg CJ: Trends in postpartum hemorrhage: United States, 1994–2006. Am J Obstet Gynecol 2010,202(4):353. e351–356 CrossRef
- Knight M, Callaghan WM, Berg C, Alexander S, Bouvier-Colle M-H, Ford JB, Joseph K, Lewis G, Liston RM, Roberts CL, et al.: Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth 2009, 9:55. CrossRef
- (CMACE) CfMaCE: Maternal obesity in the UK: Findings from a national project. London: CMACE; 2010.
- Ford JB, Roberts CL, Simpson JM, Vaughan J, Cameron CA: Increased postpartum hemorrhage rates in Australia. Int J Gynaecol Obstet 2007,98(3):237–243. CrossRef
- Joseph KS, Rouleau J, Kramer MS, Young DC, Liston RM, Baskett TF, Maternal Health Study Group of the Canadian Perinatal Surveillance S: Investigation of an increase in postpartum haemorrhage in Canada. BJOG 2007,114(6):751–759. CrossRef
- Heslehurst N, Simpson H, Ells LJ, Rankin J, Wilkinson J, Lang R, Brown TJ, Summerbell CD: The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications: a meta-analysis. Obes Rev 2008,9(6):635–683. CrossRef
- Sebire NJ, Jolly M, Harris JP, Wadsworth J, Joffe M, Beard RW, Regan L, Robinson S: Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London. Int J Obes Relat Metab Disord 2001,25(8):1175–1182. CrossRef
- Magann EF, Doherty DA, Briery CM, Niederhauser A, Chauhan SP, Morrison JC: Obstetric characteristics for a prolonged third stage of labor and risk for postpartum hemorrhage. Gynecol Obstet Invest 2008,65(3):201–205. CrossRef
- Combs CA, Murphy EL, Laros RK Jr: Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991,77(1):69–76.
- Driessen M, Bouvier-Colle M-H, Dupont C, Khoshnood B, Rudigoz R-C, Deneux-Tharaux C, Pithagore G: Postpartum hemorrhage resulting from uterine atony after vaginal delivery: factors associated with severity. Obstet Gynecol 2011,117(1):21–31. CrossRef
- Naef RW 3rd, Chauhan SP, Chevalier SP, Roberts WE, Meydrech EF, Morrison JC: Prediction of hemorrhage at cesarean delivery. Obstet Gynecol 1994,83(6):923–926. CrossRef
- Stones RW, Paterson CM, Saunders NJ: Risk factors for major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol 1993,48(1):15–18. CrossRef
- Blomberg M: Maternal obesity and risk of postpartum hemorrhage. Obstet Gynecol 2011,118(3):561–568. CrossRef
- Bergholt T, Lim LK, Jorgensen JS, Robson MS: Maternal body mass index in the first trimester and risk of cesarean delivery in nulliparous women in spontaneous labor. Am J Obstet Gynecol 2007,196(2):163. e161–165 CrossRef
- Fyfe E, Anderson N, North R, Chan E, Taylor R, Dekker G, McCowan L: Risk of First-Stage and Second-Stage Cesarean Delivery by Maternal Body Mass Index Among Nulliparous Women in Labor at Term. Obstet Gynecol 2011,117(6):1315–1322. CrossRef
- Zhang J, Bricker L, Wray S, Quenby S: Poor uterine contractility in obese women.[see comment]. BJOG 2007,114(3):343–348. CrossRef
- Raja UA, McAree T, Bassett P, Sharma S: The implications of a raised maternal BMI: a DGH experience. J Obstet Gynaecol 2012,32(3):247–251. CrossRef
- Global Database on Body Mass Index: BMI Classification. http://apps.who.int/bmi/index.jsp?introPage=intro_3.html.
- Women’s Hospitals Australasia: Supporting Excellence in Maternity Care: The Core Maternity Indicators Project. Turner, Australian Capital Territory: Women's Hospitals Australasia; 2007.
- Gilstrap ILC, Ramin SM: Postpartum hemorrhage. Clin Obstet Gynecol 1994,37(4):824–830. CrossRef
- Drife J: Management of primary postpartum haemorrhage. Br J Obstet Gynaecol 1997, 104:275–277. CrossRef
- Australasian Society for Ultrasound in Medicine: Statement on normal ultrasonic fetal measurements. In: Policies and Statements D7. 2007. http://www.asum.com.au/site/policies.php:ASUM;2001–2007.
- Australasian Society for Ultrasound in Medicine: Guidelines for the mid trimester obstetric scan. In Policies and Statements D2 2007. http://www.asum.com.au/site/policies.php:ASUM;2001–2007.
- Ministry of Health: Ethnicity Data Protocols for the Health and Disability Sector. Wellington: Ministry of Health; 2004.
- Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, Peek MJ, Rowan JA, Walters BN, Austalasian Society of the Study of Hypertension in P: The detection, investigation and management of hypertension in pregnancy: full consensus statement. Aust N Z J Obstet Gynaecol 2000,40(2):139–155. CrossRef
- Hoffman L, Nolan C, Wilson JD, Oats JJ, Simmons D: Gestational diabetes mellitus--management guidelines. The Australasian Diabetes in Pregnancy Society (updated Dec 2002). Med J Aust 1998,169(2):93–97.
- Chamberlain G: Turnbull's Obstetrics. 2nd edition. Edinburgh: Churchill Livingstone; 1995.
- National Centre for Classification in Health (Sydney): Australian Coding Standards for ICD-10_AM. 4th edition. Sydney: National Centre for Classification in Health; 2004. Volume 5
- Fernando RJ, Williams AA, Adams EJ: The Management of Third and Fourth Degree Tears. In vol. Green-top Guideline No. 29, 2007 edn. Royal College of Obstetricians and Gynaecologists; 2007.
- ADHB Policies and Procedures. http://adhbintranet/ADHB_Policies_and_Procedures/Clinical/National_Women's/Maternity/retained_placenta.htm.
- McCowan LM, Stewart AW, Francis A, Gardosi J: A customised birthweight centile calculator developed for a New Zealand population. Aust N Z J Obstet Gynaecol 2004,44(5):428–431. CrossRef
- Bateman BT, Berman MF, Riley LE, Leffert LR: The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg 2010,110(5):1368–1373. CrossRef
- Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B: Prevalence and risk factors of severe obstetric haemorrhage. BJOG 2008,115(10):1265–1272. CrossRef
- Bhattacharya S, Campbell DM, Liston WA, Bhattacharya S: Effect of Body Mass Index on pregnancy outcomes in nulliparous women delivering singleton babies. BMC Publ Health 2007, 7:168. CrossRef
- Mantakas A, Farrell T: The influence of increasing BMI in nulliparous women on pregnancy outcome. Eur J Obstet Gynecol Reprod Biol 2010,153(1):43–46. CrossRef
- World Health Organisation: WHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organisation. Italy: World Health Organisation; 2012.
- Athukorala C, Rumbold AR, Willson KJ, Crowther CA: The risk of adverse pregnancy outcomes in women who are overweight or obese. BMC Pregnancy Childbirth 2010, 10:56. CrossRef
- Haeri S, Guichard I, Baker AM, Saddlemire S, Boggess KA: The effect of teenage maternal obesity on perinatal outcomes. Obstet Gynecol 2009,113(2 Pt 1):300–304.
- Usha Kiran TS, Hemmadi S, Bethel J, Evans J: Outcome of pregnancy in a woman with an increased body mass index. BJOG 2005,112(6):768–772. CrossRef
- Doherty DA, Magann EF, Chauhan SP, O'Boyle AL, Busch JM, Morrison JC: Factors affecting caesarean operative time and the effect of operative time on pregnancy outcomes. Aust N Z J Obstet Gynaecol 2008,48(3):286–291. CrossRef
- Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M: Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. J Matern Fetal Neonatal Med 2005,18(3):149–154. CrossRef
- Magann EF, Evans S, Hutchinson M, Collins R, Lanneau G, Morrison JC: Postpartum hemorrhage after cesarean delivery: An analysis of risk factors. South Med J 2005,98(7):681–685. CrossRef
- Bais JMJ, Eskes M, Pel M, Bonsel GJ, Bleker OP: Postpartum haemorrhage in nulliparous women: incidence and risk factors in low and high risk women. A Dutch population-based cohort study on standard (> or = 500 ml) and severe (> or = 1000 ml) postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol 2004,115(2):166–172.
- Magann EF, Evans S, Hutchinson M, Collins R, Howard BC, Morrison JC: Postpartum hemorrhage after vaginal birth: an analysis of risk factors. South Med J 2005,98(4):419–422. CrossRef
- Combs CA, Murphy EL, Laros RK Jr: Factors associated with hemorrhage in cesarean deliveries. Obstet Gynecol 1991,77(1):77–82.
- Duthie S, Ven D, Yung G, Guang D, Chan S, Ma H-K: Discrepancy between laboratory determination and visual estimation of blood loss during normal delivery. Eur J Obstet Gynecol Reprod Biol 1990, 38:119–124. CrossRef
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/12/112/prepub
- Maternal obesity and postpartum haemorrhage after vaginal and caesarean delivery among nulliparous women at term: a retrospective cohort study
- Open Access
- Available under Open Access This content is freely available online to anyone, anywhere at any time.
BMC Pregnancy and Childbirth
- Online Date
- October 2012
- Online ISSN
- BioMed Central
- Additional Links
- Nulliparity obesity postpartum haemorrhage
- Author Affiliations
- 1. Department of Obstetrics and Gynaecology, University of Auckland, Private Bag, 92019, Auckland, New Zealand
- 2. Department of Paediatrics, University of Auckland, Private Bag, 92019, Auckland, New Zealand