Despite lower mortality and shorter hospital stays, uterine artery embolization (UAE) is used far less commonly than hysterectomy in the management of clinically significant postpartum haemorrhage. This conclusion, presented at the Society of Interventional Radiology (SIR) annual meeting (20–26 March, online) by Janice Newsome (Emory University Hospital, Atlanta, USA), has led investigators to call for a postpartum haemorrhage response team, akin to a trauma response team. MD candidate Linzi Ardnt, also at Emory University Hospital, is the lead researcher for this work.
Speaking to press ahead of the annual meeting, Newsome expanded on her vision: “When our Ob-Gyn [Obstetrician and gynaecologist] colleagues make the decision to perform a hysterectomy, most of the time the estimated blood loss or the actual blood loss is under-calculated or unknown—so we are in a real dire situation at that point. Interventional radiologists are at many of these hospitals as well. So I believe, in order for UAE to become more utilised in these situations, we need to develop more techniques so we can find out earlier what the actual blood loss is, mobilise a team of people early so that these women can actually have this procedure [UAE] done, before a hysterectomy is chosen at the last minute. We are advocating for forming a postpartum haemorrhage team, so we can train together with our colleagues in Ob-Gyn—I believe that then, we can save more lives.”
Ardnt, Newsome et al picture the postpartum response team consisting of “anyone who cares for mothers and babies”, including anaesthesiologists, interventional radiologists, Ob-Gyns, and in some cases possibly neonatologists.
Contextualising this research, she stated: “Unfortunately, roughly 100,000 mothers will experience significant postpartum haemorrhage, a leading cause of the loss of life associated with childbirth”. The research identified 31 incidences of postpartum haemorrhage per 1,000 live births in the USA, of 9.8 million identified live births in total.
“Additionally,” Newsome continued, “20% of new mothers will have no risk factors. Because postpartum haemorrhage can occur quickly and threaten the life of the mother, the treatment options are sometimes limited. Currently, the most common treatment is just a transfusion [with an average incidence of 116.4 per 1,000 cases of postpartum haemorrhage]. But because physicians must act quickly, in many cases, the mother’s uterus is removed via hysterectomy.”
UAE represents an “underutilised”, less invasive second option, she explained, going on to note that the procedure has the benefit of being uterus-sparing, with quicker recovery times, and fewer adverse events.
The study investigators therefore set out to evaluate the utilisation and comparative effectiveness of hysterectomy versus UAE in patients with clinically significant postpartum haemorrhage requiring blood transfusion.
Using the Healthcare Cost and Utilisation Project Nationwide Inpatient Sample database from 2005 through 2017, they identified all women with live-birth deliveries who experienced clinically significant postpartum haemorrhage (defined as those receiving a blood transfusion only or transfusion plus hysterectomy or UAE). They utilised univariate analysis chi-square testing to determine demographic and clinical predictors of receipt of various therapies. Logistic regression was used to compare mortality and prolonged length of hospital stay (>14 days) for different treatment groups correcting for statistically significant predictors of receipt of various therapies.
The investigators noted that the incidence of hysterectomy to treat postpartum haemorrhage was significantly greater than incidence of UAE (20.4 vs. 12.9; p< 0.001). The following factors predicted the type of therapies received: race, maternal age, year of admission, elderly primigravida, previous or current caesarean section, breech position of foetus, placenta previa, pre-existing hypertension, pre-eclampsia, eclampsia, gestational diabetes, post-date pregnancy, premature rupture of membranes, cervical laceration, uterine rupture, dystocia, forceps delivery and haemorrhagic shock (all p<0.001).
Newsome noted: “We saw this disparity [between the number of hysterectomies and the number of UAEs] across racial lines and geography as well. Hysterectomy was twice as common as embolization in Latinx patients, and also more common in rural and non-teaching urban hospitals, as well as in the South [of the USA], and among Medicare and self-paying patients.
“Additionally, prolonged hospital stays of more than 14 days were twice as likely [2.1 times more likely with hysterectomy than UAE; p<0.001] in patients who had hysterectomies, and the hysterectomy procedure resulted in higher hospital charges—around US$18,000 more than if it were for UAE,” Newsome commented.
On logistic regression, the likelihood of mortality from hysterectomy was 3.1 times that of UAE (p< 0.001).
“Because of the evidence supporting UAE and benefits it provides to patients, we encourage hospitals to provide this treatment option to these women who may be at risk from postpartum haemorrhage. To do this, hospitals can create postpartum haemorrhage teams with an interventionalist, similar to other trauma teams, where we would train together and develop response protocols so they are better able to identify the risk factors o postpartum haemorrhage and ensure that the proper staff is on hand, for any delivery, and to be able to respond quickly, so that we can save mother’s lives before it goes too far, to the point where radical surgery is needed.”