Rising postpartum hemorrhage linked to higher costs and SMM

Rising postpartum hemorrhage linked to higher costs and SMM | Image Credit: © Meeko Media - © Meeko Media - stock.adobe.com.

Abnormal postpartum bleeding has a higher prevalence than previously reported, alongside a significant clinical and economic burden, according to a recent study published in Pregnancy.¹

Link Between PPH and severe maternal outcomes

Twelve percent of US maternal deaths have been linked to postpartum hemorrhage (PPH), which has also been linked to severe maternal morbidity (SMM) events such as intensive care unit (ICU) admission and hysterectomy, increasing hospital stay and health care costs.² A steady increase in incidence has also been observed in the United States.¹

“Understanding the treatment patterns and economic burden associated with PPH may help to optimize the management of this potentially life-threatening condition,” wrote investigators. Therefore, the study was conducted to assess treatment patterns, SMM events, and associated costs of abnormal postpartum uterine bleeding.

Obtaining PPH data

Data about deliveries between January 2016 and March 2022 was obtained from the PINC AI Healthcare Database (PHD). This included diagnoses, procedures, and products from over 1190 hospitals and health care systems.

Demographic data included race and ethnicity, age, and payer type, and diagnoses were determined using International Classification of Diseases (ICD-10) codes. Patients aged at least 15 years receiving at least one second-line uterotonic (UT) medication beyond oxytocin within the PHD were included in the analysis.

Patients with at least 1 ICD-10 code for PPH were classified as cases. Exclusion criteria included ectopic pregnancy, abortion, hydatidiform mole, and other abnormal products of conception.

Billing codes were assessed to determine treatment patterns for UTs and tranexamic acid (TXA) during the index hospitalization. ICD-10 codes were used to identify nonsurgical treatments and surgical interventions utilized among participants.

Health care resource utilization metrics

Total hospital length of stay (LOS), admission to ICU, ICU length of stay, and receipt of blood transfusion were reported as health care resource utilization measures. These were analyzed in the overall study population and specific subgroups.

Investigators also assessed total hospital costs, including medical procedures, hospital services, drugs, supplies, equipment fees, and diagnostic evaluations. These costs were reported on a hospital level.

PPH incidence and patient characteristics

There were 5,345,753 deliveries reported during the study period, 787,964 of which were to patients diagnosed with PPH or UT use. These patients were aged a mean of 29.0 ± 6.0 years.

Of patients with PPH or UT use, 50.7% were non-Hispanic White, 14.8% had traditional Medicaid and 30.2% Medicaid managed care, 65.7% delivered vaginally and 34.1% through cesarean section, and 95% used oxytocin. A mean SMM comorbidity score of 6.8 and a nontransfusion SMM comorbidity score of 8.5 were reported.

These comorbidity scores indicated a moderate overall burden of risk factors for maternal health. Age over 35 years, preexisting anemia, and prior cesarean delivery were the most common comorbidities, with rates of 18.8%, 17.3%, and 14.8%, respectively.

A PPH diagnosis or second-line UTs or TXA use was reported in 14.7% of patients. UTs or TXA were provided without a PPH diagnosis code to 11.3% of patients, while 2.6% received these therapies and had a PPH diagnosis, and 0.8% had only a PPH diagnosis.

Treatment and diagnosis trends over time

An increase in the prevalence of having PPH or receiving second-line UTs or TXA was reported over time, from 12.1% in 2016 to 19.7% in 2022. For second-line UTs or TXA use alone, rates were 9.4% and 15.4%, respectively. In comparison, rates of PPH diagnosis only were 2.7% and 4.3%, respectively.

The most common method of treatment was to use a single UT or TXA, reported in 70.3% of patients. The odds of using multiple UTs and TXA combinations were increased in patients with PPHs, with 18% of patients using 2 combinations and 6% using 3 or more.

Only 0.6% of patients received hysterectomy, and 0.3% received uterine artery embolization. More common treatments included methylergonovine maleate in 51.9% of patients and misoprostol 800 µg or higher in 47%.

Hospitalization costs and SMM correlation

A total mean cost during the index hospitalization of $9693 was reported. This cost was $7939 in patients with vaginal delivery vs $13,072 in those with cesarean delivery. These costs increased in patients receiving UT and TXA administrations, ranging from $7576 to $10,084 in vaginal deliveries and $12,279 to $16,288 in cesarean deliveries.

Overall, the hospital LOS was not significantly impacted by UTs or TXA administration, with a mean of 2.4 ± 1.8 days in the overall study population. However, an increase was observed in patients with 3 to 4 UT or TXA administrations. Finally, increasing use of UTs or TXA were linked to higher rates of SMM, such as blood transfusion and ICU admission.

“Overall, these results highlight the need for appropriate intervention, improved treatment options, and preventive strategies to better manage obstetric bleeding and reduce the burden of PPH,” wrote investigators.

References:

1. Rood KM, Yong C, Carney PI, et al. Treatment patterns and costs among hospital births with abnormal postpartum uterine bleeding and postpartum hemorrhage in the United States (2016–2022). Pregnancy. 2025. doi:10.1002/pmf2.70050
2. Corbetta-Rastelli CM, Friedman AM, Sobhani NC, Arditi B, Goffman D, Wen T. Postpartum hemorrhage trends and outcomes in the United States, 2000-2019. Obstet Gynecol. 2023;141(1):152-161. doi:10.1097/AOG.0000000000004972