(599) Differing clinical management for postpartum hemorrhage and associated risk for intensive care unit admission

Objective: Examine the risk of intensive care unit (ICU) admission associated with differing levels of care for postpartum hemorrhage (PPH) at 4 hospitals within 1 healthcare system.

Study Design: Retrospective study of patients with PPH from 2013-2023 without placenta accreta spectrum disorders. A unified EHR database was used with standardized definitions and diagnosis codes. PPH was defined by ≥1 of 3 criteria: ICD codes, estimated blood loss ≥1L, or postpartum blood transfusion. PPH treatment was examined in 2 ways as the exposure: (1) dichotomous variable comparing usual care (including oxytocin infusion and uterine massage) vs. additional treatment (carboprost, methylergonovine, misoprostol, tranexamic acid ± procedures) and (2) 4-way comparison between usual care vs. additional treatment further categorized into 3 groups: less aggressive medication (2 types with < 2 doses of either or 1 type with < 3 doses), more aggressive medication (≥3 types, 2 type with ≥2 doses of either, or 1 type with ≥3 doses), and procedures (intrauterine balloon, curettage, O’Leary or B-lynch sutures, uterine artery embolization, and/or hysterectomy ± medications). The outcome was ICU admission. Bivariable and multivariable logistic regression analyses were performed.

Results: Of 10,394 patients with PPH, 5047 (48.6%) had usual care and 5347 (51.4%) had additional treatment (3073 less aggressive medication use, 1347 more aggressive medication use, and 927 with procedures) (Table). In the dichotomous comparison, ICU admission risk was increased >2-fold with additional treatment vs. usual care. In the 4-way comparison, ICU admission risk increased with more aggressive treatment, with >7-fold increased risk with procedures vs. usual care. These increased odds persisted after adjusting for potential confounders. There was significant hospital-level variation in treatment patterns and risk for ICU admission.

Conclusion: Increasingly aggressive PPH treatment was associated with higher risks for ICU admission. Whether treatment differences indicate variability in quality of care or associate with other morbidities should be explored.