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observed OR effects are consistent in
both groups and therefore suggest a possible benefit of using both therapies
together.
If 17P prevented cervical shortening
from occurring, then women who responded best to 17P might never have
developed a CL 25 mm and therefore
this study may have inadvertently selected for women who are not responders to 17P. In them, this would
obviate ultrasound-indicated cerclage
and justify using both approaches (17P
for prior SPTB; cerclage for short CL) for
prevention of PTB in women with a
prior SPTB.

CLINICAL IMPLICATIONS

In women with a prior spontaneous

preterm birth (PTB), a transvaginal
ultrasound (TVU) cervical length
(CL) 25 mm 23 weeks, and no cerclage, 17-alpha-hydroxyprogesterone
caproate (17P) given for the prior
PTB reduced previable birth and perinatal mortality.
In women with a prior spontaneous
PTB and a TVU CL 25 mm 23
weeks who received ultrasound-indicated cerclage, 17P was associated
with similar trends, but not to a statistically significant extent, for benefits

Research

in PTB outcomes and perinatal

mortality.
Women with a prior spontaneous
PTB should be offered 17P starting at
16 weeks and then cerclage if their
TVU screening reveals the CL to be
f
25 mm 23 weeks.

ACKNOWLEDGMENTS
Other members of the Vaginal Ultrasound Trial
Consortium: Robert S. Egerman, MD; Mark
Tomlinson, MD; Richard Silver, MD; Susan M.
Ramin, MD; Michael Gordon, MD; Helen Y.
How, MD; Eric J. Knudtson, MD; Suzanne
Cliver, MSPH; John C. Hauth, MD.

Trends in postpartum hemorrhage: United States, 1994 2006

William M. Callaghan, MD, MPH; Elena V. Kuklina, MD, PhD; Cynthia J. Berg, MD, MPH
OBJECTIVE: The purpose of this study was to estimate the incidence of

postpartum hemorrhage (PPH) in the United States and to assess trends.

STUDY DESIGN: Population-based data from the 1994 2006 National
Inpatient Sample were used to identify women who were hospitalized
with PPH. Data for each year were plotted, and trends were assessed.
Multivariable logistic regression was used in an attempt to explain the
difference in PPH incidence between 1994 and 2006.
RESULTS: PPH increased 26% between 1994 and 2006 from 2.3%
(n 85,954) to 2.9% (n 124,708; P .001). The increase primarily

was due to an increase in uterine atony, from 1.6% (n 58,597) to

2.4% (n 99,904; P .001). The increase in PPH could not be explained by changes in rates of cesarean delivery, vaginal birth after cesarean delivery, maternal age, multiple birth, hypertension, or diabetes
mellitus.
CONCLUSION: Population-based surveillance data signal an apparent
increase in PPH caused by uterine atony. More nuanced clinical data
are needed to understand the factors that are associated with this trend.

Cite this article as: Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum hemorrhage: United States, 1994 2006. Am J Obstet Gynecol 2010;202:353.e1-6.

B ACKGROUND AND O BJECTIVE

Postpartum hemorrhage (PPH) is a frequent complication of pregnancy and
among the most common causes of
pregnancy-related death in the United
States. Recent reports demonstrated a

rising trend in severe maternal morbidity

during US delivery hospitalizations that
was attributable largely to the increased use
of blood transfusions. In addition, data

From the Divisions of Reproductive Health (Drs Callaghan and Berg) and Heart Disease and
Stroke Prevention (Dr Kuklina), Centers for Disease Control and Prevention, Atlanta, GA.
Presented in part at a meeting of the International Postpartum Haemorrhage Collaborative Group
in Montreal, QC, Canada, Nov. 10, 2008.
The findings and conclusions in this report are those of the authors and do not necessarily
represent the official position of the Centers for Disease Control and Prevention.
Authorship and contribution to the article is limited to the 3 authors indicated. There was no
outside funding or technical assistance with the production of this article.

from Canada and Australia indicate recent

increases in PPH rates, and aggregate US
data show that the percentage of women
whose discharge records contained International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
codes for PPH increased from 2.0% in
19931997 to 2.6% in 20012005.
As a first step to better understanding the
problem of PPH in the United States, we undertook a descriptive analysis of US population-based administrative hospital discharge
data to examine trends in PPH, with special
attentiontothecontributionofuterineatony
and associated obstetric factors.

0002-9378/free Published by Mosby, Inc. doi: 10.1016/j.ajog.2010.01.011

For Editors Commentary, see Table of Contents

M ATERIALS AND M ETHODS

Data for this investigation were obtained
from the Nationwide Inpatient Sample
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The percentage of delivery hospitalizations with the ICD-9-CM code for uterine atony varied by the mode of delivery
and whether pregnancy was induced
(Figure). The highest rate of uterine atony occurred among women whose labor was induced and who delivered vaginally. This was followed by women
whose induction ended in cesarean delivery and women who had vaginal births
without induction of labor. Women who
had cesarean deliveries and did not have
induced labor consistently had the lowest rates of PPH caused by atony.

FIGURE

Annual rates of postpartum hemorrhage caused by atony, by mode

of delivery, and by induction status (United States, 1994 2006)
4

3.5

Percent of deliveries

2.5

1.5

Vaginal induced
Cesarean induced
Vaginal not induced
Cesarean not induced
All atony

0.5

0
1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Callaghan. Trends in postpartum hemorrhage. Am J Obstet Gynecol 2010.

(NIS) for 1994 2006. The NIS is part of

the Healthcare Cost and Utilization
Project of the Agency for Healthcare Research and Quality. Details of the NIS have
been described elsewhere. The database
contains 15 diagnosis fields and 15 procedure fields for each discharge; diagnoses
and procedures are coded at the hospital at
discharge with ICD-9-CM codes.
Except for age, the NIS does not collect
individual demographic information, nor
does it report obstetric characteristics for
individual pregnancies, except those that
can be translated to ICD-9-CM codes.
Cases of uterine atony at delivery were
identified by the 5-digit code 666.1X. All
other PPH was identified by the codes
666.0X (retained, trapped, or adherent
placenta), 666.2X (delayed and secondary
PPH), and 666.3X (postpartum coagulation defects). We collapsed the latter 3
codes (for cases of PPH not attributable to
uterine atony) into a single category labeled other hemorrhage.
In an attempt to explain trends in rates,
we used logistic regression to model uterine atony as a function of time, maternal
age, induced labor, cesarean delivery, multiple birth, hypertension during pregnancy, diabetes mellitus during pregnancy, and hospital location and
characteristics. We compared rates of uter354

ine atony in 2006 with those in 1994 for

each mode of delivery after age, standardizing the 2006 rate to the age distribution of
women who delivered in 1994.

R ESULTS
From 1994 2006, the NIS collected data
on 10,481,197 delivery hospitalizations,
which represented a weighted estimate
of 51,674,542 delivery hospitalizations in
the United States during that period;
2.7% of women who were discharged after delivery during that period received a
code for PPH. Three-fourths of these
women were identified by the presence
of the single code for uterine atony.
From 1994 through 2006, the percentage of deliveries with a code for PPH increased by 26%, from 2.3% (85,954 deliveries) to 2.9% (124,708 deliveries; test
of trend, P .001). There was a parallel
increase in PPH caused by atony during
this same time period, from 1.6%
(58,597 cases) to 2.4% (99,904 cases; P
.001). Delivery hospitalizations with
PPH codes not caused by atony did not
increase (P .05). Multivariable logistic
regression with simultaneous adjustment showed no significant effect of
many variables on the change in the risk
for PPH between 1994 and 2006.

American Journal of Obstetrics & Gynecology APRIL 2010

C OMMENT
The percentage of US women whose
hospital discharge records after a delivery contained ICD-9-CM codes for PPH
increased substantially between 1994
and 2006. This increase was driven primarily by an increase in the percentage of
women with an ICD-9-CM code for
uterine atony and occurred for vaginal
and cesarean deliveries regardless of induction status.
Although the increase that we found in
the reported rate of PPH caused by uterine
atony could have alternative explanations
(such as changes in coding practices,
changing definitions of the event, or a general increased awareness and documentation of the event), our findings are consistent with those of other recently published
reports. Over a similar time period and using similar methods, Joseph et al reported
an increase in PPH from 4.15.1% in Canada that largely was due to an increase in
the rate of uterine atony; adjustments for
changes in the prevalence of PPH risk factors did not explain the increase. A similar
increase in PPH rates from 1994 through
2002 was reported in New South Wales,
Australia.
It is unknown how variation in the
definition of PPH or in how blood loss is
estimated affects variation in coding or
how medical coders use narrative in the
medical record, checkboxes in labor and
delivery summaries, and written estimates to arrive at a coded diagnosis for
uterine atony.
Prevention of PPH remains a challenge.
Risk factors that include high infant birthweight, induced labor, chorioamnionitis,

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and multiple gestations are well established
but have only moderate positive predictive
value for PPH caused by uterine atony and
hence are of limited clinical value. The extent to which active management occurs in
the United States is not known. Secondary
prevention of hemorrhage relies on the accurate and timely estimation of blood loss
in real time. Researchers who use simulation exercises have reported improvements in estimates of maternal blood loss
during delivery.

Taken together with similar reports

from other countries with well-developed systems for delivery of health services, the apparent increase in PPH in
recent years suggests an emerging threat
to women during labor and delivery.

CLINICAL IMPLICATIONS

The apparent increased incidence

of postpartum hemorrhage in the

Research

United States makes increased knowledge of risk factors and management

strategies for postpartum hemorrhage
caused by atony more important than
ever before.
Research to improve the clinical estimate of blood loss is needed.
Standardizing the definitions for
postpartum hemorrhage should be
considered.
f

Frequent epidural dosing as a marker for impending

uterine rupture in patients who attempt
vaginal birth after cesarean delivery
Alison G. Cahill, MD, MSCI; Anthony O. Odibo, MD, MSCE; Jenifer E. Allsworth, PhD;
George A. Macones, MD, MSCE, Associate Editor
OBJECTIVE: The purpose of this study was to estimate the association

RESULTS: Of 804 women in the nested case-control study, 504 women

between epidural dosing and the risk of uterine rupture in women who
attempt vaginal birth after cesarean delivery (VBAC).
STUDY DESIGN: A nested case-control study within a multicenter retrospective cohort of 25,000 women with previous cesarean delivery
compared cases of uterine rupture with women without rupture (control
subjects) while attempting VBAC with epidural anesthesia. Dose timing,
frequency, and quantity were compared. Time-to-event analyses were
performed to estimate the association between epidural dosing and risk
for uterine rupture while accounting for labor duration.

(62.7%) had epidural anesthesia, with no statistical difference in epidural

usage rates between cases and control subjects (70.4% vs 62.4%; P
.09). Cox-regression analysis revealed a dose-response relationship between the number of epidural doses and uterine rupture risk: 1 dose (hazard
ratio, 2.8; 95% confidence interval [CI], 1.4 5.7), 2 doses (hazard ratio,
3.1; 95% CI, 2.2 6.2), 3 doses (hazard ratio, 6.7; 95% CI, 3.8 12.1), 4
doses (hazard ratio, 8.1; 95% CI, 5.4 18.2).
CONCLUSION: Clinical suspicion for uterine rupture should be high in
women who require frequent epidural dosing during a VBAC trial.

Cite this article as: Cahill AG, Odibo AO, Allsworth JE, et al. Frequent epidural dosing as a marker for impending uterine rupture in patients who attempt vaginal
birth after cesarean delivery. Am J Obstet Gynecol 2010;202:355.e1-5.

B ACKGROUND AND O BJECTIVE

From the Department of Obstetrics and
Gynecology, Washington University in St.
Louis School of Medicine, St. Louis, MO.
Presented orally at the 30th Annual Meeting of
the Society for Maternal-Fetal Medicine,
Chicago, IL, Feb. 1-6, 2010. The racing flag
logo above indicates that this article was
rushed to press for the benefit of the scientific
community.
Supported in part by the National Institute of
Child Health and Human Development Grant
no. R01 HD 35631 (G.A.M.).
0002-9378/free
2010 Published by Mosby, Inc.
doi: 10.1016/j.ajog.2010.01.041

Attempting vaginal delivery after previous cesarean delivery (VBAC) remains an important delivery option for
women with such a history. Physicians
who manage VBAC attempts take great
care to identify the classically described signs and symptoms of uterine
rupture, including fetal heart rate abnormalities, pain, vaginal bleeding,
loss of fetal station, and maternal hemodynamic instability. However, in
the setting of epidural use, maternal
pain from uterine rupture may be
blunted and result in the loss of this
objective measure.

We undertook this study to test the hypothesis that dosing patterns were related directly to the risk of uterine rupture and specifically that women who
attempt VBAC with epidural anesthesia
still sensed pain, as measured by an increase in number of epidural doses before rupture.

M ATERIALS AND M ETHODS

A nested case-control study was conducted in 1999-2005 within a 17-center
retrospective cohort study of pregnant
women with at least 1 previous cesarean
delivery. The parent cohort study was
designed to estimate the maternal risks

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