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ABSTRACT
Article history:
Objectives: 1) Describe the distribution of heart rate in the rst 48 h postpartum in women with no
evidence of sepsis, anaemia or haemorrhage. 2) Investigate the relationship between postpartum heart
rate and other maternal factors.
Study design: A retrospective cross-sectional study of postpartum women who delivered between July
2012 and June 2015 in a tertiary hospital. Data was analysed from the local maternity system and
electronic vital signs database. The main outcome measures: Heart rate at 6, 12, 24 and 48 h postpartum.
Results: Data were obtained on 11401 women. After exclusion of women with possible sepsis, anaemia or
haemorrhage, 7627 heart rate readings from 5164 women were analysed. Mean heart rate (+2SD/+3SD) at
6 h was 83.6 (108.2/120.6), 12 h 84.5 (109.4/121.9), 24 h 85.4 (110.4/122.9), and 48 h 84.3 (109.7/122.4).
There was statistical correlation of post partum heart rate with body mass index (BMI), age and discharge
haemoglobin.
Conclusion: This study describes the distribution of maternal heart rate in the early postpartum period, in
women with no evidence of sepsis, anaemia or major haemorrhage. This will facilitate identication and
appropriate investigation of women with abnormal heart rates. Although correlation with BMI, age and
discharge haemoglobin was demonstrated, the differences were small and not clinically meaningful.
Further work investigating the relationship between postpartum heart rate and poor maternal outcomes
is required.
2016 Elsevier Ireland Ltd. All rights reserved.
Keywords:
Postpartum
Tachycardia
Heart rate
Introduction
Throughout pregnancy and the puerperium signicant cardiovascular changes occur. Maternal heart rate increases by approximately 20% from the pre-conception baseline to the third trimester
of pregnancy [1,2], with a further increase during labour [3]. Whilst
these changes are well understood, the changes in the postpartum
period are less well dened. Studies show maternal heart rate
returns to baseline weeks to months post-delivery [47], yet the
* Corresponding author.
E-mail address: jacksamways1991@googlemail.com (J.W. Samways).
ttp://dx.doi.org/10.1016/j.ejogrb.2016.08.040
0301-2115/ 2016 Elsevier Ireland Ltd. All rights reserved.
42
J.W. Samways et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 206 (2016) 4147
the
distribution
of heart
rate
in the
rst
48 h
non-
Data grouping
BMI
Study design
Data were
collected
retrospectively
from
all women
who
Data source
Maternal age and BMI at booking, puerperal blood loss, method
of delivery, discharge haemoglobin and length of hospital stay
were sourced from the maternal
database
(CMIS, Advance
1
Learning , Derby, UK). Patient observations (temperature and
heart rate observations at 6, 12, 24 and 48 h postpartum [1 h])
were sourced from the electronic vital signs and MEOWS database
delivering
on the
midwifery
lead
unit
were
not
onto Patientrack .
All women in whom tachycardia may have been due to sepsis,
haemorrhage or anaemia were excluded. Sepsis was excluded by
removing women with a recorded temperature outside of 36
38.3 C during their hospital stay (in line with the International
Guidelines on Management of Severe Sepsis & Septic Shock:
2012 [18]). Haemorrhage and anaemia were accounted for by
excluding results from women whose puerperal blood loss was
!1000 ml
(Royal College of Obstetricians
& Gynaecologists
guidelines for major postpartum haemorrhage [19]) or whose
discharge haemoglobin was <100 g/l (British Society of Haematology guidelines on maternal and postpartum anaemia [20]).
Statistical analyses
1
Statistical analyses were performed using IBM SPSS Statistics 22 (The International Business Machines Corporation1, New
York, NY, USA).
Central tendency for heart rate at each time period postpartum
(6, 12, 24 and 48 h) was calculated using the mean (m). Spread was
calculated using standard deviation (SD) and suggested normal
range upper thresholds were calculated using the mean in addition
to two and three standard deviations (m + 2SD, m + 3SD).
J.W. Samways et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 206 (2016) 4147
43
Fig. 1. Histograms demonstrating the normal distribution of heart rate with x-intercepts at 2 and 3 standard deviations from the mean (A: 6 h postpartum; B: 12 h
postpartum; C: 24h postpartum; D: 48 h postpartum).
Table 1
Mean (m) and standard deviation (SD) of maternal heart rate a 6, 12, 24 and 48 h postpartum in the included and excluded cohorts.
Time postpartum (h)
Included cohort
Excluded cohort
Temperature > 38.3, <36 C
6
12
24
48
2677
2630
1896
424
83.6
85.5
85.4
84.3
12.3
12.5
12.5
12.7
2144
1913
1507
367
82.4
83.4
86.7
85.5
13.7
13.7
14.2
12.6
Total
7627
84.4 12.5
5931
84.0 13.9
382
486
505
169
85.0 13.7
87.2 13.9
90.3 14.3
88.5 13.4
1486
1502
1434
485
86.0 14.3
87.9 14.5
90.8 14.2
88.6 12.7
1542
87.8 14.1
4907
88.2 14.3
Table 2
Mean (m), standard deviation (SD) and upper limit of normal (m + 2SD, m + 3SD) maternal heart rate at 6, 12, 24 and 48 h postpartum.
Total
44
6
12
24
48
SD
p Value
m + 2SD
m + 3SD
2677
2630
1896
424
83.6
84.5
85.4
84.3
12.3
12.5
12.5
12.7
<0.001
108.2
109.4
110.4
109.7
120.6
121.9
122.9
122.4
7627
84.4
12.5
109.3
121.8
J.W. Samways et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 206 (2016) 4147
Table 3
Baseline characteristics of women split into cohorts according to hours postpartum.
Variable
Age (years)
2
BMI (kg/m )
Method of delivery
Non-instrumental vaginal
Caesarean section
Instrumental vaginal
7627
7436
3999
2534
1094
7627
5071
Hours postpartum
p Value
12
24
48
29.9 5.6
26.0 6.4
1391 (52.0)
911 (34.0)
375 (14.0)
286 234
114 10
29.9 5.6
26.0 6.4
1432 (54.4)
833 (31.7)
365 (13.9)
288 234
114 10
30.0 5.6
25.9 6.5
985 (52.0)
627 (33.1)
284 (15.0)
294 240
114 10
30.4 6.1
25.9 6.4
191 (45.0)
163 (38.4)
70 (16.5)
305 240
112 9
Values are mean standard deviation or n (%) and compared with one way ANOVA or Chi-squared tests respectively. BMI, body mass index; Hb, haemoglobin.
0.273
0.881
0.020
0.324
0.009
BMI
Data for BMI were missing for 191 readings from the 7627,
thus leaving 7436 readings across all time intervals postpartum (6,
12, 24 & 48 h).
The mean heart rate was 83.2 bpm in underweight, 83.2 ideal
weight, 84.9 in overweight, 86.3 in obese I, 85.1 in obese II and 87.9
in obese III women (Table 4) (p < 0.001, observed power = 1.000).
Age
The mean heart rate was 86.7 in women less than 20 years old,
85.1 in 2029 years old, 83.6 in 3039 years old and 84.4 in
!40 years old (p < 0.001, observed power = 1.000) (Table 4).
Table 4
The observed effect of potentially confounding factors (body mass index, maternal age, puerperal blood loss, discharge haemoglobin, method of delivery and length of stay) on
mean (m) postpartum heart rate between 6 and 48 h.
Variables
2
<18.5 (underweight)
18.524.9 (ideal weight)
2529.9 (overweight)
3034.9 (obese I)
3539.9 (obese II)
!40 (obese III)
<20
Method of delivery
p Value
304
3051
2284
1158
443
196
83.2
83.2
84.9
86.3
85.1
87.9
<0.001
<0.001
247
86.7
2029
3039
!40
3300
3734
346
85.1
83.6
84.4
100
2278
85.1
100199
200299
300399
400499
500599
600699
700799
800899
900999
891
1298
1094
983
468
277
234
99
5
82.6
83.4
83.9
84.7
86.3
84.8
85.6
86.1
85.8
100109
2175
85.7
110119
120129
130139
140149
!150
1694
832
294
61
15
84.5
85.2
84.1
84.1
87.7
Non-instrumental vaginal
3999
83.9
Caesarean section
Instrumental vaginal
2534
1094
84.7
85.5
2180
83.1
2
3
4
5
6
!7
2047
1224
757
510
329
580
84.0
85.4
85.3
85.7
85.2
85.7
7627
84.4
Total
<0.001
0.044
0.002
<0.001
J.W. Samways et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 206 (2016) 4147
of the
heart
rate
readings
had
missing
entries
for
discharge haemoglobin.
It was not hospital policy to take a
postpartum
haemoglobin
measurement
unless indicated. This
45
the
study
provides
sound
statistical
basis
fo
r
postpartum EWS development, it has not yet been correlated with
outcome measures i.e. morbidity or mortality. Therefore despite
being able to suggest thresholds for abnormality, this study does
not
help
predict
the
likelihood
of
underlying
pathology
if
a
tachycardia is detected. Even with a cohort this size, this is not
possible since serious maternal morbidity and mortality are rare
outcomes.
Each heart rate reading was treated separately, therefore any
women
with
multiple
readings
would
have
multiple
entries
(maximum of 4) for the independent variables (e.g. BMI, age,
delivery method, etc.) and thus would be over represented within
46
J.W. Samways et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 206 (2016) 4147
that variable when combining the postpartum heart rate data for
all time intervals (6, 12, 24 and 48 h). Given the signicantly lower
rate of non-instrumental vaginal deliveries at 48 h, this may have
led to women who had Caesarean section and instrumental vaginal
deliveries being overrepresented.
Whilst the studys dataset size is a strength,
it meant
statistically signicant differences between groups were identied
despite small margins. Some of these differences are unlikely to be
clinically signicant.
Data were collected retrospectively, thus with no standard way
of measuring heart rate identied; both electronic and manual
recordings were included. However, this reects past and current
practice within the unit.
Use of medication at the time the heart rates were recorded was
not considered in this study. Negatively chronotropic drugs such as
beta blockers, commonly prescribed to postpartum women with
hypertension [34,35], could lower heart rate and thus skew the
data.
All women in the study came from one tertiary centre for
obstetrics, where women with pre-existing medical conditions
may be overrepresented. Furthermore, this study looked at heart
rates up to 48 h postpartum;
the cohort studied at 48 h in
particular, may include a greater proportion
of women with
medical problems as healthy women with healthy babies may have
already been discharged.
Conclusion
We have
reported
heart
rate
data
at 6, 12,
24 and
48 h
for conducting
the data
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