A USF Health-Tampa General Hospital study suggests different management protocols may be needed for obese vs. nonobese patients to improve maternal outcomes

TAMPA, Fla (Dec. 21, 2020) — Postpartum hemorrhage, or excessive bleeding after delivery, is still one of the leading causes of severe maternal injury and death in the United States. And the rise in obesity among pregnant women has been linked to increased rates of this potentially serious, largely preventable obstetric complication.

As part of an academic medical center initiative to improve maternal health, researchers at the University of South Florida Health (USF Health) and Tampa General Hospital (TGH) examined how obesity affected the management and outcomes of postpartum hemorrhage at a tertiary care center. Their findings were published Oct. 14 in the American Journal of Perinatology.

“This study showed that we managed postpartum hemorrhage the same way for women who were obese and those who were not. That’s good overall – but the same medical treatment is not always equitable because the obese women still experienced worse outcomes,” said study senior author Judette Louis, MD, MPH, the James Ingram Endowed Professor and chair of Obstetrics and Gynecology at the USF Health Morsani College of Medicine and co-medical director of Women’s and Children’s Services at TGH. “It highlights that certain groups of high-risk obstetric patients, such as obese women, may need some additional support or a different treatment protocol for postpartum hemorrhage.”

The researchers conducted a retrospective analysis of all deliveries complicated by postpartum hemorrhage from February 2013 through January 2014 – about 2.6% of the hospital’s 9,890 deliveries during that period (a rate consistent with the national average). Controlling for confounding variables, they compared two groups of patients treated for postpartum hemorrhage: obese women (a body mass index of 30 or higher) and nonobese women (BMI characteristic of normal weight or overweight). Both groups were similar in age, race, insurance status, and alcohol and tobacco use.

Judette Louis, MD, MPH, is a USF Health maternal-fetal medicine specialist at Tampa General Hospital.

Among the study’s key findings:

• Obese patients were more likely to have had cesarean deliveries, a risk factor for hemorrhage complications, than nonobese patients.
• Both groups were equally likely to receive the same medications (carboprost, methylergonovine and misoprostol) to treat excessive blood loss, but obese women tended to receive more than one of these uterotonic agents. The medications are administered to induce contractions when the uterus does not contract enough to shrink to normal size after childbirth. This condition, known as uterine atony, is a primary cause of postpartum hemorrhage.
• Despite similar management, obese women experienced more of any severe hemorrhage-related complications (including shock, renal failure, transfusion-related lung injury, and cardiac arrest), and they were more apt to sustain more than one of the serious complications.
• While the need for blood transfusion was similar for both groups, obese women were more likely to have greater blood loss and require more units of transfused blood. “Hemorrhage-related complications are largely driven by blood loss and the number of units of blood transfused,” said Dr. Louis, a USF Health maternal-fetal medicine specialist at TGH.
• Although obese women were more often transferred to the operating room, the rates of intrauterine pressure balloon tamponade (a device used to promote uterine contraction), interventional radiology procedures, or hysterectomy were no different for obese and nonobese women.

Some basic science and clinical studies investigating uterine contractions during labor indicate obesity can impair uterine tone, so that the reproductive organ may not react as quickly or well to contraction-inducing medications. The underlying reasons for this are undefined, but a disruption of the hormonal balance in obese women may contribute to the impaired uterine response to control bleeding, Dr. Louis said. “Perhaps they need a higher dose of uterotonic agents, or the order in which the medications are administered should be changed to work more effectively for them.”

The USF Health-TGH study points to the need for larger, multisite studies to better understand the different responses to treatment protocols for postpartum hemorrhage in obese women, she added. That includes looking into the possible physiological connections between obesity, pharmacokinetics of the treatment (how the body processes medications) and the impact on uterine atony.

“With higher rates of obesity affecting higher numbers of pregnant women each year, it is important to evaluate how this is affecting the management of obstetric complications,” the study authors conclude. “This study shows that despite similar (postpartum hemorrhage) management, key differences do exist in outcomes based on obesity status. There are numerous directions for future research… many of which have the potential for significant clinical implications and improvement of maternal outcomes.”

ABOUT USF HEALTH
USF Health’s mission is to envision and implement the future of health. It is the partnership of the USF Health Morsani College of Medicine, the College of Nursing, the College of Public Health, the Taneja College of Pharmacy, the School of Physical Therapy and Rehabilitation Sciences, the Biomedical Sciences Graduate and Postdoctoral Programs, and USF Health’s multispecialty physicians group. The University of South Florida is a high-impact global research university dedicated to student success. Over the past 10 years, no other public university in the country has risen faster in U.S. News & World Report’s national university rankings than USF. For more information, visit health.usf.edu

ABOUT TAMPA GENERAL HOSPITAL
Tampa General Hospital, a 1006-bed non-profit academic medical center, is one of the largest hospitals in America and delivers world-class care as the region’s only center for Level l trauma and comprehensive burn care. It is one of the nation’s busiest adult solid organ transplant centers and is the primary teaching hospital for the USF Health Morsani College of Medicine. With five medical helicopters, Tampa General Hospital transports critically injured or ill patients from 23 surrounding counties to receive the advanced care they need. Tampa General houses a nationally accredited comprehensive stroke center and its 32-bed Neuroscience Intensive Care Unit is the largest on the West Coast of Florida. It also is home to the Jennifer Leigh Muma 82-bed Level IV neonatal intensive care unit, and a nationally accredited rehabilitation center. Tampa General Hospital’s footprint includes 17 Tampa General Medical Group Primary Care offices, TGH Family Care Center Kennedy, TGH Brandon Healthplex, TGH Virtual Health and 19 outpatient Radiology Centers. Tampa Bay residents also receive world-class care from the TGH Urgent Care powered by Fast Track network of clinics, and they can even receive home visits in select areas through TGH Urgent Care at Home, powered by Fast Track.  As one of the largest hospitals in Florida, Tampa General Hospital is first in the state to partner with GE Healthcare and open a clinical command center that uses artificial intelligence and predictive analytics to improve and better coordinate patient care at a lower cost.  For more information, go to www.tgh.org.