Am J Obstet Gynecol. 2025 Dec 18:S0002-9378(25)00938-X. doi: 10.1016/j.ajog.2025.12.041. Online ahead of print.
ABSTRACT
OBJECTIVE: Postpartum hemorrhage (PPH) is a common obstetrical complication that, in severe cases, may necessitate blood transfusion. We hypothesized that severe PPH, defined as PPH requiring transfusion, constitutes a cardiovascular insult that confers risk beyond the immediate postpartum period. Severe PPH may plausibly be linked to cardiovascular disease (CVD) by large-volume acute blood loss, causing hypoperfusion and ischemia, leading to impaired cardiac function. We additionally aimed to examine the impact of preeclampsia co-occurring with PPH, as preeclampsia is strongly associated with new-onset postpartum cardiovascular disease and is also an independent risk factor for PPH.
STUDY DESIGN: Using the Healthcare Cost and Utilization Project's Nationwide Readmissions Database, we designed a retrospective cohort study of delivery hospitalization discharges in the United States, 2010-2020. ICD-9 and ICD-10 coding were used to identify deliveries complicated by PPH, with and without blood transfusion. Associations between PPH and CVD-related hospital readmissions and mortality within the calendar year following delivery were derived from a Cox proportional hazards model, expressed as the confounder-adjusted hazard ratio (HR) with a 95% confidence interval (CI). Additional analysis was performed of the associations between PPH and CVD events stratified by patients who were normotensive and those with preeclampsia.
RESULTS: Of 38,311,537 delivery hospitalizations, 3.9% (n = 1,501,235) were complicated by PPH. Of these, 13.3% (n = 199,810) received a blood transfusion. Compared to patients without PPH, patients with PPH without transfusion had a similar risk of overall CVD mortality and heart disease mortality, and a similar risk of non-fatal CVD readmission. Patients with PPH with transfusion had about a 2.6-fold increased risk of overall and heart disease-related CVD mortality and a 67% increased risk of CVD readmission compared to patients without PPH. When exposures were stratified by preeclampsia status, the risk of CVD readmission for PPH without transfusion was similar to the risk with no PPH for both normotensive and preeclampsia patients. The risk of CVD readmission for PPH with transfusion versus no PPH was elevated two-fold in normotensive patients and by 36% in patients with preeclampsia.
CONCLUSIONS: Severe PPH is associated with an increased risk of CVD readmission and mortality within the calendar year of delivery. The highest risk for CVD events was observed in patients with co-occurring preeclampsia. These findings underscore the burden of CVD risk associated with severe PPH and highlight the need for additional research to identify interventions that can mitigate the risk of adverse cardiovascular outcomes.
PMID:41421749 | DOI:10.1016/j.ajog.2025.12.041