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Revista Peruana de Ginecología y Obstetricia

versión On-line ISSN 2304-5132

Rev. peru. ginecol. obstet. vol.68 no.2 Lima abr./jun. 2022  Epub 06-Jul-2022

http://dx.doi.org/10.31403/rpgo.v68i2424 

Original paper

Factors associated with uterine atony

Angie Távara1 

Maritza Núñez2 

Miguel Ángel Tresierra3 

1Student, School of Medicine, Universidad Privada Antenor Orrego, Trujillo, Peru

2Professor of Gynecology and Obstetrics, School of Medicine, Universidad Privada Antenor Orrego; Obstetrician and Gynecologist, Hospital Regional Docente de Trujillo, Peru

3Doctor in Clinical and Translational Research, Professor of Public Health, Faculty of Medicine, Universidad Privada Antenor Orrego, Trujillo, Peru

ABSTRACT

Postpartum hemorrhage (PPH) is the most important pathology in terms of maternal mortality, being one of the main public health concerns. Uterine atony is the main cause of PPH.

Objective

: To determine the factors associated with the development of uterine atony.

Methods

: Observational analytical case-control study of 4,148 immediate postpartum patients attended at the Obstetrics Department of the Hospital Regional Docente de Trujillo, Peru, between 2009 and 2019; 1,037 patients presented uterine atony and 3,111 were controls.

Results

: When performing the bivariate analysis, the variables that presented statistical significance as associated factors for the development of uterine atony were cesarean delivery [OR 1.98 (95% CI: 1.71-2.29)], being from the highlands [OR 1.38 (95% CI: 1.12-1.70)], multiple pregnancy [OR 4.48 (95% CI: 3.43-5.83)], dysfunctional delivery [OR 1.82 (95% CI: 1.44-2.31)] and macrosomic fetus [OR 1.37 (95% CI: 1.08-1.73)]. On the other hand, having been primiparous [OR 0.79 (95% CI: 0.65-0.94)] and being multiparous [OR 0.82 (95% CI: 0.69-0.97)] were shown as factors not associated with statistical significance.

Conclusions

: Factors associated with the development of uterine atony were cesarean section as the route of delivery, being from the highlands, and having had a macrosomic fetus, polyhydramnios and multiple pregnancies.

Key words: Uterine hemorrhage; Uterine inertia.

INTRODUCTION

Maternal mortality is one of the main public health concerns, with postpartum hemorrhage (PPH) being the most important pathology in this problem worldwide1, with a high incidence in developing countries such as ours. The main cause of postpartum hemorrhage is uterine atony2.

Predicting the risk of PPH due to uterine atony would minimize its occurrence in the postpartum period3, through early intervention or adequate and timely referral to a care center that has the necessary tools to save the patient's life.

Uterine atony can occur in 1 in 20 deliveries1, produces 80% of PPH cases and can cause up to 50% of maternal deaths in low-resource countries1,4. In Peru, in 2018, the National Center for Epidemiology, Prevention and Disease Control5 reported uterine atony as the second leading cause of direct maternal death at 19.6%.

Uterine atony is defined as the lack of ability of the uterus to contract and remain so during the immediate puerperium (24 hours), generating the lack of closure of the arteries6. In normal labor, the myometrial vessels have an immediate adaptive mechanism for physiological hemostasis, and thus act by contracting themselves, resulting in occlusion of placental bed arteries. In the absence of arterial closure, a flaccid uterus will be found in the physical evaluation, with the presence of bleeding of 500 mL after vaginal delivery or more than 1000 mL after cesarean section, in the first 24 hours of the puerperium. On palpation there will be little or no response to manual stimulation1,6).

In a hemorrhage due to uterine atony, about 500 to 600 mL of blood can be lost per minute3,7. Treatment depends on how compromised the patient’s hemodynamic status is; it may be medical or surgical, up to hysterectomy1).

There are several factors that predispose to the development of uterine atony, among them, muscle fiber depletion in a multiparous woman. In older women (over 35 years of age), sclerotic changes may make it more difficult for the vessels to close, thus facilitating bleeding8,9).

Among the factors that generate uterine atony are cesarean delivery, multiple gestations10,11), extreme ages of reproductive life10,12, eutocic delivery and nulliparity10.

In a Peruvian EsSalud hospital13), cesarean section was found to be a risk factor for uterine atony (OR 6.64) compared to vaginal delivery. In Trujillo, at the Hospital Regional Docente14, multiparity was found to be a high-risk factor.

This has motivated the present research project to determine the factors associated with uterine atony for proper management. Carrying out this project in the Obstetrics Service of the Hospital Regional Docente de Trujillo will allow us to have statistics of our environment.

METHODS

This is a retrospective analytical observational retrospective longitudinal case-control study. The sample size was obtained from a database of the Perinatal Informatics System (SIP, for its acronym in Spanish) of clinical histories of immediate postpartum women attended in the obstetrics service of the Hospital Regional Docente de Trujillo during the period 20092019.

Of a total of 39,722 patients, 31,615 met the inclusion and exclusion criteria, ending with 1,037 cases. The 3,111 controls were selected by simple random sampling until completing the sample size of 3 controls for each case. All immediate postpartum women who presented with uterine overdistension, including multiple pregnancy, polyhydramnios, macrosomic fetuses or dysfunctional labor were included. Immediate puerperal women with incomplete perinatal clinical history or with presumptive history and/or diagnosis of chorioamnionitis, uterine inversion, retained placental debris, hypertensive disorders of pregnancy, coagulation disorders or birth canal lesions were excluded.

The information obtained was recorded in a spreadsheet for statistical analysis and presentation in tables. The odds ratio and the chi-square statistical test were applied, and a multivariate analysis was performed with the significant factors using logistic regression.

RESULTS

As shown in Table 1, the variables that showed statistical significance as factors associated with the development of atony were cesarean delivery [OR 1.98 (95% CI: 1.71-2.29)] and proceeding from the highlands [OR 1.38 (95% CI: 1.12-1.70)]. On the other hand, the following factors were not associated with statistical significance: having been a primiparous mother [OR 0.79 (95% CI 0.65-0.94)] and being multiparous [OR 0.82 (95% CI 0.69-0.97)].

In the bivariate analysis (Table 2), the intervening variables that were statistically significant were multiple pregnancy [OR 4.48 (95% CI 3.43-5.83)], dysfunctional delivery [OR 1.82 (95% CI 1.44-2.31)] and macrosomic fetus [OR 1.37 (95% CI 1.08-1.73)].

Table 1 factors associated with the development of uterine atony. 

Source: hospital regional docente de trujillo data collection forms 2009 2019.

Table 2 intervening variables associated with the development of uterine atony. 

Source: hospital regional docente de trujillo data collection forms 2009 2019.

The multivariate analysis in Table 3 of the independent factors associated with the development of uterine atony shows that both educational level and marital status were not statistically significant.

In the multivariate analysis (Table 4) of the independent factors associated with the development of uterine atony, it was observed that being great multiparous was not statistically significant, p value = 0.145 [OR 1.261 (95% CI: 0.923-1.724)].

DISCUSSION

The factors associated with the development of uterine atony can be identified, allowing us to predict the risk and thus minimize the consequences in the postpartum period by performing an early intervention to reduce patient morbidity and mortality.

Table 3 multivariate analysis of factors associated with the development of uterine atony. 

multiple logistic regression, p < significant

Source: hospital regional docente de trujillo data collection sheets 2009 2019.

Table 4 multivariate analysis of factors associated with the development of uterine atony. 

*multiple logistic regression

**p <0.05 significant

Source: Hospital Regional Docente de Trujillo Fichas de recolección de datos 2009 2019.

Among the associated factors in the study was cesarean section; 67% of the patients had PPH due to uterine atony in comparison to the control group, where 50% of patients did not have this result, p =0.000 [OR 1.98 (95% CI: 1.71-2.29)]. Cesarean section as the route of delivery was significantly 1.98 times more likely to result in PPH due to uterine atony. This data is related to the results of Gil's studies, where cesarean section patients had 6.64 times more risk of uterine atony in contrast to patients who delivered vaginally(13).

The demographic factor associated with the development of uterine atony was being from the highlands: 14% of patients had PPH compared to the control group with 10%, p = 0.003 [OR 1.38 (95% CI 1.12 to 1.70)]. Patients from the highlands were significantly 1.38 times more likely to have PPH due to uterine atony. This result is like that of Altamirano, in Huancavelica, a highland region, where 55.2% of postpartum women had atony15.

Being multiparous was not an associated factor for the development of uterine atony, with p=0.001 [OR 0.82 (95% CI: 0.69-0.97)] statistically significant, which agrees with Machado, who also found no association between multiparity and PPH due to uterine atony16).

In relation to the intervening variables that presented statistical significance and were associated with the development of uterine atony was dysfunctional labor, since 12% of the patients had PPH due to uterine atony compared to 7% of the control group, p=0.000 [OR 1.82 (95% CI: 1.44-2.31)]. This result is similar to that of Jiménez, where dysfunctional labor accounted for 70.4% of the cases vs. 36.1% of the controls17).

Another associated factor was multiple pregnancy; 13% of the pregnant women had PPH due to uterine atony compared to 3% of the control group, p=0.000 [OR 4.48 (95% CI: 3.435.83)]. Multiple pregnancy was significantly 4.48 times more likely to cause PPH due to uterine atony, having similarity with Ponce's study which found that 4.7% of postpartum women with uterine atony were significantly associated with multiple gestation (p=0.017). In addition, it was found that postpartum women with multiple gestation had 10.5 times more uterine atony than postpartum women without multiple gestation18).

The macrosomic fetus was an associated factor, since 11% of the patients had PPH due to uterine atony compared to the control group, 8%, p=0.000 [OR 1.37 (95% CI: 1.08-1.73)]. Our results were similar to those of Gutierrez, since 43.3% of the puerperal women who presented uterine atony had macrosomia as a significant associated factor (p=0.003) [OR 4.79 (95% CI 3.37-6.80)]19).

In conclusion, the present study showed that there are factors associated with the development of uterine atony such as cesarean section as the route of delivery, being from the highlands, having had a macrosomic fetus, polyhydramnios, and multiple pregnancy.

Acknowledgments

To the obstetrics service of the Hospital Regional Docente de Trujillo, Peru, which allowed the use of the database for the present study.

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3The material contained in this manuscript has not been previously published or submitted to another biomedical journal. Consent was obtained from the institution for this manuscript. The authors approved the final manuscript, declare no conflicts of interest.

Cite as: Távara A, Núñez M, Tresierra MA. Factors associated with uterine atony. Rev peru ginecol obstet. 2022;68(2). DOI: https://doi.org/10.31403/rpgo.v68i2424

Received: May 02, 2022; Accepted: June 23, 2022

Corresponding author: Angie Carolina Távara Mendoza Pasaje Luna Victoria 173 Urb. San Andres primera etapa TrujilloPerú. 945389168 angie_13tm@hotmail.com

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