The impact of a multilevel approach to reduce emergency hysterectomy for postpartum haemorrhage: Insights from a tertiary referral centre in Northern Italy

Objective: To assess the effectiveness of the implementation of a multilevel institutional program to reduce the rate of emergency peripartum hysterectomy (EPH) secondary to postpartum haemorrhage (PPH) in a Western world referral centre for obstetrics. Study design: Women who delivered at a tertiary care regional obstetric hub in Milan between 2012 and 2020 were retrospectively reviewed to identify cases of EPH. During the study period, several measures aimed at preventing EPH were progressively implemented: reduction of primary and repeated caesarean, update of PPH treatment protocol, implementation of massive transfusion protocol, dedicated clinical pathway for high-risk patients, regular educational sessions, daily review of critical cases with senior consultant, and periodical review of near miss cases by quality improvement committee. To investigate the possible benefits, we divided the detected cases into two groups based on the historical period (Period I, 2012-2016 vs. Period II, 2017-2020) with the main aim of comparing the rate of EPH calculated as EPH ratio per 1000 deliveries. Results: During Period I and II there were 30,241 and 21,270 births; a total of 60 and 25 EPH were performed, respectively. EPH incidence decreased from 2.0 to 1.2 parts per thousand across the study periods (p = 0.027). Between Period I and II, we observed a reduction of institutional caesarean section rate (44.4% vs. 40.4%, p < 0.0001); among cases undergoing EPH, we reported a significant reduction of massive blood transfusion (83.3% vs. 52.2%, p = 0.002), increased use (56.7% vs. 96.0%, p = 0.0004) and appropriate administration (25.0% vs. 88.0%, p < 0.0001) of tranexamic acid, increased use of non-invasive Bakri Balloon tamponade (3.3% vs. 32.0%, p = 0.0002) instead of surgical techniques (38.3% vs. 16.0%, p = 0.043). Conclusion: A reduction of EPH incidence as a severe outcome of obstetric haemorrhage is achievable through a multilevel institutional effort. Our study may inspire a larger-scale program to improve the safety of patients experiencing PPH.