A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis

Abstract

Background/objectives:

There is limited research on the associated immediate and long-term outcomes of postpartum hemorrhage. Mothers with a pre-existing psychiatric disease prior to delivery may be especially vulnerable to postpartum hemorrhage outcomes but little is known on this topic. Barriers to studying this population exist and add to knowledge gaps. The goal of this study is to determine the clinical characteristics and frequency of complications within 1 year of a postpartum hemorrhage diagnosis and the psychiatric sequelae within 7 days of a postpartum hemorrhage diagnosis in mothers with a pre-existing mental health diagnosis prior to delivery versus those without.

Methods/design:

This is a multicenter retrospective observational cohort study using TriNetX, a de-identified electronic health record database. The following electronic health record data were collected and evaluated in postpartum females who were billed for either a vaginal or cesarean delivery: age, race, ethnicity, diagnostic codes, medication codes, and number of deaths.

Results:

We included 10,649 subjects (6994 (65.7%) no mental health diagnosis and 3655 (34.3%) pre-existing mental health diagnosis). Haloperidol administration (118 (3.2%) versus 129 (1.8%), p < 0.001) was more prevalent in subjects with a pre-existing mental health diagnosis. Adjusting for demographics, pre-existing mental health diagnoses were associated with complications within 1 year after postpartum hemorrhage diagnosis (OR = 1.39, 95% CI: 1.26–1.52, p < 0.001).

Conclusion:

Having a mental health disorder history is associated with a higher odds of developing subsequent complications within 1 year of postpartum hemorrhage diagnosis. Mothers with a pre-existing mental health disorder have a significantly higher frequency of certain severe postpartum hemorrhage sequelae, including acute respiratory distress syndrome, retained placenta, sickle cell crisis, and need for mechanical ventilation/tracheostomy up to 1 year after delivery. Medications such as haloperidol were ordered more frequently within 7 days of a postpartum hemorrhage diagnosis in these mothers as well. Further research is needed to understand and manage the unique consequences of postpartum hemorrhage in this vulnerable maternal population.

Keywords

haloperidol maternal complications maternal mental health postpartum hemorrhage pregnancy

Introduction

Despite the fact that roughly 14 million women worldwide experience postpartum hemorrhage (PPH) each year,¹ much of PPH research focuses on risk factors, prevention, and management.² Less of an emphasis has been placed on the associated outcomes of PPH. A recent review noted that of 2210 papers on PPH, only 6 focused on outcomes and 1 focused on emotional sequelae.² The National Institute for Health and Care Excellence considers PPH to be physical birth trauma.³ Reframing the understanding of PPH as an experience with both “in the moment” and “after-effects” may help highlight the significance of outcomes, both immediate and long term.^3,4 The “in the moment” consequences include severe anemia, acute kidney injury, hepatic failure, adult respiratory distress syndrome, pituitary infarction, blood product transfusions, surgical procedures, or death.^5
–8 The “after-effects” may include fear of dying or anxiety in subsequent pregnancies and may develop or continue many years after the PPH experience.² Although a large cohort study conducted in Sweden did not specifically show an association between PPH and postpartum depression, study design limitations may have influenced these results.⁹ Research on birth trauma indicates that these experiences can have lasting emotional impacts,⁴ such as postpartum depression, birth-related post-traumatic stress disorder, or anxiety from simply surviving a life-threatening event.^10
–12 If not recognized or left untreated, these psychiatric sequelae can impact bonding, breastfeeding, or may result in infanticide or maternal death from suicide or substance overdose.^10,13

Mothers with a pre-existing psychiatric disease prior to pregnancy or delivery may be especially vulnerable after experiencing PPH. These mothers can have poor obstetrical outcomes^14,15 or have higher risks of postpartum psychiatric symptoms^16
–18 and less is known about how PPH specifically affects this population. There may be barriers to studying mothers with pre-existing psychiatric conditions, such as under-diagnosis of peripartum psychiatric disorders¹⁹ or the challenges associated with conducting research on patients with acute psychiatric emergencies,²⁰ which adds to the knowledge gap in this space. Scant treatment guidelines for severe psychiatric conditions after delivery, such as postpartum psychosis,^19,20 may lead to management variations differentially affecting certain patients. Pharmacologic agents, such as haloperidol, can be used to treat both postpartum psychosis and acute delirium, aggression, or agitation.^21,22 It is unknown whether there are differences in the use of these medications after PPH in patients with and without pre-existing psychiatric disease. Advancing the understanding of PPH outcomes in mothers with a pre-existing psychiatric diagnosis may enhance the clinical care of this vulnerable population and add to the limited literature available.

Given the large prevalence of PPH and reported birth trauma in addition to the sparse data on PPH outcomes as it relates to mothers with and without a pre-existing psychiatric diagnosis, we aimed to identify PPH outcomes in a large de-identified, multi-institutional longitudinal database. The objective of this study was to determine the clinical characteristics and frequency of obstetric and psychiatric complications within 1 year after PPH diagnosis in patients with a psychiatric diagnosis prior to delivery versus those without. We hypothesize that both of these complications would be greater in patients with a pre-existing psychiatric diagnosis. We also hypothesize that medications used in psychiatric emergencies, such as haloperidol, would be greater in patients with a pre-existing psychiatric diagnosis as compared to those without within 7 days postpartum.

Materials and methods

Study design

This is a retrospective observational cohort study that was conducted using the TriNetX^® (https://www.trinetx.com) electronic health record (EHR) database of postpartum women aged 15–54 years with a PPH-related diagnostic code (International Classification of Diseases, 10th edition (ICD-10) code “O72”) and who were reported to have an inpatient encounter. TriNetX is a global federated health research network that provides researchers access to continuously update data elements on EHR from participating healthcare organizations, predominantly in the United States. TriNetX is certified to the ISO 27001:2013 standard and protects healthcare data by maintaining compliance with the Health Insurance Portability and Accountability Act (HIPPA) Security Rule. The EHR data elements are aggregated and de-identified, including demographic characteristics, diagnoses, procedures, medications, laboratory values, and genomics, all in compliance with the de-identification standard outlined in Section §164.514(a) of the HIPPA privacy rule. Because no protected health information is received by the user, we were provided a waiver from the Penn State Health Institutional Review Board to perform this study (STUDY00020794). Study design, conduct, and result reporting were constructed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.²³

Data collection

On 5 October 2021, we analyzed the available EHR data of 10,649 postpartum females who had a PPH-related ICD diagnostic code during or after the year 2012 and were also coded to have one of the following procedures: (1) vaginal delivery or (2) cesarean delivery. To avoid subjects with repeat deliveries, we excluded subjects with a delivery coded before PPH-related ICD-10 diagnostic code entry and 90–365 days after. In addition, to minimize potential selection biases of subjects who could be lost to follow-up (i.e. subjects could have changed health systems or moved out of state), we only included subjects who had at least one encounter up to 5 years before delivery and 1 year after delivery. We excluded subjects who did not meet the above criteria.

After the query, we obtained the following data: age, race, ethnicity, Center for Disease Classification (CDC)–related maternal morbidity diagnoses²⁴ and related common procedural terminology (CPT), and healthcare common procedure coding system (HCPCS) codes reported up to 1 year after PPH diagnosis (see Supplementary Table 1). We used a 1-year timeframe which is consistent with maternal mortality review committees which define obstetric complications as up to 1-year postpartum.²⁴ We then extracted all the mental health diagnosis categories, haloperidol presence, and other psychedelic medication (as classified by the Anatomical Therapeutic Chemical Classification) presence after the PPH diagnosis. The subjects were categorized based on prior history of mental health disorder.

Statistical analysis

By the presence or absence of mental health diagnostic history, we reported the demographic characteristics (Table 1), the obstetric complications detected within 1 year after the PPH diagnosis (Table 2), and several health conditions within 1 week after the PPH diagnosis (Table 3) for the included patients using the summary statistics. Two-sample t-test was applied to compare the age between the groups with and without pre-existing mental health disorders, Wilcoxon sum rank test was used to test the difference of the numbers of complications within 1 year after PPH diagnosis between the two mental health condition groups, and Pearson’s chi-square test and Fisher’s exact test were applied for comparing categorical factors, including race, ethnicity, delivery type, and presence of certain complication or other health conditions.

Table 1.

Demographic factors of subjects diagnosed with postpartum hemorrhage divided by the absence and presence of a mental health diagnosis history.

	Absence of mental health diagnosis history(N = 6994)	Presence of mental health diagnosis history(N = 3655)	p
Race			<0.001
White	3933 (56.2%)	2319 (63.4%)
Black or African American	1338 (19.1%)	709 (19.4%)
Asian	475 (6.8%)	113 (3.1%)
American Indian or Alaska Native	25 (0.4%)	22 (0.6%)
Native Hawaiian or Other Pacific Islander	25 (0.4%)	12 (0.3%)
Unknown	1198 (17.1%)	480 (13.1%)
Ethnicity			<0.001
Not Hispanic or Latino	4535 (64.8%)	2919 (79.9%)
Hispanic or Latino	1862 (26.6%)	507 (13.9%)
Unknown	597 (8.5%)	229 (6.3%)
Age			<0.001
Mean (SD)	28.9 (6.2)	29.5 (6.2)
Median [min, max]	29.0 [15.0, 51.0]	30.0 [15.0, 51.0]
Delivery type			0.005
Vaginal delivery	3913 (55.9%)	1941 (53.1%)
Cesarean delivery	3081 (44.1%)	1714 (46.9%)

SD: standard deviation.

Table 2.

Complications 1 year after postpartum hemorrhage diagnosis divided by the absence and presence of a mental health diagnostic code history.

	Absence of mental health diagnostic code history(N = 6994)	Presence of mental health diagnostic code history(N = 3655)	p
No. of complication types present 0–365 days after PPH diagnosis			<0.001^a
M (SD)	0.4 (0.8)	0.5 (0.9)
Median [min, max]	0 [0.0, 11.0]	0 [0.0, 8.0]
Acute myocardial infarction, aneurysm			0.150
Absence	6985 (99.9%)	3645 (99.7%)
Presence	9 (0.1%)	10 (0.3%)
Acute renal failure			0.437
Absence	6858 (98.1%)	3575 (97.8%)
Presence	136 (1.9%)	80 (2.2%)
Air and thrombotic embolism			0.302
Absence	6957 (99.5%)	3629 (99.3%)
Presence	37 (0.5%)	26 (0.7%)
Amniotic fluid embolism			0.458^b
Absence	6990 (99.9%)	3651 (99.9%)
Presence	4 (0.1%)	4 (0.1%)
Anesthesia complications			0.384
Absence	6966 (99.6%)	3645 (99.7%)
Presence	28 (0.4%)	10 (0.3%)
Acute respiratory distress syndrome			0.043
Absence	6912 (98.8%)	3594 (98.3%)
Presence	82 (1.2%)	61 (1.7%)
Cardiac arrest			0.287
Absence	6980 (99.8%)	3643 (99.7%)
Presence	14 (0.2%)	12 (0.3%)
Disseminated intravascular coagulation			0.044
Absence	6651 (95.1%)	3508 (96.0%)
Presence	343 (4.9%)	147 (4.0%)
Eclampsia			0.103
Absence	6862 (98.1%)	3568 (97.6%)
Presence	132 (1.9%)	87 (2.4%)
Heart failure/arrest during procedure			0.556^b
Absence	6991 (100.0%)	3655 (100%)
Presence	3 (0.0%)	0 (0%)
Hysterectomy			0.004
Absence	6845 (97.9%)	3543 (96.9%)
Presence	149 (2.1%)	112 (3.1%)
Acute heart failure and pulmonary edema			0.817
Absence	6936 (99.2%)	3627 (99.2%)
Presence	58 (0.8%)	28 (0.8%)
Puerperal cerebrovascular disorders (stroke)			0.256
Absence	6943 (99.3%)	3620 (99.0%)
Presence	51 (0.7%)	35 (1.0%)
Retained placenta			<0.001
Absence	6571 (94.0%)	3363 (92.0%)
Presence	423 (6.0%)	292 (8.0%)
Sepsis			0.672
Absence	6925 (99.0%)	3615 (98.9%)
Presence	69 (1.0%)	40 (1.1%)
Shock			0.516
Absence	6892 (98.5%)	3595 (98.4%)
Presence	102 (1.5%)	60 (1.6%)
Sickle cell crisis			0.010^b
Absence	6992 (100.0%)	3648 (99.8%)
Presence	2 (0.0%)	7 (0.2%)
Transfusion of blood products (any)			0.575
Absence	6381 (91.2%)	3322 (90.9%)
Presence	613 (8.8%)	333 (9.1%)
Need for mechanical ventilation/tracheostomy			<0.001
Absence	6775 (96.9%)	3278 (89.7%)
Presence	219 (3.1%)	377 (10.3%)

SD: standard deviation.

Wilcoxon rank sum test was used for testing the group difference and reporting the p-value.

Fisher’s exact test was used for testing the group difference and reporting the p-value.

Table 3.

Mental health diagnosis and psychiatric medications 0–7 days after PPH diagnosis.

	Absence of mental health diagnostic code history(N = 6994)	Presence of mental health diagnostic code history(N = 3655)	p
Psychiatric medications 0–7 days after PPH diagnosis			<0.001
Absence	5011 (71.6%)	2275 (62.2%)
Presence	1983 (28.4%)	1380 (37.8%)
Haloperidol 0–7 days after PPH diagnosis			<0.001
Absence	6865 (98.2%)	3537 (96.8%)
Presence	129 (1.8%)	118 (3.2%)
Mental health diagnosis 0–7 days after PPH diagnosis			<0.001
Absence	6576 (94.0%)	2018 (55.2%)
Presence	418 (6.0%)	1637 (44.8%)

PPH: postpartum hemorrhage.

We conducted univariable and multivariable logistic regression analyses to investigate the association between the presence of any complications within 1 year of PPH diagnosis and the mental health disorder history. In the analyses, we combined “Asian,” “American Indian or Alaska Native,” and “Native Hawaiian or Other Pacific Islander” in “race” to the “Other” category due to their relatively small proportions in the data. We first fit univariable logistic regression models for mental health condition history, age, race, ethnicity, and delivery mode to estimate the unadjusted odds ratios (ORs) with 95% confidence intervals (CIs). We then fit a multivariable model including all covariates to explore the effects controlling for other factors. The adjusted ORs with 95% CIs were summarized in Table 4 in parallel to the univariable analysis result.

Table 4.

Univariable and multivariable analysis for the presence of any complications within 1 year after PPH and association with the history of mental health disorder, age, race, ethnicity, and delivery type.

	Univariable analysis		Multivariable analysis
	OR (95% CI)	p	OR (95% CI)	p
Mental health condition history (Ref: absence)
Presence	1.44 (1.32–1.57)	<0.001	1.39 (1.26–1.52)	<0.001
Age
1-year increase	1.03 (1.02–1.03)	<0.001	1.01 (1.01–1.02)	<0.001
Race (Ref: White)
Black or African American	1.18 (1.06–1.32)	0.003	1.08 (0.96–1.21)	0.208
Other	1.04 (0.87–1.25)	0.671	1.00 (0.82–1.20)	0.968
Unknown	1.28 (1.13–1.44)	<0.001	1.38 (1.21–1.58)	<0.001
Ethnicity (Ref: not Hispanic or Latino)
Hispanic or Latino	0.80 (0.72–0.90)	<0.001	0.82 (0.72–0.92)	0.001
Unknown	0.81 (0.68–0.95)	0.012	0.78 (0.65–0.93)	0.006
Delivery type (Ref: vaginal delivery)
Cesarean delivery	2.10 (1.92–2.29)	<0.001	1.99 (1.82–2.18)	<0.001

PPH: postpartum hemorrhage; OR: odds ratio; CI: confidence interval.

Statistical software R v.4.2.2 was used to preprocess the data, conduct the statistical tests, and perform the logistic regression analyses. p-values of less than or equal to 0.05 were regarded as statistically significant.

Results

Patient characteristics

A total of 10,649 subjects were included in this study (6994 (65.7%) no mental health diagnosis history prior to PPH and 3655 (34.3%) mental health diagnosis history). Patient demographics were summarized in Table 1.

Mental health disorders

Mental health diagnosis categories were summarized in Table 5. The most common mental health diagnoses reported were depressive disorders (953 (26.1%)), anxiety disorders (869 (23.8%)), maternal mental illness or substance abuse during pregnancy, delivery, or postpartum (1692 (46.3%)), and substance-related and addictive disorders (584 (16.0%)).

Table 5.

Categorized mental health disorders of subjects diagnosed with PPH and a mental health diagnosis history.

Mental health disorder category	n (%)
Accidental or undetermined poisoning	0 (0.0%)
Attention-deficit hyperactivity disorder	86 (2.4%)
Anxiety disorders	869 (23.8%)
Autism spectrum disorder	4 (0.1%)
Bipolar and related disorders	114 (3.1%)
Communication disorders	14 (0.4%)
Depressive disorders	953 (26.1%)
Developmental delay or unspecified neurodevelopmental disorder	5 (0.1%)
Disruptive, impulse control, and conduct disorders	5 (0.1%)
Dissociative disorders	1 (0.0%)
Elimination disorders	2 (0.1%)
Feeding and eating disorders	5 (0.1%)
Fetal or newborn damage related to maternal substance abuse	8 (0.2%)
Intellectual disability	5 (0.1%)
Maternal mental illness or substance abuse during pregnancy, delivery, or postpartum	1692 (46.3%)
Mental health symptom	10 (0.3%)
Miscellaneous	54 (1.5%)
Motor disorders	1 (0.0%)
Neurocognitive disorders	11 (0.3%)
Obsessive-compulsive and related disorders	20 (0.5%)
Personality disorders	26 (0.7%)
Schizophrenia spectrum and other psychotic disorders	21 (0.6%)
Sexuality and gender identity disorders	1 (0.0%)
Sleep–wake disorders	4 (0.1%)
Somatic symptom and related disorders	4 (0.1%)
Specific learning disorders	1 (0.0%)
Substance abuse-related medical illness	10 (0.3%)
Substance-related and addictive disorders	584 (16.0%)
Suicide or self-injury	3 (0.1%)
Trauma and stressor-related disorders	129 (3.5%)

Several maternal morbidity indicators 1 year after PPH diagnosis

Of the severe maternal morbidity indicators identified, a higher proportion of acute respiratory distress syndrome (61 (1.7%) versus 82 (1.2%), p = 0.043), retained placenta (292 (8.0%) versus 423 (6.0%), p < 0.001), sickle cell crisis (7 (0.2%) versus 2 (0.0%), p = 0.010), and need for mechanical ventilation/tracheostomy (377 (10.3%) versus 219 (3.1%), p < 0.001) was noted in the mental health diagnosis group. There was a higher proportion of disseminated intravascular coagulation (147 (4.0%) versus 343 (4.9%), p = 0.044) noted in the group with no mental health diagnosis history.

Haloperidol and psychedelic prescription up to 7 days after PPH diagnosis

A higher proportion of haloperidol (118 (3.2%) versus 129 (1.8%), p < 0.001) and psychedelic (1380 (37.8%) versus 1983 (28.4%), p < 0.001) was noted in the mental health diagnosis history group when compared to the group with no mental health diagnosis history.

Associations between the presence of complications in 1 year after PPH diagnosis and the patient demographic and mental health characteristics

Having a mental health disorder history was associated with a higher odds of developing obstetric long-term complications (OR = 1.44 (95% CI: 1.32–1.57)), or after controlling for other factors (OR = 1.39 (95% CI: 1.26–1.52)). In univariable analysis, increasing age was associated with a higher risk of having complications (OR = 1.03 for 1-year increase (95% CI: 1.02–1.03)). Those who identified as Hispanic or Latino tended to have lower risks of complications after PPH diagnosis compared to those non-Hispanic or Latino (OR = 0.80 (95% CI: 0.72–0.90)). Finally, those who experienced a cesarean delivery tended to have a higher odds to develop obstetric complications compared to those who had a vaginal delivery (OR = 2.10 (95% CI: 1.92–2.29)).

Discussion

Consistent with our hypothesis, this study demonstrates that having a mental health disorder history is associated with higher odds of developing subsequent complications within 1 year of PPH diagnosis (OR = 1.39 (95% CI: 1.26–1.52), p < 0.001). Specifically, a statistically significantly higher proportion of acute respiratory distress syndrome, retained placenta, sickle cell crisis, and need for mechanical ventilation/tracheostomy was noted in mothers with a pre-existing mental health diagnosis. Furthermore, a higher frequency of haloperidol and psychedelic medications ordered within 7 days of a PPH experience was noted in the mothers with a pre-existing mental health diagnosis.

During the study timeframe, approximately 40% of mothers with a PPH diagnosis also had a pre-existing mental health diagnosis. Previous literature has demonstrated associations between PPH and mental health disorders.²⁵ There are various explanations as to why mothers with a pre-existing mental health disorder may develop PPH. This patient population is at increased risk for metabolic issues, such as obesity, which may have a modest effect on PPH risk.^26
–32 The serotonergic agents used in mental health disorders may interfere with platelet aggregation and adhesion, increasing the risk for hemorrhage.^33,34 It is also possible that the mood disorder itself may impact serotonin transmission resulting in platelet dysfunction and subsequent bleeding.³³ Overall trends show that rates of PPH and associated risk factors may be increasing^35,36 and the rates of mood disorders in pregnancy.³⁷ Although PPH is difficult to predict,^8,35 it is a significant cause of maternal morbidity and mortality,⁸ underscoring the clinical importance of recognizing additional risk factors, such as the possible associations between PPH and mental health diagnoses.

Consistent with the literature, we identified PPH-associated complications;⁸ however, our analysis demonstrates that some of these sequelae (acute respiratory distress syndrome, retained placenta, sickle cell crisis, and need for mechanical ventilation/tracheostomy) were significantly higher in mothers who had a mental health diagnosis prior to delivery. Cesarean delivery has been associated with PPH risk³⁸ and severe maternal morbidities.³⁹ After controlling for other factors, cesarean section was significantly associated with increased odds of developing subsequent complications; however, as delivery mode did not significantly differ between our two groups, this alone does not account for the higher odds of complications in mothers with a pre-existing mental health diagnosis prior to delivery. It may be possible that mothers with pre-existing mental health disorders are more medically complicated in general,^40
–42 thereby increasing overall risks for complications postpartum especially after PPH.^43,44 As previously mentioned, these patients are at increased risk for obesity⁴⁵ which itself increases maternal risks due to cardiovascular diseases, thromboembolism, hypertension, and stroke.^46
–48 Our study was unable to account for obesity as body mass index was not consistently available in the TriNetX^® database. In addition, PPH associated outcomes may be impacted by health determinants, stigma, access to care, and patient trust with the health system.^49,50 Further study may be needed to understand this possible phenomenon and potentially better care for mothers with a mental health diagnosis.

Our data also demonstrated significant differences in mental health diagnoses within 7 days of PPH in mothers with a pre-existing mental health disorder. Based on data constraints and availability, it is unclear whether the mental health diagnoses after PPH were new or demonstrated clinical worsening of their pre-existing mental health condition. Further research is needed to clarify this finding; however, it may suggest that these mothers are particularly vulnerable after experiencing a birth trauma, such as PPH, especially in the immediate postpartum timeframe. Notably, in the mothers without a mental health diagnosis prior to delivery, approximately 7% of these individuals acquired a mental health diagnosis within 7 days after experiencing PPH, suggesting that these mothers are not immune to the possible psychiatric sequela associated with this birth trauma. Close monitoring of all patients who experience PPH may be warranted given our study findings.

Finally, our results also demonstrated significantly higher rates of ordering haloperidol in the pre-existing mental health diagnosis group within 7 days of a PPH diagnosis. Haloperidol is a first-generation antipsychotic that is commonly used to manage agitation or aggression and delirium.^51,52 It also may be prescribed to manage the positive symptoms of patients with schizophrenia.⁵³ Due to data constraints, our study was unable to identify the indications for which haloperidol was ordered; however, all of these reasons are plausible. Our data show that mothers with pre-existing mental health diagnoses experienced higher rates of certain severe PPH outcomes. Some of these critical outcomes could have resulted in delirium and agitation, potentially placing the patient at increased risk of self-harm^36,54 necessitating the use of a pharmacological solution. Haloperidol does have side effects and can be associated with increased mortality in particular clinical situations.^43,53 It is therefore important to assess the appropriate use in every clinical context. There is a lack of guidelines for prescribing antipsychotic medications in the postpartum state^52,53 and the literature has noted that caregiver distress in acute situations can lead to medication overuse.⁵⁵ Understanding the indications for haloperidol use in patients with a pre-existing mental health diagnosis who experience PPH is clinically relevant and can identify possible opportunities for improvement.^52,56

Limitations

There are several limitations to this study. Due to database limitations, diagnostic codes could not be validated with the clinical notes from providers and therefore determining the timing of certain events was not possible for each subject included in the study. We only included subjects where the patient was coded to have PPH; thus, this study may have excluded patients who did not have this diagnostic code but did experience PPH. In addition, we could not establish PPH by objective criteria, such as estimated blood loss (EBL) or drop in hematocrit/vital sign changes and the severity of the illness for each subject was unknown. Similarly, we depended on clinicians to enter diagnostic codes for mental health diagnoses. It is possible that subjects did have a mental health disorder and did not have a mental health diagnostic code entered. Furthermore, we could not account for the role that obesity may have played in PPH-associated outcomes.

Conclusion

Having a mental health disorder history is associated with a higher odds of developing subsequent complications within 1 year of PPH diagnosis. Mothers with a pre-existing mental health disorder have a significantly higher frequency of certain severe PPH sequelae, including acute respiratory distress syndrome, retained placenta, sickle cell crisis, and need for mechanical ventilation/tracheostomy up to 1 year after delivery. These mothers also have higher rates of psychiatric medications ordered, specifically haloperidol, within 7 days of a PPH diagnosis. Further research and public health efforts may be needed to identify and manage the unique consequences of PPH in this vulnerable maternal population.

Supplemental Material

sj-docx-1-whe-10.1177_17455057231211094 – Supplemental material for A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis

Supplemental material, sj-docx-1-whe-10.1177_17455057231211094 for A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis by Kodi Endres, Nina Razavi, Zizhong Tian, Shouhao Zhou, Conrad Krawiec and Sona Jasani in Women’s Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057231211094 – Supplemental material for A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis

Supplemental material, sj-docx-2-whe-10.1177_17455057231211094 for A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis by Kodi Endres, Nina Razavi, Zizhong Tian, Shouhao Zhou, Conrad Krawiec and Sona Jasani in Women’s Health

Supplemental Material

sj-docx-3-whe-10.1177_17455057231211094 – Supplemental material for A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis

Supplemental material, sj-docx-3-whe-10.1177_17455057231211094 for A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis by Kodi Endres, Nina Razavi, Zizhong Tian, Shouhao Zhou, Conrad Krawiec and Sona Jasani in Women’s Health

Supplemental Material

sj-docx-4-whe-10.1177_17455057231211094 – Supplemental material for A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis

Supplemental material, sj-docx-4-whe-10.1177_17455057231211094 for A retrospective analysis of complications associated with postpartum hemorrhage up to 1 year postpartum in mothers with and without a pre-existing mental health diagnosis by Kodi Endres, Nina Razavi, Zizhong Tian, Shouhao Zhou, Conrad Krawiec and Sona Jasani in Women’s Health

Footnotes

Acknowledgements

Not applicable.

Declarations

ORCID iD

Kodi Endres

Supplemental material

Supplemental material for this article is available online.

References

World Health Organization. WHO and postpartum haemorrhage (PPH) summit, https://www.who.int/publications/m/item/who-postpartum-haemorrhage-(pph)-summit (accessed 19 March 2023).

Carroll

Daly

Begley

CM.

The prevalence of women’s emotional and physical health problems following a postpartum haemorrhage: a systematic review. BMC Pregnancy Childbirth 2016; 16(1): 261.

NICE. Antenatal and postnatal mental health: clinical management and service guidance. Essentially MIDIRS 2015; 6(1): 6–13.

Gough

Giannouli

A qualitative study exploring the experience of psychotherapists working with birth trauma. Heal Psychol Res 2021; 8(3): 9178.

Feduniw

Warzecha

Szymusik

, et al Epidemiology, prevention and management of early postpartum hemorrhage—a systematic review. Ginekol Pol 2020; 91(1): 38–44.

Attali

Many

Kern

, et al Predicting the need for blood transfusion requirement in postpartum hemorrhage. J Matern Neonatal Med 2022; 35(25): 7911–7916.

Kong

WW.

Prognostic factors for the use of intrauterine balloon tamponade in the management of severe postpartum hemorrhage. Int J Gynaecol Obstet 2018; 142(1): 48–53.

Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstetric Gynecol 2017; 130(4): e168–e186.

Canfield

Silver

RM.

Detection and prevention of postpartum posttraumatic stress disorder: a call to action. Obstet Gynecol 2020; 136(5): 1030–1035.

10.

Dekel

Stuebe

Dishy

Childbirth induced posttraumatic stress syndrome: a systematic review of prevalence and risk factors. Front Psychol 2017; 8: 560–510.

11.

Pranal

Legrand

De Chazeron

, et al Prevalence of maternal psychological disorders after immediate postpartum haemorrhage: a repeated cross—sectional study—The PSYCHE* study protoco. BMJ Open 2019; 9(9): e027390.

12.

Rodriguez-Cabezas

Clark

Psychiatric emergencies in pregnancy and postpartum. Clin Obstet Gynecol 2018; 61(3): 615–627.

13.

Nguyen

Faulkner

Frayne

, et al Obstetric and neonatal outcomes of pregnant women with severe mental illness at a specialist antenatal clinic. Med J Aust 2013; 199(3): S26–S29.

14.

Sūdžiūtė

Murauskienė

Jarienė

, et al Pre-existing mental health disorders affect pregnancy and neonatal outcomes: a retrospective cohort study. BMC Pregnancy Childbirth 2020; 20(1): 419.

15.

Munk-Olsen

Laursen

Meltzer-Brody

, et al Psychiatric disorders with postpartum onset: possible early manifestations of bipolar affective disorders. Arch Gen Psychiatry 2012; 69(4): 428–434.

16.

Milgrom

Gemmill

Bilszta

, et al Antenatal risk factors for postnatal depression: a large prospective study. J Affect Disord 2008; 108(1–2): 147–157.

17.

Patton

Romaniuk

Spry

, et al Prediction of perinatal depression from adolescence and before conception (VIHCS): 20-year prospective cohort study. Lancet 2015; 386: 9996.

18.

Liu

Butwick

Sand

, et al The association between postpartum hemorrhage and postpartum depression: a Swedish national register-based study. PLoS ONE 2021; 16(8): e0255938.

19.

Rai

Pathak

Sharma

Postpartum psychiatric disorders: Early diagnosis and management. Indian J Psychiatry 2015; 57(Suppl. 2): S216–S221.

20.

Allen

Currier

Carpenter

, et al The expert consensus guideline series. Treatment of behavioral emergencies 2005. J Psychiatr Pract 2005; 11(1): 5–112.

21.

Rommel

Molenaar

Gilden

, et al Long-term outcome of postpartum psychosis: a prospective clinical cohort study in 106 women. Int J Bipolar Disord 2021; 9(1): 31.

22.

Bergink

Burgerhout

Koorengevel

, et al Treatment of psychosis and mania in the postpartum period. Am J Psychiatry 2015; 172(2): 115–123.

23.

von Elm

Altman

Egger

, et al The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 2007; 147(8): 573–577.

24.

CDC. How does CDC identify severe maternal morbidity? https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/severe-morbidity-ICD.htm (accessed 17 January 2023).

25.

Logue

Wen

Monk

, et al Trends in and complications associated with mental health condition diagnoses during delivery hospitalizations. Am J Obstet Gynecol 2022; 226(3): 405e1–405.

26.

Momen

Plana-Ripoll

Agerbo

, et al Association between mental disorders and subsequent medical conditions. N Engl J Med 2020; 382(18): 1721–1731.

27.

Alva ML. Co-occurrence of diabetes and depression in the U.S. PLoS ONE 2020; 15(6): e0234718.

28.

Nousen

Franco

Sullivan

EL.

Unraveling the mechanisms responsible for the comorbidity between metabolic syndrome and mental health disorders. Neuroendocrinology 2014; 98(4): 254–266.

29.

Lilly

Culpepper

Stuart

, et al

Stroke survivors with severe mental illness: are they at-risk for increased non-psychiatric hospitalizations?

PLoS ONE 2017; 12(8): e0182330.

30.

Krishnamurthi

Schopfer

Shen

, et al Association of mental health conditions with participation in cardiac rehabilitation. J Am Heart Assoc 2019; 8(11): e011639.

31.

Fisher

Gonzalez

Polonsky

WH.

The confusing tale of depression and distress in patients with diabetes: a call for greater clarity and precision. Diabet Med 2014; 31(7): 764–772.

32.

Butwick

Abreo

Bateman

, et al Effect of maternal body mass index on postpartum hemorrhage. Anesthesiology 2018; 128(4): 774–783.

33.

Heller

Ravelli

ACJ

Bruning

AHL

, et al Increased postpartum haemorrhage, the possible relation with serotonergic and other psychopharmacological drugs: a matched cohort study. BMC Pregnancy Childbirth 2017; 17(1): 166.

34.

Bruning

Heller

Kieviet

, et al Antidepressants during pregnancy and postpartum hemorrhage: a systematic review. Eur J Obstet Gynecol Reprod Biol 2015; 189: 38–47.

35.

Corbetta-Rastelli

Friedman

Sobhani

, et al Postpartum hemorrhage trends and outcomes in the United States, 2000-2019. Obstet Gynecol 2023; 141(1): 152–161.

36.

Merriam

Wright

Siddiq

, et al Risk for postpartum hemorrhage, transfusion, and hemorrhage-related morbidity at low, moderate, and high volume hospitals. J Matern Neonatal Med 2018; 31(8): 1025–1034.

37.

Burger

Hoosain

Einspieler

, et al Maternal perinatal mental health and infant and toddler neurodevelopment—evidence from low and middle-income countries. J Affect Disord 2020; 268: 158–172.

38.

Gao

Liu

, et al Incidence and risk factors of postpartum hemorrhage in China: a multicenter retrospective study. Front Med 2021; 8: 673500.

39.

Edwards

Safe prevention of the primary cesarean delivery. AIMS J 2014; 26(2): 20.

40.

Salvi

Aguglia

Barone-Adesi

, et al Cardiovascular risk in patients with severe mental illness in Italy. Eur Psychiatry 2020; 63(1): e96.

41.

Stubbs

Williams

Gaughran

, et al How sedentary are people with psychosis? A systematic review and meta-analysis. Schizophr Res 2016; 171(1–3): 103–109.

42.

Sara

Chen

Large

, et al Potentially preventable hospitalisations for physical health conditions in community mental health service users: a population-wide linkage study. Epidemiol Psychiatr Sci 2021; 30: e22.

43.

Ostinelli

Brooke-Powney

, et al Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev 2017; 7(7): CD009377.

44.

Pluym

Holliman

Afshar

, et al Emergency department use among postpartum women with mental health disorders. Am J Obstet Gynecol MFM 2021; 3(1):100269.

45.

Roberts

Johnson

Hopwood

, et al The potential impact of a public health approach to improving the physical health of people living. Int J Environ Res Public Health 2022; 19(18): 11746.

46.

Simoila

Isometsä

Gissler

, et al Schizophrenia and pregnancy: a national register-based follow-up study among Finnish women born between 1965 and 1980. Arch Womens Ment Health 2020; 23(1): 91–100.

47.

Saucedo

Esteves-Pereira

Pencolé

, et al Understanding maternal mortality in women with obesity and the role of care they receive: a national case-control study. Int J Obes 2021; 45(1): 258–265.

48.

Björkstedt

Koponen

Kautiainen

, et al Preconception Mental Health, Socioeconomic Status, and Pregnancy Outcomes in Primiparous Women. Front Public Health 2022; 10: 880339.

49.

Dossa

Glickman

Berlowitz

Association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation. BMC Health Serv Res 2011; 11: 311.

50.

Roberts

Puri

Trzeciak

, et al Socioeconomic, racial and ethnic differences in patient experience of clinician empathy: Results of a systematic review and metaanalysis. PLoS ONE 2021; 16(3): e0247259.

51.

Osborne

LM.

Recognizing and managing postpartum psychosis: a clinical guide for obstetric providers.obstetrics and gynecology clinics of North America

Obstet Gynecol Clin North Am. 2018; 45(3): 455–468.

52.

Herzig

Rothberg

Guess

, et al Antipsychotic use in hospitalized adults: rates, indications, and predictors. J Am Geriatr Soci 2016; 64(2): 299–305.

53.

Dold

Samara

, et al Haloperidol versus first-generation antipsychotics for the treatment of schizophrenia and other psychotic disorders. Cochrane Database Syst Rev 2015; 1: CD009831.

54.

Bateman

Mhyre

Hernandez-Diaz

, et al Development of a comorbidity index for use in obstetric patients. Obstet Gynecol 2013; 122(5): 957–965.

55.

Hui

Bush

Gallo

, et al Neuroleptic dose in the management of delirium in patients with advanced cancer. J Pain Symptom Manage 2010; 39(2): 186–196.

56.

Sharp

Pallegadda

Baecker

, et al Are mental health and substance use disorders risk factors for missed acute myocardial infarction diagnoses among chest pain or dyspnea encounters in the emergency department. Ann Emerg Med 2022; 79(2): 93–101.

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