Predicting unplanned return to the operating room and postpartum haemorrhage in twin pregnancies following caesarean delivery: a multicentre retrospective cohort study in China

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BACKGROUND: Although some prediction models have been developed to evaluate postpartum haemorrhage in caesarean delivery with complications, limited attention has focused on unplanned return to the operating room (UPROR), especially in twin pregnancies. On this note, this study seeks to investigate the risk factors for UPROR and Postpartum Haemorrhage (PPH) in twin pregnancies after caesarean section (CS) and develop a nomogram for predicting PPH. OBJECTIVE: This study aimed to investigate the risk factors for UPROR and PPH in twin pregnancies after CS in China and develop a nomogram for PPH prediction. METHODS: A multicentre retrospective cohort study was conducted. There were a total of 1198 twin pregnant women who underwent a CS at the Women's Hospital, School of Medicine, Zhejiang University in Hangzhou, Ninghai Maternal and Child Health Hospital, Fuyang Women and Children's Hospital in China from January 2017 to December 2021. All 1198 pregnant women were randomly divided into two groups (D for development and V for validation), one for training and one for validation by ratio 7:3. A nomogram was developed to predict PPH (blood loss ≥1000 ml) and UPROR based on the model generated by logistic regression analysis. The training cohort and the validation cohort were evaluated in PPH, and a decision curve analysis was developed. RESULTS: 16.77% (201/1198) women experienced PPH, 142 of which (142/840, 16.90%) in the training cohort and 59 (59/358, 16.48%) in the validation cohort. Seven optimal variates were obtained as predictors of PPH in twin pregnancies, including assisted reproductive technology (ART), advanced gestational weeks, placenta previa, emergency operation, total birth weight, and the use of uterotonic and anticoagulants. The AUC for the nomogram was 0.75 (95% CI, 0.71-0.79) for the training cohort, while that was 0.83 (95% CI, 0.79-0.88) for the validation dataset. 3.67% (44/1198) of women experienced UPROR for tamponade after the CS; PPH was the cause in all cases, none of whom had a hysterectomy. Six optimal variates were obtained as predictors of UPROR in twin pregnancies, including advanced maternal age, ART, parity ≥ 1, placenta previa, total amount of amniotic fluid (ml) ≥ 1500, and twin growth discordance. The AUC for the nomogram was 0.74 (95% CI, 0.66-0.82). CONCLUSION: cesarean section has clinical potentials, including the prevention of PPH in twin pregnancies.

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