A study conducted at a single public maternity unit in Hong Kong reports a 67 percent increase in massive primary postpartum haemorrhage (PPH) between 2006–2011 and 2017–2022, as well as considerable improvements in maternal outcomes, such as lower blood loss and hysterectomy rate, owing to increased use of second-line (2L) therapies.
In Hong Kong, massive primary PPH is defined as blood loss ≥1,500 mL within the first 24 hours after delivery and represents a key clinical performance indicator for obstetric services in public hospitals. The present study evaluated trends in massive primary PPH, use of 2L therapies, and maternal outcomes, including peripartum hysterectomy, since the implementation of prospective electronic data collection across Hong Kong public hospitals’ obstetric services in 2017. [Hong Kong Med J 2026;32:300-308]
The electronic data of 20,348 women who delivered at Kwong Wah Hospital in 2017–2022 were retrieved using the Clinical Data Analysis and Reporting System and compared with a previous study, which evaluated outcomes among 34,296 women who delivered at the same institution in 2006–2011. [Int J Gynaecol Obstet 2013;122:238-243]
The incidence of massive primary PPH rose from 0.27 percent in 2006–2011 to 0.44 percent in 2017–2022 (p<0.001), representing a 67 percent increase in absolute terms. The researchers noted that although women in the more recent cohort were older (mean age, 35.2 vs 33.3 years) and that more women were of advanced maternal age (58.9 vs 42.9 percent), other baseline characteristics, including body mass index, parity, twin pregnancy, gestational age at delivery, and length of hospital stay, were similar between cohorts. Furthermore, the overall distributions of mode of delivery and causes of PPH did not differ significantly between the two cohorts.
At the same time, maternal outcomes improved in the recent cohort: estimated blood loss was significantly lower (1,700 vs 2,000 mL; p<0.001), as was the number of transfused units of packed red blood cells (2 vs 4; p<0.001) and proportion of patients with massive primary PPH requiring hysterectomy (2.2 vs 14.3 percent; p=0.003). “Earlier and more frequent implementation of 2L therapies, particularly balloon tamponade, may have contributed to the observed reduction in hysterectomy rates,” suggested the researchers.
Indeed, there was a pronounced increase in the use of 2L therapies, from 46.2 percent in the earlier cohort to 68.9 percent in the more recent cohort (p<0.001). Management with oxytocin alone became less common, whereas use of oxytocin combined with other uterotonics or tranexamic acid increased in the recent cohort.
The distribution of specific 2L therapies significantly differed between cohorts (p<0.001). “In the recent cohort, balloon tamponade was used more frequently, whereas uterine artery embolization was no longer performed. Fewer women were managed with uterine compression sutures alone. Additionally, the proportion of women receiving more than one 2L therapy increased from 14.3 percent in the earlier cohort to 21.0 percent in the recent cohort,” elaborated the researchers.
Regression analyses demonstrated that although 2L therapy was associated with greater blood loss overall – likely reflecting its use in more severe cases – this association was weaker in the recent cohort, suggesting a shift to earlier implementation of 2L therapies, before occurrence of excessive blood loss.