Association between ionised calcium and severity of postpartum haemorrhage: a retrospective cohort study

Danny Epstein*, Neta Solomon, Alexander Korytny, Erez Marcusohn, Yaacov Freund, Ron Avrahami, Ami Neuberger, Aeyal Raz, Asaf Miller

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Background: Postpartum haemorrhage (PPH) is often complicated by impaired coagulation. We aimed to determine whether the level of ionised calcium (Ca2+), an essential coagulation co-factor, at diagnosis of PPH is associated with bleeding severity. Methods: This was a retrospective cohort study of women diagnosed with PPH during vaginal delivery between January 2009 and April 2020. Ca2+ levels at PPH diagnosis were compared between women who progressed to severe PPH (primary outcome) and those with less severe bleeding. Severe PPH was defined by transfusion of ≥2 blood units, arterial embolisation or emergency surgery, admission to ICU, or death. Associations between other variables (e.g. fibrinogen concentration) and bleeding severity were also assessed. Results: For 436 patients included in the analysis, hypocalcaemia was more common among patients with severe PPH (51.5% vs 10.6%, P<0.001). In a multivariable logistic regression model, Ca2+ and fibrinogen were the only parameters independently associated with PPH severity with odds ratios of 1.14 for each 10 mg dl−1 decrease in fibrinogen (95% confidence interval [CI], 1.05–1.24; P=0.002) and 1.97 for each 0.1 mmol L−1 decrease in Ca2+ (95% CI, 1.25–3.1; P=0.003). The performance of Ca2+ or fibrinogen was not significantly different (area under the curve [AUC]=0.79 [95% CI, 0.75–0.83] vs AUC=0.86 [95% CI, 0.82–0.9]; P=0.09). The addition of Ca2+ to fibrinogen improved the model, leading to AUC of 0.9 (95% CI, 0.86–0.93), P=0.03. Conclusions: Ca2+ level at the time of diagnosis of PPH was associated with risk of severe bleeding. Ca2+ monitoring may facilitate identification and treatment of high-risk patients.

Original languageEnglish
Pages (from-to)1022-1028
Number of pages7
JournalBritish Journal of Anaesthesia
Issue number5
StatePublished - May 2021


  • coagulation
  • fibrinogen
  • hypocalcaemia
  • ionised calcium
  • postpartum haemorrhage


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