Prognostic Value of the Shock Index and the Impact of Surgical Intensivist Co-management in Postpartum Hemorrhage: A 10-Year Retrospective Cohort Study (2015–2024)

Objective: To validate the prognostic value of shock index (SI) as an early risk-stratification tool and assess the impact of a surgical intensivist-led co-management model on outcomes in outborn patients with postpartum hemorrhage (PPH). Design: Retrospective cohort study with a before-and-after analysis. Setting: Emergency department of a tertiary referral center. Population: Outborn patients with PPH transferred between 2015 and 2024 (n = 495). Methods: Severe PPH was defined by transfusion requirements and major hemostatic interventions. Multivariate logistic regression identified predictors of severe PPH and composite poor prognosis. Discriminatory performance of SI was evaluated using receiver operating characteristic analysis. Clinical outcomes before and after implementation of intensivist-led co-management in 2021 were compared. Main Outcome Measures: Severe PPH, composite poor prognosis, and post-implementation clinical outcomes. Results: Of 495 patients, 326 (65.9%) had severe PPH. Primary PPH, prior uterine surgery, and higher SI on emergency department arrival were independently associated with severe PPH. For composite poor prognosis, SI and hypovolemic shock were independent predictors, whereas higher hemoglobin and fibrinogen levels were protective. After implementation of intensivist-led co-management, angioembolization rates increased significantly without increased mortality, despite greater case complexity. Mortality remained stable in the post-intervention period, suggesting improved rescue capacity. Conclusions: SI at emergency department arrival is a practical and robust predictor of severe PPH and adverse outcomes in outborn patients. Incorporating SI-based risk stratification into a surgical intensivist-led multidisciplinary model may enable timely escalation of hemostatic interventions and mitigate the impact of increasing clinical severity on maternal outcomes.