Risk factors for severe postpartum hemorrhage after cesarean delivery: case-control studies. Anesth Analg. Risk factors for severe postpartum hemorrhage: a case-control study. Bmc Pregnancy Childb. Prevalence and risk factors of severe obstetric haemorrhage. Evaluation of risk-assessment tools for severe postpartum hemorrhage in women undergoing cesarean delivery.
Severe maternal morbidity: screening and review. Obstetric Care Consensus No. Obstetrics group, obstetrics and Gynecology branch, Chinese Medical Association. Guidelines for prevention and management of postpartum hemorrhage Chin J Obstet Gynecol. Google Scholar. Identifying regional variation in the prevalence of postpartum haemorrhage: a systematic review and meta-analysis.
PLoS One. Visual estimation versus gravimetric measurement of postpartum blood loss: a prospective cohort study. Arch Gynecol Obstet. Schorn MN. Measurement of blood loss: review of the literature. J Midwifery Womens Health.
Increasing trends in atonic postpartum haemorrhage in Ireland: an year population-based cohort study. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Prevalence and main outcomes of placenta accreta spectrum: a systematic review and meta-analysis. Postpartum hemorrhage with transfusion: trends, near misses, risk factors and management at the scale of a perinatal network.
J Gynecol Obstet Hum Reprod. Incidence and risk factors for postpartum hemorrhage among transvaginal deliveries at a tertiary perinatal medical facility in Japan. Incidence and risk factors for postpartum hemorrhage in Uganda. Reprod Health. World Health Organization. Worldwide prevalence of anaemia — WHO global database on Anemia.
Geeneva: WHO; National and international guidelines for patient blood management in obstetrics: a qualitative review. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. Rethinking our approach to postpartum haemorrhage and uterotonics.
Correlation of placental microbiota with fetal macrosomia and clinical characteristics in mothers and newborns. Prevention, management, and outcomes of macrosomia: a systematic review of literature and meta-analysis.
Obstet Gynecol Surv. Maternal age and risk for adverse outcomes. Durmaz A, Komurcu N. Relationship between maternal characteristics and postpartum hemorrhage: a meta-analysis study. J Nurs Res. Advanced maternal age and postpartum hemorrhage — risk factor or red herring? J Matern Fetal Neonatal Med. Hospital data reporting on postpartum hemorrhage: under-estimates recurrence and over-estimates the contribution of uterine atony.
Matern Child Health J. Patterns of recurrence of postpartum hemorrhage in a large population-based cohort. Maternal and live-birth outcomes of pregnancies following assisted reproductive technology: a retrospective cohort study. Sci Rep. Maternal morbidity associated with cesarean delivery without labor compared with spontaneous onset of labor at term.
Download references. You can also search for this author in PubMed Google Scholar. FH and DJC were responsible for conception, study design and approved the final version. All authors read and approved the final manuscript.
Correspondence to Fang He or Dun-jin Chen. The study was approved by the medical research ethics committee of the Third Affiliated Hospital of Guangzhou Medical University. The need for informed consent was waived due to the retrospective nature of this study.
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Reprints and Permissions. Liu, Cn. Prevalence and risk factors of severe postpartum hemorrhage: a retrospective cohort study. BMC Pregnancy Childbirth 21, Download citation. Received : 16 August Accepted : 20 April Published : 26 April Anyone you share the following link with will be able to read this content:.
Sorry, a shareable link is not currently available for this article. The multivariable analysis was preceded by estimation of collinearity between risk factors.
When collinearity existed between two variables, we omitted the one with least clinical relevance. Finally, multivariable logistic regression with manual backward elimination was used to identify independent risk factors for severe PPH [ 20 ].
The continuous variables of maternal age, BMI, and birth weight were introduced into the model in its logged form as they were linearly associated with the outcome. However, birth weight is presented dichotomized in Table 3 as this was judged clinically more interesting. Because we were applying a pragmatic strategy, the predictive accuracy of the model was evaluated by calibration and discrimination [ 21 ]. Calibration , which measures the ability of the model to assign the appropriate risk, was evaluated by the Hosmer and Lemeshow H-L goodness-of-fit test.
If the area under the curve is greater than 0. The identified causes of severe PPH are listed in Table 1. The most common cause was uterine atony Abnormal placentation was diagnosed post-delivery in 4. The distribution of potential risk factors is presented in Table 2. Europe, the United States, and Oceania were countries of origin for the majority of cases and controls The median interquartile ranges values for maternal age, BMI, and birthweight were similar among cases and controls; maternal age: 32 29—36 years vs.
Risk factors independently associated with severe PPH are presented in Table 3. The area under the ROC curve was 0. When considering the same risk factors, the results of the sub-analysis did not change our conclusions Appendix : Table 4. In this case-control study, we evaluated risk factors for severe PPH. A history of severe PPH was the strongest independent risk factor in our study.
Our findings suggest that women with increased risk of severe PPH can be identified when antepartum and intrapartum variables are considered. Furthermore, retained placental tissue was a much more frequent cause of severe PPH than previously reported.
The main strength of this case-control study was the quality of the data source. By reviewing medical records, we were able to evaluate potential risk factors for severe PPH using a broad selection of clinical variables which may not be easily retrieved from registries. In addition, reading the medical records enabled us to present accurate information on the causes of severe PPH and especially on the rate of retained placental tissue including abnormal placentation in the cases.
We lacked data on women with suspected abnormal placentation prior to delivery as there was little awareness around pre-delivery diagnosis of abnormal placentation in Norway during the study period. Abnormal placentation could therefore not be included as a risk factor for severe PPH in our model.
Assessing risk factors in retrospect is a limitation in this study. In order to minimize selection bias, we selected all cases of severe PPH and a random sample of controls from the same source population. There is a possibility that some cases were misclassified.
Blood loss was estimated visually in the three hospitals included in our study, and the blood loss may have been underestimated [ 23 , 24 ]. However, we had further data in medical records to assess the severity of the hemorrhage by need for blood transfusion. There is a possibility of information bias due to misclassification of the exposures. However, neither the resident obstetrician nor midwife were aware of our research questions, therefore the potential for misclassification of risk factors would be non-differential creating a bias toward the null [ 20 ].
The sample size provided adequate power to highlight risk factors mildly associated with severe PPH, such as infant birth weight. However, we did not account for multiple testing in the power analysis and the smallest detectable odds ratios may have been underestimated. We based our results on deliveries in three hospitals in or close to Oslo, Norway, and our results may not necessarily be generalizable to other delivery populations in well-resourced countries.
The majority of the women in this study had European, USA, or Oceanian ethnicity, and was non-obese and married. These characteristics reflect a society with a low proportion of women with low socioeconomic status and fewer immigrants compared to other well-resourced countries.
Furthermore, the hospitals mainly reflect an urban setting, but urban-rural differences in Norway are small and home births are an exception. The strongest risk factor in our study was a history of severe PPH. Previously reported estimates on recurrence risk are mainly from register-based studies [ 25 — 27 ], presenting lower estimates between 2.
Having a history of PPH may be less well-reported to the registries than in our data sources. The causes of PPH recurrence were investigated in a population study from Sweden [ 27 ]. They reported that recurrence risk could not be explained by known risk factors for PPH, suggesting that recurrence may depend on environmental and genetic factors. Alterations in maternal hemostasis and oxytocin signaling at the myometrial level were postulated as possible pathways for a maternal genetic predisposition to PPH.
A close to five-fold increased risk of severe PPH was found in women using anticoagulant drugs in pregnancy. The obstetric guidelines in Norway recommend stopping anticoagulants at the onset of labor or 12 h before a planned cesarean delivery. Our finding is in line those from a Swedish study [ 30 ]. In this study, the risk of PPH was increased three-fold for women using anticoagulants in pregnancy.
Other studies, however, have not found any significantly increased risk of severe PPH associated with the use of anticoagulant drugs [ 31 , 32 ]. Differences in anticoagulant drug regimens may explain why this association has not been consistently shown across these studies. Of note, in our analyses, we did not account for drug dosing or the time interval between last anticoagulant dose and PPH onset. Obstetric interventions, such as augmentation and induction of labor, instrumental vaginal delivery, and cesarean delivery, were all significantly associated with severe PPH.
A potential for risk reduction is likely if the use of these interventions are limited to situations where existing evidence supports their safe use. In line with previous studies, compared with spontaneous vaginal delivery, the odds of severe PPH were higher among women undergoing either in-labor or planned cesarean delivery [ 1 , 33 ].
Previous studies have shown conflicting results [ 1 , 34 — 36 ] on whether labor augmentation is a risk factor independent of induction. Oxytocin receptor desensitization may explain why labor augmentation with oxytocin is associated with uterine atony leading to PPH [ 37 — 39 ].
The association between oxytocin administration and PPH has been reported to be dose related and evidence-based guidelines are needed to determine optimal oxytocin regimens for labor augmentation to lessen the risk of atonic PPH [ 34 ]. This association has been poorly described, and previous studies observing an association between assisted reproductive technology and severe PPH are from retrospective infertility cohorts [ 40 — 42 ]. Events around the implantation of the placenta, such as low placement of the embryo into the uterus and endometrial function disturbances, could play a role here.
In our study, the frequency of severe PPH was 2. The difference can be explained by a tendency to underreport cases of severe PPH to the birth registries. In a study examining risk factors and outcomes of massive blood transfusions during delivery [ 44 ], abnormal placentation was reported to be the most common cause The same study reported that a disproportionate number of women who received a massive blood transfusion experienced severe maternal morbidity, illustrating why abnormal placentation is becoming a major concern in obstetrics.
In addition, abnormal placentation may have been present for some cases diagnosed as retained placenta as pathology reports are not available for the majority of these cases.
Our findings suggest that retained placental tissue may be a more prominent cause of severe PPH than previously reported. False reporting of cases caused by retained placental tissue as atonic bleeding in registries could explain this discrepancy. Access to detailed medical information enabled us to accurately estimate the proportion of cases with placental problems in our population.
We believe the high rate of placental problems revealed in the current study could reflect an increasing rate of placental problems. Including these risk factors in clinical guidelines could help to identify women with high risk of severe PPH prior to delivery.
By identifying these women, adequate resources and staff could be mobilized in preparation for severe bleeding at the time of delivery. Several of the identified risk factors in our study were related to medical and obstetric interventions such as anticoagulant medication, assisted reproductive technologies, labor induction, and labor augmentation with oxytocin.
Further studies are needed to better understand the risk-benefit profile of each intervention on maternal outcomes. Risk factors identified in our study could be considered in future studies examining risk prediction models for severe PPH. Incidence and predictors of severe obstetric morbidity: case-control study. Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a surrogate marker for severe maternal morbidity in a European population-based study: the MOMS-B survey.
Article PubMed Google Scholar. Severe acute maternal morbidity: a pilot study of a definition for a near-miss. Quantifying severe maternal morbidity: a Scottish population study.
Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the international postpartum hemorrhage collaborative group. BMC Pregnancy Childbirth. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg. Risk factors for postpartum hemorrhage: can we explain the recent temporal increase?
J Obstet Gynaec Can. Article Google Scholar. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obst Gynecol. Increased postpartum hemorrhage rates in Australia. Bakri balloon or a Foley catheter to put pressure on the bleeding inside the uterus. Your healthcare provider may pack the uterus with sponges and sterile materials. This may be done if a Bakri balloon or Foley catheter is not available. Tying off or sealing bleeding blood vessels.
This is done using uterine compression sutures, special gel, glue, or coils. The surgery is done during a laparotomy.
This is surgery to remove the uterus. In most cases, this is a last resort. Replacing lost blood and fluids is important in treating postpartum hemorrhage. You may quickly be given IV intravenous fluids, blood, and blood products to prevent shock. Oxygen may also help. Postpartum hemorrhage can be quite serious. But when your provider quickly finds and treats the cause of bleeding, you often will be able to recover fully.
Losing lots of blood quickly can cause a severe drop in your blood pressure. This may lead to shock and death if not treated. It's important to have emergency care available in case it is needed at the time of delivery and after birth. Early care can reduce the amount of blood loss. Most cases of postpartum hemorrhage occur at delivery or soon after.
But you may bleed heavily after you go home from the hospital. Talk with your healthcare provider about the symptoms of postpartum hemorrhage and what to watch for. During your hospital stay or once you get home, call your healthcare provider right away if you have any of the following:.
Vaginal bleeding that needs a new sanitary pad after an hour, or you pass large blood clots. It may lead to shock and death if not treated. The most common cause of postpartum hemorrhage is when the uterus does not contract enough after delivery. Quickly finding and treating the cause of bleeding can often lead to a full recovery. Bring someone with you to help you ask questions and remember what your provider tells you.
At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests.
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