Risk Factors for Severe Secondary Postpartum Hemorrhages: A Historical Cohort Study.

BACKGROUND: The predictive factors of secondary postpartum hemorrhage (PPH) are little known. Our principal objective was to determine if immediate PPH is a risk factor for severe secondary PPH. We also sought to identify other factors associated with severe secondary PPH. METHODS: Our historical cohort study included all women who gave birth (≥ 22 weeks) in our level III hospital from 2004 through 2013. The hospital discharge database enabled us to identify all women readmitted during the 42-day postpartum period or who underwent a surgical, medical, or interventional radiology procedure during their immediate postpartum hospitalization. We then examined all medical records to identify the cases involving severe secondary PPH. We studied the known risk factors of secondary PPH and assessed other potential ones: maternal age, multiple pregnancy, induction of labor, cesarean birth, preterm birth, and stillbirth. RESULTS: The study included 63 women with a severe secondary PPH and 25,696 women without a secondary PPH. Immediate PPH (aOR 2.7 [95% CI 1.3-5.6]) and maternal age ≥ 35 years (aOR 2.0 [95% CI 1.1-3.7]) were the only factors associated with severe secondary PPH. DISCUSSION: This cohort study confirms that immediate PPH is a risk factor for severe secondary PPH and reports for the first time an association between secondary PPH and advanced maternal age. It is likely that risk factors for immediate PPH are also risk factors for severe secondary PPH and thus that immediate PPH may be an intermediate factor between its own known risk factors and secondary PPH.

Severe secondary postpartum hemorrhage: a historical cohort.

OBJECTIVES: The principal objective of our study was to describe the frequency of severe secondary postpartum hemorrhages (PPH). Our secondary objectives were to describe the different causes of PPH and to assess if the PPH etiologies varied by parity. METHODS: This is a historical cohort study covering the period from January 1, 2004, through February 13, 2013, in a level III maternity ward. Women were eligible if they were treated for severe secondary PPH during their postpartum hospitalization or were admitted for it after discharge but before the 42nd day postpartum, regardless of the type of delivery. Women were excluded if they gave birth before 22 weeks of gestation or if they had experienced only an immediate PPH (≤ 24 hours after delivery). Eligible patients were identified by the hospital's administrative software. Primiparas and multiparas were compared with Student's t test and a chi-squared or Fisher's exact test. RESULTS: The incidence of severe secondary PPH was 0.23 percent (n = 60/26,023). The mean time between delivery and PPH onset was 13.4 ± 10.8 days. The women's mean age was 30.4 ± 5.7 years and their mean body mass index was 23.4 ± 5.7 kg/m². Placental retention was the cause to which these hemorrhages were most frequently attributed (30.0%). Subinvolution of the placental bed was noted in 13.3 percent of the patients, endometritis in 10.0 percent, pseudoaneurysm of the uterine artery in 3.3 percent, and excessively strong resumption of menses in 3.3 percent; no cause could be determined for 16.7 percent of the cases. Neither clinical signs nor causes differed by parity. CONCLUSION: Secondary PPH is rare. Accurate diagnosis is based most often on histopathologic findings.