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      Risk factors and recurrence of cause-specific postpartum hemorrhage: A population-based study

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          Abstract

          Objective

          To explore risk profiles of the different types of postpartum hemorrhage (PPH >500ml or severe PPH >1500ml) and their recurrence risks in a subsequent delivery.

          Methods

          With data from The Medical Birth Registry of Norway and Statistics Norway we performed a population-based cohort study including all singleton deliveries in Norway from 1967–2017. Multilevel logistic regression was used to calculate odds ratio (OR), with 95% confidence interval (CI), with different PPH types (PPH >500ml or PPH >1500ml (severe PPH) combined with retained placenta, uterine atony, obstetric trauma, dystocia, or undefined cause) as outcomes.

          Result

          We identified 277 746 PPH cases of a total of 3 003 025 births (9.3%) from 1967 to 2017. Retained placenta (and/or membranes) was most often registered as severe PPH (29.3%). Maternal, fetal, and obstetric characteristics showed different associations with the PPH types. Male sex of the neonate was associated with reduced risk of PPH. This effect was strongest on PPH due to retained placenta (adjusted OR, (aOR): 0.80, 95% CI 0.78–0.82), atony (aOR 0.92, 95% CI: 0.90–0.93) and PPH with undefined cause (aOR 0.96, 95% CI: 0.95–0.97). Previous cesarean section showed a strong association with PPH due to dystocia (aOR of 13.2, 95% CI: 12.5–13.9). Recurrence risks were highest for the same type: PPH associated with dystocia (aOR: 6.8, 95% CI: 6.3–7.4), retained placenta and/or membranes (aOR: 5.9, 95% CI: 5.5–6.4), atony (aOR: 4.0, 95% CI: 3.8–4.2), obstetric trauma (aOR: 3.9, 95% CI: 3.5–4.3) and PPH of undefined cause (aOR: 2.2, 95% CI: 2.1–2.3).

          Conclusion

          Maternal, fetal and obstetric characteristics had differential effects on types of PPH. Recurrence differed considerably between PPH types. Retained placenta was most frequently registered with severe PPH, and showed strongest effect of sex; delivery of a boy was associated with lower risk of PPH. Previous cesarean increased the risk of PPH due to dystocia.

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          Most cited references56

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          Global causes of maternal death: a WHO systematic analysis.

          Data for the causes of maternal deaths are needed to inform policies to improve maternal health. We developed and analysed global, regional, and subregional estimates of the causes of maternal death during 2003-09, with a novel method, updating the previous WHO systematic review. We searched specialised and general bibliographic databases for articles published between between Jan 1, 2003, and Dec 31, 2012, for research data, with no language restrictions, and the WHO mortality database for vital registration data. On the basis of prespecified inclusion criteria, we analysed causes of maternal death from datasets. We aggregated country level estimates to report estimates of causes of death by Millennium Development Goal regions and worldwide, for main and subcauses of death categories with a Bayesian hierarchical model. We identified 23 eligible studies (published 2003-12). We included 417 datasets from 115 countries comprising 60 799 deaths in the analysis. About 73% (1 771 000 of 2 443 000) of all maternal deaths between 2003 and 2009 were due to direct obstetric causes and deaths due to indirect causes accounted for 27·5% (672 000, 95% UI 19·7-37·5) of all deaths. Haemorrhage accounted for 27·1% (661 000, 19·9-36·2), hypertensive disorders 14·0% (343 000, 11·1-17·4), and sepsis 10·7% (261 000, 5·9-18·6) of maternal deaths. The rest of deaths were due to abortion (7·9% [193 000], 4·7-13·2), embolism (3·2% [78 000], 1·8-5·5), and all other direct causes of death (9·6% [235 000], 6·5-14·3). Regional estimates varied substantially. Between 2003 and 2009, haemorrhage, hypertensive disorders, and sepsis were responsible for more than half of maternal deaths worldwide. More than a quarter of deaths were attributable to indirect causes. These analyses should inform the prioritisation of health policies, programmes, and funding to reduce maternal deaths at regional and global levels. Further efforts are needed to improve the availability and quality of data related to maternal mortality. © 2014 World Health Organization; licensee Elsevier. This is an Open Access article published without any waiver of WHO's privileges and immunities under international law, convention, or agreement. This article should not be reproduced for use in association with the promotion of commercial products, services, or any legal entity. There should be no suggestion that WHO endorses any specific organisation or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.
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            The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries.

            In this study, we sought to (1) define trends in the incidence of postpartum hemorrhage (PPH), and (2) elucidate the contemporary epidemiology of PPH focusing on risk factors and maternal outcomes related to this delivery complication. Hospital admissions for delivery were extracted from the Nationwide Inpatient Sample, the largest discharge dataset in the United States. Using International Classification of Diseases, Clinical Modification (ninth revision) codes, deliveries complicated by PPH were identified, as were comorbid conditions that may be risk factors for PPH. Temporal trends in the incidence of PPH from 1995 to 2004 were assessed. Logistic regression was used to identify risk factors for the most common etiology of PPH-uterine atony. In 2004, PPH complicated 2.9% of all deliveries; uterine atony accounted for 79% of the cases of PPH. PPH was associated with 19.1% of all in-hospital deaths after delivery. The overall rate of PPH increased 27.5% from 1995 to 2004, primarily because of an increase in the incidence of uterine atony; the rates of PPH from other causes including retained placenta and coagulopathy remained relatively stable during the study period. Logistic regression modeling identified age or =40 years, cesarean delivery, hypertensive diseases of pregnancy, polyhydramnios, chorioamnionitis, multiple gestation, retained placenta, and antepartum hemorrhage as independent risk factors for PPH from uterine atony that resulted in transfusion. Excluding maternal age and cesarean delivery, one or more of these risk factors were present in only 38.8% of these patients. PPH is a relatively common complication of delivery and is associated with substantial maternal morbidity and mortality. It is increasing in frequency in the United States. PPH caused by uterine atony resulting in transfusion often occurs in the absence of recognized risk factors.
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              Placenta accreta: pathogenesis of a 20th century iatrogenic uterine disease.

              Placenta accreta refers to different grades of abnormal placental attachment to the uterine wall, which are characterised by invasion of trophoblast into the myometrium. Placenta accreta has only been described and studied by pathologists for less than a century. The fact that the first detailed description of a placenta accreta happened within a couple of decades of major changes in the caesarean surgical techniques is highly suggestive of a direct relationship between prior uterine surgery and abnormal placenta adherence. Several concepts have been proposed to explain the abnormal placentation in placenta accreta including a primary defect of the trophoblast function, a secondary basalis defect due to a failure of normal decidualization and more recently an abnormal vascularisation and tissue oxygenation of the scar area. The vast majority of placenta accreta are found in women presenting with a previous history of caesarean section and a placenta praevia. Recent epidemiological studies have also found that the strongest risk factor for placenta praevia is a prior caesarean section suggesting that a failure of decidualization in the area of a previous uterine scar can have an impact on both implantation and placentation. Ultrasound studies of uterine caesarean section scar have shown that large and deep myometrial defects are often associated with absence of re-epithelialisation of the scar area. These findings support the concept of a primary deciduo-myometrium defect in placenta accreta, exposing the myometrium and its vasculature below the junctional zone to the migrating trophoblast. The loss of this normal plane of cleavage and the excessive vascular remodelling of the radial and arcuate arteries can explain the in-vivo findings and the clinical consequence of placenta accreta. Overall these data support the concept that abnormal decidualization and trophoblastic changes of the placental bed in placenta accreta are secondary to the uterine scar and thus entirely iatrogenic.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: SupervisionRole: ValidationRole: Writing – review & editing
                Role: SupervisionRole: ValidationRole: Writing – review & editing
                Role: SupervisionRole: ValidationRole: Writing – review & editing
                Role: SupervisionRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                14 October 2022
                2022
                : 17
                : 10
                : e0275879
                Affiliations
                [1 ] Department of Clinical Science, University of Bergen, Bergen, Norway
                [2 ] Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
                [3 ] Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
                [4 ] Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
                [5 ] Finnish Institute for Health and Welfare, Department of Knowledge Brokers, Helsinki, Finland
                [6 ] Karolinska Institute, Department of Molecular Medicine and Surgery, Stockholm, Sweden
                University of Oslo, NORWAY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                https://orcid.org/0000-0001-5865-0581
                https://orcid.org/0000-0003-0933-6988
                https://orcid.org/0000-0002-4331-1250
                Article
                PONE-D-22-13255
                10.1371/journal.pone.0275879
                9565392
                36240210
                44301332-8fe5-44d0-bd79-4c9ce1f8d039
                © 2022 Linde et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 6 May 2022
                : 23 September 2022
                Page count
                Figures: 2, Tables: 5, Pages: 18
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100005036, Universitetet i Bergen;
                Award ID: employed in a 4-year Doctoral Research Fellowship
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100005029, Helse Vest Regionalt Helseføretak;
                Award ID: project no. 990226
                Award Recipient :
                L.E.L. is employed in a position at the University of Bergen: a 4-year Doctoral Research Fellowship. The research file was financed by a research grant from The Western Norway Regional Health Authority (project no. 990226). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Critical Care and Emergency Medicine
                Severe Blood Loss
                Postpartum Hemorrhage
                Medicine and Health Sciences
                Clinical Medicine
                Signs and Symptoms
                Hemorrhage
                Severe Blood Loss
                Postpartum Hemorrhage
                Medicine and Health Sciences
                Vascular Medicine
                Hemorrhage
                Severe Blood Loss
                Postpartum Hemorrhage
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Birth
                Postpartum Hemorrhage
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Birth
                Postpartum Hemorrhage
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Birth
                Labor and Delivery
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Birth
                Labor and Delivery
                Biology and Life Sciences
                Developmental Biology
                Embryology
                Placenta
                Biology and Life Sciences
                Anatomy
                Reproductive System
                Placenta
                Medicine and Health Sciences
                Anatomy
                Reproductive System
                Placenta
                Medicine and Health Sciences
                Epidemiology
                Medical Risk Factors
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Medicine and Health Sciences
                Women's Health
                Maternal Health
                Pregnancy
                Medicine and Health Sciences
                Women's Health
                Obstetrics and Gynecology
                Pregnancy
                Medicine and Health Sciences
                Clinical Medicine
                Signs and Symptoms
                Hemorrhage
                Medicine and Health Sciences
                Vascular Medicine
                Hemorrhage
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Obstetric Procedures
                Cesarean Section
                Custom metadata
                Availability of data and material: Legal restrictions do not permit the authors to provide the data that constitute the basis of this study. The main data utilized are available from the data owner, the Norwegian Institute of Public Health ( https://www.fhi.no/en/more/research--access-to-data/), after obtaining approval from The Regional Committee for Medical Research Ethics ( https://rekportalen.no/), for researchers who meet the criteria for access to confidential data. Contact information: The Medical Birth Registry of Norway, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway. Code availability: The data are confidential and cannot be shared.

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