Risk factors for primary postpartum hemorrhage in Bhumibol Adulyadej Hospital.

Abstract

Postpartum hemorrhage remains one of the main causes of maternal morbidity and mortality in both developed and developing countries. Hemorrhages account for 28%of all direct maternal deaths and remain the most common cause of direct maternal deaths worldwide.
To study the incidence and risk factors for postpartum hemorrhage (PPH) in Bhunibol Adulyadej Hospital.
Retrospective cohort study of 19,429 patients who gave birth between P' January 2004 and 31st December 2007 at Bhumibol Adulyadej Hospital. One thousand five hundred and thirty women were enrolled in the present study, three hundred and eighty five women had postpartum hemorrhage and one thousand one hundred and forty-five had no postpartum hemorrhage. The present study analyzed one postpartum hemorrhage woman compared to three women who gave birth in nearly the same period and had no postpartum hemorrhage both vaginal deliveries and cesarean section.
The PPH rate in Bhumibol Adulyadej Hospital was 1.98%. Maternal age, height and fetal birth weight were not different between the PPH group and no PPH group. The strongest risk factors for postpartum hemorrhage in the present study were prolonged 3rd stage of labor, retained placenta, lacerations of birth passage, and placenta previa.
The strongest risk factors for postpartum hemorrhage in the present study were prolonged 3rd stage of labor, retained placenta, lacerations of birth passage, and placenta previa.

Full text

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1586J Med Assoc Thai Vol. 92 No. 12 2009
Risk Factors for Primary Postpartum Hemorrhage in
Bhumibol Adulyadej Hospital
Wibool Rueangchainikhom MD*, Siriwan Srisuwan MD**,
Sinart Prommas MD*, Saravut Sarapak BSc (MT)*
* Department of Obstetrics and Gynecology, Bhumibol Adulyadej Hospital, Bangkok, Thailand
** Department of Obstetrics and Gynecology, Srinakharinwirot University, Bangkok, Thailand
Background: Postpartum hemorrhage remains one of the main causes of maternal morbidity and mortality in
both developed and developing countries. Hemorrhages account for 28%of all direct maternal deaths and
remain the most common cause of direct maternal deaths worldwide.
Objective: To study the incidence and risk factors for postpartum hemorrhage (PPH) in Bhunibol Adulyadej
Hospital
Material and Method: Retrospective cohort study of 19,429 patients who gave birth between 1st January 2004
and 31st December 2007 at Bhumibol Adulyadej Hospital. One thousand five hundred and thirty women
were enrolled in the present study, three hundred and eighty five women had postpartum hemorrhage and
one thousand one hundred and forty five had no postpartum hemorrhage. The present study analyzed one
postpartum hemorrhage woman compared to three women who gave birth in nearly the same period and had
no postpartum hemorrhage both vaginal deliveries and cesarean section.
Results: The PPH rate in Bhumibol Adulyadej Hospital was 1.98%. Maternal age, height and fetal birth
weight were not different between the PPH group and no PPH group. The strongest risk factors for postpartum
hemorrhage in the present study were prolonged 3rd stage of labor, retained placenta, lacerations of birth
passage, and placenta previa.
Conclusion: The strongest risk factors for postpartum hemorrhage in the present study were prolonged
3rd stage of labor, retained placenta, lacerations of birth passage, and placenta previa.
Keywords: Postpartum hemorrhage, Risk factors
Correspondence to: Rueangchainikhom W, Department of
Obstetrics and Gynecology, Bhumibol Adulyadej Hospital,
Paholyothin Road, Bangkok 10220, Thailand. Phone: 0-2534-
7314-7, E-mail: wibool99@yahoo.co.uk
Postpartum hemorrhage remains one of the
main causes of maternal morbidity and mortality in both
developed and developing countries(1). Approximately
40% of pregnant women experience pregnancy-related
health problems, and 15% of all pregnant women suffer
long term or life threatening complications(2). There are
an estimated 14 million cases of pregnancy-related
hemorrhage every year; at least 128,000 of these women
bleed to death(3). The World Health Organization
(WHO) estimates that, in 1995, nearly 515,000 women
worldwide died from complications of pregnancy
and childbirth especially in developing countries(4,5).
Hemorrhages account for 28% of all direct maternal
deaths and remain the most common cause of direct
maternal deaths worldwide(6,7). In 1990, the World
Health Organization (WHO) defined primary post-
partum hemorrhage (PPH) as blood loss equaling or
exceeding 500 ml in vaginal deliveries and 1,000 ml
in cesarean section, which occurs within 24 hours
after deliveries(8,9). Recent maternal death reviews in
Australia and the United Kingdom have reported
increases in deaths attributable to postpartum
hemorrhage(10,11). Postpartum hemorrhage occurs in
approximately 4-6% of vaginal deliveries(12,13). Increases
in the incidence of postpartum hemorrhage have been
reported in Australia(14,15) and Canada(16). In Australia,
postpartum hemorrhage have increased by 29%
from 4.9% of deliveries in 1993 to 6.3% of deliveries in
J Med Assoc Thai 2009; 92 (12): 1586-90
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J Med Assoc Thai Vol. 92 No. 12 2009 1587
2002(14). Advancing maternal age, and increasing rates
of cesarean section, more induction and augmentation
of labor and multiple births have been postulated as
the causes of increased postpartum hemorrhage rates
and postpartum hemorrhage-related deaths(11). There
are many risk factors suggested for PPH such as over-
distended uterus (multiple gestation, polyhydramnios,
macrosomia), primigravida and chorioamnionitis.
The present study aimed to investigate risk factors
associated with postpartum hemorrhage in Bhumibol
Adulyadej Hospital.
Material and Method
The present study was a retrospective cohort
study of 19,429 patients who gave birth between
1st January 2004 and 31st December 2007 at Bhumibol
Adulyadej Hospital. One thousand five hundred and
thirty women were enrolled in the present study,
three hundred and eighty five women had postpartum
hemorrhage and one thousand one hundred and forty
five had no postpartum hemorrhage. The present
study analyzed one postpartum hemorrhage woman
compared to three women who gave birth in nearly
the same period and had no postpartum hemorrhage,
both vaginal deliveries and cesarean section. The
control groups were selected by matched with time 3:1
cases. Age, height, gravida, parity, income, education,
birth weight, previous PPH, failure to progress,
cephalopelvic disproportion (CPD), prolonged 2nd stage
of labor, prolonged 3rd stage of labor, lacerations of
birth passage, abnormal presentation, multifetal
pregnancy, induction of labor, placenta previa, large
for gestational age, previous cesarean section, retained
placenta, augmentation of labor, pregnancy induced
hypertension, hydramnios, and placenta abruption
were studied. The main objective of the present study
was the prediction of risk factors of postpartum
hemorrhage. Results are expressed as mean + SD or
percentage, as appropriate. Univariate and multivariate
relative risks were presented with their 95% confidence
intervals (CI). The present study was approved by
Bhumibol Adulyadej Hospital Ethics Committee.
Results
There were 19,429 parturients who gave birth
between 1st January 2004 and 31st December 2007 and
385 patients had postpartum hemorrhage. The PPH rate
in Bhumibol Adulyadej Hospital was 1.98%. Maternal
age, height and fetal birth weight were not different
between the PPH group and no PPH group as shown
in Table 1. The maternal gravidity, parity,abortion and
postpartum hemorrhage are presented in Table 2.
Patients who had gravida 1, parity 0, and no history
of abortion had decreased relative risk of postpartum
hemorrhage. Seventeen risk factors were identified by
univariate logistic regression analysis and found that
only ten factors had a significantly increased risk of
postpartum hemorrhage as shown in Table 3. There
were eight cases of hydramnios and all of them had no
postpartum hemorrhage. All four cases of placental
abruption had postpartum hemorrhage. Cases of
augmentation of labor can reduce the risk of post-
partum hemorrhage as shown in Table 3. In the multi-
variate logistic regression analysis, four significant
risk factors emerged for postpartum hemorrhage such
as retained placenta, prolonged 3rd stage of labor,
lacerations of birth passage, and placenta previa as
shown in Table 4.
PPH+ (n = 385) PPH- (n = 1145)p-value
Age (years)
Height (cm)
Birth weight (g)
29.40 + 9.07
155.80 + 4.32
2,940.40 + 407.31
31.67 + 16.63
157.07 + 5.89
3,083.32 + 498.62
0.663
0.548
0.477
PPH+ = postpartum hemorrhage, PPH- = no postpartum hemorrhage
Table 1. Demographic data
PPH+ PPH-RR95% CI
G1 P0
Previous abortion
p > 1, A0
113/385 499/1145
148/385 592/1145
104/385 209/1145
0.53
0.58
0.60
0.41-0.69
0.46-0.73
0.46-0.79
Table 2. Gravida, parity and abortion related to PPH
RR = relative risk, 95% CI = 95% confidence interval, G1 P0
= gravida 1, parity 0, p > 1, A0 = parity > 1, no abortion

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1588J Med Assoc Thai Vol. 92 No. 12 2009
Discussion
Although the prevalence of postpartum
hemorrhage (PPH) varies between developing and
developed countries, it is the leading cause of maternal
morbidity and mortality worldwide(7). An estimated
blood loss more than 500 ml for a vaginal delivery and
more than 1,000 ml for a cesarean section defines early
or primary PPH, which occurs within the first 24 hours
after delivery(9,17). The postpartum hemorrhage (PPH)
rate in the present study (1.98%) is lower than previously
reported in Australia, the United States of America and
Canada. (4-6%)(12-16). The reason for lower PPH rate in
the present study may be from underestimate of blood
loss by observation. Although PPH occurs in women
without risk factors, it is often a predictable event.
There are many risk factors suggested for PPH. These
include an over-distended uterus, primigravida,
chorioamnionitis, prolonged rupture of membranes,
fibroid, previous cesarean section, coagulation disorders,
labor induction and augmentation, prolonged labor,
preeclampsia, obesity, and general anesthetics(18-20).
One of the most important risk factors for PPH is a prior
PPH. Univariate logistic regression analysis showed
that cephalopelvic disproportion (CPD), prolonged 3rd
stage of labor, retained placenta, lacerations of birth
passage, abnormal presentation, multifetal pregnancy,
induction of labor, placenta previa, large for gestational
age (LGA), and pregnancy induced hypertension were
significant risk factors for postpartum hemorrhage
(PPH) in the present study. Risk factors for PPH from
the present study such as prolonged 3rd stage of
labor, lacerations of birth passage, multifetal pregnancy,
large for gestational age (LGA) and pregnancy induced
hypertension are similar to previous studies except
retained placenta and augmentation of labor. The
present study found that augmentation of labor had
decreased risk of postpartum hemorrhage as shown in
PPH+ (%) PPH- (%) RR 95% CI
Previous PPH
Failure to progress
CPD
Prolonged 2nd
Prolonged 3rd
Lacerations
Abnormal presentation
Multifetal pregnancy
Induction of labor
Placenta previa
LGA
Previous CS
Augmentation
Retained placenta
PIH
2 (0.52)
16 (4.15)
55 (14.2)
13 (3.37)
19 (4.93)
43 (11.16)
48 (12.46)
13 (3.37)
22 (5.70)
24 (6.24)
5 (1.29)
40 (10.38)
104 (27.01)
51 (14.8)
41 (10.64)
3 (0.26)
41 (3.58)
73 (6.37)
26 (2.27)
3 (0.26)
9 (0.78)
46 (4.01)
10 (0.87)
24 (2.09)
10 (0.87)
4 (O.35)
108 (9.43)
415 (36.24)
12 (1.04)
41 (3.58)
1.96
1.16
2.45
1.50
19.76
15.87
3.40
3.96
2.83
7.54
3.75
1.13
0.65
16.40
3.20
0.33-11.94
0.65-21.06
1.69-3.54*
0.76-2.95
5.81-67.19*
7.65-32.88*
2.23-5.19*
1.75-9.12*
1.56-5.10*
3.57-15.92*
1.003-14.01*
0.75-1.62
0.50-0.84
8.69-30.94*
2.04-5.03*
Table 3. Risk factors related to PPH (univariate analysis)
Hydramnios 8 cases, no PPH, CPD = cephalopelvic disproportion, LGA = large for gestational age, CS = cesarean section
Placenta Abruption 4 cases, all had PPH (cannot identified RR)
Augmentation can reduce PPH
* Significant p < 0.05
Adjusted RR 95% CI
Prolonged 3rd
CPD
Lacerations
Abnormal presentation
Multifetal pregnancy
Induction of labor
Placenta previa
Retained placenta
LGA
PIH
3.17
1.03
2.94
1.39
1.32
0.80
2.40
2.92
1.00
1.23
1.92-4.42*
0.63-1.43
2.20-3.68*
0.94-1.85
0.43-2.21
0.14-1.46
1.63-3.17*
2.23-3.61*
0.49-2.47
0.74-1.71
Table 4. Risk factors related to PPH (multivariate analysis)
* Still significant (p < 0.05)

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J Med Assoc Thai Vol. 92 No. 12 20091589
Table 3(12,18). Multivariate logistic regression analysis
of postpartum hemorrhage risk factors in the present
study revealed a significant role of prolonged 3rd stage
of labor, lacerations of birth passage, retained placenta
and placenta previa. The strongest risk factors for
postpartum hemorrhage in the present study were
prolonged 3rd stage of labor, retained placenta,
lacerations of birth passage, and placenta previa
which correspond to previous studies except retained
placenta(12,21). There were 8 cases of hydramnios and
all of them had no postpartum hemorrhage. Four cases
had placental abruption, all of them had postpartum
hemorrhage. Cases of augmentation of labor had
decreased risk of postpartum hemorrhage.
Conclusion
The rate of postpartum hemorrhage in
Bhumibol Adulyadej Hospital was 1.98%. The
strongest risk factors for postpartum hemorrhage in
the present study were prolonged 3rd stage of labor,
retained placenta, lacerations of birth passage, and
placenta previa.When paturients who had risk
factors of postpartum hemorrhage as described in
the present study especially the strongest risk factors
the caregivers should prepare and alert to prevent
postpartum hemorrhage as soon as possible to reduce
maternal morbidity and mortality.
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1590J Med Assoc Thai Vol. 92 No. 12 2009
ปัจจัยเสี่ยงของการตกเลือดภายใน 24 ชั่วโมงแรกหลังคลอดในโรงพยาบาลภูมิพลอดุลยเดช
วิบูลย์ เรืองชัยนิคม, สิริวรรณ ศรีสุวรรณ, สินาท พรหมมาศ, สราวุธ สารภักดิ์
วัตถุประสงค์: เพื่อศึกษาอุบัติการณ์และปัจจัยเสี่ยงของการตกเลือดภายใน 24 ชั่วโมงแรกหลังคลอดใน
โรงพยาบาลภูมิพลอดุลยเดช
วัสดุและวิธีการ: เก็บข้อมูลย้อนหลังจากรายงานการคลอดและแฟ้มเวชระเบียนของโรงพยาบาลภูมิพลอดุลยเดช
ตั้งแต่วันที่ 1 มกราคม พ.ศ. 2547 ถึง วันที่ 31 ธันวาคม พ.ศ. 2550 ได้ผู้คลอดทั้งหมด 19,429 ราย นำมาวิเคราะห์
หาอุบัติการณ์และปัจจัยเสี่ยงของการตกเลือดภายใน24ชั่วโมงแรกหลังคลอดทั้ง univariate logistic regression และ
multivariate logistic regression
ผลการศึกษา: พบอุบัติการณ์ของการตกเลือดภายใน24ชั่วโมงแรกหลังคลอดในโรงพยาบาลภูมิพลอดุลยเดช
ร้อยละ 1.98 พบปัจจัยเสี่ยงของการตกเลือดภายใน 24 ชั่วโมงแรกหลังคลอด ได้แก่ prolonged 3rd stage of labor,
lacerations of birth passage, multifetal pregnancy, large for gestational age (LGA),pregnancy induced
hypertension, retained placenta,abnormal presentation, Induction of labor, placenta previa, cephalopelvic
disproportion แต่เมื่อนำมาวิเคราะห์แบบ multivariate พบว่ามีเพียง 4 ปัจจัยเท่านั้นที่สำคัญเช่น prolonged 3rd
stage of labor, retained placenta, lacerations of birth passage, and placenta previa
สรุป: ปัจจัยเสี่ยงของการตกเลือดภายใน 24 ชั่วโมงแรกหลังคลอดที่สำคัญได้แก่ prolonged 3rd stage of labor,
retained placenta, lacerations of birth passage, and placenta previa