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Risk Factors for Postpartum Hemorrhage: Can We Explain the Recent Temporal Increase?

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      Abstract

      Objective

      To assess risk factors for postpartum hemorrhage (PPH) and the extent to which changes in those risk factors may explain the rising incidence of PPH recently reported from industrialized countries.

      Methods

      We carried out a hospital-based cohort study of 103 726 consecutive deliveries from January 1, 1978, to January 31, 2007, from the computerized medical records of a tertiary-care university maternity hospital in Montreal. We examined adjusted odds ratios for any PPH (estimated blood loss > 500 mL for vaginal deliveries, > 1000 mL for Caesarean sections), severe PPH (estimated blood loss ≥ 1500 mL), and PPH accompanied by blood transfusion and/or hysterectomy.

      Results

      Major independent risk factors for PPH included primiparity, prior Caesarean section, placenta previa or low-lying placenta, marginal umbilical cord insertion in the placenta, transverse lie, labour induction and augmentation, uterine or cervical trauma at delivery, gestational age < 32 weeks, and birth weight ≥ 4500 g. An overall increase in rate of PPH over the study period (OR 1.029; 95% CI 1. 024 to 1.034 per year) disappeared (OR 0.995; 95% CI 0.988 to 1.001 per year) after inclusion of maternal age, parity, prior Caesarean section, labour induction and augmentation, placenta previa or low-lying placenta, and abnormal placenta, with most of the reduction attributable to rises in previous Caesarean section and labour augmentation.

      Conclusion

      Labour induction, augmentation of labour, and prior Caesarean section are significantly associated with the risk of PPH, and their increase over the study period largely explains the observed rise in PPH.

      Résumé

      Objectif

      Évaluer les facteurs de risque d’hémorragie postpartum (HPP) et la mesure dans laquelle les changements qu’ont connus ces facteurs de risque peuvent expliquer la hausse de l’incidence d’HPP récemment constatée au sein des pays industrialisés.

      Méthodes

      Nous avons mené une étude de cohorte en milieu hospitalier ayant porté sur 103 726 accouchements consécutifs (du 1er janvier 1978 au 31 janvier 2007) à partir des dossiers médicaux informatisés d’un hôpital de maternité universitaire de soins tertiaires de Montréal. Nous avons examiné les rapports de cotes corrigés en ce qui concerne toute HPP (perte sanguine estimée > 500 ml dans les cas d’accouchement vaginal, >1 000 ml dans les cas de césarienne), I’HPP grave (perte sanguine estimée ≥ 1 500 ml) et I’HPP s’accompagnant d’une transfusion sanguine et/ou d’une hystérectomie.

      Résultats

      Parmi les principaux facteurs de risque indépendants d’HPP, on trouvait la primiparité, le fait d’avoir déjà subi une césarienne, le placenta praevia ou le placenta en présentation basse, une insertion marginale du cordon ombilical dans le placenta, une présentation transversale, le déclenchement et l’accélération du travail, un traumatisme utérin ou cervical au moment de l’accouchement, un âge gestationnel < 32 semaines et un poids de naissance ≥ 4 500 g. Une hausse globale du taux d’HPP au cours de la période d’étude (RC, 1,029; IC à 95 %, 1,024 – 1,034 par année) s’est estompée (RC, 0,995; IC à 95 %, 0,988 – 1,001 par année) à la suite de l’inclusion de l’âge maternel, de la parité, du fait d’avoir déjà subi une césarienne, du déclenchement et de l’accélération du travail, du placenta praevia ou du placenta en présentation basse et du placenta anormal, cette rectification à la baisse étant en grande partie attribuable à des hausses des taux de césarienne préalable et d’accélération du travail.

      Conclusion

      Les taux de déclenchement du travail, d’accélération du travail et de césarienne préalable sont significativement associés au risque d’HPP et leur hausse au cours de la période d’étude explique en grande partie la hausse constatée en ce qui concerne le taux d’HPP.

      Key Words

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