Increasing incidence of postpartum hemorrhage: the Dutch piece of the puzzle.

INTRODUCTION: An increase of postpartum hemorrhage (PPH) has been reported in many high-income countries. In addition to this data, this study reports on trends in the incidence of PPH in the Netherlands in 2000-2013, and examines the extent to which temporal changes in risk indicators could explain a possible change in incidence of PPH. MATERIAL AND METHODS: We used data from the Dutch Perinatal Registry, which contains prospectively collected antenatal, peripartum and neonatal data of 95-99% of all women and neonates in the Netherlands. We selected births ≥22 weeks of gestation from January 2000 until December 2013. Changes in the incidence of PPH and its risk indicators were studied over time. Main outcome measure was PPH, defined as blood loss >1000 mL within 24 h following delivery. RESULTS: The data comprised 2 406 784 women. The incidence of PPH rose significantly from 4.1% in 2000 to 6.4% in 2013 (p < 0.0001). The incidence of previously identified risk indicators for PPH increased over time. Manual removal of placenta was strongly associated with PPH (OR 29.3, CI 28.8-29.8). The incidence of PPH-related blood transfusion decreased remarkably. CONCLUSIONS: In line with international observations, Dutch data suggest a considerable increase in the incidence of PPH which can only partly be explained by the studied risk indicators. The decreasing incidence of obstetric blood transfusion suggests an increased incidence of blood loss of 1000-1500 mL.

Pre-eclampsia increases the risk of postpartum haemorrhage: a nationwide cohort study in the Netherlands.

BACKGROUND: Postpartum haemorrhage is a leading cause of maternal morbidity and mortality worldwide. Identifying risk indicators for postpartum haemorrhage is crucial to predict this life threatening condition. Another major contributor to maternal morbidity and mortality is pre-eclampsia. Previous studies show conflicting results in the association between pre-eclampsia and postpartum haemorrhage. The primary objective of this study was to investigate the association between pre-eclampsia and postpartum haemorrhage. Our secondary objective was to identify other risk indicators for postpartum haemorrhage in the Netherlands. METHODS: A nationwide cohort was used, containing prospectively collected data of women giving birth after 19 completed weeks of gestation from January 2000 until January 2008 (n =  1,457,576). Data were extracted from the Netherlands Perinatal Registry, covering 96% of all deliveries in the Netherlands. The main outcome measure, postpartum haemorrhage, was defined as blood loss of ≥1000 ml in the 24 hours following delivery. The association between pre-eclampsia and postpartum haemorrhage was investigated with uni- and multivariable logistic regression analyses. RESULTS: Overall prevalence of postpartum haemorrhage was 4.3% and of pre-eclampsia 2.2%. From the 31 560 women with pre-eclampsia 2 347 (7.4%) developed postpartum haemorrhage, compared to 60 517 (4.2%) from the 1 426 016 women without pre-eclampsia (odds ratio 1.81; 95% CI 1.74 to 1.89). Risk of postpartum haemorrhage in women with pre-eclampsia remained increased after adjusting for confounders (adjusted odds ratio 1.53; 95% CI 1.46 to 1.60). CONCLUSION: Women with pre-eclampsia have a 1.53 fold increased risk for postpartum haemorrhage. Clinicians should be aware of this and use this knowledge in the management of pre-eclampsia and the third stage of labour in order to reach the fifth Millenium Developmental Goal of reducing maternal mortality ratios with 75% by 2015.