Who is at risk of severe secondary PPH?

15495947576_41e0a9b37eAn analysis of ten years’ worth of medical records of women who had a severe secondary postpartum haemorrhage (PPH) after giving birth in a hospital in France has shown that the only risk factors which were associated with severe secondary PPH were (1) having had a primary PPH and (2) having a maternal age of 35 years or more.

As I’m aware that there is a bit of tendency for any little tidbit of age-related research to be thrown at pregnant women who may be older then average, I wanted to share this and point out that, as is often the case, we need to take care to remember that the key word here is association.  That is, there looks like there may be a relationship between secondary PPH and maternal age (as well as primary PPH), but this might not actually mean anything, and even if the two things are related, there might be an entirely different cause that does not mean that older women are necessarily at risk here.

These results are still very interesting, and it would be fascinating to explore these possible associations more deeply but, again, at this point we can’t say whether either of these factors are causal of or even definitely linked to secondary PPH.  Especially maternal age, which is connected to such a wide range of other variables that more and deeper analysis is the key to understanding what is really going on.  I mention this last bit, because as much as I want to share and ponder this really interesting finding, I also want to share my hope that we (and our colleagues who might interpret things from other, perhaps slightly different, standpoints) can look at and discuss the range of interesting possibilities which stem from this with open minds rather than simply deciding that this constitutes further confirmation of the ‘knackered uterus theory‘.


Debost-Legrand A, Rivière O, Dossou M et al (2015). Risk Factors for Severe Secondary Postpartum Hemorrhages: A Historical Cohort Study.  Birth: Issues in Perinatal Care. DOI: 10.1111/birt.12175

The Research


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.


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.


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.


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.

photo credit: Leaves and Roots via photopin (license)

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