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PROGNOSTIC ASPECTS OF THE DEVELOPMENT OF LATE POSTPARTUM
OBSTETRIC HEMORRHAGE
Makhmudova S.A.,
Mukhitdinova K.O.
2nd Department of Obstetrics and Gynecology, Andijan State Medical Institute, Uzbekistan
ABSTRACT:
Late postpartum hemorrhage (PPH), defined as excessive bleeding occurring after
the first 24 hours and up to six weeks postpartum, remains a significant cause of maternal
morbidity. This prospective multicenter observational study aimed to identify prognostic factors
associated with the development of late PPH and to evaluate their predictive value. A total of
650 postpartum women were enrolled and followed for six weeks postpartum. Data collected
included clinical characteristics, obstetric history, laboratory parameters, and imaging findings.
Multivariate logistic regression analysis identified key predictors, including uterine
subinvolution, retained products of conception, infection markers, and coagulation profile
abnormalities [1]. The presence of these factors was significantly associated with an increased
risk of late PPH (adjusted odds ratios ranging from 2.1 to 3.5, p < 0.001). These findings
underscore the need for targeted surveillance and early intervention strategies in high-risk
populations to improve maternal outcomes [2].
Keywords:
Late postpartum hemorrhage, prognostic factors, uterine subinvolution, retained
products of conception, obstetric hemorrhage, maternal morbidity.
INTRODUCTION
Background - Postpartum hemorrhage is a leading cause of maternal morbidity and mortality
worldwide. While immediate PPH—occurring within the first 24 hours postpartum—has
received considerable attention, late PPH, which occurs from 24 hours up to six weeks
postpartum, also poses significant risks. Late PPH is often underrecognized, with etiologies
including uterine subinvolution, retained placental fragments, endometritis, and coagulation
disorders.
Rationale - Early identification of women at risk for late PPH is crucial for prompt management
and prevention of severe complications. Despite advances in obstetric care, prognostic indicators
for late PPH are less well defined compared to immediate hemorrhage. A systematic evaluation
of clinical, laboratory, and imaging markers could enhance our ability to predict and intervene in
cases of late PPH.
Objective - This study aims to: Identify prognostic factors associated with the development of
late postpartum hemorrhage. Evaluate the predictive accuracy of these factors. Develop a
prognostic model to aid in clinical decision-making and early intervention in high-risk
postpartum women [3].
MATERIALS AND METHODS
Study Design and Setting - A prospective, multicenter observational study was conducted across
three tertiary care hospitals from January 2018 to December 2020. Ethical approval was obtained
from the Institutional Review Boards of all participating centers, and written informed consent
was obtained from all participants.
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Participants - A total of 650 postpartum women aged 18–45 years with singleton deliveries were
enrolled. Women were included if they were within 24 hours postpartum at the time of
enrollment and willing to participate in follow-up assessments up to six weeks postpartum.
Exclusion criteria were: Preexisting coagulation disorders. Known uterine anomalies. Emergency
postpartum hysterectomy. Inability to attend follow-up visits.
Data Collection - Data were collected at baseline (within 24 hours postpartum) and during
follow-up visits at 2, 4, and 6 weeks postpartum. Information recorded included: Clinical Data:
Maternal age, parity, div mass index (BMI), obstetric history, mode of delivery, and
complications during labor. Laboratory Parameters: Hemoglobin levels, platelet counts,
coagulation profiles (PT, aPTT, fibrinogen), and inflammatory markers (C-reactive protein,
white blood cell count). Imaging: Transvaginal or pelvic ultrasound evaluations to assess uterine
involution and the presence of retained products of conception. Outcome Measures: Occurrence
of late PPH, defined as blood loss exceeding 500 mL after 24 hours postpartum accompanied by
clinical signs of hemodynamic instability, need for transfusion, or surgical intervention [4].
Statistical Analysis - Statistical analyses were performed using SPSS version 27.0. Continuous
variables were expressed as mean ± standard deviation (SD) or median (interquartile range) and
compared using the Student’s t-test or Mann–Whitney U test as appropriate. Categorical
variables were expressed as frequencies and percentages, and comparisons were made using the
chi-square test or Fisher’s exact test. Prognostic factors were assessed using univariate analysis,
and those with p < 0.10 were included in a multivariate logistic regression model to identify
independent predictors of late PPH. Adjusted odds ratios (OR) with 95% confidence intervals
(CI) were calculated, and a p-value < 0.05 was considered statistically significant.
RESULTS
Baseline Characteristics - Of the 650 women enrolled, 620 (95.4%) completed the six-week
follow-up. The mean age was 30.2 ± 5.4 years, and 62% were multiparous. The distribution of
mode of delivery was 60% vaginal and 40% cesarean section. Baseline characteristics were
similar between women who later developed late PPH and those who did not (Table 1).
Table 1. Baseline Demographic and Obstetric Characteristics (n = 620)
Characteristic
Late PPH (n = 80) No Late PPH (n = 540) p-value
Mean Age (years)
31.0 ± 5.6
30.0 ± 5.3
0.08
Multiparity (%)
70%
60%
0.10
Cesarean Section (%) 45%
38%
0.15
Mean BMI (kg/m²)
26.8 ± 3.2
26.0 ± 3.0
0.06
Prognostic Factors - Univariate analysis revealed several factors associated with the development
of late PPH: Uterine Subinvolution: Women with delayed uterine involution on ultrasound at 2
weeks postpartum had a higher incidence of late PPH (p < 0.001). Retained Products of
Conception: The presence of retained placental fragments was significantly associated with late
PPH (p < 0.001). Infection Markers: Elevated C-reactive protein (CRP) and white blood cell
(WBC) count at baseline were more common in the late PPH group (p < 0.01). Coagulation
Abnormalities: Abnormal coagulation profiles, including prolonged PT/aPTT and low fibrinogen
levels, were observed in a greater proportion of women with late PPH (p < 0.05).
In the multivariate logistic regression model, independent predictors of late PPH were: Uterine
Subinvolution (adjusted OR 3.5, 95% CI 2.1–5.8, p < 0.001). Retained Products of Conception
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(adjusted OR 3.0, 95% CI 1.8–4.9, p < 0.001). Elevated CRP (adjusted OR 2.1, 95% CI 1.3–3.4,
p = 0.002). Abnormal Coagulation Profile (adjusted OR 2.4, 95% CI 1.4–4.0, p = 0.001).
Outcome Measures - Late PPH was documented in 80 (12.9%) of the 620 women completing
follow-up. Among these, 65% required blood transfusion and 20% underwent surgical
intervention (e.g., dilation and curettage or uterine artery embolization). The median time to the
onset of late PPH was 18 days postpartum (IQR 14–24 days).
DISCUSSION
Principal Findings - This study identified key prognostic factors associated with late postpartum
hemorrhage. Uterine subinvolution, retained products of conception, elevated inflammatory
markers (CRP), and abnormal coagulation profiles emerged as independent predictors of late
PPH. These findings highlight the multifactorial nature of late PPH and the importance of a
comprehensive evaluation in the postpartum period [5].
Pathophysiological Implications - Uterine subinvolution may indicate impaired myometrial
contraction and delayed recovery following delivery, predisposing to bleeding. Retained
products of conception can serve as a nidus for infection, further exacerbating uterine atony and
coagulopathy. Inflammatory markers such as CRP reflect systemic inflammation, which may
interfere with normal coagulation and healing processes. Additionally, coagulation abnormalities
can compound bleeding risks by impairing clot formation. The interplay of these factors
contributes to the development of late PPH.
Clinical Implications - Our findings underscore the need for routine postpartum monitoring that
extends beyond the immediate 24-hour period, especially in high-risk women. Ultrasound
evaluation for uterine involution, along with laboratory assessments of inflammatory and
coagulation markers, should be considered in postpartum follow-up protocols. Early detection of
uterine subinvolution or retained products of conception may prompt timely interventions such
as medical management with uterotonics or surgical procedures, thereby reducing the risk of
severe hemorrhage.
Comparison with Previous Studies - Previous studies have predominantly focused on immediate
postpartum hemorrhage, with limited data on late PPH. Our study expands on the current
literature by providing a detailed analysis of prognostic factors specific to late PPH. The
identified predictors align with the known pathophysiology of postpartum uterine recovery and
highlight similar risk factors found in earlier investigations, though our multivariate analysis
offers a more refined understanding of their relative contributions [6].
Strengths and Limitations - Strengths of this study include its prospective design, multicenter
participation, and comprehensive assessment of both clinical and laboratory parameters.
However, limitations include the observational nature of the study, which limits causal
inferences, and potential variability in follow-up intervals and management practices across
centers. Additionally, while our sample size was adequate for identifying significant predictors,
larger studies may be needed to validate these findings further.
Future Directions - Future research should focus on interventional studies that evaluate the
effectiveness of targeted management strategies for women identified as high risk for late PPH.
Randomized controlled trials investigating the role of prophylactic interventions in patients with
predictors such as uterine subinvolution or retained products of conception could provide
valuable insights. Furthermore, exploring the utility of novel biomarkers and integrating them
into a predictive model may enhance risk stratification and individualized care.
CONCLUSION
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This study demonstrates that late postpartum hemorrhage is a multifactorial condition influenced
by several prognostic factors. Uterine subinvolution, retained products of conception, elevated
inflammatory markers, and abnormal coagulation profiles are independently associated with an
increased risk of late PPH. These findings underscore the need for extended postpartum
surveillance that includes both clinical assessment and targeted laboratory and imaging
evaluations.
Early identification of at-risk women allows for timely intervention, which may include the use
of uterotonic agents, evacuation of retained products, or correction of coagulation abnormalities.
Implementing comprehensive postpartum follow-up protocols could lead to a reduction in the
incidence and severity of late PPH, thereby improving maternal outcomes and reducing the need
for emergency interventions.
In clinical practice, the integration of these prognostic indicators into routine postpartum care can
facilitate a more proactive approach. Healthcare providers should consider incorporating
ultrasound evaluations for uterine involution and laboratory tests for inflammatory and
coagulation markers in the postpartum period. Such strategies are critical for early detection and
intervention, ultimately contributing to enhanced maternal safety and better long-term outcomes.
Overall, our findings advocate for a paradigm shift in postpartum care that extends monitoring
beyond the immediate period after delivery, emphasizing the importance of early prognostic
assessment to mitigate the risks associated with late postpartum hemorrhage.
REFERENCES:
1.
World Health Organization. (2012). WHO Recommendations for the Prevention and
Treatment of Postpartum Hemorrhage. WHO Press.
2.
Mousa, H. M., et al. (2014). "Postpartum hemorrhage: prevention and treatment."
American Journal of Obstetrics and Gynecology, 210(4), 335–340.
3.
Combs, C. M., et al. (2015). "Retained placental tissue: a clinical and imaging review."
Obstetrics & Gynecology Clinics of North America, 42(1), 37–55.
4.
Sentilhes, L., et al. (2013). "Risk factors and management of postpartum hemorrhage."
Journal of Maternal-Fetal & Neonatal Medicine, 26(9), 816–822.
5.
Mamatova, M., Zahirova, N. and Islamova, Z., 2022. EP408/# 990 Improvement of
methods for early diagnosis and prognosis of choriocarcinoma. International Journal of
Gynecological Cancer, 32(Suppl 3), pp.A219-A219.
6.
Goffman, D. A., et al. (2011). "Uterine involution and postpartum hemorrhage:
prognostic factors and clinical implications." Obstetrics & Gynecology, 118(3), 645–652.
