Iranian Society of Gynecology Oncology

Document Type : Original Research Article


1 Department of Obstetrics and Gynecology, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 Department of Obstetrics and Gynecology, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

3 Department of Anesthesiology, Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran


Background & Objective: Globally, postpartum hemorrhage (PPH) remains a leading cause of maternal deaths. However, in many low and middle-income countries, information on the magnitude of and risk factors for PPH is scarce. Understanding the relative contributions of different risk factors for PPH is important. We assessed the incidence of and risk factors for postpartum hemorrhage among women who had a cesarean section in Iran.
Materials & Methods: Between March 2021 and March 2022, a prospective cohort study was conducted at a university-affiliated general hospital for women who had a cesarean section in Iran. We used Spearman’s correlation for the variables associated with PPH.
Results: Among the 300 women, the overall incidence of postpartum hemorrhage was 15.7%. Risk factors for postpartum hemorrhage among deliveries by cesarean section were: body-mass index, previous PPH, preoperative anemia, and preoperative hypofibrinogenemia.
Conclusion: The incidence of postpartum hemorrhage in the cesarean section was high. Extra vigilance in all women with cesarean section could address the risk factors identified.


 The incidence of postpartum hemorrhage in the cesarean section was high. Extra vigilance in all women with cesarean section could address the risk factors identified.


Main Subjects

1. Postpartum Hemorrhage | ACOG 2022. [Available from:]
2. Escobar MF, Nassar AH, Theron G, Barnea ER, Nicholson W, Ramasauskaite D, et al. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet. 2022;157(S1):3-50. [DOI:10.1002/ijgo.14116] [PMID] [PMCID]
3. Pouyanfar A, Bolourian M, Fazli B, Ghazanfarpour M, Sabaghian M, Shakeri F. Factors Affecting the Maternal Mortality in different Areas of Iran: A Systematic Review. Health Provid. 2022;1(3):131-47.
4. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-e33. [DOI:10.1016/S2214-109X(14)70227-X] [PMID]
5. Kebede BA, Abdo RA, Anshebo AA, Gebremariam BM. Prevalence and predictors of primary postpartum hemorrhage: An implication for designing effective intervention at selected hospitals, Southern Ethiopia. PloS One. 2019;14(10):e0224579. [DOI:10.1371/journal.pone.0224579] [PMID] [PMCID]
6. Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg. 2010;110(5):1368-73. [DOI:10.1213/ANE.0b013e3181d74898] [PMID]
7. James AH, McLintock C, Lockhart E. Postpartum hemorrhage: When uterotonics and sutures fail. Am J Hematol. 2012;87(S1):S16-S22. [DOI:10.1002/ajh.23156] [PMID]
8. Tort J, Rozenberg P, Traoré M, Fournier P, Dumont A. Factors associated with postpartum hemorrhage maternal death in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey. BMC Pregnancy Childbirth. 2015;15(1):235. [DOI:10.1186/s12884-015-0669-y] [PMID] [PMCID]
9. Ngwenya S. Postpartum hemorrhage: incidence, risk factors, and outcomes in a low-resource setting. Int J Womens Health. 2016(8):647-50. [DOI:10.2147/IJWH.S119232] [PMID] [PMCID]
10. Gani GN, Ali ATS. Prevalence and factors associated with maternal postpartum haemorrhage in Khyber Agency, Pakistan. J Ayub Med Coll Abbottabad. 2013;25(1-2):81-5.
11. Kramer MS, Dahhou M, Vallerand D, Liston R, Joseph KS. Risk Factors for Postpartum Hemorrhage: Can We Explain the Recent Temporal Increase? J Obstet Gynaecol Can. 2011;33(8):810-9. [DOI:10.1016/S1701-2163(16)34984-2] [PMID]
12. Ononge S, Mirembe F, Wandabwa J, Campbell OMR. Incidence and risk factors for postpartum hemorrhage in Uganda. Reprod Health. 2016;13(1):38. [DOI:10.1186/s12978-016-0154-8] [PMID] [PMCID]
13. Nyfløt LT, Sandven I, Stray-Pedersen B, Pettersen S, Al-Zirqi I, Rosenberg M, et al. Risk factors for severe postpartum hemorrhage: a case-control study. BMC Pregnancy Childbirth. 2017;17(1):17. [DOI:10.1186/s12884-016-1217-0] [PMID] [PMCID]
14. Sample size calculator. 2022.
15. Sheldon WR, Blum J, Vogel JP, Souza JP, Gülmezoglu AM, Winikoff B, et al. Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health. Int J Obstet Gynecol. 2014;121(s1):5-13. [DOI:10.1111/1471-0528.12636] [PMID]
16. Fawcus S, Moodley J. Postpartum haemorhage associated with caesarean section and caesarean hysterectomy. Best Pract Res Clin Obstet Gynaecol. 2013;27(2):233-49. [DOI:10.1016/j.bpobgyn.2012.08.018] [PMID]
17. Lutomski JE, Byrne BM, Devane D, Greene RA. Increasing trends in atonic postpartum haemorrhage in Ireland: an 11‐year population‐based cohort study. Int J Obstet Gynecol. 2012;119(3):306-14. [DOI:10.1111/j.1471-0528.2011.03198.x] [DOI:10.1111/j.1471-0528.2012.03370.x]
18. Shahbazi Sighaldeh S, Nazari A, Maasoumi R, Kazemnejad A, Mazari Z. Prevalence, related factors and maternal outcomes of primary postpartum haemorrhage in governmental hospitals in Kabul-Afghanistan. BMC Pregnancy Childbirth. 2020;20(1):428. [DOI:10.1186/s12884-020-03123-3] [PMID] [PMCID]
19. Sharifizad M, Khodakaram N, Jannesari S, Akbarzadeh A. The Outcomes of Natural Childbirth and C-Section on the Mother and Infant's Health in Selected Hospitals in Tehran. Horiz Med Sci. 2012;18:5-11.
20. Nigussie J, Girma B, Molla A, Tamir T, Tilahun R. Magnitude of postpartum hemorrhage and its associated factors in Ethiopia: a systematic review and meta-analysis. Reprod Health. 2022;19(1):1-13. [DOI:10.1186/s12978-022-01360-7] [PMID] [PMCID]
21. Bazirete O, Nzayirambaho M, Umubyeyi A, Karangwa I, Evans M. Risk factors for postpartum haemorrhage in the Northern Province of Rwanda: A case control study. PloS One. 2022;17(2):e0263731. [DOI:10.1371/journal.pone.0263731] [PMID] [PMCID]
22. Ruppel H, Liu VX, Gupta NR, Soltesz L, Escobar GJ. Validation of postpartum hemorrhage admission risk factor stratification in a large obstetrics population. Am J Perinatol. 2021;38(11):1192-200. [DOI:10.1055/s-0040-1712166] [PMID] [PMCID]
23. Rajput N, Paldiya D. Reproduction YVIJ of, 2018 undefined. Effects of advanced maternal age on pregnancy outcome 2023. [Available from:]
24. Laxmy R, Beena G. Pregnancy outcome in women of advanced maternal age. Int J Bioassays. 2013;2(9):1193-8.
25. Ashouri N, Kordi M, Shakeri M-T, Tara F. Vaginal delivery Postpartum Hemorrhage: Incidence, Risk Factors, and Causes. Iran J Obstet Gynecol Infertil. 2019;21(12):65-76.
26. Wang C, Zhang C. Meta-analysis to assess the role of maternal characteristics and risk factors on postpartum hemorrhage. Adv Clin Exp Med. 2023:1-9.
27. Zandi S, Imani B, Mostafayi M, Rabie S. Prevalence of Early Maternal Complications of Cesarean Section and its Relationship with Body Mass Index in Fatemieh Hospital of Hamadan. Pajouhan Sci J. 2020;18(2):52-7. [DOI:10.52547/psj.18.2.52]
28. Butwick AJ, Abreo A, Bateman BT, Lee HC, El-Sayed YY, Stephansson O, et al. Effect of Maternal Body Mass Index on Postpartum Hemorrhage. Anesthesiology. 2018;128(4):774-83. [DOI:10.1097/ALN.0000000000002082] [PMID] [PMCID]
29. Abdel-Razik MS. Postpartum haemorrhage as a public health problem. J Egypt Soc Obstet Gynaecol. 1991;17(1):51-61.
30. Jardine J, Gurol‐Urganci I, Harris T, Hawdon J, Pasupathy D, van der Meulen J, et al. Risk of postpartum haemorrhage is associated with ethnicity: A cohort study of 981 801 births in England. Int J Gynaecol Obstet. 2022;129(8):1269-77. [DOI:10.1111/1471-0528.17051] [PMID]
31. Okunlola O, Raza S, Osasan S, Sethia S, Batool T, Bambhroliya Z, et al. Race/Ethnicity as a Risk Factor in the Development of Postpartum Hemorrhage: A Thorough Systematic Review of Disparity in the Relationship Between Pregnancy and the Rate of Postpartum Hemorrhage. Cureus. 2022;14(6). [DOI:10.7759/cureus.26460]
32. Ambounda N, Woromogo S, Yagata-Moussa F, Ossouka L, Tekem V, Ango E, et al. Primary postpartum haemorrhage at the Libreville University Hospital Centre: Epidemiological profile of women. PLoS One. 2021 (16):9. [DOI:10.1371/journal.pone.0257544] [PMID] [PMCID]
33. Yang J, Wang Y, Wang X-y, Zhao Y-y, Wang J, Zhao Y-y. Adverse Pregnancy Outcomes of Patients with History of First-Trimester Recurrent Spontaneous Abortion. BioMed Res Int. 2017;2017:4359424. [DOI:10.1155/2017/4359424] [PMID] [PMCID]
34. Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M. Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: A population-based study. J Matern Fetal Neonatal Med. 2005;18(3):149-54. [DOI:10.1080/14767050500170088] [PMID]
35. Ende HB, Lozada MJ, Chestnut DH, Osmundson SS, Walden RL, Shotwell MS, et al. Risk Factors for Atonic Postpartum Hemorrhage: A Systematic Review and Meta-analysis. Obstet Gynecol. 2021;137(2):305-23. [DOI:10.1097/AOG.0000000000004228] [PMID] [PMCID]
36. Akinyemi OA, Lipscombe C, Omokhodion OV, Akingbule AS, Fasokun ME, Oyeleye OA, et al. Disparities in Incidences of Cesarean Section Among Women with Gestational Diabetes Mellitus in the United States. Cureus. 2022;14(9). [DOI:10.7759/cureus.29400]
37. Chung YS, Moon H, Kim EH. Risk of obstetric and neonatal morbidity in gestational diabetes in a single institution: A retrospective, observational study. Medicine. 2022;101(39):e30777. [DOI:10.1097/MD.0000000000030777] [PMID] [PMCID]
38. Butwick AJ, Ramachandran B, Hegde P, Riley ET, El-Sayed YY, Nelson LM. Risk Factors for Severe Postpartum Hemorrhage After Cesarean Delivery: Case-Control Studies. Anesth Analg. 2017;125(2):523-32. [DOI:10.1213/ANE.0000000000001962] [PMID] [PMCID]
39. Yildiz K, Dogru K, Dalgic H, Serin IS, Sezer Z, Madenoglu H, et al. Inhibitory effects of desflurane and sevoflurane on oxytocin-induced contractions of isolated pregnant human myometrium. Acta Anaesthesiol Scand. 2005;49(9):1355-9. [DOI:10.1111/j.1399-6576.2005.00804.x] [PMID]
40. van Stralen G, von Schmidt auf Altenstadt JF, Bloemenkamp KWM, van Roosmalen J, Hukkelhoven CWPM. Increasing incidence of postpartum hemorrhage: the Dutch piece of the puzzle. Acta Obstet Gynecol Scand. 2016;95(10):1104-10. [DOI:10.1111/aogs.12950] [PMID]
41. Magann EF, Evans S, Hutchinson M, Collins R, Lanneau G, Morrison JC. Postpartum hemorrhage after cesarean delivery: an analysis of risk factors. South Med J. 2005;98(7):681-6. [DOI:10.1097/01.SMJ.0000163309.53317.B8] [PMID]
42. Karlsson O, Jeppsson A, Thornemo M, Lafrenz H, Rådström M, Hellgren M. Fibrinogen plasma concentration before delivery is not associated with postpartum haemorrhage: a prospective observational study. Br J Anaesth. 2015;115(1):99-104. [DOI:10.1093/bja/aev039] [PMID]
43. Niepraschk-von Dollen K, Bamberg C, Henkelmann A, Mickley L, Kaufner L, Henrich W, et al. Predelivery maternal fibrinogen as a predictor of blood loss after vaginal delivery. Arch Gynecol Obstet. 2016;294(4):745-51. [DOI:10.1007/s00404-016-4031-z] [PMID]
44. de Lloyd L, Bovington R, Kaye A, Collis RE, Rayment R, Sanders J, et al. Standard haemostatic tests following major obstetric haemorrhage. Int J Obstet Anesth. 2011;20(2):135-41. [DOI:10.1016/j.ijoa.2010.12.002] [PMID]
45. Endo-Kawamura N, Obata-Yasuoka M, Yagi H, Ohara R, Nagai Y, Mayumi M, et al. Higher D-dimer level in the early third trimester predicts the occurrence of postpartum hemorrhage. J Perinat Med. 2016;44(5):551-6. [DOI:10.1515/jpm-2015-0287] [PMID]
46. Charbit B, Mandelbrot L, Samain E, Baron G, Haddaoui B, Keita H, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost. 2007;5(2):266-73. [DOI:10.1111/j.1538-7836.2007.02297.x] [PMID]
47. Cortet M, Deneux-Tharaux C, Dupont C, Colin C, Rudigoz RC, Bouvier-Colle MH, et al. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. Br J Anaesth. 2012;108(6):984-9. [DOI:10.1093/bja/aes096] [PMID]
48. Rubio-Álvarez A, Molina-Alarcón M, Arias-Arias Á, Hernández-Martínez A. Development and validation of a predictive model for excessive postpartum blood loss: A retrospective, cohort study. Int J Nurs Stud. 2018;79:114-21. [DOI:10.1016/j.ijnurstu.2017.11.009] [PMID]