{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T17:37:08Z","timestamp":1790703428106,"version":"4.1.0"},"reference-count":30,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2019,10,17]],"date-time":"2019-10-17T00:00:00Z","timestamp":1571270400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2019,10,17]],"date-time":"2019-10-17T00:00:00Z","timestamp":1571270400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Pregnancy Childbirth"],"published-print":{"date-parts":[[2019,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n              <jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>The absence of a uniform and clinically relevant definition of <jats:italic>severe<\/jats:italic> postpartum haemorrhage hampers comparative studies and optimization of clinical management. The concept of <jats:italic>persistent postpartum haemorrhage<\/jats:italic>, based on refractoriness to initial first-line treatment, was proposed as an alternative to common definitions that are either based on estimations of blood loss or transfused units of packed red blood cells (RBC). We compared characteristics and outcomes of women with severe postpartum haemorrhage captured by these three types of definitions.<\/jats:p>\n              <\/jats:sec>\n              <jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>In this large retrospective cohort study in 61 hospitals in the Netherlands we included 1391 consecutive women with postpartum haemorrhage who received either \u22654\u2009units of RBC or a multicomponent transfusion. Clinical characteristics and outcomes of women with severe postpartum haemorrhage defined as <jats:italic>persistent postpartum haemorrhage<\/jats:italic> were compared to definitions based on estimated blood loss or transfused units of RBC within 24\u2009h following birth. Adverse maternal outcome was a composite of maternal mortality, hysterectomy, arterial embolisation and intensive care unit admission.<\/jats:p>\n              <\/jats:sec>\n              <jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>One thousand two hundred sixty out of 1391 women (90.6%) with postpartum haemorrhage fulfilled the definition of <jats:italic>persistent postpartum haemorrhage<\/jats:italic>. The majority, 820\/1260 (65.1%), fulfilled this definition within 1 h following birth, compared to 819\/1391 (58.7%) applying the definition of \u22651\u2009L blood loss and 37\/845 (4.4%) applying the definition of \u22654\u2009units of RBC. The definition <jats:italic>persistent postpartum haemorrhage<\/jats:italic> captured 430\/471 adverse maternal outcomes (91.3%), compared to 471\/471 (100%) for \u22651\u2009L blood loss and 383\/471 (81.3%) for \u22654\u2009units of RBC. <jats:italic>Persistent postpartum haemorrhage<\/jats:italic> did not capture all adverse outcomes because of missing data on timing of initial, first-line treatment.<\/jats:p>\n              <\/jats:sec>\n              <jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>The definition <jats:italic>persistent postpartum haemorrhage<\/jats:italic> identified women with severe postpartum haemorrhage at an early stage of haemorrhage, unlike definitions based on blood transfusion. It also captured a large majority of adverse maternal outcomes, almost as large as the definition of \u22651\u2009L blood loss, which is commonly applied as a definition of postpartum haemorrhage rather than <jats:italic>severe<\/jats:italic> haemorrhage.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12884-019-2499-9","type":"journal-article","created":{"date-parts":[[2019,10,17]],"date-time":"2019-10-17T14:59:24Z","timestamp":1571324364000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["Clinical characteristics of women captured by extending the definition of severe postpartum haemorrhage with \u2018refractoriness to treatment\u2019: a cohort study"],"prefix":"10.1186","volume":"19","author":[{"name":"on behalf of the TeMpOH-1 study group","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3164-8611","authenticated-orcid":false,"given":"Dacia D. C. A.","family":"Henriquez","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ada","family":"Gillissen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sharissa M.","family":"Smith","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roos A.","family":"Cramer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"van den Akker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joost J.","family":"Zwart","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jos J. M.","family":"van Roosmalen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kitty W. M.","family":"Bloemenkamp","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Johanna G.","family":"van der Bom","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2019,10,17]]},"reference":[{"issue":"4","key":"2499_CR1","doi-asserted-by":"publisher","first-page":"353.e351","DOI":"10.1016\/j.ajog.2010.01.011","volume":"202","author":"WM Callaghan","year":"2010","unstructured":"Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum hemorrhage: United States, 1994-2006. Am J Obstet Gynecol. 2010;202(4):353.e351\u20136.","journal-title":"Am J Obstet Gynecol"},{"key":"2499_CR2","doi-asserted-by":"publisher","first-page":"334","DOI":"10.1186\/s12884-015-0788-5","volume":"15","author":"JB Ford","year":"2015","unstructured":"Ford JB, Patterson JA, Seeho SK, Roberts CL. Trends and outcomes of postpartum haemorrhage, 2003-2011. BMC Pregnancy Childbirth. 2015;15:334.","journal-title":"BMC Pregnancy Childbirth"},{"key":"2499_CR3","doi-asserted-by":"publisher","first-page":"55","DOI":"10.1186\/1471-2393-9-55","volume":"9","author":"M Knight","year":"2009","unstructured":"Knight M, Callaghan WM, Berg C, Alexander S, Bouvier-Colle MH, Ford JB, Joseph KS, Lewis G, Liston RM, Roberts CL, et al. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the international postpartum hemorrhage collaborative group. BMC Pregnancy Childbirth. 2009;9:55.","journal-title":"BMC Pregnancy Childbirth"},{"issue":"1","key":"2499_CR4","doi-asserted-by":"publisher","first-page":"21","DOI":"10.1016\/S1701-2163(15)30680-0","volume":"36","author":"A Mehrabadi","year":"2014","unstructured":"Mehrabadi A, Liu S, Bartholomew S, Hutcheon JA, Kramer MS, Liston RM, Joseph KS. Temporal trends in postpartum hemorrhage and severe postpartum hemorrhage in Canada from 2003 to 2010. J Obstet Gynaecol Can. 2014;36(1):21\u201333.","journal-title":"J Obstet Gynaecol Can"},{"key":"2499_CR5","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1186\/1471-2393-9-7","volume":"9","author":"CL Roberts","year":"2009","unstructured":"Roberts CL, Ford JB, Algert CS, Bell JC, Simpson JM, Morris JM. Trends in adverse maternal outcomes during childbirth: a population-based study of severe maternal morbidity. BMC Pregnancy Childbirth. 2009;9:7.","journal-title":"BMC Pregnancy Childbirth"},{"issue":"10","key":"2499_CR6","doi-asserted-by":"publisher","first-page":"1104","DOI":"10.1111\/aogs.12950","volume":"95","author":"G van Stralen","year":"2016","unstructured":"van Stralen G, von Schmidt Auf Altenstadt JF, Bloemenkamp KW, van Roosmalen J, Hukkelhoven CW. Increasing incidence of postpartum hemorrhage: the Dutch piece of the puzzle. Acta Obstet Gynecol Scand. 2016;95(10):1104\u201310.","journal-title":"Acta Obstet Gynecol Scand"},{"issue":"6","key":"2499_CR7","doi-asserted-by":"publisher","first-page":"e323","DOI":"10.1016\/S2214-109X(14)70227-X","volume":"2","author":"L Say","year":"2014","unstructured":"Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J, Gulmezoglu AM, Temmerman M, Alkema L. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323\u201333.","journal-title":"Lancet Glob Health"},{"issue":"2","key":"2499_CR8","doi-asserted-by":"publisher","first-page":"256","DOI":"10.1007\/s00134-009-1707-x","volume":"36","author":"JJ Zwart","year":"2010","unstructured":"Zwart JJ, Dupuis JR, Richters A, Ory F, van Roosmalen J. Obstetric intensive care unit admission: a 2-year nationwide population-based cohort study. Intensive Care Med. 2010;36(2):256\u201363.","journal-title":"Intensive Care Med"},{"issue":"10","key":"2499_CR9","doi-asserted-by":"publisher","first-page":"1265","DOI":"10.1111\/j.1471-0528.2008.01859.x","volume":"115","author":"I Al-Zirqi","year":"2008","unstructured":"Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B. Prevalence and risk factors of severe obstetric haemorrhage. BJOG. 2008;115(10):1265\u201372.","journal-title":"BJOG"},{"issue":"6","key":"2499_CR10","doi-asserted-by":"publisher","first-page":"751","DOI":"10.1111\/j.1471-0528.2007.01316.x","volume":"114","author":"KS Joseph","year":"2007","unstructured":"Joseph KS, Rouleau J, Kramer MS, Young DC, Liston RM, Baskett TF. Investigation of an increase in postpartum haemorrhage in Canada. BJOG. 2007;114(6):751\u20139.","journal-title":"BJOG"},{"issue":"7","key":"2499_CR11","doi-asserted-by":"publisher","first-page":"1756","DOI":"10.1111\/trf.12550","volume":"54","author":"R Abdul-Kadir","year":"2014","unstructured":"Abdul-Kadir R, McLintock C, Ducloy AS, El-Refaey H, England A, Federici AB, Grotegut CA, Halimeh S, Herman JH, Hofer S, et al. Evaluation and management of postpartum hemorrhage: consensus from an international expert panel. Transfusion. 2014;54(7):1756\u201368.","journal-title":"Transfusion"},{"issue":"4","key":"2499_CR12","doi-asserted-by":"publisher","first-page":"e168","DOI":"10.1097\/AOG.0000000000002351","volume":"130","author":"ACOG","year":"2017","unstructured":"ACOG. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017;130(4):e168\u201386.","journal-title":"Obstet Gynecol"},{"issue":"5","key":"2499_CR13","doi-asserted-by":"publisher","first-page":"481","DOI":"10.1111\/j.1471-0528.2004.00101.x","volume":"111","author":"V Brace","year":"2004","unstructured":"Brace V, Penney G, Hall M. Quantifying severe maternal morbidity: a Scottish population study. BJOG. 2004;111(5):481\u20134.","journal-title":"BJOG"},{"issue":"5","key":"2499_CR14","doi-asserted-by":"publisher","first-page":"723","DOI":"10.1111\/1471-0528.14417","volume":"124","author":"RS Kerr","year":"2017","unstructured":"Kerr RS, Weeks AD. Postpartum haemorrhage: a single definition is no longer enough. BJOG. 2017;124(5):723\u20136.","journal-title":"BJOG"},{"issue":"5","key":"2499_CR15","doi-asserted-by":"publisher","first-page":"421","DOI":"10.1111\/j.1600-0412.2011.01107.x","volume":"90","author":"WH Rath","year":"2011","unstructured":"Rath WH. Postpartum hemorrhage--update on problems of definitions and diagnosis. Acta Obstet Gynecol Scand. 2011;90(5):421\u20138.","journal-title":"Acta Obstet Gynecol Scand"},{"key":"2499_CR16","unstructured":"Postpartum haemorrhage, prevention and management (Green-top guideline no. 52) [\n                    https:\/\/www.rcog.org.uk\/en\/guidelines-research-services\/guidelines\/gtg52\/\n                    \n                  ]. Accessed 1 Sept 2018."},{"key":"2499_CR17","unstructured":"WHO recommendations for the prevention and treatment of postpartum haemorrhage. [\n                    http:\/\/apps.who.int\/iris\/bitstream\/10665\/75411\/1\/9789241548502_eng.pdf\n                    \n                  ]. Accessed 1 Sept 2018."},{"issue":"7","key":"2499_CR18","doi-asserted-by":"publisher","first-page":"842","DOI":"10.1111\/j.1471-0528.2008.01713.x","volume":"115","author":"JJ Zwart","year":"2008","unstructured":"Zwart JJ, Richters JM, Ory F, de Vries JI, Bloemenkamp KW, van Roosmalen J. Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study of 371,000 pregnancies. BJOG. 2008;115(7):842\u201350.","journal-title":"BJOG"},{"issue":"3","key":"2499_CR19","doi-asserted-by":"publisher","first-page":"394","DOI":"10.1111\/1471-0528.14833","volume":"126","author":"T Schaap","year":"2017","unstructured":"Schaap T, Bloemenkamp K, Deneux-Tharaux C, Knight M, Langhoff-Roos J, Sullivan E, van den Akker T. Defining definitions: a Delphi study to develop a core outcome set for conditions of severe maternal morbidity. BJOG. 2019;126(3):394\u2013401. \n                    https:\/\/doi.org\/10.1111\/1471-0528.14833\n                    \n                  . Epub 2017 Aug 24.","journal-title":"BJOG: An International Journal of Obstetrics & Gynaecology"},{"key":"2499_CR20","doi-asserted-by":"publisher","first-page":"230","DOI":"10.1186\/s12884-015-0653-6","volume":"15","author":"A Hancock","year":"2015","unstructured":"Hancock A, Weeks AD, Lavender DT. Is accurate and reliable blood loss estimation the \u2018crucial step\u2019 in early detection of postpartum haemorrhage: an integrative review of the literature. BMC Pregnancy Childbirth. 2015;15:230.","journal-title":"BMC Pregnancy Childbirth"},{"key":"2499_CR21","doi-asserted-by":"publisher","first-page":"162","DOI":"10.1016\/j.ajog.2018.04.013","volume":"219","author":"A Borovac-Pinheiro","year":"2018","unstructured":"Borovac-Pinheiro A, Pacagnella RC, Cecatti JG, Miller S, El Ayadi AM, Souza JP, Durocher J, Blumenthal PD, Winikoff B. Postpartum hemorrhage: new insights for definition and diagnosis. Am J Obstet Gynecol. 2018;219:162\u20138.","journal-title":"Am J Obstet Gynecol"},{"key":"2499_CR22","unstructured":"Evaluating the quality of care for severe pregnancy complications. The WHO near-miss approach for maternal health. [Available at: \n                    http:\/\/www.who.int\/reproductivehealth\/publications\/monitoring\/9789241502221\/en\/\n                    \n                  ]. Accessed 1 Sept 2018."},{"issue":"8","key":"2499_CR23","doi-asserted-by":"publisher","first-page":"1441","DOI":"10.1111\/j.1538-7836.2011.04398.x","volume":"9","author":"C McLintock","year":"2011","unstructured":"McLintock C, James AH. Obstetric hemorrhage. J Thromb Haemost. 2011;9(8):1441\u201351.","journal-title":"J Thromb Haemost"},{"issue":"2","key":"2499_CR24","doi-asserted-by":"publisher","first-page":"118","DOI":"10.1111\/j.1365-3148.2009.00967.x","volume":"20","author":"J. J. Zwart","year":"2010","unstructured":"Zwart JJ, Yazdani ST, Harvey MS, de Vries RR, van Roosmalen J. Underreporting of major obstetric haemorrhage in the Netherlands. Transfus Med (Oxford, England). 2010;20(2):118\u201322.","journal-title":"Transfusion Medicine"},{"key":"2499_CR25","doi-asserted-by":"publisher","first-page":"12","DOI":"10.1016\/j.ejogrb.2015.12.012","volume":"198","author":"L Sentilhes","year":"2016","unstructured":"Sentilhes L, Vayssiere C, Deneux-Tharaux C, Aya AG, Bayoumeu F, Bonnet MP, Djoudi R, Dolley P, Dreyfus M, Ducroux-Schouwey C, et al. Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF): in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR). Eur J Obstet Gynecol Reprod Biol. 2016;198:12\u201321.","journal-title":"Eur J Obstet Gynecol Reprod Biol"},{"issue":"10084","key":"2499_CR26","doi-asserted-by":"publisher","first-page":"2105","DOI":"10.1016\/S0140-6736(17)30638-4","volume":"389","author":"WOMAN_Trial_Collaborators","year":"2017","unstructured":"WOMAN_Trial_Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet (London, England). 2017;389(10084):2105\u201316.","journal-title":"Lancet (London, England)"},{"issue":"2","key":"2499_CR27","doi-asserted-by":"publisher","first-page":"239.e231","DOI":"10.1016\/j.ajog.2015.04.017","volume":"213","author":"TF Howard","year":"2015","unstructured":"Howard TF, Grobman WA. The relationship between timing of postpartum hemorrhage interventions and adverse outcomes. Am J Obstet Gynecol. 2015;213(2):239.e231\u20133.","journal-title":"Am J Obstet Gynecol"},{"issue":"3","key":"2499_CR28","doi-asserted-by":"publisher","first-page":"716","DOI":"10.1097\/ALN.0b013e318245c47b","volume":"116","author":"AM Ho","year":"2012","unstructured":"Ho AM, Dion PW, Yeung JH, Holcomb JB, Critchley LA, Ng CS, Karmakar MK, Cheung CW, Rainer TH. Prevalence of survivor bias in observational studies on fresh frozen plasma:erythrocyte ratios in trauma requiring massive transfusion. Anesthesiology. 2012;116(3):716\u201328.","journal-title":"Anesthesiology"},{"issue":"2","key":"2499_CR29","doi-asserted-by":"publisher","first-page":"358","DOI":"10.1097\/TA.0b013e318196c3ac","volume":"66","author":"CW Snyder","year":"2009","unstructured":"Snyder CW, Weinberg JA, McGwin G Jr, Melton SM, George RL, Reiff DA, Cross JM, Hubbard-Brown J, Rue LW 3rd, Kerby JD. The relationship of blood product ratio to mortality: survival benefit or survival bias? J Trauma. 2009;66(2):358\u201362 discussion 362-354.","journal-title":"J Trauma"},{"issue":"1","key":"2499_CR30","doi-asserted-by":"publisher","first-page":"60","DOI":"10.1111\/vox.12121","volume":"107","author":"AJ Zatta","year":"2014","unstructured":"Zatta AJ, McQuilten ZK, Mitra B, Roxby DJ, Sinha R, Whitehead S, Dunkley S, Kelleher S, Hurn C, Cameron PA, et al. Elucidating the clinical characteristics of patients captured using different definitions of massive transfusion. Vox Sang. 2014;107(1):60\u201370.","journal-title":"Vox Sang"}],"container-title":["BMC Pregnancy and Childbirth"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12884-019-2499-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/article\/10.1186\/s12884-019-2499-9\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12884-019-2499-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,10,15]],"date-time":"2020-10-15T23:24:35Z","timestamp":1602804275000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcpregnancychildbirth.biomedcentral.com\/articles\/10.1186\/s12884-019-2499-9"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,10,17]]},"references-count":30,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2019,12]]}},"alternative-id":["2499"],"URL":"https:\/\/doi.org\/10.1186\/s12884-019-2499-9","relation":{},"ISSN":["1471-2393"],"issn-type":[{"value":"1471-2393","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,10,17]]},"assertion":[{"value":"5 October 2018","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"10 September 2019","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"17 October 2019","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The study was approved by the medical research ethics committee of the Leiden University Medical Center (P12.273). A waiver for informed consent from the individual patients was granted by this medical research ethics committee. Each participating hospital (Additional file ) provided permission to conduct the study, ethics approval was not required from each hospital. All data were anonymized before being received by the research team. The study was registered in the Netherlands Trial Register (NTR4079).","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"TA and JR are on the editorial board of BMC Pregnancy and Childbirth. All other authors declare that they have no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"361"}}