{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,27]],"date-time":"2026-10-27T00:21:27Z","timestamp":1793060487955,"version":"4.5.0"},"reference-count":45,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2025,2,3]],"date-time":"2025-02-03T00:00:00Z","timestamp":1738540800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100006095","name":"Helse S\u00f8r-\u00d8st RHF","doi-asserted-by":"publisher","award":["2018024"],"award-info":[{"award-number":["2018024"]}],"id":[{"id":"10.13039\/501100006095","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Objective<\/jats:title>\n<jats:p>To compare trends, outcomes and risk factors for severe postpartum hemorrhage (PPH) due to uterine atony and retained tissue separately.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Study design<\/jats:title>\n<jats:p>This retrospective hospital-based study of severe PPH included deliveries from a 10-year cohort (2008\u20132017) and a four-year case-control group (2008\u20132011). Severe PPH was defined as an estimated blood loss of \u22651500 ml or a blood transfusion. Poisson regression was used to estimate the temporal trend in the 10-year cohort. Risk factors were investigated in the case-control group. We performed multinomial regression analysis to investigate associations between pregnancy characteristics and severe PPH caused by uterine atony and by retained tissue compared to controls without severe PPH.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>During the 10-year study period, 2.7% of all deliveries were complicated by severe PPH. Uterine atony without concurring retained tissue was the cause in 55.4%, while retained tissue was listed as a cause in 32.2% of the cases. Among women who received \u2265 four units of blood products, retained tissue caused 42.6% of cases, and severe PPH resulting in a hysterectomy was caused by retained tissue in 61.2% of cases. The rate of severe PPH caused by uterine atony significantly increased during the study period with an estimated annual percentage change of 8.6%, while the increase in severe PPH due to retained tissue was non-significant. Risk factors associated only with uterine atony were multiple pregnancy, macrosomia, Asian ethnicity and operative delivery, while induction of labor, augmentation of labor, use of anticoagulants and assisted reproduction were associated with both uterine atony and retained tissue.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>The observed increased rate of PPH in the study period was mainly driven by an increase in atonic PPH, while the rate of severe PPH caused by retained tissue remained stable. The proportion caused by retained tissue was highest among the most severe cases of PPH. The reason for the increase in severe PPH due to uterine atony, but not retained tissue was not clear, but we speculate that it may be a combination of increasing risk factors with increased awareness of PPH.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0318770","type":"journal-article","created":{"date-parts":[[2025,2,3]],"date-time":"2025-02-03T18:33:03Z","timestamp":1738607583000},"page":"e0318770","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":7,"title":["Tone or tissue? A comparison of trends and risk factors of severe postpartum hemorrhage according to uterine atony or retained tissue in a hospital setting"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8156-5606","authenticated-orcid":true,"given":"Silje","family":"Pettersen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ragnhild S\u00f8rum","family":"Falk","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Siri","family":"Vangen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lill Trine","family":"Nyfl\u00f8t","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,2,3]]},"reference":[{"key":"pone.0318770.ref001","doi-asserted-by":"crossref","first-page":"e323","DOI":"10.1016\/S2214-109X(14)70227-X","article-title":"Global causes of maternal death: a WHO systematic analysis","volume":"2","author":"L Say","year":"2014","journal-title":"The Lancet Global health"},{"key":"pone.0318770.ref002","doi-asserted-by":"crossref","first-page":"1112","DOI":"10.1111\/aogs.13172","article-title":"Maternal deaths in the Nordic countries.","volume":"96","author":"S Vangen","year":"2017","journal-title":"Acta Obstet Gynecol Scand"},{"key":"pone.0318770.ref003","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1016\/S1701-2163(15)30680-0","article-title":"Temporal trends in postpartum hemorrhage and severe postpartum hemorrhage in Canada from 2003 to 2010.","volume":"36","author":"A Mehrabadi","year":"2014","journal-title":"J Obstet Gynaecol Can."},{"key":"pone.0318770.ref004","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1186\/1471-2393-9-55","article-title":"Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group.","volume":"9","author":"M Knight","year":"2009","journal-title":"BMC Pregnancy Childbirth"},{"key":"pone.0318770.ref005","doi-asserted-by":"crossref","first-page":"723","DOI":"10.1111\/1471-0528.14417","article-title":"Postpartum haemorrhage: a single definition is no longer enough.","volume":"124","author":"RS Kerr","year":"2017","journal-title":"BJOG"},{"key":"pone.0318770.ref006","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1016\/j.ajog.2018.04.013","article-title":"Postpartum hemorrhage: new insights for definition and diagnosis.","volume":"219","author":"A Borovac-Pinheiro","year":"2018","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0318770.ref007","doi-asserted-by":"crossref","first-page":"76.e1","DOI":"10.1016\/j.ajog.2015.02.023","article-title":"Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines.","volume":"213","author":"JD Dahlke","year":"2015","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0318770.ref008","author":"organization Wh.","year":"2012","journal-title":"WHO recommendations for the prevention and treatment of postpartum haemorrhage"},{"key":"pone.0318770.ref009","doi-asserted-by":"crossref","first-page":"e168","DOI":"10.1097\/AOG.0000000000002351","article-title":"Practice Bulletin No. 183: Postpartum Hemorrhage.","volume":"130","author":"ACOG","year":"2017","journal-title":"Obstet Gynecol."},{"key":"pone.0318770.ref010","first-page":"875","article-title":"Prevention and management of postpartum hemorrhage.","volume":"75","author":"JM Anderson","year":"2007","journal-title":"Am Fam Physician"},{"key":"pone.0318770.ref011","doi-asserted-by":"crossref","first-page":"1265","DOI":"10.1111\/j.1471-0528.2008.01859.x","article-title":"Prevalence and risk factors of severe obstetric haemorrhage.","volume":"115","author":"I Al-Zirqi","year":"2008","journal-title":"BJOG"},{"key":"pone.0318770.ref012","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1097\/GRF.0b013e3181cc406d","article-title":"Postpartum hemorrhage: epidemiology, risk factors, and causes.","volume":"53","author":"Y Oyelese","year":"2010","journal-title":"Clin Obstet Gynecol"},{"key":"pone.0318770.ref013","doi-asserted-by":"crossref","first-page":"1043","DOI":"10.1080\/17474086.2016.1245135","article-title":"Postpartum haemorrhage: prevention and treatment.","volume":"9","author":"L Sentilhes","year":"2016","journal-title":"Expert Rev Hematol"},{"key":"pone.0318770.ref014","doi-asserted-by":"crossref","first-page":"1368","DOI":"10.1213\/ANE.0b013e3181d74898","article-title":"The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries.","volume":"110","author":"BT Bateman","year":"2010","journal-title":"Anesth Analg"},{"key":"pone.0318770.ref015","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1097\/AOG.0000000000004228","article-title":"Risk Factors for Atonic Postpartum Hemorrhage: A Systematic Review and Meta-analysis.","volume":"137","author":"HB Ende","year":"2021","journal-title":"Obstet Gynecol."},{"key":"pone.0318770.ref016","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1002\/ijgo.12407","article-title":"FIGO consensus guidelines on placenta accreta spectrum disorders: Epidemiology.","volume":"140","author":"E Jauniaux","year":"2018","journal-title":"Int J Gynaecol Obstet"},{"key":"pone.0318770.ref017","first-page":"1","article-title":"Risk factors for abnormally invasive placenta: a systematic review and meta-analysis.","author":"A Iacovelli","year":"2018","journal-title":"J Matern Fetal Neonatal Med"},{"key":"pone.0318770.ref018","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1016\/j.ijgo.2007.03.011","article-title":"Increased postpartum hemorrhage rates in Australia.","volume":"98","author":"JB Ford","year":"2007","journal-title":"Int J Gynaecol Obstet"},{"key":"pone.0318770.ref019","doi-asserted-by":"crossref","first-page":"751","DOI":"10.1111\/j.1471-0528.2007.01316.x","article-title":"Investigation of an increase in postpartum haemorrhage in Canada.","volume":"114","author":"KS Joseph","year":"2007","journal-title":"BJOG"},{"key":"pone.0318770.ref020","doi-asserted-by":"crossref","first-page":"449","DOI":"10.1016\/j.ajog.2013.07.007","article-title":"Incidence, risk factors, and temporal trends in severe postpartum hemorrhage.","volume":"209","author":"MS Kramer","year":"2013","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0318770.ref021","doi-asserted-by":"crossref","first-page":"1248","DOI":"10.3109\/00016349.2010.514324","article-title":"Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions?","volume":"89","author":"J Rossen","year":"2010","journal-title":"Acta Obstet Gynecol Scand"},{"key":"pone.0318770.ref022","doi-asserted-by":"crossref","first-page":"733","DOI":"10.1007\/s00404-019-05066-3","article-title":"The increasing role of a retained placenta in postpartum blood loss: a cohort study","volume":"299","author":"HM Edwards","year":"2019","journal-title":"Arch Gynecol Obstet"},{"key":"pone.0318770.ref023","doi-asserted-by":"crossref","first-page":"534.e1","DOI":"10.1016\/j.ajog.2021.04.233","article-title":"Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States","volume":"225","author":"S Matsuzaki","year":"2021","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0318770.ref024","doi-asserted-by":"crossref","first-page":"814","DOI":"10.1097\/AOG.0000000000000722","article-title":"Contribution of placenta accreta to the incidence of postpartum hemorrhage and severe postpartum hemorrhage","volume":"125","author":"A Mehrabadi","year":"2015","journal-title":"Obstet Gynecol"},{"key":"pone.0318770.ref025","doi-asserted-by":"crossref","first-page":"853","DOI":"10.1111\/1471-0528.12149","article-title":"Epidemiological investigation of a temporal increase in atonic postpartum haemorrhage: a population-based retrospective cohort study.","volume":"120","author":"A Mehrabadi","year":"2013","journal-title":"BJOG"},{"key":"pone.0318770.ref026","doi-asserted-by":"crossref","first-page":"810","DOI":"10.1016\/S1701-2163(16)34984-2","article-title":"Risk factors for postpartum hemorrhage: can we explain the recent temporal increase?","volume":"33","author":"MS Kramer","year":"2011","journal-title":"J Obstet Gynaecol Can"},{"key":"pone.0318770.ref027","doi-asserted-by":"crossref","first-page":"801","DOI":"10.1097\/AOG.0b013e31824acb3b","article-title":"Epidemiology of retained placenta: oxytocin as an independent risk factor","volume":"119","author":"M Endler","year":"2012","journal-title":"Obstet Gynecol"},{"key":"pone.0318770.ref028","doi-asserted-by":"crossref","first-page":"601","DOI":"10.1515\/jpm-2021-0632","article-title":"Risk factors for postpartum hemorrhage in patients with retained placenta: building a predict model","volume":"50","author":"X Wei","year":"2022","journal-title":"J Perinat Med"},{"key":"pone.0318770.ref029","doi-asserted-by":"crossref","first-page":"1341","DOI":"10.1016\/S0140-6736(18)31928-7","article-title":"Global epidemiology of use of and disparities in caesarean sections","volume":"392","author":"T Boerma","year":"2018","journal-title":"Lancet"},{"key":"pone.0318770.ref030","doi-asserted-by":"crossref","first-page":"363","DOI":"10.1186\/s12884-023-05702-6","article-title":"Exploring trends of severe postpartum haemorrhage: a hospital-based study.","volume":"23","author":"S Pettersen","year":"2023","journal-title":"BMC Pregnancy Childbirth"},{"key":"pone.0318770.ref031","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1186\/1471-2164-9-488","article-title":"BioVenn\u2014a web application for the comparison and visualization of biological lists using area-proportional Venn diagrams","volume":"9","author":"T Hulsen","year":"2008","journal-title":"BMC Genomics"},{"key":"pone.0318770.ref032","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1186\/s12884-016-1217-0","article-title":"Risk factors for severe postpartum hemorrhage: a case-control study.","volume":"17","author":"LT Nyflot","year":"2017","journal-title":"BMC Pregnancy Childbirth"},{"key":"pone.0318770.ref033","doi-asserted-by":"crossref","first-page":"306","DOI":"10.1111\/j.1471-0528.2011.03198.x","article-title":"Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study.","volume":"119","author":"JE Lutomski","year":"2012","journal-title":"BJOG"},{"key":"pone.0318770.ref034","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1186\/s12884-017-1384-7","article-title":"Incidence, management and outcome of women requiring massive transfusion after childbirth in the Netherlands: secondary analysis of a nationwide cohort study between 2004 and 2006.","volume":"17","author":"PI Ramler","year":"2017","journal-title":"BMC Pregnancy Childbirth."},{"key":"pone.0318770.ref035","doi-asserted-by":"crossref","first-page":"1104","DOI":"10.1111\/aogs.12950","article-title":"Increasing incidence of postpartum hemorrhage: the Dutch piece of the puzzle.","volume":"95","author":"G van Stralen","year":"2016","journal-title":"Acta Obstet Gynecol Scand"},{"key":"pone.0318770.ref036","doi-asserted-by":"crossref","first-page":"1542","DOI":"10.1007\/s10995-011-0919-1","article-title":"Hospital data reporting on postpartum hemorrhage: under-estimates recurrence and over-estimates the contribution of uterine atony.","volume":"16","author":"JB Ford","year":"2012","journal-title":"Matern Child Health J"},{"key":"pone.0318770.ref037","volume-title":"MFR Statistikkbank.","author":"FMB Register","year":"2023"},{"key":"pone.0318770.ref038","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1016\/j.ejogrb.2017.06.035","article-title":"Underlying mechanisms of retained placenta: Evidence from a population based cohort study","volume":"216","author":"S Greenbaum","year":"2017","journal-title":"Eur J Obstet Gynecol Reprod Biol"},{"key":"pone.0318770.ref039","doi-asserted-by":"crossref","first-page":"e0275879","DOI":"10.1371\/journal.pone.0275879","article-title":"Risk factors and recurrence of cause-specific postpartum hemorrhage: A population-based study.","volume":"17","author":"LE Linde","year":"2022","journal-title":"PLoS One"},{"key":"pone.0318770.ref040","doi-asserted-by":"crossref","first-page":"229.e1","DOI":"10.1016\/j.ajog.2013.10.872","article-title":"Patterns of recurrence of postpartum hemorrhage in a large population-based cohort.","volume":"210","author":"AS Oberg","year":"2014","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0318770.ref041","doi-asserted-by":"crossref","first-page":"568.e1","DOI":"10.1016\/j.ajog.2020.04.026","article-title":"In vitro fertilization as an independent risk factor for placenta accreta spectrum","volume":"223","author":"B Salmanian","year":"2020","journal-title":"Am J Obstet Gynecol"},{"key":"pone.0318770.ref042","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1186\/s12884-021-03721-9","article-title":"Risk factors for non-adherent retained placenta after vaginal delivery: a systematic review","volume":"21","author":"A Favilli","year":"2021","journal-title":"BMC Pregnancy Childbirth"},{"key":"pone.0318770.ref043","doi-asserted-by":"crossref","first-page":"e0175306","DOI":"10.1371\/journal.pone.0175306","article-title":"Duration of labor and the risk of severe postpartum hemorrhage: A case-control study.","volume":"12","author":"LT Nyflot","year":"2017","journal-title":"PLoS One."},{"key":"pone.0318770.ref044","doi-asserted-by":"crossref","first-page":"103705","DOI":"10.1016\/j.midw.2023.103705","article-title":"Association of oxytocin augmentation and duration of labour with postpartum haemorrhage: A cohort study of nulliparous women.","volume":"123","author":"S Bernitz","year":"2023","journal-title":"Midwifery"},{"key":"pone.0318770.ref045","doi-asserted-by":"crossref","first-page":"247.e1","DOI":"10.1016\/j.ajog.2023.07.054","article-title":"Oxytocin is not associated with postpartum hemorrhage in labor augmentation in a retrospective cohort study in the United States.","volume":"230","author":"H Zhu","year":"2024","journal-title":"Am J Obstet Gynecol"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0318770","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,2,3]],"date-time":"2025-02-03T18:33:17Z","timestamp":1738607597000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0318770"}},"subtitle":[],"editor":[{"given":"Gizachew Tadele","family":"Tiruneh","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,2,3]]},"references-count":45,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2025,2,3]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0318770","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,2,3]]}}}