title: Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study.
abstract: OBJECTIVE
  To derive nationally representative incidence rates of postpartum haemorrhage (PPH), and to investigate trends associated with method of delivery, blood transfusion and morbidly adherent placenta (accreta, percreta and increta).
  
  
  METHODS
  Population-based retrospective cohort study.
  
  
  METHODS
  Republic of Ireland.
  
  
  METHODS
  Childbirth hospitalisations during the period 1999-2009.
  
  
  METHODS
  International Classification of Diseases (ICD)-9-CM and ICD-10-AM diagnostic codes from hospital discharge records were used to identify cases of PPH. Significant temporal trends in PPH incidence were determined using Cochrane-Armitage tests for trend. Log-binomial regression was conducted to assess annual changes in the risk of PPH diagnosis, with adjustment for potential confounding factors.
  
  
  METHODS
  PPH, uterine atony, blood transfusion and morbidly adherent placenta.
  
  
  RESULTS
  A total of 649,019 childbirth hospitalisations were recorded; 2.6% (n = 16,909) included a diagnosis of PPH. The overall PPH rate increased from 1.5% in 1999 to 4.1% in 2009; atonic PPH rose from 1.0% in 1999 to 3.4% in 2009. Significant increasing trends in atonic PPH rates were observed across vaginal, instrumental, and emergency and elective caesarean deliveries (P < 0.001). The rate of atonic PPH co-diagnosed with blood transfusion also significantly increased (P < 0.001). Relative to 1999, the risk of atonic PPH in 2009 was three-fold increased (adjusted RR 3.03; 95% CI 2.76-3.34). Women diagnosed with a morbidly adherent placenta had a markedly higher risk of total PPH (unadjusted RR 13.14; 95% CI 11.43-15.11).
  
  
  CONCLUSIONS
  Increasing rates of atonic PPH highlight the pressing need for research and for clinical audit focusing on aetiological factors, preventative measures and quality of care, to guide current clinical practice.
authors.affiliation: National Perinatal Epidemiology Centre, Cork University Maternity Hospital, Wilton, Cork, Ireland. j.lutomski@ucc.ie
authors.forename: J E
authors.initials: JE
authors.lastname: Lutomski
authors.forename: B M
authors.initials: BM
authors.lastname: Byrne
authors.forename: D
authors.initials: D
authors.lastname: Devane
authors.forename: R A
authors.initials: RA
authors.lastname: Greene
mesh_terms: D000293:Adolescent; D000328:Adult; D001803:Blood Transfusion / Q000706:statistics & numerical data; D015331:Cohort Studies; D036861:Delivery, Obstetric / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D015994:Incidence; D007494:Ireland / Q000453:epidemiology; D008875:Middle Aged; D015999:Multivariate Analysis; D010921:Placenta Accreta / Q000453:epidemiology*; D006473:Postpartum Hemorrhage / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy; D011247:Pregnancy; D012044:Regression Analysis; D012189:Retrospective Studies; D012306:Risk; D014593:Uterine Inertia / Q000453:epidemiology; D055815:Young Adult